Using Ultrasonography for Vessel Diameter Assessment to Prevent Infiltration

Optimizing Infusate Flow Patterns for Minimizing Vein Wall Trauma: An Exploratory Study with a Modified off-Axis Catheter Tip Opening

Objective

Modifying the PIVC tip to direct infusates toward areas of highest hemodilution may reduce vein wall damage. This study compared flow patterns between a traditional PIVC with a central opening and one with an off-axis aperture.

Methods

This was an exploratory observational analysis conducted at a tertiary care emergency department (ED) comparing flow patterns of two intravenous catheters: PIVC 1 (2.95 cm 20 gauge [Autoguard, Becton Dickinson]) and PIVC 2 (3.68 cm 20 gauge [Osprey, SkyDance Vascular]). Adult ED patients with PIVCs placed via traditional palpation/visualization method and with ultrasound capturing the flushing were eligible participants. Ultrasounds were reviewed to determine vein, catheter, and flow characteristics. The primary outcome was angle of the infusate leaving the catheter. Secondary outcomes included direction of catheter tip against vein wall, distance away from vein wall, vasospasm, and laminar/turbulent flow.

Results

Data from December 2023 included 28 catheters (10 PIVC 1, 18 PIVC 2). The average patient age was 53.7 years; 53.6% were female. Vein diameter/depth were similar: 0.35 cm/0.41 cm for PIVC 1 and 0.37 cm/0.47 cm for PIVC 2. The catheter tip pointed posteriorly towards the vein wall in 60% of PIVC 1 vs 11.1% in PIVC 2 (P=0.018). The angle of infusate flow away from the vein wall was 0.20° (SD 0.63) for PIVC 1 and 7.61° (SD 5.71) for PIVC 2 (P<0.001). Flow at 0° occurred in 90% of PIVC 1 vs 16.7% in PIVC 2 (P<0.001).

Conclusion

In this exploratory investigation, a peripheral vascular access device with an off-axis tip aperture of demonstrated a sharper infusate flow angle away from the vein wall compared to a traditional central opening device. This redirection may reduce vein wall trauma and complications, though further research is needed to pair clinical outcomes with this technology.

Effects of ultrasound with an automatic vessel detection system using artificial intelligence on the selection of puncture points among ultrasound beginner clinical nurses

BACKGROUND

Ultrasound guidance increases the success rate of peripheral intravenous catheter placement. However, the longer time required to obtain ultrasound-guided access poses difficulties for ultrasound beginners. Notably, interpretation of ultrasonographic images is considered as one of the main reasons of difficulty in using ultrasound for catheter placement. Therefore, an automatic vessel detection system (AVDS) using artificial intelligence was developed. This study aimed to investigate the effectiveness of AVDS for ultrasound beginners in selecting puncture points and determine suitable users for this system.

METHODS

In this crossover experiment involving the use of ultrasound with and without AVDS, we enrolled 10 clinical nurses, including 5 with some experience in peripheral intravenous catheterization using ultrasound-aided methods (categorized as ultrasound beginners) and 5 with no experience in ultrasound and less experience in peripheral intravenous catheterization using conventional methods (categorized as inexperienced). These participants chose two puncture points (those with the largest and second largest diameter) as ideal in each forearm of a healthy volunteer. The results of this study were the time required for the selection of puncture points and the vein diameter of the selected points.

RESULTS

Among ultrasound beginners, the time required for puncture point selection in the right forearm second candidate vein with a small diameter (<3 mm) was significantly shorter when using ultrasound with AVDS than when using it without AVDS (mean, 87 vs 247 s). Among inexperienced nurses, no significant difference in the time required for all puncture point selections was found between the use of ultrasound with and without AVDS. In the vein diameter, significant difference was shown only in the absolute difference at left second candidate among inexperienced participants.

CONCLUSION

Ultrasonography beginners needed less time to select the puncture points in a small diameter vein using ultrasound with AVDS than without AVDS.

Predictors of ultrasound-guided peripheral intravenous catheter failure: A secondary analysis of existing trial data

OBJECTIVES

Ultrasound-guided (US) peripheral intravenous catheters (PIVC) have a high failure rate with many failing prior to completion of therapy. Risk factors associated with catheter failure are poorly delineated. This study aimed to assess risk factors related to catheter failure including patient, procedure, catheter, and vein characteristics to further elucidate which variables may impact catheter longevity.

METHODS

This was a secondary analysis using an existing trial dataset that primarily compared survival of two catheters: a standard long (SL) and an ultra-long (UL) US PIVC. Adult emergency room patients with difficult intravenous access at a tertiary care suburban academic center were study participants. Kaplan-Meier was employed to estimate the median catheter survival time. Cox regression univariable and multivariable analyses were used to evaluate the primary outcome of catheter survival.

