Transcript
- [Laura] Welcome to the Sonosite Behind the Scan webinar
on Ultrasound-Guided Peripheral IV Insertions
for Difficult Venous Access Patients.
I'm delighted to introduce our presenter today,
Timothy Spencer.
Tim has been a critical care and vascular access specialist
for over 30 years,
and is currently the director
for Global Vascular Access, LLC.
His clinical background and qualifications are
in intensive and critical care, nursing,
vascular ultrasound,
and advanced clinical nutrition.
As a clinical nurse consultant of the Central Venous Access
and Parenteral Nutrition Service
at the Liverpool Hospital in Australia,
Timothy established, developed, and led a team
from 1996 to 2014.
Mr. Spencer has been a past director-at-large
for the Vascular Access Certification Corporation,
and was the first Australian clinician
to be Vascular Access Board Certified in 2014.
As the founding president of
the Australian Vascular Access Society or AVAS,
founded in 2009,
he has remained involved
with the current AVAS board ever since.
After relocating to U.S. in 2014,
Global Vascular Access, LLC,
an education and consultancy agency was founded.
This engages in clinical mentoring,
research, simulation, education,
and compliance for all vascular access,
and ultrasound-related issues
both nationally and internationally.
And with that, I will turn it over to you, Tim.
- Thank you very much for the introduction.
And welcome everybody to today's webinar
focusing on ultrasound-guided PIV insertion,
particularly in the difficult venous access patient.
As Laura said, my name is Tim Spencer,
and thank you for joining us.
We're just going to move on in.
So just like any other educational opportunity
that we should always review our objectives.
And so these are the objectives
for this afternoon's session.
We're going to look at the definition
of difficult intravenous access,
which is commonly termed now,
and is certainly gaining, you know, much greater footprint
is the term DIVA.
And while it has several connotations in its own right,
DIVA is certainly a term that is
more frequently used and seen within,
you know, healthcare settings.
We're going to look at appropriate strategies
around ultrasound-guided vascular access device choices.
We're going to review some of the assessment strategies,
particularly around Rapid Peripheral Vein Assessment
or what we call RaPeVA.
It's a standardized approach to vessel assessment.
We're going to look at and discuss and review
some educational and training strategies.
And also look around some of the clinical evidence
that's being generated in, you know,
clinical and scientific research looking at
ultrasound-guided PIVC insertion as well in DIVA patients.
So this is a little caricature from quite a few years ago
out of a presentation that I did back in 2000 and,
oh, goodness me '10, '11,
when I was doing some peripheral IV education
at my old hospital.
And it's such a suitable and very accurate representation of
what peripheral vascular access can quite often be.
And it says, yes, in the year, er, 2021,
unfortunately,
this is still representative of clinical practice
in today's healthcare settings.
So while the nurse is standing at the end of the bed saying,
I'm sorry, sir, I'm just looking for a good vein,
we now have technology that's been around
for a vast number of years that can actually assist us,
and to help improve our vascular access procedures
in our patients that have difficult access.
So when it comes to ultrasound guidance.
I'm just going to, you know, get rid of my screen for a minute.
There we go.
In regards to ultrasound practice,
there's a number of guidelines and clinical recommendations
for the use of ultrasound in vascular access.
Now, if you look at this slide,
there are a lot of hard-hitting and big time
professional and educational bodies,
not just here in the United States but around the world
that are very much advocating
for the use of ultrasound for vascular access procedures.
And so while these professional bodies have a large voice,
you know, we're seeing a lot more integration of ultrasound
into vascular access procedures
that are driven by these recommendations and guidelines.
So what is PIVC use and what's its impact?
So a number of studies have focused on
peripheral intravenous cannulation for decades,
but of the recent literature,
there's a lot of evidence that supports
that over 70% of patients, probably even higher numbers now,
probably up to 90% of patients actually have an IV
that's inserted when they present to a hospital.
Whether they're being admitted,
or whether they're being seen in the emergency,
and even discharged,
a lot of patients are getting a peripheral IV placed
for administration of therapies
or they might even be used just to initially
collect blood samples for laboratory testing.
So when we look at the number of catheters that are placed
as a percentage of a patient population,
that really blows out into much larger figures
when we look at it on a more global perspective.
And certainly, you know, there's been evidence saying that
at least 330 million PIVCs are being purchased
in the United States alone.
And that over a billion catheters
are being placed annually worldwide.
That's a lot of peripheral IVs.
So when we think about the number,
and the volume of peripheral IVs that are being placed,
we also have to take into consideration
the amount of complications and the difficult access
that also come along
for patients that are receiving these devices.
And when we start looking at
some of these percentages where we see,
you know, up to 65% peripheral IV device failure,
out of that one billion catheters,
that equilibrates to a large number of catheters
that are failing and failing our patients.
A lot of patient pain and overall suffering
is increased by repeated attempts.
And this is where our DIVA patients
are really sort of highlighted
because it's taking multiple attempts
to get in a peripheral IV.
And quite often after several attempts,
or several clinicians actually having multiple attempts,
we're left with a patient that's,
you know, quite battered and bruised,
but also we might have a device
that may not be in an appropriate area,
such as the hand or the wrist,
or even in the antecubital fossa.
You know, breast tissue, lower limbs and the feet,
all are at high-risk of
subsequent related complications to the device,
and probably from multiple punctures as well.
We also need to consider
the bloodstream infection rates of PIVCs.
And although the literature reports, you know, .2%,
and approximately 20% of those are bloodstream infections
caused by staph aureus,
there's certainly widespread appreciation of the risk.
And peripheral IVs have sort of been under the radar
for a large number of years
because a lot of the focus around device-related infection
was being very much focused on
central line-associated bloodstream infection or CLABSI.
But peripheral IVs have definitely
a much greater volume of devices that are being placed.
And so while there may be, you know,
lesser bloodstream infections as per numbers,
but less a focus on bloodstream infection
until more recent research has really highlighted
that these are significant complications
that are impacting on our patients,
financial, you know, impingements to hospitals,
et cetera, et cetera.
And so, you know,
there may be patients that are experiencing
more bloodstream-related infections
that are related to peripheral IVs
than there are central venous catheters.
So this is pretty much a closeup image of a peripheral IV
that was inserted to a patient's antecubital fossa
on the left-hand side.
It's a picture that I took several years ago.
You can see the date there, actually, it's March 2012.
And you can see that right at the forefront of the screen,
there's quite a nasty purple bruise with a puncture point
where this patient actually had several attempts
to get in a catheter.
And then eventually a 20-gauge was placed right in the ACF,
but, you know, it's in an area
that's now been traumatized and punctured several times.
You know, the risk of potential
for infection and infiltration,
you know, is far greater also with these patients
that have had multiple punctures,
but also having a device that's been inserted
into an area of flexion.
So what's the current status quo?
All right, so in many situations,
you know, PIVC insertion is time-intensive,
particularly when there are multiple attempts
that are often required to gain a successful insertion.
And that can be,
that time-intensive can be taken
when we look at it from the number of clinicians
that are actually attempting.
Now, the current standard of practice is that
one clinician can only have two attempts
before they have to call someone with more experience,
or utilize additional technologies to help assist them
in gaining access to the patient.
But if we fail and fail and fail several times,
that means a number of clinicians
are each having two attempts,
and that's also causing significant trauma to the patient
as far as pain and anxiety.
There's also increased risk of healthcare worker exposure
to needlestick injuries.
The more number of attempts that are taken,
there's more risk that's involved
to the healthcare clinician as well,
particularly in regards to blood splashes
and other bloodborne pathogens.
Delays and whether being partial or total losses
in terms of prescribed administration and medication,
that can actually extend hospital length of stay,
or certainly increased stay in departments overnight,
which can have, you know,
increased financial cost and inefficient use of resources.
