Wayne A. Satz

Ultrasound-Guided Peripheral Venous Access vs. the External Jugular Vein as the Initial Approach to the Patient with Difficult Vascular Access

BACKGROUND Traditionally, Emergency Physicians (EPs) have used the external jugular (EJ) vein to gain vascular access in patients who have failed nursing attempts at peripheral access. Recently, some EPs have used ultrasound (USIV) to gain peripheral access. STUDY OBJECTIVE This study seeks to determine which initial approach by EPs would lead to greater success. METHODS This was a prospective, randomized study of all adult patients who presented to the Emergency Department (ED) between June and December 2007. Inclusion criteria were failed nursing attempts at peripheral access (at least three). EPs were 2(nd)- or 3(rd)-year residents who had previously performed more than five each of EJs and USIVs. Patients were randomized into either an initial EJ or USIV approach. RESULTS Sixty patients were enrolled, 32 in the ultrasound group, 28 in the EJ group. Fifteen different EPs performed access. Initial Success: USIV 84% (95% confidence interval [CI] 68-93%) vs. EJ 50% (95% CI 33-67%), p = 0.006. Success if EJ visible: USIV 84% vs. EJ 66% (p = 0.18). Overall success, including data from the crossover pathway: a total of 41 lines were successfully placed by ultrasound out of 46 attempts (89%) vs. 18 out of 33 for EJ (55%), p = 0.001. In total, 59/60 patients (98%) had a peripheral i.v. successfully placed. The percentage of functioning lines when the patient left the ED was: USIV 89% (95% CI 72-96%) vs. EJ 93% (95% CI 68-98%), p = 0.88. CONCLUSION As an initial approach to all patients with difficult venous access, ultrasound-guided peripheral lines are superior to the EJ approach. However if the EJ was visible, there was no difference in success among the initial approaches. Both techniques, when used together, could achieve peripheral vascular access in 98% of difficult access patients.

The effects of a commercially available weight loss program among obese patients with type 2 diabetes: a randomized study.

Abstract The purpose of this study was to assess the effects of a commercially available weight loss program on weight and glycemic control among obese patients with type 2 diabetes. Participants included 69 patients (49 females, 20 males) with type 2 diabetes who had a mean ± SD age of 52.2 ± 9.5 years, a body mass index of 39.0 ± 6.2 kg/m2, and hemoglobin A1c (HbA1c) of 7.5 ± 1.6%. Over half (52.2%) of the participants were African American. Participants were randomly assigned to: 1) a portion-controlled diet (NutriSystem® D™) (PCD) or 2) a diabetes support and education (DSE) program. After the initial 3 months, the PCD group continued on the PCD for the remaining 3 months, and the DSE group crossed over to PCD for the remaining 3 months. The primary comparison for this study was at 3 months. At 3 months, the PCD group lost significantly more weight (7.1 ± 4%) than the DSE group (0.4 ± 2.3%) (P < 0.0001). From 3 to 6 months the change in weight for both groups was statistically significant. After 3 months, the PCD group had greater reductions in HbA1c than the DSE group (−0.88 ± 1.1 vs 0.03 ± 1.09; P < 0.001). From 3 to 6 months the PCD group had no further change in HbA1c, while the DSE group showed a significant reduction. These data suggest that obese patients with type 2 diabetes will experience significant improvements in weight, glycemic control, and cardiovascular disease risk factors after the use of a commercially available weight management program.

