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Senevirathne SAMDRU, Nimana HKV, Pirannavan R, Fernando P, Salvin KA, Liyanage UA, Malalasekera AP, Mathangasinghe Y, Anthony DJ. Anatomic description of the distal great saphenous vein to facilitate peripheral venous access during resuscitation: a cadaveric study. Patient Saf Surg 2023; 17:2. [PMID: 36691095 PMCID: PMC9872368 DOI: 10.1186/s13037-023-00351-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/02/2023] [Indexed: 01/24/2023] Open
Abstract
The distal great saphenous vein is a popular site for venous access by means of percutaneous cannulation or venous cutdown in a hemodynamically unstable patient. The aim of this study was to precisely define the surface anatomy and dimensions of the distal part of the great saphenous vein to facilitate the aforementioned procedures. Cross-sectional anatomy of the distal saphenous vein was studied in 24 cadaveric ankles sectioned at a horizontal plane across the most prominent points of the medial and lateral malleoli. The curvilinear distance from the most prominent point of the medial malleolus to the center of the saphenous vein, its widest collapsed diameter and skin depth were obtained. The great saphenous vein was located at a mean distance of 24.4 ± 7.9 mm anterior to the medial malleolus. The mean widest collapsed diameter was 3.8 ± 1.5 mm. The mean distance from the skin surface to the vein was 4.1 ± 1.2 mm. These measurements could be used to locate the saphenous vein accurately, particularly in hemodynamically unstable patients with visually indiscernible veins.
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Affiliation(s)
- Samitha A. M. D. R. U. Senevirathne
- grid.8065.b0000000121828067Department of Anatomy, Genetics and Biomedical Informatics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Hesitha K. V. Nimana
- grid.8065.b0000000121828067Department of Anatomy, Genetics and Biomedical Informatics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Ratnasingam Pirannavan
- grid.8065.b0000000121828067Department of Anatomy, Genetics and Biomedical Informatics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Poorni Fernando
- grid.8065.b0000000121828067Department of Anatomy, Genetics and Biomedical Informatics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Karahin A. Salvin
- grid.45202.310000 0000 8631 5388Department of Anatomy, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Udari A. Liyanage
- grid.8065.b0000000121828067Department of Anatomy, Genetics and Biomedical Informatics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Ajith P. Malalasekera
- grid.8065.b0000000121828067Department of Anatomy, Genetics and Biomedical Informatics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Yasith Mathangasinghe
- grid.8065.b0000000121828067Department of Anatomy, Genetics and Biomedical Informatics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Dimonge J. Anthony
- grid.8065.b0000000121828067Department of Anatomy, Genetics and Biomedical Informatics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Drozd A, Wolska M, Szarpak L. Intraosseous vascular access in emergency and trauma settings: a comparison of the most universally used intraosseous devices. Expert Rev Med Devices 2021; 18:855-864. [PMID: 34325586 DOI: 10.1080/17434440.2021.1962287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Obtaining successful vascular access is an essential component of the emergency and trauma setting. The modern practice of medicine advocates IO access for patients in a critical condition, especially when IV access is problematic or unobtainable. Various medical devices allowing for IO access have been coined and used in the management of critical patients.Areas covered: This study aims to review the literature regarding different intraosseous devices used to obtain vascular access (Bone Injection Gun (BIG), EZ-IO, NIO, Jamshidi, and First Access for Shock and Trauma (FAST-1) and discuss their clinical and experimental role in the emergency and trauma settings.Expert opinion: The development of medical technology contributes to an increasing number of intraosseous devices facilitating vascular access in challenging scenarios, including cardiopulmonary resuscitation, anaphylactic, or hypovolemic shock. Each of these devices provides an effective route for fluid resuscitation, drug delivery, laboratory evaluation, and shortening the timeframe for established vascular access, provided that the person obtaining the access is acquainted with the use of the device.
