Needle and guidewire visualization in ultrasound-guided internal jugular vein cannulation

Study objective

Reimbursement for ultrasound-guided central lines requires documenting the needle entering the vessel lumen. We hypothesized that physicians often successfully perform ultrasound-guided internal jugular (IJ) cannulation without visualizing the needle in the lumen and that guidewire visualization occurs more frequently.

Methods

This prospective, observational study enrolled emergency physicians performing ultrasound-guided IJ cannulations over an 8-month period. Physicians reported sonographic visualization of the needle or guidewire and recorded DVD images for subsequent review. Outcome measures were the proportion of successful procedures in which the operator reported seeing the needle or guidewire in the vessel lumen and the proportion of successful, recorded procedures, in which a reviewer noted the same findings. Procedures were deemed successful when functioning central venous catheters were placed. Fisher exact test was used for comparisons.

Results

Of 41 attempted catheterizations, 35 (85.4%) were successful. Eighteen of these were recorded on DVD for review. The operator reported visualizing the needle within the vessel lumen in 23 (65.7%) of 35 successful cannulations (95% confidence interval [CI], 47.7%-80.3%). In 27 cases, the operator attempted to view the guidewire and reported doing so in 24 cases (88.9%; 95% CI, 69.7%-97.1%). On expert review, the needle was seen penetrating the vessel lumen in 1 (5.6%) of 18 cases (95% CI, 0.3%-29.4%). Among recorded procedures in which the operator also attempted wire visualization, the reviewer could identify the wire within the vessel lumen in 12 (75.0%) of 16 cases (95% CI, 47.4%-91.7%).

Conclusions

During successful ultrasound-guided IJ cannulation, physicians can visualize the guidewire more readily than the needle.     

Improvement of internal jugular vein cannulation using an ultrasound-guided technique

Objective: To determine whether ultrasound guidance can help operators to improve the results of jugular vein access in the ICU. Design: Prospective, randomized study. Setting: General Intensive Care Unit of a University Hospital. Patients: Seven-nine patients were assigned to internal jugular vein cannulation using anatomical landmarks alone (control group, n = 42) or with ultrasound guidance (ultrasound group, n = 37). Intervention: All cannulations were performed by junior house staff under the direct supervision of a senior physician. In the ultrasound group, an ultrasonography (7.5 MHz) was used and the transducer was covered by a sterile sheath. The placement and direction of the cannulating needle were determined on the ultrasound image. Measurements and results: Internal jugular vein cannulation was successful in 37/37 (100 %) patients in the ultrasound group and in 32/42 patients (76 %) in the control group (p < 0.01). Average access time was longer in the control group (235 ± 408 s vs 95 ± 174 s, p = 0.06) and carotid artery puncture occurred in five patients in each group (p = 0.83). Jugular cannulation was successful at the first attempt in 26 % in the control group and 43 % in the ultrasound group (p = 0.11). Thirty-two patients (86 %) in the ultrasound group and 23 patients (55 %) in the control group (p < 0.05) were cannulated within 3 min. The cannula could therefore not be inserted within 3 min in 19 patients (45 %) in the control group. Failure was explained by thrombosis (n = 1), small caliber of the internal jugular vein (< 5 mm, n = 3), abnormal vascular relations (n = 3). Among the ten primary failures of cannulation, an internal jugular vein catheter was able to be inserted in four cases by an experienced physician on the side initially selected and with ultrasound guidance in two cases. The catheter was inserted into the contralateral internal jugular vein under ultrasound guidance in the remaining four cases. Conclusion: Ultrasound guidance improved the success rate of jugular vein cannulation in ICU patients. Our results suggest that ultrasound guidance should be used when the internal jugular vein has not been successfully cannulated within 3 min by the external landmark-guided technique. Received: 4 November 1996 Accepted: 22 May 1997     

Randomized trial of tourniquet vs blood pressure cuff for target vein dilation in ultrasound-guided peripheral intravenous access

Background

Ten percent of the time, peripheral intravenous access (PIV) is not obtained in 2 attempts in the emergency department. Typically, a tourniquet is used to dilate the target vein; but recent research showed that a blood pressure (BP) cuff improves dilation, which may translate to increased PIV success.

Objectives

We sought to determine if there is improved success in obtaining ultrasound-guided PIV using a BP cuff vs a tourniquet in “difficult stick” patients.

Methods

This is a prospective, randomized, single-blinded trial. Adult patients requiring PIV with at least 2 prior failed attempts were enrolled. Patients were assigned to tourniquet or BP cuff for target vein dilation randomly. Nurses prepared the patient for PIV attempt by either placing a BP cuff inflated to 150 mm Hg or placing a tourniquet on the chosen extremity. The extremity was draped to blind the physician to assignment. Physicians then attempted ultrasound-guided PIV. Failures were defined as IVs requiring greater than 3 ultrasound-guided attempts or 30 minutes, or patient intolerance. If failure occurred, the physician was unblinded; and the patient could be crossed over and reattempted.

