- Email: [email protected]
Prospective evaluation of ultrasound-guided short catheter placement in internal jugular veins of difficult venous access patients
Prospective Evaluation of Ultrasound Guided Short Catheter Placement In Internal Jugular Veins Of Difficult Venous Access Patients David Kiefer MD, S. Michael Keller MD, Anthony Weekes MD PII: DOI: Reference:
S0735-6757(15)01055-4 doi: 10.1016/j.ajem.2015.11.069 YAJEM 55439
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
23 October 2015 24 November 2015
Please cite this article as: Kiefer David, Keller S. Michael, Weekes Anthony, Prospective Evaluation of Ultrasound Guided Short Catheter Placement In Internal Jugular Veins Of Difficult Venous Access Patients, American Journal of Emergency Medicine (2015), doi: 10.1016/j.ajem.2015.11.069
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Prospective Evaluation of Ultrasound Guided Short Catheter Placement In Internal Jugular Veins Of Difficult Venous Access Patients David Kiefer, MDa, S. Michael Keller, MDa and Anthony Weekes, MDa a Carolinas Medical Center Department of Emergency Medicine, Charlotte, NC
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RUNNING TITLE: Internal Jugular Short Catheter Placement
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David Kiefer, MD Carolinas Medical Center Department of Emergency Medicine 1000 Blythe Blvd. Charlotte, NC 28203 317.374.5946 [email protected]
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S. Michael Keller, MD2 Carolinas Medical Center/ CHS Union Hospital Department of Emergency Medicine 765.437.8930 [email protected]
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Anthony Weekes, MD Carolinas Medical Center Department of Emergency Medicine [email protected] 704.620.2950
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Corresponding Author: David Kiefer, MD 110 Hammocks View Savannah, GA 31410 [email protected] 317.374.5946 Re-Print Requests should be sent to David Kiefer, MD Equipment support obtained in form of free catheters from Vascular Pathways. Keywords: Internal Jugular, Ultrasound Guided, Peripheral IV, Difficult Venous Access, Safety, Complications 1
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Permanent Address: 110 Hammocks View, Savannah, GA 31410 Permanent Address: 59 Hickory Ridge Circle, Cicero, IN 46034
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ABSTRACT Rationale: Difficult vascular access (DVA) is a common problem. Placement of ultrasound guided standard length catheters (USPIV) in the internal jugular vein (IJ) is a potential solution.
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Objectives: Evaluate the immediate and short-term incidence of complications after USPIV placement in IJ of DVA patients.
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Methods: We conducted a prospective convenience study of USGPIV into IJ of ED patients with DVA. All USGPIV were performed with standard aseptic techniques with either an 18-gauge 6.35 cm single lumen catheter or 20-gauge 5.7 cm catheter. Immediate complications were evaluated. Clinical follow up consisted of review of the electronic medical record (EMR) for physician and nursing documentation, laboratory data and imaging studies in a multiple hospital network. Outcome measures 1 and 6 weeks l included: local site abnormalities, bleeding, local or systemic infection, pneumothorax, or thrombosis at time of placement, and death.
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Results: We enrolled 33 patients (58% female, mean age 56.4 years and median body mass index of 24.7). Eleven physicians performed USPIV placement. Median access time was 4.0 (IQR 5.5) minutes and 1 attempt for placements. There were no immediate complications. Follow-up successful in 5/7 of discharged patients and 26/27 admitted patients. Three deaths within 6 weeks were unrelated to USPIV. Three patients lost to follow-up were not discovered on EMR or death registries. No patient had catheter related complications.
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Conclusions: There were no immediate or short-term complications associated with aseptic USGPIV placement into IJ. USGPIV IJ placement was a rapid and safe approach in DVA patients.
