Even Fewer Central Lines? - US Guided IVs

The Gist:  Patients in the ED often need venous access for fluid resuscitation or medication but may have poor peripheral venous access due to a myriad of reasons.  Ultrasound guided peripheral IV placement reduces the need for central venous catheters (and may also spare patients undue pain).

Doesn't sound that exciting, why should I care?  A patient presented with the clinical picture of sepsis - febrile, hypotensive, tachycardic, headache, visual changes and a possible source of cellulitis on his leg.  It was incredibly easy to order initiation of an early goal directed protocol; however, implementation was another story since we were unable to establish venous access.  The patient was morbidly obese and clearly intravascularly depleted, as evidenced by his very collapsed IVC on US.  The IV team eventually established access, but by that point, greater than one hour had elapsed.  The patient ended up doing well, but I think would have been better served had we begun fluid resuscitation, IV antibiotics, and the battery of lab tests more quickly.  The family and the patient were frustrated by the multiple unsuccessful attempts, and all interventions were dependent upon that access (no, he did not want an intraosseous line).    

The paper:  Au A, Rotte M, Grzybowski R, Ku B, Fields J.  Decrease in central venous catheter placement due to use of ultrasound guidance for peripheral intravenous catheters.  Am J of Emergency Medicine.  Online first 15 July 2012.

Methods

• 100 patients enrolled after meeting the following criteria:  after "multiple" failed peripheral attempts, nurse and physician discussed need for IV access and, if necessary, the physician attempt at external jugular placement must have been unsuccessful.  Physicians only enrolled patients who they thought would need a central venous catheter if peripheral access were unsucessful.
• Patients then underwent attempted cannulation with a 20g with single-operator US by a resident or attending

Results

• 88% of US guided peripheral IVs successful, of which, 11 eventually ended up with a CVC (1 with a central line, 10 with a PICC).
• 1 patient with a central catheter had a line infection requiring antibiotics.
• 12% of initial US guided peripheral IVs were unsuccessful.  7 of these underwent successful US guided IV in the ED and another 4 received a central line in the ED. 

This study builds upon other evidence that US guided IV access reduces time and number of attempts to successful cannulation (1,2, 3), although there has been a study demonstrating no difference (4).  This small study certainly has limitations:

• Not randomized 
• Some of the junction points in the study are subjective.  For example, patient or operator "fatigue" is variable.
• US guided IV only performed by physicians, not nurses or technicians
• Further attempts at standard IV access may have been abandoned earlier than usual due to availability of US (this is not a bad thing, especially from the patient perspective)
• No standard number of attempts prior to use of US.

Where to from here?

• Excessive attempts on pediatric patients seems brutal and studies demonstrate US works well for IV access in this population (6).  It's a study about ultrasound so, of course, I must mention something from the Ultrasound Podcast.  These guys are offering an incredible opportunity for US IV access education under the event "Not A Pin Cushion."  Check out their personal, touching story, which will inspire one to use US for difficult IVs.  There are many local programs and resources throughout the country that promote US guided IVs by physicians and nurses.  Here's a link to some FAQ regarding nurse placement of US guided peripheral lines from the "Stone's Side" of the Ultrasound Podcast.  Get on it. 
• There are two things I never argue "for," but I don't think this case fits either one. 
• Procedures that encourage providers to rely upon technology.  As someone with first hand disaster experiences following natural disasters, I'm fearful of dependence on things that require being "plugged in" (being without electricity for a month will instill this in one) and of becoming lazy.  I think that US is a great adjunct in the IV process for patients who fail initial attempts, thus could serve as an augmentation aid in difficult scenarios rather than foster dependence.
• Fewer procedures (unless it's actually in the patient's best interest, which turns out to not be infrequently).  Some patients will need a central line, period, perhaps for pressors or due to failure of peripheral access.  However, the risks associated with central lines including infection, probably the most common, are not negligible.  When indicated, central lines are still the way to go, US guided IV just reduces the number of unnecessary central lines (by up to 85% in the abovementioned study).

If it's a family member or friend, I'm breaking out the US even earlier.

References:
1.  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 Nov;46(5):456-61.

2.  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 Mar;25(3):154-9.

