Ultrasound-guided Intravenous Access For Difficult Venous Access: Evidence Review

Background on Difficult Venous Access

Question:

Discuss About The Journal Vascular Interventional Radiology?

In the emergency department, establishing vascular access is the most common procedure.  However, handling patients with difficult vascular access becomes a challenge for nurses. Certain conditions like obesity, vasculopathy, hypovolemia and chronic vascular access increase the likelihood of difficult vascular access. The review of research studies on interventions for difficult intravenous access has revealed that CVC (Central Venous Catheterization) is an alternative approach for the management of difficult access and achieving cannulation (Crowley et al. 2012). Although CVC helps in providing vascular access for different medical purpose, however there are many evidence which shows the risk associated with CVC cannulation. Kornbau et al. (2015) has revealed that CVC increases large number of complications in patient. Immediate complications include vascular, cardiac and pulmonary complication and some of delayed complications include catheter infection. Parienti et al (2015) also showed that CVC is associated with infectious and thrombotic complications and catheter related bloodstream infection has negative implications on health care cost, morbidity and mortality of patient. These evidences points out to the uncertainties in management of difficult access by CVC method. However, there is also abundant evidence regarding the effectiveness of ultrasound guided venous access in increasing success rate in cannulation and decreasing complications. Hence, it would be beneficial to review

Population (P): Patients with suspected or known difficult venous access

Intervention (I): Ultrasound-guided Intravenous access

Comparison (C): Traditional techniques

Outcome (O): Improved intravenous access and less complications

In patients with suspected or known difficult venous access, does Ultrasound-guided Intravenous access compared to traditional technique improve intravenous access and lessen complication?

While looking at highest level of evidence related to the research topic, it is necessary to start from the top of the 6S pyramid. The 6S pyramid consists of systems, summaries, synopses of syntheses, syntheses, synopses of single studies and single studies (Murad et al. 2016). When seeking to find answer to the above research question, the main focus was to find highest level of evidence and then move down the list. The electronic databases that can help in getting answer to healthcare and clinical questions include Google Scholar, CINAHL, PubMed, Cochrane Library and PyschINFO (Kable, Pich and Maslin-Prothero 2012). On the basis of hierarchy of evidence, systematic reviews comes at the top of the list followed by evidence syntheses, article synopses, RCTs (Randomized Controlled Trial), Cohort Studies, case controlled studies and expert opinion (Hansen 2014). While searching relevant articles related to ultrasound guided intravenous access, the focus will be to start finding articles from highest level of evidence.

Mention of CVC as Alternative Approach

To answer the PICO questions, Google Scholar, CINAHL, PubMed, Cochrane Library and PyschINFO databases were search. These databases were selected as it provides peer-reviewed articles on health care research. The search was first started with broad search terms like ‘Ultrasound-guided Intravenous access’ and this was typed in Google Scholar. If the search for top two levels failed, then broad search term was also applied in CINAHL, PubMed, Cochrane Library and PyschINFO databases. For searching articles from CINAHL, PubMed and PyschINFO databases, certain specific search terms and Boolean operators like AND, OR and NOT was used. The search result was limited by limiting the search full text and peer reviewed articles. When more than one search term such as ‘Ultrasound-guided Intravenous access’ and ‘reduction in venous access complication’ was used, then AND or OR was used. In this way, combination of two search term was added to get relevant and highest quality evidences. After entering different combinations of search terms in databases and analyzing them according to hierarchies of evidence, three highest piece of evidence was found. One article was a randomized study by Wu et al. (2013) focusing on comparison between two-dimensional ultrasound guidance technique and land mark method in critical patient. The second article was a retrospective analysis done in emergency department Scoppettuolo et al. (2016) and the final included prospective observation study in cancer patients (Cavanna et al. 2010).

To effectively apply highest level of evidence to current practice in nursing setting, comparison and critical analysis of three research articles are presented below:

The first randomized study by Wu et al. (2013) is considered relevant to answer the PICO question by reviewing at its title, abstract and background. The population, intervention as well as the comparator is evident from the title of the research article. It clearly showed that that real time two-dimensional ultrasound guidance technique for CVC was the main intervention and landmark method was comparator. The population of interest was also evident after reading the methodology and the outcomes of the technique was mainly evaluated in patients undergoing CVC. The landmark method compared in the RCT study also became clear after reviewing the introduction section of the article. Hence, based on this justification, the article is found relevant to answer the research question. Finding such articles specific to the research question also proves that PICO question has been appropriately formulated for clinical research and evidence based practice. Evidence has proved that formulation of clinical question by using PICO format helps in framing questions directly relevant to patient problem or clinical issue. Developing a researchable question facilitates implementing quality research and evidence based clinical practice (Aslam and Emmanuel 2010).

