Article

Hand dominance in intravenous drug using patients does not affect peripheral venous access sites identified by ultrasound

a b s t r a c t

Background: The peripheral veins in the arms and forearms of patients with a history of intravenous (IV) drug use may be sclerosed, calcified, or collapsed due to damage from previous injections. These patients may consequent- ly require alternative, more invasive types of vascular access including central venous or intraosseous catheters. We investigated the relationship between hand dominance and the presence of patent upper extremity (UE) veins specifically in patients with a history of IV drug-use. We predicted that injection into the non-dominant UE would occur with a higher frequency than the dominant UE, leading to fewer damaged veins in the dominant UE. If hand dominance affects which upper extremity has more patent veins, providers could focus their first vas- cular access attempt on the dominant upper extremity.

Methods: Adult patients were approached for enrollment if they provided a history of IV drug use into one of their upper extremities. Each upper extremity was examined with a high frequency linear transducer in 3 areas: the antecubital crease, forearm and the proximal arm. The number of fully compressible veins >= 1.8 mm in diameter was recorded for each location.

Results: The mean vein difference between the numbers of veins in the dominant versus the non-dominant UE was -1.5789. At a .05 significance level, there was insufficient evidence to suggest the number of compressible veins between patients’ dominant and non-dominant arms was significantly different (P = .0872.) Conclusions: The number of compressible veins visualized with ultrasound was not greater in the dominant upper extremity as expected. Practitioners may gain more information about potential Peripheral venous access sites by asking patients their previous injection practice patterns.

(C) 2016

Background

The peripheral veins in the arms and forearms of patients with a his- tory of intravenous (IV) Drug users may be sclerosed, calcified, or col- lapsed due to damage from previous injections. There can be difficulty in establishing peripheral IV access on presentation to the Emergency Department (ED), resulting in delays in Resuscitative efforts with IV hy- dration, the administration of medications or in obtaining blood for lab- oratory analysis. These patients may consequently require alternative, more invasive types of vascular access including central venous or intraosseous catheters.

? There is no grant support or involvement.

?? There are no conflicts of interest.

* Corresponding author at: Mount Sinai St. Luke’s Hospital, Mount Sinai West Hospital, Department of Emergency Medicine, 1000 10th Avenue, New York, NY 10019. Tel.: +1 212 523 3981; fax: +1 212 523 2186.

E-mail address: [email protected] (T. Saul).

Ultrasound guidance increases peripheral IV catheter placement success rates in patients with difficult IV access [1-3]. One study which investigated the relationship between certain patient and vein characteristics and the success of ultrasound-guided peripheral IV placement found that successful placement was primarily associated with increasing diameter of the vessel [4]. Although the inclusion criteria varied, these prior study populations included combinations of patients who reported a history of IV drug use or a history of difficult IV access, patients who already had a number of prior IV access attempts during their ED visit, and patients with a history of certain disease enti- ties associated with difficult peripheral IV access (e.g. Sickle cell anemia and end stage renal disease). The population of patients with a history of IV drug use has not been specifically previously studied, and the pat- terns of poor vascular access in this group may be different from other difficult access groups.

IV drug-using patients may use their dominant hand to inject vessels in the non-dominant arm or conversely inject their dominant arm with their non-dominant hand. We hypothesized that, due to issues of dex- terity, the dominant hand would be more often used for needle and sy- ringe manipulation; thus, injection into veins in the non-dominant

http://dx.doi.org/10.1016/j.ajem.2016.02.049

0735-6757/(C) 2016

N.L. Kaban et al. / American Journal of Emergency Medicine 34 (2016) 10881091 1089

Fig. 1. Locations of probe placement for scanning the different sites.

upper extremity would occur more frequently, resulting in more dam- age from recurrent injection.

If hand dominance affects which extremity has more patent and com- pressible veins, providers could focus their first attempt on the patient’s veins in that extremity. This approach could potentially save time, reduce painful procedure attempts, decrease frustration for both providers and patients, and lead to greater success in establishing peripheral IV access, thereby reducing the need for more invasive alternatives.

The objective of this study was to investigate if patients with a histo- ry of IV drug use have more sonographically identifiable, patent, and compressible peripheral veins in their dominant upper extremity as compared to their non-dominant upper extremity.

Methods

This was a prospective convenience sample study of patients enrolled from January 2014 through June 2014 at an academic, urban ED when one of the study investigators was available. Study physicians did not enroll patients if they were the treating physician. Those enrolling included two emergency ultrasound fellowship-trained emergency medicine fac- ulty members and two emergency ultrasound fellows. All physicians completed at least 10 supervised examinations, the minimum number re- quired for proficiency in vascular access as delineated by the 2008 American College of Emergency Physicians policy statement [5]. Prior to patient enrollment, the primary investigator held a one-hour

Fig. 2. Vessels with diameter of N1.8 mm.

