SonoStudy: Meta-analysis of 9 trials – ultrasound use for peripheral IVs in kids and adults #FOAMed

Not that we didnt already know this, but at least we have more data to say it is so – in a recent study in Annals of Emergency medicine – a meta analysis reviewed 9 trials – both kids and adults.

This concept has been getting a lot of press, and many of my ultrasound enthusiast friends have passed this around. It’s good to know the concept – and use it when you are in a conversation with someone who thinks the blind technique it still the way to go.

“Pediatric trials yielded conflicting data, the authors reported February 18 online in Annals of Emergency Medicine, but there appeared to be significantly fewer attempts and shorter procedure times when ultrasound guidance was used in the emergency department, as well as significantly decreased risk of first-attempt failure, reduced attempts, and shorter procedure time when ultrasound guidance was used in the operating room…..”Ultrasonographically guided peripheral intravenous cannulation may perform better in the pediatric population because failure rates with the traditional method are much higher in children than adults,” the researchers note. “Ultrasonography may not be as beneficial in adults, in whom target vessels are easier to locate.” – Now, these trials were from operating room patients, where the setting is a bit more controlled, the patients may be a bit different in their difficult IV access spectrum – but the authors still suggest that if faced with a difficult IV – use ultrasound.

Below is the abstract:

Study objective

Peripheral intravenous cannulation is procedurally challenging and painful. We perform a systematic review to evaluate ultrasonographic guidance as an aid to peripheral intravenous cannulation.

Methods

We searched MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, ClinicalTrials.gov, and Google.ca. We included randomized trials evaluating ultrasonographically guided peripheral intravenous cannulation and reporting risk of peripheral intravenous cannulation failure, number of attempts, procedure time, or time from randomization to peripheral intravenous cannulation. We separately analyzed pediatric and adult data and emergency department (ED), ICU, and operating room data. Quality assessment used the Cochrane Risk of Bias Tool.

Results

We identified 4,664 citations, assessed 403 full texts for eligibility, and included 9 trials. Five had low risk, 1 high risk, and 3 unclear risk of bias. A pediatric ED trial found that ultrasonography decreased mean difference (MD) in the number of attempts (MD −2.00; 95% confidence interval [CI] −2.73 to −1.27) and procedure time (MD −8.10 minutes; 95% CI −12.48 to −3.72 minutes). In an operating room pediatric trial, ultrasonography decreased risk of first-attempt failure (risk ratio 0.23; 95% CI 0.08 to 0.69), number of attempts (MD −1.50; 95% CI −2.52 to −0.48), and procedure time (MD −5.95; 95% CI −10.21 to −1.69). Meta-analysis of adult ED trials suggests that ultrasonography decreases the number of attempts (MD −0.43; 95% CI −0.81 to −0.05). Ultrasonography decreased risk of failure (risk ratio 0.47; 95% CI 0.26 to 0.87) in an adult ICU trial.

Conclusion

Ultrasonography may decrease peripheral intravenous cannulation attempts and procedure time in children in ED and operating room settings. Few outcomes reached statistical significance. Larger well-controlled trials are needed.

For more info and a how-to for ultrasound guided procedures, including ultrasound-guided peripheral IV and central IV acces – go here.

SonoStudy: A time-series analysis: central IV rate after US-guided peripheral IV program

A recent study in the Annals of EM by Shokoohi et al did a time series analysis of the rate of central line requirements after an US-guided peripheral IV program was implemented – 80% reduction! you read that right…. read on for the abstract:

“Study objective
We examine the central venous catheter placement rate during the implementation of an ultrasound-guided peripheral intravenous access program.

Methods
We conducted a time-series analysis of the monthly central venous catheter rate among adult emergency department (ED) patients in an academic urban ED between 2006 and 2011. During this period, emergency medicine residents and ED technicians were trained in ultrasound-guided peripheral intravenous access. We calculated the monthly central venous catheter placement rate overall and compared the central venous catheter reduction rate associated with the ultrasound-guided peripheral intravenous access program between noncritically ill patients and patients admitted to critical care. Patients receiving central venous catheters were classified as noncritically ill if admitted to telemetry or medical/surgical floor or discharged home from the ED.

Results
During the study period, the ED treated a total of 401,532 patients, of whom 1,583 (0.39%) received a central venous catheter. The central venous catheter rate decreased by 80% between 2006 (0.81%) and 2011 (0.16%). The decrease in the rate was significantly greater among noncritically ill patients (mean for telemetry patients 4.4% per month [95% confidence interval {CI} 3.6% to 5.1%], floor patients 4.8% [95% CI 4.2% to 5.3%], and discharged patients 7.6% [95% CI 6.2% to 9.1%]) than critically ill patients (0.9%; 95% CI 0.6% to 1.2%). The proportion of central venous catheters that were placed in critically ill patients increased from 34% in 2006 to 81% in 2011 because fewer central venous catheterizations were performed in noncritically ill patients.

