Evidence-Based Practice:

Ultrasound-Guided Peripheral Intravenous

Access

Joseph Arab, Haley Kehler, Sharon Kim, Jessica Shaw

Mission Moment

All the evidence that we have indicates that it is reasonable to assume in practically every human

being, and certainly in almost every newborn baby, that there is an active will toward health, an impulse

towards growth, or towards the actualization.

-Abraham Maslow

What is Ultrasound-Guided Peripheral Access?

• Ultrasonography uses a machine to better visualize veins. (White, Lopez & Stone, 2010)

• Ultrasound-Guided Peripheral Intravenous Access is used in anatomically challenging patients, as a result of difficulty visualizing the veins. (Ault, Tanabe & Rosen, 2015)

• Ultrasonography helps to visually see the veins and successfully guide the placement of the catheter during insertion. (Schoenfeld, Boniface & Shokoohi, 2011)

• Peripheral Intravenous Insertion Video

Ultrasonography Machines

http://69.167.166.201/wp-content/uploads/2012/09/M-Turbo_Left_TT_2011-06-130.jpg

http://i.ytimg.com/vi/lREUPXCpK8Y/hqdefault.jpg

PICO Question

Population

• Hospitalized patients

Intervention

• Ultrasound systems

Comparison

• Traditional intravenous insertion methods

Outcome

• Successful intravenous cannulation/access

PICO Question

In the hospitalized patient requiring peripheral intravenous insertion, does the use of a guided peripheral ultrasound system,

compared to the traditional/palpation method, increase intravenous insertion success rate?

Learning Objectives

• The reader will identify the benefits of using ultrasound-guided peripheral intravenous insertion

• The reader will describe what is needed to implement ultrasound-guidance systems

• The reader will describe what aspects are detrimental to the implementation of the ultrasound guided peripheral intravenous insertion

• The reader will be able to form an educated opinion regarding ultrasound-guided peripheral intravenous access

• The need for peripheral intravenous access is becoming more common. (Ault, Tanabe &

Rosen, 2015)

• Intravenous insertion complications have been shown to extend hospital stays and contribute

to more health costs. (Gregg, Murthi, Sisley, Stein & Scalea, 2009)

• Difficult access requires multiple intravenous attempts, utilizing staff resources and delaying

care. (Egan, Healy, O’Neill, Clarke-Moloney, Grace & Walsh, 2013)

• Commonly seen patients with difficult access: obese, history of intravenous drug use, sickle

cell disease, chronic renal failure, hypovolemia, shock, elderly, and other chronic illnesses.

(Egan, Healy, O’Neill, Clarke-Moloney, Grace & Walsh, 2013; White, Lopez & Stone, 2010;

Bauman, Braude & Crandall, 2007)

• Failed peripheral intravenous access often requires more invasive procedures such as a

central venous access. (Egan, Healy, O’Neill, Clarke-Moloney, Grace & Walsh, 2013)

Significance: Patients with Difficult Access

Question???

• Which category of population is subjected for ultrasound-guided peripheral venous access?

A) Obesity

B) History of IV drug use

C ) Chronic renal failure

D) Sickle cell disease

E) All of the above

Significance: Good Samaritan Hospital

• Most patients on the floor require peripheral intravenous lines.

• Most patients are obese or have a chronic illness, making intravenous insertion more difficult.

• Nurses are responsible for inserting all patients’ intravenous lines.

• Difficult intravenous access delays care of patients, decreases patient satisfaction, and causes unnecessary pain from multiple sticks.

https://www.google.com/search?q=accuvein+finder&espv=2&biw=1280&bih=923&source=lnms&tbm=isch&sa=X&ei=jCgsVev2DJCRsQSrtIGYBQ&ved=0CAcQ_AUoAg#tbm=isch&q=good+samaritan+hospital

Considerations: Benefits to Nursing

• Reduces the frequency of complications associated with the traditional technique

• Improves the ability of the nurse to quickly gain intravenous access

• Reduces hospital expenses

• Increases patient satisfaction

• Reduces the amount of time it takes to gain intravenous access(Stein, George, River, Hebig, McDermott, 2009; Bauman, Braude & Crandall, 2009; Egan, Healy, O’Neill, Clarke-Moloney, Grace & Walsh,

