COMMENTARY

Ultrasound-Guided IV Insertion in Children: How and Why

Alexandra M. Vinograd, MD, MSHP, DTM&H

Disclosures

March 02, 2020

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Hello. I am Alexandra Vinograd. I am an attending physician in the Division of Emergency Medicine at the Children's Hospital of Philadelphia and an assistant professor at the University of Pennsylvania Perelman School of Medicine.

Establishing intravenous (IV) access is a common but challenging procedure in pediatrics. Difficulty in placing an IV can lead to treatment delays, diagnostic delays, pain for the patient, and anxiety for the family members watching their child undergo multiple IV sticks. Point-of-care ultrasound has become routine, particularly for invasive procedures in the emergency department.

We conducted a study that examined whether ultrasound-guided peripheral IV access would improve the first-attempt success rate when compared with traditional IV access in children. We enrolled 167 patients with presumed difficult IV access, based on a previously validated scoring system. We randomly assigned patients to receive ultrasound-guided IV access or traditional IV access. First-attempt success was nearly twice as high in the ultrasound-guided IV group than in the traditional IV access group—85.4% vs 45.8%. In addition, there were, overall, fewer attempts in the ultrasound-guided IV group than in the traditional IV access group.

Because it takes time to locate and set up the ultrasound, we were concerned that this procedure could cause delays in time to IV placement. In fact, the opposite was true. For children who received an ultrasound-guided IV, the time from randomization into the study to IV flush was 14 minutes; in the children in the peripheral IV access group, the time from randomization to IV flush was 28 minutes.

We were also concerned about how long the IVs would last. In adults, studies show that 32% of ultrasound-guided IVs may fail within 48 hours of insertion. This would mean that the children would require multiple sticks again to replace IVs that no longer worked. In our study, however, the ultrasound-guided IVs lasted much longer than the traditionally inserted IVs; we found no difference in the type or number of complications in either group.

In adults, vessel depth and the location of the IVs have been shown to affect how long they last. IVs placed in shallower vessels and in the antecubital area or the forearm are more likely to last longer than those placed in the upper arm. In our study, 93% of the ultrasound-guided IVs were placed in the forearm. We also used longer IV catheters, most commonly the 48-mm, 22-gauge catheters or the longer 20-gauge catheters. This probably meant that more of the IV catheter was seated in the vein, promoting a longer survival of that IV.

A Brief How-to

In our study, the ultrasound-guided IVs were placed by a dynamic technique wherein the provider took the transverse probe, located the vessel on the patient's forearm, identified that it was a vein and that it was not pulsatile, and that they were able to track it forward easily so they would be able to place the IV. The provider then took the catheter, typically a longer catheter, entered the skin at a 45-degree angle, identified the tip of the IV [it appears as a white dot at the top of the ultrasound screen], advanced the probe, and then advanced the ultrasound, each time making sure to advance the tip of the needle into view.

They continued until they entered the vein. Then they flattened out the catheter and continued tracking inside the vessel until the entire IV was seated in the vein.

In this study, attending physicians, fellows, and nurses placed the ultrasound-guided IVs. The three nurses who enrolled patients had a 91% first-attempt success rate. We have continued to train nurses in our department to place ultrasound-guided IVs. It has become standard of care at our institution to use ultrasound-guided placement in children with difficult IV access.

On the basis of our study results, showing a decreased number of first attempts at sticks and overall a lower number of IV sticks, decreased time to IV placement, and increased longevity without increasing complications or the type of complications in children with ultrasound-guided IVs, we believe that ultrasound-guided IV access should be standard of care for children presenting to the emergency department with presumed difficult IV access.

Alexandra M. Vinograd, MD, MSHP, DTM&H, is an attending physician in the emergency department at Children's Hospital of Philadelphia. She was lead investigator of the recent study examining first-attempt success, longevity, and complication rates of ultrasound-guided peripheral intravenous catheters in children, discussed in this commentary.

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