Risk Associated with CVC Cannulation

Apart from the relevance of the article by Wu et al. (2013) in addressing research question, another attribute that resulted in the selection of this article for critical appraisal includes the position of the evidence in the hierarchy of evidence. As this assessment mainly aimed to finding out the best evidence to inform current nursing practice, taking highest level of evidence has an advantage. The hierarchical system of classifying evidence is one of the cornerstone of evidence based practice and practitioners are mainly encouraged to find highest level of evidence because maximize its effectiveness for particular intervention. The level of evidence helps to prioritize information and providing a guide to effectively evaluate results of the research (Burns, Rohrich, and Chung 2011). The article by Wu et al. (2013) has also been selected for addressing research questions because it is the highest level of evidence as it is a meta-analysis of various RCT study. The main rational for regarding systematic reviews and meta-analysis as being the best evidence in informing health care practice is that systematic reviews are synthesis of many good quality evidence. This helps the reviewers having time constraints to get reliable idea about the effectiveness of intervention. In case of meta-analysis, the precision of the result increases because it is a mathematical synthesis of two or more research studies (Gopalakrishnan and Ganeshkumar 2013).

After reviewing the first article on the basis of relevance to the research question and hierarchy of evidence, the next goal is to evaluate the article on the basis of informing the effectiveness of ultrasound guided venous access in improving cannulation process and reducing complications. To compare and contrast real time two-dimensional ultrasound (RTUS) guidance technique with anatomical landmark method, Wu et al. (2013) retrieved randomized studies from PubMed, EMBASE, ISI Web of knowledge and OVID EMB reviews.  Selection of these databases are commendable because all are updated and versatile medical databases.

The methodological rigor in selecting article is seen because Wu et al. (2013) used two reviewers screened articles. One was involved in reviewing the title and abstract and other reviewed the whole article. The assessment of studies has been validated by the use of Jadad tool, which is a reliable tool to assess quality of RCT studies (Zeng et al. 2015). The impact of ultrasound techniques on puncture site, patient’s age and risk of cannulation failure was evaluated. The final result of the meta-analysis showed that RTUS technique reduced risk of cannulation failure in adult patient, however the same result was not found for pediatric patients. However, it reduced the risk of accidental puncture. Overall the benefits of RTUS in reducing cannulation failure incidence, accidental puncture and hematoma was proved. One significant value of this research is that it has pointed out to the changes in outcome in case of pediatric patient. Hence, while deciding to use this evidence for real practice, it would be essential for practitioners to assess the role of RTUS in pediatric patients or find out other approach for them. Such consideration is important in evidence based research because before implementing such evidence, there is a need to address complexity in system of care and different patient group (Hamer and Collinson 2014).

Effectiveness of Ultrasound Guided Venous Access

The second research article that has been found to address the PICO question include the article by Scoppettuolo et al. (2016) which focused on conducting retrospective analysis for ultrasound-guided short midline catheters for difficult venous access in the emergency department. The congruence of the article to the PICO question is partly understood from reading the title of the article and partly by reading the abstract. The title gave idea about outcome and the intervention. The population of interest became evident by reviewing the background section of the article. The manner in which PICO question has helped to retrieve relevant research article also proves that PICO format is an essential tool to pursue research and explore the validity of research for application in real setting (Riva et al. 2012). 

On the basis of level and hierarchy of evidence, it can be said that Scoppettuolo et al. (2016) has focused on retrospective analysis comes under level II evidence for clinical studies. Burns, Rohrich and Chung (2011) have proved that for prognostic studies, retrospective analysis comes under level II of evidence. A retrospective analysis is a method that looks back at the outcome of an event that has been already established. In such cases, the data is secondary and the advantage of this method for research is that it helps to further evaluate and identify potential biasness in past studies (Smith 2015). Assessing the hierarchy of evidence is a major factor in evidence based practice and evidence based hierarchies provides the right guidance to determine the quality of evidence. This can be said because hierarchy of evidence in constructed by evaluating the research methods on the basis strength and precision in research design (Greenhalgh, Howick and Maskrey 2014). Hence, selecting research articles on by using evidence hierarchy as a guide provides the best approach to validate the quality of evidence at the first place.

