American Journal of Emergency Medicine (2012) 30, 1950-1954

Original Contribution

Decrease in Central venous catheter placement due to use of ultrasound guidance for peripheral intravenous catheters^?

Arthur K. Au MD ^a,?, Masashi J. Rotte MD ^a, Robert J. Grzybowski ^b,

Bon S. Ku MD, MPP ^a, J. Matthew Fields MD ^a

^aDepartment of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA

^bJefferson Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA

Received 8 March 2012; revised 10 April 2012; accepted 11 April 2012

Abstract

Study objectives: Obtaining Intravenous access in the emergency department (ED) can be especially challenging, and physicians often resort to placement of central venous catheters . Use of ultrasound-guided peripheral IV catheters (USGPIVs) can prevent many “unnecessary” CVCs, but the true impact of USGPIVs has never been quantified. This study set out to determine the reduction in CVCs by USGPIV placement.

Methods: This was a prospective, observational study conducted in 2 urban EDs. Patients who were to undergo placement of a CVC due to inability to establish IV access by other methods were enrolled. Ultrasound-trained physicians then attempted USGPIV placement. Patients were followed up for up to 7 days to assess for CVC placement and related complications.

Results: One hundred patients were enrolled and underwent USGPIV placement. Ultrasound-guided peripheral IV catheters were initially successfully placed in all patients but failed in 12 patients (12.0%; 95 confidence interval [CI], 7.0%-19.8%) before ED disposition, resulting in 4 Central lines, 7 repeated USGPIVs, and 1 patient requiring no further intervention. Through the inpatient follow-up period, another 11 patients underwent CVC placement, resulting in a total of 15 CVCs (15.0%; 95 CI, 9.3%- 23.3%) placed. Of the 15 patients who did receive a CVC, 1 patient developed a catheter-related infection, resulting in a 6.7% (95 CI, 1.2%-29.8%) complication rate.

Conclusion: Ultrasound prevented the need for CVC placement in 85% of patients with difficult IV access. This suggests that USGPIVs have the potential to reduce morbidity in this patient population.

(C) 2012

Introduction

1.2. Background

^? Previously presented as a poster presentation at the American College of Emergency Physicians Scientific Assembly October 2011, San Francisco, Calif.

* Corresponding author.

E-mail address: [email protected] (A.K. Au).

Peripheral intravenous (IV) (PIV) catheters are routinely placed in the emergency department (ED). Over a quarter of patients treated in the ED receive IV ftuids, and close to 40% require blood tests [1]. However, up to 23% of patients have veins that are difficult to cannulate by traditional techniques [2] often because of smaller and more fragile

0735-6757/$ – see front matter (C) 2012 http://dx.doi.org/10.1016/j.ajem.2012.04.016

vessels, larger body habitus, or prior IV drug use. In these difficult IV access (DIVA) cases, Traditional methods of PIV cannulation are frequently unsuccessful. When other methods such as external jugular or basilic venous cannulation also fail, physicians often resort to use of a Central venous catheter for IV access. Unfortunately, CVCs have been shown to have a 5% to 15% complication rate including both immediate (Arterial puncture, pneumo- thorax, and hematoma) and delayed (infection and throm- bosis) complications resulting in significant morbidity and mortality [3]. In addition, the cost attributed to a single CVC-related infection in 2002 was estimated at $34508 to

$56000, resulting in annual costs of $296 million to $2.3 billion nationally [4].

An ideal solution to this problem would be to improve the success rate of placing PIVs, thereby avoiding the need for CVCs altogether. Bedside ultrasound can identify deeper vessels not apparent by physical examination and dynami- cally guide PIV cannulation in real time. When successful, ultrasound-guided PIV catheters (USGPIVs) avoid the need for CVC placement; however, the impact of USGPIVs on the rate of CVC placement has never been quantified. Studies have demonstrated a higher failure rate in USGPIVs when compared with CVCs and traditional PIVs with up to 47% becoming unusable after 24 hours [5-7]. Because of these high Failure rates, it is unclear if USGPIVs placed in the ED truly obviate the need for CVC placement in patients with DIVA during hospitalization. This study set out to quantify the reduction in CVC placement in patients with DIVA by use of USGPIVs.