COMPARISON OF ULTRASOUND-GUIDED AND STANDARD LANDMARK TECHNIQUES FOR KNEE ARTHROCENTESIS

BACKGROUND Ultrasound is a useful adjunct to many Emergency Department (ED) procedures. Arthrocentesis is typically performed using a landmark technique but ultrasound may provide an opportunity to improve arthrocentesis performance. OBJECTIVE To assess the success of emergency physicians performing landmark (LM) vs. ultrasound (US)-guided knee arthrocentesis techniques. METHODS This was a prospective, randomized, controlled study of patients requiring knee arthrocentesis who presented to one urban university ED and two community EDs between June 2005 and February 2007. RESULTS There were 66 patients enrolled (39 US-guided, 27 LM). Among all users, there was no difference in arthrocentesis success (US 37/39 vs. LM 25/27); p = 1.0. SECONDARY ENDPOINTS: 1) Patients reported less pain with ultrasound; US-guided 3.71 (95% confidence interval [CI] 2.61-4.80) cm vs. LM 5.19 (95% CI 3.94-6.45) cm; p = 0.02. 2) Providers felt the US-guided technique was easier to perform than LM; 1.67 units on 5-point scale (95% CI 1.37-1.97) vs. 2.11 (95% CI 1.79-2.42) units; p = 0.02. 3) The total procedure time was shorter with the US-guided technique; 10.58 (95% CI 7.36-13.80) min vs. LM 13.37 (95% CI 9.83-16.92) min; p = 0.05. 4) There was no difference in the amount of fluid obtained between techniques; US-guided 45.33 (95% CI 35.45-55.21) mL vs. LM 34.7 (95% CI 26.09-43.32) mL; p = 0.17. CONCLUSION US-guided knee arthrocentesis technique does not improve overall success of obtaining joint fluid aspirate vs. the standard LM and palpation technique. An US-guided approach does not result in more pain for the patient, takes no additional time to perform and, at least for novice physicians, leads to more fluid aspiration and greater novice provider confidence with the procedure. Further studies with more participants and standardization of anesthetic quantity are required to validate these findings.

Randomized Trial Comparing Intraoral Ultrasound to Landmark-based Needle Aspiration in Patients with Suspected Peritonsillar Abscess

OBJECTIVES Traditionally, emergency physicians (EPs) have used anatomic landmark-based needle aspiration to drain peritonsillar abscesses (PTAs). If this failed, an imaging study and/or consultation with another service to perform the drainage is obtained. Recently, some EPs have used ultrasound (US) to guide PTA drainage. This study seeks to determine which initial approach leads to greater successful drainage. The primary objective of this study was to compare the diagnostic accuracy of EPs for detecting PTA or peritonsillar cellulitis (PTC) using either intraoral US or initial needle aspiration after visual inspection (the landmark technique [LM]). Secondary objectives included the successful aspiration of purulent material in those patients with a PTA in each arm, the use of computed tomography (CT) scanning in each arm, and the otolaryngology (ENT) consultation rate in each arm. METHODS This was a prospective, randomized, controlled clinical trial of a convenience sample of adult patients who presented to a single, large, urban university hospital. Patients were enrolled if they presented with a constellation of signs and symptoms that were judged to be a PTA. These patients were randomized to receive intraoral US or to undergo LM drainage. The US was performed using an 8-5 MHz intracavitary transducer immediately prior to the procedure. The probe was then withdrawn and the provider who did the US also performed the needle aspiration. The LM was performed using visual landmarks in a superior to inferior approach until pus was obtained or at least two sticks were performed. Anesthesia was standardized. Patients returned for follow-up in 2 days where a final diagnosis was rendered. RESULTS   There were 28 patients enrolled, with 14 in each arm. US established the correct diagnosis more often than LM [(100%, 95% confidence interval [CI] = 75% to 100% vs. 64%, 95% CI = 39% to 84%; p = 0.04)]. US also led to more successful aspiration of purulent material by the EP than LM in patients with PTA [(100%, 95% CI =63% to 100% vs. 50%, 95% CI = 24% to 76%; p = 0.04)]. The ENT consult rate was 7% (95% CI = 0% to 34%) for US versus 50% (95% CI = 27% to 73%) for LM (p = 0.03). The CT usage rate was 0% for US versus 35% for LM (p = 0.04). CONCLUSIONS   An initial intraoral US performed by EPs can reliably diagnose PTC and PTA. Additionally, using intraoral US to assist in the drainage of PTAs with needle aspiration leads to greater success compared to the traditional method of LM relying on physical exam alone.