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Affiliation(s)
- Anna Drozd
- Outcomes Research Unit, Polish Society of Disaster Medicine, Warsaw, Poland
| | - Marta Wolska
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Center for Preclinical Research and Technology CEPT, Warsaw, Poland
| | - Lukasz Szarpak
- Outcomes Research Unit, Polish Society of Disaster Medicine, Warsaw, Poland.,Institute of Outcomes Research, Maria Sklodowska-Curie Medical Academy in Warsaw, Warsaw, Poland.,Outcomes Research Unit, Maria Sklodowska-Curie Bialystok Oncology Center, Bialystok, Poland
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Ferry T, Lodise TP, Gallagher JC, Forestier E, Goutelle S, Tam VH, Mohr JF, Roubaud-Baudron C. Outpatient Subcutaneous Antimicrobial Therapy (OSCAT) as a Measure to Improve the Quality and Efficiency of Healthcare Delivery for Patients With Serious Bacterial Infections. Front Med (Lausanne) 2020; 7:585658. [PMID: 33425938 PMCID: PMC7785854 DOI: 10.3389/fmed.2020.585658] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/24/2020] [Indexed: 11/13/2022] Open
Abstract
Since the 1970s, outpatient parenteral antimicrobial therapy (OPAT) has been a viable option for patients who require intravenous antibiotics when hospitalization is not warranted. While the benefits of OPAT as a measure to improve the efficiency of healthcare delivery (i.e., reduced hospital days) and patient satisfaction are well-documented, OPAT is associated with a number of challenges, including line complications and reliance on daily healthcare interactions in some cases at home or in a clinic. To minimize the continued need for intensive healthcare services in the outpatient setting, there is trend toward patients self-administering antibiotics at home without the presence of healthcare workers, after adequate training. In most cases, patients administer the antibiotics through an established intravenous catheter. While this OPAT practice is becoming more accepted as a standard of care, the potential for line complications still exists. Outpatient subcutaneous antimicrobial therapy (OSCAT) has become an increasingly accepted alternative route of administration of antibiotics to IV by French infectious diseases physicians and geriatricians; however, currently, no antibiotics are approved to be administered subcutaneously. Antibiotics with longer half-lives that are completely absorbed and have a favorable local tolerability profile are ideal candidates for OSCAT and have the potential to maximize the quality and efficiency of parenteral antibiotic delivery in the outpatient setting. The increasing development of wearable, on-body subcutaneous delivery systems make OSCAT even more viable as they increase patient independence while avoiding line complications and potentially removing the need for direct healthcare professional observation.
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Affiliation(s)
- Tristan Ferry
- Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY, United States
| | - Jason C Gallagher
- Department of Pharmacy Practice, Temple University, Philadelphia, PA, United States
| | - Emmanuel Forestier
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier de Métropole Savoie, Chambéry, France
| | - Sylvain Goutelle
- Pharmacie hospitalière, Hospices Civils de Lyon, Groupement Hospitalier Nord, Lyon, France.,Univ Lyon, Université Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France
| | - Vincent H Tam
- Department of Pharmacy Practice and Translational Research, University of Houston, Houston, TX, United States
| | - John F Mohr
- scPharmaceuticals, Burlington, MA, United States
| | - Claire Roubaud-Baudron
- CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France.,Univ. Bordeaux, INSERM UMR 1053 BaRITOn, Bordeaux, France
