Ultrasound-guided small vessel cannulation: long-axis approach is equivalent to short-axis in novice sonographers experienced with landmark-based cannulation.

Eric Christensen,Margaret Digeronimo,Emily Hopkins,Erica Douglass,Michael Liao,Brooke Bender,Catherine Erickson,Jason Haukoos,John Kendall

doi:10.5811/westjem.2014.9.22404

Abstract

IntroductionOur primary objective was to describe the time to vessel penetration and difficulty of long-axis and short-axis approaches for ultrasound-guided small vessel penetration in novice sonographers experienced with landmark-based small vessel penetration.MethodsThis was a prospective, observational study of experienced certified emergency nurses attempting ultrasound-guided small vessel cannulation on a vascular access phantom. We conducted a standardized training, practice, and experiment session for each participant. Five long-axis and five short-axis approaches were attempted in alternating sequence. The primary outcome was time to vessel penetration. Secondary outcomes were number of skin penetrations and number of catheter redirections. We compared long-axis and short-axis approaches using multivariable regression adjusting for repeated measures, vessel depth, and vessel caliber.ResultsEach of 10 novice sonographers made 10 attempts for a total of 100 attempts. Median time to vessel penetration in the long-axis and short-axis was 11 (95% confidence interval [CI] 7–12) and 10 (95% CI 6–13) seconds, respectively. Skin penetrations and catheter redirections were equivalent and near optimal between approaches. The median caliber of cannulated vessels in the long-axis and short-axis was 4.6 (95% CI 4.1–5.5) and 5.6 (95% CI 5.1–6.2) millimeters, respectively. Both axes had equal success rates of 100% for all 50 attempts. In multivariable regression analysis, long-axis attempts were 32% (95% CI 11%–48%; p=0.009) faster than short-axis attempts.ConclusionNovice sonographers, highly proficient with peripheral IV cannulation, can perform after instruction ultrasound-guided small vessel penetration successfully with similar time to vessel penetration in either the long-axis or short-axis approach on phantom models.

Highlights

Our primary objective was to describe the time to vessel penetration and difficulty of long-axis and short-axis approaches for ultrasound-guided small vessel penetration in novice sonographers experienced with landmark-based small vessel penetration
Median time to vessel penetration in the long-axis and short-axis was 11 (95% confidence interval [confidence intervals (CI)] 7-12) and 10 seconds, respectively
The median caliber of cannulated vessels in the long-axis and short-axis was 4.6 and 5.6 millimeters, respectively

Summary

Introduction

Our primary objective was to describe the time to vessel penetration and difficulty of long-axis and short-axis approaches for ultrasound-guided small vessel penetration in novice sonographers experienced with landmark-based small vessel penetration. Placing central venous catheters is costly and puts patients at increased risk for complications.[1]. An alternative for those with difficult IV access is the placement of IV peripheral catheters under ultrasound guidance. Prior studies have shown that physicians, nurses, and technologists can use ultrasound guidance to obtain successful peripheral venous access when landmark approaches have failed.[2,3,4] suboptimal technique leads to unnecessary early complications and morbidity; including posterior wall penetration, arterial punctures, hematoma formation, excessive needle punctures and redirections within the skin, and delays in obtaining access.[5] Long-axis and short-axis approaches remain the primary methods for ultrasound guidance. Each has distinct advantages and disadvantages that may either increase or decrease complications.[6]

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