801302

research-article2018
JVA0010.1177/1129729818801302The Journal of Vascular AccessBrugioni et al.

Techniques in vascular access

JVA The Journal of
Vascular Access

The Journal of Vascular Access

A new device for ultrasound-guided

1­–4
© The Author(s) 2018
Article reuse guidelines:
peripheral venous access sagepub.com/journals-permissions
https://doi.org/10.1177/1129729818801302
DOI: 10.1177/1129729818801302
journals.sagepub.com/home/jva

Lucio Brugioni, Marco Barchetti, Giovanni Tazzioli,

Roberta Gelmini, Massimo Girardis, Marcello Bianchini,
Filippo Schepis, Matteo Nicolini, Giovanni Pinelli, Pietro Martella,
Marco Barozzi, Francesca Mori, Serena Scarabottini,
Andrea Righetti, Mirco Ravazzini and Elisabetta Bertellini

Abstract
Background: In patients with difficult peripheral venous access, alternative techniques require expertise and are
invasive, expensive, and prone to serious adverse events. This brought us to designing a new venous catheter (JLB®
Deltamed, Inc.) for the cannulation of medium and large bore veins; it is echogenic, and available in different lengths (60
/ 70 / 80 mm) and Gauges (14 / 16 / 17 / 18).
Methods: We led a multi-center observational convenience sampling study to evaluate safety and effectiveness of JLB.
Data was collected from June 2015 to February 2018. Inclusion criteria were age ⩾ 18, difficulty in obtaining superficial
venous access in the veins of the arm, need for rapid infusion, or patient’s preference.
Results: We enrolled 1000 patients, mean age 66.8 years. In total, 951 (95.1%) had the device placed in internal jugular
vein, 28 in basilic or cephalic vein, 15 in femoral vein, 5 in axillary vein (infra-clavicular tract), and 1 in the external jugular
vein. The procedure was performed by attending physicians or emergency medicine residents under US guidance.
Mean procedure time (from disinfection to securing) was approximately 240 s. Mean attempts number was 1.21. Early
complications (<24 h) occurred in four patients, consisting in two soft tissue hematoma, one phlebitis, and one atrial
tachyarrhythmia. No major complications (such as pneumothorax) were reported. Mean indwelling time was 168 h
(7 days); early occlusion/dislocation occurred in four cases.
Conclusion: According to preliminary data, the application of JLB appears to be safe, cost-effective, and rapid to place
bedside.

Keywords
Catheter, internal jugular vein, over the needle, emergency, peripheral, safety, long cannula

