- Email: [email protected]
222 What Is the Ideal Site for Ultrasonography-Guided Saphenous Vein Cannulation in Adults?
Research Forum Abstracts There was a difference in proficiency on the pre-test written exam between the 2 groups, p⬍0.05 (Group 1⫽60%, Group 2⫽73.2%). There was no difference between the 2 groups on the post-test written exams, p⫽0.07 (Group 1⫽96.5%, Group 2⫽100%). Both groups had significant improvement from written pre-test to post-test, p⬍0.05. Conclusion: Traditional didactic lectures and multimedia tutorial provides equal education to emergency medicine residents. The lack of improvement on the handson practical in the multimedia group may be accounted by the small number or inability to interact with the lecturer.
222
What Is the Ideal Site for Ultrasonography-Guided Saphenous Vein Cannulation in Adults?
Jones T, Adhikari S, Stolz U/University of Arizona Medical Center, Tucson, AZ
Study Objectives: Peripheral intravenous (IV) access is a common and essential procedure of patient care in the emergency department (ED). Ultrasonography-guided peripheral IV cannulation has been shown to be safe, rapid and has high success rate in patients with difficult peripheral venous access. Patients with history of kidney failure, IV drug use, organ transplant and obesity lack easily located upper extremity peripheral venous sites. The saphenous vein was mostly identified with venous cut down in prior studies and in the recent years physician experience with saphenous vein cut down is limited. To our knowledge no literature exists demonstrating ultrasonography visualization of the saphenous vein for peripheral IV cannulation in adults. The objective of our study is to identify the saphenous veins using ultrasonography in adult ED patients, and to determine the ideal location for ultrasonography guided cannulation. Methods: Prospective observational study at an urban academic ED. Inclusion Criteria: Adult patients ⬎ 18 years. Exclusion Criteria: evidence of pathologic changes to the leg, including fracture, amputation, congenital or acquired deformity/contractures, skin infection, venous insufficiency. After obtaining an informed consent, an ultrasonography examination was performed using a 10-5 MHz linear transducer. saphenous vein was identified at 3 distinct sites after placing the tourniquet: the ankle, mid-calf, and below the knee. The time taken to visualize the saphenous vein was recorded. The depth of saphenous vein from the skin surface and the diameter of saphenous vein were measured. All measurements were obtained in supine and reverse trendelenburg positions in both extremities. Other variables such as age, sex and BMI were collected. The images were reviewed by an expert sonographer for technical quality and confirmation of visualization of saphenous vein and measurements. Continuous variables are presented as means with 95% confidence intervals. Multilevel (hierarchical) mixed effects linear regression models were used for data analysis. Results: A total of 27 subjects were enrolled in the study. The mean age of the patients (female-17, male-10) was 50 years ⫹/⫺ 20.9 (SD). The average BMI was 28.5 ⫹/⫺ 7.4 (SD). saphenous vein was visualized at all locations using ultrasonography in all subjects without any difficulty. The mean time to visualize saphenous vein with ultrasonography was 2.8 sec. The mean depth of saphenous vein form the skin surface at the ankle level was 4.64 mm (CI, 4.18-5.11) and was significantly smaller than the other 2 anatomic locations after controlling for BMI, age, and sex. The mean depth of saphenous vein at the calf location was 2.3 mm deeper than at the ankle, and the vein depth at the knee was 5.4 mm deeper than at the ankle. The mean diameter of saphenous vein at ankle level was 3.13 mm (CI, 2.75 3.51) and was significantly larger than at the other locations, after controlling for BMI, age, sex, and patient orientation (reverse trendelenberg versus supine). The mean saphenous vein diameter at the calf was 0.43 mm smaller than at the ankle and the saphenous vein diameter at the knee was 0.26 mm smaller than at the ankle. In addition, the saphenous vein diameter was 0.37 mm larger in reverse trendelenberg position compared to supine position, after controlling for vein location (ankle, calf, or knee), BMI, age, and sex. Conclusion: Saphenous vein was identified in all subjects using ultrasonography. Our results suggest that ultrasonography-guided saphenous vein cannulation can be ideally performed at the level of ankle while the patient is in the reverse trendenlenberg position because of its superficial location and greatest diameter.