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Keywords: Internal Jugular, Ultrasound Guidance, Peripheral Venous Access, Difficult Venous Access, Emergency Medicine Internal Jugular, Ultrasound Guided, Peripheral IV, Difficult Venous Access, Safety,
Abbreviations: ( USPIV: Ultrasound guided peripheral intravenous; DVA: Difficult venous access; IJ: Internal Jugular; EJ: External Jugular; EMR: Electronic medical record; CVC: Central Venous Catheter2
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1. Introduction: Vascular access is a critical and time sensitive management step in most ED patients. Prompt vascular access allows rapid serum laboratory testing and the administration of fluids and medications. Pre-hospital providers and nurses are usually successful in attaining vascular access, however, 1 in 10 ED patients can be considered to have difficult venous access (DVA).1 Traditional targets in DVA patients include the external jugular (EJ) vein and ultrasound guided peripheral catheter (USPIV) insertion into deeper arm veins although both have limitations. The EJ vein is a common vascular access site for emergency providers, however, when not easily identified, success rates for EJ access decline significantly. Deep arm veins are small and, even with US guidance, attempts may be unsuccessful or catheters may become easily dislodged.2 When access is unobtainable by these methods providers may decide to proceed with central venous catheter (CVC) placement or intraosseous placement. 2-4 The internal jugular (IJ), subclavian and femoral veins are the common CVC insertion sites for long (15-22 cm), large diameter (2.3 mm) multichannel catheters.3-5 Disadvantages and complications of CVC placement include: time for set-up and completion; loss of the guidewire; dysrhythmias; hematoma; pneumothorax; infection; and thrombosis.5-8 Additionally, CVCs often remain in place for an extended period of time, often longer than required, further contributing to complications of infection and thrombosis. Most ED patients do not require CVC but need vascular access for fluid resuscitation, blood testing and administration of medications. The IJ is a large vein readily identified by ultrasound easily accessible located 0.5-1.0 cm below the skin. In a recent case series of 9 patients, Teismann et al reported on the safe placement of non-CVC in the IJ and could be an option in DVA patients going forward and avoid unnecessary CVC placement. The primary goal of this study was to prospectively assess for immediate and short-term complications of USGPIV IJ placement in ED patients. Secondary goals were to determine time to completion and number of attempts for successful USGPIV IJ placement. This was a prospective convenience study at two emergency departments in North Carolina: an urban academic center with an annual census of 86, 000 and a regional community ED with an annual census of 60, 000 patients within in the same hospital network. The Carolinas HealthCare System Institutional Review Board reviewed and approved the study with a waiver of informed consent. Patients were considered for enrollment of US guided IJ catheter placement by emergency physicians if they met the following inclusion criteria: age >18 years old, failed attempts at peripheral IV access by nurses; absence of an easily identified external jugular vein for IV placement ;and absence of clinical indications for CVC placement at the time of vascular access. Exclusion criteria included: overlying skin infection or intention by the treating physician to insert CVC. Abbreviations: USPIV: Ultrasound guided peripheral intravenous; DVA: Difficult venous access; IJ: Internal Jugular; EJ: External Jugular; EMR: Electronic medical record; CVC: Central Venous Catheter
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Emergency medicine residents and board certified physicians were made aware of ongoing quality assurance of standard catheters placed in internal jugular veins in the emergency department. We used a 4-11MHz liner transducer on a Philips Sparq (Philips Healthcare, Andover, MA) or the Ultrasonix Touch Analogic (Vancouver, Canada) with 5-14 MHz linear transducers. Either the Arrow 18 gauge 6.35 cm single lumen catheter over needle devices or Vascular Pathways Accucath 20 gauge 5.7 cm catheter over needle device with built in echogenic guide wire (Bard Access Systems, Salt Lake City, UT) were used. The linear transducer was used for dynamic ultrasound guidance. The aseptic technique is identical to standard IV start but with chlorhexidine skin cleansing preparation and use of sterile probe covers/jelly. Full sterile drape coverage of the patient was not used. Standard catheter over needle method device was used and bio-occlusive dressing was applied over the catheter to secure the IV. Data collection instruments included patient demographics, number of insertion attempts, and time for procedure completion. The investigators used the completed forms to perform an EMR review of patients’ charts for data relating to the procedure and any complications. Patient identifiers, immediate complications, catheter type used, access location and number of attempts were recorded by EM physicians performing the procedure. The number of attempts and time to successful completion of catheter placement were documented by the provider performing the procedure. Study investigators reviewed documentation of clinician and nurses within the EMR, collected demographics, past medical history, admitting and discharge diagnoses, length of hospitalization, discontinuation date and time, and complications during hospitalization or at time of discontinuation. The EMR allowed access to multiple hospitals and clinic sites within the extensive Carolinas Healthcare System network. Chart review included all physician and nursing documentation and assessments (institution required assessments of vascular catheters at 8-12 hour intervals), imaging studies and microbiological data at one week and six week time-points from time of catheter placement. When a specific catheter discontinuation time was not documented in the EMR, the time of next nursing assessment when the catheter was no longer present was used as discontinuation time. This method could lead to an overestimation of catheter dwell time by up to 12 hours. Our primary objective was to assess for complications of this procedure (local neck abnormality, bleeding, pneumothorax, pulmonary embolism/Internal jugular clot or positive blood culture). Catheter related complications were assessed at the time of procedure as well as after procedure was completed at 1-week and 6-week timeline. For follow up assessments, if patients were evaluated by a healthcare provider between 1 week and 6 weeks after procedure the data was used for 1 week follow up only. The first healthcare provider assessment at a time greater than 6 weeks was used as surrogate for 6-week assessment. Some patients were seen only at follow up visits greater than 6 weeks and if the patient had no complications it was inferred that they had no complications at 1 week or 6 weeks. Secondary outcome measures were the number of separate needle insertion attempts before successful catheter over needle passage into the IJ and the time to procedure completion.
