Ultrasound-guided Intravenous Research Articles

Difficult Intravenous Access Requiring Ultrasound in the Emergency Department: Associations With Delays in Care and Areas for Quality Improvement.

Background Patients with difficult intravenous access (DIVA) requiring ultrasound-guided intravenous (USGIV) access have been associated with delays in treatment, imaging, and disposition in academic emergency department (ED) patient populations. Our objective in this study was to characterize differences in time to intravenous access, imaging, and disposition between patients with DIVA versus those without DIVA requiring USGIV access in a community ED while also assessing for DIVA-associated comorbidities. Methods A cross-sectional, observational analysis was performed on admitted ED patients evaluated from September 2to September 31, 2022, at a community ED. Patients with DIVA were defined as patients with two failed attempts at traditional intravenous placement. These patients require USGIV placement per institutional protocol. Patients younger than 18 years of age, trauma admissions, repeated visits from the same patient, patients with missing data, and direct hospital admissions were excluded. Continuous variables were recorded with medians and included ED throughput measures of time to vascular access, contrast CT imaging, and disposition. Differences in median times between DIVA patients versus non-DIVA patients were assessed with the Mann-Whitney U-test. Categorical data involving comorbidities were reported as percentages, and differences in proportions between DIVA versus non-DIVA patients were assessed via chi-square tests. Multivariate logistic regression analysis evaluated for correlations between DIVA and times to access, contrast CT imaging, disposition, and significant covariates while adjusting for demographic information. Results A total of 1250 patients were included in this investigation (5.8% associated with DIVA requiring USGIV access). The median age of all subjects was 69 (interquartile range = 58, 79) with no significant difference between the DIVA and non-DIVA groups. Patients with DIVA were more likely to be female in comparison to patients without DIVA (65.3% and 51.2%, respectively, p < 0.05). Patients with a history of end-stage renal disease (ESRD) (p < 0.001), intravenous drug use (IVDU) (p < 0.001), and venous thromboembolism (p < 0.05) had statistically significant associations with DIVA. On regression analysis, patients with DIVA were more likely to have a history of ESRD with an odds ratio (OR) of 3.56 (95% confidence interval (CI): 1.62-7.81) and a history of IVDU with an OR of 14.29 (95% CI: 5.17-39.54). Patients with DIVA were associated with statistically significant greater median times to vascular access, contrast CT imaging, and disposition (p < 0.001 for time to access and disposition and p < 0.01 for time to contrast CT imaging). Conclusion In this study, DIVA cases requiring USGIV access were positively associated with significantly longer times to access, contrast CT imaging, and disposition compared to patients without DIVA at our community ED. Comorbidities such as IVDU and ESRD had statistically significant associations with DIVA requiring USGIV access.

Using Ultrasound-guided PIV Insertion in the Pediatric Population to Decrease Insertion Attempts

Intravenous (IV) therapy using a peripheral IV (PIV) in children is a medical intervention frequently used in hospitals. Current evidence supports ultrasound-guided PIV placement in the adult patient population. The purpose of this study was to implement an evidence-based practice approach to determine if ultrasound-guided IV insertion decreased the number of attempts for successful cannulation and improved staff and patient satisfaction with the treatment in the pediatric inpatient population. Data collection was conducted in a pediatric medical surgical unit and pediatric intensive care unit (PICU). After the implementation of ultrasound-guided IV insertion, the average number of attempts necessary for successful insertion decreased from 2 to 1.37. Findings support the integration of ultrasound-guided IV insertion into the standard of care on pediatric medical surgical units and PICUs.

Difficult intravenous access in the emergency department: Performance and impact of ultrasound-guided IV insertion performed by nurses.

