Introduction

Point of care ultrasound (PoCUS) is the use of portable ultrasonography to answer focused clinical questions or to guide procedures.

Peripheral intravenous (PIV) access is one of the most frequent and essential emergency and inpatient medical procedures. It allows for the timely administration of medications, intravenous fluids and the collection of blood samples. Despite being a high frequency procedure, PIV access is often challenging in children, resulting in multiple attempts and significant distress.  Risk factors for difficult PIV placement include young age, history of prematurity, obesity, dehydration, critical illness, chronic illness, IV drug use, difficulty visualizing or palpating veins with a tourniquet and patient anxiety [1,2,3]. The difficult IV access score (DIVA) is externally validated to predict children likely to fail PIV access attempts and includes age, prematurity, and vein characteristics [4]. Difficulty in obtaining PIV access results in diagnostic and treatment delays, as well as increased patient discomfort, anxiety and stress. In this patient population, PoCUS allows for direct visualization of the vasculature and can facilitate access.

 

Why Ultrasound?

Traditionally, peripheral intravenous (PIV) access is performed blindly using a basic knowledge of human anatomy, surface landmarking, and palpation. Ultrasound allows for the visualization of veins that are not clinically apparent and guides placement through visualization of the catheter and the vein [5].

Studies show the use of ultrasound to guide PIV placement results in increased overall success rates [6]. Importantly, ultrasound use decreases the numbers of attempts and number of needle redirections required; this results in less pain and anxiety for the patient and results in a faster time to successfully obtain IV access [7]. In addition, ultrasound allows access to the larger vessels of the upper arm in the case of difficult access or preference for mid-length catheter placement. Ultrasound guided (USG) PIV access is an easily acquired skill. Following a one-hour course, emergency technicians showed significant improvements in speed, patient satisfaction, number of punctures and complications [8]. A study looking at the competency of emergency nurses trained on ultrasound guided PIV procedure for difficult access patients found an 88% success rate was achieved after 15-26 attempts [9].

These benefits are particularly salient in the pediatric setting where PIV access is inherently challenging and creates significant distress for patients and their caregivers. In one hospital setting where a USG PIV program was established, there was a 20% reduction in referral for PICC placements [10] and a recent randomized controlled trial found for every 3 UG PIVs one missed attempt was prevented [11]. Finally, the use of ultrasound guided PIV access has been endorsed by the Agency for Health Care Research and Quality in the United States.