The Journal of Emergency Medicine, Vol. 46, No. 2, pp. 228–230, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
Letters to the Editor , RE: ULTRASOUND-GUIDED PERIPHERAL INTRAVENOUS ACCESS
ney Foundation practice guidelines state that in “patients with chronic kidney disease stage 4 or 5, forearm and upper-arm veins suitable for placement of vascular access should not be used for venipuncture or for the placement of intravenous catheters, subclavian catheters, or peripherally inserted central catheter lines” (3). Puncture and cannulation of veins can lead to stenosis or thrombosis, rendering the veins unavailable for dialysis access. Because the basilic and cephalic veins are used to create fistulae but the brachial veins are not, the brachial vein may be a good choice for ultrasound-guided venous access in patients with kidney disease if other superficial veins cannot be accessed. Mahler et al. have described the incidence of complications as “rare,” but it was actually four (arterial puncture, extravasation, hematoma 2) out of 25 (20%) (1). Although I would not consider this rare, I would expect the incidence of complications to decrease significantly as one becomes more experienced with the ultrasoundguided technique.
, To the Editor: I read with interest the article, “Ultrasound-guided Peripheral Intravenous Access in the Emergency Department Using a Modified Seldinger Technique,” by Mahler et al. (1). This technique is not “previously undescribed,” but was actually already published (2). Figure 2 in Mahler et al. shows very close proximity of an unsterile ultrasound probe to the needle insertion site (1). It would be better to cover the ultrasound probe with a sterile occlusive dressing to keep the insertion site sterile. It also helps reduce the possibility of blood transfer to the probe surface and thus, makes it easier to properly clean the ultrasound probe. I have used Tegaderm Film 10 12 cm (3M Health Care, St. Paul MN) for this purpose. I also would suggest that a 3.8-cm catheter might be too short in most cases. The basilic vein is commonly located 2 cm deep to the skin in the antecubital fossa (often more, in obese individuals). Given your angle of approach of approximately 45 , as shown in Figure 2, the vein would be entered in a diagonal distance of 2.8 cm, leaving only 1 cm of the catheter in the vein. Flexion or extension of the patient’s arm might promote movement of the catheter tip out of the vein and result in infiltration. For this reason, I currently use a 4.45-cm 20-gauge catheter (arterial catheterization kit RA 04020; Arrow International, Reading, PA) or a 10.8-cm 20-gauge catheter (FA 04020) in individuals with a deeper vein. There are already a wide variety of lengths and catheter gauges currently available. Do note that the use of the arterial kits is considered “off label” use by the manufacturer (personal communication from Jonathan M. Stapley, Senior Global Marketing Manager, Teleflex Medical, Reading, PA). In addition to the basilic vein, I commonly access the cephalic and brachial veins. The brachial veins can be more difficult to access due to their smaller size and proximity to both the brachial artery and median nerve. With experience, one should be able to visualize and avoid these structures. However, the brachial veins do offer an advantage in patients with kidney disease. National Kid-
Bradley A. Stone, MD Asheville Surgery Center Asheville, North Carolina http://dx.doi.org/10.1016/j.jemermed.2011.10.033 REFERENCES 1. Mahler SA, Wang H, Lester C, Conrad SH. Ultrasound-guided peripheral intravenous access in the emergency department using a modified Seldinger technique. J Emerg Med 2010;39:325–9. 2. Stone BA. Ultrasound guidance for peripheral venous access: a simplified Seldinger technique. Anesthesiology 2007;106:195. 3. Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48(Suppl 1):S176–247.
, ULTRASOUND-GUIDED PERIPHERAL INTRAVENOUS ACCESS: A REPLY TO DR. STONE , To the Editor: I appreciate the interest and comments of Dr. Stone. In his letter, he brings up some important points worth considering when placing an ultrasound-guided peripheral intravenous line (i.v.). First, he recommends using a sterile 228
Letters to the Editor , RE: ULTRASOUND-GUIDED PERIPHERAL INTRAVENOUS ACCESS
ney Foundation practice guidelines state that in “patients with chronic kidney disease stage 4 or 5, forearm and upper-arm veins suitable for placement of vascular access should not be used for venipuncture or for the placement of intravenous catheters, subclavian catheters, or peripherally inserted central catheter lines” (3). Puncture and cannulation of veins can lead to stenosis or thrombosis, rendering the veins unavailable for dialysis access. Because the basilic and cephalic veins are used to create fistulae but the brachial veins are not, the brachial vein may be a good choice for ultrasound-guided venous access in patients with kidney disease if other superficial veins cannot be accessed. Mahler et al. have described the incidence of complications as “rare,” but it was actually four (arterial puncture, extravasation, hematoma 2) out of 25 (20%) (1). Although I would not consider this rare, I would expect the incidence of complications to decrease significantly as one becomes more experienced with the ultrasoundguided technique.
, To the Editor: I read with interest the article, “Ultrasound-guided Peripheral Intravenous Access in the Emergency Department Using a Modified Seldinger Technique,” by Mahler et al. (1). This technique is not “previously undescribed,” but was actually already published (2). Figure 2 in Mahler et al. shows very close proximity of an unsterile ultrasound probe to the needle insertion site (1). It would be better to cover the ultrasound probe with a sterile occlusive dressing to keep the insertion site sterile. It also helps reduce the possibility of blood transfer to the probe surface and thus, makes it easier to properly clean the ultrasound probe. I have used Tegaderm Film 10 12 cm (3M Health Care, St. Paul MN) for this purpose. I also would suggest that a 3.8-cm catheter might be too short in most cases. The basilic vein is commonly located 2 cm deep to the skin in the antecubital fossa (often more, in obese individuals). Given your angle of approach of approximately 45 , as shown in Figure 2, the vein would be entered in a diagonal distance of 2.8 cm, leaving only 1 cm of the catheter in the vein. Flexion or extension of the patient’s arm might promote movement of the catheter tip out of the vein and result in infiltration. For this reason, I currently use a 4.45-cm 20-gauge catheter (arterial catheterization kit RA 04020; Arrow International, Reading, PA) or a 10.8-cm 20-gauge catheter (FA 04020) in individuals with a deeper vein. There are already a wide variety of lengths and catheter gauges currently available. Do note that the use of the arterial kits is considered “off label” use by the manufacturer (personal communication from Jonathan M. Stapley, Senior Global Marketing Manager, Teleflex Medical, Reading, PA). In addition to the basilic vein, I commonly access the cephalic and brachial veins. The brachial veins can be more difficult to access due to their smaller size and proximity to both the brachial artery and median nerve. With experience, one should be able to visualize and avoid these structures. However, the brachial veins do offer an advantage in patients with kidney disease. National Kid-
Bradley A. Stone, MD Asheville Surgery Center Asheville, North Carolina http://dx.doi.org/10.1016/j.jemermed.2011.10.033 REFERENCES 1. Mahler SA, Wang H, Lester C, Conrad SH. Ultrasound-guided peripheral intravenous access in the emergency department using a modified Seldinger technique. J Emerg Med 2010;39:325–9. 2. Stone BA. Ultrasound guidance for peripheral venous access: a simplified Seldinger technique. Anesthesiology 2007;106:195. 3. Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48(Suppl 1):S176–247.
, ULTRASOUND-GUIDED PERIPHERAL INTRAVENOUS ACCESS: A REPLY TO DR. STONE , To the Editor: I appreciate the interest and comments of Dr. Stone. In his letter, he brings up some important points worth considering when placing an ultrasound-guided peripheral intravenous line (i.v.). First, he recommends using a sterile 228