RESULTS

Among 257 subjects, 63% of PIVCs survived until completion of therapy. In a multivariable Cox regression model, length of catheter in vein >2.75 cm (adjusted hazard ratio [aHR] 0.58, 95% confidence interval [CI] 0.37-0.90, p = 0.01) was associated with improved survival. First stick success decreased the risk of catheter failure (aHR 0.68, 95% CI 0.44-1.06, p = 0.09) but was not statistically significant. Factors associated with the increased risk of catheter failure included: depth of vein >1.2 cm (aHR 1.68, 95% CI 1.06-2.66, p = 0.03) and PIVC placement in right extremity (aHR 1.64, 95% CI 1.07-2.51, p = 0.02).

CONCLUSIONS

This study demonstrated that catheter length in vein (>2.75 cm) was associated with improved US PIVC survival highlighting the value of longer catheters in US PIVC survival. Choosing targets in the non-dominant extremity with shallower depths (⩽1.2 cm) may also increase catheter survival.

Operation STICK: A vascular access specialty program for the generalist emergency medicine clinician

OBJECTIVE

Comprehensive education and training programs are urgently needed to improve vascular access outcomes in the emergency department (ED). This study aimed to demonstrate the success of a formalized vascular access program in developing competent ED clinicians in traditional and ultrasound-guided insertion methods.

METHODS

This was a retrospective observational study exploring the success of trainees in obtaining competency in peripheral vascular access at an academic suburban ED with 120,000 annual visits. Eligible participants included healthcare workers that enrolled in the Operation STICK vascular access program and perform vascular access procedures as an aspect of their clinical practice. Competency in vascular access included both traditional and ultrasound-guided (US) peripheral intravenous catheter (PIVC) insertions. Competency was defined as demonstration of successful insertion of one traditional and one US PIVC in compliance with checklist. The primary objective was competency. Secondary objectives included trainee time to competency, trainee number of line encounters, and changes in program competency achievements over time.

RESULTS

From October 15, 2021, to April 15, 2023, 141 clinicians participated in peripheral vascular access training via the Operation STICK model, which included 72 (51.1%) nurses, 52 (36.9%) ED technicians, and 17 (12.0%) healthcare personnel with other medical training. Clinicians overall reported an average of 5.6 years of experience inserting peripheral intravenous catheters (PIVCs) and 23 (16.3%) had experience with using ultrasound. About 122 (86.5%) clinicians successfully completed the program and demonstrated competency in traditional and ultrasound-guided techniques. Time to competency varied over time, with a median of 124 days in the early phase, 32.5 days middle phase, and 10.6 h over 9.5 days in the later phase of the program (p < 0.001).

CONCLUSIONS

Achieving competency in PIVC insertion necessitates a focused effort on refining and systematizing education and training approaches. Recognizing the inherent challenges present in ED settings, it is feasible to effectively and efficiently train emergency clinicians to be expert in both basic and advanced PIVC placement techniques through participation in a well-organized vascular access training program.

A standardized educational program to improve peripheral vascular access outcomes in the emergency department: A quasi-experimental pre-post trial

OBJECTIVE

Difficult intravenous access (DIVA) patients are known to have disproportionately poorer vascular access outcomes. The impact of education and training on vascular access outcomes in this vulnerable population is unclear. We aim to demonstrate the success of a program (Operation (O) STICK) on improving vascular access outcomes in DIVA patients.

METHODS

This was a quasi-experimental pre-post interventional study conducted at a tertiary care emergency department (ED) with 120,000 annual visits and 1100 hospital beds. Adult patients requiring an ultrasound-guided (US) peripheral intravenous catheter (PIVC) in the ED were eligible participants. Traditional (palpation method) insertions were excluded. Using multivariable linear regression and inverse probability weighted (IPW) linear regression, the standard group inclusive of PIVCs inserted by staff without formalized OSTICK training were compared to the interventional group inclusive of PIVCs inserted by staff with training and competency in the OSTICK training model.

RESULTS

Data were collected over two time intervals: 4/1/21-9/30/21 (pre; non-OSTICK) and 10/1/22-3/31/23 (post; OSTICK). 2375 DIVA patients included 1035 (43.6%) non-OSTICK and 1340 (56.4%) OSTICK PIVCs. Overall, OSTICK PIVCs had a higher proportion of upper arm or forearm placements (94.6% vs 57.4%; p < 0.001), 20 gauge catheters (97.1% vs 92.3%; p < 0.001), and left-sided placements (54.4% vs 43.5%; p < 0.001). 62.7% of OSTICK PIVCs were placed by ED technicians, compared to 25.5% in the non-OSTICK group (p < 0.001). OSTICK PIVCs were placed on the first attempt 86.2% of the time and by the second attempt 95.4% of the time. In a subanalysis of 1343 hospitalized patients (689 (51.3%) OSTICK vs 654 (48.7%) non-OSTICK), OSTICK PIVCs survived for a median of 92% of the patient's hospital length of stay, compared to non-OSTICK PIVCs at 74% (p < 0.001).

CONCLUSIONS

Formalized vascular access training in the ED leads to improved adherence to best practices for PIVC insertion, high success of cannulation with minimal attempts, and improved PIVC functionality during hospitalization for DIVA patients. Importantly, these outcomes are sustainable as they were captured 12 months after implementation of the program.

