Ultrasound-guided Peripheral Intravenous Placement Research Articles

The ultrasound-guided versus standard technique for peripheral intravenous catheter placement by nurses: A systematic review and meta-analysis

AimTo comprehensively evaluate the efficacy of Ultrasound-guided technique for peripheral intravenous catheter placement by nurses in their daily practice. BackgroundPeripheral intravenous catheter insertion is a common clinical procedure in healthcare settings. Ultrasound-guided peripheral intravenous placement has emerged in recent decades and was recognized as particularly useful in some specific patient groups. MethodsStudies that had compared the ultrasound-guided and traditional approaches were eligible for inclusion and further analysis. The primary outcome was the success rate on the first intravenous insertion attempt. The secondary outcomes included the time needed for successful insertion, and the average number of attempts to establish the IV access. We systematically assess all studies using Cochrane Collaboration's Risk of Bias tool and the Newcastle-Ottawa Scale. We calculated the odds ratio and standardized mean difference with 95 % confidence intervals for the outcomes. Data were analyzed and visualized on Review Manager 5.3.4 and Stata 16.0. Results23 studies were included (17 randomized controlled trials and six cohort studies) with a population of 2051 patients offered ultrasound-assisted technique and 2479 treated with the conventional approach for comparison. The former approach was associated with a higher success rate on the first attempt in comparison (OR = 2.95, 95 % CI: 1.86, 4.69). This technique also took less time and less acupuncture to patients’ skin (SMD = −0.62, 95 % CI: 1.01, −0.23; SMD = −0.55, 95 % CI: 0.92, −0.18). In the sub-group analyses, children were more likely to benefit from ultrasound guided technique. Ultrasound guided technique demonstrated consistent and significant benefits in emergency clinical settings. Hospitals from different geographical locations exhibited similar trends in the three outcomes. Year of publication and study design revealed inconsistent and insignificant outcomes. ConclusionsUltrasound-guided technique can be a safer, faster, and more effective alternative to the traditional approach for nurses to establish intravenous access across different clinical settings and age groups.

Feasibility study of cumulative sum (CUSUM) analysis as a competency assessment tool for ultrasound-guided venous access procedures.

Typically, physician training programs use a self-reported case-log competency assessment that does not measure procedure success or objectively assess competency. Cumulative sum (CUSUM) analysis could provide objective assessments of competency and progress over the training period. Our study objective was to determine the feasibility of CUSUM analysis to assess competency of ultrasound-guided peripheral intravenous (USG-PIV) line placement in pediatric anesthesiology fellows. We applied a CUSUM analysis to assess competency in USG-PIV placement in three consecutive pediatric anesthesia fellowship classes. After a didactic and hands-on training session, fellows placed a USG-PIV line and self-reported the outcomes via a web-based application. Fellows were deemed competent if the CUSUM curve crossed two consecutive boundary lines from above. Twenty-nine fellows reported 1,388 USG-PIV attempts, with 74% success. Most fellows (26/29; 90%) achieved competency by the end of the fellowship. Two fellows identified in the mid-year CUSUM as not progressing towards competency achieved competency after targeted interventions. Fellows achieving competency (11/29 vs 25/29; odds ratio, 15; 95% confidence interval [CI], 1.98 to 113.56; P = 0.01) and attempts needed to achieve competency (19 vs 11; mean difference, 8.5; 95% CI, 3.3 to 13.7; P = 0.002) were significantly lower in younger patients and significantly higher in older patients. Our study showed that CUSUM can be used to assess competence in USG-PIV procedures performed by pediatric anesthesia fellows and to identify learners not progressing toward competency in procedural skills. Ultrasound-guided venous access required more attempts to achieve competency in younger patients.

Ultrasound-guided peripheral intravenous access in chronic kidney disease patients.