And so these detrimental clinical outcomes and complications
that are related to, you know,
poor vascular access decision-making processes
can have significant affect on the patients,
the running of departments and also,
you know, facilities as well.
Here's another photo
that highlights an unfortunate practice,
a peripheral IV in the foot.
While there are a number of clinicians that,
you know, say sometimes,
you know, I've got to place a catheter in the foot.
Yes, you know, that has been known for some time,
and people have been doing this for many years,
but it actually increases
the risk of lower extremity DVT considerably.
So avoiding, you know,
IVs in the feet are an important strategy.
I wanted to put this picture in
because, you know, there's going to be,
you know, a number of images that are going to come through
on the webinar today.
But these really just are to highlight the fact
that we want to try and avoid using these sites
as much as possible.
Remember, you know,
if the patient is going to continually fail
to have suitable access for a device,
then a peripheral IV may not be
the most appropriate device for that patient.
And we need to consider that
as part of our ongoing plan with our patients,
and certainly when we're looking at
doing our patient assessment.
All right, so where is your best IV placement?
Well, as you can see, this was an image.
Well, it was actually a video that I found on TikTok,
not an empirical source of
evidence-based practices or medicine,
but what it is highlighting is poor practice.
There's no need for peripheral IVs
to be placed in breast tissue at all.
It's not best practice and it should never be considered.
If there's other alternative devices that could be utilized,
then that's what should be utilized.
Some, you know,
I've seen a number of posts on the internet about this.
Oh, yes, I can get a,
you know, 20-gauge in a breast IV, you know, vein.
Well, that's great, but it's not great at all.
It actually just shows a lack of understanding of
vessel health and preservation strategies.
So, you know, utilizing images like this
are really more about driving home
the need to avoid placing peripheral IVs,
whether, you know, palpation-based or ultrasound-guided
into areas that really shouldn't have an IV at all.
So DIVA, difficult intravenous access.
I was in a hospital last week, actually, in New York City,
and talked about DIVA,
and got a couple of giggles from the staff
because they hadn't really heard the term before.
But once I explained to them what a DIVA actually was,
they said, oh, we have a lot of DIVAs in our hospital.
And I'm like, this is exactly why this term
is now starting to become more mainstream
certainly in vascular access circles,
but certainly in other areas such as,
you know, cancer care, emergency medicine, critical care,
et cetera, et cetera.
So the term difficult intravenous access is
now starting to be more frequently used in the literature,
but there was inconsistency on how it was defined.
And we're going to go into that,
and there's been some research that we'll cover shortly,
particularly around the clinical evidence
around how it has been defined.
It certainly has identified management strategies
for these patients,
which have led to suboptimal outcomes,
and certainly increased patient's burden
and, you know, unnecessary resource use within facilities.
A systematic review was performed,
which collated literature around DIVA,
which was the aim of arriving
at a evidence-based definition.
And this was a publication by Amit Bahl
out of Beaumont up in Michigan.
And their systematic review highlight a number of points,
but the three main focal areas
that forged the definition of DIVA
were the three points that are listed here on the screen.
The number of failed attempts at PIV access
using traditional techniques.
Looking at physical examination findings,
for example, of no palpable or visible vessels.
And a personal history of DIVA,
or where the patient says,
they have a really hard time getting an IV on me.
Well, that's an indication for DIVA.
And, you know, if the patients are explaining to them,
to clinicians themselves that,
you know, they're a difficult stick,
then this is why we should be really using
ultrasound as our first choice to help get a device placed.
Another photo from my clinical library from many years ago,
which really just highlights, you know,
the number of multiple sticks that it's taken
to get in an IV.
So you can see here that there's at least,
well, there's three puncture points that have got,
you know, cotton wool balls over the top,
and are blood-soaked,
you know, dry blood-soaked gauze squares.
So even though I don't remember exactly
how many puncture points that might have taken place
at each of those sites,
it does tell me that the vessels in this patient's forearm
have been quite extensively traumatized from,
you know, multiple attempts at getting an IV insertion.
And then finally getting in,
you know, a 22-gauge up in the cephalic vein
in the upper extremity.
You know, we want to avoid this,
and this is the whole point about what ultrasound guidance
is really going to help us with.
Here's another example taken once again,
looking at a device that was placed
in the antecubital fossa,
but then you can see that there's been a few attempts
with the moderate amount of bruising
that's on the medial aspect of the antecubital fossa.
But if you look closely,
you can see that the arm is actually quite swollen,
and that there's been a bit of infiltration
that's actually contributed to this bruising and swelling
in this extremity.
So I like to talk about evidence,
and evidence is a really important process
that we need to evaluate when we're,
you know, making clinical-related practice changes.
So if we look back at some of the earlier DIVA research,
certainly within, you know, the last decade,
the focus on this slide particularly between 2010 and 2016,
there was a lot of research that was being published,
looking at ultrasound-guided peripheral venous access
in patients in the emergency department,
but other areas as well,
focusing on patients with difficult intravenous access.
So as you can see,
you know, publications out of, you know, emergency medicine,
and a variety of different places and journals,
high-quality journals,
have really been focusing and doing
clinical generation of evidence to say
we need to do this better,
we need to do it better for our patients,
but we also need to have improved policy and practice
around education and training,
which you know will come
to a little bit later in the session.
But there's been a lot of focus,
you know, in this from 2010 to 2016 on DIVA,
and there's ongoing evidence.
And now with all these research papers
that are being published,
we're now starting to see a lot more systematic reviews
and meta-analysis that are coming out
that are evaluating the use of ultrasound for PIV insertion.
And whether that's just for DIVA
or whether it's for all our patients,
it doesn't matter, they all benefit from it.
But patients with a history of DIVA
create a different challenge to someone that's got
relatively stable and healthy peripheral venous access.
So the DIVA definition,
which was published by Amit Bahl in this paper,
which was a systematic review published
in "The Journal of Vascular Access" this year was that
a patient is considered to have DIVA
if any of the following elements are present.
A clinician has two or more failed attempts at PIV access
using traditional techniques,
physical examination of findings suggestive of DIVA
that there's no palpable or no visible vessels,
or that the patient has stated
or documented history of DIVA.
We did mention that on the previous slide.
Along with the previous themes,
certainly the inclusion of patient history in the definition
highlights the importance of assessment,
and listening to patients when they actually say
that they're difficult access or they're a difficult stick,
or that they've had a history of failures.
You know, we shouldn't fail one device
to be able to progress to the next,
but, unfortunately, that does sometimes occur.
The definition of DIVA, which has come about now,
it also aligns with the definition that was used
in the "Infusion Therapy Standards of Practice,"
the 2021 publication that was released
earlier this year in January,
which also includes to include
the number of multiple attempts, physical assessment,
and patient history as well.
So this very much aligns with
what the outcomes of the systematic review had as well.
So should clinicians use ultrasound
to place peripheral IV catheters in DIVA patients?
Well, the simple answer is yes.
But there's been a number of studies
that have supported this decision to say yes as well.
And a study by Davis et al. also demonstrated
that the prevalence of DIVA,
and showed an association between delays
in critical care therapies,
and the state of the DIVA patient.
Patients experienced multiple delays,
particularly in the emergency department and the outcomes.
They looked at the outcomes of ultrasound-guided PIVs
that were inserted by nurses versus physicians.
Patients who required ultrasound-guided PIV insertion,
vascular access was obtained faster and more efficiently
when it was performed by clinicians
that were properly trained,
and it led to more expedient care in the emergency room.
These results should encourage clinicians,
hospital leadership, and other professional organizations
to continue to drive improved outcomes
for all of these patient populations.
A study by Acuna in 2020,
looked at implementing a handheld ultrasound device
to improve guidance in DIVA patients
in the emergency department,
and demonstrated a 92% successful placement,
and 82% first pass attempt,
which is very, you know, it's still very good.