Methods

Study design

This was a prospective, observational study of patients with DIVA undergoing USGPIV placement. The institu- tional review board reviewed and approved the study, and written, informed consent was obtained from all patients.

Study setting and population

The study was conducted at an urban ED with a 3-year emergency medicine (EM) residency program as well as at a second affiliated urban ED with rotating EM residents with a combined annual census of 105000. All EM residents complete 4 weeks of ultrasound training during which the requirements for emergency ultrasound, as recommended by the American College of Physicians 2001 guidelines, are met [8]. Ultrasound-guided PIV catheter placement is taught during the intern year and involves both didactic and hands- on instruction using commercially available Training models. Physicians at all levels of training placed USGPIVs. A convenience sample of patients with DIVA, defined as at

least 2 failed PIV attempts or inability to palpate veins on physical examination plus the inability to establish external jugular access (failure, patient refusal, or inability to lay supine) were enrolled from November 2010 to June 2011. Patients were determined to require IV access if IV ftuids, IV medications, IV contrast for radiography, or transfusion of blood products was necessary during their ED encounter. Patients were excluded if unable to give verbal consent, if the caring attending physician determined CVC to be required for patient stabilization, or if the attending physician indicated that a CVC would not be necessary despite the failure to establish PIV access.

Study protocol

Emergency department nurses or technicians performed the initial PIV attempts. After multiple failed PIV attempts, the treating nurse informed a senior resident who then reviewed each patient’s plan of care with the treating attending physician. At this time, it was determined whether IV access was required for patient care as well as ensuring that CVC was not needed immediately for patient stabilization. The treating resident then attempted external jugular access. If this was unsuccessful, the patient was determined to have DIVA and was enrolled in the study. Patients underwent USGPIV placement with the following protocol: a proximal tourniquet was applied to the upper extremity. The extremity was then scanned for a target vessel using a Sonosite MicroMaxx or M-Turbo (Sonosite Inc, Bothell, WA) with a high-frequency 13 to 6 MHz linear array transducer. Once a target vessel was identified, the overlying skin was sterilized with an alcohol or chlorhex- idine swab. Catheters were standardized to 20-gauge, 48- mm long (Angiocath Autoguard; BD Medical Systems, Sandy, UT) catheters.

The physicians then attempted catheter placement using a single-operator technique in which the needle was visualized entering the target vessel in real time. Longitudinal and/or transverse planes were used depending on the physicians’ preference. Successful catheter placement was defined as aspiration of 5 mL of blood and the ability to ftush the IV without resistance. Failure was defined as inability to successfully place an IV catheter resulting in patient or operator fatigue. All immediate complications from USGPIV placement attempts were recorded. Potential immediate complications included arterial puncture, nerve irritation, and hematoma formation.

Prior unsuccessful attempts at PIV placement were documented for each patient. In addition, patient character- istics and relevant medical history were recorded for each patient. A combination of medical record review and in- hospital Bedside examination was done to assess for subsequent CVC (central line or peripherally inserted central catheter [PICC]) placement as well as related complications. Potential immediate complications of CVC placement

included arterial puncture and pneumothorax, whereas potential delayed complications included infection and thrombosis. Patients were followed up for up to 7 days or until hospital discharge. Based on an estimated reduction in CVC placement of 60%, it was calculated that 100 patients needed to be enrolled to achieve a desired 95% confidence interval (CI) width of 0.2.

Table 2 Training level and experience of sonographers placing USGPIVs

Sonographer	Training level	Prior USGPIVs placed	Patients enrolled (N = 100)
1	Attending	N 20	6
2	Attending	N 20	2
3	PGY-3	10-20	2
4	PGY-3	10-20	2
5	PGY-3	N 20	12
6	PGY-3	N 20	2
7	PGY-3	10-20	6
8	PGY-3	10-20	6
9	PGY-3	N 20	20
10	PGY-2	10-20	1
11	PGY-2	N 20	13
12	PGY-2	10-20	3
13	PGY-2	10-20	1
14	PGY-2	10-20	12
15	PGY-2	10-20	1
16	PGY-2	10-20	1
17	PGY-2	10-20	1
18	PGY-1	b 10	1
19	PGY-1	b 10	2
20	PGY-1	b 10	2
21	PGY-1	10-20	3
22	PGY-1	b 10	1

Results

There were 119 patients who underwent USGPIV placement. Nineteen patients were excluded because the caring provider determined that the patient would not have required CVC placement even if USGPIV placement had failed, yielding 100 patients for analysis. Characteristics of patients requiring USGPIV are reported in Table 1. All

patients in this cohort required IV access for 1 or more of the

following reasons: IV medication (92%), IV ftuids (64%), IV contrast for diagnostic computed tomographic scan (28%), and transfusion of blood products (13%).