Ultrasound-guided peripheral intravenous (USPIV) catheters are being placed in emergency department (ED) patients with increasing frequency. USPIV catheters have been shown to improve the success rates of cannulation. It is unknown what the long-term effect of USPIV placement will be on fistula creation in chronic kidney disease (CKD) patients considering these ultrasound-guided peripheral lines often target the same deeper vessels used for fistulas. This study aimed to survey whether emergency medicine programs place restrictions on USPIV placement in patients with CKD stages 3-5. This was a survey study encompassing all 110 emergency ultrasound fellowship directors in the United States at the time the survey was conducted. Data was collected on an anonymous and voluntary basis. The primary outcome was the number of programs with restrictions on USPIV placement in patients with CKD stage 3 or greater. Of the 56 programs that responded, 21% reported having policies limiting which patients were appropriate for USPIV. Despite this, only one program reported placing restrictions on USPIV in CKD stage 3 or greater (p < 0.0001). Emergency departments do not have or follow restrictions placed on USPIV placement in patients with CKD stage 3 or greater. The use of these veins in the ED may result in thrombosis as well as inflammation and permanent scarring which could negatively impact the ability to utilize those vessels for fistula creation. Future studies are needed to further characterize the impact of USPIV on fistula creation.

Medical Student Ultrasound-Guided Intravenous Catheter Education: A Randomized Controlled Trial of Overtraining in a Simulation-Based Mastery Learning Setting.

Simulation-based mastery learning (SBML) improves skill transfer to humans. However, limited data exist to support the practice of performing additional training attempts once mastery has been achieved. We explored whether implementing this concept in an SBML model improves skill transfer in ultrasound-guided peripheral intravenous (USGPIV) catheter placement from simulator to humans. Forty-eight first- and second-year medical students underwent SBML for USGPIV placement to mastery standards on a simulator once to achieve minimum passing standard based on a 19-item checklist. Next, they completed either 0, 4, or 8 additional mastery level simulated performances in nonconsecutive order before attempting USGPIV placement on a human. An unplanned post hoc retention phase occurred 6 months later where participants' USGPIV skills were reassessed on a second human volunteer using the same checklist. In this sample, the success rate among the 3 training cohorts did not improve as the number of additional training sessions increased (exact P = 0.60) and were comparable among the 3 cohorts (exact P = 0.82). The overall checklist performance was also comparable among the 3 cohorts (exact P = 0.57). In an unplanned (small) sample of returning participants, the USGPIV retention rate exceeded 80% for those originally assigned to 4 or 8 sessions, whereas the retention rate fell less than 50% for those originally assigned to control. Among these returning participants, the overall success rate was 58% on the initial assessment and was 68% on retention. In this sample of novices, we were unable to show that up to 8 additional mastery level performances of USGPIV placement on a simulator following SBML training improve skill transfer for both USGPIV placement success and total checklist performance.

The Effect of Catheter Length Placed Into the Vein on Peripheral Ultrasound-Guided Catheter Survival Time: A Prospective Observational Study

IntroductionEstablishing and maintaining peripheral intravenous access in patients with no visible or palpable veins can be arduous. Intravenous catheters placed with ultrasound do not survive as long as traditionally placed catheters. This study was performed to determine the relationship between the catheter length placed into the lumen of the vein using ultrasound and catheter survival. MethodsThis was a nonrandomized prospective observational study of admitted patients with difficult intravenous placement in 2017. Subjects had ultrasound-guided peripheral intravenous placement in the emergency department or intensive care unit. The main outcome was the time of catheter survival. Data were analyzed using descriptive statistics and Cox regression. ResultsA total of 98 patients with an average age of 63 years were enrolled. The total number of cases examined was 97 (N = 97), of which 29 intravenous catheters were removed for catheter-related problems (events). The mean (SD) survival time for catheters placed using ultrasound was 3,445 minutes (2,414) or 2.39 days. Peripheral catheter survival was not significantly related to the in-vein length of the catheter (X2 = 0.03, P = 0.86) nor was it significantly related to any of the covariates. DiscussionThe survival time of ultrasound-guided intravenous access doubled in the present study from 1674 minutes in a previous 2013 study. The results may have been due to clinician expertise and experience with the peripheral ultrasound-guided method and the use of updated equipment.

Handheld Ultrasound: Overcoming the Challenge of Difficult Peripheral Intravenous Access in the Emergency Department.

