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Three Part Question

In [patients presenting to the emergency department with difficult intravenous access] does the use of [ultrasonography-guided peripheral intravenous access] improve [number of successful venous cannulations, time required to obtain access, number of percutaneous punctures]

Clinical Scenario

A 33 year old female with morbid obesity presents to the emergency department with a 2 hour history of severe sharp pleuritic chest pain. She smokes and is on birth control pills. Her vital signs suggest mild hypoxia and tachycardia. With pulmonary emboli at or near the top of your differential, the patient requires a peripheral IV for contrast material during a CT scan of the thorax. The nurse, and colleagues have made multiple attempts at IV access and return to tell you an IV could not be obtained. You contemplate the efficacy of ultrasound to obtain peripheral intravenous access under these circumstances.

Search Strategy

Medline 1966-05/06 using the OVID interface, Cochrane Library (2006), PubMed clinical queries.
[(exp Ultrasonography/ OR ultrasonography.mp) AND (exp catheterization, Peripheral/mt). LIMIT to human AND English.

Search Outcome

54 papers found of which 52 were irrelevant or of insufficient quality.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Keyes et al 1999 USA	101 ED patients requiring peripheral IV cannulation after 2 unsuccessful attempts. Using 7.5-MHz probe, brachial vein or basilic vein.	Prospective, observational	1) Successful cannulations	Cannulation successful 91 %	Not a randomized trial. Small sample size. Variable staff training and skill level.
			2) Number of percutaneous attempts	1st attempt success 73 %
			3) Complications	Line infiltrated or fell out 8%, 2 cases of brachial artery puncture, severe pain 1%
			4) Time from probe placement to cannulation	Mean time for cannulation was 77 seconds
Costantino et al 2005 USA	60 patients included from 2 university hospitals. Included if nurse unable to obtain IV access after 3 attempts. Excluded if need for central line. Odd group (39) allocated to ultrasonography, Even group (21) allocated to traditional land mark techniques.	Prospective systematic allocation 2b evidence Critical appraisal completed	1) Successful cannulation	97% in Ultrasound group, 33% in control(traditional techniques)	Small study, learning curve for ultrasonography, equipment barriers for many facilities.
			2) Number of percutaneous punctures	1.7 (ultrasound), 3.7 (control)
			3) Total time required	13 minutes (ultrasound), 30 minutes (control)
			4) Patient satisfaction	8.7 (ultrasound), 5.7 (control)

Comment(s)

There has been increasing evidence to support routine use of ultrasound for aiding in central venous access when the clinical environment allows it. However, there is limited evidence on the use of ultrasonography to aid in establishing peripheral intravenous access in patients with difficult intravenous access. The information reviewed most certainly does raise substantial interest in adding ultrasound to the clinical repertoire for IV access. However, the use of ultrasound as a routine instrument to aid in peripheral venous cannulation will be dependent on the ubiquity of the necessary equipment and the aquired skills of the clinician. At the very least, persuing larger well performed studies is indicated. Since this review, I have personally adopted the use of ultrasonography in difficult peripheral cannulations (such as the patient described in the clinical scenario) with encouraging results.

Clinical Bottom Line

The limited evidence available would suggest the use of ultrasonography for difficult intravenous cannulations can improve numbers of successful cannulations, decrease the time required to achieve access, decrease the number of total percutaneous punctures, and improve patient satisfaction.

References

1. 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 Annals of Emerg Med Dec 1999; 711-714
2. Costantino TG, Parikh AK, Satz WA, Fojtik JP Ultrasonography-Guided Peripheral Intravenous Access Versus Traditional Approaches in Patients With Difficult Intravenous Access. Annals of Emerg Med Nov 2005; 456-461