Results

Thirty-eight patients were enrolled. The success rate for the tourniquet group (n = 17) and BP cuff group (n = 21) was 82.4% and 47.6%, respectively (P = .04). There were no differences between groups for vessel depth, diameter, or procedure time. Six in the BP cuff group were crossed over and had successful PIV obtained with tourniquet.

Conclusions

Tourniquet is superior to BP cuff for target vein dilation in ultrasound-guided PIV.     

A comparison of longitudinal and transverse approaches to ultrasound-guided axillary vein cannulation

ObjectiveThe axillary vein is an easily accessible vessel that can be used for ultrasound-guided central vascular access and offers an alternative to the internal jugular and subclavian veins. The objective of this study was to identify which transducer orientation, longitudinal or transverse, is better for imaging the axillary vein with ultrasound.MethodsEmergency medicine physicians at an inner-city academic medical center were asked to cannulate the axillary vein in a torso phantom model. They were randomized to start with either the longitudinal or transverse approach and completed both sequentially. Participants answered questionnaires before and after the cannulation attempts. Measurements were taken regarding time to completion, success, skin punctures, needle redirections, and complications.ResultsFifty-seven operators with a median experience of 85 ultrasound procedures (interquartile range, 26-120) participated. The frequency of first-attempt success was 39 (0.69) of 57 for the longitudinal method and 21 (0.37) of 57 for the transverse method (difference, 0.32; 95% confidence interval [CI], 0.12-0.51 [P = .001]); this difference was similar regardless of operator experience. The longitudinal method was associated with fewer redirections (difference, 1.8; 95% CI, 0.8-2.7 [P = .0002]) and skin punctures (difference, 0.3; 95% CI, ? 2 to + 0.7 [P = .07]). Arterial puncture occurred in 2 of 57 longitudinal and 7 of 57 transverse attempts; no pleural punctures occurred. For successful attempts, the time spent was 24 seconds less for the longitudinal method (95% CI, 3-45 [P = .02]).ConclusionsThe longitudinal method of visualizing the axillary vein during ultrasound-guided venous access is associated with greater first-attempt success, fewer needle redirections, and a trend of fewer arterial punctures compared with the transverse orientation.     

A randomized controlled trial comparing one-operator versus two-operator technique in ultrasound-guided basilic vein cannulation

The basilic vein offers an alternative site for peripheral intravenous access for emergency access. The use of a two-operator ultrasound-guided basilic vein cannulation technique has been shown to be a safe and effective technique for use on Emergency Department patients. However, the one-operator technique is more customary by other services. We sought to compare the more customary one-person technique to the two-person technique in basilic vein cannulation in novice operators. This was a prospective, randomized controlled trial of two techniques of ultrasound-guided basilic vein cannulation (one-operator vs. two-operators) in healthy adult volunteers. Each volunteer underwent each technique, one technique on each arm. We selected the initial arm and technique using computer-generated block randomization. In the one-operator technique, a single operator held the transducer in transverse short-axis plane while attempting cannulation using a 20-gauge, 1.88-inch catheter. In the two-operator technique, a second operator held the transducer in place while the first operator attempted cannulation. The primary outcome variable was first-attempt cannulation success. Secondary outcome variables were overall success, number of attempts, time-to-cannulation, complications, and ease-of-technique rated by the operators. There were 32 subjects enrolled. One-operator first-attempt success was 18/32 (56%); two-operator was 21/32 (65%), with a mean difference in proportion of −9% (95% confidence interval [CI] −33–14%). Overall success for one operator was 23/32 (72%) and two-operator was 24/32 (75%), with mean difference in proportion of −3% (95% CI −24–18). The median number of attempts for one-operator was 1.6 (interquartile range [IQR] 1–5) and two-operator was 1.4 (IQR 1–5) (p = 0.8). Time to cannulation for one-operator was 57 s (± 62) and two-operator was 44 s (± 37) (p = 0.33). The median score for ease-of-technique for one-operator was 4.3 (IQR 1–6) and for two-operator was 3.6 (IQR 1–6) (p = 0.26). There were no complications with either technique (95% CI 0–10%). Novice operators can reliably perform a basilic vein cannulation using ultrasound guidance. However, we were unable to demonstrate any advantage for any particular technique in cannulating the basilic vein.     