Conclusion
The ultrasound-guided peripheral intravenous access program was associated with reductions in central venous catheter placement, particularly in noncritically ill patients. Further research is needed to determine the extent to which such access can replace central venous catheter placement in ED patients with difficult vascular access.”

Great videos for Peripheral venous access:

And, to watch an installment of the UltrasoundPodcast of their IV course, watch here.

SonoStudies: US for hip dislocations, septic hips, and fascia ilaca block for hip fractures

Quite a few recent studies on bedside ultrasound have focused on the hip, as it should, since it is so darn hard to evaluate it by the physical exam alone. Well, not only could ultrasound be used for diagnosing hip dislocations (as evidenced by the below case report), but it is also great for evaluating septic hip joints by visualizing the effusions and helping in its arthrocentesis needs …..as well as using ultrasound for ultrasound-guided fascia iliaca compartment block for hip fractures (especially in the elderly who you’d rather not give a ton of opiates to). – These are all from the Journal of EM.

The first case report discusses a 51 yr old man who was brought in the ED 20 minutes after a fall on wet grass while playing basketball (I know -good for him for staying active!). The current standard of care is to order an Xray. But, sometimes the Xray will not give you the information you need and you may go to CT, or the radiology tech is busy with traumas or other inpatient needs. In this case, the Ap Pelvis XR was normal. Well, never fear – the ultrasound is here! The diagnosis was made of an anterior hip dislocation by ultrasound. See the image below of his dislocated Right hip and normal Left hip when they used their curvilinear probe in anterior, mid-axial and coronal planes:

Another case report recently published discusses an 18 yr old female c/o 5 days of hip pain radiating down her anterior thigh and worse with weight bearing and hip movement. No fevers or other symptoms… oh, and she is 23 weeks pregnant. Now, the diagnosis of septic hips is a clinical one yet, sometimes, it can fool the best of us. I know Ive seen a patient with a septic hip walk…yes, with a limp, but still walk… saying “I think I just twisted it.” She was a bounce back to the (different) ED for persistent hip pain after an US was negative for DVT. She had mild leukocytosis (but what pregnant patient doesn’t!?!). The ED docs took a look with their ultrasound machine and saw an effusion (top picture below) (compared it to the opposite a-symptomatic hip (bottom picture below)) and then performed an ultrasound-guided arthrocentesis of purulent fluid: arrow and closed arrow is the femoral head and neck, respectively.

For a great podcast, the only way they know how to make it even more enjoyable – check out UltrasoundPodcast insert for hip ultrasund, aspiration and injection.

Now, the last study I will highlight, is one that is a more common concept/indication for hip issues – the fascia iliaca block for hip fractures. “”Hip fracture (HFx) is a painful injury that is commonly seen in the emergency department (ED). Patients who experience pain from HFx are often treated with intravenous opiates, which may cause deleterious side effects, particularly in elderly patients. An alternative to systemic opioid analgesia involves peripheral nerve blockade”  – word! A small study showing a decrease in pain scale in over 75% of the patients:

SonoStudy: US-guided lines by nurses (& docs) reduce need for physician intervention (& central lines!) for difficult access

A recent study, from the Journal of Emergency Medicine, by Weiner et al at Tufts University, in addition to so many of the prior studies, proves that nurses SHOULD perform ultrasound guided peripheral line placement. they are good at it, they do it right, and they do it well. Oh, and patients love it.

“Emergency physicians (EPs) have become facile with ultrasound-guided intravenous line (USIV) placement in patients for whom access is difficult to achieve, though the procedure can distract the EP from other patient care activities…..A prospective multicenter pilot study: Interested emergency nurses (ENs) received a 2-h tutorial from an experienced EP. Patients were eligible for inclusion if they had either two failed blind peripheral intravenous (i.v.) attempts, or if they reported or had a known history of difficult i.v. placement. Consenting patients were assigned to have either EN USIV placement or standard of care (SOC).” 50 patients enrolled, 29 assigned to USIV and 21 to SOC. “Physicians were called to assist in 11/21 (52.4%) of SOC cases and 7/29 (24.1%) of USIV cases (p = 0.04). Patient satisfaction was higher in the USIV group, though the difference did not reach statistical significance (USIV 86.2% vs. SOC 63.2%, p = 0.06). ”

And, even more recently, another study:

Ultrasound-Guided Peripheral Intravenous Access Program Is Associated With a Marked Reduction in Central Venous Catheter Use in Noncritically Ill Emergency Department Patients.

by Shokoohi et al from George Washington University published in the Annals of Emergency Medicine has been getting quite a bit of press – particularly from MedwireNews: “Training emergency department (ED) staff in use of ultrasound to guide difficult peripheral intravenous catheter placement appears to reduce the unnecessary use of central venous lines, a study suggests. The reduction in central venous line use after the introduction of ultrasound training was particularly notable for patients who were not critically ill, report Hamid Shokoohi (George Washington University, DC, USA) and colleagues…..They say that this has “potentially major implications for patient safety,” noting that around 15% of the 5 million central venous catheters placed in the USA annually result in complications, which can include blood infections, thrombosis, vessel damage, and hematomas.”

