A simple diagnostic test to confirm correct intravascular placement of peripheral catheters in order to avoid extravasation

Precordial Doppler to assess vascular access in children: A preliminary report

BACKGROUND

Delayed identification and dysfunction of peripheral intravenous (PIV) infiltration can lead to serious injury in children. This preliminary study aimed to describe the application of precordial Doppler ultrasound to detect and confirm the correct PIV access in children with congenital heart disease (CHD).

METHODS

This study was conducted on children (<18 years) diagnosed with CHD and admitted to the pediatric intensive care unit (PICU) of a single center after cardiac surgery or cardiac catheterization between February 2020 and May 2021. Three raters judged the precordial Doppler sound change (S test) after injection of 0.5 mL/kg of normal saline (NS) through the PIV access. Blood-flow velocities before and after the NS injection were recorded and the accuracy of detecting PIV catheter infiltration and dysfunction was analyzed (V test).

RESULTS

The overall incidence of PIV infiltration and dysfunction was in 3 out of 103 patients (2.9%). The sensitivity, specificity, positive and negative likelihood ratios, and area under the receiver operating characteristic curve were 3 out of 3 [100%, 95% confidence interval (CI): 29.2-100], 86 out of 100 (86%, 95% CI: 77.6%-92.1), 7.1, 0.0, and 0.93, respectively, in the S test and they were 2 out of 3 (66.7%, 95% CI: 9.4%-99.2), 94 out of 100 (94.0%, 95% CI: 87.4%-7.8%), 11.1, 0.36, and 0.80, respectively in the V test.

CONCLUSIONS

Precordial Doppler ultrasound was a feasible and accurate technique for confirming correct PIV access in children with CHD; however, a larger, prospective investigation is necessary to examine its diagnostic accuracy.

Introduction of precordial Doppler ultrasound to confirm correct peripheral venous access during general anesthesia in children: A preliminary study

Background

Delayed identification of infiltration and dysfunction of peripheral intravenous (PIV) access can lead to serious consequences during general anesthesia in children. This preliminary study aimed to describe the application of precordial Doppler ultrasound during general anesthesia in children to detect and confirm the correct PIV access and to evaluate the accuracy of this method.

Methods

This was a single-center, preliminary study that was conducted in children (<18 years) who were scheduled for elective surgeries between October 2019 and March 2020. Rater anesthesiologists judged the change in precordial Doppler sound (S test) before and after injection of 0.5 mL/kg of normal saline (NS) via PIV. Blood flow velocity before and after NS injection was recorded, and multiple cutoff points were set to analyze the accuracy of detecting the infiltration and dysfunction of PIV catheter (V test).

Results

The total incidence of peripheral infiltration and dysfunction of PIV catheter was 7/512 (1.4%). In the S test, the sensitivity, specificity, positive and negative likelihood ratios, and area under the receiver-operating characteristic curves (AUCs) were 5/7 (71.4%; 95% confidence interval [CI], 29.0%–96.3%), 490/505 (97.0%; 95% CI, 95.1%–98.3%), 24.0, 0.29, and 0.84, respectively. The V test showed that the reasonable threshold of blood flow velocity change was 1.0 m/s, with sensitivity, specificity, positive and negative likelihood ratios, and AUC of 4/7 (57.1%; 95% CI, 18.4%–90.1%), 489/505 (96.8%; 95% CI, 94.9%–98.2%), 18.0 and 0.44, and 0.84, respectively.

Conclusions

This preliminary study demonstrated that precordial Doppler ultrasound is a feasible, easy-to-use, and noninvasive technique with good accuracy to confirm the correct PIV access during general anesthesia in children. However, its accuracy requires further evaluation.

Introduction of color-flow injection test to confirm intravascular location of peripherally placed intravenous catheters

BACKGROUND

The incidence of infiltration and extravasation when using peripheral intravenous catheters is high in pediatric patients. Due to the lack of a gold standard test to confirm intravascular location of a peripherally placed intravenous catheter, we introduce a novel method, the color-flow injection test to assess the intravascular location of these catheters. For the color-flow injection test, 1 mL of normal saline was injected within 2 seconds in the distal intravenous catheter and changes in color-flow via ultrasonography were observed at the proximal draining veins. The primary objective of the study was to demonstrate feasibility of the color-flow injection test.

METHODS

A prospective study was conducted on children <18 years old undergoing general anesthesia. All peripheral intravenous catheters were subject to the color-flow injection test and standard confirmation tests.

RESULTS

Out of the 100 patients enrolled, 22 patients came to the operating room with preexisting peripheral intravenous catheters. Intraoperatively, 105 attempts were made on 78 patients of which 27 catheters were considered as infiltrated during their placement. A final set of 100 catheters were considered for intraoperative usage after they had passed at least one of the standard confirmatory tests. For the color-flow injection test, the ideal sites for ultrasound evaluation of proximal draining veins were the axillary veins and femoral veins. The color-flow injection test was positive in 93 of the 100 catheters with color-flow changes noticed in the proximal veins during the saline injection. Of the 100 catheters, infiltration around seven catheter sites were observed within 2 hours of intraoperative usage and the color-flow injection test was negative in these seven catheters. The color-flow injection test was also negative in the 27 catheters that had infiltrated during their placement. The color-flow injection test was sensitive at 100% [95% confidence interval (CI)=95-100] and specific at 100% (95% CI=56-100) to indicate intravascular location.

CONCLUSION

We were able to confirm intravascular location of peripheral intravenous catheters using the color-flow injection test in pediatric patients. The test can lead to early recognition of malfunctioning peripheral intravenous catheters and decrease rate of infiltration-extravasation injuries associated with their use.