ACCEPTED MANUSCRIPT 3. RESULTS:
We enrolled 33 patients between November 2014 and May 2015. Table 1 shows demographic characteristics of the study patients.
4. DISCUSSION:
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Eleven different physicians performed the US guided IJ placement with peripheral catheters. Twenty-one of 33 (64%) catheters were placed in the right IJ. The Arrow 6.35 cm catheter was used in 25 (75%) patients and Vascular Pathways Accucath 5.7 cm catheter was used in 7 patients. The median length of hospital stay for admitted patients was 5 days (IQR 7) with catheter dwell times of 49 hours (58.5) hours. Three catheters failed after admission secondary to dislodgement. There were no complications at time of USGPIV placement into the IJ. Chart review up to 6 weeks after procedure revealed no documented evidence or clinical suspicions about complications from line placement. One admitted patient had blood culture growth with staphylococcus aureus growth. The blood cultures were obtained at time of admission and at the time of catheter placement and were due to admitting diagnosis of pneumonia and sepsis during the ED management. No patients were found otherwise to have positive blood cultures during hospitalization or at later visit within 6 weeks. Three patients died within 6 weeks of USGPIV procedure. Two died under hospice care and one from complications of pneumonia for which the patient was originally admitted. The deaths were from progression and deterioration from chronic illness and their deaths were not related to catheter placement. All three patients had been admitted to the hospital, and none of the three patients had catheter complications at one week follow up. The median number of catheter insertion attempts was 1 (IQR 0). The most attempts required for successful placement was 3. The median time for the procedure was 4.0 (IQR 5.5) minutes. Seven patients were discharged from the emergency department and 26 were admitted to the hospital. Ultrasound guided internal jugular venous access with 5-7 cm catheters in DVA patients had no immediate or short-term complications in our cohort of patients. Vascular access was obtained within minutes and with the first attempt in the majority of patients. Difficult venous access (DVA) poses a challenge to the treatment and diagnostic workup of patients. Fields et al found 11.8% of 743 non-critically ill patients had difficult venous access defined as failing two standard IV placement attempts and 2.5% of total patients required USPIV placement.1 They similarly found that obesity was not the major contributor (our median BMI being 24.7), but instead chronic disease seems to be the primary associated factor though causality was not determined. Currently, there is no established best practice guideline or algorithm for patients with DVA and multiple strategies exist. Costantino et al evaluated ultrasound guided peripheral access versus anatomic-guided external jugular access in patients with DVA and found a 66% success rate for anatomic EJ catheter placement when the EJ was visible, falling to 50% when the EJ not easily visible. 6 The same study found an 84% success rate using USPIV in
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arm/forearm veins. Typical targets are the basilic and brachial veins, but standard catheters (35 cm) have an 8% reported failure within the first hour. 7 A randomized control trial by Stein et al showed that USPIV focused on arm veins was challenging with a median time to success of 39 minutes compared to 26 minutes for the non US IV access group.8 Mills et al3 looked at US guided placement of 15 cm long catheters into the basilic or brachial veins in DVA patients and reported with successful placement in 92% of patients, however, the median procedure completion time was 8 (6-16) minutes and required two or greater attempts 33% of the time. We feel the next logical step is to consider US guided access to comparatively larger and more superficial neck veins with standard catheters (see figure 1). Teismann et al discussed the technique of ultrasound-guided placement of a 6.35 cm standard catheter into the internal jugular vein. 9 They demonstrated successful placement without complications in 9 patients and used sterility similar to placement of standard peripheral IV catheter we also used in our study. The technique is similar to ultrasound guided internal jugular CVC placement but uses only a catheter over needle device therefore is an already known skill for most emergency medicine providers with a proven safety profile. We further evaluated this procedure and found placement easy and time efficient with median number of attempts 1 (0) and median time 4 min (5.5). This is more efficient compared to CVC placement