Original ContributionStandard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation
Introduction
Peripheral venous cannulation is a common procedure in hospitalized patients, but approximately 20% of intravenous insertions are unsuccessful [1]. Variables influencing catheter insertion failure are obesity, intravenous drug abuse (IVDA), chronic medical conditions, and hospital length of stay. Central line placement is a frequently used alternative in patients lacking accessible peripheral venous sites. However, central line is associated with several short-term and long-term complications [2]. Avoiding central line placement and removing central line that is no longer essential reduce the bloodstream infection risk [3].
Ultrasound (US) may be useful for peripheral vein cannulation in patients with difficult venous access, allowing to identify peripheral vessels and guide the procedure. Ultrasound-guided peripheral vein cannulation is successful in more than 90% of cases [4]. Compared with blind technique, US-guided technique showed a higher success rate [5]. Furthermore, US guidance reduces time to cannulation and improves patient satisfaction with fewer skin punctures and fewer immediate complications [6]. Perceived difficulty of emergency nurse significantly decreased [7].
Despite the fact that US-guided cannulation seems to be an effective alternative to central line placement, few data about the survival of US-guided peripheral catheters in acute care setting exist. Standard-length (3-5 cm) catheters positioned in deep brachial or basilic vein are frequently complicated by infiltration or dislodgment. Keyes et al [4] observed that peripheral line was infiltrated or fell out within 1 hour of cannulation in 8% of patients. In a recent study, the authors found out that the survival rate of intravenous catheters after 96 hours was only 56%, with a median survival rate of 26 hours [8]. Use of longer than normal catheters may provide a solution to high failure rate. Ultrasound-guided insertion of a 15-cm catheter appeared fast, safe, and well tolerated [9]. Evidence on effectiveness of different-length US-guided peripheral catheters for patients with difficult venous access in acute care setting is lacking.
The aim of the present study was to compare US-guided peripheral standard-length catheters (SC) vs US-guided peripheral long catheters inserted with Seldinger technique (LC) in acute hospitalized patients with difficult venous access, with particular regard to failure rate (primary end point).
Section snippets
Study design
This was a prospective, randomized study. The institutional review board approved the study protocol, and patients gave informed consent before entering the study.
Study setting and population
The study was conducted in the High Dependency Unit of San Giovanni Bosco Hospital, Torino, Italy. Our center treats patients coming from emergency department, medical ward, surgical ward, and intensive care unit, requiring monitoring and subintensive care.
Inclusion criterion was failure of 3 peripheral intravenous attempts through
Results
A total of 100 consecutive patients with difficult venous access according to inclusion criteria were enrolled from May 2009 to March 2010. In this time, 612 patients were admitted to our center. Rate of subjects with difficult venous access was 16.3%. No patient refused to participate in the study.
Patient characteristics are similar for both the groups except for obesity rate (Table 1).
The basilic vein was cannulated in 79% of patients, the brachial vein in 14% of patients, and the cephalic
Discussion
Ultrasound is a useful tool for peripheral vein cannulation in patients with difficult venous access. However, SC cannulation may be associated with a high premature failure due to dislocation, especially in obese patients and subjects with diffuse edema. The use of long catheters placed with Seldinger technique could reduce the displacement risk and, more generally, the catheter failure risk. In this study, we have compared SC with longer catheters inserted with Seldinger technique to evaluate
Limitations
Our study is subject to a number of limitations. First, we did not record vein depth and diameter. Both the measures are related to the procedure's success rate. Panebianco et al [18] observed that increasing vessel diameter was associated with a higher likelihood of success and that beyond a threshold depth of 16 mm, there was no successful cannulation with SCs. Furthermore, procedures were performed by experienced and inexperienced operators entailing hypothetical provider-related
Conclusion
Both SC and LC US-guided cannulations have a high success rate in patients with difficult venous access. Notwithstanding a higher time to cannulation, LC US-guided procedure is associated with a lower risk of catheter failure compared with SC US-guided procedure. Future investigations are warranted to assess thrombotic and infectious risks for both approaches.
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