Of these, 82% of patients had no complications.
So reducing patient-related complications
from device insertion is quite significant.
And the use of ultrasound is really beneficial
in helping drive some of those changes.
A review by Baribeau et al.
the authors evaluated the benefits of
several compact handheld ultrasounds,
and described using
artificial intelligence and augmented reality
in both novice and experts to acquire images.
And this led to faster diagnosis,
a more focused clinical care picture,
and better clinical decision-making.
A lot of the ultrasound really assists clinicians,
not only in the insertion process,
but also in an astute venous assessment of the patient.
A lot of the time,
particularly many years ago
when ultrasound was just being taken into vascular access,
device placement or vessel assessment was just really
in one or two focal areas,
usually in the antecubital fossa
or somewhere in the mid forearm,
or even maybe in the upper arm region.
And then, you know, the vessel may have been punctured
either using a direct visualization
or the ultrasound machine was put down,
and then they just did a blind puncture.
So the introduction of POCUS
or point-of-care ultrasound in a daily practice,
is really not just a possibility anymore,
but it's a certainty.
And certainly not just handheld devices,
but all ultrasound devices that are available
to clinicians are crucial to implement these changes
so that patients will benefit, and also the staff.
Now, this is just a screen capture from a YouTube video.
And while I tend to think that
YouTube is not an empirical site for clinical education,
you do find a lot of information out there.
The only thing wrong,
well, it's not wrong with this picture,
but the only thing to really address in this picture is that
there's no sterile ultrasound probe cover,
which is covering the transducer.
And while there are clinicians out there
that have been utilizing ultrasound guidance
without one for years,
with the new guidelines around high-level disinfection,
this is a really important strategy to maintain,
you know, disinfection and cleanliness of the probe.
So making sure that
using a sterile ultrasound probe cover is essential.
This, you know, view also demonstrates that,
you know, a puncture is also in the antecubital fossa,
not the greatest area because of the area of flexion.
And also we can see that there's a tourniquet
that has been placed on the patient,
which is great for engorging the vessel
to help improve first-time success,
but when we're doing our patient assessment,
we also want to be assessing
the patient without a tourniquet on,
so that we see the vessel in its natural state.
Elevating or engorging the vessel size
and making it bigger than what it is
for the puncture is fine,
but when we want to place
an appropriate size device in the vessel,
a tourniquet gives us a false sense of security
that our vessel is an appropriate size
because quite often it's larger than what's expected.
And that just allows a clinician to put in a bigger device.
Once the tourniquet is released,
the vessel goes back down to its normal resting state,
and it has decreased blood flow around it.
And that can lead to superficial thrombosis
and a variety of other complications.
So what about the use of ultrasound
and improving facility efficiencies?
Well, there's been a number of publications.
And the majority of these screen captures of the papers
have been from 2020, 2019.
And, you know, there's been a number of publications
that are very much focused on cost savings and improvement
in departmental workflow.
The references are included,
but I put screen captures on here
because it just allows everybody to be able to see
the publications where they are.
And certainly the fact that
they're within the last few years.
So there's a lot of focus that's now driving,
you know, in-house efficiencies.
And with the advent of implementation of
ultrasound-guided programs in a facility,
we're starting to see much better workflow efficiencies
within departments and within facilities as well.
A recent study by Shokoohi et al.
correlated DIVA with the time to administration of
intravenous pain medications,
fluids, imaging contrast, laboratory results,
and the disposition within the emergency department.
They also determined that patients with DIVA
were more likely to be female, identified as Black,
and have a higher acuity of illness.
And of the pediatric patients that were also studied,
DIVA occurred within the first year of the patient's life.
So we're already starting to see
challenges across different patient populations
based on their existing vascular access.
So, you know, taking into those considerations
when you have those types of patients
that are now presenting to the emergency department,
or, you know, ward settings where,
you know, they may not have access
to an ultrasound machine straightaway,
patients are still possibly experiencing,
you know, device-related insertion failures
because they're having a number of attempts.
And some of these patient populations are
at more risk than the others.
Shokoohi also looked at looking at age-related peaks,
and they discovered that the two DIVA age peaks were
at ages 35 and at ages 63.
And certainly workflow metrics,
the DIVA patient was associated with an increase
in median times to completion.
So 50 minutes for patients
to receive pain medication administration,
if they require a new peripheral intravenous catheter
for insertion of these medications.
36 minutes for IV fluid administration.
Nearly half an hour for laboratory results to be collected.
57 minutes for contrast administration
after 87 minutes for discharge orders.
So DIVA was associated with increased time to therapies,
diagnostic studies, imaging completion,
and obviously, their ED disposition.
So a more expeditious approach to achieving
intravenous access in DIVA patients is improved.
Well, certainly in the emergency department,
and in overall patient care
with the advent of using ultrasound guidance.
Vanno Sou et al.,
colleagues of mine actually from Australia
did a clinical pathway
in the management of difficult venous access patients.
And they did a study over 12 months
looking at after-hours clinical support for DIVA patients
to improve first-time success.
And what they found was
the median number of unsuccessful attempts
before referral to the after-hours clinical support was two.
So while that is great
because the patients are only experiencing two attempts
before their after-hours clinical support was called,
the numbers range between a first-time attempt,
but up to 10 attempts per patient for a particular patient,
when compared to only one attempt
when the after-hours clinical support was used
with ultrasound guidance.
So strong statistical p-value there of .001,
but what it did demonstrate that first-time success rate
by the after-hours clinical support team was really high.
It was looking around 93%.
The median pain scores were much lower,
and demonstrated statistical significance as well.
Also nine out of 10 catheters were inserted,
and achieved a first-time insertion rate
with low pain scores.
Another paper by Russell Piper, also from Australia,
looked at the mechanistic causes of
peripheral intravenous catheter failure.
And they did a parametric computational study
to try and understand more about
the hemodynamic environment.
And what they demonstrated was that excessive infusion rates
led to extremely large increases
in damage to the vessel wall,
and actually to the blood itself.
And that if faster infusion rates were required,
then the largest gauge catheter suitable for the vessel size
should be used to reduce ejection velocity,
and resulting damage.
One of the things that we try and achieve,
particularly in the vascular access realm is
to use a small catheter in a large vein.
But what this study showed was actually that
at higher infusion rates with a smaller catheter,
the ejection velocity was actually causing more
and significant trauma to the endothelium
than what was expected.
And so the presence of the catheter itself,
even with slow infusion rates,
can also lead to increased stasis time.
It promotes fibrin and platelet deposition
around the catheter,
and obviously thrombosis at the catheter tip,
and this can lead to device-related occlusion.
So if we put all of that together,
that ejection velocity,
because it's traumatizing the endothelial layer,
that's creating the inflammatory response that then creates
that platelet and fibrin deposition and thrombosis.
And superficial thrombosis is
a very common complication
related to peripheral IV insertion
and ongoing care.
(Timothy sniffles)
Excuse me.
So, Civetta published
a paper looking at difficult venous access
and the identification of parameters
to develop a tool to identify patients with DIVA.
It was called the EA-DIVA score,
so Enhanced Adult DIVA score.
Once again, this was published out of Italy
in "The Journal of Vascular Access."
And they've looked at difficult intravenous access
in 127 patients.
Sorry, and the number of patients in the study,
12.6% of them were difficult intravenous access patients.
And they devised a score that ranged from zero to 12.
They validated their study at the same time,
and suggested that a cutoff score of eight,
which maximizes sensitivity and specificity
in detecting peripheral venous access was very useful.
And so this tool has been implemented to determine
what are some of the functional aspects of
identification of criteria and parameters for DIVA patients.
There was a study that was done by Takahashi in 2020
that's open access.