and USGPIV for arm veins. Higher ED patient volumes, with a larger number of chronically ill patients with higher acuity will make DVA challenges more common. Providers therefore need strategies to overcome DVA. Our impression was that internal jugular access with aseptic USGPIV technique was efficient, rapid, and safe. We feel it is a reasonable option to offer patients at this time instead of CVC placement if central venous monitoring is not indicated, and particularly well suited for DVA patients who are likely to be discharged from the ED. 5. Limitations: This was a convenience sample of patients limited and could be biased by physician reporting and reliance on documented evaluations. There were no direct in-person evaluations by a clinical investigator team specifically looking for complication of the catheter insertion site. However follow up evaluations of the catheter sites were performed by clinicians who were not involved and independent of research study. Electronic medical record review was limited to Carolinas Healthcare System network of hospitals that included clinical urgent care centers and freestanding emergency departments. Patients lost to follow-up may have sought care at other area hospital centers or may have moved to other states. 6. CONCLUSIONS: Ultrasound guided internal jugular venous access with 5-7 cm catheters had no immediate or short-term complications in our cohort of patients. Vascular access was obtained within minutes and with the first attempt in the majority of patients. In the absence of required central venous monitoring, the IJ can be accessed in patients with difficult vascular access.
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REFERENCES
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[1] Fields JM, Piela NE, Au AK, Ku BS. Risk factors associated with difficult venous access in adult ED
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patients. The American journal of emergency medicine 2014;32:1179-82. [2] Fields JM, Dean AJ, Todman RW, et al. The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity. The American journal of emergency medicine 2012;30:1134-40. [3] American College of Emergency Physicians. Emergency ultrasound guidelines (Policy Statement). Annals of emergency medicine 2009;53:550-70. [4] Miller AH, Roth BA, Mills TJ, Woody JR, Longmoor CE, Foster B. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2002;9:800-5. [5] Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Critical care medicine 1996;24:2053-8. [6] Costantino TG, Kirtz JF, Satz WA. Ultrasound-guided peripheral venous access vs. the external jugular vein as the initial approach to the patient with difficult vascular access. The Journal of emergency medicine 2010;39:462-7. [7] Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Annals of emergency medicine 1999;34:711-4. [8] Stein J, George B, River G, Hebig A, McDermott D. Ultrasonographically guided peripheral intravenous cannulation in emergency department patients with difficult intravenous access: a randomized trial. Annals of emergency medicine 2009;54:33-40. [9] Teismann NA, Knight RS, Rehrer M, Shah S, Nagdev A, Stone M. The ultrasound-guided "peripheral IJ": internal jugular vein catheterization using a standard intravenous catheter. The Journal of emergency medicine 2013;44:150-4.
ACCEPTED MANUSCRIPT TABLE 1. Baseline Characteristics Male
12
Age - mean (Std)
56.4 (14.8)
BMI - median (IQR)
24.7 (9.2)
RACE: African America White Other
16 15 2
(42%)
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(48%) (45%) (6%)
(48%)
6
(18%)
IVDU
3
(9%)
HTN
21
(64%)
HLD
12
(36%)
PVD
1
(3%)
CAD
10
(30%)
Chronic Pain/ Hx of illicit or narcotic drug abuse
14
(42%)
Cirrhosis
4
(12%)
Metastatic CA
4
(12%)
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ESRD on HD
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DM
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Comorbidities:
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*DM= Diabetes Mellitus (includes type 1 and type2), ESRD on HD = End Stage Renal Disease on Hemodialysis, IVDU = Intravenous Drug Use, SCC = Sickle Cell Disease, HTN = Hypertension, HLD = Hyperlipidemia, PVD = Peripheral Vascular Disease, CAD = Coronary Artery Disease, Drug Abuse does NOT include alcohol or tobacco abuse, BMI = Body Mass Index
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Figure 1: Ultrasound images of the medial upper arm show the basilic vein (Bv) and brachial veins (arrows) in short axis. The ultrasound field depth setting is 2 cm. The ultrasound image on the right shows internal jugular vein ((IJ) in short axis with ultrasound field setting to a depth of 3 cm. The anterior wall of the IJ is 1 cm below the skin surface. The carotid is located below and medial to the IJ.
