Difficulties Related to Peripheral Intravenous Access in Children in an Emergency Room

Operational Definition of the Concept of Success in Peripheral Intravenous Catheterization in Hospitalized Children

The objective of this study was to operationally define the concept of success in peripheral intravenous catheterization in children considering the Walker and Avant model. This is a methodological study, carried out through the following steps: concept selection, the definition of the analysis objective, identification of possible uses of the concept, determination of critical or essential attributes, construction of a model and opposite case, and identification of antecedents and consequences. The study was carried out based on a search in international databases from January to March 2021. The sample consisted of 47 studies conducted in 17 countries between 2008 and 2021. Five attributes, 20 antecedents, 10 consequences, and an empirical reference of the studied concept were identified. Also, 2 cases, model and opposite, were elaborated, and an operational definition of the concept was developed. The Walker and Avant method enabled the operationalization of the concept of success of peripheral intravenous catheterization in children based on attributes, antecedents and consequents, and model and opposite cases.

Discursive analysis of nursing care toward childhood fever and its contextual differences: An ethnomethodological study

Fever is the most common clinical sign during infancy. Nurses deal with fever in children most directly and it is an integral aspect of their role as pediatric nurses. The objective of this study is to analyze the perceptions, knowledge and attitudes toward childhood fever of nurses in three health contexts: pediatric hospitalization, pediatric emergency and primary care. To respond this objective, a qualitative study with ethnomethodological approach has been carried out. In-depth interviews were conducted and theoretical clinical cases were presented to nurses working in pediatrics in the three settings studied. After the analysis of the discourses, the codes were classified into three categories: static and number-centric knowledge, dependent nursing attitude, and unconscious model nurses. On the one hand, when we analyze and compare the perceptions, attitudes and knowledge of the nurses between the different contexts, we find differences that consist mainly of what the context requires of them. On the other hand, in general and regardless of the context, the nurses interviewed place themselves in a traditional framework when faced with the phenomenon of fever in children.

Patient and Technical Factors Associated with Difficult Arterial Access and Ultrasound Use in the Operating Room

Arterial catheterization enables continuous hemodynamic monitoring but has been shown to cause severe complications, especially when multiple attempts are required. The aim of this study was to explore what factors were associated with multiple attempts and ultrasound use in the operating room. We performed a retrospective analysis of patients who had arterial catheters inserted at a tertiary care children's hospital from January 2018 to March 2022, identifying clinical factors that were associated with both outcomes. A total of 3946 successful arterial catheter insertions were included. Multivariable analysis showed multiple attempts were associated with noncardiac surgery: pediatric (OR: 1.79, 95% CI: 1.30-2.51), neurologic (OR: 2.63, 95% CI: 1.89-3.57), orthopedic (OR: 3.23, 95% CI: 2.27-4.55), and non-radial artery placement (OR: 5.00, 95% CI: 3.33-7.14) (all p < 0.001). Multivariable analysis showed ultrasound use was associated with neonates (OR: 9.6, 95% CI: 4.1-22.5), infants (OR: 6.98, 95% CI: 4.67-10.42), toddlers (OR: 6.10, 95% CI: 3.8-9.8), and children (OR: 2.0, 95% CI: 1.7-2.5) compared to teenagers, with cardiac surgery being relative to other specialties-pediatric (OR: 0.48, 95% CI: 0.3-0.7), neurologic (OR: 0.27, 95% CI: 0.18-0.40), and orthopedic (OR: 0.38, 95% CI: 0.25-0.58) (all p < 0.001). In our exploratory analysis, increased odds of first-attempt arterial catheter insertion success were associated with cardiac surgery, palpation technique, and radial artery placement. Younger patient age category, ASA III and IV status, cardiac surgery, and anesthesiologist placement were associated with increased odds of ultrasound use.

Outcomes of a Comprehensive Ultrasound Guided Peripheral IV Insertion (USGPIV) Training Program in a Pediatric Emergency Department

INTRODUCTION

Timely and reliable peripheral intravenous cannulation is an imperative skill in a pediatric emergency department. Utilization of point-of-care ultrasound guidance has proven to significantly improve first-attempt peripheral intravenous cannulation insertion rates in pediatric patients. We sought to develop, implement, and evaluate an ultrasound-guided peripheral intravenous training program for emergency nurses in a tertiary care pediatric center.

METHODS

Twelve emergency nurses underwent a training program that consisted of an interactive asynchronous learning module followed by 8 hours of training by a vascular access clinical instructor. Data was collected on each ultrasound-guided peripheral intravenous insertion via survey methodology.