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Broadhurst D, Cooke M, Sriram D, Gray B. Subcutaneous hydration and medications infusions (effectiveness, safety, acceptability): A systematic review of systematic reviews. PLoS One 2020; 15:e0237572. [PMID: 32833979 PMCID: PMC7446806 DOI: 10.1371/journal.pone.0237572] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 07/29/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To synthesize the current evidence for subcutaneous hydration and medication infusions from systematic reviews and to assess their methodological quality. INTRODUCTION Peripheral intravascular cannula/catheter insertion is a common invasive procedure for administering fluids and medications. Venous depletion is a growing concern for several patient populations. Subcutaneous access for the administration of isotonic solutions and medications is an alternative; however, vascular access assessment and planning guidelines rarely consider this route. METHODS Systematic review of systematic reviews (PROSPERO CRD42018046504). We searched 6 databases published in English language from 1990 to June 2020, identifying subcutaneous infusions an alternate route for fluids or medication. Methodological quality was evaluated using AMSTAR 2 criteria and data for mechanisms of infusion and outcomes related to effectiveness, safety, efficiency and acceptability extracted. The Johanna Briggs Institute's grades of recommendation informed the strength of recommendation. RESULTS The search yielded 1042 potential systematic reviews; 922 were excluded through abstract and duplicate screen. Of the remaining articles, 94 were excluded, and 26 were included. Overall, evidence is strong for recommending subcutaneous hydration infusions for older adults, weak for pediatric patients and inconclusive for palliative patients. There is strong evidence for 10 medications; weak evidence supporting 28 medications; however, there are eight medications with inconclusive evidence to make a recommendation and four medications not appropriate for subcutaneous delivery. CONCLUSION Subcutaneous access should be considered alongside intravenous therapy for hydration in older adults, and several medications. There are additional benefits in terms of ease of use and cost-effectiveness of this mode. Inclusion of subcutaneous access in clinical guidelines may promote uptake of this route to help preserve vessel health of vulnerable patients. Further high-quality research is needed to inform subcutaneous infusion therapy in a variety of populations (including pediatrics and palliative care) and medications and clarifying the mechanism of delivery.
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Affiliation(s)
- Daphne Broadhurst
- Alliance for Vascular Access Teaching and Research (AVATAR) group, Menzies Health Institute Queensland, Queensland, Australia
- Infusion Excellence Consulting, Ottawa, Canada
| | - Marie Cooke
- Alliance for Vascular Access Teaching and Research (AVATAR) group, Menzies Health Institute Queensland, Queensland, Australia
- School of Nursing and Midwifery, Nathan Campus, Griffith University, Queensland, Australia
| | - Deepa Sriram
- Alliance for Vascular Access Teaching and Research (AVATAR) group, Menzies Health Institute Queensland, Queensland, Australia
| | - Brenda Gray
- Clinical Pharmacy Partners, Tampa, Florida, United States of America
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Lamontagne F, Fowler RA, Adhikari NK, Murthy S, Brett-Major DM, Jacobs M, Uyeki TM, Vallenas C, Norris SL, Fischer WA, Fletcher TE, Levine AC, Reed P, Bausch DG, Gove S, Hall A, Shepherd S, Siemieniuk RA, Lamah MC, Kamara R, Nakyeyune P, Soka MJ, Edwin A, Hazzan AA, Jacob ST, Elkarsany MM, Adachi T, Benhadj L, Clément C, Crozier I, Garcia A, Hoffman SJ, Guyatt GH. Evidence-based guidelines for supportive care of patients with Ebola virus disease. Lancet 2018; 391:700-708. [PMID: 29054555 PMCID: PMC6636325 DOI: 10.1016/s0140-6736(17)31795-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/25/2017] [Accepted: 06/04/2017] [Indexed: 01/02/2023]
Abstract
The 2013-16 Ebola virus disease outbreak in west Africa was associated with unprecedented challenges in the provision of care to patients with Ebola virus disease, including absence of pre-existing isolation and treatment facilities, patients' reluctance to present for medical care, and limitations in the provision of supportive medical care. Case fatality rates in west Africa were initially greater than 70%, but decreased with improvements in supportive care. To inform optimal care in a future outbreak of Ebola virus disease, we employed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to develop evidence-based guidelines for the delivery of supportive care to patients admitted to Ebola treatment units. Key recommendations include administration of oral and, as necessary, intravenous hydration; systematic monitoring of vital signs and volume status; availability of key biochemical testing; adequate staffing ratios; and availability of analgesics, including opioids, for pain relief.
