Article, Emergency Medicine

Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access

Original Contribution

Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access?

James M. Dargin MD?, Casey M. Rebholz MPH, Robert A. Lowenstein MD, Patricia M. Mitchell RN, James A. Feldman MD

Department of Emergency Medicine, Boston Medical Center, Boston, MA 02118, USA

Received 25 June 2008; revised 31 August 2008; accepted 1 September 2008

Abstract

Objectives: We determined the survival and complications of ultrasonography-guided peripheral intravenous catheters in emergency department (ED) patients with difficult peripheral access.

Methods: This was a prospective, observational study conducted in an academic hospital from April to July of 2007. We included consecutive adult ED patients with difficult access who had ultrasonography- guided peripheral IVs placed. Operators completed data sheets and researchers examined admitted patients daily to assess outcomes. The primary outcome was IV survival N96 hours. As a secondary outcome, we recorded IV complications, including central line placement. We used descriptive statistics, univariate survival analysis with Kaplan Meier, and log-rank tests for data analysis.

Results: Seventy-five patients were enrolled. The average age was 52 years. Fifty-three percent were male, 21% obese, and 13% had a history of Injection drug use. The overall IV survival rate was 56% (95% confidence interval, 44%-67%) with a median survival of 26 hours (interquartile range [IQR], 8-61). Forty-seven percent of IVs failed within 24 hours, most commonly due to infiltration. Although 47 (63%) operators reported that a central line would have been required if peripheral access was unobtainable, only 5 (7%; 95% confidence interval, 2%-15%) patients underwent central venous catheterization. Only 1 central line was placed as a result of ultrasonography-guided IV failure. We observed no infectious or thrombotic complications.

Conclusion: Despite a high premature failure rate, ultrasonography-guided peripheral IVs appear to be an effective alternative to central line placement in ED patients with difficult access.

(C) 2010

Introduction

? 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.

* Corresponding author.

E-mail address: [email protected] (J.M. Dargin).

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 [1-3], 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

0735-6757/$ – see front matter (C) 2010 doi:10.1016/j.ajem.2008.09.001

(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 cathe- ters 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 cathe- ters 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.

Methods

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 ultrasonography-guided peripheral venous catheter inserted into the deep brachial or basilic vein from April to July of 2007. Ultrasonography-guided peripheral IVs were placed at the discretion of the treating physician in patients with difficult to obtain peripheral IV access. The practice at our institution for patients with difficult IV access involves multiple blind attempts by more than 1 ED nurse, followed by attempts at peripheral access by the treating physician, including use of the external jugular veins. To accurately examine survival rates, we included in our study all patients with ultrasonography- guided peripheral IVs placed in the ED, including patients who were ultimately discharged home from the ED, admitted patients who were “boarding” in the ED for prolonged periods of time, and patients who were physically admitted to an inpatient treatment area.

All catheters were placed by emergency medicine (EM) residents (“novices”) or EM attending physicians (“experts”). All first-year EM residents at our institution received training in ultrasonography-guided vascular access applications, including a 1-hour lecture and a 1-hour training session involving simulated ultrasonography-guided periph- eral IV placement. All attending physicians who placed ultrasonography-guided IVs in this study were credentialed in emergency ultrasound applications, including IV access, according to our institution’s protocol. Each of the attending physicians also had more than 5 years experience in placing ultrasonography-guided peripheral IVs and was responsible for teaching this application to EM residents.

Ultrasonography-guided peripheral IV catheters were placed in real time using a linear array probe (SonoSite, Inc, Bothell, Wash; Bard, Inc, Murray Hill, NJ; Philips Medical Systems, Inc, Andover, Mass; Hitachi Medical Systems America, Inc, Twinsburg, Ohio). The skin was cleansed using a chlorhexidine antiseptic swab; the ultra- sound probe was covered in a sterile, 4 x 6-in Tegaderm dressing (3M, Inc, St. Paul, Minn); and sterile lubricating jelly was applied to the probe. A tourniquet was then placed around the upper arm, and the operator held the ultrasound probe over the forearm at the level of the elbow. Veins were identified by their collapsibility with gentle pressure and use of Doppler if necessary for confirmation. A 6.35-cm (2-1/2 inch), 18-gauge angiocatheter (Arrow International, Inc, Reading Pa) was inserted into the vein, and successful venous cannulation was confirmed by aspiration of dark, nonpulsatile blood. A Leur lock was subsequently secured to the catheter hub and a sterile Veni-Gard IV catheter dressing (CONMED Corporation, Utica, NY) or a 4 x 6-in Tegaderm dressing was used to secure the line at the discretion of the physician performing the procedure.