超声引导颈内静脉穿刺置管术在I-gel喉罩通气时的应用

目的探讨喉罩通气时行颈内静脉穿刺置管时超声引导法与传统体表标志定位方法的差异。方法将40例全身麻醉置入I-gel喉罩通气拟行平卧位腹部手术的成年患者随机分为超声引导组(U组,20例)与传统体表标志定位方法组(C组,20例),U组在超声实时引导下行颈内静脉置管术,C组使用传统的体表标志定位法行颈内静脉置管术。两组穿刺点均选择甲状软骨水平入路。记录U组患者喉罩置入前后甲状软骨水平颈内静脉与颈总动脉各自中心点的体表投射点与正中线间距离等变化。记录两组首次穿刺成功率、试穿次数、总成功率、穿刺时间及并发症情况。结果 U组患者喉罩置入前后颈内静脉与颈总动脉各自中心点与正中线距离均明显增加(P0.01),颈内静脉内径、两者间水平距离、两者水平重叠率差异有统计学意义(P0.01)。两组首次穿刺成功率、试穿次数、总成功率、穿刺时间及并发症差异均有统计学意义(P0.01)。结论 I-gel喉罩置入会导致颈部血管外移,右颈内静脉内径及其与颈总动脉的水平距离及重叠率显著变化,不利于颈内静脉穿刺置管;喉罩通气中颈内静脉穿刺置管时超声引导法相对于传统体表标志定位方法可明显提高穿刺成功率。     

Predictors of success in nurse-performed ultrasound-guided cannulation

The objective of this study was to characterize factors affecting the success rate of nurse-performed ultrasound (US)-guided peripheral vein cannulation in difficult access patients. We prospectively enrolled patients who had two previous unsuccessful i.v. attempts. Nurses were trained in US-guided cannulation using a 7.5-MHz linear probe. The following characteristics were recorded: 1) reason for difficult access, 2) which upper arm veins could be sonographically visualized, 3) cannulation success, and 4) one- or two-person technique used. One hundred patients were enrolled. The cannulation success rate was 63%. Cannulation of the basilic vein was successful in 39 of 55 attempts (71%), whereas the success rate for the brachial vein was only 19 of 46 attempts (41%). The reason for difficult access and the one- or two-person technique did not affect success rate. The basilic vein was the best choice for cannulation, and the one-person technique was as successful as the two-person technique.     

Real-time ultrasound-guided infraclavicular axillary vein cannulation: A prospective study in mechanically ventilated critically ill patients

PurposeThe main purpose of this study was to define the venipuncture and catheterization success rates and early mechanical complication rates of ultrasound-guided infraclavicular axillary vein cannulation.Materials and methodsWe performed in-plane, real-time, ultrasound-guided infraclavicular axillary vein catheterizations under emergency and nonemergency conditions in mechanically ventilated, critically ill patients.ResultsWe performed 202 cannulation attempts. One hundred and twenty-six procedures (62.4%) were performed under emergency conditions. The puncture of the axillary vein was successful in 98.5% of patients, and the entire procedure success rate was 95.1% (95% confidence interval, 91.1%-97.6%). For the majority of patients (84.1%; P < .001, exact test), the venipuncture occurred during the first attempt. We noted a 22.4% overall complication rate, and most of the complications were malpositions (13.4%). We observed 8.5% of cases with potentially serious complications (puncture of the axillary artery and needle contact with the brachial plexus) and 1 case (0.5%) of pneumothorax. The puncture of the axillary artery occurred in 5 (2.5%) patients.ConclusionsIn-plane, real-time, ultrasound-guided, infraclavicular axillary vein cannulation in mechanically ventilated, critically ill patients is a safe and reliable method of central venous cannulation and can be considered to be a reasonable alternative to other central venous catheterization techniques.     

超声引导下经上臂贵要静脉和肱静脉穿刺行PICC的并发症比较研究

目的探讨超声系统引导下的改良塞丁格技术（MST）选择肱静脉行经外周静脉穿刺置入中心静脉导管（PICC）置管术在临床患者中应用的可行性和并发症的发生率。方法回顾分析本院超声引导下经上臂贵要静脉和经肱静脉穿刺行PICC患者的临床资料,比较2种穿刺途径在并发症发生率上的差异,并试图找出并发症发生的独立危险因素。结果2种置管途径在各种并发症发生率上均无统计学差异;非1次成功置管和非恶性肿瘤患者是PICC并发症发生特别是感染发生的独立危险因素。结论超声引导下PICC穿刺可以避开血管内的不良因素,避开静脉瓣,从肘上较粗的肱静脉穿刺置管,减少了肘部运动时导管对血管壁的刺激以及导管在血管内外的进出,从而减少了血管相关性感染、机械性静脉炎等并发症的发生,尤其可以直接选择深静脉——肱静脉行PICC置管,既提高了PICC置管成功率,也保障了置管的安全性和有效性,值得临床推广应用。     

A novel technique for ultrasound-guided supraclavicular subclavian cannulation

Objective

Ultrasound-guided subclavian (SC) access is an inadequately described procedure in the current literature. We recommend using the endocavitary (EC) probe to perform supraclavicular (SUP) SC line placement and evaluate emergency medicine residents' skill and comfort in using this technique after an education session.

