Ultrasound-guided peripheral Venous Cannulation: Exploring the Literature Brian S. Fromm, M.D.

The Dark Ages Your options in 1990… Blind stick Central venous access Intraosseous (IO) access Venous cutdown

1991: ultrasound for Central access Denys et al. N Engl J Med, letter to the editor Described new US-guided technique for placing IJ lines Prospective study of 300 patients (200 US, 100 landmark): 100% success by US vs 90% success by landmark shorter access time Greater first-pass success rate, fewer attempts Lower complication rate published a larger trial with similar results in Circulation in 1993

1992: echo Ortega. J Cardiothorac Vasc Anesth, letter to the editor Describes method for confirming placement of PIV if traditional methods fail Infuse 10 mL of agitated saline, observe bubbles on echo

1995: Doppler Whitely et al. Ann R Coll Surg Engl Used handheld doppler and squeezing patient’s hand to correctly identify the largest forearm vein in 23/24 extremities All 12 patients had invisible and nonpalpable forearm veins Confirmed by color-flow duplex Did not actually attempt to cannulate veins

1999: us-guided piv first described Keyes et al. Ann Emerg Med Enrolled 101 patients (50% IVDU, 20% obese) with 2+ unsuccessful attempts Successful US-guided cannulation (1-2 attempts) in 91%, 73% on first attempt Brachial artery puncture in 2%, severe pain in 1%, lost access within 1 hr in 8% Case series: No control group

2005: US-guided vs. traditional approach Costantino et al. Ann Emerg Med First RCT of US-guided PIV 60 patients with 3+ unsuccessful attempts by RN  up to 3 more attempts by MD, +/- US (2-person technique) US 97% success, control 33% success US fewer attempts, less time, higher patient satisfaction Of 14 failures in control group, 11 patients opted to try US-guided. All were successful (Mean 1.8 attempts). Other 3 got central lines

2010: infection rate Adhikari et al. J Ultrasound Med Retrospective review (402 patients per group) 2 infections in US group, 3 in traditional group: No statistically significant difference in infection rate US-guided placement used Surgilube as gel and nonsterile glove as probe cover

Refining our technique 2008: No significant differences in time, success, or ease between one-operator and two-operator technique (in healthy volunteers) 2010: significantly greater success rate with vein diameter ≥ 0.4 cm and vein depth 0.3-1.5 cm 2012: Higher failure rate in 5 cm catheters (45%) vs. 12 cm catheters (14%) – but long catheter placement was much more involved and took longer 2014: tourniquet is superior to inflated BP cuff for target vein dilation 2016: Meta-analysis showed no significant difference between short and long axis imaging in first-pass success, time to success, # attempts, or hematoma rate

Not just for the docs 2011: 19 ED techs were taught to place US-guided IVs with 78.% success, with strong correlation between success rate and experience Multiple studies showing ED nurses can do this too (Several Jeff ED nurses place US-guided IVs) 2013: Significant reduction in need for physician intervention on difficult-access patients when nurse can perform US-guided IV placement

Out of the dark ages 2013, Shokoohi et al. Ann Emerg Med Large single-ED time-series analysis of monthly rate of central line placement between 2006-2011 (the time during which the EM residents and ED techs were trained in US-guided IV placement) Central line placement decreased by 80% Proportion of total ED central lines being done on noncritically ill patients dropped from 66% to 19%

Final thoughts: Practice makes perfect 2016, Stolz et al. J Vasc Access Prospective observational study of 33 ED nurses and techs with competence in traditional PIV placement after receiving training in US-guided IV placement After placement of four US-guided IVs, new learners are capable of >70% success rate. Success of >88% is achieved after 15-26 attempts.

References Adhikari S, Blaivas M, Morrison D, Lander L. Comparison of infection rates among ultrasound-guided versus traditionally placed peripheral intravenous lines. J Ultrasound Med 2010;29:741-7. Costantino TG, Parikh AK, Satz WA, Fojtik JP. Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med 2005;46:456-61. Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation 1993;87:1557-62. Denys BG, Uretsky BF, Reddy PS, Ruffner RJ, Sandhu JS, Breishlatt WM. An ultrasound method for safe and rapid central venous access. N Engl J Med 1991;324:566. Elia F, Ferrari G, Molino P, et al. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. Am J Emerg Med 2012;30:712-6. Gao YB, Yan JH, Ma JM, et al. Effects of long axis in-plane vs short axis out-of-plane techniques during ultrasound-guided vascular access. Am J Emerg Med 2016;34:778- 83. Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med 1999;34:711-4. Nelson D, Jeanmonod R, Jeanmonod D. Randomized trial of tourniquet vs blood pressure cuff for target vein dilation in ultrasound-guided peripheral intravenous access. Am J Emerg Med 2014;32:761-4. Ortega R. Peripheral intravenous catheterization: confirmation with echocardiography. J Cardiothorac Vasc Anesth 1992;6:383-4. Rose JS, Norbutas CM. A randomized controlled trial comparing one-operator versus two-operator technique in ultrasound-guided basilic vein cannulation. J Emerg Med 2008;35:431-5. Schoenfeld E, Boniface K, Shokoohi H. ED technicians can successfully place ultrasound-guided intravenous catheters in patients with poor vascular access. Am J Emerg Med 2011;29:496-501. Shokoohi H, Boniface K, McCarthy M, et al. Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients. Ann Emerg Med 2013;61:198-203. Stolz LA, Cappa AR, Minckler MR, et al. Prospective evaluation of the learning curve for ultrasound-guided peripheral intravenous catheter placement. J Vasc Access 2016;17:366-70. Weiner SG, Sarff AR, Esener DE, et al. Single-operator ultrasound-guided intravenous line placement by emergency nurses reduces the need for physician intervention in patients with difficult-to-establish intravenous access. J Emerg Med 2013;44:653-60. Whiteley MS, Chang BY, Marsh HP, Williams AR, Manton HC, Horrocks M. Use of hand-held Doppler to identify 'difficult' forearm veins for cannulation. Ann R Coll Surg Engl 1995;77:224-6. Witting MD, Moayedi S, Yang Z, Mack CB. Advanced intravenous access: technique choices, pain scores, and failure rates in a local registry. Am J Emerg Med 2016;34:553-7. Witting MD, Schenkel SM, Lawner BJ, Euerle BD. Effects of vein width and depth on ultrasound-guided peripheral intravenous success rates. J Emerg Med 2010;39:70-5.

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