Virginia Nurses Today - August 2020

Page 22 | August, September, October 2020
ULTRASOUND PIVS
Virginia Nurses Today | www.VirginiaNurses.com
Patrick Hill, DNP
Stephen Ankiel, RN
Lisa Milam, DNP
Virginia Commonwealth University Health System
Background
Intravenous (IV) therapy is one of the most frequent
types of treatment in the inpatient setting (Soifer,
Borzak, Edlin, & Weinstein, 1998), with up to 90% of
patients having peripheral intravenous access (PIV)
(Brown, 2004). Aside from discomfort related to the
disease process, insertion of PIVs are often considered
by patients to be the most distressing experience of
hospital stays (Stephens, O’Brian, Casey, et al, 1982).
The discomfort associated with PIV insertion may
lead to increased anxiety and physical responses to
future attempts to obtain access (Kennedy, Luhmann,
& Zempsky, 2008). This pain and anxiety can be a
contributing factor in patient dissatisfaction.
Although there may be several methods to reduce
discomfort secondary to PIV insertion (Hosseinabadi,
Biranvand, Pournia, & Anbari, 2015), minimizing
attempts is ideal, but this may not be feasible with
all patient populations. Notwithstanding the fact
that patients who are difficult to obtain vascular
access, and thus undergo more PIV attempts, the
literature reflects that there is no consensus on what
constitutes the difficult access patient population
(Partovi-Deilami, Nielson, Moller, Nesheim, &
Jorgensen, 2016). One study in the United States
found that patient populations with diabetes,
intravenous drug abuse, and sickle cell disease were
predisposed to be difficult for placing PIVs, whereas
renal failure and increased body mass index were
not significant factors (Fields, Piela, Au, & Ku, 2014).
However, Lapostelle, et al. (2007) found body mass
index to be a significant factor.
There is a substantial body of evidence supporting
the use of ultrasound (US) for vascular access. The
use of US has been shown to reduce complications
and has been used in practice for more than 30
years (Lamperti, et al., 2012). The evidence shows
that the utilization of US to guide PIV insertion
takes less time than traditional methods of insertion
(Egan, et al., 2013). Studies also show that US
guided PIV insertion has increased success rate
(89%), as opposed to the traditional method (55%)
(Constantino, Parlkh, Satz, & Fojtik, 2005). This
decrease of attempts at IV access has been shown
to lead to improved patient satisfaction (Bauman,
Evaluation of Methods for Ultrasound Guided
Peripheral Intravenous Catheter Insertion
Braude, & Crandall, 2009), and patients actually
preferred the US methods to traditional methods of
IV insertion because it was faster and required less
attempts (Schoenfeld, Shokoohi, & Boniface, 2011).
Using US can also reduce time by as much as 50%
to 75% (Partovi-Deilami, Nielson, Moller, Nesheim,
& Jorgensen, 2016). The success of cannulation on
the first attempt often averages 77 seconds (Keyes,
Frazee, Snoey, Simon, & Christy, 1999). The use of US
guided PIV insertion can also reduce the use of more
risky central venous catheter insertion (CVC) (Gregg,
Murthi, Sisley, Stein, & Scalea, 2010), although there
have been instances of US guided PIV insertion when
patient situation dictates that CVCs would be more
appropriate (Egan, et al., 2013), such as with certain
medications, for example vasopressors or long term
antibiotic treatments. Although US guidance is most
useful when veins cannot be visualized or palpated,
(Liu, Alsaawi, & Bjornsson, 2014), the chance of
success is eliminated with veins greater than 16 mm
deep and less than 3 mm in diameter (Panebianco,
et al., 2009). Panebianco (2009) also found that
increased vein size was a factor in success of vein
cannulation.
The traditional method of vein cannulation may be
defined as using palpation or visualizing the vessel
for venipuncture, usually accompanied by a form of
dilation with either a tourniquet or blood pressure
cuff inflation. The utilization of US has been shown
to be beneficial, however there are differing methods
of insertion, each with their possible advantages.