S0735-6757(15)01055-4 doi: 10.1016/j.ajem.2015.11.069 YAJEM 55439
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
23 October 2015 24 November 2015
Please cite this article as: Kiefer David, Keller S. Michael, Weekes Anthony, Prospective Evaluation of Ultrasound Guided Short Catheter Placement In Internal Jugular Veins Of Difficult Venous Access Patients, American Journal of Emergency Medicine (2015), doi: 10.1016/j.ajem.2015.11.069
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Prospective Evaluation of Ultrasound Guided Short Catheter Placement In Internal Jugular Veins Of Difficult Venous Access Patients David Kiefer, MDa, S. Michael Keller, MDa and Anthony Weekes, MDa a Carolinas Medical Center Department of Emergency Medicine, Charlotte, NC
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RUNNING TITLE: Internal Jugular Short Catheter Placement
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David Kiefer, MD Carolinas Medical Center Department of Emergency Medicine 1000 Blythe Blvd. Charlotte, NC 28203 317.374.5946 [email protected]
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S. Michael Keller, MD2 Carolinas Medical Center/ CHS Union Hospital Department of Emergency Medicine 765.437.8930 [email protected]
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Anthony Weekes, MD Carolinas Medical Center Department of Emergency Medicine [email protected] 704.620.2950
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Corresponding Author: David Kiefer, MD 110 Hammocks View Savannah, GA 31410 [email protected] 317.374.5946 Re-Print Requests should be sent to David Kiefer, MD Equipment support obtained in form of free catheters from Vascular Pathways. Keywords: Internal Jugular, Ultrasound Guided, Peripheral IV, Difficult Venous Access, Safety, Complications 1
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Permanent Address: 110 Hammocks View, Savannah, GA 31410 Permanent Address: 59 Hickory Ridge Circle, Cicero, IN 46034
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ABSTRACT Rationale: Difficult vascular access (DVA) is a common problem. Placement of ultrasound guided standard length catheters (USPIV) in the internal jugular vein (IJ) is a potential solution.
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Objectives: Evaluate the immediate and short-term incidence of complications after USPIV placement in IJ of DVA patients.
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Methods: We conducted a prospective convenience study of USGPIV into IJ of ED patients with DVA. All USGPIV were performed with standard aseptic techniques with either an 18-gauge 6.35 cm single lumen catheter or 20-gauge 5.7 cm catheter. Immediate complications were evaluated. Clinical follow up consisted of review of the electronic medical record (EMR) for physician and nursing documentation, laboratory data and imaging studies in a multiple hospital network. Outcome measures 1 and 6 weeks l included: local site abnormalities, bleeding, local or systemic infection, pneumothorax, or thrombosis at time of placement, and death.
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Results: We enrolled 33 patients (58% female, mean age 56.4 years and median body mass index of 24.7). Eleven physicians performed USPIV placement. Median access time was 4.0 (IQR 5.5) minutes and 1 attempt for placements. There were no immediate complications. Follow-up successful in 5/7 of discharged patients and 26/27 admitted patients. Three deaths within 6 weeks were unrelated to USPIV. Three patients lost to follow-up were not discovered on EMR or death registries. No patient had catheter related complications.
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Conclusions: There were no immediate or short-term complications associated with aseptic USGPIV placement into IJ. USGPIV IJ placement was a rapid and safe approach in DVA patients.