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instructional session to review the study protocol and scanning tech- nique. Institutional review board approval was obtained for this study.

Adult patients were approached for enrollment if they provided a history of IV drug use into one of their upper extremities. Patients were excluded if they had a vital sign abnormality, upper extremity am- putation proximal to the hand, a history of mastectomy or arteriove- nous fistula, or could not tolerate a tourniquet on either arm for several minutes for any reason. Patients were also excluded if participa- tion in the study would delay their medical care or if they were unable or unwilling to provide informed consent.

In order to keep the physician performing the ultrasound blinded to the patient’s handedness, each patient was enrolled by a different phy- sician than the one performing the ultrasound. The ultrasound was per- formed using a Sonosite (Bothell, WA) Edge system with a 10-5 MHz linear transducer with the machine set to the musculoskeletal setting and the multi-frequency probe set to resolution. Gain settings and the amount of conducting gel used were at the discretion of the physician sonographer. Depth was also at the discretion of the sonographer with the stipulation that the setting was deep enough to visualize bone (hu- merus or radius/ulna).

After applying a tourniquet to the patient’s upper extremity, the physician sonographer examined the volar aspect of the upper arm and forearm. Because there can be variations in the exact pattern and distributions of extremity veins, particularly in those with a history of previous venous trauma leading to collateral vessels, our scan protocol included three regions on the arm and forearm rather than the identifi- cation of named veins. The first location (forearm) was 10 cm distal to the antecubital crease, the second location was at the antecubital crease and the third location (proximal) was 5 cm proximal to the antecubital crease. (See Fig. 1) At each location, the volar aspect of the arm was ex- amined by scanning 180 degrees of the circumference of the upper ex- tremity, from the ulnar aspect to the radial aspect of the upper extremity in the transverse plane. Each time that a vein was identified, the sonographer attempted to compress the vein fully to confirm paten- cy and then measured the vein. (See Fig. 2). Only veins >= 1.8 mm in di- ameter (large enough for intravenous cannulation with a large bore angiocatheter) were included. The number of fully compressible veins N 1.8 mm in diameter at each location was recorded on a data form. The right upper extremity was examined first, followed by the left. Fol- lowing the ultrasound examination, the subject filled out a question- naire about his/her demographics, history of IV drug use, and hand dominance. Hand dominance was defined as the hand used to write.

We considered a 2-vein difference between upper extremities, in 70% of patients enrolled, to be clinically significant. Using the standard, 2-tailed criterion of 0.05, and powering our study at 0.8, we estimated that we needed to enroll 19 patients in order to satisfy these criteria. We assumed a standard deviation of a normal distribution of 0.34, given that there is no published data on this variation.

Results

Nineteen patients were enrolled. The average age of the patients was

53.4 years (range 36-66 years). 84% of the patients were male and 16% were female. 89% (17/19) were right handed and 11% (2/19) were left-handed. Patients had an average of 14.6 years of IV drug use (range 3-36) with an average of 20.9 years (range 0-23 years) since their last use. 90% (17/19) patients had a history of heroin injection, 76% (14/19) of cocaine injection and 16% (3/19) of methamphetamine injection with 68% (13/19) reporting the use of more than one sub- stance. 84% (16/19) of patients reported at least daily use during the pe- riod they were active with 16% (3/19) using only weekly. 79% (15/19) of patients stated they injected themselves 100% of the time, and the other 4 patients had another person inject for them 20, 10, 5, and 1% of the time. Patients showed a variety of injection use patterns with patients using their dominant hand to inject their non-dominant UE an average of 54% (range, 0-100) of the time. Patient’s had an average of 11.47

(range, 6-19) compressible vessel sites in their right upper extremity and an average of 12.84 (range, 7-21) compressible vessel sites in their left upper extremity. The mean vein difference between the num- bers of veins in the dominant versus the non-dominant UE was

-1.5789. At a .05 significance level, there was insufficient evidence to suggest the number of compressible veins between patients’ dominant and non-dominant arms was significantly different (P = .0872.)

Discussion

Our study results suggest that there is significant variability among in- travenous drug-using patients with regards to their Injection sites and hand they use for needle and syringe manipulation during injection. The majority of patients reported that they injected themselves exclusively; however, they injected their dominant and non-dominant extremities with almost equal frequency. This could be due to variations in the prom- inence of their veins when a tourniquet was applied, the desire to use veins that were less visible or more covered by clothing, or the practice of alternating sites due to tenderness or inflammation from recent injec- tion. These are all potential explanations for our finding that the number of compressible veins visualized with ultrasound was not statistically sig- nificantly greater in the dominant upper extremity, as expected.

