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
The Journal of Emergency Medicine
probe cover to keep the insertion site sterile. Although peripheral i.v. placement is typically a clean procedure rather than a sterile procedure, this is an important consideration in patients in whom i.v. access may be prolonged, patients with deeper veins, or in patients at higher risk of infection, such as diabetics or the immunocompromised. A recent study showed no increase in infection from ultrasound-guided peripheral i.v.s with standard aseptic techniques compared to traditional (nonultrasound) i.v.s (1). He also discusses using a longer, 4.45-cm, catheter to aid insertion. The catheter used in our study was 3.81 cm long. Although this is longer than most i.v. catheters used for traditional peripheral i.v. insertion, it is shorter than many sonographers recommend. At the time that our study was being designed, there were no studies comparing short and long catheters, but a study by Elia et al. recently demonstrated that shorter catheters are associated with higher failure rates after insertion (2). Therefore, longer catheters are likely preferable in most cases. Dr. Stone also points out that using a Seldinger technique for ultrasound-guided peripheral i.v.s had been previously reported in the literature. The article he references was published in the correspondence section of the journal Anesthesiology (3). This article describes Dr. Stone’s clinical experience with a similar placement technique. However, this was not a research study and does not describe methods such as selection of participants or how his outcomes were assessed. Finally, Dr. Stone is concerned about the adverse events described in our manuscript. He states that we have a 20% event rate, but his arithmetic is slightly off, as 4/25 is 16%. Although 16% still seems high, it is important to consider the severity and context of these events. Two of the events were small hematomas from failed initial attempts in patients who ultimately had i.v.s successfully placed. These events were minor, but met our a priori definition of adverse events and therefore, were reported. Furthermore, to be enrolled in our study, patients had to have at least three prior failed attempts at i.v. access using traditional landmark methods. None of the patients in our study suffered any long-term sequelae, and most were spared central venous catheter placement, a procedure with a much higher complication rate. Simon A. Mahler, MD, MS Department of Emergency Medicine Wake Forest School of Medicine Winston Salem, North Carolina http://dx.doi.org/10.1016/j.jemermed.2013.09.029
229
REFERENCES 1. Adhikari S, Blaivas M, Morrison D, Lander L. Comparison of infection rates among ultrasound-guided versus traditionally placed peripheral intravenous lines. J Ultrasound Med 2010;29:741–7. 2. Elia F, Ferrari G, Molino P, et al. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. Am J Emerg Med 2012;30:712–6. 3. Stone BA. Ultrasound guidance for peripheral venous access: a simplified seldinger technique. Anesthesiology 2007;106:195.
, QUALITY IMPROVEMENT OF EMERGENCY CARE IN SEVERE SEPSIS: IS IT ONLY FEASIBLE BASED ON THE TIME OF ANTIBIOTIC PRESCRIPTION? , To the Editor: I read with much interest the article written by Eveline A. Hitti et al. on improving door-to-antibiotic time in septic patients, published in The Journal of Emergency Medicine (1). The authors concluded that storing key antibiotics in the emergency department (ED) can significantly reduce order-to-antibiotic times and increase the percentage of patients receiving antibiotics within the recommended 3 h of ED arrival. Management of patients with severe sepsis in the ED is multidimensional. Obviously, severe sepsis is a critical diagnosis and emergency management of patients with this diagnosis will affect their outcome. The appropriateness of this care is also a very important issue (2). For example, it is well known that administration of broadspectrum antibiotics within 3 h of ED admission in patients diagnosed with severe sepsis will improve their outcome if and only if the appropriate antibiotics are chosen (3). I would like to draw your attention to some potential flaws in the study: First, the sources of severe sepsis among patients in the study were not clearly described. There is the potential for selection bias in this study because selection criteria for the study are not adequately reported. Second, the authors reported that the nurses and physicians were trained on the new process of administration of antibiotics in the ED before the study started. How did the authors control the Hawthorn effect of this educational intervention on the study results? Third, as was emphasized in the study, the detection of suspected infection by the physicians (MD-to-order time) is one of the most delaying factors in administration of antibiotics to patients with severe sepsis in the ED. It is clear that MD-to-order time can indirectly affect the study results. In the study methods, it was unclear how the physicians detected the suspected infection in the study population.
