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Three Part Question

Abstract:

Establishing peripheral intravenous access (PIV) is an essential skill for a physician working in an emergency department (ED). The traditional method can prove to be time consuming in acute situations. New techniques to improve ease of PIV through cannulation are welcomed due to positive influences on patient safety. A review was performed to determine if advances in ultrasound (US) guided PIV in patients with a troublesome PIV history reduced the need for central venous catheter (CVC) placement in the ED.
Five papers were found to be of relevance, of which four focused directly on US-guided PIV in the ED and one reviewed CVC placements in ED patients. No papers directly evaluated the influence of the advances in US for PIV compared to CVC rates over time.

Three part question:

In [non-critically Ill emergency department patients] does using [ultrasound to guide peripheral intravenous cannula access] reduce the need for [central venous catheters]?

Clinical Scenario

A 55-year-old female presents to the emergency department with an infective exacerbation of chronic obstructive pulmonary disease. The patient requires intravenous (IV) fluids and IV antibiotics whilst on non-invasive ventilation. The patient does not require ionotropic support. You and your fellow colleagues have failed at siting a peripheral cannula using traditional methods to administer IV medication. Does the use of US help obtain PIV and reduce the need for a CVC in this clinical scenario?

Search Strategy

We searched the Embase and Medline (1996 to September 2016) databases using the Ovid interface, together with the Cochrane Database of Systematic Reviews (2005 to September 2016). We used the following search terms:
[Emergency patient* OR emergency department patient* OR non*critically ill ti.ab] AND [Ultrasound* OR ultrasonography OR sonograph* ti.ab] AND [peripheral intravenous cannula* OR Peripheral intravenous access ti.ab] LIMIT to [human, English].

Altogether 15 papers were found in MEDLINE, EMBASE and COCHRANE.

Search Outcome

12 were irrelevant. A further 2 papers were found by reference dredging of the relevant papers.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Shokoohi et al 2013 USA	1,583 ED patients receiving a CVC between 2006-2011	Retrospective cohort study (2a)	To determine if there is a reduction in CVC placement rates in an ED	CVC rates reduced from 0.81% to 0.16% between 2006-2011, an 80% reduction. Significantly greater reduction in CVC rate in non-critically ill patient group at 4.4% reduction per month (CI 3.6-5.1), compared to critically ill patient group at 0.9% (CI 0.6-1.2) reduction per month.	Percentage of patients with unsuccessful PIV; hence requiring CVC placement was not analysed, nor was an US guided PIV rate. It is difficult to correlate the decrease in CVC rate to an increase in US-guided PIV rate. One ED was studied with a small intake of 401,532 patients over 5 years. Lack of p values for significance data.
Stein et al 2009 USA	59 ED patients who required PIV with 2 failed attempts with traditional method	Non-blinded respective randomized trial with 28 assigned to the US group and 31 to the non-US group (2b)	i. Clinical difference between US and non-US guided PIV ii. Time taken for each method iii. Patient satisfaction	i. 2 further IV attempts in each group with a difference of 0 attempts (CI 0-1, p=0.81). ii. Median of 13 minutes longer to use the US method compared to non-US (CI 5-28, p=0.20). Median 36 minutes for US and median 26 minutes for non-US technique. iii. Small increase in patient satisfaction for US guided technique on the 10 point Likert scale (CI 0-2 median increase, p=0.10).	Small sample size of 59 out of 40,000 patients visiting the ED every year with no power sample size calculation Subjective data for patient satisfaction. Physician training was not assessed through length of experience, type or length or training.
Mahler et al 2010 USA	25 ED patients with  3 failed PIV attempts with traditional method.	Prospective audit (2c)	i. Success rate ii. Time required iii. Number of needles used iiii. Patient satisfaction	i. US procedure effective in 96%. Reason for failed attempts and outcome of patient not stated. ii. Median total procedure time 7 minutes. iii. Mean 1.32 needle sticks (CI 1.1-1.5) iv. Mean score 9.38 on a 10-point Likert scale (CI 8.88-9.87).	Convenient sample size with self-reporting data for patient satisfaction. No comparison to an alternative technique with no US guidance comparison. Staff training levels and experience were not formally assessed or standardised.
Schoenfeld et al 2011 USA	219 ED patients with 2 failed PIV attempts with traditional method.	Prospective audit (2c)	i. Success rate ii. Complication rate iii. Site of eventual cannulation	i. 1.35 mean attempts (CI 1.26-1.43) and 78.5% PIV success rate, which was proportional to physician experience. Success rate 86.8% with >10 previous US-guided PIV attempts, 45.8% for 0-3 previous attempts(p<0.0001). ii. 4.1% complication rate. iii. 61% sited in antecubital veins.	Research was not independent with possibility of incorrect documentation of findings by clinicians. Due to mix of US experience amongst clinicians, there may have been a preference of experienced US physicians performing more procedures, influencing success rate.
Bauman et al 2009 USA	75 ED patients with ≥2 failed PIV attempts with traditional method.	Prospective trial with 34 subjects in US group and 41 in non-US group (2b)	i. Successful cannulation ii. Time taken iii. Complications iv. Number of sites of skin puncture v. Patient satisfaction	i. 80.5% success rate with US guidance compared with 70.6% without, a 9.9% increase (CI -9.3-29.1). ii. US guidance proved to be twice as fast (CI 1.3, 3.1), with a mean time of 26.8 minutes compared to 74.8 minutes. iii. US had 23% fewer complications (CI 0.6-42.7). iv. US had half the number of skin puncture sites (CI 1.6-2.7). v. Improved patient satisfaction on a 100mm visual analogue scale from a median of 91mm for US group to 33mm for non-US cohort (p=0.0001).	Bias with selection of patients as no randomisation. Physician experience and the US technique were not standardised or reported, nor was skill level. Patients were not ‘blinded’ meaning patient satisfaction data was biased.