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Keywords: Internal Jugular, Ultrasound Guidance, Peripheral Venous Access, Difficult Venous Access, Emergency Medicine Internal Jugular, Ultrasound Guided, Peripheral IV, Difficult Venous Access, Safety,
Abbreviations: ( USPIV: Ultrasound guided peripheral intravenous; DVA: Difficult venous access; IJ: Internal Jugular; EJ: External Jugular; EMR: Electronic medical record; CVC: Central Venous Catheter2
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1. Introduction: Vascular access is a critical and time sensitive management step in most ED patients. Prompt vascular access allows rapid serum laboratory testing and the administration of fluids and medications. Pre-hospital providers and nurses are usually successful in attaining vascular access, however, 1 in 10 ED patients can be considered to have difficult venous access (DVA).1 Traditional targets in DVA patients include the external jugular (EJ) vein and ultrasound guided peripheral catheter (USPIV) insertion into deeper arm veins although both have limitations. The EJ vein is a common vascular access site for emergency providers, however, when not easily identified, success rates for EJ access decline significantly. Deep arm veins are small and, even with US guidance, attempts may be unsuccessful or catheters may become easily dislodged.2 When access is unobtainable by these methods providers may decide to proceed with central venous catheter (CVC) placement or intraosseous placement. 2-4 The internal jugular (IJ), subclavian and femoral veins are the common CVC insertion sites for long (15-22 cm), large diameter (2.3 mm) multichannel catheters.3-5 Disadvantages and complications of CVC placement include: time for set-up and completion; loss of the guidewire; dysrhythmias; hematoma; pneumothorax; infection; and thrombosis.5-8 Additionally, CVCs often remain in place for an extended period of time, often longer than required, further contributing to complications of infection and thrombosis. Most ED patients do not require CVC but need vascular access for fluid resuscitation, blood testing and administration of medications. The IJ is a large vein readily identified by ultrasound easily accessible located 0.5-1.0 cm below the skin. In a recent case series of 9 patients, Teismann et al reported on the safe placement of non-CVC in the IJ and could be an option in DVA patients going forward and avoid unnecessary CVC placement. The primary goal of this study was to prospectively assess for immediate and short-term complications of USGPIV IJ placement in ED patients. Secondary goals were to determine time to completion and number of attempts for successful USGPIV IJ placement. This was a prospective convenience study at two emergency departments in North Carolina: an urban academic center with an annual census of 86, 000 and a regional community ED with an annual census of 60, 000 patients within in the same hospital network. The Carolinas HealthCare System Institutional Review Board reviewed and approved the study with a waiver of informed consent. Patients were considered for enrollment of US guided IJ catheter placement by emergency physicians if they met the following inclusion criteria: age >18 years old, failed attempts at peripheral IV access by nurses; absence of an easily identified external jugular vein for IV placement ;and absence of clinical indications for CVC placement at the time of vascular access. Exclusion criteria included: overlying skin infection or intention by the treating physician to insert CVC. Abbreviations: USPIV: Ultrasound guided peripheral intravenous; DVA: Difficult venous access; IJ: Internal Jugular; EJ: External Jugular; EMR: Electronic medical record; CVC: Central Venous Catheter
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Emergency medicine residents and board certified physicians were made aware of ongoing quality assurance of standard catheters placed in internal jugular veins in the emergency department. We used a 4-11MHz liner transducer on a Philips Sparq (Philips Healthcare, Andover, MA) or the Ultrasonix Touch Analogic (Vancouver, Canada) with 5-14 MHz linear transducers. Either the Arrow 18 gauge 6.35 cm single lumen catheter over needle devices or Vascular Pathways Accucath 20 gauge 5.7 cm catheter over needle device with built in echogenic guide wire (Bard Access Systems, Salt Lake City, UT) were used. The linear transducer was used for dynamic ultrasound guidance. The aseptic technique is identical to standard IV start but with chlorhexidine skin cleansing preparation and use of sterile probe covers/jelly. Full sterile drape coverage of the patient was not used. Standard catheter over needle method device was used and bio-occlusive dressing was applied over the catheter to secure the IV. Data collection instruments included patient demographics, number of insertion attempts, and time for procedure completion. The investigators used the completed forms to perform an EMR review of patients’ charts for data relating to the procedure and any complications. Patient identifiers, immediate complications, catheter type used, access location and number of attempts were recorded by EM physicians performing the procedure. The number of attempts and time to successful completion of catheter placement were documented by the provider performing the procedure. Study investigators reviewed documentation of clinician and nurses within the EMR, collected demographics, past medical history, admitting and discharge diagnoses, length of hospitalization, discontinuation date and time, and complications during hospitalization or at time of discontinuation. The EMR allowed access to multiple hospitals and clinic sites within the extensive Carolinas Healthcare System network. Chart review included all physician and nursing documentation and assessments (institution required assessments of vascular catheters at 8-12 hour intervals), imaging studies and microbiological data at one week and six week time-points from time of catheter placement. When a specific catheter discontinuation time was not documented in the EMR, the time of next nursing assessment when the catheter was no longer present was used as discontinuation time. This method could lead to an overestimation of catheter dwell time by up to 12 hours. Our primary objective was to assess for complications of this procedure (local neck abnormality, bleeding, pneumothorax, pulmonary embolism/Internal jugular clot or positive blood culture). Catheter related complications were assessed at the time of procedure as well as after procedure was completed at 1-week and 6-week timeline. For follow up assessments, if patients were evaluated by a healthcare provider between 1 week and 6 weeks after procedure the data was used for 1 week follow up only. The first healthcare provider assessment at a time greater than 6 weeks was used as surrogate for 6-week assessment. Some patients were seen only at follow up visits greater than 6 weeks and if the patient had no complications it was inferred that they had no complications at 1 week or 6 weeks. Secondary outcome measures were the number of separate needle insertion attempts before successful catheter over needle passage into the IJ and the time to procedure completion.
