Ultrasonography-Guided Peripheral Intravenous Access : Regular Technique Versus Seldinger Technique in Patients with Difficult Vascular Access

We sought to compare ultrasonography (US)-guided peripheral intravenous (PIV) access by regular technique using standard length catheters with a Seldinger technique using 16-cm central venous catheters in a randomized trial of adult patients with difficult intravenous (IV) access. Patients were randomized into two groups: (1) An US-guided IV access obtained through a regular technique or (2) An US-guided IV access obtained through a Seldinger technique. Outcomes measured were IV access success rates, number of attempts after enrollment, IV survival > 96 hours. As a secondary outcomes, we recorded IV complications rates and subject satisfaction. The two groups were matched in demographics, risk factors for difficult PIV access. No significant difference of clinical importance was found between the 2 groups in IV success rate or number of successful PIV catheter placement after one and two attempts. Median duration of access was 26 vs. 72 hours in regular technique group compared with Seldinger technique group, respectively. Forty one percent of IV catheters failed within 24 hours in regular technique group, most commonly due to infiltration with only 4.4 percent in Seldinger technique group. We observed low rate of immediate complications in both groups, however no infectious or thrombotic complication during the study period. Seldinger technique group had greater patient satisfaction compared with regular technique group. US-guided deep brachial or basilic vein cannulation with a 16-cm catheter offers a potentially safe and rapid alternative to central line placement in patients with difficult IV access.


INTRODUCTION
Obtaining peripheral intravenous (PIV) access can be a challenge even to experienced physicians, especially in infants, obese adults, history of injection drug use (IDU), edematous patients, or other chronic medications (1), a central venous catheter is often placed at considerable risk to the patient.Placement of a central line is associated with a greater than 15% rate of significant complications, including arterial puncture, pneumothorax, deep vein thrombosis (DVT), and infection (2).Use of ultrasonographic (US) guidance in central line placement is now widely recommended because it improves success and reduces complications (3,4).Ultrasonography has also been used to cannulate deep peripheral veins.US guided cannulation of the deep brachial or basilic vein using a standard intravenous catheter was found to be a rapid and highly successful technique in 2 previous studies (5,6).However, its drawbacks, are that intravenous catheters may dislodge and intravenous fluid infiltrates because standard length catheters may not extend far enough into the vein lumen.Mills et al (7) reported that ultrasonographically guided insertion of a 15-cm catheter into the deep brachial or basilic vein offers a potentially safe and rapid alternative to central line placement in adult patients with difficult intravenous access.We sought to compare US-guided PIV access by regular technique using standard catheters with Seldinger technique using central venous catheters.

Patients
After obtaining approval of the Institutional Review Board/IRB and written informed consent, 45 critical care and hemodialysis patients with difficult vascular access were enrolled in a prospective, non blinded, randomized study from August 2010 to April 2011, twenty-two were underwent ultrasonography-guided PIV cannulation with regular technique using standard catheter (1.77-inch length) and 23 patients to the USguided PIV cannulation with Seldinger technique using 16-cm central venous catheter.The inclusion criterion was inability of any available nurse/attending physician to obtain intravenous access after at least 3 attempts on a subgroup of patients who had a history of difficult intravenous access because of end stage renal disease (ESRD), obesity, history of IDU, or other chronic medi-cal problems.Pregnant patients and children were excluded, as were those who were critically ill, in need for central line as defined by the treating physician or unable to give consent.The study was performed by the attending anesthetist, nephrologist and physician who were familiar with US-guided peripheral and central venous access.Each of the attending physicians had more than 5-years experience in placing US-guided PIV catheters.Successful venous cannulation was defined as withdrawal of 5 ml non-pulsatile blood or infusion of 5 ml of saline without evidence of extravasation.Failure of PIV access was defined as extravasation with initial infusion, inability to withdraw 5 ml of blood, inability to obtain access by the operator.Time was recorded in minutes in real time by the attending physician with time zero was chosen as the time the US probe first touched the patient's skin.The end time was marked by success or where failure criteria were met.Complications were defined as hematoma, arterial puncture, nerve injury, infection or thrombosis.Patients satisfaction with intravenous access (a Likert scale from 0-to 10 was used to gauge patient satisfaction).

Methods
Ultrasonography-guided PIV catheters were placed in real time by the attending physician using a 10-MHZ linear array probe (GE Logiq Book XP Portable Ultrasound Machine; General Electric Company, GE Healthcare -Americas, U.S.A.).A transverse image of the vein, accompanying artery and nerve is obtained, the vein is brought into the middle of the image, and the probe is rotated through 90° to visualize a longitudinal image of the vein (Figure 1).Veins were identified by their collapsibility with gentle pressure and flow can be confirmed by color Doppler.

Regular technique
The skin entry site is cleaned with Chlorhxidine antiseptic swab and infiltrated with lidocaine 1%, about 1-2 cm from the probe.The ultrasound was covered in a sterile, 4x6-in Tegaderm dressing (3M, Inc, St. Paul, Minn), and sterile lubricating jelly was applied to the probe.A tourniquet is applied high up on the arm.A 1.77-in, 18-gauge angiocatheter (BD VenflonTM; Becton Dickinson infusion therapy AB SE-251 06 Helsingborg, Sweden) was inserted at a 45° angle to the skin and visualized by real-time imaging during its advance through superficial and deep fasciae into the vein and successful venous cannulation was confirmed by aspiration of dark, nonpulsatile blood.
A Luer lock was subsequently secured to the catheter hub and a 4 × 6-in Tegaderm dressing was used to secure the line.

