Ultrasound in emergency medicine
Predictors of Success in Nurse-Performed Ultrasound-Guided Cannulation

Abstract presented at the Society for Academic Emergency Medicine Annual Meeting in New York, New York, May 2005.
https://doi.org/10.1016/j.jemermed.2007.02.027Get rights and content

Abstract

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.

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

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