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Affiliation(s)
- François Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada; Centre de recherche du CHUS de Sherbrooke, Sherbrooke, QC, Canada.
| | - Robert A Fowler
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Neill K Adhikari
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Srinivas Murthy
- Department of Paediatrics, University of British Columbia, Vancouver, BC, Canada
| | - David M Brett-Major
- US Military HIV Research Program, Henry M. Jackson Foundation, Bethesda, MD, USA
| | | | - Timothy M Uyeki
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - William A Fischer
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Adam C Levine
- Ebola Research Team, International Medical Corps, Washington, DC, USA; Department of Emergency Medicine, Warren Alpert Medical School, Providence, RI, USA
| | - Paul Reed
- Center for Global Health Engagement-Uniformed Services University of the Health Sciences, Bethesda, MD, USA; US Public Health Service, Rockville, MD, USA
| | - Daniel G Bausch
- World Health Organization, Geneva, Switzerland; Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Sandy Gove
- Integrated Management of Adolescent and Adult Illness-Integrated Management of Childhood Illness) Alliance, San Francisco, CA, USA
| | | | - Susan Shepherd
- Alliance for International Medical Action, Dakar, Senegal
| | - Reed A Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Rashida Kamara
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | | | - Ama Edwin
- Palliative Care Service, Korle Bu Teaching Hospital, Accra, Ghana; Ghana Health Service Ethical Review Committee, Accra, Ghana
| | - Afeez A Hazzan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Healthcare Studies, The College at Brockport, State University of New York, NY, USA
| | - Shevin T Jacob
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Takuya Adachi
- Department of Infectious Diseases, Toshima Hospital, Tokyo, Japan
| | - Lynda Benhadj
- Department of Community Health Sciences, Université de Sherbrooke, Sherbrooke, Canada; Centre de recherche, Hôpital Charles-Le Moyne, Longueuil, QC, Canada
| | | | - Ian Crozier
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Steven J Hoffman
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health, and Osgoode Hall Law School, York University, Toronto, ON, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Gomes NS, Silva AMBD, Zago LB, Silva ÉCDLE, Barichello E. Nursing knowledge and practices regarding subcutaneous fluid administration. Rev Bras Enferm 2017; 70:1096-1105. [PMID: 28977240 DOI: 10.1590/0034-7167-2016-0424] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/22/2017] [Indexed: 11/22/2022] Open
Abstract
Objective: To describe the evidence in the literature regarding the knowledge and practices of the nursing team about subcutaneous administration of drugs and fluids in adults. Method: Integrative review of the literature using the descriptors "nursing", "hypodermoclysis", "drug administration routes", "adult health," and "knowledge," in English, Spanish, and Portuguese, with no publication deadline. Of the 569 articles found, eight made up the sample. Results: A predominance of international journals (75%) with more than five years of publication (62.5%). The analysis of the methodological characteristics showed a predominance of literature reviews (25%), quantitative studies (62.5%), cross-sectional studies (50%), and non-experimental studies (50%). Conclusion: Although it is an old technique with proven efficacy, hypodermoclysis is still little used, a puzzling fact due to its advantages and indications for any age. Objetivo: descrever as evidências, na literatura, sobre os conhecimentos e as práticas da equipe de enfermagem na administração de medicamentos e de fluidos por via subcutânea no adulto. Método: revisão integrativa da literatura utilizando os descritores enfermagem, hipodermóclise, vias de administração de medicamentos, saúde do adulto e conhecimento; nos idiomas inglês, espanhol e português, sem data limite de publicação. Dos 569 artigos encontrados, oito compuseram a amostra. Resultados: predomínio de revistas internacionais (75%) e com mais de cinco anos de publicação (62,5%). Ao analisarem-se as características metodológicas, predominaram: revisões de literatura (25%), estudos quantitativos (62,5%), estudos transversais (50%) e não-experimentais (50%). Conclusão: apesar de se tratar de uma técnica antiga com eficácia comprovada, a hipodermóclise ainda é pouco utilizada, fato incoerente pelas suas vantagens e suas indicações para qualquer idade.
