Ultrasonography-guided peripheral intravenous catheter in emergency department patients with difficult access.

Sir,

Emergency nurses (ENs) place peripheral intravenous (IV) lines, but if repeated attempts fail, emergency physicians have to obtain peripheral or central access. Some patients such as those who are obese, chronically ill, hypovolemic, IV drug users, or those with vascular pathology may prove exceedingly difficult for peripheral IV placement.

Several studies have evaluated the use of ultrasound (US) guidance for central venous access.[12] Also,this technique has been applied by peripheral vein brachial and basilic veinchanneling by doctors and nurses in emergency department (ED) patients showing aconsiderable profit.[3-5]

These studies have evaluated US-guided peripheral IV line placement in a group of ED patients, the majority of whom were IV drug users or significantly obese. The lines were placed by emergency physicians with a reported success rate of > 90%.[3] These studies involved emergency physicians using US to place peripheral lines even though the initial attempts were made by the nursing staff.

With this method the only complication is arterial puncture and nerve contact, and only a very small percentage of patients require a central line.[4] However, placement of a central line is associated with a greater than 15% rate of significant complications, including arterial puncture, pneumothorax, deep vein thrombosis and infection.[5]

Our experience is limited, but this is of higher quality when inserting catheters, (less time, a more direct technique, fewer attempts), particularly in overweight patients withedema when vascular access is very limited [Figure 1].

Figure 1

Entry via cephalic catheter (arrow)

Therefore, in patients with difficult access who are admitted to an intensive care setting or in whom there is a high potential for clinical deterioration, it may be prudent to consider placing a central line rather than attempting US-guided peripheral IV access in the ED. Although the percentage of difficult-access patients who go on to receive a central line probably varies from one ED to another.

In conclusion, US-guided peripheral IV access is more successful than traditional "blind" techniques, requires less time, decreases the number of percutaneous punctures, and improves patient satisfaction in the group of patients who have difficult intravenous access.