Difficult intravenous access (DIVA) is a common problem in Emergency Departments (EDs), yet the prevalence and clinical impact of this condition is poorly understood. Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is a successful modality for obtaining intravenous (IV) access in patients with DIVA. We aimed to describe the prevalence of DIVA, explore how DIVA affects delivery of care, and determine if nurse insertion of USGPIV improves care delays among patients with DIVA. We retrospectively queried the electronic medical record for all ED patients who had a peripheral IV (PIV) inserted at a tertiary academic medical center from 2015 to 2017. We categorized patients as having DIVA if they required ≥3 PIV attempts or an USGPIV. We compared metrics for care delivery including time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED length of stay (LOS) between patients with and without DIVA. We also compared these metrics in patients with DIVA with a physician-inserted USGPIV versus those with a nurse-inserted USGPIV. A total of 147,260 patients were evaluated during the study period. Of these, 13,192 (8.9%) met criteria for DIVA. Patients with DIVA encountered statistically significant delays in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients without DIVA (all p<0.001). Patients with nurse-inserted USGPIVs also had statistically significant improvements in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients with physician-inserted USGPIVs (all p<0.001). DIVA affects many ED patients and leads to delays in PIV access-related care. Nurse insertion of USGPIVs improves care in patients with DIVA.

Ultra Long versus Standard Long Peripheral Intravenous Catheters: A Randomized Controlled Trial of Ultrasound-Guided Catheter Survival

Background: Ultrasound-guided intravenous (US-IV) peripheral catheters have dismal dwell time with most IVs failing prior to completion of therapy. Catheter length in vein is a variable directly related to catheter longevity. We investigate the survival of an ultra long (UL) US-IV compared to a standard long (SL) US-IV. Methods: We conducted a single site, 2-arm, nonblinded, randomized controlled trial of catheter survival. Adult patients presenting to the Emergency Department (ED) with difficult vascular access were recruited and randomized to receive either SL 4.78 cm 20 gauge US-IV or UL 6.35 cm 20 gauge US-IV. The primary outcome was catheter survival. Functional catheters removed with less than 24 hours dwell time were excluded per protocol analysis. Secondary outcomes included: first-stick success, time to insertion, number of attempts, thrombosis and infection. Findings: 270 patients were enrolled between October 2018 and March 2019.194 patients met study criteria, with 99 in the SL US-IV group and 95 in the UL US-IV group. Kaplan-Meier estimate of catheter median survival time was 135.88 hours (5.66 days) [95%CI 115-310] for the UL US-IVs compared to 77.67 hours (3.23 days) [95%CI 63-102] for the SL US-IVs(p = 0.008). IVs with greater than 2.75 cm of the catheter situated in the vein lumen had a median survival of 128.90 hours (5.37 days) [95%CI 102-210] compared to 75.05 hours (3.12days) [95%CI 52-116] for IVs with ≤ 2.75 cm in the vein(p=0.006). There were no cases of catheter-related bloodstream infection or thrombosis. Interpretation: This study demonstrates increased catheter survival when >2.75 cm is situated in the vessel. UL US-IV catheters facilitate establishing this cutoff length at commonly encountered vessel depths. Further, as UL catheters have similar insertion characteristics and no additional education/training is needed for insertion competency, adoption of these catheters can occur seamlessly. Trial Registration: The trial is registered on clinicaltrials.gov Identifier: NCT03655106 and is closed to recruitment. Funding Statement: B. Braun Medical, Inc. Declaration of Interests: Dr. Bahl reports grants from B Braun Medical, Inc, during the conduct of the study. All other authors declare none. Ethics Approval Statement: The study was approved by the home institution Internal Review Board.

