Difficult venous access in the emergency department: are we placing the right device? Blind short cannulas versus ultrasound guided long peripheral devices
- Department of Emergency Medicine, “Maggiore” hospital ASST-Lodi, piazza Ospitale 10, Lodi, Italy
- Vascular Access service of Emergency Department, “Maggiore” hospital ASST-Lodi, piazza Ospitale 10, Lodi, Italy
Placement of peripheral venous devices (PIV) could be challenging, especially in difficult venous access (DIVA) patients. Ultrasound guided long peripheral intravenous devices (US-LPIV) have been proposed as an alternative. The aim of our study is to compare performance of PIVs vs US-LPIVs in DIVA patients admitted to the emergency department.
We prospectively enrolled 56 DIVA patients admitted to the ED. Performance of PIV vs US-LPIV was compared. Failure rate was primary outcome. Number of punctures, time to placement and mean dwell time were secondary.
Failure rate was 48,2% in PIVs vs 10,7% in LPIVs (p < 0,0001; OR 7,76, 95% CI 2,87 – 21,0). A statistical significance was found in the mean number of punctures (2,85 vs 1,39; p < 0,0001) and in the mean time needed to placement (PIV 19 minutes vs LPIV 16 minutes; p = 0,026). The overall mean dwell time of LPIVs was 12,38 days.
US-LPIVs showed a success rate of 89,3%, significantly higher than PIVs. Moreover, placing a US-LPIV, required significantly less time and less number of punctures compared to PIVs. Mean dwell time was about 12 days, with a premature removal of 12,2%. US-LPIVs requested the same time of placement of PIVs in DIVA patients with better performance in term of success rate and number of punctures.
Vascular access devices; Ultrasonography interventional / methods; Catheterization peripheral / methods; Emergency medicine / methods; Punctures / statistics & numerical data.
Placement of an adequate and stable venous device is crucial in admitted patients. This is even more important in the critically ill admitted to the emergency department (ED). A recent survey estimated that more than 70% of the admitted patients need venous access and, among these, the 80% are peripheral short cannulas (PIV)1, usually placed blind with an over the needle technique. The critically ill often requires venous access for blood testing, therapy or administrating contrast media. On the other hand PIV placement could be challenging in this setting due to hemodynamic instability, low volume state, edema or poor venous asset. Moreover, some patients show difficult venous access (DIVA) due to obesity, history of drug abuse, neoplasm or other conditions that sometimes make vein cannulation tough. The use of ultrasound guidance for PIVs (USG-PIV) has been suggested to improve cannulation rate but some authors have shown that, even if the overall success increased, the catheter survival was not modified2. Moreover, Keyes et al. have observed that about 8% of USG-PIVs infiltrate or dislocate within one hour3 and Dargin et al. found out that USG-PIVs have a high premature failure rate, most commonly due to infiltration4. Alternative routes in DIVA patients are usually considered the intraosseus device (IO) or the central venous catheter (CVC). Unfortunately the IO could be painful when large volumes of fluids are used5 and it lasts from few to a maximum of 24 hours due to the risk of complications6. CVCs present some acute complications (such as pneumothorax or hematoma) and late complications (infection and thrombosis) that are unacceptable when there is no need to a central line; moreover its placement is time consuming7. In the recent years long peripheral intravenous devices (LPIV) have been proposed as an alternative to PIVs. Some evidences showed they could reduce failure rate and last longer than standard cannulas2,8. LPIVs are usually 8 to 15 cm polyurethane cannulas, placed in an ultrasound guided (US) sterile method by the seldinger technique. Recently Raio et al. showed that use of LPIVs in DIVA patients in the ED is not only feasible in term of success and number of punctures, but was also worthwhile as to time to catheter placement and patient satisfaction9. The aim of our study is to compare use of PIV vs US-LPIV in DIVA patients admitted to the ED, in term of failure rate, number of punctures, time needed to placement and dwell time.
