Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Peripheral, ultrasound-guided intravenous (IV) access occurs frequently in the emergency department, but certain populations present unique challenges for successfully completing this procedure. Prior research has demonstrated decreased compressibility under double tourniquet technique (DT) compared with single tourniquet (ST). We hypothesized that catheters inserted under DT method would have a higher first-stick success rate compared with those inserted under ST method.

Methods: We randomized 100 patients with a history of difficult IV access, as defined by past ultrasound IV, prior emergency visit with two or more attempts required for vascular access, history of IV drug abuse, history of end stage renal disease on hemodialysis or obesity, to ultrasound-guided IV placement under either DT or ST method. We measured the vein characteristics measured under ultrasound, and recorded the number of attempts and location of attempts at vascular access.

Results: Of an initial 100 patients enrolled, we analyzed a total of 99 with 48 placed under ST and 51 placed under DT. Attending physicians inserted 41.7% of ST and 41.2% of DT, with non-attending inserters (including residents, nurses, and technicians) inserted the remainder. First-stick success rate was observed at 64.3% in ST and 66.7% in DT (p=0.93). Attendings had an overall higher first-stick success rate (95.1%) compared to non-attending inserters (65.5%) (p=<0.001). The average vein depth measured in ST was 0.73 centimeters (cm) compared with 0.87 cm in DT (p=0.02).

Conclusion: DT technique did not produce a measureable increase in first-stick success rate compared to ST, including after adjusting for level of training of inserter. However, a significant difference in average vein depth between the study arms may have limited the reliability of our overall results. Future studies controlling for this variable may be required to more accurately compare these two techniques.