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Affiliation(s)
- Nathália Silva Gomes
- Universidade Federal do Triângulo Mineiro, Strictu Sensu Postgraduate Program in Health Care. Uberaba, Minas Gerais, Brazil
| | - Andrea Mara Bernardes da Silva
- Universidade Federal de São Paulo, Ribeirão Preto College of Nursing, Postgraduate Program in Fundamental Nursing. Ribeirão Preto, São Paulo, Brazil
| | - Luana Barbosa Zago
- Universidade Federal do Triângulo Mineiro, Strictu Sensu Postgraduate Program in Health Care. Uberaba, Minas Gerais, Brazil
| | | | - Elizabeth Barichello
- Universidade Federal do Triângulo Mineiro, Strictu Sensu Postgraduate Program in Health Care. Uberaba, Minas Gerais, Brazil
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Abstract
Under a traditional paradigm, only those with the expected background knowledge consume academic literature. The lay press, as well as government and non-government agencies, play a complementary role of extracting findings of high interest or importance and translating them for general viewing. The need for accurate reporting and public advising is paramount when attempting to tackle epidemic outbreaks through behavior change. Yet, public trust in media outlets is at a historic low. The Crisis and Emergency Risk Communication (CERC) model for media reporting on public health emergencies was established in 2005 and has subsequently been used to analyze media reporting on outbreaks of influenza and measles as well as smoking habits and medication compliance. However, no media analysis had yet been performed on the 2013–2016 Ebola Virus Disease (EVD) outbreak. This study compared the EVD information relayed by lay press sources with general review articles in the academic literature through a mixed-methods analysis. These findings suggest that comprehensive review articles could not serve as a source to clarify and contextualize the uncertainties around the EVD outbreak, perhaps due to adherence to technical accuracy at the expense of clarity within the context of outbreak conditions. This finding does not imply inferiority of the academic literature, nor does it draw direct causation between confusion in review articles and public misunderstanding. Given the erosion of the barriers siloing academia, combined with the demands of today’s fast-paced media environment, contemporary researchers should realize that no study is outside the public forum and to therefore consider shifting the paradigm to take personal responsibility in the process of accurately translating their scientific words into public policy actions to best serve as a source of clarity.
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Cancedda C, Davis SM, Dierberg KL, Lascher J, Kelly JD, Barrie MB, Koroma AP, George P, Kamara AA, Marsh R, Sumbuya MS, Nutt CT, Scott KW, Thomas E, Bollbach K, Sesay A, Barrie A, Barrera E, Barron K, Welch J, Bhadelia N, Frankfurter RG, Dahl OM, Das S, Rollins RE, Eustis B, Schwartz A, Pertile P, Pavlopoulos I, Mayfield A, Marsh RH, Dibba Y, Kloepper D, Hall A, Huster K, Grady M, Spray K, Walton DA, Daboh F, Nally C, James S, Warren GS, Chang J, Drasher M, Lamin G, Bangura S, Miller AC, Michaelis AP, McBain R, Broadhurst MJ, Murray M, Richardson ET, Philip T, Gottlieb GL, Mukherjee JS, Farmer PE. Strengthening Health Systems While Responding to a Health Crisis: Lessons Learned by a Nongovernmental Organization During the Ebola Virus Disease Epidemic in Sierra Leone. J Infect Dis 2016; 214:S153-S163. [PMID: 27688219 PMCID: PMC5050485 DOI: 10.1093/infdis/jiw345] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
An epidemic of Ebola virus disease (EVD) beginning in 2013 has claimed an estimated 11 310 lives in West Africa. As the EVD epidemic subsides, it is important for all who participated in the emergency Ebola response to reflect on strengths and weaknesses of the response. Such reflections should take into account perspectives not usually included in peer-reviewed publications and after-action reports, including those from the public sector, nongovernmental organizations (NGOs), survivors of Ebola, and Ebola-affected households and communities. In this article, we first describe how the international NGO Partners In Health (PIH) partnered with the Government of Sierra Leone and Wellbody Alliance (a local NGO) to respond to the EVD epidemic in 4 of the country's most Ebola-affected districts. We then describe how, in the aftermath of the epidemic, PIH is partnering with the public sector to strengthen the health system and resume delivery of regular health services. PIH's experience in Sierra Leone is one of multiple partnerships with different stakeholders. It is also one of rapid deployment of expatriate clinicians and logistics personnel in health facilities largely deprived of health professionals, medical supplies, and physical infrastructure required to deliver health services effectively and safely. Lessons learned by PIH and its partners in Sierra Leone can contribute to the ongoing discussion within the international community on how to ensure emergency preparedness and build resilient health systems in settings without either.