We conducted a prospective study. All PIVs and US-LPIVs were placed in the ED and the follow-up was conducted from the ED until discharge. DIVA patients, older than 18, that were admitted to the ED from January 2018 to May 2018 were enrolled. Informed consent was obtained from all patients included in the study. A patient was defined as DIVA if he failed at least 2 attempts of blind PIV placement or if a previous history of neoplasm disease treated with chemotherapy , history of intravenous drug abuse, poor venous asset, related or not to chronic diseases, or previous access to the ED and difficult vascular access was known . Patients that needed CVC for monitoring or therapy and patients with PIV placed in pre-hospital care were excluded. After recruitment, a DIVA patient could receive up to 4 attempts of blind PIV placement (up to 2 if the initial 2 were already failed) at discretion of the nurse. Failure or success, number of punctures, time needed to PIV placement, PIV gauge and side were registered. Independently of PIV failure or success, a second nurse or physician, trained in US-LPIV technique, attempted its placement and registered number of punctures, time needed to US-LPIV placement, LPIV bore and side. The second operator was blind about number of punctures and time needed to PIV placement. The PIVs we used were polyurethane cannulas, inserted by an over the needle technique, of 18 or 20 Gauge, length of 42 and 35 mm respectively (Neo delta self safe1®, Deltamed SPA). Target veins were identified blind by palpation and through nurse experience. LPIVs were polyurethane guide-wire cannulas inserted by direct seldinger method, of 3 or 4 French, length of 8 and 10 cm respectively (Leader Flex®, Vygon SA). All US-LPIVs were placed by a nurse or physician after a brief course and, at least, 5 tutoring placements. Target vein was individuated by ultrasound examination of both arms. Only brachial or basilic veins have been selected and should have a diameter larger than 3 mm for 3Fr LPIV or larger than 4 mm for the 4Fr LPIV. Vein depth should not exceed 2 cm when a 4 Fr catheter was inserted or 1 cm when a 3 Fr LPIV was inserted. After vein selection, we checked by ultrasound for patency and regular path. A tourniquet was placed on the axilla and all US-LPIVs were inserted by a short-axis out-of-plane technique. The same ultrasound machine was used for all placements (NanoMaxx®, Fujifilm Sonosite Inc.) with a linear array 5 – 10 Mhz. A sample size calculation indicated that we should recruit 79 patients to reach a statistical power of 80% at 5% with 2-sided level of significance, assuming a difference in failure rate of 20% as showed in precedent data10. Statistical Package for Social Science (SPSS) version 23 was used for statistical analysis. Continuous variables were compared with student’s t-test while dicotomus variables were analysed by fisher’s exact test.
In five months we recruited 56 patients (M 27; F 29), mean age 74,32 ± 14,11 (main characteristics are summarized in table 1).
Mean Age ± SD
74,32 ± 14,11
Mean BMI ± SD
27,88 ± 6,50
Neoplasm, n (%)
Drug abuse, n (%)
Obesity, n (%)
Shock, n (%)
Debilitation, n (%)
Table 1. Main characteristics of enrolled patients. Body Mass Index (BMI), standard deviation (SD)
Each patient was itself control to avoid selection biases. PIVs cannulation failed in 27 out of 56 patients (failure rate 48,2%) while LPIV failed in 6 out of 56 (failure rate 10,7%) with statistical significance (p < 0,0001; OR 7,76, 95% CI 2,87 – 21,0). Among the 50 LPIVs inserted, 48 were 4-French and 2 were 3-French LPIVs. We moreover found a statistical difference in mean number of punctures of PIV vs LPIV (2,85 vs 1,39 respectively; p < 0,0001) and mean time needed to placement (PIV 19 minutes vs LPIV 16 minutes; p = 0,026). We excluded the ultrasound preliminary study of vessels in measuring time needed for LPIV placement because sometimes the vein was not cannulated immediately after, making total time measurement difficult. A complete LPIV follow-up was available in 49 patients. Most LPIVs were removed when the patient was dismissed or suspended intravenous therapy. In 6 out of 49 patients (12,2%) the LPIV was removed prematurely for complications (1 Dislocation, 3 Phlebitis, 2 Occlusions) (Table 2).