Methods

The EC probe placed in the SUP fossa was used for direct visualization of SUP SC cannulation. Fifteen residents at the University of Utah were educated on this technique. Residents were graded on their ability to visualize the SC vein and answered questions before and after the training. Residents reported their comfort with the technique using a 5-point Likert scale.

Results

All 15 residents correctly identified the SC vein and rated their understanding of the SUP anatomy before and after the training; average resident comfort rating was 2.9 before training and 4.4 after (95% confidence interval, 1.1-1.9; P < .001). Most residents reported significant ease of visualization and stated that they would likely attempt the procedure as their next method of central venous access.

Conclusion

Ultrasound-guided SUP SC central access using the EC probe may be technically advantageous because of the relatively small probe footprint and fit into the SUP fossa. All participants were able to identify the vein and reported subjective improvement in the understanding of anatomy and comfort with the procedure after a brief training session.     

Randomized controlled trial of peripherally inserted central catheters vs. peripheral catheters for middle duration in-hospital intravenous therapy

Summary.  Introduction: Intravenous (i.v.) therapy may be associated with important catheter-related morbidity and discomfort. The safety, efficacy, comfort, and cost-effectiveness of peripherally inserted central catheters (PICCs) were compared to peripheral catheters (PCs) in a randomized controlled trial. Methods: Hospitalized patients requiring i.v. therapy ≥ five days were randomized 1:1 to PICC or PC. Outcomes were incidence of major complications, minor complications, efficacy of catheters, patient satisfaction, and cost-effectiveness. Results: 60 patients were included. Major complications were observed in 22.6% of patients in the PICC group [six deep venous thrombosis (DVT), one insertion-site infection] and 3.4% of patients in the PC group [one DVT; risk ratio (RR) 6.6; P  = 0.03]. Superficial venous thrombosis (SVT) occurred in 29.0% of patients in the PICC group and 37.9% of patients in the PC group (RR 0.60; P  = 0.20). Patients in the PICC group required 1.16 catheters on average during the study period, compared with 1.97 in the PC group ( P  < 0.04). The mean number of venipunctures (catheter insertion and blood sampling) was 1.36 in the PICC group vs. 8.25 in the PC group ( P  < 0.001). Intravenous drug administration was considered very or quite satisfying by 96.8% of the patients in the PICC group, and 79.3% in the PC group. Insertion and maintenance mean cost was 690 US$ for PICC and 237 US$ for PC. Discussion: PICC is efficient and satisfying for hospitalized patients requiring i.v. therapy ≥ five days. However, the risk of DVT, mostly asymptomatic, appears higher than previously reported, and should be considered before using a PICC.     

Femoral vein cannulation: a review

The femoral vein is an excellent potential venous access site. The technique of cannulation is described and its applications and complications are reviewed. More extensive future use of this technique is necessary to determine its proper role in emergency medicine.     

Short- vs long-axis approach to ultrasound-guided peripheral intravenous access: a prospective randomized study

Objective

The objective of the study was to determine if the short-axis approach and long-axis approach to ultrasound-guided peripheral intravenous access (USGPIV) differ in success rate, catheter insertion time, and number of needle sticks.

Methods

A convenience sample of emergency department patients aged 18 to 65 years with difficult IV access (2 or more failed landmark attempts) was prospectively randomized to short-axis or long-axis USGPIV. Time from skin puncture to catheter insertion (insertion time) and number of needle sticks were recorded. Number of needle sticks and insertion time were compared using Mann-Whitney U tests.

Results

Forty subjects were enrolled; 20 were randomized to the short-axis and 20 to the long-axis approach. Success rate was 95% (19/20; 95% confidence interval, 85%-100%) in the short-axis group compared with 85% (17/20; 95% confidence interval, 69%-100%) in the long-axis group. All 3 subjects with failed IV placement in the long-axis group had successful rescue USGPIV placement in short axis. Median insertion time was 34 seconds (interquartile range, 35 seconds) for the short-axis group compared with 91 seconds (interquartile range, 59 seconds) for the long-axis group (P = .02). Mean number of needle sticks was 1.5 (±SD 0.7) in the short-axis group compared with 1.4 (±SD 0.7) in the long-axis group (P = .82).

Conclusions

Short-axis USGPIV technique required less insertion time than the long-axis technique. Success rate was higher in the short-axis group, but this difference was not statistically significant. However, all of the failed IVs in the long axis were rescued successfully in short axis.