Article Summary
1. Why is this topic important? Obtaining intravenous (i.v.) access is
Establishing intravenous (i.v.) access is one of the more common tasks asked of Emergency Nurses (ENs), and the importance of this task—both for acquiring serum samples and for administering fluids and medications—is central to the care of patients with many emergent conditions. As a result, ENs are among the most experienced clinicians in the placement of peripheral i.v. lines.
Despite the frequency of i.v. line placement, sometimes this fundamental intervention is difficult to achieve. Past research has demonstrated that patients with obesity, sickle cell anemia, or a history of i.v. drug use, as well as those undergoing treatment with renal dialysis and general sufferers of chronic illness, are more likely to have difficult i.v. placement (1). One utilized model is that nurses will make several venopuncture attempts, and if unable to achieve access will then ask the physician to intervene, perhaps to place a central venous catheter (CVC). Unfortunately, CVC placement exposes patients to multiple possible complications, including greater risk of infection, large artery cannulation, and pneumothorax, as compared to peripheral lines 2, 3, 4. Placing a CVC is time-consuming and occupies the attention of an Emergency Physician who often has multiple patients to care for simultaneously.
Use of ultrasound guidance for the placement of CVCs is now widely recommended because it improves success and reduces complications 3, 5, 6. More recently, physicians have been using ultrasound to cannulate peripheral veins with greater frequency. The technique, first described by Keyes et al., was associated with a 91% success rate in patients who had two previously unsuccessful blind attempts in their study (7). Costantino et al. demonstrated that ultrasound-guided i.v. (USIV) placement by physicians, when compared with blind technique, was more successful, required less time, decreased the number of percutaneous punctures, and improved satisfaction in patients who had difficult-to-establish i.v. access (8). Regardless, even peripheral i.v. placement by the physician is time-consuming and may take the physician away from other activities in the Emergency Department (ED). However, if an EN, who routinely places i.v.s, can utilize the ultrasound when faced with difficult cannulation, it could save the physician from having to intervene. Previous works have described successful training and implementation programs for EN placement of USIV, as well as its associated positive effects on decreasing patient throughput times and reducing costs and complications, while increasing patient satisfaction and nurse autonomy 9, 10, 11, 12, 13.
This study aims to determine if placement of USIVs by ENs who undergo a brief training session can be performed with less physician intervention than standard i.v. line placement. As secondary endpoints, we also evaluated differences in the time it takes to achieve i.v. access, the number of skin punctures, and patient satisfaction and pain perception associated with USIV vs. standard of care.
This was a two-site, prospective, non-blinded, pilot study comparing placement of i.v.s in patients whose veins are difficult to cannulate using either USIV placement by trained single nurse operators or each hospital’s standard of care for such patients. The study took place in the EDs of two teaching hospitals. Hospital A is in the center of a large city and its ED sees an annual volume of approximately 42,000 patient visits. Enrollment took place at this hospital between June 2010 and
Hospital A enrolled 29 patients, of whom 16 (55.2%) were assigned to USIV and 13 (44.8%) were assigned to SOC. Hospital B enrolled 24 patients, of which 14 (58.3%) were assigned to USIV and 10 (41.7%) were assigned to SOC. At hospital B, 3 patients (1 from the USIV group and 2 from the SOC group) were withdrawn from the study before study completion. The patient assigned to the USIV group was excluded due to an issue with the consent form, and the SOC group patients refused further attempts at
A recent comprehensive review declared that point-of-care ultrasound is “a safe and effective form of imaging that has been used by physicians for more than half a century to aid in diagnosis and guide procedures” (17). The same article delineates multiple uses for point-of-care ultrasonography that are now used on a daily basis in the ED, including the Focused Assessment of Sonography in Trauma examination looking for free fluid in the abdomen, the diagnosis of intrauterine pregnancy, and
The results of this pilot study suggest that ENs performing ultrasound-guided i.v. placement in patients with difficult i.v. access greatly reduces the requirement of physician intervention. Secondary outcome measures including mean time to i.v. placement, number of skin punctures, patient satisfaction, and patient perception of pain on a 10-point scale, were not significantly different between EN-performed USIV and the existing standard of care in our EDs. 1. Why is this topic important? Obtaining intravenous (i.v.) access is Article Summary
Owing to differences in reporting methods across studies, the results are reported as a standardized mean difference, but demonstrated no statistical difference between favoring SOC and ultrasound guidance. Four studies9,22,24,27 reported data on procedural length in minutes, favoring SOC, but cumulatively showed no statistical difference (Figure 3B). Only 2 studies9,25 included within our meta-analysis reported patient satisfaction data (Figure 3C).