Mini-midline in difficult intravenous access patients in emergency department: A prospective analysis

Journal: The Journal of Vascular Access
Author: Emanuele Gilardi
IF: 2.283
Publication Date: September 2019

Abstract
Background: "Difficult intravenous access" patients represent a challenge within an emergency department as they often require many attempts to insert a peripheral short cannula in the emergency room or during the whole hospitalization. This can lead to many problems in terms of patient discomfort, increase of cost, and prolonged treatment time.

Obiectives: This study aimed to reduce the number of attempts needed for a short-cannula insertion or preventing insertion of a central vascular access by placing an ultrasound-guided long cannula during the emergency department visit.

Material and methods: The insertion of mini-midline was monitored within an emergency room in 50 patients considered dificult intravenous access patients, who failed two attempts at peripheral yenous access insertion and/or required the use of an alternative vascular device.

Results: A total of 46 patients out of 50 were monitored. In 38 (82%) patients, the device was removed due to the end of the indication, and in six of them, it was replaced by a central venous catheter. Two devices were left inside even after discharge and were then removed at the end of indication. In eight (17%) patients, the device was removed due to accidental removal (4) and malfunction (4). In all the cases, the average duration of the insertion procedure was 10 min. The mean dwell time accounted to 7 and 9 days.

Conclusion: The insertion of a mini-midline as part of the first emergency room visit in selected patients is a rapid, safe and cost-effective procedure, which can provide the patient with stable venous access during the all hospitalization time.

Background

Patients with "difficult venous access" represent a challenge in the emergency department (ED) as they often require multiple attempts at peripheral venous catheter (PVC) insertion, both in the ED and throughout hospitalization. This leads to numerous issues including patient discomfort, increased costs, and prolonged treatment times.

Objective

This study aims to reduce the number of attempts required for PVC insertion or to avoid the placement of central venous catheters (CVC) by using ultrasound-guided mini-central venous catheters during the patient’s emergency department visit.

Materials and Methods

Fifty patients with difficult venous access were monitored in the emergency department for mini-line insertion. These patients had failed two attempts at PVC insertion and/or required the use of alternative vascular access devices.
Results: Of the 50 patients, 46 were monitored. In 38 patients (82%), the mini-line was removed when the indication ended, with six cases being replaced by central venous catheters. Two patients still retained the mini-line after discharge, which was removed when the indication ended. In 8 patients (17%), the catheter was removed due to accidental dislodgement (4) or dysfunction (4). The average insertion time for all cases was 10 minutes, and the average dwell time was 7 to 9 days.

Conclusion

In selected patients, ultrasound-guided mini-central venous catheter insertion as part of an emergency department visit is a fast, safe, and cost-effective procedure that can provide stable venous access during hospitalization.

Research Background

1. In the emergency department (ED), failure rates for establishing venous access can reach up to 25% due to special circumstances such as obesity, hypovolemia, chronic medical conditions, history of drug use, or vascular problems.
2. Recent studies have shown that ultrasound-guided peripheral venous access is superior to traditional landmark-based techniques, with greater benefits for patients with difficult venous access (DIVA).
3. Traditional peripheral venous catheters are short (3-5 cm) and suitable for inserting into superficial veins. When used for ultrasound-guided deep venous cannulation, the rates of extravasation and dislodgement significantly increase. In contrast, polyurethane mini-central venous catheters (6-12 cm), introduced into clinical practice, differ not only in length but also in insertion technique and stability. These can be inserted into peripheral deep veins using the direct Seldinger technique under ultrasound guidance.

Study Objectives

To verify whether ultrasound-guided mini-central venous catheter insertion in patients with difficult venous access during their first emergency department visit can avoid PVC insertion failures, reduce multiple attempts, and even avoid the need for CVC placement (unless absolutely necessary), thus reducing patient discomfort, hospital costs, and the risk of major complications.

To assess the feasibility of performing this procedure in the busy and chaotic environment of the emergency department.

Study Methods

Study Duration: January 2018 – April 2018
Study Population: Patients in the ED requiring venous access with difficult venous puncture
Inclusion Criteria:

• Age > 18 years
• DIVA patients (veins "invisible or inaccessible" or known history of DIVA)
• Patients with two unsuccessful attempts at PVC insertion
• Patients who have had venous access devices placed, but staff consider the specifications, location, or condition of the venous access device to be ineffective.
  Exclusion Criteria:
• Unstable or critically ill patients
• Patients who have already received a CVC, PICC, or infusion port under observation

Implementation Details:

1. Mini-line Selection: 3Fr × 8 cm, flow rate 24 mL/min
2. Insertion Procedure:

Following the GAVeCeLT guidelines (2010), the SIP protocol was modified to SIPUA (Environment, Time, Materials Preparation—Hand washing, sterile technique, protective equipment—Ultrasound arm vein exploration—Selecting the most suitable vein—Ultrasound assessment of the median nerve and brachial artery prior to puncture—Ultrasound-guided venous puncture—Confirming blood return and flushing the catheter—Fixation using non-absorbable sutures—Recording information).

The goal is to reduce the likelihood of all complications (infectious, mechanical, and thrombotic) to zero.

Research Results

1. The primary diagnoses for the hospitalized patients were heart failure, severe urinary or airway infections, dehydration and metabolic damage, unexplained anemia, epilepsy, and COPD.
2. The success rate of ultrasound-guided mini-central venous catheter placement in this study was 100%.
3. 80% of patients did not experience catheter-related complications, such as local hematoma, difficulty advancing the guidewire or catheter, or absence of blood return.
4. The preferred site for catheter placement in this study was the right internal jugular vein.
5. 82.6% of the patients had their catheters removed when the indication ended.