ACCEPTED MANUSCRIPT 3. RESULTS:
We enrolled 33 patients between November 2014 and May 2015. Table 1 shows demographic characteristics of the study patients.
4. DISCUSSION:
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Eleven different physicians performed the US guided IJ placement with peripheral catheters. Twenty-one of 33 (64%) catheters were placed in the right IJ. The Arrow 6.35 cm catheter was used in 25 (75%) patients and Vascular Pathways Accucath 5.7 cm catheter was used in 7 patients. The median length of hospital stay for admitted patients was 5 days (IQR 7) with catheter dwell times of 49 hours (58.5) hours. Three catheters failed after admission secondary to dislodgement. There were no complications at time of USGPIV placement into the IJ. Chart review up to 6 weeks after procedure revealed no documented evidence or clinical suspicions about complications from line placement. One admitted patient had blood culture growth with staphylococcus aureus growth. The blood cultures were obtained at time of admission and at the time of catheter placement and were due to admitting diagnosis of pneumonia and sepsis during the ED management. No patients were found otherwise to have positive blood cultures during hospitalization or at later visit within 6 weeks. Three patients died within 6 weeks of USGPIV procedure. Two died under hospice care and one from complications of pneumonia for which the patient was originally admitted. The deaths were from progression and deterioration from chronic illness and their deaths were not related to catheter placement. All three patients had been admitted to the hospital, and none of the three patients had catheter complications at one week follow up. The median number of catheter insertion attempts was 1 (IQR 0). The most attempts required for successful placement was 3. The median time for the procedure was 4.0 (IQR 5.5) minutes. Seven patients were discharged from the emergency department and 26 were admitted to the hospital. Ultrasound guided internal jugular venous access with 5-7 cm catheters in DVA patients had no immediate or short-term complications in our cohort of patients. Vascular access was obtained within minutes and with the first attempt in the majority of patients. Difficult venous access (DVA) poses a challenge to the treatment and diagnostic workup of patients. Fields et al found 11.8% of 743 non-critically ill patients had difficult venous access defined as failing two standard IV placement attempts and 2.5% of total patients required USPIV placement.1 They similarly found that obesity was not the major contributor (our median BMI being 24.7), but instead chronic disease seems to be the primary associated factor though causality was not determined. Currently, there is no established best practice guideline or algorithm for patients with DVA and multiple strategies exist. Costantino et al evaluated ultrasound guided peripheral access versus anatomic-guided external jugular access in patients with DVA and found a 66% success rate for anatomic EJ catheter placement when the EJ was visible, falling to 50% when the EJ not easily visible. 6 The same study found an 84% success rate using USPIV in
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arm/forearm veins. Typical targets are the basilic and brachial veins, but standard catheters (35 cm) have an 8% reported failure within the first hour. 7 A randomized control trial by Stein et al showed that USPIV focused on arm veins was challenging with a median time to success of 39 minutes compared to 26 minutes for the non US IV access group.8 Mills et al3 looked at US guided placement of 15 cm long catheters into the basilic or brachial veins in DVA patients and reported with successful placement in 92% of patients, however, the median procedure completion time was 8 (6-16) minutes and required two or greater attempts 33% of the time. We feel the next logical step is to consider US guided access to comparatively larger and more superficial neck veins with standard catheters (see figure 1). Teismann et al discussed the technique of ultrasound-guided placement of a 6.35 cm standard catheter into the internal jugular vein. 9 They demonstrated successful placement without complications in 9 patients and used sterility similar to placement of standard peripheral IV catheter we also used in our study. The technique is similar to ultrasound guided internal jugular CVC placement but uses only a catheter over needle device therefore is an already known skill for most emergency medicine providers with a proven safety profile. We further evaluated this procedure and found placement easy and time efficient with median number of attempts 1 (0) and