So everybody can access a lot of these
because a lot of them are open access papers,
which is really useful.
A study that was done in Japan looking at
5,300 plus catheters from 2,400 and something patients.
And they looked at the rate of catheter removal
due to catheter failure was around about 20%.
It was associated with signs and symptoms of
erythema, swelling, induration, bleeding, pain,
and insufficient blood flow.
So this study really correlated that
a number of clinical symptoms that we can monitor
very closely, very accurately and fairly simply
were contributors to one out of five catheters failing
in patient populations.
Ian Blanco-Mavillard did a study
that was published in "The Lancet Hematology"
looking at multimodal intervention
to prevent device-related failure in adults.
It was a randomized controlled trial
to determine the efficacy and cost of
multimodal intervention in hospitalized patients
looking at device-related failure.
It was done in seven hospitals
in a cluster-randomized, controlled trial
that was done in Spain.
The primary outcome was looking at PIV failure at 12 months.
So looking at phlebitis,
extravasation, obstruction, or infection.
And they ran, and subsequently made an amendment
to the study protocol midway through this year,
which included dislodgement
as part of the failure of the PIVC device failure.
Peripheral intravenous cannula insertion
in a study that was done by Angles
had a roughly 20.3% failure.
They also used a VENSCORE predictive scale.
So we can start to see that
there are a number of authors and researchers
that are now starting to investigate predictive scales
to look at identification of risk factors
and potential for device-related failure.
And certainly a lot of these publications
have been published within the last, you know,
12 to 24 months.
Pain at intravenous cannulation insertion was described
in around about 17% of patients.
And the VENSCORE was found to be very useful
for identifying adults at risk of device-related failure.
Amit Bahl, also, again,
looked at early recognition of peripheral catheter failure
using serial ultrasonic assessments.
And this study was published,
I think in PLOS One from memory, which is open access.
The primary objective was to identify
ultrasonic PIVC failure.
And their secondary outcome was to look at
if ultrasound indicators occurred earlier
than clinical recognition.
So they were using ultrasound to try and determine
prior to seeing visual changes
that would contribute to device-related failure.
PIVC failure occurred in 39% of participants.
And roughly 9.7% of patients
had subcutaneous edema present on clinical examination,
while 56 1/2 percent had
subcutaneous emphysema identified on ultrasound.
So the benefit of using ultrasound to look at
even just soft tissue swelling has
greatly increased the number of patients
that have a positive result.
And so the presence of subcutaneous emphysema
is a strong predictor to PIVC failure
as determined in this paper.
And it often occurs early and frequently
throughout the PIVC life cycle.
So this can really,
you know, directly impinge on PIVCs failures,
and certainly can be overlooked
in the clinical examination setting.
So what about ultrasound-guided patient assessment?
Well, we all know that
scanning the peripheral veins and structures are,
you know, important strategies
when we're looking at placing an ultrasound-guided device.
Going back to some of the manuscripts
that were published back even in 2010,
looking at ultrasound needle access
in a vein that's either two to four millimeters in diameter,
and at least .3 to 1.5 centimeters in depth,
it was studied by Witting et al. in 2010 and published.
They looked at ultrasound assessment being undertaken
without the use of a tourniquet
to assess the vessel size as I had previously mentioned,
to see the vessel in its normal state.
Ultrasound assessment really should be performed.
And one of the things that we really are driving is
what we call Rapid Peripheral Vein Assessment.
It's a very simple and standardized approach
to vessel assessment prior to insertion of a device.
And this both works
in the peripheral and the central setting,
and we have rapid central vein assessment,
or what we call receiver,
which is also part of
the entire process of patient assessment
looking for and determining the most appropriate location
for catheter insertion,
but also choosing the most appropriate vessel.
Scanning of the peripheral vasculature really includes
visualization by starting in the forearm,
and moving up from the wrist to the antecubital region
and towards the chest,
particularly if we're going to scan the upper portion
or the upper extremity of the arm as well.
Because peripheral assessment is
not just from the wrist to the antecubital fossa,
it's the full length of the arm.
(Timothy coughs)
Excuse me.
It's an important strategy
when determining appropriateness of a device
because remember,
even though we might be looking at ultrasound-guided PIVs,
we still have to take into consideration
other peripheral devices such as midline catheters
that may be used,
and they're frequently placed in the upper extremity.
And so peripheral assessment needs to be relevant
to that area of insertion as well.
So if we look here
we've got an old picture from quite some time ago.
I can't remember the textbook that it came from,
but it's one of the old, very famous anatomy textbooks.
But if we look at the pathway of the vessels,
regardless of the image,
whether it was taken 200 years ago and hand-drawn,
or, you know, scanned with an ultrasound today,
the majority of our vessels are pretty much textbook,
and usually located in pretty close proximity
to what, you know,
a lot of the images in our anatomy books highlight.
And so when we're scanning our patients
to look and perform vessel assessment,
the majority of these venous structures are going to be
in, you know, similar areas.
So step one, if we're going to be following,
particularly in the forearm assessment area,
we're going to assess the cephalic vein
along the length of the lateral forearm.
Now the cephalic vein is the longest vessel in the arm.
It reaches from the dorsal aspect of the wrist
all the way up to the shoulder,
where it joins the axillary vein just laterally
from outside the lateral border of the first rib.
We need to also be able to follow the basilic vein
along the posterio-medial aspect of the forearm,
and assess the brachial artery and veins
in the antecubital fossa and the elbow.
The reason why it's important
to be able to assess all these veins is,
one, not only is it helping us look at
the state of vessel health
and see what condition and size
the compressibility of these vessels are,
but we also want to be able to visualize
the pathway along the entire region of the forearm.
This allows us to be able to choose and optimize
the insertion site.
That's going to be a very important strategy
to help improve device dwell
and prevent device-related failure.
If we cannulate at the wrist and patients start doing this,
then the device is going to fail much faster,
if it was, you know,
as opposed to if it was inserted in the forearm
where there's no areas of flexion.
So choosing an appropriate insertion site
is part of that assessment process.
And this is where RaPeVA is really helpful.
So Rapid Peripheral Vein Assessment really involves
the identification of the main veins and arteries
along the upper extremity.
It's not just about the upper extremity.
We extend RaPeVA down to the wrist.
And this allows us to be able to incorporate
all the vessels in the forearm as well.
Now, if you look at the table here,
it goes through the cephalic vein,
the brachial artery and veins, the basilic vein,
looking at the neurovascular bundle,
so the brachial vessels and the median nerve
in the mid-arm area,
following along these vessels,
up towards the axillary and the subclavian
and external jugular.
Now that's fine for the upper extremity.
And as you can see this sort of outlines
the RaPeVA protocol to the upper extremity.
But essentially,
a full arm assessment is actually starting at the wrist,
and working our way up to the antecubital fossa,
and then repeating the same process as we do RaPeVA.
So really the forearm could be called RaSuVA,
Rapid Superficial Venous Assessment
because the majority of the vessels in the forearm
are relatively superficial.
The median vein can be fairly deep
in the mid forearm region,
but generally the cephalic vein and the basilic vein
are fairly superficial.
And once again, you know, RaPeVA really highlights
the ultrasound process that clinicians really would,
you know, be recommended to follow
when they're doing ultrasound-guided peripheral assessments.
Education and training.
Well, I was just even on my personal experience,
I was just in New York City just last week,
doing ultrasound-guided PIVC training
at a large cancer facility.
And, you know, clinicians are very excited
to be wanting to utilize ultrasound
to help improve their outcomes for their patients
and place more appropriate devices,
but with it comes, you know, a steep learning curve.
You know, regardless of your,
you know, patient-based, landmark-based skills,
which, you know, we all started off learning in that method,
ultrasound provides a different dimension
to looking at patient's anatomy,
and when we start incorporating device.
