Background: Traditional ultrasound (US) guided intravenous (IV) placement has been taught with the bevel up technique though this practice lacks significant evidence based support as superior to bevel down. Bevel down placement may reduce the likelihood of premature catheter insertion and increase the margin between needle tip and deep vein wall during insertion reducing risk of hematoma. Modern angiocatheter design favors the traditional bevel up orientation so the bevel down technique may not be a viable option. With little prior research comparing these methods the purpose of this study was to compare bevel down versus bevel up placement of US guided IVs.
Methods: A non-randomized, prospective trial was conducted in a Level 1 trauma center with alternating weeks designated to bevel up or bevel down placement. All IVs were placed under US guidance by experienced nurses and physicians in patients who were already receiving US guided IVs as part of their treatment. A post-procedure survey completed by the practitioner measured variables including successful placement, number of attempts, catheter size and length, axis of placement, and patient body mass index (BMI). Frequencies and percentages were generated for categorical variables for the entire population as well as for bevel orientation subgroups and compared using Chi-Square and Fisher’s Exact tests.
Results: 141 IV placements were recorded with 68 bevel down and 73 bevel up. The catheter characteristics, number of successful procedures and number of attempts of the groups were not statistically different. Bevel down approach showed a 84.1% and 11.6% success with the 1st and 2nd attempt compared to 82.2% and 12.3% for the bevel up approach. (OR 1.14, 95% CI [0.47, 2.76]).
Conclusion: In patients receiving US guided peripheral IV, bevel down placement is non-inferior to bevel up in number of attempts to success. Further analysis of data for this study intends to compare effect of BMI, axis of placement, catheter size and length on success rates. These results open the door to future studies with further investigation into success rates of both techniques with potential long term observation of longevity of catheter and subsequent complications from catheter insertion that are frequently not observed while patient is still in the ER.