The purpose of this study was to evaluate the performance of a handheld ultrasound device for difficult peripheral intravenous (PIV) access performed by nurses and paramedics in the emergency department (ED). This was a retrospective review at an academic medical center. Participants were ED nurses and paramedics with competence in ultrasound-guided PIV placement. Participants were asked to log their use of the handheld device when used on patients deemed to have "difficult" access and complete a questionnaire, which consisted of items related to the effectiveness and ease of use of the device. Data were collected over the course of 1 year. An electronic medical record review was performed to track the success rates and the occurrence of any associated complications throughout the hospital stay. Nurses and paramedics logged a total of 483 cases in which PIV access was attempted with the handheld ultrasound device. Ninety-two percent (95% confidence interval [CI], 89%-94%) of the ultrasound-guided PIV lines attempted were placed successfully. Eighty-four percent (95% CI, 80%-87%) of the lines were placed successfully on the first attempt. In most cases (396 of 483 [82%]), no complications associated with the PIV occurred. A total of 429 questionnaires were completed over the study period. Most of the operators (84%; 95% CI, 80%-87%) stated that the handheld device was adequate to perform ultrasound-guided PIV access. The handheld ultrasound device performed well in terms of usability and reliability for PIV access.

Ultrasound-guided techniques for peripheral intravenous placement in children with difficult venous access.

Peripheral intravenous placement in children can be challenging. Different techniques have been used to improve first pass success rates in children with known history of difficult venous access including surface landmarking, local warming, transillumination, ultrasonography, epidermal nitroglycerin, central venous access, intraosseous placement, and venous cutdown. Among these, ultrasound guidance has garnered the most interest among anesthesiologists. The cumulative literature surrounding the utility of ultrasound-guided peripheral intravenous placement in children with and without difficult venous access has shown mixed results. Literature on the utility of ultrasound guidance for peripheral intravenous placement in children under deep sedation or anesthesia is limited but encouraging. This review summarizes the overall evidence for ultrasound-guided peripheral intravenous placement in children with difficult venous access under deep sedation or general anesthesia. Furthermore, five subtly varying approaches to ultrasound-guided peripheral intravenous placement with their advantages and disadvantages will be discussed. One of these five approaches is Dynamic Needle Tip Positioning. Utilizing a short axis out of plane ultrasound view, this promising technique allows for accurate needle tip localization and may increase the success rate of peripheral intravenous placement, even in small children, under deep sedation, or general anesthesia.

Contrast Extravasation as a Complication of Emergency Nurse-Performed Ultrasound-Guided Peripheral Intravenous Catheter Placement

IntroductionVascular access procedures are among the most commonly performed procedures in the emergency department. The objective of the current study was to compare the contrast extravasation rate for ultrasound-guided peripheral intravenous (USGPIV) catheter placement by emergency nurses with peripheral intravenous catheters placed by standard landmark techniques. MethodsA retrospective chart review of all ED patients at our urban tertiary-care institution who underwent contrasted computed tomography examination and suffered contrast extravasation events was performed. A logbook of all ED patients who underwent USGPIV placement and an institution-wide electronic patient safety incident-reporting system was reviewed for all contrast extravasation events between May 2014, and February 2017. Data were analyzed using descriptive statistics, Student t-tests for continuous data, and χ2 or Fisher’s exact test for categorical data. ResultsOne thousand five hundred USGPIV catheters were placed by 27 emergency nurses. Contrast material was administered 29,508 times, and, of these, 291 were administered via USGPIV placement. There were 74 peripheral IV lines with documented contrast extravasations (0.25%) as reported in the safety-event database; 12 (4.1%) were from the USGPIV population, and 62 (0.21%) occurred in the standard landmark technique population. Relative risk of contrast extravasation events with USGPIV placement was 19.4 (95% confidence interval [CI], 10.6-35.6), and the absolute risk difference was 3.9% (95% CI 1.6%-6.2%). DiscussionUSGPIV placement by trained emergency nurses has higher rates of contrast extravasation than with standard landmark technique placement.

Hand motion analysis for assessment of nursing competence in ultrasound-guided peripheral intravenous catheter placement.

