Welcome to the November 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Vascular Access. Peripheral intravenous (PIV) access is one of the most common procedures we perform in the emergency department (ED) and central venous catheter (CVC), although decreasing in frequency, has some very real complications associated with it. It is always good to question clinical practice, especially in procedures that we perform on a daily basis. IV access is important to patient care for things that we may take for granted such as lab work and initiation of treatment. So with that introduction today we are going to specifically tackle:
Topic #1: Intravascular Complications of Central Venous Catheter (CVC) Access
Topic #2: US vs Landmark Technique for Peripheral IV Access
November 2015 REBELCast: All Vascular Access Podcast
Topic #1: Intravascular Complications of Central Venous Catheterization by Insertion Site
- Question #1: Do major complications of central venous catheters differ by site of insertion (central, subclavian and femoral)?
- Article #1: Parienti J.J et al. Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med September 2015; 373:1220-1229(26398070)
- Background #1: Three anatomical sites are commonly used to insert central venous catheters, but insertion at each site has the potential for complications including infection, thrombosis and mechanical dysfunction (pneumothorax, hematoma). The authors’ previous research led them to believe that these complications will differ according to the site of insertion.
- What They Did #1:
- Multi-center randomized comparative adverse outcomes trial
- Patients age 18 and older who were admitted to an ICU setting and requiring non tunneled central venous vascular access and had at least two of the three sites appropriate for cannulation. Study was conducted in France in a total of ten different ICUs (4 university affiliated hospitals and 5 general hospitals).
- Bottom Line #1: Although Subclavian lines appear to have a lower infection rate there is the tradeoff of more mechanical complications; ultimately the clinician should decide which site is the most appropriate on a patient to patient basis.
Topic #2: US vs Landmark Technique for Peripheral Intravenous (PIV) Cannulation
- Question #2: Does an Ultrasound-Guided technique or a Traditional Landmark technique for peripheral IV access have a higher 1st attempt success rate for peripheral IV cannulation?
- Article #2: McCarthy ML et al. Ultrasonography Versus Landmark for Peripheral Intravenous Cannulation: A Randomized Controlled Trial. Ann Emerg Med 2015. [epub ahead of print] (26475248)
- Background #2: One of the most common procedures performed in the ED is peripheral IV (PIV) access. Visual inspection and palpation to identify the vein has been the traditional means of gaining PIV access. The failure rate on first attempt ranges from 12 – 26% amongst adults, but can be even higher than this in “difficult access” patients. Ultrasound has gained lots of popularity in the past years and its use could potentially increase first attempt success rate, therefore decreases multiple attempts and therefore decreases pain for patients and delay in care. Looking at the CVC literature the use of ultrasound, if not already, should be standard care in placing central access. It has decreased number of attempts, time to cannulation, infection, as well as other complications commonly associated with CVC placement. The use of US in PIV access however is a little more inconsistent, due to prior small studies and heterogeneous patient populations. Currently, there just aren’t a lot of large randomized clinical trials having looked to answer this question of US vs landmark for PIV access, until now.
- What They Did #2:
- 2-Group, Parallel, Randomized, Controlled Trial of 1,189 Adult ED Patients from a single center
- Randomized to Landmark vs Ultrasonography
- Patients also stratified by difficulty of access: Difficult, Moderately Difficult, and Easy
- If 1st attempt failed, randomized subjects a 2nd time
- Exclusion Criteria: All High-acuity patients (Triage level 1 – 2 patients)
- Pertinent Figure:
- Bottom Line #2: If a patient needs peripheral IV access and has visible and/or palpable veins, stick with the traditional landmark technique of IV access as this is quicker and has a better 1st and 2nd attempt rate vs ultrasound guided techniques. However, if you have a patient that has peripheral veins that are not visible and/or palpable consider jumping to ultrasound guided peripheral IVs.
For More Details of the above Studies Checkout the November 2015 REBELCast Show Notes
For more on what others thought on these topics checkout:
- EM Literature of Note: Central Line Showdown
- EM Nerd: The Case of the Blind Allocator
- The Bottom Line: Intravascular Complications of Central Venous Catheterization by Insertion Site
- Vibha Gupta at CORE EM: Intravascular Complications of Central Line by Insertion Site
Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)