The usefulness of the research by Scoppettuolo et al. (2016) in terms of its applicability by nursing practice can be understood by analyzing the results of the study. The retrospectives analysis on ultrasound-guided peripheral venous access in patients admitted to emergency department in 1 year revealed that success rate of insertion of 100% and no thrombotic complications or infection was reported. On the basis of this outcome, it can be said that the research article has addressed and provided answer to the PICO question. The data based on clinical charts has convincingly proved that no complication occurred during cannulation in patient. In terms of comparison of the ultrasound guided venous access technique with traditional palpation approach, it was proved that the ultrasound guided technique was the superior method for successful venous cannulation (Scoppettuolo et al. 2016). The strength of the evidence is that the author has not only defined outcome and superiority of the technique, but also gave clear about the reason for positive outcome. The main reason for high success rate was that ultrasound guided technique reduced the rate of percutaneous punctures that occurred in traditional method. However, one limitation that can act as barrier in the implementation of the evidence for practice is that the study showed that success rate is dependent on characteristics of vessel. Secondly, the cost effectiveness of the method has been hampered by short duration limit for the procedure. Hence, this study points out to the need for future research in the area of addressing short duration related challenges for staffs. It also point to the need for simulation based training regarding the technique to maximize the utility of evidence for evidence based practice This points out to the need for simulation based training (Ma et al. 2011)

PICO Question

The third article by Cavanna et al. (2010) was also found to address the PICO question and this is evident clearly by looking at the title of the article. The interventions and outcome mentioned in the title matches with the PICO question. The title is not matching the population group as the study has been done with cancer patients. However, still the research is significant to inform practice because evidence has showed that risk of complications in central venous access mainly increases in patients with chronic illness (Tapson et al. 2017). Hence, the research work on cancer patient is considered inform to inform practice in clinical setting because central venous access is necessary for all cancer patients. In terms of hierarchy of evidence, Cavanna et al. (2010) occupies the level I hierarchy as it is a prospective study (Burns, Rohrich and Chung 2011). The strength of this methodology for research is that it helps in analysis of subjects based on outcomes over a long period of time. This evidence is also found fewer biases and confounding factors compared to retrospective study. Hence, such results obtained from such study are reliable.

Cavanna et al. (2010) mainly conducted the research with cancer patients requiring CVC. The Seldinger technique was used to place the catheter and 16 needle was placed under real time ultrasound guidance. Within two hours of the procedure, any CVC related complication was recorded. The outcome study done on participants for 9 years showed no bleeding and nerve puncture, however self limiting hematoma was observed. The study is found useful because it also answers the PICOT question and proves that ultrasound guidance can reduce complications in cancer patients. The strength of this evidence is that this research performed the procedure on largest number of patient thus enhancing the reliability and credibility of the result. It is the most accurate prospective trial as it has been carried out over a longer period of time. Such piece of evidence can readily applied in practice after providing some period of training to nurses.

Among the three evidence, two was highest level of evidence and one was II level of evidence. In case of meta analysis and prospective study, the prospective study by Cavanna et al. (2010) is found to be the most strongest level of evidence from the three articles. This is because the methodology is free from biasness compared to other methods and analysis of outcome for long period has further enhanced the validity of the study for application in real setting. The other two studies are not reliable for application in real setting because of limitations in methodology and research outcomes as explained in sections for respective studies.

Search for Highest Level of Evidence

Among the three evidences, Cavanna et al. (2010) can be implemented as evidence based practice (EBP) in current setting because the article has clearly discussed the procedure and also addressed the limitations related to short time limit in implementing the procedure. This can be said because Seldinger technique was applied to address this shortcoming in the procedure (Goldstein et al. 2015). However, while trying to implement this evidence, certain barriers may arise in practice setting. For instance, nurses may feel reluctant to adopt the new method and abandon the traditional technique of cannulation. To address this barrier, it will be necessary to hold two or more session with nurses so that they understand the effectiveness of evidence for patient safety and reducing health care cost. This will help to address individual level barrier and changes the attitude of nurses towards EBP (Jordan, Bowers and Morton 2016).

Another barrier to the implementation of EBP may include lack of time in learning about the new technique. This barrier can be addressed once the organization realize the need to change traditional practice and provide support to nurses so that they can manage their work priorities as well as attend training for effectively implementing new intervention in real setting. Such barrier can be addressed by clinical leader in organization as they can develop strategic climate for implementation of EBP (Aarons et al. 2014).

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