Objective measures such as hand motion analysis are needed to assess competency in technical skills, including ultrasound-guided procedures. Ultrasound-guided peripheral intravenous catheter placement has many potential benefits and is a viable skill for nurses to learn. The objective of this study was to demonstrate the feasibility and validity of hand motion analysis for assessment of nursing competence in ultrasound-guided peripheral intravenous placement. We conducted a prospective cohort study at a tertiary children's hospital. Participants included a convenience sample of nurses with no ultrasound-guided peripheral intravenous experience and experts in ultrasound-guided peripheral intravenous placement. Nurses completed hand motion analysis before and after participating in a simulation-based ultrasound-guided peripheral intravenous placement training program. Experts also completed hand motion analysis to provide benchmark measurements. After training, nurses performed ultrasound-guided peripheral intravenous placement in clinical practice and self-reported details of attempts. A total of 21 nurses and 6 experts participated. Prior to the hands-on training session, experts performed significantly better in all hand motion analysis metrics and procedure time. After completion of the hands-on training session, the nurses showed significant improvement in all hand motion analysis metrics and procedure time. Few nurses achieved hand motion analysis metrics within the expert benchmark after completing the hands-on training session with the exception of angiocatheter motion smoothness. In total, 12 nurses self-reported 38 ultrasound-guided peripheral intravenous placement attempts in clinical practice with a success rate of 60.5%. We demonstrated the feasibility and construct validity of hand motion analysis as an objective assessment of nurse competence in ultrasound-guided peripheral intravenous placement. Nurses demonstrated rapid skill acquisition but did not achieve expert-level proficiency.

335 Procedural Competency in Ultrasound-Guided Peripheral Intravenous Catheter Insertion in a Pediatric Emergency Department

To evaluate if there is a threshold number of encounters after which providers reliably perform ultrasound guided peripheral intravenous (USGPIV) catheter placements in children with a high success rate. A secondary aim was to analyze complication rates of USGPIV catheters placed by providers. As part of a quality improvement program, a database was maintained for all USGPIV encounters in our emergency department (ED) from June 2011 to May 2017. Our ED is located within a free-standing tertiary care children’s hospital and sees over 90,000 children annually. The name of the ED practitioner attempting placement and whether it was successful was recorded for all USGPIV encounters. Patient electronic medical records were reviewed for the reason for IV removal. ED practitioners included attending physicians, pediatric emergency medicine (EM) fellows, nurses, and pediatric and EM residents. All USGPIVs were placed by a single-operator using dynamic ultrasound guidance in an out-of plane approach. The probability of successful IV placement at each encounter was calculated using Microsoft Excel (2008). These probabilities were plotted versus encounter number to graph a best-fit logarithmic regression. Using this regression equation, the number of encounters needed to achieve a probability of success of 90% was calculated. The probability of a complication after each successful USGPIV placement was also calculated, plotted versus encounter number, and overlayed with a logarithmic regression line. We analyzed 3,047 encounters involving 88 providers. Of those, 2,860 (94%) were successful and 187 (6%) were unsuccessful. 35 providers had 10 or more encounters. The probability of successfully placing an USGPIV increased as providers had more experience placing USGPIVs (Figure 1). After 2 encounters, the probability of success was 80%. After 10 encounters, the probability of success reached 88%. At 14 encounters, the probability of success was 90%. IV removal reason was available for 1,178 encounters. 850 (72%) were removed because they were no longer needed. 260 (22%) had complications, and 68 (6%) were unintentionally dislodged. Complications included infiltration, phlebitis, line occlusion, and “other” (eg, pain or bleeding at site). Complication rates were calculated and graphed for 31 providers who had at least 5 encounters. There was no statistically significant relationship between the number of encounters per provider and complication rates (R2 =0.015). Our data suggests a threshold number of encounters after which providers reliably place USGPIVs in children with a high success rate. In our single institution study, a 90% success rate was achieved after an average of 14 encounters. Additionally, we found an overall low complication rate of 22%, and no change in complication rates as providers gained more experience.

Simulation-Based Mastery Learning Improves Medical Student Performance and Retention of Core Clinical Skills.