A total of 22 different physicians enrolled patients. The training level, previous USGPIV experience, and number of patients enrolled by each provider are outlined in Table 2. There was a median of 3 (interquartile range, 2-4) traditional PIV attempts made before patient enrollment, with 34% (95 CI, 25%-44%) of patients having undergone 4 or more PIV attempts. USGPIV catheters took a median of

1 (interquartile range, 1-2) attempt, with 69% (95% CI, 58%-79%) requiring only 1 attempt and 90% (95% CI,

81%-96%) successful within 2 attempts. A ftowchart of USGPIV placement and outcomes is presented in the Fig. In

12 patients (12.0%; 95 CI, 7.0%-19.8%), USGPIV was

Table 1 Demographic characteristics of ED patients with DIVA requiring USGPIV placement

N = 100

Sex

Male Female Race

African American Caucasian

History

IV drug abuse Hypertension Diabetes Dialysis

Prior DIVA Obese Chemotherapy Disposition Discharged Admitted

Intensive care unit Telemetry

General medicine ftoor Observation

44

56

62

32

9

46

35

11

83

39

7

19

81

8

40

30

2

successfully inserted and functional but ultimately failed before ED disposition (infiltration and dislodgement). This resulted in 7 repeat USGPIVs, 4 central lines, and 1 patient requiring no further intervention. Of the 4 patients with central lines placed while in the ED, 3 were admitted to the hospital, and 1 had their central line removed and was

discharged from the ED after workup was completed. Through the follow-up period, an additional 11 patients underwent CVC placement (1 central line and 10 PICC lines) while hospitalized. In total, 15 patients (15.0%; 95 CI, 9.3%-23.3%) had CVCs placed during their hospital course; 5, central lines; and 10, PICC lines. There were 4 (4.0%; 95 CI, 1.6%-9.8%) documented complications from USGPIV placement: 1 patient (1.0%; 95 CI, 0.2%-5.5%) with infiltration of IV contrast and 3 patients (3.0%; 95 CI, 1.0%-8.5%) with extravasation of IV ftuids. However,

through the follow-up period, these infiltrations did not result in any long-term complications, such as infection,

Skin necrosis, or compartment syndrome. Of the 15 patients who underwent CVC placement, 1 developed a catheter- related infection requiring IV antibiotics and removal of their PICC line, resulting in a 6.7% (95 CI, 1.2%-29.8%) complication rate.

Patients with difficult IV access (n = 119)

Excluded – IV access not necessary for ED disposition (n = 19)

IV successfully placed under ultrasound guidance (n = 100)

IV failure prior to ED disposition

(n = 12)

IV functional to ED disposition

(n = 88)

Patient discharged from ED (n = 16)

Patient admitted (n = 72)

No further IV Repeat USGPIV CVC placed CVC placed in hospital access (n = 1) in ED (n = 7) in ED CL (n = 1)

CL (n = 4) PICC (n = 10)

No CVC placed through 7-day follow-up (n = 61)

Fig. Flow diagram of outcomes of patients with DIVA requiring ultrasound-guided IV access. CL indicates central line.