After successful ultrasonography-guided peripheral IV placement, the medical record number, date and time of the procedure, patient comorbidities, and immediate complica- tions, including arterial puncture (bright red, pulsatile blood return), nerve contact (sharp pain radiating up or down the arm or paresthesias), and hematoma formation or bruising, were recorded on a standard data collection sheet by the physician performing the procedure. The physicians per- forming the procedure were also asked to document their initials on the data collection sheet to determine the operator’s level of training, the number of attempts (individual skin punctures) required for successful placement of the IV using ultrasound guidance, and whether the operator intended to place a central venous catheter had the ultrasonography-guided attempt not been successful. Trained ED research assistants recorded each patient’s age, sex, admitting diagnosis, disposition from the ED, and markers of difficult IV access, including IDU and body mass index (BMI). We reviewed the hospital electronic medical record for the number of hospital admissions and ED discharges in the 12 months before ultrasonography-guided IV placement for each patient, as frequent hospitalizations and chronic

illness [2,3] are also markers of difficult IV access. We used the results of the data sheet completed by the clinician prospectively, the results of daily prospective catheter observation in admitted patients, and retrospective medical record review to determine demographic characteristics, and final end points.

Consistent with the Centers for Disease Control and Prevention guidelines [7], peripheral IVs are routinely changed 96 hours after initial placement at our institution. To determine IV survival time and complication rates, various modes of data collection were used on a daily basis during a 4- day period or until the catheter was no longer indwelling. A structured data collection form with explicit definitions for complications was used for recording information. Trained research assistants or the study investigators examined each patient’s catheter site once daily to determine survival and complications. If the catheter was not present at the time of examination or the patient was discharged from either the hospital or the ED before direct inspection could be performed, the medical record was reviewed and the treating nurses and physicians were interviewed to determine failure or complications. Data collected on a daily basis included time and date of IV removal and reasons for catheter removal, such as completion of IV therapy, the IV failed (due to catheter occlusion or infiltration of infusate into the subcutaneous tissue), a complication developed, or the catheter was changed per hospital routine 96 hours after it had been inserted. We also recorded complications directly related to the IV, including infection (localized cellulitis, abscess formation, or suppurative phlebitis requiring anti- biotics), phlebitis (pain, tenderness, Erythema and edema, with or without a palpable venous cord), ultrasonographic evidence of DVT proximal to the IV insertion site, and bruising or hematoma formation that was not initially recorded as an immediate complication. In addition, when a patient underwent central venous catheterization, we recorded the date, time, and indication for this procedure.

The primary outcome measured was IV survival, which we defined as a patent catheter; catheter removal before 96 hours because IV treatment was completed or the patient was discharged from the ED or inpatient service; any catheter changed at 96 hours per hospital routine or if the patient removed the catheter. We included the latter event in the survival group, as we attributed self-discontinuation of the IV to patient-related factors rather than to failure of the catheter itself. Catheter failure was defined as removal of the IV due to occlusion of the catheter, subcutaneous infiltration of infusate with associated pain and edema, infection, DVT, or inadvertent dislodgement of the catheter. Secondary outcomes measured included immediate complications (hematoma formation or bruising, nerve contact, number of skin punctures, and arterial puncture) and delayed complications (catheter occlusion, inadvertent catheter dislodgement, delayed hematoma formation or bruising, phlebitis, infiltration, infection, DVT, and the need for central line placement).

