Ultrasound in emergency medicinePredictors of Success in Nurse-Performed Ultrasound-Guided Cannulation
Introduction
It is often difficult to obtain peripheral venous access in patients who have a history of intravenous (i.v.) drug use, a medical problem requiring multiple previous i.v. cannulations, or obesity. These patients are often subjected to numerous unsuccessful peripheral i.v. attempts, followed by physician-performed central venous access, resulting in lost nursing and physician time. Previous studies have shown that emergency physicians and emergency nurses can be proficient in performing ultrasound (US)-guided peripheral venous cannulation in these patients, with success rates of 87–92% (1, 2, 3).
Although proficiency was demonstrated, the studies did not address what characteristics might contribute to differences in cannulation success rate. First, the veins of the upper arm have very different characteristics that might affect success rate. The basilic vein, although not as superficial and easy to access as the cephalic or median antecubital veins, is often larger and more likely to be sonographically visible. The brachial vein, although thought to be more universally present, is deep and in close proximity to the brachial artery and nerve (Figure 1). Second, the reason for difficult venous access, such as i.v. drug use or obesity, may affect the rate of successful cannulation. Finally, the cannulation success rates might be dependant upon whether a one- or two-person technique is utilized.
The purpose of this study was to determine how the choice of vein, the reason for difficult access, or the one- vs. two-person technique affected the success rate of nurse-performed US-guided i.v. cannulation in patients with difficult i.v. access.
Section snippets
Study Design
This was a prospective observational study of a convenience sample of patients needing peripheral venous cannulation who had difficult venous access.
Setting and Population
The study was conducted at an urban, academic medical center with an annual Emergency Department (ED) census of 60,000, which serves a largely low-income population. Before the study, US-guidance for peripheral venous cannulation was not used by nurses, and such patients were candidates for physician-performed central venous access.
Study
Study Subjects
Characteristics of the study group are reported in Table 1. The reason cited for difficult venous access was evenly divided between intravenous drug abuse (IVDA) and multiple previous medical procedures, with 17% of patients having two or more reasons cited. Fifty-one of 74 (69%) patients asked had required central venous access on a past visit. The brachial and basilic veins were the most often visualized, and the basilic was most often chosen for a cannulation attempt (Table 1). The nurses
Discussion
Our overall patient success rate was lower than the 87% success rate in emergency nurse-performed and 91–92% success rates in emergency physician-performed cannulation cited in earlier articles (1, 2, 3). One reason may be experience with the procedure. In one physician-performed study, five physicians performed 101 procedures, whereas we had 20 nurses performing 100 procedures (2). However, when we examined the data of our top four enrolling nurses to determine whether they improved with more
References (5)
- et al.
Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access
Ann Emerg Med
(1999) - et al.
Emergency nurses’ utilization of ultrasound guidance for placement of peripheral intravenous lines in difficult-access patients
Acad Emerg Med
(2004)
Cited by (61)
Ultrasound-guided peripheral intravenous canulation by emergency nurses: A systematic review and meta-analysis
2024, International Emergency NursingMono- and bi-plane sonographic approach for difficult accesses in the emergency department – A randomized trial
2023, American Journal of Emergency MedicineA randomized trial of ultrasound-guided peripheral IV catheter placement in difficult access patients using a guidewire approach
2020, American Journal of Emergency MedicineDevelopment of a nurse-led ultrasound-guided peripheral intravenous program
2019, Journal of Vascular NursingNurse-performed focused ultrasound in the emergency department: A systematic review
2018, Australasian Emergency Care