Failure rate, n (%)
Mean time to placement, minutes ± SD
19,35 ± 9,35
16,21 ± 7,35
Mean number of punctures, n ± SD
2,85 ± 1,04
1,39 ± 0,68
Prematurely removed, n (%)
· DIVA conditions
Table 2. PIV vs US-LPIV failure rate and performance. Peripheral intravenous device (PIV), Long peripheral intravenous device (LPIV), difficult venous access (DIVA), standard deviation (SD)
Placing venous access is a regular activity in emergency departments. Sometimes it could be challenging even for expert nurses or physicians. Difficult venous access could delay blood testing and therapy administration with negative consequences, especially in the critically ill. Although have been demonstrated that ultrasonography improves the cannulation rate of PIVs10,11, Keyes showed that 8% of USG-PIV infiltrate or dislocate in one hour and Dargin demonstrated that 47% of USG-PIV does not survive at 24 hours3,4. Mills et al. hypothesized that USG-PIVs may be too short to adequately reach the lumen of deeper peripheral veins and therefore tend to be easily dislodged8. Similarly Panebianco et al. demonstrated that successful USG-PIV placement is correlated to vein diameter and no vessel deeper of 1,6cm was successfully cannulated12. LPIVs have been proposed as an alternative even if there are some concerns about time needed to placement especially in the ED, as they require a sterile field and a direct seldinger technique. Our study compared blind short PIVs with US-LPIVs placement in the ED in DIVA patients. We found that US-LPIVs have a success rate of 89,3%, significantly higher than PIVs. Moreover, placing a US-LPIV, took less time than a blind search for a vessel with more attempts of cannulation. This result forsakes the idea that using ultrasound in a sterile technique for venous access takes longer compared to a blind PIV. Probably because it is not considered that in DIVA patients most of the time is consumed in a blind quest of a vein and often the access fails. So placement time was shorter because ultrasound reduces the search of an adequate vessel to less than a minute and requests only few minutes in preparing a sterile field. Furthermore our study, in line with literature data, showed a significant reduction of number of punctures in the ultrasound guided approach and other authors have found that this result could improve patient satisfaction13. Prospective trials with larger population are necessary to find out if reducing number of punctures could decrease long term complications of these devices. In fact, it has been clearly demonstrated that implementation of ultrasound in placing central lines reduces short term and long term complications, probably thanks to the reduction of numbers of punctures6,14, but there are not data comparing long term complications of peripheral blind accesses versus ultrasound guided ones. It is reasonable to think that reduction of punctures of a vessel leads to reduction of insults and so decreases long term complications, as it happens to central vessels. If so, this result should not to be underestimated, as preserving venous asset in DIVA patients should be of primary importance when placing a venous device. Some authors have tried to compare performance of ultrasound guided PIV vs LPIV. Even if success rate of placement was similar, PIVs showed a shorter time of survival, particularly due to dislocations2. In our population LPIVs had a high success rate, with a premature removal in 12% of patient, in accordance with literature, while mean dwell survival was about 12 days (range 2 – 32 days), time useful for the most of treatments. Taking into account that, in our setting, LPIVs were placed in the ED and used for treatments and blood testing, the most of DIVA patients received a single peripheral device for the whole period of admission. Unfortunately we do not have data of our PIV survival to compare with LPIVs, but many trials have shown that PIVs, placed both in ultrasound guidance or standard technique, rarely survive more than 4 days with a mean dwell time of 3.5 days4,15,16.
Although we failed to find a DIVA condition that could predispose to LPIV failure, we did find a higher mean BMI among patients who experienced a premature removal, independently from LPIV complication. Even if this difference does not reach the significance, probably due to the small sample size, it suggests that obesity is the main predisposing condition to LPIV prematurely removal and probably the choice of the right vascular device in this setting of patients is of crucial importance. LPIV complications in our study were a dislodgment, probably due to ineffective securement, two occlusions and three phlebitis. The two occlusions were probably related to the use of drugs not indicated for peripheral infusion (vancomicine and potassium at high concentration), as we did not put any restriction to LPIV use during admission. On the other hand one out of the three phlebitis was related to infusion of vesicant medications (potassium and magnesium at elevated concentration), the remaining twos were not correlated to any particular drug but all happened in the same ward and probably were related to an inadequate nursing of the catheter. Our hypothesis is that performances of LPIVs are strictly correlated not only to vessel position and dimension, as already evaluated12, but probably also to management and nursing during the admission. In our opinion future trials should focus on this topic evaluating the principal predisposing conditions to premature removal of LPIVs, taking into consideration patient characteristics but also management protocols and drugs administered.
