Have you ever performed a procedure, when suddenly, you are overcome by a sinking feeling that something just is not right? A mix of fear, guilt, and anger: Fear that you endangered a patient, guilt that you missed an important step in the procedure, and anger at yourself for being careless. The oath we take as physicians echoes loudly: Primum non nocere. First, do no harm.
Ultrasound-Guided Peripheral IV
Consider the ultrasound-guided peripheral IV (USGPIV) procedure, which is performed an estimated 12 million times annually in North America.1 Numerous authors, organizations, and societies have published guidelines and safety recommendations for USGPIVs (Table 1).
|2010||Adhikari et al.2||Ultrasound-guided IV lines were inserted using bacteriostatic lubricant (Surgilube; Altana, Inc, Melville, NY) and a nonsterile glove …Both traditional and ultrasound-guided approaches had low infection rates, suggesting that there is no increased risk of infection with ultrasound guidance for peripheral IV lines.|
|2017||Gottlieb et al.1||Standard PIV placement and cleaning procedures should be followed. There is limited evidence with respect to the benefit of probe covers and adhesive barriers. Manufacturer recommendations should be followed when using adhesive barriers.|
|2017||Nyhsen et al. and the European Society of Radiology Ultrasound Working Group3||High level disinfection is mandatory for… all interventions. Dedicated transducer covers must be used for … all interventions.|
|2018||American Institute of Ultrasound in Medicine (AIUM)4||Prudent use of ultrasound includes guidance for vascular access. In this case, use of sterile gel and single-use protective covers [including condoms] justify subsequent LLD [Low Level Disinfection], analogous to institutional healthcare guidelines for use of gloves and LLD hand-disinfection for medical personnel.|
|2018||American College of Emergency Physicians (ACEP)5||Probes used externally for percutaneous procedures should be covered with single-use protective covers and sterile gel applied. They should subsequently be cleaned using low-level disinfection.|
|2018||Carrico et al.6||This study, which included 305 (8%) Emergency Medicine practitioners, indicated that the adherence to probe covers or HLD was 22% for U/S-guided peripheral IV lines placed by all practitioners.|
|Table 1: Evidence and Guideline Summary|
All appear to recommend a probe cover of some sort. Many also recommend sterile gel for the procedure.
What is the evidence for probe covers?
This is less likely about giving the patient, on whom you are performing the USGPIV, an infection. Rather, it is more about decreasing the spread of bloodborne pathogens to the next set of patients.7,8 The Spaulding Classification for disinfection and sterilization of medical devices (Table 2) is helpful here. Created in 1957, the FDA continues to utilizes this classification system today and it is the standard to which we are held.9
|Degree of contact||Class||Processing||Example|
|Sterile tissue or vascular system||Critical||Sterilization||Surgical instruments, central lines|
|Non-intact skin, mucus membranes||Semi-Critical||High Level Disinfection (HLD) or Sterile Probe Cover with Sterile Gel||Probe for U/S-guided peripheral IV, nerve block, thoracentesis, paracentesis|
|Intact skin||Non-Critical||Low Level Disinfection (LLD)||Transabdominal diagnostic U/S|
|Table 2: Spaulding Classification for disinfection and sterilization 9|
The sanitation wipes most institutions use are intermediate level disinfection and do not meet the criteria for High Level Disinfection (HLD).10 Therefore, wiping the probe before and after a procedure may not be enough. Some may argue that there is no solid evidence that this actually prevents infections or that we are causing infections. While that may be true, it is difficult to stand behind a lack of evidence, when there are clear guidelines in place.
Carrico et al. found that only 22% of providers placing USGPIVs used any barrier.6 In December 2017, we posted a Twitter poll to which 397 users responded. 41% of respondents did not use any probe cover at all. The poll had 6,178 impressions, or total views, after 4 days. Half of those who retweeted were physicians. Not exactly Level I evidence, but it gives us a clue that we are likely not using probe covers.
— Dan Mirsch (@DanMirsch) December 12, 2017
Both the American Institute for Ultrasound in Medicine (AIUM) and the American College of Emergency Physicians (ACEP) recommend a single use probe cover with sterile gel when placing USGPIVs. Neither specifies if that probe cover should be sterile. Both of these organizations discuss the pore size of certain barriers indicating that < 30 nm helps prevent the passage bloodborne pathogens such as HPV, HIV, and Hepatitis C. This includes sterile adhesive films (e.g. Tegaderm-like materials) and sterile probe covers. Condoms are an option, but have pore sizes >110 nm, which are larger than recommended.11
Conclusion: Advocating for Change
It thus appears that the best way to protect our patients and ourselves while performing the USGPIV is:
- Use a sterile adhesive barrier (such as Tegaderm) or a sterile probe cover.
- Use sterile gel.
- Perform the procedure using gloves (no specific recommendation for sterile gloves).
This is the minimum protocol that is adherent to the guidelines.
It’s time to clean up our act.