So the hand-eye coordination starts to change a little bit
because we start spending more time
looking at the ultrasound screen
rather than at our patients.
So one of the things that I find that a lot of clinicians
when they first start learning ultrasound is to actually,
you know, they continuously look at the patient.
They're not looking at the ultrasound screen.
And that's one of the things that,
you know, comes with time,
and, you know, remember that ultrasound-guided IV
or even just, you know, IV insertion,
it's a volumetric-based skill.
The more you do it the better you're going to get at it.
So the same process applies when we use ultrasound.
The big thing is that we need to remember
that we divert our gaze away from the insertion site,
and we're actually following the needle tip,
and the process of insertion
actually on the ultrasound screen.
So there was a study that was performed
by Sarah Feinsmith from Chicago,
looking at performance of peripheral catheters inserted
with ultrasound guidance versus the landmark technique
after having performed
a simulation-based mastery learning intervention.
It was a large study.
They had a total of 43,470 short peripheral cannulas
that were inserted in almost 24,000 patients.
Of that number, only 16.8% or just under 8,000 catheters
were inserted under ultrasound peripheral,
ultrasound guidance, sorry.
At 30-day follow-up for peripheral IVs
with an indication for removal that was documented
ultrasound-guided IVs had
a higher Kaplan-Meier survival probability.
So statistically,
meaning that ultrasound-guided IVs lasted longer,
and stayed in dwelling for longer
than a traditional blind insertion technique.
And what they did was they evaluated
this simulation-based mastery
with ultrasound-guided-peripheral IVs,
and helped determine that lower failure rates
after standard peripheral IVs occurred after two days.
And it exhibited improved survival rates of the device
within patients with DIVA.
And, you know, these findings suggested that
rigorous simulation-based insertion training models
really improve ultrasound-guided placement,
but also survival when it's compared to traditional IVs.
And we're seeing a lot more research that's coming out,
focusing on these particular strategies.
So this really highlights
the importance of good quality simulation-based education
when we're learning ultrasound
and guided-peripheral IV placement.
This study from "The Ultrasound Journal"
looked at residents of internal medicine,
critical care, and emergency medicine,
saying that their procedural demonstration for ultrasound
for peripheral IVs was pretty poor.
It was relevant to their practice obviously,
because they work in critical care areas
or internal medicine areas
that said, however, internal medicine residents
performed fewer procedures than the critical care
and emergency medicine residents,
which that doesn't surprise me.
There's a much faster turnover through the emergency
and critical care areas of patients
than maybe in the internal medicine areas.
But what they did highlight was
training and ultrasound procedures
reduced landmark techniques and improved patient safety.
Well, you know, even though this is a 2021 study
that really highlights that, you know,
clinicians that are coming out of school
are not getting taught how to place devices,
you know, using ultrasound guidance,
and they're learning it once they're in,
you know, in the clinical setting.
We don't want to be using our patients as,
you know, as practice pincushions,
but certainly ultrasound training, you know, is required,
and that, you know, across all disciplines
whether it's internal medicine, critical care,
and across all, you know, healthcare professionals,
whether you're a nurse,
whether you're an NP, an RT, a physician,
everybody needs a certain amount of
simulation-based training to really master that skill
prior to actually performing it on patients.
Fredericus van Loon published a systematic review
in "Medical Ultrasonography"
looking at training and knowledge of ultrasound physics
and certainly ultrasound-guided peripheral cannulation,
and performed a systematic review and meta-analysis.
What they did find was that
having a good understanding of the ultrasound physics
before applying ultrasound-guided procedures
was an important strategy for clinicians to understand
before, you know, going on and doing further education.
So understanding the physics of ultrasound,
the transducer properties,
and understanding the respect of the beam
with elevation plane,
and certainly when it came to the use of
cannulating small vessels such as peripheral veins
was really important strategy.
Competency around
ultrasound-guided peripheral intravenous cannulation
can certainly be achieved after,
you know, using fixed training curriculum.
This has been demonstrated,
not just in the systematic review by van Loon,
but in other research that's been published,
you know, very recently as well.
Davis, you know, Feinsmith,
all those authors have all come to the same conclusions.
So a combination of didactics training
followed by hands-on session training
using a simulated environment,
really allowed clinicians to have
supervised life-case training,
which is an important strategy to be successful.
Another study from this year in the journal,
Scandinavian Journal of Trauma,
Resuscitation and Emergency Medicine,
looking at education,
again, in ultrasound-guided peripheral catheters,
another systematic review.
So what we're starting to see is
a lot more high-quality evidence that is now coming out
that's going to be driving our clinical practice,
and our policy-related changes
as we move into the future with ultrasound use
and looking at ultrasound guidance.
You know, Jorgensen found that, you know,
the potential benefits of ultrasound-guided training
on success rates, procedural time, cannulation attempts,
and reducing the need
for subsequent CVC or PICCs in adult patients,
you know, had a significant outcome.
And certainly having an assessment tool
with a proven validity of evidence to ensure competence is
an important strategy in the mastering process.
And certainly looking at e-learning
and use of color Doppler,
they did investigate that
and said that there are promising results,
but obviously it still needs further investigation.
But all these high-level publications and systematic reviews
are really just driving home the clinical evidence to say,
we should be using ultrasound more often and more frequently
in our patient populations,
not just DIVA but in our other patients as well.
A number of other studies.
I'm just going to go through these just quickly.
Once again, peripheral IV placement,
looking at an observational study in pediatric patients.
A lot of the focus is DIVA is looking at adults,
but neonatal and our pediatric patients
also fall under the same category of DIVA.
It's not an age-restricted, you know, criteria.
And certainly, you know,
clinicians that specialize in neonatal and pediatric care
still require the use of ultrasound
to improve their performance and reduce,
you know, unwarranted complications and pain
for patients in their clinical domains as well.
And certainly this paper by Anderson demonstrated
that 30 minutes of didactics were taught to clinicians
to try and improve their first line approach,
particularly in patients with a history of difficult access,
or no palpable visual vein,
even with the application of a tourniquet
and two more attempts.
So once again we're starting to see that correlation
amongst the pediatric patients,
also with our adult patient populations,
all fitting the same criteria.
So ultrasound-guided training is an essential process.
And in this study,
nurses were or pediatric nurses were given
two hours of training on ultrasound-guided IVs.
And after training,
40% of participants adopted ultrasound-guided PIV insertion
into their practice.
Now, hopefully, what we'll see is
that number just increasing at a more rapid rate,
and that we start seeing more clinicians
utilizing ultrasound guidance
in their regular clinical practice for IV insertion
across all our patient populations.
So what are some of the other
ultrasound assessment criterias that we need to consider?
So when we're looking at using ultrasound
for peripheral cannulations,
we need to take into consideration several other things,
particularly when it comes around
to appropriate vessel choice.
We know and we understand,
and the evidence says that we can achieve
high rates of first-time insertion,
and we can reduce failure,
we can promote longer dwell times,
and improve patient and clinician satisfaction,
but there are other things
that we also need to take into consideration
when we're doing our patient assessment.
And these are really identified here in these five points.
So vessel diameter and catheter vessel ratio.
Vessel diameter is really important
because if we're trying to put
a large device in a small vessel,
we're going to have a higher degree of device-related failure,
but also a higher degree of (coughs)
excuse me,
related complications,
purely around the fact that the device is maybe
too big for the actual vessel
and it has poor blood flow,
increasing the risk of superficial venous thrombosis.
Depth of the overall vessel.
I'm going to go through these points individually
in the following successive slides.
But compression of the artery and referred pulsation
using ultrasound to determine
what is a vein and artery is a very, you know, simple,
but very important strategy
to help prevent unwarranted arterial puncture.
The proximity of the vessel to other structures.
So is it close to a nerve?
You know, are there lymph structures that are close by?