Date received: 22 March 2018; accepted: 22 August 2018

Background
A rapid and safe peripheral venous access is always man-
datory in emergency medical care, for administration of
fluids, drugs, and contrast agents. Successful achievement
of a peripheral venous access can be affected by various
factors related to the patient1 (deficiency or absence of pal-
pable/visible superficial veins, diabetes mellitus, sickle
cell disease, obesity, edema, vascular abnormalities, burn
injuries, intravenous drug abuse, sex, and age), but also to
the operator (practical skills, experience) and the materials
and methods available (type of catheter, imaging by ultra-
sound or by near infrared technology (NIR)).
Multiple unsuccessful attempts to cannulate a periph-
eral vein are not uncommon in the emergency room and
correlate with negative effects both on the patient (stress-
ful experience and associated additional risks) and on the
clinician.2
Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
Corresponding author:
Lucio Brugioni, Azienda Ospedaliero-Universitaria Policlinico - ZIP
code 41124 - Modena, Italy.
Email: luciob2362@gmail.com
2 The Journal of Vascular Access 00(0)
Time spent in providing venous accesses may be criti-
cal in the emergency department. Failure to obtain a
peripheral intravenous access can delay diagnosis and
treatment and may expose patients to risks associated with
central venous cannulation.3
In patients with difficult venous access (DIVA2), there
are several alternative options:
•• “Blind” insertion of a short cannula in the external
jugular vein (EJV);4
•• Cannulation of a superficial vein of the upper
or lower extremity, visualizing it by NIR,
although its efficacy is not fully supported by the
literature.5
•• Ultrasound-guided insertion of a peripheral cannula
(short cannula, long cannula, or midline catheter) in
a deep vein of the arm (i.e. basilic, brachial, or
cephalic).
•• Ultrasound-guided insertion of a central venous
catheter either in the supra/infra-clavicular area
(centrally inserted central catheter (CICC)), a deep
vein of the arm (peripherally inserted central cath-
eter (PICC)), or in the femoral vein (femorally
inserted central catheter (FICC)).
•• Intra-osseous access.6
Although many of these options may have disadvantages,
cannulas in the EJV are quite unstable and unreliable;
peripheral insertion, regardless the device used, is inap-
propriate for infusion of fluid with osmolality >500 or
<5 mOsm/L, or with pH >9, or if an intravenous therapy
is planned to last more than 2 weeks;7 central venous cath-
eters might be an option if the therapy is planned to last
more than 6 days,8 but PICCs, CICCs, and FICCs may not
be cost-effective;9 near infrared devices are not always
available.
As long as there is no specific indication for a central
venous catheter (such as need for hemodynamic monitor-
ing, irritant/vesicant infusions which require a central
venous access), the best option is to place a peripheral can-
nula by ultrasound guidance.10,11 Evidence suggests that
ultrasound guidance can increase the likelyhood of suc-
cessful peripheral venous cannulation; thus, US-guided
insertion of long peripheral cannulas (6–15 cm) might be
considered an appropriate alternative to short cannulas (<
6cm) in critically ill patients owning poor superficial
venous pool.
In this study, we report our experience with a new type
of long peripheral cannula, specifically designed to be
inserted by ultrasound guidance in different venous sites,
allowing high flow rates infusion. Its features make it the
ideal peripheral device in unstable patients who require
immediate access in emergency, particularly if character-
ized by DIVA.
Methods
The device
The device (nicknamed JLB) is a single-lumen polyure-
thane power injectable over-the-needle catheter available
in different lengths 60, 70, and 80 mm and calibers (14, 16,
17, and 18 Gauge). Depending on the length and caliber, it
allows administration of fluids and drugs with flow rates
ranging from 74 to 283 mL/min. Maximum dwell time is
defined as 30 days.
It allows administration of an osmolarity of 900 mmol/L
as specified for standard peripheral and midline devices.12
The extended length makes it more stable and less prone to
dislocation if compared to standard short cannulas.
JLB has recently been implemented with the introduc-
tion of a protecting system for the needle (safe box) which
grants the reduction of biological risk for the clinician dur-
ing the procedure. Furthermore, a blood-stop valve has
been added in order to prevent air aspiration and/or blood
exit during the time interval between vein cannulation and
connection to the infusion tubing.
The technique of insertion
The device is designed to be inserted by ultrasound, theo-
retically in any deep vein of the arm or of the supra/infra-
clavicular area. Since the “Easy IJ” was already pioneered
by Moyaedi et al.13 most of our experience was focused on
the internal jugular vein (IJV). Other sites included the
brachial, cephalic, and basilic veins (in the upper limb),
the axillary vein (infra-clavicular area), and the femoral
vein. Ultrasound (usually provided with a linear probe
10–14 MHz) is also used to assess the best vein for can-
nulation in terms of caliber and location.
Catheter gauge must not exceed ⅓ of the measured vein
caliber;14 the chosen catheter length should allow at least
2 cm of indwell cannula, taking into account that the seg-
ment from skin to the center of the vessel is approximately
1.5 times the vein depth (given the 45° angle of insertion).
Once the site is chosen, standard aseptic technique is used:
hand hygiene, sterile gloves, skin preparation with 2%
chlorhexidine, sterile cover for the probe, wide sterile
field. Ultrasound-guided venipuncture can be performed
visualizing the vessel in short or long axis.
The needle is inserted with the chosen technique (out-
of-plane or in-plane) with a 45° angle; correct positioning
is assumed after direct US visualization of the needle
inside the vessel and further confirmed as blood is aspi-
rated into the syringe. From this phase on, the technique do
not further require US-guidance. The cannula is then com-
pletely slid into the vessel while firmly holding the needle
with the other hand.
The catheter is flushed and secured to the skin using
transparent membrane dressing. After cannulation of IJV
Brugioni et al. 3
and axillary vein, ultrasound is also used to rule out iatro-
genic pneumothorax.
The study
We designed a multi-center observational prospective