Comment(s)

Obtaining PIV is a common procedure in the ED; it is often a time critical procedure when rapid fluid resuscitation and administration of medication is required. Difficult PIV is a regular occurrence in the ED with obesity, peripheral vascular disease and IV drug use making access even more challenging.4 Only one paper published by Shokoohi et al studied CVC placement in ED patients, speculating an association between a reduction in CVC rates over six years and the introduction of US guidance for PIV1 Four studies used US to obtain PIV in patients with which traditional techniques had failed.2–5 Two of the studies directly compared US and non-US techniques with conflicting results. Stein et al concluded that US took 13 minutes longer and required equal number of attempts as traditional methods2; in contrast to this Bauman et al believe US-guidance proved to 48 minutes faster with half the number of skin puncture sites compared with the traditional approach.2,5 However, both studies were limited to the sample size, the patient selection and the experience of the operators. A further two studies analysed US-guided PIV techniques; Mahler et al concluded that the technique took a median of 7 minutes with a 96% success rate3 and Schoenfeld et al found it to be 88.6% effective with 1.35 mean attempts4. It is important to note that no studies were found to directly study the use of US for difficult PIV and CVC rates meaning no associations can be made at the moment.

Editor Comment

RB

Clinical Bottom Line

The clinical bottom line is there is limited robust evidence proving that US guided PIV reduces the need for CVC placement in non-critically ill patients. While further research is clearly needed, the existing evidence suggests the utilisation of US is another alternative to difficult PIV in the ED.

References

1. Hamid Shokoohi, MD, MPH, RDMS, RDCS; Keith Boniface, MD, RDMS, RDCS; Melissa McCarthy, ScD; Tareq Khedir Al-tiae, MD; Mehdi Sattarian, MD, MBA; Ru Ding, MS; Yiju Teresa Liu, MD, RDMS; Ali Pourmand, MD Ultrasound-Guided Peripheral Intravenous Access Program Is Associated With a Marked Reduction in Central Venous CatheterUse in Noncritically Ill EmergencyDepartment Patients Annals of Emergency Medicine 2013; 198-203:
2. John Stein, MD Brian George, MD Gerin River, BA Anke Hebig, BA Daniel McDermott, MD Ultrasonographically Guided Peripheral Intravenous Cannulation in Emergency Department Patients With Difficult Intravenous Access: A Randomized Trial Annals of Emergency Medicine 2009; 33-40:
3. Simon A. Mahler, MD, Hao Wang, MD, PHD, Chad Lester, RN, and Steven A. Conrad, MD, PHD ULTRASOUND-GUIDED PERIPHERAL INTRAVENOUS ACCESS IN THE EMERGENCY DEPARTMENT USING A MODIFIED SELDINGER TECHNIQUE Ultrasound in Emergency Medicine 2010; 325-329:
4. Elizabeth Schoenfeld MD, Keith Boniface MD⁎, Hamid Shokoohi MD ED technicians can successfully place ultrasound-guided intravenous catheters in patients with poor vascular access American Journal of Emergency Medicine 2011; 496-501:
5. Michael Bauman MD⁎, Darren Braude MD, Cameron Crandall MD Ultrasound-guidance vs. standard technique in difficult vascular access patients by ED technicians American Journal of Emergency Medicine 2009; 135-140