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Ultrasound PIV Floor Protocols
pererap
Posted: Thursday, May 12, 2016
Joined: 8/31/2011
Posts: 231


We have had a pretty successful launch of an ultrasound guided PIV education program for our nursing staff.  I guess the inevitable has now happened and the ICU/floors are wanting training but also have questions on how these lines should be treated.  Specifically they are curious as to their life span or dwell times.  Does anyone have a hospital protocol developed for how long the lines should dwell prior to being replaced?  Any literature to back this up?  I have only found a single small nursing study published last December saying 24 hours was their max time prior to replacement.
Thanks for the help,

Brett Marvel MD

Ultrasound Director Department of Emergency Medicine


pererap
Posted: Thursday, May 12, 2016
Joined: 8/31/2011
Posts: 231


It is a question due to gel usage affecting sterility, depth and length of catheter, or site of placement (deep vs. superficial)?  
Otherwise, I agree with Howie, that it shouldn’t be any different that landmark placed PIV.



Scott Sparks, MD, RDMS, RDCS  Director,

Emergency Ultrasound DelMarVa Emergency Physicians Assistant Medical Director,

Emergency Department Bayhealth Medical Center, Milford Campus


pererap
Posted: Thursday, May 12, 2016
Joined: 8/31/2011
Posts: 231


Regarding gel use surgilube? (And cover probe with tegaderm) I'm sure it's more sterile than the no-glove-palpate-for-vein traditional technique...

-Calvin (MGH)


pererap
Posted: Thursday, May 12, 2016
Joined: 8/31/2011
Posts: 231


Most often we utilizing ultrasound for midline vein placement in the upper arm. When placed using Chlora prep, probe cover and sterile gel, our midline catheter has been approved to dwell up to 29 days. (Bard power glide)

Guy W. Tarleton MD

Santa Barbara Cottage Hospital


pererap
Posted: Thursday, May 12, 2016
Joined: 8/31/2011
Posts: 231


http://www.ncbi.nlm.nih.gov/m/pubmed/26369828/
There are some time table for peripheral IVs in the article with US IV being rated for a longer dwell time if there are no problems.
pererap
Posted: Thursday, May 12, 2016
Joined: 8/31/2011
Posts: 231


I appreciate everyones responses and largely agree with the prevailing theme being that they should not differ in their treatment from traditional pivs.  However there are differences in these and traditonal PIVs.  Depth, catheter length, and position are all different from what floor nurses are used to checking in ivs distal to the ac.  Due to this we are seeing an average dwell time of approximately 24 hours.  We are also beginning to note an increase frequency of extravasation of greater volumes than in traditional ivs.  (this has also been noted in the radiology literature for CT angios)
Whether this is a learning curve and will improve when our nurses get more facile remains to be seen.  
Thanks, Brett
pererap
Posted: Thursday, May 12, 2016
Joined: 8/31/2011
Posts: 231


Brett,
You bring up many different issues relating to USGPIV lines, including dwell times, likelihood of infection, length of catheter used for USGPIV insertion, and frequency of infiltration for IV contrasted studies. 
We end up lumping them together and that leads to problems in understanding their utility and potential complications. This is further complicated by the fact that many hospitals have a policy that all IVs placed in the ED are considered "dirty" and need to be changed within the first 24 hours of admission to the floor. 
We have an internal database of over 1500 USGPIV placed over 5 years. We presented 2 abstracts at ACEP last October trying to answer 2 of these many questions:
1. Is there an increase in infiltration rates through USGPIVs once admitted to the floor compared to another PIV placed on the same patient during their inpatient stay. There was essentially no difference between the IVs in regards to infiltration rates throughout their hospital stay. Most patients had their USGPIVs throughout their entire hospitalization.   http://dx.doi.org/10.1016/j.annemergmed.2015.07.413

2. What is the infiltration rate for patients underling CT with IV contrast though an USGPIV compared to other ED patients who had a traditionally paced PIV. While these are similar patients, they still differ in that one was a "difficult IV access patient" that required an USGPIV and the other was an "easy IV access patient" that could have a PIV placed with a traditional approach. The radiology study you refer to is BS and full of errors. 
Our data showed that we had 3.6% infiltration rate for USGPIV vs 0.2% for matched controls. That's a big difference, but there was no morbidity other than pain from the infiltration that occurred in the USGPIV group. Besides, what was the other option in these patients? A central line? 10 more unsuccessful sticks? I will accept the small risk of infiltration compared to my other options. 
 http://dx.doi.org/10.1016/j.annemergmed.2015.07.307

We are currently looking at other complication rates, including phlebitis, infection, pain, etc. These are all retrospective and rely on RN charting and are somewhat limited. Hopefully we will have that data later this year. 
You should obviously wait for these to be published before making any policy change, but I'm hoping they will be coming down the pike soon. 

