CRITICAL CARE MEDICINE SECTION
In Praise of the Ultrasound-Guided Peripheral Intravenous Catheter David Gordon, MD FAAEM,* Alexander Bracey, MD FACEP,† and Neil Dasgupta, MD FAAEM‡
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xcellence at any kind of ultrasound guided vascular access begins with the humble peripheral intravenous catheter (IV). While it can be a hassle, time consuming, and certainly not as exciting or catecholamine-secretion-inducing as a central line, placing peripheral lines will make you a master of ultrasound guided procedures. Mastery of the ultrasound guided vascular access technique is an essential skill for the emergency physician. Ultrasound guided venous cannulation are more successful, and just as safe. Ultrasound guided central venous access for the internal jugular, subclavian, axillary, and femoral veins is recommended by the European Society of Anesthesiology, and offers several benefits over the landmark or palpation based approach.1,2 Further, ultrasound use for radial arterial lines can result in faster insertion, in less attempts compared to palpation technique. This remains true for the ultrasound guided peripheral IV (USIV).3 A 2018 meta-analysis of 1660 patients from eight studies found that USIVs were more successful (81% vs. 70%), required less attempts, and did not increase complications when compared to the palpation technique. These results suggest the use of US improves successful cannulation in those with difficult IV access. Perhaps most importantly, USIVs lead to better patient satisfaction.4 USIV has all the components to serve as the foundational technique for any ultrasound guided vascular access procedure in that it is common, low risk, and is arguably a more difficult technique than the cannulation of larger vessels that utilize modified Seldinger technique. Every step in the process reinforces key fundamentals: gathering supplies, setting up the room and optimizing positioning, talking your patient through the fear and apprehension, how much pressure you place on the skin, and following your needle tip to a small target. Once you develop the technique for placement of the USIV it translates to any ultrasound guided procedure. Beyond simply serving as a training tool for the venous cannulation during higher risk procedures, peripheral IVs can and should be used for critical interventions in the early resuscitation phase. Peripheral vasopressors have a very low risk of complications, especially in the setting of a safety protocol.5 Most extravasation can be managed conservatively, and vasopressors can often be restarted at another peripheral site.6 Peripheral IV’s can also be used to rapidly transfuse blood, with short, large-bore peripheral IVs providing flow rates far faster than a triple lumen, and approaching a centrally placed introducer sheath.7 Hypertonic saline (3%) can also be safely administered through
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a peripheral IV.8 This is all accomplished without the complications of central lines. However, none of these interventions are possible without dedicated, frequent practice. USIV’s are a fast, safe, and effective way to obtain IV access in all patients, and can be used for critical interventions that prevent morbidity and mortality. The technical skills are transferable to every other IV access and ultrasound guided procedure-excellence with placing an USIV can lead to excellence at central venous lines and arterial lines. Their safety and tolerability allow safe skill acquisition for other high-risk procedures. This skill translates to the Emergency Physician’s expanding vascular access toolbox to include newer techniques, such as midlines, REBOA, and ECMO. The road to mastery of vascular cannulation is paved with ultrasound guided peripheral IVs.
References * Assistant Professor, Department of Emergency Medicine, University of Florida-Jacksonville Assistant Professor, Program Director, Resuscitation and Emergency Critical Care and Assistant Program Director, Emergency Medicine, Albany Medical Center Hospital †
Assistant Clinical Professor, Director of Emergency Critical Care, Nassau University Medical Center ‡
1. Lamperti M, Biasucci DG, Disma N, Pittiruti M, Breschan C, Vailati D, Subert M, Traškaitė V, Macas A, Estebe JP, Fuzier R, Boselli E, Hopkins P. European Society of Anaesthesiology guidelines on perioperative use of ultrasound-guided for vascular access (PERSEUS vascular access). Eur J Anaesthesiol. 2020 May;37(5):344-376. doi: 10.1097/EJA.0000000000001180. Erratum in: Eur J Anaesthesiol. 2020 Jul;37(7):623. PMID: 32265391. 2. Saugel B, Scheeren TWL, Teboul JL. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care. 2017 Aug 28;21(1):225. doi: 10.1186/s13054-0171814-y. PMID: 28844205; PMCID: PMC5572160. 3. Shiver S, Blaivas M, Lyon M. A prospective comparison of ultrasoundguided and blindly placed radial arterial catheters. Acad Emerg Med. 2006 Dec;13(12):1275-9. doi: 10.1197/j.aem.2006.07.015. Epub 2006 Nov 1. PMID: 17079789.
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