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Xu HG, Corley A, Young ER, Doubrovsky A, Ware RS, Afoakwah C, Wang C, Stirling S, Marsh N. Long guidewire peripheral intravenous catheters in emergency departments for management of difficult intravenous access: A multicenter, pragmatic, randomized controlled trial. Acad Emerg Med 2024. [PMID: 39248350 DOI: 10.1111/acem.15004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 07/30/2024] [Accepted: 08/08/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND A quarter of patients who present to emergency departments (EDs) have difficult intravenous access (DIVA), making it challenging for clinicians to successfully place a peripheral intravenous catheter (PIVC). Some literature suggests that guidewire PIVC improves first-insertion success rate. AIM The aim was to determine the clinical and cost-effectiveness of a novel long PIVC (5.8 cm) with a retractable coiled guidewire (GW-PIVC) for patients with DIVA, compared with standard care PIVCs. METHODS A pragmatic randomized controlled trial was conducted in two Australian EDs. Eligible participants were adults assessed as meeting DIVA criteria. Participants were randomized (1:1 ratio; stratified by hospital) to either GW-PIVC (long) or standard care group (short or long PIVC). The use of ultrasound was discretionary in the standard care group and was recommended in the GW-PIVC group due to the pragmatic design that was primarily testing the GW-PIVC rather than the ultrasound use. Primary outcome was first-insertion success and secondary outcomes included all-cause device failure, patient and staff satisfaction, and cost-effectiveness. The analysis was intention to treat. RESULTS A total of 446 participants were randomized and 409 received PIVCs. The use of GW-PIVC, compared with standard PIVC, had a lower first-insertion success rate (68% vs. 77%, odds ratio [OR] 0.65, 95% confidence interval [CI] 0.43-0.99, p < 0.05). There was no difference in PIVC failure (134.0 per 1000 catheter days [GW-PIVC] vs. 111.8 [standard PIVC] per 1000 catheter days, hazard ratio 1.18, 95% CI 0.72-1.95). Both participant (8/10 vs. 9/10, median difference [MD] -1.00, 95% CI -1.37 to -0.63) and clinician (8/10 vs. 10/10, MD -2.00, 95% CI -2.37 to -1.63) satisfaction was lower with GW-PIVCs compared with standard PIVCs. More nurses inserted standard PIVCs than GW-PIVCs (56.9% vs. 36.5%) and had less confidence in their ultrasound skills (28.0% vs. 46.6% self-claimed as advanced/expert users). The cost per participant of GW-PIVC insertions was 2.46 times greater than standard PIVC insertions ($AU80.24 vs. $AU32.57). CONCLUSIONS GW-PIVCs had significantly lower first-insertion success and non-significantly higher all-cause catheter failure. Additional training and device design familiar to clinicians are vital factors to enhance the likelihood of successful future implementation of GW-PIVCs.