Volume , . : October
223
Difficult Intravenous Catheter Access in Emergency Department Patients: Can Ultrasonography Help Reduce Central Line Days?
Rice CG, Leeson B, Adams K, Leeson K/Christus Spohn Memorial Residency Program, Corpus Christi, TX
Study Objectives: To evaluate whether ultrasonography-guided IV serves as an effective alternative to central line placement in the emergency department setting. This study also evaluated whether ultrasonography-guided IV can help reduce central line days to patients visiting an academic emergency department. Methods: Patients in which experienced emergency department nurses were not successful at placing an intravenous catheter were optionally enrolled in a prospective, observational study conducted at CHRISTUS Spohn Memorial emergency department between 09/1/2011 to 08/30/2012. After appropriate consent was obtained, an attending emergency physician or a resident physician placed an ultrasonography-guided deep brachial or basilic IV. The treating physician subsequently completed a data collection sheet documenting the number of nursing attempts, reason for intravenous access, number of physician attempts, size of IV catheter, and any complications. At the completion of the study period a retrospective chart review was performed on each patient to determine: the longevity of the IV, any documented complication, the percent of patients admitted to the hospital, and any need for central line during hospitalization. Results: Fourteen patients were enrolled in the study. The mean number of central line days saved in the study was 2.29 ⫾3.52. The first attempt success rate of US guided IV was 64.29%. The mean nursing IV attempts in the study population was 3.86 ⫾ 1.46. The mean physician ultrasonography-guided IV attempts was 1.71 ⫾ 1.14. 64.29 % of the patients enrolled in the study were admitted to the hospital. 44.44 percent of these patients eventually required a central line. The complication rate carried out throughout the hospital admission was 0%. A central line was eventually placed in 28.57% of the patients enrolled in this study. 42.86% of the patients in the study had a central line during a previous hospitalization. Conclusion: More than 15 percent of patients who receive central line catheters have complications. Complications include mechanical complications, infectious complications and thrombotic complications. This study confirmed the low complication rate of ultrasonography-guided IVs performed by physicians in an emergency department. The mean number of central line days saved was 2.29 central line days per patient, which lower than originally expected. Central line placement was avoided in 71.43% of patients enrolled in the study. This demonstrates that the use of US guided IVs in the emergency department can reduce the need for central lines safely in patients who have failed traditional peripheral IV attempts in the emergency department. The mean number of US guided IV attempts in the study was 1.71 attempts, which was satisfactory to the patients enrolled in the study. Further inference of clinical and statistical significance will require a larger patient sample size then obtained in this study.
224
Sonographic Measurement of Glenoid to Humeral Head Distance in Normal and Dislocated Shoulders in the Emergency Department
Becker B, Chiem A, Youssefian A, Le L, Peyton M, Fox C/UC Irvine, Orange, CA
Study Objectives: There is very little data on the normal distance between the glenoid rim and the posterior aspect of the humeral head in normal and dislocated shoulders. While shoulder radiography is commonly used to detect shoulder dislocations, they may be inadequate, exacerbate pain in the acquisition of some views, and lead to delay in treatment, compared to bedside ultrasonography evaluation. Our objective was to compare the glenoid rim to humeral head distance in normal shoulders with that in anteriorly dislocated shoulders. This is the first study proposing to set normal and abnormal limits. Methods: Subjects were enrolled in this prospective observation study if they had a chief complaint of shoulder pain or injury, and received a shoulder ultrasonography as well as a shoulder radiography. The sonographers were undergraduate students given ten hours of training to perform the shoulder ultrasonography. They were blinded to the radiography interpretation, which was used as the gold standard. We used a posterior-lateral approach, capturing an image with the glenoid rim, the humeral head, as well as the infraspinatus muscle. Two parallel lines were applied to the most posterior aspect of the humeral head and the most posterior aspect of the glenoid rim. A line perpendicular to these lines was applied, and the distance
Annals of Emergency Medicine S81
222
What Is the Ideal Site for Ultrasonography-Guided Saphenous Vein Cannulation in Adults?