Discussion

Placing PIV catheters is the most frequent ED procedure and is necessary for administration of IV ftuids and medications [1]. Inability to place a PIV can result in Delays in diagnosis and treatment. ultrasound-guided techniques have improved the success rate of placing PIV catheters [6,9- 11], however, at the cost of frequent early failure rates [5-7]. Because of this questionable longevity, it is unclear whether USGPIVs truly prevent CVCs or if they merely delay their placement. Dargin et al [6] previously demonstrated a 1% rate of central line placement due to USGPIV failure, and Costantino et al [11] found that, of 46 attempted USGPIV placements, failure to achieve USGPIV only resulted in the placement of 1 CVC. However, it is not clear in these studies that providers would have gone on to place a CVC had ultrasound not been available. The current study attempted to more purely determine the effect of USGPIVs by isolating the subset of patients in whom providers would have placed a CVC due to the inability to obtain IV access by other means. The study found that USGPIVs eliminated the need for CVC placement in 85% of DIVA cases. After USGPIV placement in 100 ED patients, only 15 eventually required CVC placement through up to 7 days of their hospital course. Given that the entire cohort was determined to require CVC placement purely for IV access, this is a substantial reduction in the number of unnecessary CVCs placed. Assuming a CVC complication rate of 15% [3], avoiding the need for CVC placement in 85% of cases would reduce the

complication rate to 2.25% in this cohort. By this estimate, for every 8 patients with DIVA who get an USGPIV instead of a CVC, at least 1 CVC complication is avoided. Ultrasound has previously been shown to decrease compli- cation rates associated with CVC placement [12,13], and the current study reveals that the modality can further help avoid CVC placement altogether. In addition to an overall 15% complication rate [3], central and PICC lines have been found to result in 2.7 and 2.1 blood stream infections (BSIs) per 1000 catheter-days, respectively, compared with 0.5 BSI per 1000 catheter-days in PIVs [14]. Our study reftects this finding, as 1 of the 15 patients who received a CVC had a catheter-related BSI resulting in administration of broad- spectrum antibiotics and discontinuance of the device. The estimated cost of a single CVC-related BSI has been estimated at $34508 to $56 000 [4], and CVC-related injuries and their resultant claims have resulted in median payouts of $100750 [15]. There has been no statistically significant difference found in the infection rates between traditional and ultrasound-guided PIVs [16]. For this reason, the reduction of CVC placement through the use of USGPIVs may significantly reduce Health care costs.

In addition to reducing the number of CVCs, our data suggest that the number of IV attempts would be decreased by implementing ultrasound guidance earlier in the care of patients with DIVA. We found that the number of PIV attempts is lower when using ultrasound compared with traditional methods (median, 1 vs 3 attempts, respectively). One way to implement ultrasound earlier in patient care

would be to train nurses and technicians, who traditionally place IVs, to use ultrasound guidance. Prior studies have shown that, with proper training, ED nurses and technicians have similar success rates as ED physicians in placing USGPIVs [17-19].

Another potential benefit of using USGPIVs is the potential to decrease the time physicians require at the bedside to place CVCs. Because CVC placement requires universal sterile precautions and, typically, a chest x-ray for confirmation of proper placement and to exclude immediate complications, the time required to place an USGPIV should be shorter than the time needed to place a CVC. This time benefit may be offset, however, because of the traditionally higher failure rates of USGPIVs. The physician may be required to return to the bedside to obtain further IV access in the event that an USGPIV fails before ED disposition. Although frequent failures of USGPIVs may result in the placement of multiple USGPIVs in select patients, this increased time at the bedside for a minority of patients should be trumped by the vast decrease in potentially serious complications by avoiding CVC placement whenever possible. Again, by adequately training ED nurses and technicians to place USGPIVs, an even greater decrease in the amount of time required by the ED physician can be obtained, further improving throughput and patient care.

Limitations

This study was subject to several limitations. The study was not randomized and may have been limited in its ability to truly determine the absolute reduction in CVCs in this cohort. Patients were enrolled only when a physician trained in placement of ultrasound-guided IVs was available, potentially leading to selection bias from convenience sampling. However, every one of our residents is trained in USGPIV placement during their post-graduate year (PGY)-1 year, suggesting that patients were enrolled in an unbiased fashion. The availability of ultrasound may have lead to an earlier abandonment of traditional PIV attempts by ED staff, leading to over classification of patients as DIVAs; however, with a median of 3 failed tradition PIV attempts before USGPIV attempt, this does not appear to be a significant limitation. Similarly, attempts at external jugular access may have been more readily abandoned because of availability of ultrasound guidance. Again, this may have overestimated the need for CVC placement in this cohort.

Conclusion

Ultrasound prevents the need for CVC placement in up to 85% of patients with DIVA. The extrapolated reduction in

CVC-related complications suggests that USGPIVs may prevent significant morbidity in this patient population.

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