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Affiliation(s)
- Corrado Cancedda
- Partners In Health Division of Global Health Equity Department of Global Health and Social Medicine, Harvard Medical School
| | | | | | | | - J Daniel Kelly
- Division of Global Health Equity Department of Medicine, University of California-San Francisco School of Medicine Wellbody Alliance
| | - Mohammed Bailor Barrie
- Partners In Health Department of Global Health and Social Medicine, Harvard Medical School Wellbody Alliance
| | | | - Peter George
- Port Loko Government Hospital, Port Loko, Sierra Leone
| | | | | | | | - Cameron T Nutt
- Partners In Health Department of Global Health and Social Medicine, Harvard Medical School
| | - Kirstin W Scott
- Department of Global Health and Social Medicine, Harvard Medical School
| | | | | | | | | | | | | | - John Welch
- Partners In Health Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children's Hospital
| | - Nahid Bhadelia
- Partners In Health Division of Infectious Diseases, Boston University School of Medicine, Massachusetts
| | | | | | | | | | | | | | | | | | | | - Regan H Marsh
- Partners In Health Department of Emergency Medicine, Brigham and Women's Hospital Department of Global Health and Social Medicine, Harvard Medical School
| | | | | | | | - Karin Huster
- Partners In Health Department of Global Health at the University of Washington, Seattle
| | | | | | | | | | | | | | | | | | | | | | | | - Ann C Miller
- Department of Global Health and Social Medicine, Harvard Medical School
| | | | | | | | - Megan Murray
- Partners In Health Division of Global Health Equity Department of Global Health and Social Medicine, Harvard Medical School
| | - Eugene T Richardson
- Partners In Health Division of Global Health Equity Division of Infectious Diseases, Stanford University School of Medicine Department of Anthropology, Stanford University, Palo Alto, California
| | | | | | - Joia S Mukherjee
- Partners In Health Division of Global Health Equity Department of Global Health and Social Medicine, Harvard Medical School
| | - Paul E Farmer
- Partners In Health Division of Global Health Equity Department of Global Health and Social Medicine, Harvard Medical School
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9
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Ker K, Tansley G, Beecher D, Perner A, Shakur H, Harris T, Roberts I. Comparison of routes for achieving parenteral access with a focus on the management of patients with Ebola virus disease. Cochrane Database Syst Rev 2015; 2015:CD011386. [PMID: 25914907 PMCID: PMC4455225 DOI: 10.1002/14651858.cd011386.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Dehydration is an important cause of death in patients with Ebola virus disease (EVD). Parenteral fluids are often required in patients with fluid requirements in excess of their oral intake. The peripheral intravenous route is the most commonly used method of parenteral access, but inserting and maintaining an intravenous line can be challenging in the context of EVD. Therefore it is important to consider the advantages and disadvantages of different routes for achieving parenteral access (e.g. intravenous, intraosseous, subcutaneous and intraperitoneal). OBJECTIVES To compare the reliability, ease of use and speed of insertion of different parenteral access methods. SEARCH METHODS We ran the search on 17 November 2014. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, Ovid MEDLINE(R) and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP), CINAHL (EBSCOhost), clinicaltrials.gov and screened reference lists. SELECTION CRITERIA Randomised controlled trials comparing different parenteral routes for the infusion of fluids or medication. DATA COLLECTION AND ANALYSIS Two review authors examined the titles and abstracts of records obtained by searching the electronic databases to determine eligibility. Two review authors extracted data from the included trials and assessed the risk of bias. Outcome measures of interest were success of insertion; time required for insertion; number of insertion attempts; number of dislodgements; time period with functional access; local site reactions; clinicians' perception of ease of administration; needlestick injury to