Jones T, Adhikari S, Stolz U/University of Arizona Medical Center, Tucson, AZ
Study Objectives: Peripheral intravenous (IV) access is a common and essential procedure of patient care in the emergency department (ED). Ultrasonography-guided peripheral IV cannulation has been shown to be safe, rapid and has high success rate in patients with difficult peripheral venous access. Patients with history of kidney failure, IV drug use, organ transplant and obesity lack easily located upper extremity peripheral venous sites. The saphenous vein was mostly identified with venous cut down in prior studies and in the recent years physician experience with saphenous vein cut down is limited. To our knowledge no literature exists demonstrating ultrasonography visualization of the saphenous vein for peripheral IV cannulation in adults. The objective of our study is to identify the saphenous veins using ultrasonography in adult ED patients, and to determine the ideal location for ultrasonography guided cannulation. Methods: Prospective observational study at an urban academic ED. Inclusion Criteria: Adult patients ⬎ 18 years. Exclusion Criteria: evidence of pathologic changes to the leg, including fracture, amputation, congenital or acquired deformity/contractures, skin infection, venous insufficiency. After obtaining an informed consent, an ultrasonography examination was performed using a 10-5 MHz linear transducer. saphenous vein was identified at 3 distinct sites after placing the tourniquet: the ankle, mid-calf, and below the knee. The time taken to visualize the saphenous vein was recorded. The depth of saphenous vein from the skin surface and the diameter of saphenous vein were measured. All measurements were obtained in supine and reverse trendelenburg positions in both extremities. Other variables such as age, sex and BMI were collected. The images were reviewed by an expert sonographer for technical quality and confirmation of visualization of saphenous vein and measurements. Continuous variables are presented as means with 95% confidence intervals. Multilevel (hierarchical) mixed effects linear regression models were used for data analysis. Results: A total of 27 subjects were enrolled in the study. The mean age of the patients (female-17, male-10) was 50 years ⫹/⫺ 20.9 (SD). The average BMI was 28.5 ⫹/⫺ 7.4 (SD). saphenous vein was visualized at all locations using ultrasonography in all subjects without any difficulty. The mean time to visualize saphenous vein with ultrasonography was 2.8 sec. The mean depth of saphenous vein form the skin surface at the ankle level was 4.64 mm (CI, 4.18-5.11) and was significantly smaller than the other 2 anatomic locations after controlling for BMI, age, and sex. The mean depth of saphenous vein at the calf location was 2.3 mm deeper than at the ankle, and the vein depth at the knee was 5.4 mm deeper than at the ankle. The mean diameter of saphenous vein at ankle level was 3.13 mm (CI, 2.75 3.51) and was significantly larger than at the other locations, after controlling for BMI, age, sex, and patient orientation (reverse trendelenberg versus supine). The mean saphenous vein diameter at the calf was 0.43 mm smaller than at the ankle and the saphenous vein diameter at the knee was 0.26 mm smaller than at the ankle. In addition, the saphenous vein diameter was 0.37 mm larger in reverse trendelenberg position compared to supine position, after controlling for vein location (ankle, calf, or knee), BMI, age, and sex. Conclusion: Saphenous vein was identified in all subjects using ultrasonography. Our results suggest that ultrasonography-guided saphenous vein cannulation can be ideally performed at the level of ankle while the patient is in the reverse trendenlenberg position because of its superficial location and greatest diameter.
