4/15/2019 The Easy IJ: Another Option for Difficult IV Access in Stable Patients?

- REBEL EM - Emergency Medicine Blog

APRIL 24, 2017

The Easy IJ: Another Option for Difficult IV

Access in Stable Patients?
Written by Salim Rezaie 
REBEL EM 
Medical Category: Procedures and
Skills 
2 Comments

Background: We have all taken care of patients in whom IV access is di cult due
to a multitude of reasons including repeated prior IV access, advanced vascular
disease and shock. This often creates delays in patient care, increases ED length
of stay, and uses up ED sta that have other patients to care for. Many providers
have resorted to using IO access, particularly in critically ill patients due to speed
of establishing access.  In stable patients, however, this may be a less desirable. 
Ultrasound guidance has been a great addition in these patients.  Ultrasound
guided peripheral IVs and external jugular access would probably be the next
“go to options” in these patients. The authors of this paper evaluate yet another
option: The Easy IJ. 

What They Did:

Multicenter, prospective observational study to evaluate the e cacy and

safety of the easy IJ in stable ED patients with di cult intravenous access

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4/15/2019 The Easy IJ: Another Option for Difficult IV Access in Stable Patients? - REBEL EM - Emergency Medicine Blog

Definition:

Easy Internal Jugular (IJ) Access: Placement of an 18 gauge, 4.8 cm, single-
lumen catheter (the same catheter used for peripheral access) in the IJ with
ultrasound guidance

Materials Required:

Ultrasound machine with high-frequency linear transducer

Chlorhexidine
4.8cm, 18-gauge single-lumen catheter
2 bio-occlusive adherent dressings
Sterile ultrasound gel
Loop catheter extension
Saline ush

Outcomes:

Initial success rate

Mean procedure time
Average pain score
Number of Skin punctures
Complications

Inclusion:

Patients requiring IV access

Failed attempts at establishing peripheral or external jugular vein access
(Including attempts using ultrasound)
Ability to dilate IJ with Valsalva maneuver
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4/15/2019 The Easy IJ: Another Option for Difficult IV Access in Stable Patients? - REBEL EM - Emergency Medicine Blog

Ability to sign written consent

Exclusion:

Hemodynamic instability (HR >150BPM, or MAP <60mmHg)

Untreated pneumothorax
Clinical need for triple-lumen venous catheter

Results:

83 attempts in 74 patients
Median body mass index (BMI): 27kg/m2
Initial success rate: 88% (95% CI 79 – 94)
Mean procedure time: 4.4 min (95% CI 3.8 – 4.9)
Average pain score 3.9 out of 10 (95% CI 3.4 – 4.5)
Number of Skin Punctures:

One: 75%
Two: 19%
Three – Five: 6%

Complications:

Pneumothorax: 0/83 (0%)

Line Infection: 0/83 (0%)
Arterial Puncture: 0/83 (0%)
Loss of Patency: 10/73 (14%) successful lines

Strengths:

Only multicenter study to date to evaluate the Easy IJ

Absence of pneumothorax was con rmed by either CXR (82/83) or CT scan
(1/83)
This is an increasing dilemma in the care of EM patients, and gives a nice
simple solution, that does not take as long as Central venous access or the
discomfort associated with IO in stable awake patients
No major patient-centered adverse events
Time of procedure recorded as time from skin prep to con rmation of IV.
Many studies start time from when the needle hits the skin.

Limitations:
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4/15/2019 The Easy IJ: Another Option for Difficult IV Access in Stable Patients? - REBEL EM - Emergency Medicine Blog

Absence of line infection determined by chart review in 55 out of 83

patients. If patients sought care at other facilities this would underestimate the
incidence of line infection
All attempts at access were performed by physicians with >20 previous
ultrasound guided line placements, may reduce generalizability if provider is
not well versed with ultrasound
Primary outcome not clearly stated
Con dence intervals are wide relative to complication rates for the Easy IJ
Easy IJ catheters were left in for ≤24hrs in this study, therefore infection risk
beyond 24 hours cannot be ascertained from this study
Unstable patients were excluded in this study, therefore cannot draw
conclusions of the Easy IJ in unstable patients

Discussion:

The authors of the paper state that in the limited literature available on this
procedure there are no documented cases of pneumothorax, neck hematoma,
inadvertent arterial placement, line infection, or site infection
The procedure itself takes about 5 minutes which is a signi cantly shorter
time than central line placement

Author Conclusion: “The Easy IJ was inserted successfully in 88% of cases, with
a mean time of 4.4 min. Loss of patency, the only complication, occurred in 14%
of cases.”

Clinical Take Home Point: In stable patients, who have had failed attempts at
establishing peripheral or external jugular vein access, the Easy IJ is a rapid
method of achieving short-term IV access with no major adverse patient
oriented outcomes.

References:

1. Moayedi S et al. Safety and E cacy of the “Easy Internal Jugular (IJ)”: An
Approach to Di cult Intravenous Access. JEM 2016. 51(6): 636 – 42. PMID:
27658558

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

Cite this article as: Salim Rezaie, "The Easy IJ: Another Option for Di cult IV
https://rebelem.com/easy-ij-another-option-difficult-iv-access-stable-patients/ 4/8
4/15/2019 The Easy IJ: Another Option for Difficult IV Access in Stable Patients? - REBEL EM - Emergency Medicine Blog

Access in Stable Patients?", REBEL EM blog, April 24, 2017. Available at:
https://rebelem.com/easy-ij-another-option-di cult-iv-access-stable-patients/.

Bio Latest Posts

Salim Rezaie
Emergency Physician at Greater San Antonio Emergency Physicians
(GSEP)

Creator & Founder of R.E.B.E.L. EM

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TAGS: Easy IJ

2 COMMENTS

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4/15/2019 The Easy IJ: Another Option for Difficult IV Access in Stable Patients? - REBEL EM - Emergency Medicine Blog

MARGUERITE WRIGHT
Posted at 10:18h, 28 April REPLY

Why exclude hemodynamic stability and pneumothorax?

SALIM REZAIE
Posted at 11:14h, 28 April REPLY

Unclear from the paper…but it seems the authors

wanted a quick easy way to get access temporarily
(24hours to resolve/manage. Just my thoughts.
Salim

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