Investigative study of hemodilution ratio: 4Vs for vein diameter, valve, velocity, and volumetric blood flow as factors for optimal forearm vein selection for intravenous infusion

BACKGROUND

Multimodal research and guidelines recognize veins in the forearm used for peripheral intravenous catheter (PIVC) insertion can optimize dwell time. Yet, many PIVCs are still placed in areas of flexion or suboptimal locations such as the back of the hand causing premature failure of >50%. This study identified characteristics of the forearm cephalic vein that make the anatomical location highly successful for PIVC insertion. The goal was to increase the understanding of the human vasculature in association with fluid mechanics in veins above the wrist and below the antecubital fossa.

METHODOLOGY

A prospective in-vivo study with 10 consented healthy human volunteers (HHVs) was performed with Color Pulse Wave Doppler Ultrasound that captured high-resolution video and images of vein diameter, velocity of blood flow, and location of venous valves in the forearm.

RESULTS

Forearm vein diameter was not directly correlated with higher or lower Velocity of Blood Flow (0.58 cm = 3.0 cm/s). However, Volumetric Blood Flow rates tended to be lower (2.51-8.28 mL/min) with Vein Diameters smaller than 0.29 cm. Ultrasound assessments and Volumetric Blood Flow calculations confirmed natural turbulence in blood and retrograde blood reflux correlated with venous valves opening and closing. Areas of turbulence, with pulse flushing, created backflow with retrograde blood flow around and into the catheter.

CONCLUSIONS

Placement of long PIVCs in the cephalic veins of the upper forearm yield adequate flow and hemodilution capacity for veins with at least a 3 to 1 hemodilution ratio. The data from this study, along with previous research, suggest that PIVC placement in the cephalic vein, based on selection criteria, may help to reduce or eliminate intravenous complications such as chemical or mechanical thrombophlebitis causing premature catheter failure. Application of these investigational principles may result in better outcomes and catheter longevity for patients who require intravenous infusions.

Risk of midline catheter-related thrombosis due to catheter diameter: An observational cohort study

OBJECTIVE

Deep vein thrombosis is a common and serious complication associated with midline catheters (MC). The aim of this investigation was to determine if catheter diameter is related to development of thrombosis.

METHODS

This was an observational cohort study conducted at a tertiary care academic center in Southeastern Michigan. Hospitalized adults that required a MC were eligible participants. Primary outcome was symptomatic MC associated upper extremity deep vein thrombosis (DVT) comparing three catheter diameters. Secondary outcomes included complications based on size and DVT comparing catheter to vein ratio.

RESULTS

Between January 1, 2017, and December 31, 2021, 3088 MCs met inclusion criteria; the distribution of 3 French (Fr), 4 Fr, and 5 Fr MCs was 35.1 %, 57.0 %, and 7.9 %, respectively. The majority of the population was female (61.2 %) and the average age was 64.2 years old. DVT occurred in 4.4 %, 3.9 %, and 11.9 % of 3 Fr, 4 Fr, and 5 Fr MCs, respectively (p < 0.001). In multivariable regression analysis, there was no difference in the odds of developing DVT for the 4 Fr MC compared to the 3 Fr (aOR 0.88; 95 % CI 0.59-1.31; p = 0.5243), however, there was significantly higher odds for the 5 Fr (aOR 2.72; 95 % CI 1.62-4.51; p = 0.001). Additionally, for every additional day the MC was in place, the odds of DVT increased by 3 % (aOR 1.03; 95 % CI 1.01-1.05; p = 0.0039). When comparing accuracy of the size model versus catheter to vein ratio model for predicting DVT, receiver operating characteristic curve analysis demonstrated the area under the curve for size was 73.70 % (95 % CI 68.04 %-79.36 %) compared to 73.01 % (95 % CI: 66.88 %-79.10 %) for catheter-to-vein ratio.

CONCLUSIONS

Smaller diameter catheters should be preferentially chosen to mitigate the risk of thrombosis when therapy via midline catheters is required. Choosing a catheter based on reduced size or 1:3 catheter to vein ratio threshold has similar accuracy in predicting DVT.

Blood vessel detection using skin impedance tomography and spectroscopy

Blood vessel detection is an essential method in a non-invasive circulatory monitoring system. However, only using camera-based image processing for finding a vein has many limitations due to the complexity of underneath tissue. Impedance tomography and spectroscopy can collect electrical characteristics map of the biological tissue precisely. The study developed instrumentation to measure the impedance with eight small electrodes, which can observe near vein area and show the conductivity map with small patches using tomographic reconstruction. The study examined the cephalic vein of a healthy human arm to confirm the feasibility of vein location recognition. The system could perform 86.8% pixel accuracy and achieve a mIoU score of 63.7% for vessel location segmentation in 5cm2 area observation. The system could identify a human blood vessel's electrical characteristic and visualize the passage.Clinical Relevance- This approach will support intravascular therapy by identifying the vessel location automatically and providing information to the vessel monitoring system in backend. In addition, the system would allow efficient data entry into the electronic medical record for management of hospitalized patients.

