By Meaghan Mercer, DO
Emergency Medicine Resident
The nurse presents to the bedside and tells you intravenous (IV) access cannot be obtained on your patient and after attempt is made to place external jugular or ultrasound (US) guided access in the upper extremity frustration ensues. In IV drug abusers, significant peripheral edema, or patients who need multiple access points this can be a dilemma. In stable patients who do not need definitive central venous catheters (CVC) such as a triple lumen this can be frustrating. Central lines increase hospital acquired infections, come with procedural risks, and should not be inserted unless absolutely necessary. Here are a few options to explore.
Emergency Medicine Resident
The nurse presents to the bedside and tells you intravenous (IV) access cannot be obtained on your patient and after attempt is made to place external jugular or ultrasound (US) guided access in the upper extremity frustration ensues. In IV drug abusers, significant peripheral edema, or patients who need multiple access points this can be a dilemma. In stable patients who do not need definitive central venous catheters (CVC) such as a triple lumen this can be frustrating. Central lines increase hospital acquired infections, come with procedural risks, and should not be inserted unless absolutely necessary. Here are a few options to explore.
Interosseous Lines
IO access provides quick and effective access, however like other quick access lines, they are only supposed to be in place for 24 hours and are a temporary solution. In patients who need emergent access, this is a phenomenal option. IO lines allow for infiltration of life saving medication in minutes.
In patients who need IV access but who are not in a life threatening situation advocating for this access option can be difficult. Pain with IO insertion and infusion in conscious patients is a complication. One study found the mean pain level in patients increased from 3.5 on insertion to 5.5 on infusion (1). Best bets looked at local anaesthetics in intraosseous access concluded that injecting lidocaine both before and after flushing an intraosseous needle is an effective method of reducing the pain of fluid infusion via this route (2,3,4). Other barriers are patient’s perception to having a line drilled into their tibia or humerus. In the few patients that have allowed me to perform an awake IO placement, discussing studies that state that the pain is equivalent to having an IV placed does not placate their fears and patients have experienced significant pain & discomfort. Many of the studies that discuss pain level have been done on healthy adult volunteers and not in ED patients, which also makes their application more difficult in the practical setting.
Ultrasound Guided Peripheral IJ
Physicians at Highland Hospital in Oakland propose another option; the ultrasound guided peripheral internal jugular (PIJ) access (5). This study looked at nine patients that had PIJ lines placed by senior emergency medicine residents. They practiced typical sterile technique by cleaning the skin with chlorhexidine, wore sterile gloves, a mask, and used a sterile ultrasound probe cover. Using US guidance they placed an angiocatheter (18-gauge 2 ½-inchs) and confirmed placement with the return of dark venous blood. Two patients were lost to follow up, but there were no complications in the other seven patients in their study.
This study discussed that the positives of a PIJ line include time to placement, operator safety, and less risk conferred to the patient. Authors did not recommend this line as a definitive access. The authors of the study discussed four potential drawbacks to this option: 1) lack of long term access 2) Risk of spontaneous migration 3) possible elimination of a site for CVC access 4) Carotid artery puncture/pneumothorax/hematoma formation.
In EM literature of Note’s commentary about this article there was some strong opinions and critiques (6). Scott Weingart (EM:CRIT) advocated that we should be considering more permanent access and be placing mid-level lines similar to PICCs with seldinger placement of mid-length catheters. Others discussed that theoretically the risk of infection should be correlated to the length of the catheter and that the vein used is not relevant- Jon Purcell commented “all veins are created equal; unless perhaps the distance to the heart has a role, which seems a bit ludicrous that that could appreciably alter the rate of infection”. http://www.emlitofnote.com/2012/07/the-peripheral-ij.html
We advocate that there need to be more studies done on this procedure and we are disappointed to not see additional data on this over the last two years. Here at Las Vegas EM a few of many of us have tried this technique, found it very useful, and use it fairly often. We have seen success with this procedure in a multitude of patients including a chronic IV drug abuse patient with cellulitis that needed IV access for antibiotics prior to discharge and a patient that was ICU bound with one good access point but our ICU requires two lines prior to acceptance to the floor. Intuitively, with a lack of evidence, this looks like a good alternative.
Our Thoughts
PIJs will come with the same risks that are associated with attempted cannulation of veins in the arm: local infiltration, cellulitis, hematoma formation and thrombo-phlebitis (7). It has also been documented that arterial puncture occurs ~2% of the time when attempting to cannulate the deeper veins of the arm via ultrasound guidance (8). When deciding between a CVC and a PIJ an 18-guage needle has less risk of trauma and hematoma formation when compared to a 14-guage central venous catheter.
Impact on Emergency Medicine
With a shorter angiocatheter infection rates should be equivalent or less. This line can be quickly and easily placed with an operator who already is experienced with US guided CVC. Especially with potentially dischargeable patients this is an alternative to CVC or IO placement. In patients who have one access point but need an additional due to placement requirements this is a good bridge to PICC placement. As with all procedures, especially those that have not be vetted by evidence based medicine, a discussion of potential risks, benefits, and alternatives should always occur.
We would love to hear your thoughts, successes, and failures on this procedure and to find out if it is becoming common practice and we just haven’t heard about it in the literature.
References
IO access provides quick and effective access, however like other quick access lines, they are only supposed to be in place for 24 hours and are a temporary solution. In patients who need emergent access, this is a phenomenal option. IO lines allow for infiltration of life saving medication in minutes.