Seldinger technique
A 2.5-in, 18-gauge introducer needle (Central Venous Catheterization set with Blue FlexTip® Catheter.Arrow International, Inc.) was inserted by technique described above, the guide wire was threaded through it into the vein, using sterile gloves and drape.The initial needle was then removed and the track was dilated by a tissue dilator and then a 16-cm single lumen catheter (14 gauge; Arrow International, Inc. 2400 Bernvile Road, Reading, PA 19605 USA), was inserted over the wire and secured with tape and transparent dressing.

Data collection and outcome measures
After successful US-guided PIV placement, the physicians performed the procedure were asked to record on the data collection sheet each patient's age, sex, reasons of difficult IV access, including, ESRD, body mass index (BMI), date and time of the procedure, IDU, patient comorbidities, the number of attempts (individual skin punctures) required for successful placement of the IV using US guidance and immediate complications, including arterial puncture (bright red, pulsatile blood return), nerve contact (sharp pain radiating up or down the arm or paresthesias), and hematoma formation.The catheter was left in place till day 4, unless the patient was discharged or a complication developed before

DISCUSSION
All physicians need to be familiar with techniques for obtaining intravenous access.Many physicians are familiar with a subgroup of patients in which intravenous access can be very difficult, because of obesity, history of intravenous drug use, or some chronic medical condition, such as patients who have ESRD and are receiving hemodialysis (6).Although some patients will still require central venous access, using ultrasonography to achieve PIVs in patients who have no other requirement for central venous access may result in decreased complications, decreased time spent obtaining intravenous access, and increased patient satisfaction.However, the longevity of ultrasonography-guided IVs has been called into question, raising concerns that the procedure may simply delay, rather than prevent, central venous access (5,7) Limitations; Our study has a number of limitations.One limitation of that trial is small sample size.We did not record all of the potential patient and catheter-related factors that may have affected IV survival.The number of attempts, immediate complication rates, and the operator's intent to place a central line may be affected by reporter bias as we relied on the operator to document these immediate complications at the time of catheter placement.In addition, there was no long-term followup after removal of the catheter.Thus patients with delayed complications weren't detected.
In conclusion, US-guided deep brachial or basilic vein cannulation with a 16-cm catheter is a suitable and easy alternative to central venous catheterization in adult patients with difficult IV access with a low rate of short term complications.

Figure 1 .
Figure 1.Visualization of the deep brachial vein in transverse (a) and longitudinal(b) views; needle entering the lumen of the vein (c); then the guide wire (d); and the catheter(e) inside the venous lumen.

Table 1 .
Baseline characteristics of the studied groups a, interquartile range; b, peripheral intravenous access; c, end stage renal disease, BMI: body mass index

Table 2 .
Outcome measures, by groups Trained research assistants or the study investigators examined each patient's catheter site once daily to record time and date of IV removal and reasons for catheter removal, such as completion of IV therapy, the IV failed (due to catheter occlusion or infiltration of infusate into the subcutaneous tissue), a complica- IQR, interquartile range; *p <0.05 was considered statistically significant fourth day.tiondeveloped,including infection (localized cellulitis, or suppurative phlebitis requiring antibiotics), phlebitis (pain, tenderness, erythema and edema, with or without a palpable venous cord), US evidence of DVT proximal to the IV insertion site, and hematoma formation that was not recorded as an immediate complication.The primary outcomes measured were IV access success rate, time to perform successful cannulation and IV survival, which was defined as a patent catheter; cath-Data analysisData are presented as median and interquartile ranges (IQRs).Nonparametric Mann-Whitney U analysis of variance was used to analyze significance of age, body mass index, time data, number of attempts and number of skin punctures.Frequency data significance was determined by person Chi-Square test.Cox proportional hazards models were used to describe catheter survival over time and to study continuous variables associated with early failure.A P value (two-sided in all tests) of <0.05 was considered significant.SPSS software, version 16.0, was used (SPSS Inc., Chicago, IL, USA).

Table 3 .
Association of covariates with ultrasonography-guided peripheral intravenous survival time (17,18)'t observe any infectious or DVT complications during the course of the study.Similarly, there were no infectious or thrombotic complications noted in a small study of 15-cm US-guided catheters placed in the Emergency Department Multiple studies have analyzed the rates of infection and upper extremity thrombosis associated with peripherally inserted central catheters, which differ from the catheters in this study in that they extend into the central circulation and may remain in the vein for months.Rates of infection(15,16)and thrombosis(17,18)at peripherally inserted central catheter sites have been reported to be low.It is therefore not surprising that there were no cases of catheter-associated infection or thrombosis in Seldinger technique group using 16-cm central catheters in this study.A peripherally inserted central catheter is a reliable alternative to short term central venous catheters, with a lower risk of complications and possible wider range for use.