- Email: [email protected]
335 Procedural Competency in Ultrasound-Guided Peripheral Intravenous Catheter Insertion in a Pediatric Emergency Department
Research Forum Abstracts
335
Procedural Competency in Ultrasound-Guided Peripheral Intravenous Catheter Insertion in a Pediatric Emergency Department
Blick C, Vinograd A, Mitchell C, Shin S, Chen A/Children’s Hospital of Philadelphia, Philadelphia, PA
Study Objectives: To evaluate if there is a threshold number of encounters after which providers reliably perform ultrasound guided peripheral intravenous (USGPIV) catheter placements in children with a high success rate. A secondary aim was to analyze complication rates of USGPIV catheters placed by providers. Methods: As part of a quality improvement program, a database was maintained for all USGPIV encounters in our emergency department (ED) from June 2011 to May 2017. Our ED is located within a free-standing tertiary care children’s hospital and sees over 90,000 children annually. The name of the ED practitioner attempting placement and whether it was successful was recorded for all USGPIV encounters. Patient electronic medical records were reviewed for the reason for IV removal. ED practitioners included attending physicians, pediatric emergency medicine (EM) fellows, nurses, and pediatric and EM residents. All USGPIVs were placed by a single-operator using dynamic ultrasound guidance in an out-of plane approach. The probability of successful IV placement at each encounter was calculated using Microsoft Excel (2008). These probabilities were plotted versus encounter number to graph a best-fit logarithmic regression. Using this regression equation, the number of encounters needed to achieve a probability of success of 90% was calculated. The probability of a complication after each successful USGPIV placement was also calculated, plotted versus encounter number, and overlayed with a logarithmic regression line. Results: We analyzed 3,047 encounters involving 88 providers. Of those, 2,860 (94%) were successful and 187 (6%) were unsuccessful. 35 providers had 10 or more encounters. The probability of successfully placing an USGPIV increased as providers had more experience placing USGPIVs (Figure 1). After 2 encounters, the probability of success was 80%. After 10 encounters, the probability of success reached 88%. At 14 encounters, the probability of success was 90%. IV removal reason was available for 1,178 encounters. 850 (72%) were removed because they were no longer needed. 260 (22%) had complications, and 68 (6%) were unintentionally dislodged. Complications included infiltration, phlebitis, line occlusion, and “other” (eg, pain or bleeding at site). Complication rates were calculated and graphed for 31 providers who had at least 5 encounters. There was no statistically significant relationship between the number of encounters per provider and complication rates (R2 ¼0.015). Conclusions: Our data suggests a threshold number of encounters after which providers reliably place USGPIVs in children with a high success rate. In our single institution study, a 90% success rate was achieved after an average of 14 encounters. Additionally, we found an overall low complication rate of 22%, and no change in complication rates as providers gained more experience.
336
A Comparison of Anatomical Landmark vs Ultrasound Static vs Ultrasound Real-Time Technique for Internal Jugular Vein Cannulation
Jeyaraj NI, Jena NN, Smith J, Douglas K/Meenakshi Mission Hospital and Research centre, Madurai, India; George Washington University, Washington DC
Study Objectives: Ultrasound-guided real-time technique (US RT) for internal jugular vein (IJV) access is the gold standard recommendation for IJV cannulation. Ultrasound static technique (US ST) (prelocation of IJV with ultrasound and marking the venipuncture site on the neck and cannulating with guidance skin marking) can also be used to cannulate IJV in most of the patients requiring IJV assess in the emergency department (ED) and Intensive Care Unit (ICU) with equal success rate, reduced complication, better field sterility, better utilization of resources, and with an overall lower cost. However, there are limited studies that compare US RT vs US ST for IJV cannulation for emergency access in India. None of the previous studies have taken into account the depth of IJV from skin, diameter of IJV, respiratory change in diameter of IJV and have associated it with the difficulty of the cannulation and final success rate. The objective of this study was to compare the success rates, complications and mean cannulation time using 3 techniques: 1)Ultrasound real-time (US RT) 2) Ultrasound static (US ST) and 3) Anatomical landmark (ALM) techniques (without ultrasound) for IJV cannulation. Methods: We prospectively enrolled patients presenting to an emergency department or ICU setting at a single tertiary care hospital in Southern India. Patients were randomized by closed envelope method to receive IJV cannulation by US ST or US RT or ALM by emergency department residents over a 2 year period. We measure the rate of overall success, first pass success rates, and mean cannulation time in each group. In addition, among the ultrasound groups, we compared success rates in complicated cases (increased depth of the IJV from skin, degree of respiratory variation of IJV diameter and the diameter of IJV). Setting and Design: A prospective, randomized, observational study was conducted at a tertiary care hospital. Statistical Analysis: We used SPSS 16 software and Sigma stat 3.5 version to analyze data. Using ANOVA and chi-squared tests, we analyzed differences in the mean number of attempts and time until success between all the three groups in our study. A p value of less than 0.05 was taken as significant. Results: We enrolled a total of 120 patients in our study, with 40 patients in each group. Success rates were 100% in US RT, 77.5% in US ST, and 70% in the ALM group. There were no difference between first pass success rates between US ST and US RT groups; however, first pass rate was better in both groups as compared to the ALM group.There was no statistical difference between the three groups with regards to final success. Venous cannulation time was lowest in the US ST group, followed by the US RT group and longest in the ALM group. In difficult cannulation with IJV depth from the skin 1.1cm and above or with inspiratory diameter of IJV 0.7cm or less, the US RT group had 100% success rate compared to a success rate of only 10% in the US ST group (p< 0.001). Conclusions: Both US RT and US ST are superior to the ALM technique. Although US RT has better overall success rate than US ST, US RT requires adequate training, more time, sterile scanner manipulation, and more resources, which translates into increased overall cost than US ST. US ST has statistically similar success rate, reduced complication, and better field sterility in most patients where the cannulation of IJV was not difficult.
337
Accuracy of Landmark-Guided Glenohumeral Intra-Articular Injections in Patients With Anterior Shoulder Dislocations
Omer T, Mailhot T, Berona K, Swadron S, Kang T/University of Southern California, Los Angeles, CA
Study Objectives: The shoulder joint is the most commonly dislocated joint and accounts for more than 70,000 emergency department (ED) visits per year in the
Volume 70, no. 4s : October 2017
Annals of Emergency Medicine S133
335
Procedural Competency in Ultrasound-Guided Peripheral Intravenous Catheter Insertion in a Pediatric Emergency Department
Blick C, Vinograd A, Mitchell C, Shin S, Chen A/Children’s Hospital of Philadelphia, Philadelphia, PA
Study Objectives: To evaluate if there is a threshold number of encounters after which providers reliably perform ultrasound guided peripheral intravenous (USGPIV) catheter placements in children with a high success rate. A secondary aim was to analyze complication rates of USGPIV catheters placed by providers. Methods: As part of a quality improvement program, a database was maintained for all USGPIV encounters in our emergency department (ED) from June 2011 to May 2017. Our ED is located within a free-standing tertiary care children’s hospital and sees over 90,000 children annually. The name of the ED practitioner attempting placement and whether it was successful was recorded for all USGPIV encounters. Patient electronic medical records were reviewed for the reason for IV removal. ED practitioners included attending physicians, pediatric emergency medicine (EM) fellows, nurses, and pediatric and EM residents. All USGPIVs were placed by a single-operator using dynamic ultrasound guidance in an out-of plane approach. The probability of successful IV placement at each encounter was calculated using Microsoft Excel (2008). These probabilities were plotted versus encounter number to graph a best-fit logarithmic regression. Using this regression equation, the number of encounters needed to achieve a probability of success of 90% was calculated. The probability of a complication after each successful USGPIV placement was also calculated, plotted versus encounter number, and overlayed with a logarithmic regression line. Results: We analyzed 3,047 encounters involving 88 providers. Of those, 2,860 (94%) were successful and 187 (6%) were unsuccessful. 35 providers had 10 or more encounters. The probability of successfully placing an USGPIV increased as providers had more experience placing USGPIVs (Figure 1). After 2 encounters, the probability of success was 80%. After 10 encounters, the probability of success reached 88%. At 14 encounters, the probability of success was 90%. IV removal reason was available for 1,178 encounters. 850 (72%) were removed because they were no longer needed. 260 (22%) had complications, and 68 (6%) were unintentionally dislodged. Complications included infiltration, phlebitis, line occlusion, and “other” (eg, pain or bleeding at site). Complication rates were calculated and graphed for 31 providers who had at least 5 encounters. There was no statistically significant relationship between the number of encounters per provider and complication rates (R2 ¼0.015). Conclusions: Our data suggests a threshold number of encounters after which providers reliably place USGPIVs in children with a high success rate. In our single institution study, a 90% success rate was achieved after an average of 14 encounters. Additionally, we found an overall low complication rate of 22%, and no change in complication rates as providers gained more experience.