median time 4 min (5.5). This is more efficient compared to CVC placement and USGPIV for arm veins. Higher ED patient volumes, with a larger number of chronically ill patients with higher acuity will make DVA challenges more common. Providers therefore need strategies to overcome DVA. Our impression was that internal jugular access with aseptic USGPIV technique was efficient, rapid, and safe. We feel it is a reasonable option to offer patients at this time instead of CVC placement if central venous monitoring is not indicated, and particularly well suited for DVA patients who are likely to be discharged from the ED. 5. Limitations: This was a convenience sample of patients limited and could be biased by physician reporting and reliance on documented evaluations. There were no direct in-person evaluations by a clinical investigator team specifically looking for complication of the catheter insertion site. However follow up evaluations of the catheter sites were performed by clinicians who were not involved and independent of research study. Electronic medical record review was limited to Carolinas Healthcare System network of hospitals that included clinical urgent care centers and freestanding emergency departments. Patients lost to follow-up may have sought care at other area hospital centers or may have moved to other states. 6. CONCLUSIONS: Ultrasound guided internal jugular venous access with 5-7 cm catheters had no immediate or short-term complications in our cohort of patients. Vascular access was obtained within minutes and with the first attempt in the majority of patients. In the absence of required central venous monitoring, the IJ can be accessed in patients with difficult vascular access.
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REFERENCES
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[1] Fields JM, Piela NE, Au AK, Ku BS. Risk factors associated with difficult venous access in adult ED
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patients. The American journal of emergency medicine 2014;32:1179-82. [2] Fields JM, Dean AJ, Todman RW, et al. The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity. The American journal of emergency medicine 2012;30:1134-40. [3] American College of Emergency Physicians. Emergency ultrasound guidelines (Policy Statement). Annals of emergency medicine 2009;53:550-70. [4] Miller AH, Roth BA, Mills TJ, Woody JR, Longmoor CE, Foster B. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2002;9:800-5. [5] Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Critical care medicine 1996;24:2053-8. [6] Costantino TG, Kirtz JF, Satz WA. Ultrasound-guided peripheral venous access vs. the external jugular vein as the initial approach to the patient with difficult vascular access. The Journal of emergency medicine 2010;39:462-7. [7] Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Annals of emergency medicine 1999;34:711-4. [8] Stein J, George B, River G, Hebig A, McDermott D. Ultrasonographically guided peripheral intravenous cannulation in emergency department patients with difficult intravenous access: a randomized trial. Annals of emergency medicine 2009;54:33-40. [9] Teismann NA, Knight RS, Rehrer M, Shah S, Nagdev A, Stone M. The ultrasound-guided "peripheral IJ": internal jugular vein catheterization using a standard intravenous catheter. The Journal of emergency medicine 2013;44:150-4.
ACCEPTED MANUSCRIPT TABLE 1. Baseline Characteristics Male
12
Age - mean (Std)
56.4 (14.8)
BMI - median (IQR)
24.7 (9.2)
RACE: African America White Other
16 15 2
(42%)
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(48%) (45%) (6%)
(48%)
6
(18%)
IVDU
3
(9%)
HTN
21
(64%)
HLD
12
(36%)
PVD
1
(3%)
CAD
10
(30%)
Chronic Pain/ Hx of illicit or narcotic drug abuse
14
(42%)
Cirrhosis
4
(12%)
Metastatic CA
4
(12%)
NU
16
ESRD on HD
MA
DM
SC
Comorbidities:
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*DM= Diabetes Mellitus (includes type 1 and type2), ESRD on HD = End Stage Renal Disease on Hemodialysis, IVDU = Intravenous Drug Use, SCC = Sickle Cell Disease, HTN = Hypertension, HLD = Hyperlipidemia, PVD = Peripheral Vascular Disease, CAD = Coronary Artery Disease, Drug Abuse does NOT include alcohol or tobacco abuse, BMI = Body Mass Index
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Figure 1: Ultrasound images of the medial upper arm show the basilic vein (Bv) and brachial veins (arrows) in short axis. The ultrasound field depth setting is 2 cm. The ultrasound image on the right shows internal jugular vein ((IJ) in short axis with ultrasound field setting to a depth of 3 cm. The anterior wall of the IJ is 1 cm below the skin surface. The carotid is located below and medial to the IJ.