And we can also use ultrasound to identify and understand
other anatomical and physiological issues.
So vessel size and catheter vessel ratio.
So this was a picture that I actually drew on my phone
a couple of years ago when we talk about
looking at the difference
between linear and area-based catheter vessel ratio.
But in vascular access practice,
the internal vessel size or the diameter
is considered to be important.
And certainly catheter vessel ratio has now become
a recommendation to assist clinicians in determining
what is, you know, an appropriate size vessel.
In 2016, the "Infusion Therapy Standards of Practice"
made recommendations that catheter vessel ratio
could increase from 33% to 45%.
And now provided a criteria of a ratio
between 30 to 45% of the vessels diameter.
In 2021,
in the new "Standards of Practice" that were released,
it also addressed cross-sectional area
to help define catheter vessel ratio.
And this applies to any vascular device,
both peripheral, arterial, and central catheters,
and making sure and ensuring that
the catheter vessel ratio is appropriate
is an important strategy at reducing complications
particularly around thrombosis.
While there needs to be more research
focusing on catheter vessel ratio
and thrombosis relationship,
you know, putting a device that's too large for the vessel
we know does cause unwarranted complications.
When we look at the definition of catheter vessel ratio,
it's defined as the indwelling space or area
consumed or occupied by an intravascular device
inserted or positioned within the arterial
or venous blood vessels.
Now the picture on the side,
if you look at the solid line
that divides the vein or the circle in half,
that is a linear measurement,
but what happens is that
when you focus on a linear measurement
it doesn't take into consideration other areas of the vessel
that are around the catheter.
So when you see this catheter as a circle on the screen
where those X's are,
the cross-sectional area takes into this account
for blood flow, whereas, a linear doesn't.
And this is where the differences lie
between the two different types of measurement systems
when we're looking at catheter vessel ratio.
Both work well, but there needs to be more research
focusing on the differences
between linear versus area-based,
catheter vessel ratio, sorry.
Vessel related depth.
Okay, so this is an important strategy
when assessing a patient.
And certainly, a lot of vessels that are down
as deep as about 1 1/2 centimeters
are relatively easily accessible,
whether through palpation or other visual aids,
to be able to gain access or peripheral access.
The vessels that are deeper than 1 1/2 centimeters
really require ultrasound guidance.
And certainly,
once we start considering overall vessel depth,
that also changes
how much catheter actually lies within the vessel
because if you look at this image here,
we need to be able to calculate
how much of the length of the catheter
is actually sitting in the subcutaneous tissue.
So from this image here,
at a 45-degree insertion angle,
if we look at that upside down right angle triangle,
we're really basically looking at
calculating Pythagoras' theorem.
And so a randomized control trial that was done by,
again, Amit Bahl from Beaumont in Michigan,
demonstrate increased catheter survival rates
when they used catheters
that had a much longer overall length.
And what they looked at was 20-gauge 4.7 centimeters
and 20-gauge 6.35 centimeter peripheral cannulas.
And their conclusion that was
longer extended dwell catheters are very much viable option
and a favorable alternative to standard long IVs.
Particularly if the vessel was greater than
1.2 centimeters in depth.
Now to help reduce device-related failure,
we need at least minimum 50% catheter dwell in the vessel,
but other research has shown
that we really should be aiming to have
a higher amount of catheter dwell in the vessel
and up as high as 65% or more of the length of the catheter
in the vessel.
So vessel depth really can affect
the amount of residing dwell length of the device
within the vessel.
And so we need to make sure that
if we are choosing vessels that are deeper,
or in areas that require greater length
to be able to puncture down to the vessel,
particularly if we are even looking in the upper arm,
that we make sure we have an appropriate length catheter.
That's a very important strategy
to make sure that our dwell length is correct.
- [Laura] Hey Tim, this is Laura.
I just wanted to chime in real quick.
We are at time,
so I didn't know if you had another obligation.
I just wanted to make sure you're okay.
- No, no, no.
And we've only got a couple of slides to go.
- [Laura] Okay.
- Is that okay?
- [Laura] That sounds great
just wanted to make sure.
- All right, no worries,
I'll keep it going
so that we get some question and answer time.
Compression of arteries.
Very important strategy that we can use with ultrasound
to determine what is an artery and a vein
is really applying pressure with a probe,
and looking for that arterial kickback.
It's a very important strategy for clinicians to determine
so that it doesn't,
so that we don't have,
you know, unwarranted arterial puncture.
Both arteries and veins appear in similar appearance
on an ultrasound screen.
They're both anechoic,
so they have a black lumen, they're fluid-filled.
However, arteries, obviously have a thicker wall structure,
and are a little bit more hyperechoic.
And quite often you can see that
the layers within the arterial wall system.
You know, the venous walls are much thinner,
they're more subject to probe pressure and weight
and so will compress a lot easier.
But being able to use ultrasound to differentiate
between arteries and veins is a very simple
but important strategy
when we're doing our venous assessment.
(Timothy coughs)
Excuse me, talking a lot, get a dry throat.
All right, getting close to the end now.
But surrounding structures such as mentioned,
arteries, lymph, bone, nerve, venous bifurcations,
these are all frequently present
when we do an ultrasound assessment.
Other structures that are fluid-filled like arteries
don't necessarily reflect the ultrasound beam,
and obviously appear black and anechoic just like a vein.
So making sure that we differentiate
between those other structures is a very important aspect.
So bone has a bright hyperechoic rim.
That's usually the periosteal layer.
And as bone doesn't,
sorry, as the ultrasound beam doesn't penetrate the bone,
it casts an acoustic shadow behind it
leaving like a black aspect
where you don't get really much imaging at all.
So this is an example, a nice big closeup actually,
of the vessels in the upper arm numbered appropriately.
So number two would be the brachial artery,
and one and three being the brachial veins,
and vessel number four, being the basilic vein.
As you can see, the basilic vein in this image
is the largest image of the three venous structures
that are highlighted on the screen
but the artery and the vein are very similar in size.
Now there is a little bit of distance between them.
And as you can see
with images that are numbered one, two, and three,
it sort of looks like Mickey Mouse's head
but rotated around to the right.
And that's one of the classic signs
when you are assessing
the venous and arterial structures in the upper arm
that you see this, what they call a Mickey Mouse effect,
and Mickey Mouse's head can be rotated around.
So one and three are his ears, and two is his head.
But it's a classic sign that you see in the upper extremity.
You also see it in the femoral location
if clinicians are placing femoral catheters as well,
but this is fairly commonly seen in these patients.
Obviously identifying and understanding
the different anatomy and the physiology
we can use ultrasound to determine
if there's occlusions, stenosis, or thrombosis
within a vessel,
and being able to assess the vessel diameter,
to make sure it's of appropriate size.
We can use ultrasound to be able to see into the vessel.
And even if we're just scanning out the vessel
and following the pathway,
if there's any narrowing of the vessel as we go up,
and it gets narrower,
and then it opens up and gets larger again,
that's a classic sign that we're seeing some sort of
stenotic process that's occurred within the vessel.
So that's an important aspect
when we do our ultrasound assessment,
is that when we're scanning the patient
and doing our ultrasound assessment,
that we're scanning the full length of the vein,
of each vein that we want to identify,
rather than jumping and lifting our probe off
the surface of the skin
and moving it to individualized areas.
This misses all that data, that rich data in between.
And that's an important aspect
that what we want to be able to find is that
if there is thrombus or if there is stenosis of a vessel
at any given point along the pathway of the vessel.
Once again, catheter dwell length,
getting back to Amit Bahl's paper,
and a couple of other publications
getting back to dwell length.
I think I forgot to move this slide
back to the other location, but it doesn't matter,
we'll come back to it anyway.
