Ultrasound-guided versus traditional method for peripheral venous access: an umbrella review

Peripheral venous access devices (PVADs) are required in more than a billion hospitalized patients each year, which corresponds to 59–80% of hospitalized patients depending on the region, becoming the most used clinical invasive device [1, 2]. In the emergency department (ED), PVADs are placed in 70% patients [3]. However, PVADs insertion failure rate is between 43 to 59%, [4] a disappointing data considering the pain, care delays and infection probability to which patients are exposed [5]. Several patient-related circumstances such as chronic illness, edema, obesity or the use of injecting drugs could hinder the PVADs insertion [6]. Among the PVADs, according to international consensus standards, both the short peripheral catheters (SPC), the long peripheral catheters (LPC) and the midline catheters (MC) could be described [7, 8].

Regarding the SPC, the traditional method used for SPC insertion requires vein visualization and/or palpation from the provider [9]. Recently, the potential advantages of ultrasonography (US) guided over the traditional method in SPC insertion have been assessed [10]. In this sense, several reviews have been published to elucidate the outcomes which significantly improve when using the US-guided method in comparison with traditional method, especially in patients with difficult venous access (DVA) [11]. However, there are some methodological differences which could be responsible for the fact that, to date, not conclusive evidence is available supporting US-guided method over the traditional one [11, 12]. Likewise, there is a lack of information as to the differences between both methods in SPC-related complications [12, 13].

Umbrella reviews are a useful strategy to overcome these concerns because they assess the consistency of the evidence that the existing systematic reviews and meta-analyses provide. In our case, this methodology was used to synthesize and critically assess the evidence provided by previous systematic reviews and meta-analyses that have compared the effectiveness of US method to that of the traditional method in SPC insertion.

This umbrella review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (Registration Number: CRD42021290824) and was adhered to both the Cochrane Collaboration Handbook [14] and the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines (PRISMA Checklist, Table S1, Supplementary data) [15]. Because we are conscious that the Preferred Reporting Items for Overviews of Reviews (PRIOR) guidelines will be soon released, we have also considered most of the key aspects of methods and results reported in the majority of the overviews of reviews published so far [16].

The synthesis of the systematic reviews and meta-analyses included in this umbrella review support that the use of US-guided method, compared to the traditional method, increases the success rates and reduces the number of attempts needed in SPC insertion in both adults and pediatric patients. Likewise, the satisfaction was higher in those groups of patients in whom the US-guided method was used, albeit with a low certainty level. Conversely, it is not clear whether the US-guided method is more efficient than the traditional one because there was not a significant reduction in the time spent in SPC insertion.

The previously available evidence regarding the effectiveness of US guided cannulation seems to be controversial. The majority of meta-analyses published to date support that the overall success, the first-attempt success, and the number of attempts rates support the use of the US guided procedure, and it could decrease problems associated to SPC insertion, such as pain, dissatisfaction or anxiety [30].

Considering that pediatrics have particular conditions and a higher failure rate, as it happens in adults, [4, 31] US is presented as a valid alternative in both populations. However, Kleidon and colleagues [26] did not find a positive effect of US-guided method in the overall success in children, as reported in four previous meta-analyses in both adult and children [12, 23, 25, 27] and in a recent study that showed an overall success rate above 90% [32]. On the other hand, the findings of Van loon and colleagues [12] are not in line with the association between US-guided method and the first-attempt success rate, which was reported with a moderate certainty level [11, 24, 26, 27] and which is supported by a recent study in patients with DVA [32]. In regard to the number of attempts, Tran and colleagues [11] found a positive significant association in favor of US-guided method in adults, although with several discrepancies.

The variability in the estimates could be a consequence of the differences in both the way to measure the experience and training of operators and the device used [10, 25]. In the same line, providers have extensive experience in the traditional technique, which could underestimate the potential benefit of the US-guided technique [33]. On the other hand, there is neither agreement on the groups studied nor on the distribution by age group (< 3, < 7, < 10 and/or < 18 years).

Regarding efficiency, no studies found a significant positive effect of US versus traditional method in the time spent in SPC insertion, as stated by a recent RCT which has not been included in any systematic review [34]. The lack of significant findings may result from the large variability among studies. Several methodology-related reasons could be behind this variability, such as differences in the definitions of procedure length [35‐37]. Likewise, history of DVA has not been well-defined in all studies. Since a validated scale for reporting DVA is not available, each study could define it in a different way [12]. Thus, the use of a predicting scale to recognize patients with DVA may improve the methodological quality of further studies [38, 39]. The use of validated methods is important because the inexperience of the operator could be mistaken for a difficult access, which involves a risk of bias [25].

Regarding patients’ satisfaction, although our findings only referred to adult population, the higher rates were obtained when US-guided method was used, except in one study [11, 12, 24]. One reason which could respond to the variability in findings about satisfaction, and which is applicable to the rest of outcomes, is the context where studies were developed. It is logical to think that both the pressure on healthcare personnel and the target response time vary among hospital departments, [40] so the SPC insertion technique is not carried out on equal terms. For example, in the treatment of cardiac arrests in pediatric population the European Resuscitation Council Guidelines 2021 recommend getting a vascular access in 5 min at most and suggest the use of US to guide cannulation in competent providers [41]. Considering that ED is a hospital area where cardiac arrests are common, [42] it seems reasonable to assume that there might be differences between different hospital areas in the US-guided method for SPC cannulation.

In spite of the possible controversial findings and the wide heterogeneity in the studies included, US-guided method seems to be a useful technique that could improve the quality indexes regarding the care and safety of the patient. Likewise, these findings might help to reduce the central venous catheterization (CVC) in patients with DVA, as stated by Au and colleagues, [43] which could avoid the CVC-associated complications [44]. However, this technique requires an in-depth knowledge by operators, [26, 45] and the traditional technique training is more established compared to the US-guided method, [33] although the US training could be further enhanced by the use of long peripheral catheters in DVA patients [46, 47]. The development of training programs could enhance the use of this alternative and its benefits [48]. Furthermore, the inexistence of significant benefit in the time spent in US-guided method, together with pressure on healthcare personnel in certain hospital departments and the availability of the required US equipment, could limit the use of this alternative. However, according to ERPIUP Consensus, those US-guided SPC used to canalize deep vein could have a duration of about 24 h or less [7], so it is necessary further research in order to elucidate the differences between short and long peripheral catheters in terms of feasibility and duration. Likewise, operators should consider this statement in the different clinical situations because the US-guided SPC insertion could be a great tool in the immediate treatment of DVA patients, but it could also be a handicap in long-term intravenous treatments, particularly if the canalized vein is deep.

US-guided method for SPC insertions has shown itself to be more effective in terms of success rates and patient satisfaction when compared to traditional landmark method in adult and pediatric population. Our results have clinical importance because it could benefit patients with special conditions which difficult the venous access or whose venous resources have particular characteristics. Likewise, this method, by reducing the common technique-associated complications, could increase the quality of healthcare and stablish an optimal level of compliance between patients and providers. With a moderate certainty level, the US-guided method is postulated as a valid alternative in comparison with the traditional method in the SPC insertion. A higher success rate, a lower number of unsuccessful attempts and a lower presence of associated complications make the US-guided method the main option in patients with DVA.