Data analysis

We used SAS version 9.1 (SAS Institute, Cary, NC) statistical software to perform all analyses. No previous study has examined the survival of ultrasonography-guided IVs beyond the ED. We used historical data from published survival and complication rates of standard peripheral IVs and our clinical experience with ultrasonography-guided IVs to estimate an a priori sample size. Based on our estimate of ultrasonography-guided IV patency of 50% at day 4, compared to routine peripheral IV patency of 30% [8-10], with a normal approximation, 95% confidence, and power of 80%, the estimated sample size was 44. The estimated sample size for an expected proportion of 15% for overall rate of complications, compared to the estimated rate of complications for routine peripheral IVs of 5% [11,12], with a normal approximation, 95% confidence, and power of 80% was 53. We also estimated the sample size required to determine the success of ultrasonography-guided IVs using confidence intervals (CIs) and an acceptable precision around the estimate. The minimum sample size assuming an ? of .10 (confidence coefficient level of 0.90), precision of 0.10, and an estimated failure rate of 50% is 62. We examined survival with every 10 cases enrolled to ensure that the sample size estimate was accurate.

We examined the frequency of outcomes (catheter survival, complications, and central line placement rates) using descriptive statistics. In that our primary outcome of interest was a time to an event, we used a survival model with univariate analysis using Kaplan-Meier methods to describe catheter survival over time. Based on previous research involving standard peripheral IVs [9], we explored several factors thought to be related to premature IV failure. We performed bivariate analysis1 using the log-rank test for categorical variables (gender, IDU, obesity, and expert vs novice operator) and Cox proportional hazards for continuous variables (age, BMI, number of attempts, operator training level, number of hospital admissions, and ED discharges in the past 12 months) associated with early failure. Predictors significant at the P = .20 level in bivariate analysis, as well as factors of interest were included in the multivariable model. A P value cutoff of .05 was used to assess statistical significance.

Results

The study sample consisted of 75 patients, all of whom were included in the study analysis. Table 1 includes the

1 Although we examined IV survival in a single cohort, we can still perform bivariate analyses stratified by predictors of catheter failure and perform multivariate analyses. This point bears mentioning because survival methods of analyses are not commonly used in the emergency medicine literature, and one may mistakenly assume that these analyses can only be used for 2 comparative groups. For example, one could examine a single cohort of patients with cancer using longitudinal survival with bivariate analysis using the log-rank test stratified by predictors of interest, such as age or type of cancer.

guided attempt at peripheral access failed. A total of 5 (7%; 95% CI, 2%-15%) patients ultimately required central venous catheterization during their hospital course. Of the patients who required a central line, only one underwent this procedure as a direct result of ultrasonography-guided peripheral IV failure (Table 2). The other 4 patients required a central line while critically ill but had functioning ultrasonography-guided IVs at the time of central line placement. Of the 11 patients who were Discharge home, none required central venous access despite operators reporting that 46% of these patients would have require central venous catheterization had ultrasonography-guided attempts at peripheral access failed.

1

2

>=3

Training level of operator Expert

Novice

48 (64)

18 (24)

9 (12)

55 (73)

20 (27)

Patients who would have required a central line, n (%) 47 (63)

MICU indicates medical intensive care unit; CCU, cardiac care unit.

Table 1 Demographics of patients who had ultrasonography- guided peripheral IVs placed in the ED (N = 75)

Age, y (mean +- SD) 52 +- 14

Sex, n (%)

Male 40 (53)

Female 35 (47)

Disposition from ED, n (%)

Admitted to floor

40 (53)

Admitted to telemetry

19 (25)

Discharged from ED

11 (15)

Admitted to MICU/CCU

body habitus, n (%)

5 (7)

Obese

16 (21)

Nonobese

59 (79)

History of IDU, n (%)

10 (13)

ED discharges in last 12 mo (mean +- SD)

4 +- 11

Hospital admissions in last 12 mo (mean +- SD)

No. of ultrasonography-guided IV placement attempts,

3 +- 4

n (%)

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 ultrasonography- guided peripheral IV placed after 1 or 2 attempts. Most IV catheters (73%) were placed by “expert” operators.

Catheter survival data are summarized in Fig. 1 and Table 2. The overall survival rate was 56% (95% CI, 44%-67%), and the median catheter survival time was 26 hours (IQR, 8-61).