Limitations of our study are the small number of patients, the absence of a follow-up of PIVs that could be useful for an estimation of cost efficacy of LPIVs. Moreover, we do not have administrated a satisfaction questionnaire to the patients. On the other hand a strong point is the use of every patient as control of itself to eliminate any kind of selection bias.
At present is not more reasonable to use PIVs in DIVA patients, even in the ED. More data are necessary but, if confirmed, our study showed that US-LPIVs request the same time of placement of PIVs in DIVA patients with better performance in term of success rate and number of punctures. Moreover, LPIVs mean dwell time is sufficiently long to guarantee a single venous device in most of the patients recruited for the whole period of admission.
- Fernández-Ruiz M, Carretero A, Díaz D, Fuentes C, González JI, García-Reyne A, Aguado JM, López-Medrano F. (2014) Hospital-wide survey of the adequacy in the number of vascular catheters and catheter lumens. J Hosp Med. 9(1):35-41. doi: 10.1002/jhm.2130.
- Elia F, Ferrari G, Molino P, Converso M, De Filippi G, Milan A, Aprà F. (2012) Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. Am J Emerg Med. 30(5):712-6. doi: 10.1016/j.ajem.2011.04.019
- Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D (1999) Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med; 34(6):711-4.
- Dargin JM, Rebholz CM, Lowenstein RA, Mitchell PM, Feldman JA (2010) Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access. Am J Emerg Med; 28(1):1-7
- Schalk R, Schweigkofler U, Lotz G, Zacharowski K, Latasch L, Byhahn C. (2011) Efficacy of the EZ-IO needle driver for out-of-hospital intraosseous access – a preliminary, observational, multicenter study. Scand J Trauma Resusc Emerg Med; 19:65–9.
- Luck RP, Haines C, Mull CC. (2010) Intraosseous access. J Emerg Med; 39(4):468–75
- McGee DC, Gould MK. (2003) Preventing complications of central venous catheterization. N Engl J Med.; 348(12):1123-33.
- Mills CN, Liebmann O, Stone MB, Frazee BW. (2007) Ultrasonographically guided insertion of a 15-cm catheter into the deep brachial or basilic vein in patients with difficult intravenous access. Ann Emerg Med. Jul; 50(1):68-72.
- Raio C, Elspermann R, Kittisarapong N, Stankard B, Bajaj T, Modayil V, Nelson M, Chiricolo G, Wie B, Snock A, Mackay M, Ash A (2018) A prospective feasibility trial of a novel intravascular catheter system with retractable coiled tip guidewire placed in difficult intravascular access (DIVA) patients in the Emergency Department. Intern Emerg Med. 13(5):757-764.
- Egan G, Healy D, O’Neill H, Clarke-Moloney M, Grace PA, Walsh SR (2013) Ultrasound guidance for difficult peripheral venous access: systematic review and meta-analysis. Emerg Med J; 30(7):521-6
- van Loon FHJ, Buise MP2, Claassen JJF2, Dierick-van Daele ATM3, Bouwman ARA (2018) Comparison of ultrasound guidance with palpation and direct visualisation for peripheral vein cannulation in adult patients: a systematic review and meta-analysis. Br J Anaesth; 121(2):358-366.
- Panebianco NL, Fredette JM, Szyld D, Sagalyn EB, Pines JM, Dean AJ (2009) What you see (sonographically) is what you get: vein and patient characteristics associated with successful ultrasound-guided peripheral intravenous placement in patients with difficult access. Acad Emerg Med; 16(12):1298-1303.
- Costantino TG, Parikh AK, Satz WA, Fojtik JP (2005) Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med. 46(5):456-61.
- Karakitsos D, Labropoulos N, De Groot E, Patrianakos AP, Kouraklis G, et al. (2006) Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care. 10(6):R162.
- Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E (2015) Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs; 38(3):189-203.
- Rickard CM, Webster J, Wallis MC, Marsh N, McGrail MR, French V, Foster L, Gallagher P, Gowardman JR, Zhang L, McClymont A, Whitby M (2012) Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet; 380(9847):1066-74.