Rob
--  Robinson M. Ferre, MD, FACEP Director, Emergency Ultrasound Division Associate Program Director, Emergency Ultrasound Fellowship Assistant Professor, Department of Emergency Medicine Vanderbilt University  Nashville, TN
pererap
Posted: Thursday, May 12, 2016
Joined: 8/31/2011
Posts: 231


All good points.  I think proper catheter selection is critical - and a common error is using too short a catheter - I believe the infiltration rate will be even lower if a longer catheter is used.  Example - I often see a 1.88 inch catheter placed as it is readily available— which will get you venous return but very little of the actual catheter is in the vein — and hence easy dislodgment with arm motion etc. Longer catheters — 2.5 inch or greater should help alleviate this. (all the way to a midline catheter)  Also — consider catheters with guide wires - I find them easier to place with greater first pass success.

Diku Mandavia, MD


pererap
Posted: Thursday, May 12, 2016
Joined: 8/31/2011
Posts: 231


All excellent points.

The take home is that while placement of peripheral guided IV's with or without ultrasound guidance should be a similar technique and therefore utilize the same equipment, there are significant differences. When one is placing an US guided IV, it is typically because of difficult access issues. Often, deeper veins are successfully cannulated using US guidance. The issue is that longer angiocaths are needed to avoid the extravasation of fluids, medications or contrast dye that can occur when cannulating these deeper veins. There is a growing trend to use commercially available angiocaths that are longer and have a guidewire to allow for Seldinger technique placement.


Mike Stone did an excellent prior conversation thread on the ACEP EUS Forum on this topic:


https://www.acep.org/forum.aspx?param=218483&g=posts&t=87542


Currently, there are several companies that make an angiocath that might be good for US guided IV's.

These include Bard and Powerwand, among others.


Stay tuned as this is a hot topic!


We are all looking for the perfect catheter to use for US guided lines that will not extravasate with administration of fluids and medications and further, will hold the pressure needed for CT injection in case emergent imaging is needed.


Phil Perera, MD RDMS FACEP

Clinical Associate Professor

Department of Emergency Medicine

Stanford University Medical Center




pererap
Posted: Thursday, May 12, 2016
Joined: 8/31/2011
Posts: 231


I also found this narrative by Dr. Stone in the EUS Training section of the forum:


This topic was addressed in a listserve discussion that included this response from Chris Moore (which is one of the best summaries on the subject that we've seen):

While I am not aware of any published"standard technique" I can give you my take on it after learning itthe hard way and teaching it for several years. I consider ultrasound guidedperipheral venous access in challenging patients to be among the hardestprocedures I regularly perform in emergency medicine. However, once you reallyget it it can be extremely effective, fairly quick, and very helpful. I believethat some of the published literature that is not so favorable for thisincludes people who are not sufficiently experienced. I think it probably takesmore than 30 procedures to get really comfortable, and I recommend my residentsstart on patients that aren't necessarily difficult access/ not severelydehydrated, etc. I also find that these days many residents haven't or didn'tperform regular peripheral IV access (non-ultrasound guided) in medical school,so they often need to learn this skill as well. As it is not a completely sterileprocedure I generally don't use a probe cover, though I clean the skin andprobe well -- generally I keep the probe and the gel a bit away from the wherethe needle enters the skin. Other reasonable options include a tegaderm cover,sterile or non-sterile gloves, or an actual probe cover. It is pretty much essential that youhave longer angiocaths -- we generally use 20 gauge 1.88" angiocaths, asopposed to the standard 1.25" angiocaths. While with superficial veins youmight be able to get away with a shorter angiocath, anything deeper than a fewmillimeters even if you get in you want to thread it far enough up so that itdoesn't dislodge. While I strongly advocate a long-axis (in-plane) approach forcentral venous access as it is a bigger vessel nearer to important structures,in peripheral venous access I usually use a short-axis approach. This isbecause it is much harder to keep smaller vessels in view and peripheral veinsoften don't run in a straight line long enough to keep them in one frame. Ashort-axis approach allows you to make sure that you are directly over themiddle of the vein. It is important to get a sense of the axis of the vessel.As most of you are aware, the problem with a short axis approach is that youcan cut across the shaft of the needle higher up or miss it entirely. In ashort-axis approach it is important to keep "fanning" the plane ofthe US proximally and distally, often while jiggling the needle, to find outwhere the tip is. What you are looking for in the short axis approach is thetarget sign, when the needle tip is seen as a dot within the vein. However, myexperience is that often when you first see this you still need to advance thecatheter a few more millimeters in order to thread it. I believe this isbecause the endothelium of the vein "tents" into the middle of thevessel before the catheter pierces it. You may be able to feel a slight"pop" as the catheter pierces the endothelium. While many look for aflash, I prefer to keep my eyes on the screen and make sure the tip of theneedle is traveling far enough into the lumen of the vein. I then thread it,you should also be able to feel if it threads easily. 