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Affiliation(s)
- Hui Grace Xu
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
- Department of Emergency Medicine, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
- Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia
| | - Amanda Corley
- Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, Australia
| | - Emily R Young
- School of Medicine and Dentistry, Griffith University, Brisbane, Queensland, Australia
| | - Anna Doubrovsky
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Robert S Ware
- School of Medicine and Dentistry, Griffith University, Brisbane, Queensland, Australia
| | - Clifford Afoakwah
- Australian Centre for Health Services Innovation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Jamieson Trauma Institute, Metro North Health, Brisbane, Queensland, Australia
| | - Carrie Wang
- Department of Emergency Medicine, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - Scott Stirling
- Department of Emergency Medicine, Logan Hospital, Brisbane, Australia
| | - Nicole Marsh
- Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, Australia
- School of Medicine and Dentistry, Griffith University, Brisbane, Queensland, Australia
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Mielke N, Xing Y, Gibson SM, DiLoreto E, Bahl A. Bridging the Gap in Traditional PIVC Placement: An Evaluation of Operation STICK Vascular Access Outcomes. Ther Clin Risk Manag 2023; 19:937-948. [PMID: 38023627 PMCID: PMC10676087 DOI: 10.2147/tcrm.s435628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/04/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Education and training is core to improving peripheral intravenous access outcomes. This study aimed to show that a vascular access training program (Operation STICK) in the emergency department (ED) improves the outcomes of traditionally placed peripheral intravenous catheters (PIVC). Methods This was a pre-post quasi-experimental study of traditionally placed PIVCs at a large ED in southeastern Michigan, United States. A control group (non-OSTICK) was compared to an experimental group (OSTICK) using a 3:1 propensity score matched analysis. Groups were comprised of ED patients with traditional PIVC placements in two separate six-month periods: non-OSTICK PIVCs from April to September 2021 and OSTICK PIVCs (placed by an OSTICK graduate) from October 2022 to March 2023. The primary outcome was PIVC functionality. The secondary outcome was adherence to best practices. Results A total of 6512 PIVCs were included in the study; 4884 (75.0%) were in the non-OSTICK group, while 1628 (25.0%) were in the OSTICK group. 68.1% of OSTICK PIVCs and 59.7% of non-OSTICK PIVCs were placed by ED technicians (p < 0.001). 91.3% of OSTICK PIVCs were placed on the first attempt, and 98.5% were placed within two attempts. A subgroup analysis of admitted patients (2540 PIVCs; 553 (21.8%) OSTICK-trained and 1987 (78.2%) non-OSTICK-trained) revealed 87.6% of OSTICK PIVCs and 80.3% of non-OSTICK PIVCs were 20 gauge (p < 0.001). The median proportion of dwell time to hospital length of stay was 94% for OSTICK PIVCs, compared to 88% for non-OSTICK PIVCs (p < 0.001). Conclusion This study underscores the value of education and training in enhancing vascular access outcomes. Implementing Operation STICK, a comprehensive vascular access training program, at a large ED has led to high first-stick success, adherence to best practice recommendations for site and device selection, and improved PIVC functionality for traditionally placed catheters.
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Affiliation(s)
- Nicholas Mielke
- Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Yuying Xing
- Corewell Health Research Institute, Royal Oak, MI, USA
| | | | - Emily DiLoreto
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Amit Bahl
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
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Malik A, Dewald O, Gallien J, Favot M, Kasten A, Reed B, Wells R, Ehrman RR. Outcomes of Ultrasound Guided Peripheral Intravenous Catheters Placed in the Emergency Department and Factors Associated with Survival. Open Access Emerg Med 2023; 15:177-187. [PMID: 37228359 PMCID: PMC10204754 DOI: 10.2147/oaem.s405692] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/29/2023] [Indexed: 05/27/2023] Open
Abstract
Background Patients with difficult peripheral intravenous (IV) access are common in emergency departments (EDs). Ultrasound-guided peripheral intravenous catheters (USIVs) are frequently used in this population; however, information regarding the effect of patient and IV characteristics on the dwell time (DT) and survival probability (SP) of USIVs is limited. Objective Our study aimed to evaluate for associations between patient or IV characteristics and the DT and SP of USIVs. Methods Retrospective analysis was performed on a database from an ED nurse (RN) USIV training program at an urban, academic hospital. Patients over 18 years with an USIV placed during the study period were included. Subject demographics, history, IV characteristics, insertion, and removal times were collected. Data were analyzed using descriptive statistics and univariable and multivariable Cox regression. USIV survival times for variates of interest were estimated using Kaplan-Meier curves for three censoring points. Results The final analysis cohort was 388 patients. Mean age was 56.6 years, 66.5% were female, mean BMI was 29.9 kg/m2, and 42.5% were obese (BMI ≥30). Median DT was 40.3 hours in admitted patients (N=340). SP for USIVs at 96 hours was 87.8%. A total of 21 of 340 (6.2%) USIVs failed. USIV location conferred a difference on DT in obese patients when dichotomized into upper arm versus antecubital fossa and forearm together (38.6 hours vs 44.6 hours, p=0.03). No factors were associated with a difference in USIV SP. Conclusion Median USIV DT of 40.3 hours for admitted patients was higher than in previous studies. Only 7% of USIVs in our study failed. Overall, catheters survived longer than expected.
