Ultrasound-Guided Pediatric PIVC Placement

Source: Kleidon TM, Schults JA, Royle RH, et al. First-attempt success in ultrasound-guided vs standard peripheral intravenous catheter insertion: the EPIC superiority randomized clinical trial. JAMA Pediatr. 2025;179(30):255-263; doi: 10.1001/jamapediatrics.2024.5581.Investigators from multiple institutions in Queensland, Australia, conducted a randomized clinical trial to assess the effectiveness of using ultrasound guidance (USG) to aid insertion of a peripheral intravenous venous catheter (PIVC) in children. Study participants were children <18 years old being treated at Queensland Children’s Hospital, Brisbane, Australia, who required a PIVC. At enrollment, the perceived complexity of PIVC insertion in study children was categorized as low, medium, or high risk using the difficult intravenous access (DVIA) instrument that includes patient age, visibility of veins, and urgency of the procedure. Participants were randomized to USG or standard PIVC insertion, with randomization stratified by DIVA risk category. PIVC insertion was performed primarily by medical officers and vascular access nurse practitioners. The primary study outcome was successful insertion on the first attempt. Regression analysis was used to calculate the absolute risk difference (RD) for first-attempt success between patients in the USG or standard PIVC insertion, adjusting for DIVA risk group. Subgroup analyses were conducted limited to insertions by medical officers and among participants in different DIVA risk groups. Secondary outcomes included patient pain during the procedure, assessed using standardized scoring systems, and the estimated costs associated with the procedure.Data were analyzed on 164 children, with 84 randomized to USG and 80 to standard PIVC insertion. The median age of patients in the 2 groups was 24 and 30 months, respectively. There was a difference in types of provider performing PIVC insertion; 52.4% of PIVC insertions using USG guidance were performed by medical officers and 44.1% by vascular access nurse practitioners, while 93.8% of standard insertion first attempts were by medical officers. Overall, the first attempt at PIVC insertion was successful in 72 (85.7%) children in the USG group and 32.5% of those randomized to standard insertion (RD, 53.6%; 95% confidence interval [CI], 41.7, 65.4). Among the subgroup of patients in whom a medical officer performed PIVC placement, first-attempt success rates were 75% and 29.3%, respectively (RD, 42.4%; 95% CI, 27.2, 57.5). First-attempt success rates also were significantly higher among patients in each of the 3 DIVA risk groups. Using numeric rating scores, children ≥8 years old judged the pain of PIVC insertion to be significantly less when USG was used compared to standard PIVC insertion. There were no significant differences in pain scores between treatment groups in younger children. Estimated costs of PIVC insertion were significantly higher when USG was used than with standard insertion ($42.19 vs $36.36).The authors conclude that USG to aid PIVC insertion in children was associated with a higher first-attempt success rate than when standard technique was used.Dr Loyal has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Placement of PIVCs in children requires skill, competence, and proficiency. Investigators in the current study found that using USG PIVC placement improves first-time insertion rates across the spectrum of low to high risk of difficulty.Vascular access teams (VATs) are typically staffed by nurses with expertise in vascular access; studies of the proficiency of VATs have shown greater first-attempt and overall IV success.1 However, according to a recent international survey of 242 clinicians, only 25% reported having all venipuncture attempts performed by a VAT.2 Why can’t all children have “access” to these services?VATs may be available only on weekdays.2 Ensuring competency in USG PIVC insertion is time intensive. In a study of pediatric emergency medicine nurses, participants took part in didactic sessions and practice simulations and were expected to successfully insert 10 USG PIVCs. A comprehensive checklist was utilized to measure competency over a 9-month period.3 Maintaining such a workforce requires investment from hospitals.In the current study, standard technique was less costly than USG PIVC insertion, except for staff time in repeated insertion attempts. With the USG PIVC insertion approach, there is the cost of the unit, but frequency and scope of use, local factors, and incorporation of length of use can result in overall savings. Ultimately, we need to decide if the “cost” of pain and anxiety in children undergoing PIVC placement is important enough to factor into investments of services known to have better success.The addition of USG for PIVC insertion results in a high percentage of first-time insertion success in children with different levels of difficulty in obtaining access. (See AAP Grand Rounds. 2022;47[5]:55.)4If