Verification study on the catheterization of an upper arm vein using the new long peripheral intravenous catheter to reduce catheter failure incidence: A randomized controlled trial

Intravenous infusion using a peripheral intravenous catheter (PIVC) is often complicated by catheter failure (CF). We hypothesized that catheterization of an upper arm vein instead of a forearm vein may help prevent CF. This study was designed to compare the incidence of CF in patients receiving hyper-stimulant drugs when catheters are placed in the forearm using short PIVCs (SPCs) with that when catheters are placed in the upper arm using the new long PIVCs. Patients admitted to a university hospital in Tokyo, Japan were enrolled in this study and were assigned to the SPC or the new long PIVC group. The primary outcome was the incidence of CF until 7 days. The secondary outcomes were the number of CFs per 1,000 days, the duration of the indwelling catheter, and the presence of thrombi and subcutaneous edema. Forty-seven patients were analyzed (median age, 67.0 years). The incidence of CF was 0% in the new long PIVCs and 32.0% (8 catheters) in the SPCs (p = 0.007), and the number of CF per 1,000 days was 0/1,000 and 81.7/1,000 days, respectively (p = 0.001). A significant difference in the duration of the indwelling catheter until CF occurrence was observed between the two groups (p = 0.004). Thrombi and subcutaneous edema were observed more frequently in the SPC group (p < 0.001). Catheterization of an upper arm vein using the new long PIVC to administer a hyper-stimulant drug might reduce CF compared with catheterization of a forearm vein using SPC.

Fracture of an Intravenous Cannula in the Hand: A Case Report

BACKGROUND

Intravenous cannula insertion is important, given that it is the most common invasive procedure in the emergency department for blood sampling, fluid resuscitation, and intravenous drug administration. Complications of intravenous catheterization include pain, phlebitis, extravasation, inflammation, and embolization. Fracture of an intravenous cannula is rare, but delayed removal may result in secondary damage, such as vasculitis or embolization, with critical consequences. Here, we report a case of intravenous cannula fracture that occurred in our emergency department.

CASE PRESENTATION

A 63-year-old woman with a history of left ovarian cancer visited our emergency department owing to poor oral intake and general weakness. Intravenous catheterization using an 18 gauge cannula was attempted for intravenous fluid administration by a skilled operator, but it failed owing to collapsed veins and poor skin condition. After several attempts, a vein in the patient's hand was ruptured, and the patient complained of severe pain. The cannula was removed, but one-third of the cannula tip could not be seen. X-ray imaging was performed to locate the fragment of the cannula, and venotomy was performed for removal of the foreign body in the emergency department.

CONCLUSION

Emergency physicians and nurses should be vigilant about potential risk factors that can cause fracture of an intravenous cannula, and after the fracture is discovered, rapid removal of the cannula tip should be performed in the emergency department.

Effectiveness of ultrasonography for peripheral catheter insertion and catheter failure prevention in visible and palpable veins

BACKGROUND

The increase in the success rate of peripheral intravenous catheterization against a difficult intravenous access (DIVA) using ultrasonography is reported; however, reports related to the effectiveness of using ultrasonography in increasing the success rate for visible and palpable veins is limited. Furthermore, according to a previous study, first attempt success in catheterization contributes to low catheter failure incidence. Thus, we developed a catheterization method using ultrasonography for peripheral veins including visible and palpable veins. This study investigates the effectiveness of ultrasonography use in improving the success rate of catheterization and preventing the catheter failure for peripheral veins including visible and palpable veins.

METHODS

Adult inpatients were recruited. Trained nurses inserted intravenous catheters using ultrasonography. Ultrasonography was used for all vein assessment, target vein selection, and puncturing (i.e. target point selection and/or needle guidance), regardless of the target vein's visibility or palpability. Catheters with over a 24-h dwelling time were followed for catheter failure incidence.

RESULTS

Thirty-one patients were recruited, and they required 34 catheterizations. Total number of catheterization attempts were 39. Of the peripheral veins, 51.3% (20/39) were visible and palpable, 48.7% (19/39) were DIVA. The rate of successful intravenous cannulation was 29 of 34 (85.3%) after one attempt and 4 of 34 (total 97.0%) after two attempts. The catheterization failure incidence was 3.2% (1/31) in the catheter that had an over 24-h dwelling time.

CONCLUSIONS

Using ultrasonography to all target veins might have contributed to higher success rates of catheterization and extremely low incidence of catheter failure based on objective findings. Selecting the vein with larger diameters and healthy tissue as puncture point and showing center of vessel lumen clearly using ultrasonography might have been contributed the results.

Safety verification of a new peripheral intravenous catheter placed in the upper arm vein for administration of drugs with high irritant potential

Despite the widespread use of peripheral intravenous catheters, unscheduled catheter failure before completion of treatment occurs frequently. If a large vein is selected, catheter failures may be prevented despite administering a highly irritant drug. In this study, we attempted to use a catheter that can be placed in a large upper arm vein. The new catheter was 88 mm long but had no guidewire to reduce contamination risk. This study aimed to evaluate the safety of the first-in-human trial for the new catheter with the administration of highly irritant drugs. This study was conducted at a university hospital in Tokyo, Japan. Eight Japanese adults were hospitalized adults with planned administration of non-cancer drugs with high irritant potential using a peripheral catheter. A trained nurse catheterized with the new catheter in the upper arm using ultrasonography. The catheterization site was monitored by staff and a research nurse once every 24 hours for up to 7 days. No adverse events or catheter failure occurred and the catheter placement success rate was 100%. In two patients, a temporary occlusion alarm of the infusion pump occurred, possibly due to the flexion of the catheter base. The new peripheral intravenous catheter did not interrupt medical treatments as is common after placement, but safety administered the irritant drugs. However, because this catheter may be easily affected by the contraction of the muscle at the fixation position, the position and method of catheter fixation in the upper arm need to be carefully considered.

