Original ContributionUltrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access☆
Introduction
In patients with difficult to obtain peripheral intravenous (IV) access, which may be due to obesity, history of injection drug use (IDU), or other chronic medical conditions [1], [2], [3], a central venous catheter is often placed at considerable risk to the patient. Placement of a central line is associated with a greater than 15% rate of significant complications, including arterial puncture, pneumothorax, deep vein thrombosis (DVT), and infection [4]. In recent years, the use of ultrasonography in the emergency department (ED) has provided the option of placing a peripheral IV in lieu of a central venous catheter in patients whom peripheral access is difficult or impossible to obtain. Ultrasonography-guided cannulation of the deep brachial or basilic vein can be performed rapidly and with increased patient satisfaction compared to the traditional “blind” approach in ED patients with difficult peripheral IV access [2].
Although the use of ultrasonography may improve the success rate of placing peripheral IV catheters in ED patients with difficult access, little is known about the survival of ultrasonography-guided IV catheters beyond the ED. In fact, the longevity of ultrasonography-guided peripheral IV catheters has been called into question based on an 8% catheter failure in the first hour after placement [5] and anecdotal evidence of poor IV survival rates beyond the ED [6]. In addition, complications of ultrasonography-guided IV catheters beyond the ED, including the subsequent need for central venous catheterization, have not been well studied. In this prospective study, we evaluated the survival of 6.35 cm, 18-gauge ultrasonography-guided peripheral IV catheters beyond the ED. In addition, we observed complications beyond the ED, including central line placement rates, in patients who underwent ultrasonography-guided peripheral IV placement.
Section snippets
Study protocol
We performed a prospective, observational study designed to evaluate the survival of ultrasonography-guided peripheral IV catheters placed in the ED. This study was approved by the institutional review board at our institution, and informed consent was waived. We conducted this study in an urban, academic, level I trauma center with an annual ED census of approximately 132,000 visits. We included consecutive ED patients older than 21 years who had a 6.35-cm (2 1/2 in), 18-gauge
Results
The study sample consisted of 75 patients, all of whom were included in the study analysis. Table 1 includes the patient characteristics. Most (53%) were male. The mean age was 52 years with a range of 25 to 85 years. Patients were most frequently admitted to a floor bed. Sixteen subjects were considered obese (16/75, 21%) using combined clinician or actual BMI data (clinician identified 4/75, BMI data 15/49), and 10 of 75 (13%) had a history of IDU. Eighty-eight percent of patients had an
Discussion
In recent years, the use of ultrasonography has improved the success rate of placing peripheral IV catheters in ED patients with difficult to obtain peripheral access. However, the longevity of ultrasonography-guided IVs has been called into question [5], [6], raising concerns that the procedure may simply delay, rather than prevent, central venous catheterization. In addition, complication rates of ultrasonography-guided peripheral IVs beyond the ED have not been well studied. In this study,
Limitations
Our study is subject to a number of limitations. We did not record all of the potential patient and catheter-related factors that may have affected IV survival, and our study was not powered to develop a robust model of these variables. In addition, we did not have BMI data available on every patient included in our study. However, the results of our analysis were unchanged after coding the 26 of 75 without BMI as all obese or all not obese. Specifically, the primary outcome of catheter
Conclusions
Our study demonstrates that ultrasonography-guided peripheral IVs have a high premature failure rate but that this procedure provides an effective means of establishing an IV catheter in stable ED patients with difficult access. Given the low central line placement rate observed in stable patients with ultrasonography-guided IVs, the results of our study suggest that central venous catheterization should be reserved for ED patients with difficult peripheral access in whom an
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Prior Presentations: The abstract form of this article was selected for oral presentation at the New England Regional Meeting of the SAEM in Shrewsbury, MA, on April 30, 2008 and the SAEM Annual Meeting in Washington, DC, on May 31, 2008.