Ultrasound-guided Peripheral Intravenous Research Articles

Decreasing Peripherally Inserted Central Catheter Use With Ultrasound-Guided Peripheral Intravenous Lines: A Quality Improvement Project in the Acute Care Setting.

An ultrasound-guided peripheral intravenous (UGPIV) quality improvement project occurred in an 849-bed tertiary care hospital with a goal to reduce the use of central lines, in particular, peripherally inserted central catheters (PICCs). Since implementation, PICCs have decreased by 46.7% overall, and 59 nurses in-hospital are competent in placing UGPIVs. Placement of UGPIVs by the bedside nurse is a key initiative in decreasing PICC use and, potentially, infections.

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.

Ultrasound-Guided Peripheral IV Access in the Hands of Nurses' Aides

Multiple small studies since 2005 have shown that ultrasound guidance improves success of peripheral intravenous (IV) line placement when access is

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.

Pose de voie veineuse périphérique sous échographie chez les patients ayant un accès veineux difficile : intérêt et facteurs prédictifs d’échec

Ultrasound-guided peripheral intravenous (USGPIV) technology is being utilized more frequently in emergency department settings. Traditionally, physicians have performed this procedure to gain vascular access in patients for whom standard intravenous line procedures are unsuccessful. Nurses at Wexner Medical Center at The Ohio State University have shown that a nurse-driven ultrasound program can be successfully implemented in an emergency department.Standardized training for registered nurses includes a 4-hour didactic and hands-on course and 24 hours of 1-on-1 individualized instruction with a nurse champion. Emphasis is placed on avoiding the larger upper arm veins.A peripheral intravenous line database has been maintained since the beginning of the program in 2009. This database shows a significant percentage of admitted patients received USGPIV service. In 2010, USGPIVs were successfully placed 90% to 98% of the time.Utilizing UGSPIV can expedite treatment and disposition in an emergency department. Ultimately, throughput and wait time for an emergency department bed can thus be similarly affected, positively affecting customer service.

Decrease in central venous catheter placement due to use of ultrasound guidance for peripheral intravenous catheters

Study ObjectivesObtaining intravenous (IV) access in the emergency department (ED) can be especially challenging, and physicians often resort to placement of central venous catheters (CVCs). Use of ultrasound-guided peripheral IV catheters (USGPIVs) can prevent many “unnecessary” CVCs, but the true impact of USGPIVs has never been quantified. This study set out to determine the reduction in CVCs by USGPIV placement. MethodsThis was a prospective, observational study conducted in 2 urban EDs. Patients who were to undergo placement of a CVC due to inability to establish IV access by other methods were enrolled. Ultrasound-trained physicians then attempted USGPIV placement. Patients were followed up for up to 7 days to assess for CVC placement and related complications. ResultsOne hundred patients were enrolled and underwent USGPIV placement. Ultrasound-guided peripheral IV catheters were initially successfully placed in all patients but failed in 12 patients (12.0%; 95 confidence interval [CI], 7.0%-19.8%) before ED disposition, resulting in 4 central lines, 7 repeated USGPIVs, and 1 patient requiring no further intervention. Through the inpatient follow-up period, another 11 patients underwent CVC placement, resulting in a total of 15 CVCs (15.0%; 95 CI, 9.3%-23.3%) placed. Of the 15 patients who did receive a CVC, 1 patient developed a catheter-related infection, resulting in a 6.7% (95 CI, 1.2%-29.8%) complication rate. ConclusionUltrasound prevented the need for CVC placement in 85% of patients with difficult IV access. This suggests that USGPIVs have the potential to reduce morbidity in this patient population.

Ultrasound-guided peripheral intravenous access in the intensive care unit

Purpose Central venous catheters continue to be a popular means of maintaining vascular access in surgical intensive care units despite well-described complications. With edema, obesity, and difficult to visualize veins potentially affecting the surgically ill, inability to obtain peripheral intravenous (PIV) access may hinder the clinician's ability to avoid the use of central lines. With ultrasound gaining increased popularity for obtaining vascular access, we evaluated its utility in ultrasonagraphically placing PIV catheters for the purposes of either avoiding central venous access or removing central venous catheters. Materials and Methods We performed a retrospective cohort review of our requests for ultrasound-guided PIV access in the intensive care unit between September 2007 and February 2008. Results Over a 6-month period, 77 requests for ultrasound-guided PIV access were made for 59 surgical, trauma, and cardiothoracic intensive care unit patients. Reasons for inability to obtain PIVs through standard means included edema (95%), obesity (42%), IV drug abuse history (8%), and emergency access (4%). Of the 148 PIV lines that were requested, 147 PIV catheters were successfully placed (99%). Of these, 105 PIV catheters were placed on the first attempt (71%). Complications of PIVs included IV infiltration (3.4%), inadvertent removal (2.7%), and phlebitis/cellulitis (0.7%). As a result of placing these PIV catheters, 40 central lines were discontinued and 34 central lines were avoided. The average number of line days at the time of central venous catheter removal was 11 ± 11 days. Conclusion(s) In intensive care unit patients who do not require central venous lines, ultrasound-guided PIV access can have a high placement success rate and can result in fewer central line days and/or less reliance on central venous catheters for access-only purposes.