Volume , . : October
223
Difficult Intravenous Catheter Access in Emergency Department Patients: Can Ultrasonography Help Reduce Central Line Days?
Rice CG, Leeson B, Adams K, Leeson K/Christus Spohn Memorial Residency Program, Corpus Christi, TX
Study Objectives: To evaluate whether ultrasonography-guided IV serves as an effective alternative to central line placement in the emergency department setting. This study also evaluated whether ultrasonography-guided IV can help reduce central line days to patients visiting an academic emergency department. Methods: Patients in which experienced emergency department nurses were not successful at placing an intravenous catheter were optionally enrolled in a prospective, observational study conducted at CHRISTUS Spohn Memorial emergency department between 09/1/2011 to 08/30/2012. After appropriate consent was obtained, an attending emergency physician or a resident physician placed an ultrasonography-guided deep brachial or basilic IV. The treating physician subsequently completed a data collection sheet documenting the number of nursing attempts, reason for intravenous access, number of physician attempts, size of IV catheter, and any complications. At the completion of the study period a retrospective chart review was performed on each patient to determine: the longevity of the IV, any documented complication, the percent of patients admitted to the hospital, and any need for central line during hospitalization. Results: Fourteen patients were enrolled in the study. The mean number of central line days saved in the study was 2.29 ⫾3.52. The first attempt success rate of US guided IV was 64.29%. The mean nursing IV attempts in the study population was 3.86 ⫾ 1.46. The mean physician ultrasonography-guided IV attempts was 1.71 ⫾ 1.14. 64.29 % of the patients enrolled in the study were admitted to the hospital. 44.44 percent of these patients eventually required a central line. The complication rate carried out throughout the hospital admission was 0%. A central line was eventually placed in 28.57% of the patients enrolled in this study. 42.86% of the patients in the study had a central line during a previous hospitalization. Conclusion: More than 15 percent of patients who receive central line catheters have complications. Complications include mechanical complications, infectious complications and thrombotic complications. This study confirmed the low complication rate of ultrasonography-guided IVs performed by physicians in an emergency department. The mean number of central line days saved was 2.29 central line days per patient, which lower than originally expected. Central line placement was avoided in 71.43% of patients enrolled in the study. This demonstrates that the use of US guided IVs in the emergency department can reduce the need for central lines safely in patients who have failed traditional peripheral IV attempts in the emergency department. The mean number of US guided IV attempts in the study was 1.71 attempts, which was satisfactory to the patients enrolled in the study. Further inference of clinical and statistical significance will require a larger patient sample size then obtained in this study.
224
Sonographic Measurement of Glenoid to Humeral Head Distance in Normal and Dislocated Shoulders in the Emergency Department
Becker B, Chiem A, Youssefian A, Le L, Peyton M, Fox C/UC Irvine, Orange, CA
Study Objectives: There is very little data on the normal distance between the glenoid rim and the posterior aspect of the humeral head in normal and dislocated shoulders. While shoulder radiography is commonly used to detect shoulder dislocations, they may be inadequate, exacerbate pain in the acquisition of some views, and lead to delay in treatment, compared to bedside ultrasonography evaluation. Our objective was to compare the glenoid rim to humeral head distance in normal shoulders with that in anteriorly dislocated shoulders. This is the first study proposing to set normal and abnormal limits. Methods: Subjects were enrolled in this prospective observation study if they had a chief complaint of shoulder pain or injury, and received a shoulder ultrasonography as well as a shoulder radiography. The sonographers were undergraduate students given ten hours of training to perform the shoulder ultrasonography. They were blinded to the radiography interpretation, which was used as the gold standard. We used a posterior-lateral approach, capturing an image with the glenoid rim, the humeral head, as well as the infraspinatus muscle. Two parallel lines were applied to the most posterior aspect of the humeral head and the most posterior aspect of the glenoid rim. A line perpendicular to these lines was applied, and the distance
Annals of Emergency Medicine S81