3.  Bauman M, Braude D, Crandall C.  Ultrasound-guidance vs. standard technique in difficult vascular access patients by ED technicians.  Am J Emerg med. 2009 Feb; 27(2)135-40.
4.  Stein J, George B, River G, Hebig A, McDermott D.  Ultrasonographically guided peripheral intravenous cannulation in emergency department patients with difficult intravenous access: a randomized trial.  Ann Emerg Med. 2009 Jul;54(1):33-40. 
5.  Dargin JM, Rebholz CM, Lowenstein RA, Mitchell PM, Feldman JA.  Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access. Am J Emerg Med. 2010 Jan;28(1):1-7.
6.  Benkhadra M, Collignon M, Fournel I, Oeuvrard C, Rollin P, Perrin M, Volot F, Girard C.  Paediatr Anaesth. 2012 May;22(5):449-54.  Ultrasound guidance allows faster peripheral IV cannulation in children under 3 years of age with difficult venous access: a prospective randomized study.

You'll shoot your eye out, kid! - Ocular Ultrasound

The Gist:  Ultrasound (US)  training is a vital part of Emergency Medicine (EM) education and may play an even more important role in military, community setting.  Ocular US may prove especially useful in diagnosing and triaging patients with ocular trauma, particularly with regard to retinal detachment in the aforementioned settings.

Recently, EM folks on Twitter debated the utility of ED US in retinal detachment. Those arguing against US dismissed the modality due to the need for an opthalmology consult regardless of the US findings.  This reminded me of a strikingly similar debate I had with a budding PGY-1 ophthalmology resident.  Their arguments have some validity; however, I think it's easy to get swept away in the comfort of 24/7 consults in the academic hospital atmosphere.  This isn't available everywhere, even in the United States, but knowing when emergent action is warranted could prevent serious morbidity.  As the "jack of all trades," EM physicians should probably be prepared for wherever their careers may land them. 

The paper:  Retinal Detachment Due to Facial Gunshot Wound:  The Utility of Ultrasonography in a Medically Austere Environment. in The Journal of Emergency Medicine

• Case report from the military of a patient who suffered a ricochet gunshot wound to the face from an AK-47 who was initially treated for a laceration just inferior to his medial canthus.  Over the subsequent days his vision deteriorated and he was found to have a closed globe with a sluggish pupillary response to light.  Bedside US confirmed retinal detachment and the patient was transported to a combat hospital for ophthalmology care.  He did not recover his visual function in that eye.
• The article is a pretty good read as it succinctly highlights some of the technical aspects of US for retinal detachment with photos and textual descriptions.

This case study suggests:

• Bedside US in the emergency setting can rapidly identify retinal detachments.
• There is likely an incredible role in the battlefield and other remote areas.
• Facial trauma may result in ocular trauma, which isn't immediately apparent and may have permanent deleterious consequences.  Perhaps this patient's vision could have been saved if ocular US had been performed on his first visit.

How do I do this? 

• As always, check out Ultrasound Podcast's amazing Ocular Ultrasound podcast featuring Dr. Chris Fox (Ultrasound Master from UC-Irvine).  Retinal detachment discussion begins at 17:45 .  They've got everything you need to be able to get started with ocular US (and handy instructions on the One Minute Ultrasound app, naturally).
• Pearls from Dr. Chris Fox:  
• Ensure you're dealing with a closed globe and make sure you're scanning with the eyelid closed, of course.
• Use tons of chilled gel (reduces pressure and the high-frequency linear transducer 7.5-10 MHz

What does US really add..besides instant gratification?

• US can differentiate between a "mac on" and "mac off" retinal detachment, which is huge for prognosis.  Instances where the macula of the retina is not detached (mac on) is an ophthalmologic emergency.  If these aren't treated immediately, patient's can deteriorate into a "mac off" detachment, which can result in permanent vision loss (as in the patient featured in the case study).  In resource limited settings or remote areas, this may be an important way to determine patients that must immediately see an ophthalmologist from those who occupy a less precarious situation (sometimes resource allocation is an issue)

    

(Image from Wikipedia)

• Also, ED physicians are pretty good at identifying retinal detachment, with a prospective study (n=48, with 15 EM physicians performing US) demonstrating sensitivity and specificity for RD of 100% (95%CI = 78% to 100%) and 83% (95% CI = 65% to 94%), respectively. 
• US in resource limited settings is feasible and growing in importance so if one is interested in disaster medicine or global medicine, this is a great skill to have.  Check out Mount Sinai's recent US education trip to Haiti, this article discusses US training in Rwanda (and there are many more like it).