The short axis gives a cross sectional view of the
vessel, see Figure 1. The short axis method has
the advantage of visualization of the catheter tip
puncturing the vessel wall, but does not show the
length of catheter in the vessel. The long axis gives
a longitudinal view of the vessel, see Figure 2. The
long axis method of insertion may have the advantage
of visualizing a length of the vein for valves,
calcifications, or whether the vessel is tortuous, but
has the disadvantage of not showing if the tract of
catheter is lateral to the vessel during insertion.
Review of Literature
A review of the available literature to ascertain
the best methods of enhancing success of PIV
insertion with US guidance was conducted using
CINHAL, Pubmed, Google Scholar, and Ovid Medline
databases. The literature was first searched for
optimum methods of vein dilation using the search
terms: vein dilation, tourniquet, blood pressure cuff,
IV, and intravenous access. Three studies were found,
but the results were inconclusive. All of the studies
found that the use of blood pressure cuff inflation
dilates veins to a greater size (Mahler, et al., 2011),
inflated the cuff to above diastolic pressure, and did
not use this in a study of difficult access patients but
rather studied healthy volunteers.
Kule, Hang and Bahl (2013), after inflation of
the blood pressure cuff to 150 mm Hg, found the
significant increase of peripheral vein size and
decreased compressibility compared to one or two
tourniquets, but did not attempt vein cannulation
and studied healthy volunteers. The only study
that was conducted on actual patients (Nelson,
Jeanmonod, and Jeanmonod, 2014), compared the
use of tourniquet to blood pressure cuff inflated to
150mm Hg. They concluded that the tourniquet had
advantage over blood pressure cuff due to patient
discomfort of cuff inflation to that pressure. They
also reported that the cuff obstructed the site of PIV
insertion.
Using the same databases, the literature was then
searched using the keywords: ultrasound approach,
long axis, long plane, longitudinal axis, short axis,
short plane, and peripheral intravenous access using
the separator AND and OR. Four articles were found.
Fuzier, Rouge, and Pierre (2016) report that the long
axis gives the advantage of visualizing the needle
as it courses into the vessel, but may be difficult to
align, and little difference was found between the
long and short axis approach. A review by Gao, et al.
(2016) concluded that there was insufficient evidence
to determine a difference in success rate between the
long and short axis approach. Mahler, et al. (2010)
found that there was no statistical difference between
long and short axis approach, but that short axis may
have less insertion time. The operators in this study
had considerable experience in both approaches, but
mostly used the short axis method, and the study
population was healthy volunteers. Panebianco, et al.
(2009), found no significant difference between long
and short axis, but left the orientation to the choice of
the operators rather than randomization.
Study Question
From the literature available, there is no evidence
on how inflation of the blood pressure cuff to above
diastolic pressure for patients with difficult venous
access compares to a tourniquet. There is also no
conclusive evidence on the comparison of long axis to
short axis orientation of the US for needle approach
for venipuncture.
Due to this lack of definitive evidence on methods
to ensure success with US guided PIV insertion, two
research questions become relevant.
1. In difficult access adult patients, is a blood
pressure cuff inflated to above diastolic
pressure more effective for vein cannulation
than tourniquet?
2. In difficult access patients, does long axis
approach versus short axis result in more
successful vein cannulations?
Methods
Study Design
A prospective, randomized, non-blinded study
comparing long axis to short axis approach for US
guided PIV insertion. The study also compared
tourniquet to blood pressure cuff inflated to above
diastolic pressure. The patients’ method of PIV
insertion was chosen by a predetermined random
order by an Excel random number generator in order
of presentation. All members of the research team
performing the procedure were intensive care nurses
of similar levels of ultrasound training, IV insertion
skill, and experience.
Figure 1.
Short axis approach and cannulated vessel.
Figure 2.
Long axis approach and cannulated vessel.
Setting and Sample
A convenience sample of patients, N=64, with
difficult access needing US guided PIV insertion
in an urban academic hospital medical Intensive
Care Unit. For the purposes of this study, difficult
access patients were defined as any patient needing
peripheral access, but not central access, who
have had two unsuccessful attempts by traditional
landmark methods of PIV insertion.
Ultrasound PIVs continued on page 26