In patients who need IV access but who are not in a life threatening situation advocating for this access option can be difficult. Pain with IO insertion and infusion in conscious patients is a complication. One study found the mean pain level in patients increased from 3.5 on insertion to 5.5 on infusion (1). Best bets looked at local anaesthetics in intraosseous access concluded that injecting lidocaine both before and after flushing an intraosseous needle is an effective method of reducing the pain of fluid infusion via this route (2,3,4). Other barriers are patient’s perception to having a line drilled into their tibia or humerus. In the few patients that have allowed me to perform an awake IO placement, discussing studies that state that the pain is equivalent to having an IV placed does not placate their fears and patients have experienced significant pain & discomfort. Many of the studies that discuss pain level have been done on healthy adult volunteers and not in ED patients, which also makes their application more difficult in the practical setting.
Ultrasound Guided Peripheral IJ
Physicians at Highland Hospital in Oakland propose another option; the ultrasound guided peripheral internal jugular (PIJ) access (5). This study looked at nine patients that had PIJ lines placed by senior emergency medicine residents. They practiced typical sterile technique by cleaning the skin with chlorhexidine, wore sterile gloves, a mask, and used a sterile ultrasound probe cover. Using US guidance they placed an angiocatheter (18-gauge 2 ½-inchs) and confirmed placement with the return of dark venous blood. Two patients were lost to follow up, but there were no complications in the other seven patients in their study.
This study discussed that the positives of a PIJ line include time to placement, operator safety, and less risk conferred to the patient. Authors did not recommend this line as a definitive access. The authors of the study discussed four potential drawbacks to this option: 1) lack of long term access 2) Risk of spontaneous migration 3) possible elimination of a site for CVC access 4) Carotid artery puncture/pneumothorax/hematoma formation.
In EM literature of Note’s commentary about this article there was some strong opinions and critiques (6). Scott Weingart (EM:CRIT) advocated that we should be considering more permanent access and be placing mid-level lines similar to PICCs with seldinger placement of mid-length catheters. Others discussed that theoretically the risk of infection should be correlated to the length of the catheter and that the vein used is not relevant- Jon Purcell commented “all veins are created equal; unless perhaps the distance to the heart has a role, which seems a bit ludicrous that that could appreciably alter the rate of infection”. http://www.emlitofnote.com/2012/07/the-peripheral-ij.html
We advocate that there need to be more studies done on this procedure and we are disappointed to not see additional data on this over the last two years. Here at Las Vegas EM a few of many of us have tried this technique, found it very useful, and use it fairly often. We have seen success with this procedure in a multitude of patients including a chronic IV drug abuse patient with cellulitis that needed IV access for antibiotics prior to discharge and a patient that was ICU bound with one good access point but our ICU requires two lines prior to acceptance to the floor. Intuitively, with a lack of evidence, this looks like a good alternative.
Our Thoughts
PIJs will come with the same risks that are associated with attempted cannulation of veins in the arm: local infiltration, cellulitis, hematoma formation and thrombo-phlebitis (7). It has also been documented that arterial puncture occurs ~2% of the time when attempting to cannulate the deeper veins of the arm via ultrasound guidance (8). When deciding between a CVC and a PIJ an 18-guage needle has less risk of trauma and hematoma formation when compared to a 14-guage central venous catheter.
Impact on Emergency Medicine
With a shorter angiocatheter infection rates should be equivalent or less. This line can be quickly and easily placed with an operator who already is experienced with US guided CVC. Especially with potentially dischargeable patients this is an alternative to CVC or IO placement. In patients who have one access point but need an additional due to placement requirements this is a good bridge to PICC placement. As with all procedures, especially those that have not be vetted by evidence based medicine, a discussion of potential risks, benefits, and alternatives should always occur.
We would love to hear your thoughts, successes, and failures on this procedure and to find out if it is becoming common practice and we just haven’t heard about it in the literature.
References
- Fowler RL, Pierce A, Nazeer S, et al. 1,199 case series: Powered intraosseous insertion provides safe and effective vascular access for emergency patients. Ann Emerg Med. 2008;52(Suppl4):152.
- Stewart M. Local anaesthetics in intraosseous access. Best Bets. July 2013. http://bestbets.org/bets/bet.php?id=2515.
- Philbeck TE, Miller L, Montez D. Pain management during intraosseous infusion through the proximal humerus. Ann Emerg Med 2009;54:S128.
- Philbeck TE, Miller LJ, Montez D, et al. Hurts so good. Easing IO pain and pressure. J Emerg Med Serv 2010;35:58–62.
- Philbeck TE, Miller LJ, Montez D, et al. Hurts so good. Easing IO pain and pressure. J Emerg Med Serv 2010;35:58–62.
- Radecki R. “The “Periferal” IJ”: Emergency Medicine Literature of Note. 31 July, 2102. http://www.emlitofnote.com/2012/07/the-peripheral-ij.html
- Kagel EM, Rayan GM. Intravenous catheter complications in the hand and forearm. Journal of Trauma. 2004;56(1):123-7.
- Keyes L, Frazee B, Snoey E, Simon B, Christy D. Ultrasound-guided brachial and basilic vein cannulation in the emergency department patients with difficult intravenous access. Annals of Emergency Medicine. 1999;34:711-4.
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