Simulation-based mastery learning (SBML) improves procedural skills among medical trainees. We employed an SBML method that includes an asynchronous knowledge acquisition portion and a hands-on skill acquisition portion with simulation to assess senior medical student performance and retention of the following 6 core clinical skills: (a) ultrasound-guided peripheral intravenous placement, (b) basic skin laceration repair, (c) chest compressions, (d) bag-valve mask ventilation, (e) defibrillator management, and (f) code leadership. Seven emergency medicine (EM) faculty members developed curricula, created checklists, and set minimum passing standards (MPSs) to test mastery of the 6 skills. One hundred thirty-five students on an EM clerkship were pretested on all 6 skills, viewed online videos asynchronously followed by a multiple choice computer-based skill-related quiz, received one-on-one hands-on skill training using deliberate practice with feedback, and were posttested until MPS was met. We compared pretest and posttest performance. We also retested, unannounced, a convenience sample (36%) of students from 1 to 9 months postintervention to assess skill retention. All students passed each quiz. The percentage of students who reached each MPS increased significantly (P < 0.001) from pretest to posttest for all 6 clinical skills. Ninety-eight percent of the students scored at or above the MPS when retested 1 to 9 months later. There was no significant decrease in mean score for any of the 6 skills between posttest and retention testing. Simulation-based mastery learning using a substantial asynchronous component is an effective way for senior medical students to learn and retain EM clinical skills. This method can be adapted to other skill training necessary for residency readiness.

377 Infiltration Rates are Similar in Ultrasound-Guided and Traditionally Placed Peripheral IVs in Admitted Emergency Department Patients With Difficult IV Access

377 Infiltration Rates are Similar in Ultrasound-Guided and Traditionally Placed Peripheral IVs in Admitted Emergency Department Patients With Difficult IV Access

The Vanishing Target Sign: Confirmation of Intraluminal Needle Position for Ultrasound Guided Vascular Access

Ultrasound-guided peripheral intravenous (USG-PIV) catheter placement has been described in the emergency medicine literature for more than a decade.1 Several studies have shown that USG-PIV placement can decrease the number of needle insertion attempts, decrease the number of potentially unnecessary central line placements, and increase patient satisfaction scores.1-5 Additional evidence has shown that this skill is accessible to ED staff other than physicians.6, 7 However, a randomized study of USG-PIV placement by emergency physicians with variable levels of experience did not demonstrate improved success rates, decreased time to insertion, or increased patient satisfaction.8 In our experience, consistent success with USG-PIV placement in patients with difficult access using a dynamic one-person technique is a challenging procedure. In an attempt to help teach this effectively, we have developed a method that employs a sign we call the “vanishing target” to ensure intraluminal positioning of the catheter needle tip. When ultrasound is used to guide needle placement into a vessel, two traditional approaches are employed: a short-axis, or out-of-plane, approach, and long-axis, or in-plane, approach. The long axis in-plane technique has the advantage of visualizing the needle shaft and tip, but the short-axis, out-of-plane technique has been shown to be more readily used by less experienced operators.9 A recent video on the subject stated that the long-axis, in-plane technique is more frequently used for USG-PIV by experienced operators10; however, in our experience, a long axis, in-plane approach is less useful for peripheral veins (regardless of operator experience level), as these veins tend to be small, are accompanied by arteries, and often do not travel in straight lines. With the out-of-plane, short axis approach, the needle tip is visualized within the vessel lumen as a hyperechoic structure, also known as the target sign (Figure 1). Obtaining a target sign does not guarantee that the needle tip is indeed intravascular and represents a potential pitfall of using this approach. At times, the vessel wall “tents” and deforms to the pressure of the needle tip but the tip remains extravascular (Video Clip S1, available as supporting information in the online version of this paper). Also, the “bull's eye” of the target sign may not always represent the true needle tip, as the ultrasound plane may be cutting across the needle more proximal to its tip. This can result in the needle tip penetrating deeper than anticipated, resulting in inadvertent puncture of the vein's posterior wall, also known as “back-walling” the needle. We propose an additional method to confirm intravascular positioning of the needle tip using an ultrasound guided out-of-plane, short-axis approach. Once a target sign is obtained, the operator should decrease the angle between the needle and skin and then advance both the needle and the catheter 1 mm to 2 mm farther while keeping the target sign centered and visualized within the vessel. As the probe is fanned distally, the bull's eye of the target sign should stay in the center of the vessel for a couple of ultrasound planes, but disappear as fanning continues distally from the point of needle entry. This confirms that the needle tip is truly intravascular and will allow for subsequent cannulation of the vessel. Video Clip S2 (available as supporting information in the online version of this paper) demonstrates the “vanishing target sign” technique of USG-PIV placement. While helpful for peripheral vascular access, this technique can also be used for any ultrasound-guided procedure necessitating precise knowledge of the location of a needle tip. It may help avoid misplacement of the needle during central vascular access as well, where location of the needle tip in the short axis is particularly important. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.