2013; Ault, Tanabe & Rosen, 2015; White, Lopez & Stone, 2010; Gregg, Murthi, Sisley, Stein & Scalea, 2009; Schoenfeld, Boniface & Shokoohi, 2011)

Literature Review• Articles Reviewed: 11

• Articles Appraised: 7

• Databases Searched: EBSCO-HOST, Google Scholar, Alvernia Interlibrary Loan

• Keywords Used: peripheral ultrasound, ultrasound-guidance, traditional IV insertion, peripheral IV insertion, peripheral guided IV insertion, ultrasound–guided peripheral access, ultrasonography, difficult vascular access

• Search Limits: subjects older than 18 years, years 2009 – present

Current Practice

• Traditional methods using knowledge of vascular anatomy. (Egan, Healy,

O’Neill, Clarke-Moloney, Grace & Walsh, 2013)

• Multiple intravenous attempts until successful or central line placement

(Bauman, Braude & Crandall, 2009)

• If nurses are unsuccessful in placing an intravenous access, it becomes the

physician’s responsibility to place an access. (Stein, George, River, Hebig &

McDermott, 2009)

• If ultrasonography is available, it can be utilized after the traditional

methods have failed. (White, Lopez & Stone, 2010)

Current Practice: Good Samaritan Hospital

• There is no intravenous team.

• Nurses are responsible for obtaining peripheral intravenous accesses

for all patients.

• Patients that require multiple attempts due to difficult access typically

have a peripherally inserted central line placed.

• Traditional intravenous methods are most commonly used.

• Staff have access to an AccuVein Finder to assist with difficult

accesses.

https://www.google.com/search?q=accuvein+finder&espv=2&biw=1280&bih=923&source=lnms&tbm=isch&sa=X&ei=jCgsVev2DJCRsQSrtIGYBQ&ved=0CAcQ_AUoAg

https://www.google.com/search?q=accuvein+finder&espv=2&biw=1280&bih=923&source=lnms&tbm=isch&sa=X&ei=jCgsVev2DJCRsQSrtIGYBQ&ved=0CAcQ_AUoAg#tbm=isch&q=good+samaritan+hospital

Summary of Evidence:Advantages

• “The US-guidance group had fewer complications (41.5%) compared to the

traditional technique group (64.7%).”(Bauman, Braude & Crandall, 2009)

• “The use of ultrasonography as an aid to the placement of central venous catheters

has been well established, generally showing increased success and decreased

rates of complications.” (Stein, George, River, Hebig & McDermott, 2009)

• “Decreasing complications of traditional insertion that include pain, arterial

puncture, nerve damage, and paresthesia.” (White, Lopez & Stone, 2010)

Summary of Evidence: Advantages

• “Ultrasound guidance was found to increase the likelihood of successful

cannulation.” (Egan, Healy, O’Neill, Clarke-Moloney, Grace & Walsh, 2013)

• “It (ultrasound) can produce high success rates for catheter placement with low

morbidity in diverse groups of patients.” (Gregg, Murthi, Sisley, Stein & Scalea,

2009)

• “In a post hoc analysis using greater than three skin punctures as the failure criterion

for both arms, US-guidance was significantly more successful (80.5%) compared to

traditional technique (44.1%).” (Bauman, Braude, & Crandall, 2009)

Summary of Evidence: Advantages

• “Cost reduction by avoiding critical care time and use of expensive

equipment for central catheter insertion, at the same time eliminating

exposure to iatrogenic complications such as pneumothorax and

bloodstream infection, which increase mortality, hospital length of stay

and healthcare costs.” (White, Lopez & Stone, 2010)

• “Increase patient comfort and satisfaction.” (White, Lopez & Stone, 2010)

Summary of Evidence:Advantages

• “Patients benefit from decreased exposure to risk from central venous access and , as cited

in the literature, experience satisfaction during their emergency department visit with this

nurse-provided intervention.” (White, Lopez & Stone, 2010)

• “Benefits of using ultrasonography for peripheral IV access include decreasing patient

throughput, cost reduction, decreasing complications, increased patient and emergency

medicine physician satisfaction, and emergency nurse autonomy.” (White, Lopez & Stone,