P063: Ultrasound-guided peripheral intravenous access in the emergency department: a randomized controlled trial comparing single and dual-operator technique

Introduction: Ultrasound-guided intravenous (UGIV) insertion performed by nurses has been shown to be more effective than the blind approach for patients with difficult intravenous (IV) access in the emergency department (ED). While both the single-operator (SO) (where a single operator holds the IV and probe) and dual-operator (DO) (where a second operator holds the probe) techniques have been described, the DO is more resource-intensive, requiring a second operator to be present. The objective of this study is to compare the first-attempt cannulation success rates between a SO and DO technique in ED patients with predicted difficult access. Methods: We conducted a randomized controlled non-inferiority trial using a convenience sample of adult ED patients. Participating ED nurses received a one-hour UGIV training session including didactic and practical training on simulated arms. Patients were enrolled if they met any of three criteria for difficult access: (1) history of difficult access, (2) no visible or palpable veins, or (3) two failed blind attempts. Patients requiring active resuscitation, lack of suitable veins on US, or those unable to consent or comply with the procedure were excluded. Eligible patients were randomized to the SO or DO technique and a maximum of two UGIV attempts were allowed. The primary outcome was first-attempt success rate. Additional outcomes included overall success rate, number of attempts, time to successful cannulation, patient pain scores, operator ease of use scores, and complications 30 minutes after insertion. The chi-square test was used to compare success rates between groups and t-tests used for all other secondary outcomes. Results: 42 eligible patients have been approached for our study. 14 were excluded due to lack of visible veins on US or due to ongoing resuscitation. A total of 33 UGIV attempts were performed on 28 patients (17 in SO group, 16 in DO group). There was no statistically significant difference in first attempt success rates between the SO group of 76.5% (95% CI [50.1% to 93.2%]) and the DO group of 68.8% (95% CI [41.3% to 89%]) (p=0.62). There were also no statistically significant differences between the SO and DO groups in time to cannulation (140 vs 165 seconds, p=0.36), patient preference on a 10-point scale (7.0 vs 7.9, p=0.49), patient pain score (6.3 vs 6.6, p=0.87) or nursing ease of use (5.3 vs 6.5 p=0.23) respectively. There were no complications noted in either arm of the study. Conclusion: To date, the SO technique appears to be non-inferior to the DO technique for successful UGIV cannulation. Our results support the use of the SO technique, reducing the need for additional nursing resources when performing this procedure.

Ultrasound-Guided Peripheral Intravenous Catheters to Reduce Central Venous Catheter Use on the Inpatient Medical Ward

The traditional technique of placing a peripheral intravenous (IV) catheter is successful in most cases on inpatient wards. However, when the traditional method fails, a central venous catheter may be placed to maintain IV access. These catheters are associated with risks including central line-associated bloodstream infection. We evaluated the effectiveness and acceptability of an ultrasound-guided peripheral IV service to reduce the number of newly placed central venous catheters on an inpatient ward. Central venous catheters were counted daily on intervention and control wards using a standard protocol, and rates of newly placed catheters were compared using a Poisson regression model. Nurses were surveyed to assess acceptability and perceived benefit. We found a reduction in the rate of newly placed central venous catheters on the intervention unit compared with the control unit at 90 days: mean 0.47 versus 0.67 newly placed central venous catheters/day, but the difference was not significant (P = .08). Nurses were in favor of the ultrasound-guided IV service, with perceived benefit to their patients. Ultrasound-guided peripheral IV might reduce unnecessary central venous catheters on general inpatient wards. A portable ultrasound used for this purpose was found to be acceptable by nursing staff.

Outcomes of a Simplified Ultrasound-Guided Intravenous Training Course for Emergency Nurses

IntroductionVarious medical or anatomical conditions can lead to difficult intravenous access (DIVA) in the emergency department. It was hypothesized that developing an emergency nurse-training program could reduce IV attempts in the emergency department, improving throughput and patient care. MethodsEmergency nurses completed a 4-hour ultrasound-guided intravenous (USGIV) access course and achieved competency after 10 successful supervised USGIV insertions on patients. Data were collected from a nurse-completed USGIV log and the electronic medical record. Experience levels, rates of completion, rates of success, and the effects on attempts of IV access were analyzed. ResultsThirty-four emergency nurses enrolled in the study over 9 months, and 12 (35%) developed competency. Successful cannulation rates improved from 81% for procedure attempts 1 to 10, to 96% for attempts 21 to 30. Overall IV attempts by nurses and physicians (n = 24,471) decreased by 2%, P = 0.013. DIVA IV attempts (n = 1,366) decreased by 7%, P = 0.003. DiscussionUSGIV training programs can decrease total number of IV attempts. A simplified and economical USGIV training program for emergency nurses can be successful and may be dependent on emergency nurse experience levels and initiative.Image 1

