Original Research
Ultrasonography-Guided Peripheral Intravenous Access Versus Traditional Approaches in Patients With Difficult Intravenous Access

https://doi.org/10.1016/j.annemergmed.2004.12.026Get rights and content

Study objective

We assess the success rate of emergency physicians in placing peripheral intravenous catheters in difficult-access patients who were unsuccessfully cannulated by emergency nurses. A technique using real-time ultrasonographic guidance by 2 physicians was compared with traditional approaches using palpation and landmark guidance.

Methods

This was a prospective, systematically allocated study of all patients requiring intravenous access who presented to 2 university hospitals between October 2003 and March 2004. Inclusion criterion was the inability of any available nurse to obtain intravenous access after at least 3 attempts on a subgroup of patients who had a history of difficult intravenous access because of obesity, history of intravenous drug abuse, or chronic medical problems. Exclusion criterion was the need for central venous access. Patients presenting on odd days were allocated to the ultrasonographic-guided group, and those presenting on even days were allocated to the traditional-approach group. Endpoints were successful cannulation, number of sticks, time, and patient satisfaction.

Results

Sixty patients were enrolled, 39 on odd days and 21 on even days. Success rate was greater for the ultrasonographic group (97%) versus control (33%), difference in proportions of 64% (95% confidence interval [CI] 39% to 71%). The ultrasonographic group required less overall time (13 minutes versus 30 minutes, for a difference of 17 [95% CI 0.8 to 25.6]), less time to successful cannulation from first percutaneous puncture (4 minutes versus 15 minutes, for a difference of 11 [95% CI 8.2 to 19.4]), and fewer percutaneous punctures (1.7 versus 3.7, for a difference of 2.0 [95% CI 1.27 to 2.82]) and had greater patient satisfaction (8.7 versus 5.7, for a difference of 3.0 [95% CI 1.82 to 4.29]) than the traditional landmark approach.

Conclusion

Ultrasonographic-guided peripheral intravenous access is more successful than traditional “blind” techniques, requires less time, decreases the number of percutaneous punctures, and improves patient satisfaction in the subgroup of patients who have difficult intravenous access.

Introduction

Peripheral intravenous access is commonly performed in the emergency department (ED) to collect blood specimens and to provide a route for intravenous medication and fluid administration. Although this procedure is usually performed by nurses, in cases of difficult access emergency physicians are often called on to perform this task. The landmark technique for peripheral intravenous access has a success rate of 90% for ED patients.1 However, that still leaves many patients who require intravenous access but are difficult to cannulate, often because of obesity, a chronic medical condition, or a history of intravenous drug abuse. Patients who fail peripheral intravenous access will often have an external jugular intravenous line placed or undergo central venous access.

Emergency ultrasonography may provide an opportunity to increase the success rate of peripheral intravenous access. Ultrasonographic guidance for central venous access has been well studied throughout the past 2 decades, with several studies showing an increased success rate or decreased complications compared to the traditional landmark approach.2, 3, 4, 5, 6 However, we know of only 1 observational study that has examined ultrasonographic guidance of peripheral intravenous access.7

Ultrasonographic guidance may improve the rate of successful peripheral intravenous access in patients who have been historically difficult to access, leading to less time spent obtaining intravenous access and greater patient satisfaction. Ultrasonographic guidance may also decrease the number of central venous access attempts and lead to fewer overall complications.

We present a study comparing ultrasonographic-guided peripheral intravenous access versus intravenous access without ultrasonographic guidance in a subset of patients with difficult-to-obtain intravenous access, experienced emergency nurses having failed at least 3 intravenous access attempts. The primary endpoint was successful cannulation. Secondary endpoints included number of percutaneous sticks required, time of procedure, overall patient satisfaction, and complications.

Section snippets

Study Design

This was a prospective, nonblinded, systematically allocated study comparing ultrasonography-guided peripheral intravenous access with a traditional approach. Patients were systematically allocated to the ultrasonography-guided or the landmark and palpation (control) group based on their presentation to the ED on an odd (ultrasonography) or even (control) day. This study was approved by the institutional review board of the respective institutions, and patients gave informed consent before

Main Results

Results are summarized in the Table. Sixty patients were enrolled: 39 on odd days and 21 on even days. Success rate was greater for the ultrasonographic group (97%) versus the control group (33%), with a difference in proportions of 64% (95% confidence interval [CI] 39% to 71%). The median total time required from first percutaneous puncture until successful cannulation was also significantly less in the ultrasonographic group (4±5.6 minutes versus 15±11.8 minutes, for a difference of 11

Limitations

Despite our attempts at systematic allocation, there were almost twice as many patients enrolled in the ultrasonographic group as there were in the control group. The 3 extra odd days in the study period do not explain all of the difference. We strongly suspect selection bias occurred. We had no mechanism for checking whether eligible patients were always enrolled in the study, which may have biased the results toward a greater difference between ultrasonographic guidance and traditional

Discussion

Intravenous access is commonly required for patients presenting to the ED. All emergency physicians need to be familiar with techniques for obtaining intravenous access. Many emergency physicians are familiar with a subgroup of patients in which intravenous access can be very difficult, usually because of obesity, history of intravenous drug abuse, or some chronic medical condition that can distort the normal vascular anatomy, such as patients who have end-stage renal disease and are receiving

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Supervising editor: David T. Overton, MD, MBA

Author contributions: TGC, AKP, and JPF conceived the study, designed the trial, and obtained institutional review board approval. TGC and AKP supervised the conduct of the trial and data collection. WAS provided statistical advice on study design and analyzed the data. TGC drafted the manuscript, and all authors contributed substantially to its revision. TGC takes responsibility for the paper as a whole.

Funding and support: The authors report this study did not receive any outside funding or support.

Presented at the Society of Academic Emergency Medicine annual meeting, May 2004, Orlando, FL.

Reprints not available from the authors.

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