Single Versus Double Tourniquet Technique for Ultrasound-Guided Venous Catheter Placement

Abstract

IntroductionPeripheral, ultrasound-guided intravenous (IV) access occurs frequently in the emergency department, but certain populations present unique challenges for successfully completing this procedure. Prior research has demonstrated decreased compressibility under double tourniquet technique (DT) compared with single tourniquet (ST). We hypothesized that catheters inserted under DT method would have a higher first-stick success rate compared with those inserted under ST method.MethodsWe randomized 100 patients with a history of difficult IV access, as defined by past ultrasound IV, prior emergency visit with two or more attempts required for vascular access, history of IV drug abuse, history of end stage renal disease on hemodialysis or obesity, to ultrasound-guided IV placement under either DT or ST method. We measured the vein characteristics measured under ultrasound, and recorded the number of attempts and location of attempts at vascular access.ResultsOf an initial 100 patients enrolled, we analyzed a total of 99 with 48 placed under ST and 51 placed under DT. Attending physicians inserted 41.7% of ST and 41.2% of DT, with non-attending inserters (including residents, nurses, and technicians) inserted the remainder. First-stick success rate was observed at 64.3% in ST and 66.7% in DT (p=0.93). Attendings had an overall higher first-stick success rate (95.1%) compared to non-attending inserters (65.5%) (p=<0.001). The average vein depth measured in ST was 0.73 centimeters (cm) compared with 0.87 cm in DT (p=0.02).ConclusionDT technique did not produce a measureable increase in first-stick success rate compared to ST, including after adjusting for level of training of inserter. However, a significant difference in average vein depth between the study arms may have limited the reliability of our overall results. Future studies controlling for this variable may be required to more accurately compare these two techniques.

Can Non-Physician Providers Use Ultrasound to Aid in Establishing Peripheral IV Access in Patients Who are Difficult to Cannulate? A Scoping Review

“…The summary results are depicted below in addition to a summary in Table 2. 4,5,9,10,[18][19][20][21][22][23][24][25][26][27][28][29]…”

The practical integration of a hybrid model of ultrasound‐guided peripheral venous access in a large apheresis center

“…Many apheresis procedures are performed using peripheral intravenous (PIV) catheterization 4 ; however, peripheral access is not always possible due to veins that are difficult to visualize or palpate. Access can be particularly challenging in patients who are dehydrated, obese, or who may have scarring from repeated access or IV drug use 5 . In cases where PIV access cannot be established, central venous catheters (CVCs) may be required to complete apheresis procedures.…”

“…Visualization of veins using ultrasound (US) has been shown to improve successful PIV access rates 8 . Over the last several years, this has become an increasingly common approach employed for patients in the emergency department 5,9‐11 . Apheresis centers have also reported their adoption of USGPIV programs, 12 used in populations including TPE, red blood cell exchange (RBCx), ECP, and hematopoietic progenitor cell (HPC) collections, reducing need for CVC insertions to 13.2% to 20% 2,13 .…”

“…Access can be particularly challenging in patients who are dehydrated, obese, or who may have scarring from repeated access or IV drug use. 5 In cases where PIV access cannot be established, central venous catheters (CVCs) may be required to complete apheresis procedures. Although CVC insertion is a relatively safe procedure in experienced hands, 6 drawbacks of this approach can include: delayed procedures, infection risk, thromboembolism, bleeding, pain, and cost.…”

“…8 Over the last several years, this has become an increasingly common approach employed for patients in the emergency department. 5,[9][10][11] Apheresis centers have also reported their adoption of USGPIV programs, 12 used in populations including TPE, red blood cell exchange (RBCx), ECP, and hematopoietic progenitor cell (HPC) collections, reducing need for CVC insertions to 13.2% to 20%. 2,13 In addition to achieving venous access in otherwise challenging patients, USGPIV allows visualization and cannulation of anatomical sites not usually accessible with SOC practice (eg, basilic, brachial).…”