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Affiliation(s)
- Adrienne Malik
- Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, MO, 66160, USA
| | - Olga Dewald
- Department of Emergency Medicine, Sparrow Hospital, Lansing, MI, 48912, USA
| | - John Gallien
- Department of Emergency Medicine, DMC Detroit Receiving Hospital, Detroit, MI, 48201, USA
| | - Mark Favot
- Department of Emergency Medicine, DMC Detroit Receiving Hospital, Detroit, MI, 48201, USA
| | - Adam Kasten
- Department of Emergency Medicine, DMC Harper Hospital, Detroit, MI, 48201, USA
| | - Brian Reed
- Department of Emergency Medicine, Wayne State University, Detroit, MI, 48201, USA
| | - Robert Wells
- Department of Emergency Medicine, DMC Harper Hospital, Detroit, MI, 48201, USA
| | - Robert R Ehrman
- Department of Emergency Medicine, DMC Sinai Grace Hospital, Detroit, MI, 48235, USA
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Tada M, Yamada N, Matsumoto T, Takeda C, Furukawa TA, Watanabe N. Ultrasound guidance versus landmark method for peripheral venous cannulation in adults. Cochrane Database Syst Rev 2022; 12:CD013434. [PMID: 36507736 PMCID: PMC9744071 DOI: 10.1002/14651858.cd013434.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Peripheral intravenous cannulation is one of the most fundamental and common procedures in medicine. Securing a peripheral line is occasionally difficult with the landmark method. Ultrasound guidance has become a standard procedure for central venous cannulation, but its efficacy in achieving peripheral venous cannulation is unclear. OBJECTIVES To evaluate the effectiveness and safety of ultrasound guidance compared to the landmark method for peripheral intravenous cannulation in adults. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 29 November 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs (RCTs in which participants are systematically allocated based on data such as date of birth or recruitment) comparing the effects of ultrasound guidance to the landmark method for peripheral intravenous cannulation in adults. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were first-pass success of cannulation, overall success of cannulation, and pain. Our secondary outcomes were procedure time for first-pass cannulation, procedure time for overall cannulation, number of attempts, patient satisfaction, and overall complications. We used GRADE to assess the certainty of the evidence. Placing a peripheral intravenous line in individuals can be classed as 'difficult', 'moderate', or 'easy'. We use the terms 'difficult participants', 'moderate/moderately difficult participants' and 'easy participants' as shorthand to characterise the difficulty level in placing a peripheral line using the landmark method. We used the original studies' definitions of difficulty levels of peripheral intravenous cannulation with the landmark method. We analysed the results in these subgroups: 'difficult participants', 'moderate participants', and 'easy participants'. We did this because we expected the effect of ultrasound-guided peripheral venous cannulation to be largest in participants classed as 'difficult' and smaller in participants classed as 'moderate' and 'easy'. MAIN RESULTS: We included 14 RCTs and two quasi-RCTs involving 2267 participants undergoing peripheral intravenous cannulation. Participants were classed as 'difficult' in 12 studies (880 participants), 'moderate' in one study (401 participants), and 'easy' in one study (596 participants). Two studies (390 participants) did not restrict by landmark method difficulty level. The overall risk of bias assessments ranged from low to high. We judged studies to be at high risk of bias mainly because of concerns about blinding for subjective outcomes. In difficult participants, ultrasound