Automatic vein measurement by ultrasonography to prevent peripheral intravenous catheter failure for clinical practice using artificial intelligence: development and evaluation study of an automatic detection method based on deep learning

OBJECTIVES

Complications due to peripheral intravenous catheters (PIVC) can be assessed using ultrasound imaging; however, it is not routinely conducted due to the need for training in image reading techniques. This study aimed to develop and validate a system that automatically measures blood vessel diameters on ultrasound images using artificial intelligence (AI) and provide recommendations for selecting an implantation site.

DESIGN

Pilot study.

SETTING

The University of Tokyo Hospital, Japan.

PRIMARY AND SECONDARY OUTCOME MEASURES

First, based on previous studies, the vessel diameter was calculated as the mean value of the maximum long diameter plus the maximum short diameter orthogonal to it. Second, the size of the PIVC to be recommended was evaluated based on previous studies. For the development and validation of an automatic detection tool, we used a fully convoluted network for automatic estimation of vein location and diameter. The agreement between manually generated correct data and automatically estimated data was assessed using Pearson's product correlation coefficient, systematic error was identified using the Bland-Altman plot, and agreement between catheter sizes recommended by the research nurse and those recommended by the system was evaluated.

RESULTS

Through supervised machine learning, automated determination was performed using 998 ultrasound images, of which 739 and 259 were used as the training and test data set, respectively. There were 24 false-negatives indicating no arteries detected and 178 true-positives indicating correct detection. Correlation of the results between the system and the nurse was calculated from the 178 images detected (r=0.843); no systematic error was identified. The agreement between the sizes of the PIVC recommended by the research nurse and the system was 70.2%; 7% were underestimated and 21.9% were overestimated.

CONCLUSIONS

Our automated AI-based image processing system may aid nurses in assessing peripheral veins using ultrasound images for catheterisation; however, further studies are still warranted.t.

Catheter failure in the administration of hyperosmotic drugs through a peripheral vein and vascular selection: A retrospective cohort study

This study aimed to determine whether the placement of a peripheral intravenous catheter (PIVC) in the cephalic vein of the forearm could prevent PIVC failure in patients receiving hyperosmotic drugs through the peripheral vein. This retrospective cohort study included patients aged ≥ 20 years who had received infusion therapy via a PIVC in our institution between July and November 2017. Patients were divided into groups according to PIVC insertion into the cephalic, basilic, and medial veins. PIVCs used to administer drugs with osmotic pressure ratios > 2.0 were included. The primary outcome was survival time to catheter failure. Catheter failure was defined as accidental and unplanned catheter removal. We set the cephalic vein and other veins, including the medial and basilic veins, in the forearm as cohort groups. We used the Kaplan-Meier survival curves to compare the time until catheter failure in the cohort groups. The Cox proportional hazard models were fitted, and the hazard ratios were calculated. A total of 46 catheters with hyperosmotic agents were included in the analysis. Catheter failure was observed in 25 (54.3%) cases. Time to catheter failure in patients receiving high-dose drugs via the cephalic vein was significantly longer than that in the other two groups (p < 0.01). Thus, the cephalic vein, which has a high blood flow, is the ideal site of PIVC insertion in patients receiving high drug concentrations to prevent catheter failure.

Damage to subcutaneous tissue at the catheterization site during chemotherapy: A prospective observational study using ultrasonography

PURPOSE

Chemotherapy administration can affect subcutaneous tissue at the catheterization site with no macroscopic signs or subjective symptoms. Yet clinical studies about the impact of chemotherapy on tissue at the catheterization site, except for apparent extravasation cases, are limited. This study aimed to investigate subcutaneous tissue changes in nonmacroscopically damaged catheterization sites after chemotherapy administration.

METHODS

Participants were people with cancer receiving outpatient chemotherapy. Ultrasonographic images were used to assess the condition of subcutaneous tissues, including the vein, at the catheterization site before catheterization, immediately after chemotherapy, and on the next scheduled treatment day. Data on macroscopic inspection, palpation, and subjective symptoms were also collected and analyzed.

RESULTS

Data from 41 participants were analyzed. All had normal subcutaneous tissues before catheterization. After treatment, 16 (39.0%) manifested abnormalities such as subcutaneous edema, vessel wall thickening, and/or thrombosis; there was no extravasation immediately after treatment. On the next treatment day, 15 (36.6.%) showed persistent or new onset of abnormalities, including subcutaneous edema. Eight of the 15 did not exhibit any subjective symptoms or macroscopic or palpation findings.

