ACEP Now features one article each issue related to an ACEP eCME CME activity.
Intravenous access is a simple procedure of paramount importance for many emergency department patients. Although access is usually obtained with ease using the traditional blind technique, there are instances where this may prove to be exceedingly difficult. When this is the case, providers can use ultrasound to visualize and cannulate a peripheral vein. While there may be many barriers to completing this procedure, there are several ways to optimize your chances for success. Below are some tips and tricks for the EM provider that may help to improve the likelihood of success with this potentially difficult and sometimes frustrating procedure.
Placement of peripheral intravenous catheters is a common practice that occurs many times throughout the day in the ED. This is usually done with little to no difficulty. However, with the average BMI of patients on the rise as well as the number of visits to EDs continuing to increase, gaining access may become more difficult. Commonly cited reasons for difficult peripheral IV access include obesity, edema, and IV drug abuse, which unfortunately are prevalent throughout many emergency departments. Luckily, with the evolution of emergency medicine has come an increased use of ultrasound by EPs for bedside diagnostics and procedures. The use of ultrasound for gaining peripheral intravenous access in difficult cases is no exception. Many physicians and departments have looked into using ultrasound when hoping to gain peripheral IV access, but with what success? In 2005, Constantino et al studied 60 adult patients, with 39 in the ultrasound-guided group and 21 in the traditional control group. They found a 97 percent success rate in the ultrasound group versus a 33 percent success rate in the traditional group, with a statistically significant reduction in time to completion, as well as the number of percutaneous punctures in the ultrasound group.1 In a 2009 Pediatric Emergency Care study by Doniger et al, the authors found similar results to Constantino et al, but this time in pediatric patients.2 They studied 50 pediatric patients, with 25 patients in both the ultrasound and traditional access route groups. Again, results showed a trend toward improved overall success, less time to successful cannulation, and fewer attempts in the ultrasound group compared with the traditional group. In 2010, Gregg et al studied similar parameters in surgical ICU patients. The results again showed improved overall success, 99 percent for the ultrasound group, as well as improved first-attempt success (71 percent).3 Further studies were performed in the following years as the trend toward using ultrasound guidance for gaining peripheral access increased in popularity. The majority of the studies supported the use of ultrasound, but others didn’t seem to find a statistically significant improvement in overall success.4 In 2013, Egan et al performed a meta-analysis of all ultrasound-guided peripheral intravenous access papers, which yielded 62 relevant publications but only seven quality papers to review. They found ultrasound guidance increased the likelihood of successful cannulation in difficult-access patients, just as the original studies had found (odds ratio 2.42; 95% confidence interval 1.26–4.68).5 Ultrasound use for procedures within the ED is continuing to gain popularity. EM providers need to become well-versed in the use of ultrasound guidance for placement of intravenous catheters to improve the likelihood of successfully gaining access.