guidance increased the first-pass success of cannulation (risk ratio (RR) 1.50, 95% confidence interval (95% CI) 1.15 to 1.95; 10 studies, 815 participants; low-certainty evidence), and the overall success of cannulation (RR 1.40, 95% CI 1.10 to 1.77; 10 studies, 670 participants; very low-certainty evidence). There was no clear difference in pain (mean difference (MD) -0.20, 95% CI -1.13 to 0.72; 4 studies, 323 participants; very low-certainty evidence; numerical rating scale (NRS) 0 to 10 where 10 is maximum pain). Ultrasound guidance increased the procedure time for first-pass cannulation (MD 119.9 seconds, 95% CI 88.6 to 151.1; 2 studies, 219 participants; low-certainty evidence), and patient satisfaction (standardised mean difference (SMD) 0.49, 95% CI 0.07 to 0.92; 5 studies, 333 participants; very low-certainty evidence; NRS 0 to 10 where 10 is maximum satisfaction). Ultrasound guidance decreased the number of cannulation attempts (MD -0.33, 95% CI -0.64 to -0.02; 9 studies, 568 participants; very low-certainty evidence). Ultrasound guidance showed no clear difference in the procedure time for overall cannulation (MD -24.9 seconds, 95% CI -323.1 to 273.3; 8 studies, 413 participants; very low-certainty evidence) and overall complications (RR 0.64, 95% CI 0.37 to 1.10; 5 studies, 431 participants; low-certainty evidence). In moderate participants, ultrasound guidance increased the first-pass success of cannulation (RR 1.14, 95% CI 1.02 to 1.27; 1 study, 401 participants; moderate-certainty evidence). No studies assessed the overall success of cannulation. There was no clear difference in pain (MD 0.10, 95% CI -0.47 to 0.67; 1 study, 401 participants; low-certainty evidence; NRS 0 to 10 where 10 is maximum pain). Ultrasound guidance increased the procedure time for first-pass cannulation (MD 95.2 seconds, 95% CI 72.8 to 117.6; 1 study, 401 participants; high-certainty evidence). Ultrasound guidance showed no clear difference in overall complications (RR 0.83, 95% CI 0.38 to 1.82; 1 study, 401 participants; moderate-certainty evidence). No studies assessed the procedure time for overall cannulation, number of cannulation attempts, or patient satisfaction. In easy participants, ultrasound guidance decreased the first-pass success of cannulation (RR 0.89, 95% CI 0.85 to 0.94; 1 study, 596 participants; high-certainty evidence). No studies assessed the overall success of cannulation. Ultrasound guidance increased pain (MD 0.60, 95% CI 0.17 to 1.03; 1 study, 596 participants; moderate-certainty evidence; NRS 0 to 10 where 10 is maximum pain). Ultrasound guidance increased the procedure time for first-pass cannulation (MD 94.8 seconds, 95% CI 81.2 to 108.5; 1 study, 596 participants; high-certainty evidence). Ultrasound guidance showed no clear difference in overall complications (RR 2.48, 95% CI 0.90 to 6.87; 1 study, 596 participants; moderate-certainty evidence). No studies assessed the procedure time for overall cannulation, number of cannulation attempts, or patient satisfaction. AUTHORS' CONCLUSIONS: There is very low- and low-certainty evidence that, compared to the landmark method, ultrasound guidance may benefit difficult participants for increased first-pass and overall success of cannulation, with no difference detected in pain. There is moderate- and low-certainty evidence that, compared to the landmark method, ultrasound guidance may benefit moderately difficult participants due to a small increased first-pass success of cannulation with no difference detected in pain. There is moderate- and high-certainty evidence that, compared to the landmark method, ultrasound guidance does not benefit easy participants: ultrasound guidance decreased the first-pass success of cannulation with no difference detected in overall success of cannulation and increased pain.