CONCLUSION

After chemotherapy administration via peripheral intravenous catheters, it was found that this damage, which was difficult to detect by the conventional assessment method, persisted. Ultrasonography can provide useful information to avoid reusing damaged sites for chemotherapy administration.

A prospective sonographic evaluation of peripheral intravenous catheter associated thrombophlebitis

OBJECTIVE

Thrombophlebitis associated with peripheral intravenous catheters (PIVCs) is a poorly described complication in the literature. Given limited accuracy of current assessment tools and poor documentation in the medical record, the true incidence and relevance of this complication is misrepresented. We aimed to identify risk factors in the development of thrombophlebitis using an objective methodology coupling serial diagnostic ultrasound and clinical assessment.

METHODS

We conducted a single-site, prospective observational cohort study. Adult patients presenting to the emergency department that underwent traditionally placed PIVC insertion and were being hospitalized with an anticipated length of stay greater than 2 days were eligible participants. Using serial, daily ultrasound evaluations and clinical assessments via the phlebitis scale, we identified patients with asymptomatic and symptomatic thrombosis. The primary goal was to identify demographic, clinical, and IV related risk factors associated with thrombophlebitis. Univariate and multivariate analyses were employed to identify risk factors for thrombophlebitis.

RESULTS

A total of 62 PIVCs were included between July and August 2020. About 54 (87.10%) developed catheter-related thrombosis with 22 (40.74%) of the thrombosed catheters were characterized as symptomatic. Multivariate cox regression demonstrated that catheter diameter relative to vein diameter greater than one-third [AHR = 5.41 (1.91, 15.4) p = 0.0015] and angle of distal tip of catheter against vein wall ⩾5° [AHR = 4.39 (1.39, 13.8) p = 0.0116] were associated with increased likelihood of thrombophlebitis.

CONCLUSIONS

Our study found that the increased proportion of catheter relative to vein size and steeper catheter tip angle increased the risk of thrombophlebitis. Catheter size relative to vein size is a modifiable factor that should be considered when inserting PIVCs. Additional larger prospective investigations using objective methodologies are needed to further characterize complications in PIVCs.

Changes in the subcutaneous tissue of catheterization site from the precatheterization state to the onset of anticancer drug-induced induration: A case report

This case showed that anticancer drug administration induces unhealthy subcutaneous tissue (thrombus or edema) without subjective symptoms, abnormal sign by palpation, or inspection, which have an extravasation risk.

Incidence, risk factors and medical cost of peripheral intravenous catheter-related complications in hospitalised adult patients

BACKGROUND

Peripheral intravenous catheters (PVCs) are widely used vascular access devices for infusion therapy; however, they are associated with relatively high failure rates. This study aimed to identify the incidence, risk factors and medical costs of PVC-induced complications in adult hospitalised adult patients in China.

METHODS

An observational, prospective study on 1069 patients lasting 5 months was conducted at a tertiary teaching hospital.

RESULTS

Infiltration ranked first among PVC complications with an incidence of 17.8%, followed by occlusion (10.8%) and phlebitis (10.5%). Most complications in phlebitis (88.4%) and infiltration (93.7%) were Grade 1. Catheters left in for over 96 h did not show a higher incidence of complications. Patients from the surgical department were more susceptible to infiltration, phlebitis and occlusion. The 26 gauge (Ga) catheters decreased the risk of phlebitis and occlusion, whereas 24Ga catheters increased infiltration rates. Infusing irritant drugs increased phlebitis and infiltration rates. The presence of comorbidities and non-use of needleless connectors were associated with occlusion. Compared with forearm insertion, the risk of occlusion nearly doubled with the dorsum of the hand insertion and the risk of infiltration tripled with antecubital fossa insertion. Medical treatment costs for PVC complications ranged from 0.3 to 140.0 CNY.

CONCLUSIONS

Infiltration is the most common PVC-related adverse event. Clinically-indicated instead of routine replacement of catheters is safe. More efforts are warranted to improve nurses' adherence to recent guidelines in terms of insertion site selection and needleless connector utilisation to reduce medical costs associated with catheter replacement.

Ultrasound-guided peripheral vascular catheterization in pediatric patients: a narrative review

Peripheral vascular catheterization (PVC) in pediatric patients is technically challenging. Ultrasound guidance has gained the most interest in perioperative and intensive care fields because it visualizes the exact location of small target vessels and is less invasive than other techniques. There have been a growing number of studies related to ultrasound guidance for PVC with or without difficult access in pediatric patients, and most findings have demonstrated its superiority to other techniques. There are various ultrasound guidance approaches, and a comprehensive understanding of the basics, operator experience, and selection of appropriate techniques is required for the successful utilization of this technique. This narrative review summarizes the literature regarding ultrasound-guided PVC principles, approaches, and pitfalls to improve its clinical performance in pediatric settings.