study. The primary endpoint was to evaluate the feasibility
and safety (detection of procedural and device-related
complication) of achieving a peripheral venous access in
acute ill patients using our new device. The secondary end-
point was to evaluate the overall performance of the
device, registering all major and minor complications as
well as the mean dwell time. We enrolled acute ill patients
with DIVA and/or need for rapid infusion (e.g. shocked
patients) who were admitted to three different Emergency
Medicine Units, two Intensive Care Units, and one
Gastroenterology ward. Inclusion criteria were as follows:
impossibility or difficulty to obtain a peripheral venous
access, age  > 5 years old, PLTs > 50.000/mmc, normal
coagulation profile (prothrombin time and activated partial
thromboplastin time). The procedure was performed by
attending physicians or Emergency Medicine residents,
with different degrees of expertise in US-guided venous
cannulation; all of them underwent a short period of train-
ing with the device, before starting the study.
Data were collected from the medical chart for each
patient enrolled: patient’s personal and anthropometric
data (age, sex, body weight, body mass index), medical
data (diagnosis at admission, history of previous venous
access, current indication to peripheral cannula), size and
location of the insertion (IJV, deep upper-arm veins, axil-
lary vein), operator’s data (credentials, previous experi-
ence in ultrasound-guided venous cannulation), time of
procedure, early (⩽ 24 h) and late (> 24 h) complications,
total dwell time and reason of removal.
Complications were further classified into minor
(hemodynamically stable arrhythmias—soft tissue
hematomas—phlebitis15) and major (life-threatening
arrhythmias—pneumothorax—major bleedings—venous
thrombosis). Failure was defined as a total of three unsuc-
cessful attempts, performed by at least two different
physicians.
Results
Since June 2015 to February 2018, we enrolled 1000 patients
with deficiency or absence of visible/palpable superficial
veins of arms and legs, who all need peripheral venous access,
often in an emergency setting. Mean age was 66.8 years. In
most patients (951 / 1000), the device was inserted in the IJV;
in 28 patients, JLB in the basilic or cephalic vein; in 15
patients in the femoral vein, in 5 patients in the axillary vein
(infra-clavicular tract) and in 1 patient was in the EJV.
Mean procedural time (from skin preparation to cathe-
ter securement) was approximately 4 min. Mean number
of attempts before successful cannulation was 1.21. The
recorded procedural time refers to the successful attempt.
The device was successfully inserted in 99.2% of
patients (quite higher than the 88% achieved by the “Easy
IJ” experience), while six procedures failed. We found no
correlation between patients’ age and body mass index
(BMI) and success rate.
Early (< 24 h) complications occurred in four patients
(two local hematoma, one phlebitis, and one episode of
atrial tachyarrhythmia). No pneumothorax occurred and
no major early complications were reported.
As expected dislocation rate (5/1000) was significantly
lower than what observed with short peripheral cannulas.16
The median dwell time of the device was 7 days.
Discussion
Obtaining adequate vascular access is sometimes trouble-
some especially in an emergency setting. All of our patients
were DIVA patients, sharing one of more of these features:
superficial veins of the arm not palpable and/or visible,
history of difficult peripheral intravenous cannulation, an
unplanned indication for surgery, small vein diameter
(<2 mm). In these patients, our new device was success-
fully inserted in 99.2% of patients (six procedures failed),
with minimal and negligible complications (two soft tissue
hematoma, one phlebitis and one atrial tachyarrhythmia,
no pneumothorax).
There are no major studies investigating the entire time
interval between skin prep and line connection in the
adults. We can only assume that 4 min could be a reasona-
ble result in an emergency setting.
This preliminary data suggests that JLB insertion is safe
and rapid, though requiring ultrasound skills. Although
ultrasound-guided techniques have largely proven to
improve success rate in vein catheterization,17 many physi-
cians (depending on age, specialty, different trainings, etc.)
still need more confidence with US, thus probably affecting
the efficacy of US-guided techniques. Continuous quality
training is needed especially for emergency clinicians.18
If compared to other needle-cannulas, this new device
has the advantage of being longer, virtually reducing risk
of dislocation. If compared to other long peripheral can-
nulas, it has the advantage of being simpler to use, since it
adopts the “cannula-over-needle” technique and not the
Seldinger technique.
As for other long peripheral cannulas, JLB can be used
in emergency as a temporary venous access, so to allow
insertion of proper central venous access (CICC or PICC)
subsequently, in an elective setting. After establishing a
venous access for emergency delivery of fluids or drugs, if
the patient has a proper indication for a central venous
catheter (need for hemodynamic monitoring, need for
repeated blood sampling, infusion of parenteral nutrition,
or irritant/vesicant drugs), JLB can be removed or—if
4 The Journal of Vascular Access 00(0)
inserted in IJV—can be replaced over guide wire with an
appropriate central venous catheter.
The main disadvantage of JBL is that when inserted in
the IJV or in the axillary vein, it might be confused with a
central venous catheter and used as such. This event did
not occur in our experience; nonetheless, physicians and
nurses must remember to label the device in order to avoid
inappropriate use (e.g. with irritant / vesicant drugs, which
require a central venous catheter).
Conclusion
The rapid and safe catheterization of a peripheral vein
plays a major role in managing clinical emergencies, espe-
cially in DIVA patients. The JLB appears to be safe, easy,
and rapid to insert at bedside. It is a cost-effective solution
in unstable patients, who require immediate access in
emergency, but most likely also in stable patients with
DIVA, when a central venous catheter is not necessary.
JLB can be inserted in different deep veins (internal jugu-
lar, axillary, basilic, brachial, and cephalic) and may stay
in situ for days or weeks, long enough to deliver the best
treatment to the patient.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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