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Affiliation(s)
- Masafumi Tada
- Department of Health Promotion and Human Behavior, Kyoto University School of Public Health, Kyoto, Japan
- Department of Neurology, Emergency Medicine, Nagoya City University East Medical Center, Nagoya, Japan
| | - Naoki Yamada
- Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan
| | | | - Chikashi Takeda
- Department of Anesthesia, Department of Pharmacoepidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University School of Public Health, Kyoto, Japan
| | - Norio Watanabe
- Department of Psychiatry, Soseikai General Hospital, Kyoto, Japan
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Bahl A, Johnson S, Alsbrooks K, Mares A, Gala S, Hoerauf K. Defining difficult intravenous access (DIVA): A systematic review. J Vasc Access 2021; 24:11297298211059648. [PMID: 34789023 DOI: 10.1177/11297298211059648] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The term "difficult intravenous access" (DIVA) is commonly used but not clearly defined. Repeated attempts at peripheral intravenous catheter (PIVC) insertion can be a traumatic experience for patients, leading to sub-optimal clinical and economic outcomes. We conducted a systematic literature review (SLR) to collate literature definitions of DIVA, with the aim of arriving at an evidence-driven definition. METHODS The SLR was designed to identify clinical, cost, and quality of life publications in patients requiring the insertion of a PIVC in any setting, including studies on US-guidance and/or guidewire, and studies with no specific intervention. The search was restricted to English language studies published between 1st January 2010 and 30th July 2020, and the Ovid platform was used to search several electronic databases, in addition to hand searching of clinical trial registries. RESULTS About 121 studies were included in the SLR, of which 64 reported on the objectives relevant to this manuscript. Prevalence estimates varied widely from 6% to 87.7% across 19 publications, reflecting differences in definitions used. Of 43 publications which provided a definition of DIVA, six key themes emerged. Of these, themes 1-3 (failed attempts at PIV access using traditional technique; based on physical examination findings for example no visible or palpable veins; and personal history of DIVA) were covered by all but one publication. Following a failed insertion attempt, the most common number of subsequent attempts was 3, and it was frequently reported that a more experienced clinician would attempt to gain access after multiple failed attempts. CONCLUSIONS Considering the themes identified, an evidence-driven definition of DIVA is proposed: "when a clinician has two or more failed attempts at PIV access using traditional techniques, physical examination findings are suggestive of DIVA (e.g. no visible or palpable veins) or the patient has a stated or documented history of DIVA."
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Affiliation(s)
- Amit Bahl
- Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Steven Johnson
- Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | | | - Alicia Mares
- Becton Dickinson and Co, Franklin Lakes, NJ, USA
| | - Smeet Gala
- Becton Dickinson and Co, Franklin Lakes, NJ, USA
| | - Klaus Hoerauf
- Becton Dickinson and Co, Franklin Lakes, NJ, USA
- Department of Anesthesiology and Intensive Care, Medical University of Vienna, Vienna, Austria
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Tran QK, Fairchild M, Yardi I, Mirda D, Markin K, Pourmand A. Efficacy of Ultrasound-Guided Peripheral Intravenous Cannulation versus Standard of Care: A Systematic Review and Meta-analysis. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:3068-3078. [PMID: 34353670 DOI: 10.1016/j.ultrasmedbio.2021.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 06/13/2023]
Abstract
Peripheral intravenous cannulation (PIV) is a common and necessary procedure in the emergency department (ED). Patients with PIV access encounter significant treatment delay. Ultrasound guidance for PIV (USGPIV) cannulation is a modality to reduce delay of care in such patients, but its efficacy, when compared with cannulation by the standard of care (SOC), the landmark and palpation method, has not been well established. We performed a random effects meta-analysis of available literature that compared USGPIV with SOC cannulation. We searched PubMed, Scopus and EMBASE until October 2020 for eligible studies in adult patients. We excluded non-English language, non-full-text studies. Our primary outcome was rate of first successful cannulation. Other outcomes were number of attempts and patient satisfaction. After identifying 284 studies and screening 74 studies, we included 10 studies. There were 1860 patients, 966 (52%) in the USGPIV group and 894 (48%) who received the SOC. Sixty-six percent of patients were female. USGPIV cannulation was associated with a two-times higher likelihood of first successful cannulation (odds ratio: 2.1, 95% confidence interval [CI]: 1.65-2.7, p < 0.001, I2 = 2.9%). While procedure length was similar in both groups, USGPIV was associated with a significantly smaller number of attempts (standardized mean difference [SMD]: -0.272, 95% CI: -0.539 to -0.004, p = 0.047) and significantly higher patient satisfaction (SMD: 1.467, 95% CI: 0.92-2.012, p < 0.001). There was low heterogeneity among our included studies, which were mostly randomized control trials. Our study confirmed that USGPIV cannulation offers a more effective modality, compared with SOC, to improve quality of care for patients with difficult PIV access.