Preventing peripheral intravenous catheter failure by reducing mechanical irritation

Peripheral intravenous catheter failure is a significant concern in the clinical setting. We investigated the effectiveness of care protocols, including an ultrasonographic “pre-scan” for selecting a large-diameter vein before catheterization, a “post-scan” for confirming the catheter tip position after catheterization with ultrasonography, and the use of a flexible polyurethane catheter to reduce the mechanical irritation that contributes to the incidence of catheter failure. This intervention study was a non-randomized controlled trial to investigate the effectiveness of the abovementioned care protocols, the effects of which were compared to the outcomes in the control group, which received conventional care. For both groups, participants were selected from patients in two wards at the University of Tokyo in Japan between July and November 2017. Inverse probability score-based weighted methods (IPW) using propensity score were used to estimate the effectiveness of care protocols. The primary outcome was catheter failure, which was defined as accidental and unplanned catheter removal. We used Kaplan-Meier survival curves to compare rates of time until catheter failure. We analysed 189 and 233 catheters in the intervention and control groups, respectively. In the control group, 68 catheters (29.2%) were determined to have failed, whereas, in the intervention group, only 21 catheters (11.1%) failed. There was a significant difference between each group regarding the ratio of catheter failure adjusted according to IPW (p = 0.003). The relative risk reduction of the intervention for catheter failure was 0.60 (95% CI: 0.47–0.71). Care protocols, including assessment of vein diameter, vein depth, and catheter tip location using ultrasound examination for reducing mechanical irritation is a promising method to reduce catheter failure incidence.

Catheter tips are a possible resource for biological study on catheter failure

Few studies have investigated the molecular mechanisms of catheter failure (CF). Herein, we performed histological and molecular biological analyses of the catheter tip to demonstrate its potential as a resource for biological investigation. Additionally, we searched for risk factors for the development of inflammation and coagulation, which are pathological conditions clarified by biological analysis. The CF group included 30 failed catheters involving thrombus and subcutaneous edema identified by ultrasonography. The No-CF group included 26 catheters with no complications. The removed catheter tips were fixed for hematoxylin-eosin (HE) staining with the application of a real-time reverse transcriptase polymerase chain reaction for eukaryotic 18S ribosomal RNA (rRNA), interleukin 1β, tumor necrosis factor α, tissue plasminogen activator, and plasminogen activator inhibitor 1 (SERPINE1). HE staining identified attached nuclear cells on the inner surfaces of both CF and No-CF catheters. The 18S rRNA was amplified in all samples. The expression level of SERPINE1 was significantly higher in the CF group than in the No-CF group (p = 0.01), whereas the expression levels of other genes did not differ between the groups. Symptoms of CF associated with the expression of SERPINE1 were analyzed. The catheter being in contact with blood vessels during placement was a suggested factor related to the high expression of SERPINE1 (p = 0.04). Catheter tips are a potential resource for biological investigation, and expression analysis of the attached cells can reflect the pathological condition of the catheterized tissue. Further studies using catheter tips are required to elucidate the molecular mechanisms of CF.

Ultrasound-guided peripheral venous cannulation in critically ill patients: a practical guideline

BACKGROUND

Up to one-third of critically ill patients have difficult intravenous access (DIVA). This occurs often in obese patients, those with generalized edemas or in patients with previous venous cannulations. In DIVA patients, the conventional technique often fails. In contrast, ultrasound-guided cannulation has demonstrated a high success rate, improving patient satisfaction and even a reduction in the need of central venous lines. However, a high rate of premature catheter failure has been shown in cannulations performed by ultrasound guidance and thus a comprehensive knowledge of several aspects related to this procedure is mandatory to improve cannulation success, avoid complications and lengthen the survival of the catheter.

MAIN TEXT

Several practical issues related to peripheral venous cannulation are described: peripheral venous anatomy, vein size and catheter selection, distance from skin to vein, insertion angle and selection of the catheter length, cannulation technique itself (out-of-plane or in-plane) and checking catheter position.

CONCLUSION

Key concepts regarding ultrasound-guided peripheral vein cannulation should be well known for practitioners, aiding in improving cannulation success and catheter dwell time, and avoiding complications.

Quality Improvement Initiative Reduces the Occurrence of Complications in Peripherally Inserted Central Catheters

Peripherally inserted central catheters (PICCs) are commonly used to access the central venous system. However, central vascular access devices are associated with a risk of complications, which may include infection, thrombosis, occlusion, or malposition. The vascular access team of 1 midwestern hospital used a quality improvement initiative to reduce the occurrence of complications associated with PICCs. A secondary aim was to reduce the number of alteplase (Cathflo Activase; Genentech, South San Francisco, CA) doses administered. After reviewing current evidence, the vascular access team employed the Plan-Do-Study-Act cycle to document and implement changes in practice. By using a team initiative to investigate this issue, complication rates decreased and patient satisfaction improved. The thrombosis rate decreased by 67%, occlusions by 75%, and alteplase use by 87%. No infections occurred during this study.

