November 2015 REBELCast: All Vascular Access Episode

12 Nov
November 12, 2015

Vascular AccessWelcome 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

Click here for Direct Download of 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:

OR of Success

  • 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:

CVC Access

US Guided Peripheral IV Access

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

Bibliography

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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of R.E.B.E.L. EM

Latest posts by Salim Rezaie (see all)

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3 replies
  1. Parienti says:

    Thank you for your comments regarding our academic work entitled ” Intravascular Complications of Central Venous Catheterization by Insertion Site”. I would like to clarify one point regarding the study design.

    The use of selective exclusion in multi-arm trials does not necessary introduce selection bias as you suggested, provided that the data are analyzed correctly. Of note, investigators took the decision “not to include” one arm (a majority of subclavian in our study) before randomization (i.e. in compliance with the allocation concealment).

    In order to keep the advantage of random allocation, the analysis should compare only arms that were included in the randomization scheme and this was done in the paper to anticipate the risk of selection bias you correctly identified. For example, when comparing the 3 sites, only catheters randomized in the 3-choice group were included (please see the Figure 1 of the article for more details). When we reported that there were 8, 20 and 22 events in the SC, IJ and femoral sites respectively”, it is important to note that these events occured among the 2,532 (72.9%) catheters that were placed in patients in whom all three sites were 1:1:1 randomized in the three-choice comparison (i.e. deemed accessible).

    Of course, the intent-to-treat principle also contributes to keep the comparison valid, although it imputed half of the catheter-related bloodstream infection to the subclavian site for catheters that were inserted in the alternative sites. Nevertheless, despite this penalty, the subclavian site remained superior in terms of intravascular complications.

    I have no conflict of interest to declare, except that I was responsible of the analysis of the study.

    Reply
    • Anand Swaminathan says:

      Thanks for listening and for dropping your comments here. Always nice to get the authors on to give us their thoughts.

      The study is truly an amazing effort and contributes quite a bit to the discussion on central lines. We thought that the double randomization scheme was pragmatic since we often run into this with actual patients (i.e. only 2 sites available). Our concern was that the clinicians selected out the difficult group for subclavian (this is apparent as it was the most commonly excluded site in the 2 site arm) leaving an overall low risk subclavian group. Again, this is likely to reflect real life but should be noted. If all three sites were equally excluded from inclusion in the 2 site arm of the trial, I would be less concerned about a selection bias.

      Regardless, I end up with the same take home. There is no perfect central line site. The right one for your patient takes into account patient factors and clinician skill set.

      Thank you again for taking the time to comment here. This will further improve the quality of the discussion on these critical articles.

      Reply

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