Attitudes towards three ultrasound-guided vascular access techniques in a paediatric emergency department.

although nurses often place peripheral intravenous (IV) catheters, little is known about their perceptions regarding use of ultrasound guidance. the authors aimed to determine paediatric emergency department nurses' attitudes toward ultrasound-guided IV access techniques and assessed practice change after training. In a cross-sectional study of nurses, they had didactic and hands-on practice sessions, using three short-axis ultrasound-guided IV access techniques on gel models. Outcomes included likability and ease of learning and performing the techniques. A 3-month follow-up questionnaire assessed attitudes and behavioural changes. 18 nurses were enrolled and 17 analysed. Participants liked all three techniques and thought they were easy to learn and perform. Eighty-two percent of the nurses used at least one technique clinically. The two-person self-guided technique was most preferred (65%) and used 3 months later (65%). nurses reported generally positive attitudes toward all three ultrasound-guided IV access techniques, but preferred the two-person self-guided technique. Owing to the small sample size, these results cannot be generalised and further research is needed.

P020: Ultrasound-guided peripheral intravenous access in the emergency department: A randomized controlled trial comparing single and dual-operator technique

Introduction: Intravenous (IV) cannulation is a common and important procedure in the emergency department (ED). Ultrasound-guided IV (UGIV) insertion has been shown to be more effective than the blind approach for patients with difficult IV access. The optimal technique for UGIV insertion has not been determined. The objective of this study is to compare the first-attempt canulation success rate between a single-operator technique (provider holds the ultrasound probe while simultaneously placing the IV), with dual-operator technique (whereby a second provider holds the probe) in ED patients with predicted difficult access. Methods: We conducted a randomized controlled trial using a convenience sample of adult ED patients. Participating ED nurses received a one-hour UGIV training session on including didactic and practical training on simulated arms. Patients were enrolled if they met any of three criteria for difficult access: (1) history of difficult access, (2) no visible or palpable veins, or (3) two failed blind attempts. High-acuity patients or those unable to consent or comply with the procedure were excluded. Eligible patients were randomized to single or dual-operator technique and a maximum of two UGIV attempts were allowed. The primary outcome was first-attempt success rate. Additional outcomes included overall success rate, number of attempts, time to successful cannulation (needle insertion to flashback), patient pain scores, operator ‘ease of use’ scores, and complications 30 minutes after insertion including IV failure. Other variables collected included patient demographics, presenting complaint, indication for ultrasound use, relevant medical history, and location/depth of the target vessel. Fisher’s exact test was used to compare success rates between groups. Results: Data collection was ongoing at the time of submission, but is expected to be completed by May 01, 2017. Conclusion: This is the first randomized-controlled trial comparing single and dual-operator ultrasound technique for difficult IV insertion in ED patients. The results from this study will provide evidence to guide education, and ensure best practice of UGIV insertion in the ED.