The mechanistic causes of peripheral intravenous catheter failure based on a parametric computational study

Peripheral intravenous catheters (PIVCs) are the most commonly used invasive medical device, yet up to 50% fail. Many pathways to failure are mechanistic and related to fluid mechanics, thus can be investigated using computational fluid dynamics (CFD). Here we used CFD to investigate typical PIVC parameters (infusion rate, catheter size, insertion angle and tip position) and report the hemodynamic environment (wall shear stress (WSS), blood damage, particle residence time and venous stasis volumes) within the vein and catheter, and show the effect of each PIVC parameter on each hemodynamic measure. Catheter infusion rate has the greatest impact on our measures, with catheter orientation also playing a significant role. In some PIVC configurations WSS was 3254 times higher than the patent vein, and blood damage was 512 times greater, when compared to control conditions. Residence time is geometry-dependent and decreases exponentially with increasing insertion angle. Stasis volume decreased with increasing infusion rate and, to a lesser degree, insertion angle. Even without infusion, the presence of the catheter changes the flow field, causing low velocity recirculation at the catheter tip. This research demonstrates how several controllable factors impact important mechanisms of PIVC failure. These data, the first of their kind, suggest limiting excessive infusion rates in PIVC.

An Accuracy Study of the Intracavitary Electrocardiogram (IC-ECG) Guided Peripherally Inserted Central Catheter Tip Placement among Neonates

Objective

To explore the clinical application of the intracavitary electrocardiogram (IC-ECG) guided Peripherally Inserted Central Catheter (PICC) tip placement among neonates.

Background

the ECGs of neonates are difficult to perform and their wave shapes are of doubtful accuracy due to various interfering factors

Method

115 neonates were admitted to perform PICC guided by IC-ECG. Logistic regression was performed to analyze all possible influencing factors of the accuracy from the tip placement. The puncture site of the PICC, gestational age, height, weight, basal P/R amplitude and positioning P/R amplitude might be related to the accuracy of IC-ECG location.

Result

The accuracy in the lower extremity was higher than that in the upper extremity. Multivariate logistic regression analysis showed that the weight (Odds Ratio (OR)=1.93, 95%Confidence Interval(CI):1.06-3.50) and positioning P/R amplitude (OR=32.33, 95%CI: 2.02-517.41) are statistically significant risks to the accuracy PICC tip placement.

Conclusions

Possible methods to improve the accuracy might be Catheterizing through lower extremity, keeping the neonates calm, enhancing the electrocardiogram signal and strengthening technical training. Therefore it is practical to perfrom a tip placement by the dynamic change in the P waves from an electrocardiogram (ECG) guided PICC among neonates and as reliable as using X-rays.

A New Ultrasonographic Image Displaying System to Support Vein Detection

[abstFig src='/00290002/04.jpg' width='300' text='Virtual ultrasonic probe system' ] The insertion of a peripheral intravenous catheter is often required by patients during a hospital stay. However, approximately 30% of intravenous catheters experience catheter failure. Using ultrasonography to observe the depth and diameter of a vein and to thereby perform catheter site selection is a promising procedure to prevent catheter failure. Nevertheless, it is difficult to perform this procedure, as it is associated with complicated maneuvering in which a nurse simultaneously manipulates an ultrasonographic probe, assesses veins, and inserts a catheter. In this study, a new image displaying system that consists of a camera, head-mounted display, and software is proposed. The newly developed image-processing program detects the fingertip of a user, and the system displays the reconstructed ultrasonographic image at any cross-sectional plane as indicated by the user’s finger. Additionally, veins are superimposed on the ultrasonographic image, and the depth and diameter of veins are also displayed on the image. The newly developed image-processing algorithm detects markers and fingertip in the images captured by the head-mounted camera by robustly detecting the fingertip. This aids in realizing a new ultrasonographic image displaying system. This system is used to increase the success rate of vein detection by nurses in a study of volunteers.

Low-Angled Peripheral Intravenous Catheter Tip Placement Decreases Phlebitis

Introduction

Peripheral intravenous catheters (PIVCs) are frequently removed due to phlebitis. We hypothesized that catheters made of polyurethane, which is more flexible than Teflon, would decrease phlebitis, and that flexibility could be estimated by measuring the catheter-tip angle. Ultrasonography in two groups of patients with different catheter types was then used to compare catheter-tip angles and phlebitis.

Methods

Observational studies were carried out at a medical ward in a university hospital. Infusion therapy was administered to one group of patients in 2014 using Teflon catheters (control group, n = 200), and to another group of patients in 2015 using polyurethane catheters (investigational group, n = 207). The symptoms were assessed according to a scale developed by the Infusion Nurses Society. Long-axis ultrasonography images taken immediately before catheter removal were used to measure the angle between the central line of the catheter within 2 mm from the distal point and a tangent to the vessel wall.

Results

There were no significant differences between the two groups with respect to sex, age, and medical diagnosis. In the control and investigational groups, the rates of phlebitis were 37% (73/200) and 17% (36/207), respectively (p<0.001). The median angles of the catheter tip were 7.8° and 4.1°, respectively (p<0.001). Phlebitis occurred more frequently when the catheter-tip was placed at angle >5.8°.

Discussion

The frequency of phlebitis was lower in the polyurethane, in which the catheter was placed at lower angle, almost parallel to the vessel. Our results will aid in developing new catheters and in improving PIVC-securement techniques.