Warnings and Complications
Although ultrasound-guided peripheral intravenous access is gaining popularity in emergency medicine, it is not the ideal choice for gaining access in critical patients who need emergent access. All studies conducted on this subject excluded critical patients due to the extended amount of time it takes to obtain ultrasound-guided access. If a critical patient requires emergent intravenous access, you should continue to approach these patients with the traditional peripheral IV approach first, and if you are unable to quickly establish access, then proceed quickly to central venous access or intraosseous (IO) lines.
Ultrasound-guided peripheral venous access has complication rates similar to those of the traditional approach. Several studies show a trend toward improving first-attempt success or decreased number of venipunctures which in theory should lead to less hematoma formation, infiltration, and phlebitis/cellulitis.1-3 The Journal of Critical Care article by Gregg et al reported only five complications out of 148 patients, with phlebitis/cellulitis associated with 0.7 percent, and infiltration present in only 3.4 percent of total intravenous line insertions.3 Even though the complication rate may closely resemble that of the traditional approach, the number of central venous access catheters being placed in the difficult-access patients will decrease, lessening major complications that occur with this procedure. Gregg et al reported that 34 central lines were avoided and 40 were removed as a result of ultrasound-guided peripheral intravenous access being obtained.3 The downstream effect of avoiding long-term placement of central venous access or even avoiding an attempt at the placement of a central line may lead to fewer overall complications.
1 Be Prepared
This may sound simple, but like many other procedures in emergency medicine, preparation is vital to success. Providers should have all the necessary supplies at bedside, with extra or adjunct supplies within arm’s length in case of a more difficult intravenous insertion, as shown in Figure 1. The choice of catheter gauge is up to the discretion of the provider, but prior studies have shown greater success with 18- and 20-gauge catheters. Catheter size should be individualized to the patient. Factors that may influence catheter gauge include vein depth, diameter, and the indication for placing the catheter (CTA, fluid resuscitation, antibiotics, etc.). Gregg et al found greater success rates for ultrasound-guided peripheral intravenous access using guidewire catheters to allow for easier advancement of the catheter once the vein was successfully cannulated.3 Guidewire catheters are readily available in most emergency departments and may improve your chance of successfully gaining peripheral intravenous access.