But what it did show was that
ultrasound-guided peripheral IVs
had a higher failure rate of 45 to 56%
when it didn't have an adequate dwell length,
whereas, compared with 19 to 25% failure
versus traditional blind IVs.
While there is a sort of limited amount of research
looking at catheter dwell,
the catheter failure rate was higher
if there was less than 30% of the catheter in the vessel.
So if you think about vessels
that are very superficial on the surface,
even a short IV of .88 inch peripheral IV
is still going to have a good catheter dwell length
because the actual tissue depth to the vein
is relatively very, very shallow.
But as we get deeper and deeper,
we need to make sure that we accommodate
and make changes with our catheter length
and ensure that that proper length of catheter is residing,
so we're really trying to maintain
a 65% dwell within the catheter.
Now I know that Laura has said that we're at time,
and I think that's pretty much it.
So I think we can open up to question and answer time now.
So thank you very much for listening.
And if we've got any questions, please fire away.
- [Laura] Thank you so much, Tim.
That was so much information.
It was so helpful, though, to see all of that data,
and really paint that picture of
how necessary and how useful ultrasound is for.
- [Timothy] Yeah, there's a lot of evidence, you know.
And I know it was probably heavy on the evidence
in the slide deck.
But it really shows that clinicians
are really wanting to investigate,
you know, this area of clinical practice
to try and improve outcomes for our patients.
So, you know, I think we're just going to see
more and more research that's really going to contribute to
driving, you know, clinical practice,
and certainly ultrasound-guided peripheral IV insertion.
And not just in our DIVA patient population,
but also in our other patient populations as well.
- [Laura] Right, I was thinking about pediatrics as well,
and all kinds of things.
There was one question.
I don't know if you might need to back up a couple slides,
but what does a lymph node look like on ultrasound?
Can you see them?
- [Timothy] You can, absolutely.
I haven't got a picture of a lymph node
that's in the slide deck,
but a lymph node is a fluid-filled tubule just like a vein.
So it looks very similar.
It doesn't have the same level of compressibility as a vein,
but it has a smaller wall structure,
as opposed to say an arterial structure.
You will see because lymph nodes usually hover
and sort of hang around the neurovascular bundles
that's where you'll probably primarily see them.
And sometimes they can be mistaken as a vein.
So it is important to try and eliminate.
If you are seeing
a number of different structures on the screen,
you want to try and be able to eliminate
the ones that you want to avoid such as lymph node,
or, you know, even arteries as well.
Laura being a sonographer,
you know, do you have any pearls about
identification of lymph nodes on ultrasound?
- [Laura] I don't necessarily have any pearls,
but I was able to find an image of a lymph node
on our institute.
If you wouldn't mind,
I could share the screen real quick and show that,
and then if you want to speak to it a little bit.
- [Timothy] Sure, do I need to unshare my screen to do that?
- [Laura] Yes.
- [Timothy] Okay, all right, there we go.
- [Laura] There we go, okay.
So this was the one I just found on our institute.
And you're right, it's in with vessels as well, so.
This is the lymph node up here versus the other.
This is in a DVT course, so this is unrelated to PIV,
but it still, you know, gives you an idea.
- [Timothy] Yeah, well, it says at the bottom
that it's femoral,
so you've got lymph that's close to the femoral vein,
and the femoral artery as well,
hidden amongst the subcutaneous
and the lower levels of the subcutaneous tissue.
But if you look closely,
yeah, exactly where the mouse is,
you can see that it looks just like a vein, you know.
So it's part of that process
when we do our patient assessment is to make sure that
what we're looking at we know what it actually is.
Now, obviously, this is, you know, in the femoral region,
so it's a little bit different,
but the thing is,
is that what it does highlight is that lymph node.
Lymph nodes are going to be hanging around
where you do have a large artery and venous congestion
in like say the antecubital fossa
where the neurovascular bundle is,
you know, all coming together as well.
- Right. - So, you know,
careful identification.
Compressibility is going to be one of the things
that you would use to help identify,
you know, what is lymph, what is arterial,
and what is venous,
because lymph nodes don't compress down as easily
and as lightly as what a venous structure may do.
And you don't get the rebound effect on a lymph node
like you would do if you applied compression
with say an artery.
- [Laura] Right, exactly.
We got a couple more questions here.
I don't know how much time you have, but I'll fire away.
- [Timothy] I'm good, I got time.
- [Laura] Okay.
Can you insert an IV under ultrasound
without using a tourniquet?
Is there any benefit to doing so?
- [Timothy] Absolutely, you can.
And there's a lot of clinicians
that are actually using that technique these days.
I think the use of a tourniquet is a personal choice,
I think, and, you know, I'll come out and say it really,
you don't need a tourniquet
when you're doing your assessment,
but I don't see any reason why you can't use a tourniquet
doing the actual procedure.
It helps stabilize the vessel.
It creates vessel engorgement.
It can increase your first-time success at puncture.
But once again, the caveat here is is that
just because the vessel has been enlarged using a tourniquet
doesn't mean that we have to put in a bigger IV.
So making sure that once we've done our patient assessment,
and we've determined what the vessel size is
in its natural state,
so getting back to catheter vessel ratio.
Excuse me.
And determining what is going to be
the most appropriate size peripheral IV for that vessel,
using a tourniquet to actually help assist
placing the vessel,
I have no problems, you know, with that.
And I think there's a lot of clinicians
that would actually utilize maybe a tourniquet
to help assist in stabilizing the vessel
and creating that engorgement.
So it helps increase that first-time puncture.
Remember a bigger target
makes it a little bit easier to puncture
as opposed to a smaller target.
The other thing is, too,
is that when you apply a tourniquet,
and you get that filling
and that closure of the valves in the vein,
you get much more of a rebound puncture.
So when the needle comes down
and you push down on the top wall,
it comes down until it punctures,
and then it springs back up,
and your tip is automatically in the center of the vessel.
So once you get that,
you can then confirm by rotating your probe
to a longitudinal view
making sure that you're not at any risk of
back walling the vessel,
and then you can advance the catheter
off the needle or stylet and into the vessel.
So, yeah, tourniquet, useful,
absolutely, during the procedure of the puncture,
but we don't want to use it
when we're doing our patient assessment.
We want to see our vessel in its natural state.
- [Laura] Right, understood, okay.
I'm going to read this one.
So it's a little bit longer question.
Regarding excessive infusion rates for smaller vessels
that cannot accommodate larger catheters,
is the only option at the time asking for the infusion
to be started at a slower rate and gradually increased,
will this help in any way to prevent vessel damage?
- [Timothy] Well, if we look at the Piper study
that computational mechanisms of device failure,
the smaller the IV
and the higher the fluid flow rates through the device
means your ejection velocity is higher.
So that's where that endothelial damage is causing.
So, yes, I guess by slowing the rate would do that,
but if you have an infusion that is saying,
it's got to be prescribed to be administered
over a certain period of time or a certain rate
then that's going to be,
you know, that may influence
the outcome of that device's failure as well.
So, you know,
if you've only got one vessel and it's only a certain size,
and you sort of think,
well, a 20-gauge is too big for that vessel,
a 22 is the most appropriate size,
but it's going to increase my ejection velocity,
most people don't normally think about ejection velocity.
And, you know,
it's not something that you would actively,
you know, see on a daily basis,
but when we're now starting to see research
that's coming out and saying that
fluid flow rates can actually cause damage,
it sort of makes us start to think a little bit differently
and say, well, gee, you know, is the smallest device,
you know, in an appropriate vessel,
you know, the best decision?
But because we've got certain therapies and certain drugs,
and, you know, certain fluids that have to be administered
you know, given at a certain rate
or have to be prescribed over a certain timeframe,
then I suppose we have to find a happy medium and a balance
between what is going to be an appropriate device
and what is going to be too small,
and how do we prevent that,
you know, ejection velocity related injury?
