Article

Ultrasound-guided peripheral intravenous placement with standard-length catheters and long catheters

252 Correspondence

whereas changes in hemodynamic loading may facilitate arrhythmogenesis. Research on these issues might further help identify the effects of cardiac mechanotransduction during CPR.

Athanasios Chalkias PhD Elizabeth O. Johnson PhD Theodoros Xanthos PhD

Department of Anatomy, Medical School National and Kapodistrian University of Athens

11527 Athens, Greece E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2012.08.010

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Ultrasound-guided peripheral intravenous placement with standard-length catheters and long cathetersB

To the Editor,

In a prospective, randomized controlled trial comparing performance of standard-length catheters and long catheters for ultrasound (US)-guided peripheral intravenous cannula- tion (PIC) in acute hospitalized patients with difficult venous

? Statement: All authors have no financial support and potential confticts of interest for this work.

access, Elia et al [1] showed that compared with standard- length catheter US-guided PIC, long catheter US-guided PIC required a higher time but was associated with a lower risk of catheter failure. Their findings have potential implications for use of long catheters as a solution to low survival of US- guided peripheral catheters. Other than the limitations described in the discussion, we feel that several issues of this study require discussion and clarification.

First, the authors defined failure of 3 attempts through standard blind insertion techniques as an inclusion criterion of patients with difficult venous access. This is subjective because the standard blind insertion techniques may be performed by junior or inexperiencED staffs. Moreover, there may be a bias effect because the operators know that, if 3 blind attempts fail, an US-guided technique will be used. These factors might have made the validity of this study questionable.

Second, quite rightly, the primary outcome of this study is catheter failure rate. However, comparing Cannulation times with standard-length catheters and long catheters may not be an entirely appropriate comparison because the time re- quirements for cannulation procedures of long catheters include the additional times needed for aseptic technique, local anesthesia of cannulation site, insertion of guide wire via the initial catheter, removal of the initial catheter, insertion of long catheter over the wire, removal of guide wire, and fixation of long catheter with suture to the skin. Moreover, we note that cannulation times with standard-length catheters and long catheters are significantly longer in this study than in the previous studies in emergency department (ED) patients with difficult intravenous access [2-5]. Because this study does not exactly define the cannulation time in the method, it is difficult to compare results of their and previous studies.

Third, in the method, the authors stated that all US-guided PIC procedures were performed by nurses, attending physicians, or resident physicians, and all the operators received a suitable training on US-guided PIC. In discussion, they further explained that procedures were performed by experienced and inexperienced operators. It would be interesting to know how they defined experienced and inexperienced operators. More importantly, the authors should explain if they attempted to define proficiency with US-guided PIC before initiation of the study. The basic skill required for US-guided PIC can be acquired in a suitable training, but attainment of expert performance with a high success rate needs practice and experience. Resnick et al [6] observed that the operators required more than 15 procedures to achieve a high success rate of US-guided PIC in ED patients. Moreover, the rate of success is directly propor- tional to the number of previous US-guided PIC performed by the ED technician [7]. In this study, it is unclear whether the 2 groups are comparable with respect to distribution of experienced and inexperienced operators. We believe that addressing these factors would further clarify the transpar- ency of this study with a diverse group of emergency staffs. Fourth, we agree that the short-axis approach is faster than the long-axis approach in obtaining vascular access with US-

Correspondence 253

guided technique because the vessel is easy to see and the operator must perform less alignment [8]. However, 1 disadvantage of the short-axis approach is that the entire length of the needle will not be seen during cannulation procedures. In contrast, the long-axis approach is preferred by many experienced operators because it allows better visualization of the needle and may help decrease compli- cations associated with US-guided PIC [9]. The operators should learn both techniques. Recently, the 2 techniques have been combined for US-guided PIC, that is, the limb is firstly scanned to obtain a short-axis view of a vein and the setting is then changed to rotate the view to visualize the long axis of the vein. Subsequently, the US-guided PIC is completed using a long-axis approach [10].

