Ultrasonographic Guidance to Improve First-Attempt Success in Children With Predicted Difficult Intravenous Access in the Emergency Department: A Randomized Controlled Trial

• Published in: Annals of emergency medicine 2019-07, Vol.74 (1), p.19-27
• Main Authors: Vinograd, Alexandra M., Chen, Aaron E., Woodford, Ashley L., Fesnak, Sarah, Gaines, Shannon, Elci, Okan U., Zorc, Joseph J.
• Format: Article
• Language: English
• Subjects: Administration, Intravenous - adverse effects; Administration, Intravenous - instrumentation; Administration, Intravenous - methods; Adolescent; Catheterization, Peripheral - adverse effects; Catheterization, Peripheral - methods; Catheters, Indwelling - adverse effects; Child; Child, Preschool; Emergency Service, Hospital; Female; Humans; Infant; Infant, Newborn; Male; Patient Care Bundles - methods; Pediatric Emergency Medicine - methods; Personal Satisfaction; Prospective Studies; Ultrasonography, Interventional - methods
• ISSN: 0196-0644; 1097-6760
• DOI: 10.1016/j.annemergmed.2019.02.019

We determine whether ultrasonographically guided intravenous line placement improves the rate of first-attempt success by 20% for children with predicted difficult intravenous access. Secondary objectives included determining whether ultrasonographically guided intravenous line placement reduces the attempt number, improves time to access or parental satisfaction, or affects intravenous line survival and complications. This was a prospective, randomized controlled trial conducted in an urban tertiary care pediatric emergency department that enrolled a convenience sample of children requiring an intravenous line and who were predicted to have difficult intravenous access according to a previously validated score. Participants were randomized to traditional or ultrasonographically guided intravenous line placement on first attempt and stratified by aged 0 to 3 versus older than 3 years. One hundred sixty-seven patients were enrolled and randomized to traditional intravenous line or to a care bundle with a multidisciplinary team trained to place ultrasonographically guided intravenous lines. First-attempt success was increased in the ultrasonographically guided intravenous line placement arm (n=83) compared with the traditional intravenous line arm (n=84) (85.4% versus 45.8%; relative risk 1.9; 95% confidence interval [CI] 1.5 to 2.4). There were fewer attempts in the ultrasonographically guided intravenous line placement arm than in the traditional intravenous line arm (median 1 versus 2; median difference 1; 95% CI 0.8 to 1.2) and a shorter time from randomization to intravenous line flush (median 14 minutes [interquartile range 11 to 20] versus 28 minutes [interquartile range 16 to 42]). A Kaplan-Meier survival analysis demonstrated that ultrasonographically guided intravenous lines survived longer than traditional ones (median 7.3 days [95% CI 3.7 to 9.5] versus 2.3 days [95% CI 1.8 to 3.3]). There was no difference in complications between the groups. Parents were more satisfied with ultrasonographically guided intravenous line placement. Ultrasonographically guided intravenous line placement in children with predicted difficult intravenous access improved first-attempt success and intravenous line longevity when conducted by a team of trained providers.