General medicine/original research
Ultrasonography Versus Landmark for Peripheral Intravenous Cannulation: A Randomized Controlled Trial

https://doi.org/10.1016/j.annemergmed.2015.09.009Get rights and content

Study objective

Randomized controlled trials report inconsistent findings when comparing the initial success rate of peripheral intravenous cannulation using landmark versus ultrasonography for patients with difficult venous access. We sought to determine which method is superior for patients with varying levels of intravenous access difficulty.

Methods

We conducted a 2-group, parallel, randomized, controlled trial and randomly allocated 1,189 adult emergency department (ED) patients to landmark or ultrasonography, stratified by difficulty of access and operator. ED technicians performed the peripheral intravenous cannulations. Before randomization, technicians classified subjects as difficult, moderately difficult, or easy access according to visible or palpable veins and perception of difficulty with a landmark approach. If the first attempt failed, we randomized subjects a second time. We compared the initial and second-attempt success rates by procedural approach and difficulty of intravenous access, using a generalized linear mixed regression model, adjusted for operator.

Results

The 33 participating technicians enrolled a median of 26 subjects (interquartile range 9 to 55). The initial success rate was 81% but varied significantly by technique and difficulty of access. The initial success rate by ultrasonography was higher than landmark for patients with difficult access (48.0 more successes per 100 tries; 95% confidence interval [CI] 35.6 to 60.3) or moderately difficult access (10. 2 more successes per 100 tries; 95% CI 1.7 to 18.7). Among patients with easy access, landmark yielded a higher success rate (10.6 more successes per 100 tries; 95% CI 5.8 to 15.4). The pattern of second-attempt success rates was similar.

Conclusion

Ultrasonographic peripheral intravenous cannulation is advantageous among patients with difficult or moderately difficult intravenous access but is disadvantageous among patients anticipated to have easy access.

Introduction

Intravenous cannulation of a peripheral vein is the most common invasive procedure performed in hospitals worldwide.1 The traditional landmark approach involves visual inspection and palpation of the extremity to locate a vein, followed by needle puncture and catheter insertion. The landmark failure rate on first attempt ranges from 12% to 26% among adults and is twice as high in difficult-access patients.2, 3, 4 When multiple cannulation attempts are necessary, patients experience more pain and treatment delays.

Editor’s Capsule Summary

What is already known on this topic

Intravenous access is important but without technical aids can sometimes be difficult. Ultrasonography offers an alternative to standard insertion methods.

What question this study addressed

Does ultrasonographically guided intravenous insertion aid in all patients or just those deemed in advance to present more challenging access?

What this study adds to our knowledge

Using a randomized, controlled assignment in 1,189 patients, trained technicians had higher success with landmark approaches in those deemed to have easier access, but ultrasonographic intravenous insertion attempts produced higher success in the moderate- and highest-difficulty groups.

How this is relevant to clinical practice

Selective use of ultrasonographic intravenous placement approaches targeting more difficult patients is pragmatic and evidence based.

Ultrasonography increases the success rate of central venous line placement, especially at the internal jugular site, but studies evaluating ultrasonographic peripheral intravenous line placement have reported inconsistent results.5, 6 Eight randomized controlled trials have compared the initial or final peripheral intravenous line placement success rate between landmark and ultrasonography in difficult-access patients.7, 8, 9, 10, 11, 12, 13, 14 The majority of the trials9, 11, 12, 13, 14 favored ultrasonography and reported clinically meaningful differences of 10% or greater in initial13 or overall success rate.9, 11, 12, 14 However, each study’s results were based on a small sample size (range of 35 to 60 total subjects). Meta-analyses of the trials’ results have reported conflicting findings because of heterogeneous patient populations, varying definitions of difficult access, and operator experience.15, 16, 17 This randomized controlled trial of 1,189 adult emergency department (ED) patients seeks to determine whether the initial peripheral intravenous line placement success rate is higher with landmark or ultrasonography among patients with difficult, moderately difficult, or easy venous access by randomly assigning the procedural method within each difficulty of intravenous access group and operator. We originally hypothesized that the initial success rate would be at least 5% higher when ultrasonography was used among patients with difficult or moderately difficult peripheral intravenous access but no different (ie, <5%) among patients with easy access.

Section snippets

Study Design and Setting

We conducted a randomized controlled trial with a 2-group parallel design at an academic ED in Washington, DC. The university’s institutional review board approved the study protocol and we registered the trial at clinicaltrials.gov. At this ED, peripheral intravenous cannulation is the primary responsibility of technicians. The ones who work in our ED have previous training as emergency medicine technicians, certified medical assistants, certified nursing assistants, or are nursing students.

Results

During the 13-month study period, we screened 1,662 and identified 1,617 eligible patients. The main reasons eligible subjects were not enrolled were they refused (N=217) or they were classified as having easy access (N=181) and were not selected during the beginning of the study when we were enrolling a subject with easy access only after 2 subjects with more difficult access (Figure 1).

Among the 36 technicians who worked during study enrollment hours, 33 (92%) participated. The participating

Limitations

The results of this study must be considered in light of the following limitations. The main study limitation is generalizability. The research assistants were not able to enroll every consecutively eligible patient. The research assistants were enrolling and collecting data for 9 other clinical research studies being conducted in our ED at the same time as this one, dealing simultaneously with screening, enrollment, and data collection across the 10 studies. Because we successfully enrolled

Discussion

This randomized controlled trial demonstrated that the success rate of the procedural technique used to obtain peripheral intravenous access in the upper extremity of adult ED patients depends on the difficulty of intravenous access. When a technician can easily see or palpate a vein, landmark is superior in terms of initial success rate, pain mitigation, and procedural duration. Among patients with easy access, landmark resulted in an estimated 11 additional first-attempt successes per 100

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    • Efficacy of Ultrasound-Guided Peripheral Intravenous Cannulation versus Standard of Care: A Systematic Review and Meta-analysis

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      Citation Excerpt :

      Our meta-analysis included 10 studies and 1,860 patients, of whom 966 (52%) underwent USGPIV cannulation and 894 (48%) underwent cannulation via the landmark and palpation method (standard of care). Eight studies (Aponte et al. 2007; Bauman et al. 2009; Stein et al. 2009; Costantino et al. 2010; Kerforne et al. 2012; Weiner et al. 2013; Bahl et al. 2016; McCarthy et al. 2016) reported the gender of their populations; 2 studies did not (Costantino et al. 2005; Vitto et al. 2016). From the studies that reported gender, 66% of females were in the pooled population but this percentage may be different in the entire population of included studies.

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    Please see page 11 for the Editor’s Capsule Summary of this article.

    Supervising editor: Donald M. Yealy, MD

    Author contributions: MLM, HS, KSB, RE, and SLZ conceived the study and designed the trial. MLM and RS obtained research funding. MLM, HS, RE, AL, and KL supervised the conduct of the trial and data collection and undertook recruitment of patients. XL and SLZ provided statistical advice on study design and analyzed the data. MLM managed the data, including quality control, and drafted the article, and all authors contributed substantially to its revision. MLM takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist and provided the following details: This study was supported in part by award K01HS017957 from the Agency for Healthcare Research and Quality. For every 3 subjects enrolled, the authors gave the technician a $5 gift card as a token of appreciation for assisting with study enrollment and data collection in addition to his or her clinical responsibilities.

    Clinical trial registration number: NCT01859559

    The sponsor was not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the article. The content is solely the responsibility of the authors and does not represent the official views of the Agency for Healthcare Research and Quality.

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