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Affiliation(s)
- Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA; Program in Trauma, The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA; Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Matthew Fairchild
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Isha Yardi
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Danielle Mirda
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Katherine Markin
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
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Privitera D, Mazzone A, Pierotti F, Airoldi C, Galazzi A, Geraneo A, Cozzi M, Mora Garrido R, Vailati P, Scaglioni R, Capsoni N, Ganassin EC, Salinaro G, Scala CGR, Dal Molin A. Ultrasound-guided peripheral intravenous catheters insertion in patient with difficult vascular access: Short axis/out-of-plane versus long axis/in-plane, a randomized controlled trial. J Vasc Access 2021; 23:589-597. [PMID: 33794708 DOI: 10.1177/11297298211006996] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The aim of this study was to evaluate the rate of successful peripheral cannulation between short-axis and long-axis ultrasound guided techniques. METHODS A single-center, two-arm randomized controlled, intention-to-treat, open-label study was conducted at the Emergency Department, between August and November 2020. Patients requiring a peripheral intravenous catheter insertion and identified as having a difficult intravascular access, were enrolled and followed for up to 96 h.The primary endpoint was the correct placement of the peripheral intravenous catheter. The secondary endpoints were number of venipunctures, intra-procedural pain, local complications, and positive blood return during the follow up. RESULTS A total of 283 patients were enrolled: 141 subjects were randomized to the short-axis and 142 to the long-axis group. Success rate was 96.45% (135/141; 95% CI, 91.92%-98.84%) in the short-axis group compared with 92.25% (132/142; 95% CI, 86.56%-96.07%) in the long-axis group (p = 0.126). No significant differences were found in terms of intraprocedural pain and local complications. Higher rate of positive blood return at 72 h [3/17 long-axis, 14/17 short-axis (p = 0.005)] and 96 h [1/10 long-axis, 9/10 short-axis 96 h, (p = 0.022)] was found for the short-axis group. CONCLUSIONS No differences were found between short-axis and long-axis techniques in terms of success rate, intraprocedural pain, and local complications. Despite this, a slightly higher success rate, a lower number of venipunctures, and a higher rate of positive blood return at 72 and 96 h together with an easier ultrasound technique could suggest a short-axis approach.
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Affiliation(s)
- Daniele Privitera
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Annamaria Mazzone
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Federico Pierotti
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Chiara Airoldi
- Department of Translation Medicine, University of Piemonte Orientale, Novara, Italy
| | - Alessandro Galazzi
- Direction of Healthcare Professions, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Annalisa Geraneo
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mattia Cozzi
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Raquel Mora Garrido
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Paolo Vailati
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Roberta Scaglioni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Nicolò Capsoni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Gianluca Salinaro
- Direction of Healthcare Professions, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Alberto Dal Molin
- Department of Translation Medicine, University of Piemonte Orientale, Novara, Italy.,Health Professions' Direction, Maggiore della Carità Hospital, Novara, Italy
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Acuña J, Sorenson J, Gades A, Wyatt R, Stea N, Drachman M, Adhikari S. Handheld Ultrasound: Overcoming the Challenge of Difficult Peripheral Intravenous Access in the Emergency Department. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1985-1991. [PMID: 32333616 DOI: 10.1002/jum.15303] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/20/2020] [Accepted: 03/29/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the performance of a handheld ultrasound device for difficult peripheral intravenous (PIV) access performed by nurses and paramedics in the emergency department (ED). METHODS This was a retrospective review at an academic medical center. Participants were ED nurses and paramedics with competence in ultrasound-guided PIV placement. Participants were asked to log their use of the handheld device when used on patients deemed to have "difficult" access and complete a questionnaire, which consisted of items related to the effectiveness and ease of use of the device. Data were collected over the course of 1 year. An electronic medical record review was performed to track the success rates and the occurrence of any associated complications throughout the hospital stay. RESULTS Nurses and paramedics logged a total of 483 cases in which PIV access was attempted with the handheld ultrasound device. Ninety-two percent (95% confidence interval [CI], 89%-94%) of the ultrasound-guided PIV lines attempted were placed successfully. Eighty-four percent (95% CI, 80%-87%) of the lines were placed successfully on the first attempt. In most cases (396 of 483 [82%]), no complications associated with the PIV occurred. A total of 429 questionnaires were completed over the study period. Most of the operators (84%; 95% CI, 80%-87%) stated that the handheld device was adequate to perform ultrasound-guided PIV access. CONCLUSIONS The handheld ultrasound device performed well in terms of usability and reliability for PIV access.