A randomized study of training with large versus small vessel size on successful ultrasound-guided peripheral venous access

Our objective was to investigate whether training on phantoms with smaller or larger vessels would improve success rate in novice medical students learning this skill. Medical students who participated in a voluntary, extracurricular ultrasound training day were asked to participate in the study as part of their procedural training. They were given a standardized education and demonstration of how to use ultrasound to place a peripheral intravenous (IV) catheter. They were then randomized to practice three times on homemade phantom models with either a 5-mm or a 2.5-mm diameter simulated vessel. Afterwards, they were observed attempting to place an ultrasound-guided IV on a 5-mm diameter vessel. Successful cannulation rates was the primary outcome. Fifty-one students from five institutions were included in the analysis. No significant difference in success rate, time to cannulation, number of sticks, or number of redirects was seen between the group who trained on the phantoms with the smaller vessels versus those who trained on the phantoms with the larger vessel. A trend towards significance was seen for success rate and number of redirects, favoring the group trained on the smaller vessels, but this did not reach significance. In our small sample, there was no difference in success rate of novice students trained in ultrasound-guided peripheral IV access using either a smaller or a larger vessel phantom. Future work should focus on elucidating other aspects of training in ultrasound-guided procedures and should attempt a similar study with a larger sample size.

Power Injection Through Ultrasound-Guided Intravenous Lines: Safety and Efficacy Under an Institutional Protocol

BackgroundAfter an index case of contrast-associated compartment syndrome, an urban hospital instituted a protocol limiting high-speed injection to intravenous (IV) lines started proximal to the forearm and testing those lines before contrast injection. ObjectiveIn this article, we estimate the safety and efficacy of high-speed injection using this protocol in patients with IV lines inserted under ultrasound guidance. MethodsIn an ambispective study, we enrolled prospective cohorts of ED patients requiring high-speed radiographic contrast media injection (≥3.5 mL/sec) into two groups: those with IV lines placed under ultrasound guidance and those with IV lines placed using traditional inspection and palpation. We also performed a retrospective review involving those groups. In addition, we reviewed hospital records for all patients with compartment syndrome between January 2010 and December 2011. We calculated 95% confidence intervals using normal approximation or exact calculation. ResultsBetween November 2013 and August 2014, the ED referred 32 patients to the Department of Radiology for computed tomography angiography involving high-speed contrast injection through ultrasound-guided IV lines. Of these, 25 of 32 (78%) had successful injection (7 failed in the Department of Radiology) vs. 26 of 27 (96%) with catheters inserted using traditional methods (risk difference 0.18 [95% confidence interval −0.01 to 0.38]). Based on retrospective records, we estimated 79 additional cases. We found no cases of compartment syndrome during either period, for an incidence estimate of 0 per 100 cases (95% confidence interval 0–3). ConclusionA hospital policy for high-speed contrast injection through ultrasound-guided IV lines has a safe record. However, 22% of patients with ultrasound-guided IV lines were refused for CT.

Focused simulation training: emergency department nurses' confidence and comfort level in performing ultrasound-guided vascular access.

The objective of this study is to assess Emergency Department (ED) nurses' confidence, comfort level, and competency in performing ultrasound-guided vascular access after a focused ultrasound simulation training session. A cross-sectional study at an academic medical center. A simulation-based ultrasound training module was used to train ED nurses in ultrasound-guided intravenous (IV) access. The training module consisted of didactics followed by hands-on practice on human models and Blue Phantom ultrasound training block model. All subjects completed a questionnaire after completing the training module. A total of 40 nurses were enrolled. All subjects successfully demonstrated competency during the training session by identifying upper extremity sonographic vascular anatomy on a human model and performing real-time ultrasound-guided IV access on Blue Phantom ultrasound training block model. On a scale of 1-10, the average confidence level in performing the ultrasound-guided vascular access was 6.9 [95% confidence interval (95% CI) 6.3-7.46], with 98% (95% CI, 92-102%) reporting no difficulty in recognizing upper limb vascular anatomy on ultrasound. Ninety-two percent (95% CI, 84-100%) agreed that focused training in ultrasound-guided IV access was adequate to learn the procedure. After a focused simulation training session, ED nurses had a high level of comfort using ultrasound for vascular access. Despite having a moderate degree of confidence, ED nurses were accurate in identifying vascular anatomy and performing ultrasound-guided vascular access.