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
The Journal of Emergency Medicine
probe cover to keep the insertion site sterile. Although peripheral i.v. placement is typically a clean procedure rather than a sterile procedure, this is an important consideration in patients in whom i.v. access may be prolonged, patients with deeper veins, or in patients at higher risk of infection, such as diabetics or the immunocompromised. A recent study showed no increase in infection from ultrasound-guided peripheral i.v.s with standard aseptic techniques compared to traditional (nonultrasound) i.v.s (1). He also discusses using a longer, 4.45-cm, catheter to aid insertion. The catheter used in our study was 3.81 cm long. Although this is longer than most i.v. catheters used for traditional peripheral i.v. insertion, it is shorter than many sonographers recommend. At the time that our study was being designed, there were no studies comparing short and long catheters, but a study by Elia et al. recently demonstrated that shorter catheters are associated with higher failure rates after insertion (2). Therefore, longer catheters are likely preferable in most cases. Dr. Stone also points out that using a Seldinger technique for ultrasound-guided peripheral i.v.s had been previously reported in the literature. The article he references was published in the correspondence section of the journal Anesthesiology (3). This article describes Dr. Stone’s clinical experience with a similar placement technique. However, this was not a research study and does not describe methods such as selection of participants or how his outcomes were assessed. Finally, Dr. Stone is concerned about the adverse events described in our manuscript. He states that we have a 20% event rate, but his arithmetic is slightly off, as 4/25 is 16%. Although 16% still seems high, it is important to consider the severity and context of these events. Two of the events were small hematomas from failed initial attempts in patients who ultimately had i.v.s successfully placed. These events were minor, but met our a priori definition of adverse events and therefore, were reported. Furthermore, to be enrolled in our study, patients had to have at least three prior failed attempts at i.v. access using traditional landmark methods. None of the patients in our study suffered any long-term sequelae, and most were spared central venous catheter placement, a procedure with a much higher complication rate. Simon A. Mahler, MD, MS Department of Emergency Medicine Wake Forest School of Medicine Winston Salem, North Carolina http://dx.doi.org/10.1016/j.jemermed.2013.09.029
229
REFERENCES 1. Adhikari S, Blaivas M, Morrison D, Lander L. Comparison of infection rates among ultrasound-guided versus traditionally placed peripheral intravenous lines. J Ultrasound Med 2010;29:741–7. 2. Elia F, Ferrari G, Molino P, et al. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. Am J Emerg Med 2012;30:712–6. 3. Stone BA. Ultrasound guidance for peripheral venous access: a simplified seldinger technique. Anesthesiology 2007;106:195.
, QUALITY IMPROVEMENT OF EMERGENCY CARE IN SEVERE SEPSIS: IS IT ONLY FEASIBLE BASED ON THE TIME OF ANTIBIOTIC PRESCRIPTION? , To the Editor: I read with much interest the article written by Eveline A. Hitti et al. on improving door-to-antibiotic time in septic patients, published in The Journal of Emergency Medicine (1). The authors concluded that storing key antibiotics in the emergency department (ED) can significantly reduce order-to-antibiotic times and increase the percentage of patients receiving antibiotics within the recommended 3 h of ED arrival. Management of patients with severe sepsis in the ED is multidimensional. Obviously, severe sepsis is a critical diagnosis and emergency management of patients with this diagnosis will affect their outcome. The appropriateness of this care is also a very important issue (2). For example, it is well known that administration of broadspectrum antibiotics within 3 h of ED admission in patients diagnosed with severe sepsis will improve their outcome if and only if the appropriate antibiotics are chosen (3). I would like to draw your attention to some potential flaws in the study: First, the sources of severe sepsis among patients in the study were not clearly described. There is the potential for selection bias in this study because selection criteria for the study are not adequately reported. Second, the authors reported that the nurses and physicians were trained on the new process of administration of antibiotics in the ED before the study started. How did the authors control the Hawthorn effect of this educational intervention on the study results? Third, as was emphasized in the study, the detection of suspected infection by the physicians (MD-to-order time) is one of the most delaying factors in administration of antibiotics to patients with severe sepsis in the ED. It is clear that MD-to-order time can indirectly affect the study results. In the study methods, it was unclear how the physicians detected the suspected infection in the study population.