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Affiliation(s)
- Josie Acuña
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona, USA
| | - Jacob Sorenson
- College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Anthony Gades
- Philips Point-of-Care Ultrasound, Bothell, Washington, USA
| | - Ryan Wyatt
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona, USA
| | - Nicholas Stea
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona, USA
| | - Maili Drachman
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona, USA
| | - Srikar Adhikari
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona, USA
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Shaukat H, Neway B, Breslin K, Watson A, Poe K, Boniface K, Cohen JS. Utility of the DIVA score for experienced emergency department technicians. ACTA ACUST UNITED AC 2020; 29:S35-S40. [PMID: 31972107 DOI: 10.12968/bjon.2020.29.2.s35] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The DIVA score is validated for predicting success of the initial attempt at peripheral intravenous insertion by nurses and physicians. A score of 4 or greater is 50% to 60% likely to have a failed first attempt. The study objective was to assess the validity of this score for emergency department technicians. METHODS This study used a prospective convenience sample of 181 children presenting to the emergency department with intravenous access attempt by one of 29 emergency department technicians. DIVA score, total number of attempts, and median time to successful intravenous cannulation were obtained. RESULTS Comparing patients with a DIVA score <4 to ≥4, first-time IV placement failure rates were lower (9% [95% CI, 3-24] vs. 41% [95% CI, 33-49]) and median time to IV placement was shorter (75 [interquartile range (IQR) 42-157] vs. 254 [IQR 91-806]) seconds. In patients with scores ≥4, emergency department technicians with ≥5 years of experience were significantly more likely to be successful on the first attempt (OR 2.8; 95% CI, 1.03-7.63). For every year of technician experience, the time to catheter placement, adjusted for DIVA score, decreased by 25 minutes (P≤0.05, R2=0.05). Comparing our receiver operating curve to the derivation study, the areas were similar (0.67 vs. 0.65). CONCLUSIONS This study provides preliminary evidence for the validity of the DIVA score when applied to IVs placed by emergency department technicians. For patients with high DIVA scores, ≥5 years of IV experience was associated with higher odds of successful first-time IV placement and shorter time to placement. HIGHLIGHTS The difficult intravenous access (DIVA) score may be generalizable to IVs placed by experienced emergency department technicians (EDTs) Higher odds of first-time success in difficult patients with ≥5 years EDT experience Early identification of difficult access may allow for aid of alternative technology Likely first study to evaluate EDTs IV skills in patients with varying DIVA scores.
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Affiliation(s)
- Haroon Shaukat
- MD, Division of Emergency Medicine, Children's National Health System, Washington, DC; Department of Pediatrics and Emergency Medicine, George Washington University, Washington, DC, USA
| | - Beemnet Neway
- BS, Division of Emergency Medicine, Children's National Health System, Washington, DC, USA
| | - Kristen Breslin
- MD, Division of Emergency Medicine, Children's National Health System, Washington, DC; Department of Pediatrics and Emergency Medicine, George Washington University, Washington, DC, USA
| | - Ar'Reon Watson
- BA, Division of Emergency Medicine, Children's National Health System, Washington, DC, USA
| | - Kelly Poe
- BS, Division of Emergency Medicine, Children's National Health System, Washington, DC, USA
| | - Keith Boniface
- MD, Department of Pediatrics and Emergency Medicine, George Washington University, Washington, DC, USA
| | - Joanna S Cohen
- MD, Division of Emergency Medicine, Children's National Health System, Washington, DC; Department of Pediatrics and Emergency Medicine, George Washington University, Washington, DC, USA
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