The problem is we can't see it.
It's one of those.
(Timothy coughs)
Excuse me.
It's one of those investigational complications
that we understand,
but we don't necessarily get the visual cues to say
that this is actually occurring.
So it's more of about a mindset of
making sure that we're constantly aware of these issues
and helping trying to prevent them in the early phase,
rather than after the device has already gone in
and we're like, oh, you know,
gee, I've got to increase the rate to,
you know, 450 mils an hour or something like that from 100.
And that's when we start to think about it.
So, you know, while it's an uncommon thought process,
it's starting to make its way into clinical practice
where we sort of think,
well, you know, if people are researching this,
and they're finding that we're causing vessel-related trauma
because of infusion rates,
then maybe we need to be
thinking of other alternate IV devices,
you know, when we're doing our patient assessment.
As I said earlier, you know,
we don't want to fail one device
before we progress to the next.
You know, choosing the most appropriate device
is going to be an important strategy in the patient's therapy.
And that might be a PICC or a CVC, you know, in that case.
I'm not trying to, you know,
divert peripheral access to a central access,
but, you know, if a patient has limited venous access,
and they have venous depletion,
then maybe a peripheral IV is
not the right choice of device for that patient,
they should get a different type of device.
And that's another strategy that needs to be considered
in hospital policies and protocols
when, you know, we're looking at,
you know, device-related algorithms.
And, you know, I think that's an important strategy
that we need to consider.
- [Laura] Absolutely, that makes sense.
This is a kind of a big question.
I'm not sure if you'll be able to answer it very quickly,
but what is the best ultrasound technique for IV placement?
- [Timothy] Ooh.
- [Laura] Big question.
- That's a subjective question - Yeah.
- [Timothy] because everybody is a little bit different.
All right, we have a few minutes,
so I'll try and keep this brief.
I do like to talk, but I'll try and keep it brief.
If you think about the two different ways
that we can utilize ultrasound,
meaning a transverse and a longitudinal approach,
it opens the door for different aspects of the insertion,
because you have to remember
when we look at transverse and longitudinal,
that's a relationship of the beam to the vessel.
That's how we see the vessel on the screen,
either as a circle or as a tube.
When we start throwing needles into an ultrasound image,
we then start getting in-plane and out-of-plane pictures.
So now we're combining both transverse and longitudinal
with in-plane and out-of-plane.
Utilizing a combination of those techniques
is beneficial to all clinicians.
I'll never say that it's not.
Because the thing is,
is that most clinicians are taught to learn
a transverse out-of-plane technique first.
So that means they're seeing the plane here
and then the needle is coming this way.
And that's where you follow the dot on the screen,
down through the subcutaneous tissue to get into the vessel.
It's probably, actually,
the hardest technique to actually learn
because you're following a tiny little dot on the screen.
When you rotate the probe 90 degrees,
and go to a longitudinal plane,
you all of a sudden see the entire shaft of the needle,
which is much brighter, much easier to see on the screen.
The problem is you're only intersecting the vessel
in a longitudinal view.
So if your axis is slightly off,
you're going to lose visualization of the vessel,
or the actual needle under the beam relatively quickly.
My recommendations are to always try and utilize
both techniques if you can.
Now I'm not saying that one is better than the other,
because Michael Blaivas did a publication a few years ago,
evaluating techniques
looking at transverse and longitudinal,
in-plane and out-of-plane techniques.
Read the paper, it's really interesting
and it's got some good results.
But the important takeaway message here is that
utilize the technique that you are most comfortable with.
You'll learn to utilize different techniques
to help you be successful in ultrasound-guided insertion.
I could say, you know, use a longitudinal in-plane puncture.
That's fine, but if you've got experience.
But if you're a novice
or you're just starting off utilizing ultrasound
or incorporating ultrasound into your clinical practice,
going to a longitudinal technique
isn't always the best, you know, decision to go to.
You might feel more comfortable
when you see the vein on the screen is a circle
and the artery is next to it and the nerves over here,
because it gives you comfort that you know
that you can direct your needle towards the vein
and away from either the artery or the nerve.
When you go to a longitudinal view,
you lose visualization of those structures
in their perspective in the transverse view.
- [Laura] Right.
- [Timothy] My example,
just on a quick note about choice of term.
When I was in the cancer facility
in New York City last week,
we started in a transverse plane.
I was doing some work with some nurses
in an outpatient clinic.
And they went from,
they naturally wanted to go from a transverse
and went to a longitudinal,
and had better successes in a longitudinal plane.
Now that's just them.
I'm not saying that everybody's the same,
but what you will find is that if you try and incorporate
both techniques into your clinical practice,
you'll be more successful.
- [Laura] Okay, there you go.
Great answer, that was a big question so.
- [Timothy] No, well, it's a very good question as well,
because a lot of people that are starting out
with ultrasound say,
well, what technique is the best one to use?
Well, it's not the best one to use.
It's what is the most appropriate for you as the inserter,
for the image that you want to see
with your patient as well.
- [Laura] Right, right.
Okay, great, well, that is it for questions.
A couple of people have asked,
will this be available after today?
And, yes, we will be posting a recording of this webinar
on our webinar page on sonosite.com,
so that should be up in a day or two.
But that I believe are the only other questions.
So it looks like we are a wrap.
Thank you so much for your time, Tim.
Thank you for your expertise.
As always you're just a pleasure to work with,
so I really appreciate your time today.
Hopefully, we can work again on something else soon.
- [Timothy] Absolutely, thanks, Laura.
Thanks for having me.
It's always good to talk about ultrasound.
And as you know vascular access and ultrasound
are my two favorite topics.
And it's been a pleasure to be here today.
And for those of you that joined us live,
thank you very much.
And for those of you that will be joining us
in the prerecorded sessions in this session in the future,
I hope you enjoy it and get a lot of benefit
from this information that was presented today.
So thank you very much to Sonosite too.
- [Laura] Thank you so much.
Thanks for joining everyone.
Bye-bye.
There is a need to help clinicians reduce device-related peripheral IV catheter insertion failures and improve success rates. This webinar will provide discussion regarding the use of ultrasound-guidance for patients with difficult venous access. Listen to Timothy Spencer, RN, for a detailed review of current clinical evidence, recommendations, and strategies regarding the use of ultrasound-guided peripheral IV catheter insertions.
What You'll Learn
Upon viewing this webinar, viewers will be able to provide better patient care by having a better understanding of how to:
- Discuss current recommendations and best practices for ultrasound-guided peripheral IV catheter insertions
- Review the clinical benefits of using ultrasound guidance for peripheral IV catheter insertions
- Outline strategies to prevent peripheral IV catheter failure
- Discuss educational strategies for using ultrasound-guidance for peripheral IV catheter insertions
Timothy R. Spencer, RN, APRN, BHSc, Dip.App.Sc., Int.Care Cert., VA-BC™ is a Critical Care and Vascular Access Specialist for 30+ years and is currently the Director for Global Vascular Access, LLC. His clinical background and qualifications are in Intensive & Critical Care Nursing, Vascular Ultrasound, and Advanced Clinical Nutrition. As the Clinical Nurse Consultant of the Central Venous Access and Parenteral Nutrition Service at the Liverpool Hospital, Australia, Timothy established, developed, and led this team from 1996–2014 (21 years).
Mr. Spencer has been a past Director at Large for the Vascular Access Certification Corporation (VACC) and was the first Australian clinician to be Vascular Access-Board Certified in 2014. As the Founding President of the Australian Vascular Access Society (AVAS), founded in 2009, he remain involved with the current AVAS Board.
After relocating to the USA in 2014, Global Vascular Access, LLC, an education and consultancy agency was founded, which engages in clinical mentoring, research, simulation, education and compliance for all vascular access and ultrasound-related issues, at both national and international levels.
This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.