We try to document our USguided peripheral access procedures and I am pretty sure we are billing them,though I am not aware of how many are being reimbursed for how much. In orderto bill you should have "image archival of real-time needle entry",which can be challenging if you don't have someone to record while you do theprocedure. After I complete the procedure I usually check and record the flushusing the ultrasound proximal to the IV. However, if you are not concernedabout billing and don't need it for QA I'm not sure you should worry aboutpictures. Some other tips-- Vessel choice. I usually look betweenmid forearm and mid upper arm. The basilic vein is often a great choice, it isquite medial and concealed between a few millimeters of fat. It does not travelwith an artery, which is an advantage, although it is not tethered and mayroll. The often paired brachial veins are right next to the artery, but havethe advantage of not moving around so much. Tourniquet is helpful. --Make sure its a vein. Especially indehydrated patients, peripheral arteries may compress quite easily. Any vesselyou are going for, compress it half way into an oval and watch a few secondsfor any evidence of arterial pulsations. --Ideal depth. Probably about 5mm. Lessthan 3mm you usually don't need US and more than 1 cm is tough, though I'vegotten them at nearly 2cm deep. --Find the axis of the vein. Use theprobe to find the axis of the vein by sliding it up and down keeping the vesselin the center of the screen, and make sure the needle is in that axis. Veinsdon't always run straight. --Place your hand overthe catheter. I often see residents holding the catheter like a pencil, withtheir hand under the catheter. This limits your maneuverability in terms offlattening the catheter as described below. Place your hand over the top of thecatheter grasping it between the thumb and middle finger, with the index fingerready to thread it.--Center the vein onthe screen. Approach with the needle at ~45 degree angle in the middle of theprobe, at the right axis, and about the same distance from the probe. Once yousee the target sign, flatten the approach as you advance it to visualize thetarget sign as the tip of the needle pierces the endothelium and goes into thevessel, can avoid backwalling.--Backwalling. Mayoccur, and may actually be necessary in really dehydrated patients as it may bealmost impossible to pierce one side without the other. Try to follow theneedle tip if it goes deep to the vessel, then watch carefully as you draw itback and the vessel should tent open.--Local anesthetic.Very helpful, particularly for deeper vessels or while you are learning.Lidocaine in an insulin or TB syringe works well, and can help you get a senseof the orientation / depth if you look at depositing the anesthetic usingultrasound.Learning this ondifficult patients can be quite time consuming, but gets much faster as you getgood at it. With time you get a real sense of exactly where the needle is goingto show up on the screen based on depth and approach etc.At some point some ofthe technology for vessel location may make this a lot easier... but untilthen.... am sure many others have other tips or different approaches but hopethis helps.


pererap
Posted: Thursday, May 12, 2016
Joined: 8/31/2011
Posts: 231


And another great post on this topic by Dr. Stone in 2011


very frequently asked question on the listserve. Some folks favor a traditional long IV catheter (i.e. the B.Braun product below), others favor arterial line kits repurposed for peripheral IV placement (i.e. the Arrow products below), others favor the Powerwand, and others prefer to place a long flexible single lumen catheter or "mid-line" (i.e. the Cook product below). Have the materials management contact person at your hospital talk with the representatives as you can almost always obtain free samples to find out which product works best for you and your colleagues.

B. Braun Introcath Safety 18G 2.5 inch Catheters

Arrow 20G 2.5 inch Arterial Line Set (with guidewire)

Arrow 18G 3.25 inch Arterial Line Set (with guidewire)

The PowerwandCook 5 Fr 15cm single lumen catheter (with guidewire)



pererap
Posted: Thursday, May 12, 2016
Joined: 8/31/2011
Posts: 231


Last, for nursing protocols on PIV placement:

Please go to the-Running a Program Section of the webpage and look under Nursing.

There are 2 helpful documents there.

Phil


 
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