healthcare workers; patients' discomfort; and mortality. For trials involving the administration of fluids we also collected data on the volume of fluid infused, changes in serum electrolytes and markers of renal function. We rated the quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach for the following outcomes: success of insertion, time required for insertion, number of dislodgements, volume of fluid infused and needlestick injuries. MAIN RESULTS We included 17 trials involving 885 participants. Parenteral access was used to infuse fluids in 11 trials and medications in six trials. None of the trials involved patients with EVD. Intravenous and intraosseous access was compared in four trials; intravenous and subcutaneous access in 11; peripheral intravenous and intraperitoneal access in one; saphenous vein cutdown and intraosseous access in one; and intraperitoneal with subcutaneous access in one. All of the trials assessing the intravenous method involved peripheral intravenous access.We judged few trials to be at low risk of bias for any of the assessed domains.Compared to the intraosseous group, patients in the intravenous group were more likely to experience an insertion failure (risk ratio (RR) 3.89, 95% confidence interval (CI) 2.39 to 6.33; n = 242; GRADE rating: low). We did not pool data for time to insertion but estimates from the trials suggest that inserting intravenous access takes longer (GRADE rating: moderate). Clinicians judged the intravenous route to be easier to insert (RR 0.15, 95% CI 0.04 to 0.61; n = 182). A larger volume of fluids was infused via the intravenous route (GRADE rating: moderate). There was no evidence of a difference between the two routes for any other outcomes, including adverse events.Compared to the subcutaneous group, patients in the intravenous group were more likely to experience an insertion failure (RR 14.79, 95% CI 2.87 to 76.08; n = 238; GRADE rating: moderate) and dislodgement of the device (RR 3.78, 95% CI 1.16 to 12.34; n = 67; GRADE rating: low). Clinicians also judged the intravenous route as being more difficult to insert and patients were more likely to be agitated in the intravenous group. Patients in the intravenous group were more likely to develop a local infection and phlebitis, but were less likely to develop erythema, oedema or swelling than those in the subcutaneous group. A larger volume of fluids was infused into patients via the intravenous route. There was no evidence of a difference between the two routes for any other outcome.There were insufficient data to reliably determine if the risk of insertion failure differed between the saphenous vein cutdown (SVC) and intraosseous method (RR 4.00, 95% CI 0.51 to 31.13; GRADE rating: low). Insertion using SVC took longer than the intraosseous method (MD 219.60 seconds, 95% CI 135.44 to 303.76; GRADE rating: moderate). There were no data and therefore there was no evidence of a difference between the two routes for any other outcome.There were insufficient data to reliably determine the relative effects of intraperitoneal or central intravenous access relative to any other parenteral access method. AUTHORS' CONCLUSIONS There are several different ways of achieving parenteral access in patients who are unable meet their fluid requirements with oral intake alone. The quality of the evidence, as assessed using the GRADE criteria, is somewhat limited because of the lack of adequately powered trials at low risk of bias. However, we believe that there is sufficient evidence to draw the following conclusions: if peripheral intravenous access can be achieved easily, this allows infusion of larger volumes of fluid than other routes; but if this is not possible, the intraosseous and subcutaneous routes are viable alternatives. The subcutaneous route may be suitable for patients who are not severely dehydrated but in whom ongoing fluid losses cannot be met by oral intake.A film to accompany this review can be viewed here (http://youtu.be/ArVPzkf93ng).
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Affiliation(s)
- Katharine Ker
- Cochrane Injuries Group, London School of Hygiene & TropicalMedicine, Room 186, Keppel Street, London, WC1E 7HT, UK.
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