336
A Comparison of Anatomical Landmark vs Ultrasound Static vs Ultrasound Real-Time Technique for Internal Jugular Vein Cannulation
Jeyaraj NI, Jena NN, Smith J, Douglas K/Meenakshi Mission Hospital and Research centre, Madurai, India; George Washington University, Washington DC
Study Objectives: Ultrasound-guided real-time technique (US RT) for internal jugular vein (IJV) access is the gold standard recommendation for IJV cannulation. Ultrasound static technique (US ST) (prelocation of IJV with ultrasound and marking the venipuncture site on the neck and cannulating with guidance skin marking) can also be used to cannulate IJV in most of the patients requiring IJV assess in the emergency department (ED) and Intensive Care Unit (ICU) with equal success rate, reduced complication, better field sterility, better utilization of resources, and with an overall lower cost. However, there are limited studies that compare US RT vs US ST for IJV cannulation for emergency access in India. None of the previous studies have taken into account the depth of IJV from skin, diameter of IJV, respiratory change in diameter of IJV and have associated it with the difficulty of the cannulation and final success rate. The objective of this study was to compare the success rates, complications and mean cannulation time using 3 techniques: 1)Ultrasound real-time (US RT) 2) Ultrasound static (US ST) and 3) Anatomical landmark (ALM) techniques (without ultrasound) for IJV cannulation. Methods: We prospectively enrolled patients presenting to an emergency department or ICU setting at a single tertiary care hospital in Southern India. Patients were randomized by closed envelope method to receive IJV cannulation by US ST or US RT or ALM by emergency department residents over a 2 year period. We measure the rate of overall success, first pass success rates, and mean cannulation time in each group. In addition, among the ultrasound groups, we compared success rates in complicated cases (increased depth of the IJV from skin, degree of respiratory variation of IJV diameter and the diameter of IJV). Setting and Design: A prospective, randomized, observational study was conducted at a tertiary care hospital. Statistical Analysis: We used SPSS 16 software and Sigma stat 3.5 version to analyze data. Using ANOVA and chi-squared tests, we analyzed differences in the mean number of attempts and time until success between all the three groups in our study. A p value of less than 0.05 was taken as significant. Results: We enrolled a total of 120 patients in our study, with 40 patients in each group. Success rates were 100% in US RT, 77.5% in US ST, and 70% in the ALM group. There were no difference between first pass success rates between US ST and US RT groups; however, first pass rate was better in both groups as compared to the ALM group.There was no statistical difference between the three groups with regards to final success. Venous cannulation time was lowest in the US ST group, followed by the US RT group and longest in the ALM group. In difficult cannulation with IJV depth from the skin 1.1cm and above or with inspiratory diameter of IJV 0.7cm or less, the US RT group had 100% success rate compared to a success rate of only 10% in the US ST group (p< 0.001). Conclusions: Both US RT and US ST are superior to the ALM technique. Although US RT has better overall success rate than US ST, US RT requires adequate training, more time, sterile scanner manipulation, and more resources, which translates into increased overall cost than US ST. US ST has statistically similar success rate, reduced complication, and better field sterility in most patients where the cannulation of IJV was not difficult.
337
Accuracy of Landmark-Guided Glenohumeral Intra-Articular Injections in Patients With Anterior Shoulder Dislocations
Omer T, Mailhot T, Berona K, Swadron S, Kang T/University of Southern California, Los Angeles, CA
Study Objectives: The shoulder joint is the most commonly dislocated joint and accounts for more than 70,000 emergency department (ED) visits per year in the
Volume 70, no. 4s : October 2017
Annals of Emergency Medicine S133