Difficult IV access: Is ultrasound-guided cannulation the answer?

1. The benefits of ultrasound in peripheral IV catheter insertion

Traditionally, peripheral IV catheter insertion follows a visual inspection and palpation of the extremity to locate the vein.⁴ However, thanks to ultrasound guidance, healthcare professionals can identify what Dr van Loon calls “invisible veins,” or veins that cannot be seen from above the skin with the naked eye.³

With this innovation, ultrasound-guided cannulation can result in higher rates of insertion success (81%) when compared to traditional methods (70%), according to one study in which Dr van Loon participated.⁴

“More interestingly,” said Dr van Loon. “We found that ultrasound is especially beneficial in patients who are difficult to cannulate.”³ Dr van Loon and his colleagues also found that ultrasound-guided peripheral IV catheter insertion:⁴

• Reduced the number of punctures
• Reduced time needed to achieve intravenous access
• Increased patient satisfaction
• Did not affect the risk of complications

Learn more about the use of ultrasound-guided cannulation within vascular access teams: Emergency department vascular access teams–How impactful are they?

2. The learning curve: Training nurses on ultrasound-guided cannulation

“We all know that simply placing an ultrasound probe on a patient’s arm doesn’t automatically result in the correct insertion of a vascular access device,” said Dr van Loon. “So, what do healthcare professionals need to become competent in ultrasound-guided peripheral IV cannulation?”³

To raise competency amongst nurses, Dr van Loon conducted a systematic literature review to devise an evidence-based training plan, which included:⁵

• 1 hour of didactic training: Lectures focusing on ultrasound physics, vascular anatomy and the use of the ultrasound-guided cannulation technique
• 2 hours of hands-on training: Identification of veins on a live model without cannulating, followed by a cannulation practice session on a non-human tissue model
• 10 supervised cannulations: Life-case scenarios, supervised ultrasound-guided peripheral IV cannulations of veins on the upper extremity, including patients with known difficult IV access

Dr van Loon and his colleagues applied this training to a pool of 49 nurse practitioners to understand the number of ultrasound-guided peripheral IV catheter insertions a participant needed to perform in the life-case setting to become competent.⁶

For this study, competency was defined as the ratio between the least amount of time in peripheral IV catheter insertion with the highest success rate on the first attempt.^3,6

Dr van Loon found that the learning curve for ultrasound-guided cannulation was “quite steep.”³ Nurses were considered competent after only 34 procedures, decreasing their insertion time from nearly 15 minutes to about 3 minutes.⁶

The training also resulted in a 93% success rate for first-attempt insertions.⁶ Notably, this number raised to 94% for patients with difficult IV access.⁶ Without the use of ultrasound, these patients had only a 6% success rate.⁶

Learn more about proper peripheral IV catheter insertion: The European recommendations on the proper indication and use of peripheral venous access devices (ERPIUP) consensus

3. Should ultrasound-guided cannulation be used for all patients, by all nurses?

Despite this evidence, Dr van Loon stated that he still didn’t equate ‘competent’ with ‘specialist.’³

“You need much more experience over longer periods of time to become a real expert in ultrasound-guided cannulation”, Dr van Loon stated.³

For this reason, he argued that only highly trained and highly experienced healthcare professionals, such as members of a vascular access team, should cannulate patients with difficult IV access.³

He also explained that it is namely these patients (with difficult IV access) for which ultrasound guidance is needed.³ Though vascular access management should always be patient-oriented, Dr van Loon concluded that the decision to use ultrasound should come from a careful evaluation of the patient’s treatment indication, characteristics and risk profile.³

About BD MACOVA 2022

BD MACOVA 2022 was held in Berlin on the 8-10th June and welcomed over 300 guests and 31 speakers from 35 countries.

The event carries a rich history of engaging leaders in vascular access (VA) to share their experience and insight into vascular access management (VAM) with those looking to expand the use of vascular access devices and services they provide in their hospitals.

This year’s theme was to create a VA community of VAM-bassadors (Vascular Access Management Ambassadors) of change to help improve patient outcomes.

Learn more about MACOVA 2022: Are midline catheters underused in the emergency department?