Great Books to Mold Great Leaders

Great Books to Mold Great Leaders

Director's Corner

Non-medical reading material to improve and expand your skills in management

So Your Kid Swallowed a Little Magnet...

So Your Kid Swallowed a Little Magnet...

Practical Pediatrics

How to handle the ingestion of rare earth magnets

Realign Incentives to Hold Down Costs

Realign Incentives to Hold Down Costs

Night Shift

Everyone agrees that we need to lower the cost of healthcare, but that’s about where the agreement ends

Talk So Patients Will Listen

Talk So Patients Will Listen

Oh Henry

Let's worry a little less about using big words, and a little more about being understood

When Paying More Taxes is a Good Thing

When Paying More Taxes is a Good Thing

Financial Consult

Upping your tax bill today may cost you less tomorrow

RLQ Abdominal Pain in Two-Year-Old

RLQ Abdominal Pain in Two-Year-Old

Visual Dx

Worse than a tummy ache

Crack the Contract Code

Crack the Contract Code

Legal Wrangle

The big deal about small print

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Nurses or other ancillary staff routinely perform the task of acquiring IV access, but at times they are unable to obtain access, which is important for laboratory evaluation or fluid or medicine administration. When this occurs, such as in an obese patient or a patient with IV drug abuse history, the onus falls on the physician to achieve intravenous access.

While several studies have shown increased success rates using ultrasound guidance during the establishment of central venous access, Costantino et al. sought to determine if ultrasound guidance for peripheral IV access in difficult to access patients would have similar results.

The study was designed to prospectively randomize patients who had a history of difficult access—due to obesity, history of intravenous drug use, or chronic medical problems—and had failed at least three attempts at access by a nurse. All patients who had a need for central venous access were excluded, as were pregnant patients, children, and those unable to consent. The patients were allocated to the ultrasonography-guided or the landmark and palpation (control) group based on the presentation to the ED on an odd or even day, respectively. The primary endpoints measured were IV access success rate, time from first percutaneous perforation to successful cannulation, time from request for physician-performed IV access to successful establishment of intravenous access (in order to also take into account time to find and set up the ultrasound machine), number of percutaneous perorations required, patient satisfaction, and complications from intravenous access.

A total of 60 patients were enrolled—39 into the US-guided IV access group, and 21 into the landmark and palpation group. The success rate for the ultrasonographic group was 97%, versus 33% for the control group. Patients undergoing US-guided required less overall time to establish IV access (13 minutes versus 30 minutes). The US-guided group also had less time to successful access from the first percutaneous puncture (4 minutes versus 15 minutes), had fewer percutaneous punctures (1.7 versus 3.7), and had a greater patient satisfaction (8.7 versus 5.7). There were no significant complications reported in either group.

While this study showed ultrasonography is an invaluable tool in aiding the physician in establishing IV access, it is notable that this study did employ a two-operator approach. Castantino et al. addressed this, mentioning a previous study showing no difference in success with US-guided peripheral IV access using either one or two operators. However, although it may not affect overall success of the peripheral IV placement, a single operator approach may or may not prolong the time to achieve access. Another limitation listed in the study was that, although there were three additional “odd” days, a larger than expected group was enrolled into the US-guided IV access group. The authors best explain this as a probable selection bias. In addition, the authors also thought it important to mention that those in the traditional group were allowed to attempt cannulation of the external jugular vein—as that is often what takes place in the “real world”. While this may introduce more bias, it would favor the control group and not the ultrasound group.
 

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