Overall, this study was easy to perform and patent vessels easy to identify. Even patients with a history of significant heavy intrave- nous drug use typically still had multiple compressible vein sites in the three areas examined, the minimum for any one individual being 15 sites. The sonographer was permitted to adjust the depth as necessary to visualize the bony cortex of the humerus or radius/ ulna, therefore, some of these visualized veins may have been too deep to access with a standard length IV catheter (eg, deep brachial vein). When the depth required to cannulate the vessel is estimated as too deep using the scale on the side of the image, a longer IV catheter must be used.

Although we did not record the primary reason for the visit, all pa- tients enrolled were awake and alert and capable of providing informed consent. This excluded those that were in the emergency department for acute altered Mental status changes due to substance use. The ma- jority of patients enrolled had a significant amount of time since their last reported IV drug use (average 20.9 years) and were not active users. This may have been an adequate time interval for recanalization to occur and collateral vessels to form. It is possible that there would be a statistically significant difference between the numbers of vessels in each arm in a more active IV drug using population.

This study was designed to identify vessels that could be possible in- travenous access sites, and therefore excluded very small veins that may have been present, but not clinically useful for this purpose. A minimal diameter of 1.8 mm was required for a vein to be included, as the lumen must be sufficiently large enough to be cannulated and threaded by a catheter. The sclerosed or collateral vessels of patients with previ- ous IV drug use may not have met this minimal diameter. Ultrasound may still be useful in identifying these veins for venipuncture or smaller bore catheter placement. There may have been more of these very small sized vessels present in the dominant versus non-dominant extremity, but we did not evaluate such vessels in this study.

We assessed the number of sonographically identifiable compress- ible veins that could potentially be used as IV access sites. There are many other factors such as the presence of valves or confluence points, as well as operator technique, that can affect the placement of a func- tional IV line. Future studies may investigate whether using ultrasound, in conjunction with patient interviews about possible venous access sites, can increase IV success rates in this difficult access population.

Limitations

There are several limitations to this study. First, it is known that pa- tients can have variability in their peripheral Venous systems. It is possible

N.L. Kaban et al. / American Journal of Emergency Medicine 34 (2016) 10881091 1091

that there is normal variation between the number of veins in dominant and non-dominant UE related to the frequency of muscle usage, which has not been previously studied. Such a naturally-occurring difference could have influenced the results of this study. Secondly, the demographic data about the previous drug use patterns was self-reported by patients. Although patients seemed to have a good general idea of their patterns of previous use (as the majority gave very specific answers and often ex- plained that the initiation and cessation of IV drug use were major life events for them) there may still have been significant reporting bias.

Thirdly, our sample size was small and this did not allow for a sub- group analysis of patients with a history of recent versus remote IV drug use. For many of our enrolled patients, their last reported use was remote. This is likely due to active users requiring ED care related to substance use and altered mentation making them unable to ade- quately provide informed consent.

Finally, the evaluation for peripheral venous access sites requires technical skill. The physician sonographers in this study had a special in- terest in bedside ultrasound and had performed at least 10 prior vascu- lar examinations, with the faculty members having performed many more than that number. The results of this study may not be applicable to more novice or more experienced sonographers.

Conclusions

There is significant variability among intravenous drug using pa- tients regarding their injection site and the hand they use for injection.

The number of compressible veins visualized with ultrasound was not greater in the dominant upper extremity as expected. Practitioners may gain more information about the site of potential peripheral venous sites by asking patients about their previous injection practice patterns.

Acknowledgement

We thank Jessica Overbey, Biostatistician in the Department of population health Science and Policy, Icahn School of Medicine at Mount Sinai for her assistance with this project.

References

  1. Constantino TG, Parikh AK, Satz WA, Fojtik JP. Ultrasonography-guided peripheral in- travenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med 2005;46:456-61.
  2. 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.
  3. Stein JC, Cole W, Kramer N, Quinn J. ultrasound guided peripheral intravenous cannu- lation in emergency department patients with difficult IV access. Acad Emerg Med 2004;11:581-2.
  4. Panebianco NL, Fredette JM, Szyld D, Sagalyn EB, Pines JM, Dean AJ. What you see (sonographically) is what you get: vein and patient characteristics associated with successful ultrasound-guided peripheral intravenous placement in patients with dif- ficult access. Acad Emerg Med 2009;16(12):1298-303.
  5. emergency ultrasound guidelines. American college Of emergency physicians. Ann Emerg Med 2009 Apr;53(4):550-70.

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