Fu-Shan Xue MD Rui-Ping Li MD Yi Cheng MD Xu Liao MD

Department of Anesthesiology plastic surgery Hospital

Chinese Academy of Medical Sciences and Peking Union Medical College Beijing 100144, China

E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2012.08.012

References

  1. Elia F, Ferrari G, Molino P, Converso M, De Filippi G, Milan A, et al. Standard-length catheters vs long catheters in ultrasound- guided peripheral vein cannulation. Am J Emerg Med 2012;3: 712-6.
  2. Mills CN, Liebmann O, Stone MB, Frazee BW. Ultrasonographically guided insertion of a 15-cm catheter into the deep brachial or basilic vein in patients with difficult intravenous access. Ann Emerg Med 2007;50:68-72.
  3. Costantino TG, Parikh AK, Satz WA, Fojtik JP. Ultrasonography- guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med 2005;46: 456-61.
  4. 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. Ann Emerg Med 1999;34: 711-4.
  5. Doniger SJ, Ishimine P, Fox JC, Kanegaye JT. Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients. Pediatr Emerg Care 2009;25:154-9.
  6. Resnick JR, Cydulka RK, Donato J, Jones RA, Werner SL. Success of ultrasound-guided peripheral intravenous access with skin marking. Acad Emerg Med 2008;15:723-30.
  7. Schoenfeld E, Boniface K, Shokoohi H. ED technicians can successfully place ultrasound-guided intravenous catheters in patients with poor vascular access. Am J Emerg Med 2011;29: 496-501.
  8. Blaivas M, Brannam L, Fernandez E. Short-axis versus long-axis approaches for teaching ultrasound-guided vascular access on a new inanimate model. Acad Emerg Med 2003;10:1307-11.
  9. Stone MB, Moon C, Sutijono D, Blaivas M. needle tip visualization during ultrasound-guided vascular access: short-axis vs long-axis approach. Am J Emerg Med 2010;28:343-7.
  10. Benkhadra M, Collignon M, Fournel I, Oeuvrard C, Rollin P, Perrin M, et al. Ultrasound guidance allows faster peripheral IV cannulation in children under 3 years of age with difficult venous access: a prospective randomized study. Pediatr Anesth 2012;22:449-54.

The authors respond

To the Editor,

We thank the readers for their insightful comments. We take the chance to clarify and deploy further some points of our previous article.

First, we defined failure of 3 attempts through standard blind insertion techniques as an inclusion criterion of patients with difficult venous access. We know that this definition may be subjective, but a clear consensus definition of difficult intravenous access does not really exist. By the way, our inclusion criteria were based on those used in previous similar studies [1-5].

In regard to the cannulation time, in our study, we really encountered some different results in comparison with previous studies. The longer cannulation time could be attributable to different baseline characteristics of the population enrolled. In particular, our study reported a larger number of obese patients in comparison with the cited studies [1,2].

In our study, all the operators received a suitable training on ultrasound-guided vein cannulation. Training consisted of 4-hour lecture (including upper extremity anatomy and ultrasound guidance explanation with images and videos), 3- hour hands-on practice on ultrasound approach to upper extremity vessels and ultrasound-guided procedure with tissue phantom, and a minimum of 5 supervised ultrasound- guided procedures. We arbitrarily identify an experienced operator as one who had performed more than 20 procedures. We agree that provider-related differences are a limiting factor in our study. However, the relation between sonographic experience success rates was not evaluated because the primary end point was to evaluate the catheter failure rate.

Finally, we believe that the short-axis approach is a more technically simple method because this technique makes the simultaneous visualization of the needle and vascular structures easier. On the contrary, with long-axis approach, it is more difficult to keep both the needle and the target vessel precisely within the ultrasound beam. We agree that a long-axis approach or a combined short-long axis approach may be more useful, but both of these techniques require additional skill and should be undertaken by more experienced operators.

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