Thirty five (47%) ultrasonography-guided peripheral IVs failed within 24 hours (95% CI, 42%-65%), which was most commonly attributed to infiltration. Only 14 (19%) catheters survived more than 72 hours. The most common cause of IV failure over the course of the study was infiltration (28%), followed by inadvertent dislodgement of the catheter (11%). None of the covariates that we examined were significantly associated with early catheter failure (Table 3). In the multivariate analysis, there were no significant associations (data not reported).

The overall complication rate of ultrasonography-guided

IV catheters was 23% (Table 4). The most common immediate complication was nerve contact (7%). There were no infectious or thrombotic complications observed during the course of the study.

In 47 (63%) patients, the operator reported that a central line would have been required had the ultrasonography-

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 catheteriza- tion. In addition, complication rates of ultrasonography- guided peripheral IVs beyond the ED have not been well studied. In this study, we prospectively observed the survival of 6.35-cm ultrasonography-guided peripheral IV catheters placed in ED patients with difficult IVaccess. As a secondary outcome, we examined complication rates beyond the ED, including the need for central venous catheterization.

Premature failure of ultrasonography-guided peripheral IVs was first recognized by Keyes et al [5], who noted an 8% failure rate in the first hour after ultrasonography-guided placement of a 5-cm catheter, which is slightly shorter than the catheter used in our study. Taking this observation into consideration, Mills et al [6] hypothesized that standard- length ultrasonography-guided catheters (3-5 cm in length) may be too short to adequately reach the lumen of deeper peripheral veins and therefore tend to be easily dislodged. Despite the use of a slightly longer catheter in our study than that used by others [5], we found ultrasonography-guided peripheral IVs had a high premature failure rate of 47% in the first 24 hours, which was most commonly attributed to infiltration. Standard peripheral IV catheter survival rates vary considerably based on catheter, patient, and provider-related factors [8-12], but the failure rate may be as low as 2% in 24 hours and only 10% at day 4 [8]. Taking into consideration our small sample size, none of the variables that we examined were associated with premature catheter failure.

Avoidance of central venous catheterization, with its attendant risks, may be one benefit of ultrasonography- guided peripheral IV access. Operators intended to place a central line in 47 of the 75 patients in our study if attempts at obtaining ultrasonography-guided peripheral access failed. However, only 5 patients subsequently required central

Fig. 1 Kaplan-Meier estimates of ultrasonography-guided peripheral IV catheter survival through day 4.

venous catheterization, and only 1 was directly attributed to ultrasonography-guided IV failure. Although our data indicate that patients with difficult IV access rarely undergo central line placement as a direct result of ultrasonography- guided peripheral IV failure, ultrasonography-guided IV

Table 2 Ultrasonography-guided peripheral IV catheter survival data

Catheter survival rates, n (%)

Table 3 Unadjusted associations of variables with ultrasonography-guided peripheral IV survival time

Overall survival

42 (56)

Survived b24 h

35 (47)

Survived b48 h, N24 h

12 (16)

Survived b72 h, N48 h

14 (19)

Survived >=72 h

14 (19)

Reason for IV removal, n (%) Catheters that survived

Treatment completed

30 (40)

Not removed 4 d after placement

7 (9)

Changed per routine

2 (3)

Patient removed catheter

2 (3)

Catheters that failed Infiltrated

21 (28)

Inadvertent dislodgement

8 (11)

Phlebitis

3 (4)

Occluded

2 (3)

Infection requiring antibiotics

0 (0)

DVT

0 (0)

access may not be appropriate for all patients: 4 of the 5 patients in our study who underwent central venous catheterization had the procedure performed while they were critically ill, and all 4 had a functioning ultrasono- graphy-guided IV at the time of central line placement. Therefore, in patients with difficult access who are admitted to an intensive care setting or in whom there is a high potential for clinical deterioration, it may be prudent to consider placing a central line rather than attempting ultrasonography-guided peripheral IV access in the ED. Conversely, ultrasonography-guided IV placement might be

Variable ?2a P

Age 0.53 .47

Sex 2.19 .14

BMI 1.99 .16

IDU 0.08 .78

ED discharges in last 12 mo 0.11 .74

Hospital admissions in last 12 mo 0.12 .73

Operator training level 1.64 .20

No. of attempts 1.40 .24

a Log Rank Test used for gender, IDU, and training level. Cox proportional hazards model used for age, BMI, ED discharges in the last 12 months, hospital admissions in the last 12 months, and number

of attempts.