2010)

• “US-guidance had higher patient satisfaction (mean: 79mm) compared to the traditional

technique (mean 44mm).” (Bauman, Braude & Crandall, 2009)

Summary of Evidence:Advantages

• “The average time required for successful vessel cannulation was 19.57 minutes,

whereas the average time at the first attempt only was 10.88 minutes, suggesting a

clear improvement in the efficiency as proficiency improves” (Ault, Tanabe &

Rosen, 2015)

• “US-guidance was 2.0 times faster, requiring significantly less time for vascular

access compared to the traditional technique (mean 74.8 vs. 26.8 minutes).”

(Bauman, Braude & Crandall, 2009)

Summary of Evidence:Disadvantages

• “Overall, there was no statistically significant difference in procedure time

between Ultrasound and the ST group.” (Egan, Healy, O’Neill, Clarke-Moloney,

Grace & Walsh, 2013)

• “In the US-guidance group there were four arterial punctures (9.8%) whereas the

traditional technique group had none.” (Bauman, Braude & Crandall, 2009)

• “Success rates did not significantly differ (difference: 9.9%, 95% confidence

interval (CI)): -9.3%, 29.1%).” (Bauman, Braude & Crandall, 2009)

• “The patient satisfaction data also showed no clinically important difference

between groups.” (Stein, George, River, Hebig, McDermott, 2009)

Recommendations for Nursing Practice

• Educate staff on the advantages of using ultrasonography versus

traditional methods.

• Initiate a trial period using the ultrasound-guided peripheral

intravenous access method and monitor the outcomes.

• Initiate ultrasound-guided peripheral intravenous placement training

for nurses in order to obtain levels of proficiency and consistency.

• Initiate further research studies on larger study groups with varied

types of patients.

Question???

• Which of the following can be considered as a benefit to the nursing practice?

A) Reduces hospital expenses

B) Decreases infection rate

C) Allows higher rates of infusion

D) Requires less training to use ultrasound system

ReferencesArbique, D., Bordelon, M., Dragoo, R., & Huckaby, S. (2014). Ultrasound-guided access for peripheral intravenous

therapy. MEDSURG Nursing.

Ault, M. J., Tanabe, R., & Rosen, B. T. (2015). Peripheral intravenous access using ultrasound guidance: Defining the

learning curve. Journal Of The Association For Vascular Access, 20(1), 32-36. doi:10.1016/j.java.2014.10.012

Bauman, M., Braude, D., & Crandall, C. (2009). Ultrasound-guidance vs. standard technique in difficult vascular access

patients by ED technicians. American Journal Of Emergency Medicine, 27(2), 135-140.

doi:10.1016/j.ajem.2008.02.005

Egan, G., Healy, D., O'Neill, H., Clarke-Moloney, M., Grace, P. A., & Walsh, S. R. (2013). Ultrasound guidance for difficult

peripheral venous access: Systematic review and meta-analysis. Emergency Medicine Journal, 30(7), 521-526.

doi:10.1136/emermed-2012-201652

References (continued)

Gregg, S., Murthi, S., Sisley, A., Stein, D., & Scalea, T. (2010). Ultrasound-guided peripheral intravenous access in the intensive care

unit. Journal Of Critical Care, 25(3), 514-519. doi:10.1016/j.jcrc.2009.09.003

Schoenfeld, E., Boniface, K., & Shokoohi, H. (2011). ED technicians can successfully place ultrasound-guided intravenous catheters in

patients with poor vascular access. The American Journal of Emergency Medicine, 29(5), 496-501.

doi:10.1016/j.ajem.2009.11.021

Stein, J., George, B., River, G., Hebig, A., & McDermott, D. (2009). Ultrasonographically guided peripheral intravenous cannulation in

emergency department patients with difficult intravenous access: a randomized trial. Annals of Emergency Medicine,54(1), 33-

40. doi:10.1016/j.annemergmed.2008.07.048

White, A., Lopez, F., & Stone, P. (2010). Developing and sustaining an ultrasound-guided peripheral intravenous access program for

emergency nurses. Advanced Emergency Nursing Journal, 32(2), 173-188. doi:10.1097/TME.0b013e3181dbca70