Welcome to Facts on the Ground a new series brought to you by Natan Cramer, Pediatric Emergency Medicine fellow from the University of Pittsburgh. Facts on the Ground is designed to be a concise literature review that helps answer common clinical questions.

The Article

The Utility and Survivorship of Peripheral Intravenous Catheters Inserted in the Emergency Department
Shokoohi, et al.
Annals of Emergency Medicine, 2019

Objective

To compare 72-hour survivorship of IV’s inserted using different techniques in the Emergency Department. Hypothesis of the authors is that there is no difference between the techniques studied (Ultrasound guided vs. landmark). 

Study Design

Secondary analysis of an RCT comparing success rates of PIV’s placed using the traditional landmark technique vs. ultrasound guided technique. A total of 330 adult patients were abstracted from the parent study to assess survivorship of the lines. Research assistants assessing the survivorship were blinded from the hypothesis of the study. High acuity patients were excluded from the study. 

Outcome

  • Relative risk of 72-hour premature removal between the two insertion methods was 1.26 (95% Cl 0.88 to 1.80)
  • Premature removal (i.e. reduced survivorship) was significantly associated with the number of uses of the IV (i.e. blood draw, contrast administration, medication administration) on multivariate analysis; relative risk (1.36; 95% 1.16 to 1.58)
  • 25% of total IV’s placed in the ED were prematurely removed before 72hrs. 

Weaknesses

  • Research assistants were watching technicians place the IV lines which might influence success rates in either method.
  • Post hoc power analysis to detect a difference of 15% between the two insertion types for survivorship. There may still be a difference, but less than 15%. 
  • The study involved adult patients and thus it is difficult to extrapolate the IV survivorship data to children. We know that peripheral IVs are more difficult to place in certain pediatric populations (see Vukovic et al.) One randomized study showed no difference in peripheral IV success rates between static ultrasound vs. the traditional technique in young children who already failed a first IV attempt (see Blair et al.). However, another randomized study indicated that the ultrasound technique reduced the amount of attempts, needle re-directions, and overall time required to achieve success in patients with a history of difficult access (see Doniger et al.).

The Bottom Line

In the adult population, there was no significant difference in IV survivorship by the insertion method used by ED providers.

References

McCarthy et al. Ultrasonography Versus Landmark for Peripheral Intravenous Cannulation: A Randomized Controlled Trial, Annals of Emergency Medicine, 2016.

Shokoohi, et al. The Utility and Survivorship of Peripheral Intravenous Catheters Inserted in the Emergency Department, Annals of Emergency Medicine, 2019.

Vukovic et al. Video-based Assessment of Peripheral Intravenous Catheter Insertion in the Resuscitation Area of a Pediatric Emergency Department, Academic Emergency Medicine, 2016.

Blair et al. Ultrasound-Assisted Peripheral Venous Access in Young Children: A Randomized Controlled Trial and Pilot Feasibility Study, Western Journal of Emergency Medicine, 2008.

Doniger et al. Randomized Controlled Trial of Ultrasound-Guided Peripheral Intravenous CAtheter Placement Versus Traditional Techniques in Difficult-Access Pediatric Patients, Pediatric Emergency Care, 2009.