Table 4 Ultrasonography-guided peripheral IV catheter complications

Any complications (immediate or delayed), n (%) No complications

Any complications

Immediate complications, n (%) No immediate complications Nerve contact Hematoma/Bruising

Arterial puncture

Delayed complications, n (%) No delayed complications Hematoma/Bruising

Central line placement, n (%) No central line

Central line, unrelated to IV failure Central line, related to IV failure

58 (77)

17 (23)

64 (85)

5 (7)

4 (5)

2 (3)

68 (91)

7 (9)

70 (93)

4 (5)

1 (1)

the ideal approach in patients with difficult access who only require brief IV therapy, such as a single dose of IV medication, IV contrast for a radiographic study, or IV fluid resuscitation. Indeed, of the 15% of patients in our study who were discharged home from the ED after brief IV therapy, none required central venous access despite operators reporting that almost half of them would have required a central line if peripheral attempts were unsuccessful. Further underscoring the benefits of ultrasonography-guided periph- eral IV access, our data suggest that this procedure is safe, with low complication rates beyond the ED.

The immediate complication rates of ultrasonography- guided peripheral IV catheters are well documented in literature, and the 7% rate of nerve contact in our study is somewhat higher than the 1% to 3% previously reported [3,5]. However, the 2% arterial puncture rate that we observed is similar to that documented by others [3,5]. Complications beyond the ED, including infection and DVT, have not been well studied. A retrospective study of 402 ultrasonography-guided IVs demonstrated a less than 1% infection rate, which is similar to the 0.2% to 7% rate reported with standard peripheral IV catheters [9,12,13]. Similarly, there were no infectious or thrombotic complica- tions noted in a small study of 15-cm ultrasonography- guided catheters placed in the ED [5]. We did not observe any infectious or thrombotic complications during the course of our 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 survival was unaffected by this limitation. Although we attempted to identify all consecutive patients who had ultrasonography-guided IVs placed during the study by enrolling subjects 24 hours per day, 7 days per week, it is possible that we missed some patients admitted to the hospital who were eligible for the study, thus introducing bias into our estimate of the catheter failure rate. Never- theless, our study represents the largest cohort of patients who have been prospectively observed in both the ED and subsequent inpatient treatment areas for ultrasonography- guided peripheral IV survival.

We did not include a control group, and therefore, we cannot make valid comparisons of survival and complica- tion rates of traditional peripheral IVs to the ultrasono- graphy-guided catheters. However, a comparison of these 2 groups may not be valid as patients in the ultrasonography- guided IV catheter group would likely have significantly more comorbidities associated with difficult IV access, such as IDU, obesity, and chronic illness. Moreover, ED nurses place standard peripheral IVs and emergency physicians place ultrasonography-guided IVs at our institution, thus introducing the possibility of provider-related differences between these 2 groups. Finally, we could not ethically randomize patients to ultrasonography-guided peripheral IVs vs central line placement because factors such as clinical stability and the need for invasive hemodynamic monitoring could affect the decision to proceed directly to central venous catheterization.

The immediate complication rates, number of attempts, and the operator’s intent to place a central line may be affected by reporter bias as we relied on the operator to document these immediate complications at the time of catheter placement. In addition, we did not perform long- term follow-up after removal of the catheter. As a result, the complication rates may have been underestimated and patients may have subsequently developed infection or DVT that were not captured in the study period. Future study might include long-term patient follow-up after hospital discharge to obtain a more accurate estimate of ultrasono- graphy-guided IV complications.

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 ultrasonography-guided line cannot be placed. We

cannot recommend the use of ultrasonography-guided peripheral IV catheters in critically ill ED patients with difficult access, as this population has a relatively high rate of subsequent central line placement. If the results of our study are confirmed by other investigators, the use of ultrasono- graphy-guided peripheral IVs could lead to a clinically important reduction in the use of and complications associated with central venous catheterization.

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