The study itself was: “….a time-series analysis of the monthly central venous catheter rate among adult emergency department (ED) patients in an academic urban ED between 2006 and 2011. During this period, emergency medicine residents and ED technicians were trained in ultrasound-guided peripheral intravenous access. We calculated the monthly central venous catheter placement rate overall and compared the central venous catheter reduction rate associated with the ultrasound-guided peripheral intravenous access program between noncritically ill patients and patients admitted to critical care. Patients receiving central venous catheters were classified as noncritically ill if admitted to telemetry or medical/surgical floor or discharged home from the ED. RESULTS: During the study period, the ED treated a total of 401,532 patients, of whom 1,583 (0.39%) received a central venous catheter. The central venous catheter rate decreased by 80% between 2006 (0.81%) and 2011 (0.16%). The decrease in the rate was significantly greater among noncritically ill patients (mean for telemetry patients 4.4% per month [95% confidence interval {CI} 3.6% to 5.1%], floor patients 4.8% [95% CI 4.2% to 5.3%], and discharged patients 7.6% [95% CI 6.2% to 9.1%]) than critically ill patients (0.9%; 95% CI 0.6% to 1.2%). The proportion of central venous catheters that were placed in critically ill patients increased from 34% in 2006 to 81% in 2011 because fewer central venous catheterizations were performed in noncritically ill patients. CONCLUSION: The ultrasound-guided peripheral intravenous access program was associated with reductions in central venous catheter placement, particularly in noncritically ill patients. Further research is needed to determine the extent to which such access can replace central venous catheter placement in ED patients with difficult vascular access.”

A great video on the scanning technique and choosing the right vein can be found here by SonoSite and taught by my good friend, Diku Mandavia:

Another great how-to video can be found here: although long, its a good one for a step-by-step, from the New England Journal of Medicine:

SonoParty…&Journal Club… in Northern CA: Stanford, UCSF, UCSF/Fresno, UC Davis, Highland, Kaisers

Prior to leaving for ACEP in Denver, CO there was a gathering (aka “party”) at my home in sunny San Francisco with my friends and colleagues in emergency medicine / emergency ultrasound  – from all of the ultrasound programs in the region – it was amazing… and yes, wine was served! … along with pizza (of course!) We discussed 4 articles as listed below and I took down the US pearls noted from the various physicians who attended:

SonoStudy: Many emergency physicians feel uncomfortable with US-guided central venous access

In the an issue of West JEM, Backlund et al did a survey study of emergency physicians in Colorado with 116 responses asking questions about their use (or lack thereof) bedside ultrasound for central venous access. Quite a few, too many actually, feel uncomfortable using ultrasound for central venous access. 97% of them have ultrasound machines in their department, so it’s not because of a lack of equipment. 77% agree with the statement:”Ultrasound guidance is the preferred method for central venous catheter placement in the emergency department.”  So what was it? Well, it’s always the easiest and most obvious answer: their lack of training and, therefore, a lack of comfort level. “47% cite lack of training in UGCVC as a barrier to performing the technique.”

SonoReview: US-guided Interscalene nerve blocks

Hope you had a Happy 4th! To all those who received patients with an upper extremity that has been burned, fractured, or blown away from all the “legal” fireworks foreplay……

Pain control. Two words. Patient satisfaction. Two more words. Physician satisfaction. Two MORE words. Nerve blocks are the new procedural sedation for many painful procedures we do in the ED. Takes much less resources and time, and provides immediate pain control for however long your anesthetic will work without concern for respiratory distress, hypotension, hypoxia, and… well… death. So why dont we do it more? Well, in a prior post, we have discussed the ins & outs for performing US guided nerve blocks with the help of some of my colleagues, some of whom are mentioned below.

SonoStudy: US-Guided Nerve Blocks – in disasters, your ED, and your hearts

Given this memorial day weekend, and the sacrifice of our troops, lets discuss something that the military has used for years – and for good reason. US-guided nerve blocks are becoming more and more utilized in our EDs. Especially when we have the elderly patient who is in severe pain from a humeral fracture or a femoral neck fracture, and you’d rather not have to watch (and chase) their blood pressure after giving systemic opiates. It is also a great resource in resource-poor areas, like the aftermath of the disaster of the Haiti earthquake. This is all clearly discussed in the article in Annals of Emergency Medicine this month by Drs. Suzanne Lippert, Arun Nagdev, Mike Stone, Andrew Herring, and Robert Norris.