Background: Venous access is commonly required in hospitalized patients for the administration of intravenous fluids and medications and blood products. Peripherally inserted central catheters (PICCs) and central venous catheters (CVCs) are required for the administration of vasopressors, chemotherapy, or total parenteral nutrition but often they are placed due to difficulty obtaining a peripheral venous catheter (PIV) for venous access. Both carry an increased risk of central line-associated bloodstream infections (CLABSIs) and deep vein thrombosis (DVTs) when compared to PIVs.
At our hospital, when PIV placement is unsuccessful, we have a difficult vascular access algorithm utilized by nursing with escalation to nurses who can utilize ultrasound for access. Our procedure medicine team is often consulted if additional assistance is required. All consults for venous access are reevaluated for possible PIV placement. Our aim for this study was to review venous access consults and identify how often PIV access is appropriate and can be established by physicians trained in ultrasound-guided procedures.
Methods: In 2016, we developed a hospitalist-led and resident staffed procedure team. All vascular access procedures are performed using dynamic ultrasound guidance either by a hospitalist attending or a resident under direct supervision. Consults data are entered into a database and the past 16 months of data were analyzed. We identified all consults for venous access from this database and categorized all attempted procedures as a PIV or CVC and successful or unsuccessful. Consults for dialysis catheters were excluded. Data are presented as mean (standard deviation) or percentage and Chi-square or t-test were used as appropriate.
Results: Of the 241 venous access consults received, we attempted IV access on 204 patients. 37 were not attempted due to concern for patient safety, placement of venous access by another service, or placement of PICC. Mean age of the patients with attempted IV access was 56.2 (17.1) years and BMI was 29.9 (10.6) m2/kg. Eight had BMI <18.5 m2/kg (4%) and 78 had BMI >30 m2/kg (38%). PIV access was obtained in 155 (77%) of these patients while CVC placement was needed in 35 (23%) patients (success rate = 93%).
Patients with successful PIV placement were compared to those with CVC placement. There was no significant difference in age (56.8 (17.3) vs 54.8 (15.6); p=0.53), gender (male: 67 vs 17; female: 86 vs 16; p=0.42), race (African American: 98 vs 21; Caucasian: 86 vs 16; Other: 4 vs 5; p=0.06), average BMI (29.4 (10.3) vs 28.9 (6.6); p=0.78), or extremes of BMI (<18.5: 6 vs 2, 18.5-30: 92 vs 20, >30: 57 vs 13, p=0.88).
Conclusions: Hospitalist trained in ultrasound-guided venous access were able to obtain PIV access in 77% of patients who were referred to the procedure service for venous access. By avoiding placement of a PICC or CVC in over three-quarters of patients, we believe we may have prevented significant complications and morbidity in these patients.
To cite this abstract:Ritter, E; Malik, M; Miller, R; Garber, AM; Chopski, BD; Meliagros, PD; Modi, S. BIGGER IS NOT ALWAYS BETTER WHEN OBTAINING VENOUS ACCESS IN HOSPITALIZED PATIENTS. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 171. https://www.shmabstracts.com/abstract/bigger-is-not-always-better-when-obtaining-venous-access-in-hospitalized-patients/. Accessed July 23, 2019.