Assessing the utility of ultrasound‐guided vascular access placement with longer catheters in critically ill pediatric patients

Critically ill pediatric patients can have difficulty with establishing and maintaining stable vascular access. A long‐dwelling peripheral intravenous catheter placement decreases the need for additional vascular interventions.


| INTRODUC TI ON
The establishment and maintenance of stable vascular access in critically ill children with complex operations, multiple co-morbidities, and frequent hospitalizations can be challenging for several reasons, including small caliber veins, limited access sites, and high emotional stress from the child and family. Recent estimates suggest that catheter dwell time in pediatric patients with traditional, standard length catheter placement ranges between 2-3 days, with a rapid increase in malfunction following 48 h. 1 With an estimated median pediatric intensive care unit length of stay of 2 days in North America, such access may not carry patients through ICU admission, potentially causing interruptions in therapy and requiring additional interventions to maintain access. 2 The use of ultrasound guidance to enhance first-pass success with peripheral intravenous catheter placement is now well established in both adult and pediatric emergency medicine literature. [3][4][5][6] The relationship however between an ultrasoundguided peripheral intravenous catheter approach and catheter longevity has been less studied and with inconsistent results. Adult literature suggests a high failure rate of ultrasound-guided peripheral intravenous catheter placement at 48 h, correlating failure rate to the depth of vessel cannulated. 7 A recent pediatric randomized control trial comparing ultrasound-guided peripheral intravenous catheter to traditional approaches showed dwell time to extend by 5 days with the use of ultrasound; however, unlike the adult study, longer catheters were used in many of those cannulated with ultrasound guidance. 3 This study hypothesizes that placing ultrasound-guided long peripheral intravenous catheters in the pediatric intensive care unit will lead to significantly longer dwell times, with improved longevity, lower failure rates, and reduced need for additional vascular interventions when compared to a traditional approach to standard-sized peripheral intravenous catheter placement.
Our approach is unique in its exclusive use of longer peripheral intravenous catheters in the ultrasound group and its focus on pediatric critically ill patients.

| Study design and setting
This was a retrospective cohort study in a tertiary 25-bed combined cardiac and pediatric intensive care unit comparing ultrasoundguided long peripheral intravenous catheters to traditional approach standard-sized peripheral intravenous catheters in children with difficult vascular access.

| Definitions
The standard-sized peripheral intravenous catheters were defined as 24 Ga. Traditional approaches for placement of intravenous catheters included the use of landmarks, palpation of the vein, and the use of a vein illuminator. Ultrasound-guided approach for placement of intravenous catheters involved a dynamic approach, with a combination of either short or long-axis techniques, depending on proceduralist preference.

| Interventions
The vascular access team or intensivists were contacted for place-

What is already known about the topic?
Establishing and maintaining stable vascular access can be difficult in critically ill pediatric patients. Very few existing studies have investigated potential advantages of ultrasound-guided long peripheral intravenous catheters in critically ill pediatric patients.

What new information this study adds
The study identifies the advantages of placing longer intravenous catheters with ultrasound guidance.

| Outcome measures
The primary outcome measure was defined as dwell time in hours of the catheter during hospitalization and the secondary outcomes included complication rates (infiltration, catheter integrity, leak, occlusion, site tenderness, bleeding, or unplanned removal (defined as the inadvertent or deliberate displacement of the catheter by patient or other factors prior to completion of therapy)) and the need for additional intravenous access following placement in the intensive care unit.

| Data analysis
Continuous variables were summarized as medians (25th, 75th percentile) and categorical variables as frequency (percent to access the association between the additional IV access and the catheter groups after adjusting for the length of stay and to estimate adjusted odd ratios (ORs) with 95% CIs.
All analyses were performed on a complete-case basis; subjects with missing data on particular variables were only excluded for analyses in which those variables were used. All tests were 2-tailed and were performed at an overall significance level of 0.05. SAS 9.4 software (SAS Institute) was used for all analyses and plots.

| RE SULTS
Included in the ultrasound-guided long peripheral intravenous catheters group were 99 placements compared to 88 in the traditional approach standard-sized peripheral intravenous catheter, with a median age of 58 versus 10 months (95% CI for difference in medians , p = .001) between long and traditional groups, respectively. Traditional approach standard-sized peripheral intravenous catheter placement location was more often in the hand (35.2%) followed by the forearm (26.1%), whereas in the ultrasound-guided long peripheral intravenous catheters group was more often in the forearm (55.6%) followed by the upper arm (36.4%). See Table 1  Among reasons for premature intravenous catheter removal, 19.3% of short intravenous catheter placements were related to unplanned removal compared to 7.1% in the ultrasound-guided group (see Table 2). Complication rates otherwise were similar between the ultrasound-guided and standard groups, but not analyzed for statistical significance due to limited numbers of observations.

| DISCUSS ION
This study found that placement of peripheral intravenous cath- placements. Both studies, while favoring the use of longer peripheral intravenous catheters in the ultrasound groups, did not fully control for this variable. 6 Contrary to these data, existing adult and pediatric literature suggests that ultrasound-guided peripheral intravenous catheters may be associated with a higher failure rate. [7][8][9] Investigating reasons for this, Fields et al. found that vessel depth and location accounted for this higher rate, with deeper and more proximal vessel cannulation constituting the majority of early failure rate when using standard peripheral intravenous catheters. 10 Associating ultrasound guidance to select the optimal and often deeper vein with the use of a longer catheter to ensure its adequate seating within the vein could avoid this cause of failure, and may explain the differences in the ultrasound-guided success between existing pediatric and adult literature. Our data support this idea, as more ultrasound-guided peripheral intravenous catheters were placed in the oftentimes deeper forearm and upper arm locations while still maintaining greater longevity. [11][12][13] Intravenous catheter placement in pediatric patients is a known stressor to both patients and families and adds to the cumulative trauma of patients admitted to the pediatric intensive care unit. 14

Study variable
Overall (n = 187) USGPIV (n = 99) in literature search, study design, data collection, and analysis of data, manuscript preparation, and review of manuscript.

FU N D I N G I N FO R M ATI O N
No additional funding required.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors have no conflict of interest relevant to this article to disclosure.

DATA AVA I L A B I L I T Y S TAT E M E N T
The datasets during and/or analyzed during the current study are available from the corresponding author on reasonable request.

E TH I C S A PPROVA L S TATE M E NT
IRB approval was obtained by Cleveland Clinic IRB (#21-901) following review.

CO N S E NT FO R PU B LI C ATI O N
None indicated.