RESULTS

Complete data for a total of 210 ultrasound-guided peripheral intravenous were recorded over the 9-month period. A total of 65.2% (137/210) of patients who received an ultrasound-guided peripheral intravenous had known difficult intravenous access on history. A total of 89.5% (188/210) of patients had a difficult intravenous access of ≥4. The mean difficult intravenous access score for the patients in which ultrasound-guided peripheral intravenous insertions were attempted was 4.78 (95% confidence interval, 4.55-5.01). A total of 193 of 210 (91.9%) of ultrasound-guided peripheral intravenous were attained successfully. On the first attempt, 86.5% (167/193) ultrasound-guided peripheral intravenous were attained, and 98.96% (191/193) were attained within the first 2 attempts.

CONCLUSION

We found that implementing a comprehensive ultrasound-guided peripheral intravenous training program for emergency nurses in a pediatric tertiary care center led to a high first-pass success rate in attaining peripheral intravenous cannulations. It also facilitates vascular access in patients with known difficult intravenous access. Consideration should be made to implementing point-of-care ultrasound intravenous training programs to improve pediatric vascular access in the emergency department, particularly in patients with known difficult intravenous access.

Efficacy of Infrared Vein Visualization versus Standard Technique for Peripheral Venous Cannulation in Infant and Toddler Populations: A Randomized Study

Establishing intravenous (IV) access in younger patient populations via the traditional cannulation technique for procedures requiring anesthesia is often challenging. Infrared (IR) vein visualization is a modality that aids venous cannulation; however, few reports of this technique exist in the infant and toddler population. The primary aim of this study was to compare the efficacy of IR vein visualization to the standard cannulation technique for obtaining peripheral IV access in infant and toddler populations. Following Institutional Review Board (IRB) approval and written informed consent, children were randomly assigned to either a standard cannulation technique group or an IR vein visualization device group for venous cannulation. The primary outcome variable was the success rate of IV cannulation, and the secondary variables were the total number of attempts and the time to successful cannulation. No difference was noted between either group for first-attempt success rate (standard versus IR: 61.25% vs. 54.4%; p = 0.4) or time to establish IV cannulation (standard versus IR: median [interquartile range], 40 s [24-120] vs. 53 s [26-106]; p = 0.55). The anesthesiologist's grading of the anticipated difficulty of IV cannulation was a significant predictor of cannulation success (p = 0.0016). Our study demonstrated no significant benefit in utilizing the IR vein visualization device in terms of the overall success rate, number of attempts, and time to establish successful IV cannulation when compared to the standard technique. However, in difficult IV access situations, this device proved to be a valuable rescue adjunct.

Do different wiping techniques in phlebotomy have an effect on vessel visibility, procedural success, and phlebotomy-related complications?

Background:

This study was conducted to evaluate the effects of different wiping techniques used in phlebotomy on vein visibility, procedural success, and phlebotomy-related complications.

Materials and methods:

This single-center, comparative, randomized study was conducted with 90 patients in the internal medicine clinic of a tertiary hospital. During the phlebotomy procedure, the phlebotomy site was wiped with circular technique in the Group-I, vertical technique in the Group-II, and vertical + circular technique in the Group-III.

Results:

There was a significant difference between the three groups in terms of vein visibility after wiping of the phlebotomy site ( p < 0.05). The time spent for blood sampling was shorter in the Groups I and II ( p > 0.05). In the 3-day follow-up after the blood sample was taken, the ecchymosis and hematoma rates of the groups were similar ( p > 0.05).

Conclusions:

Vertical wiping and vertical + circular wiping techniques used in the cleaning of the phlebotomy site increased the visibility of the vein compared to only circular wiping. The time spent for blood sampling was shorter in the vertical wiping and vertical + circular wiping groups.

Epidemiological Analysis of the Emergency Vascular Access in Pediatric Trauma Patients: Single-Center Experience of Intravenous, Intraosseous, Central Venous, and Arterial Line Placements

Vascular access in severely injured pediatric trauma patients is associated with time-critical circumstances and low incidences, whereas only scarce literature on procedure performance is available. The purpose of this study was to analyze the performance of different vascular access procedures from the first contact at the scene until three hours after admission. Intubated pediatric trauma patients admitted from the scene to a single Level I trauma center between 2008 and 2019 were analyzed regarding intravenous (IV) and intraosseous (IO) accesses, central venous catheterization (CVC) and arterial line placement. Sixty-five children with a median age of 14 years and median injury severity score of 29 points were included, of which 62 (96.6%) underwent successful prehospital IV or IO access by emergency medical service (EMS) physicians, while it failed in two children (3.1%). On emergency department (ED) admission, IV cannulas of prehospital EMS had malfunctions or were dislodged in seven of 55 children (12.7%). IO access was performed in 17 children without complications, and was associated with younger age, higher injury severity and higher mortality. Fifty-two CVC placements (58 attempts) and 55 arterial line placements (59 attempts) were performed in 45 and 52 children, respectively. All CVC and arterial line placements were performed in the ED, operating room (OR) and intensive care unit (ICU). Ten mechanical complications related to CVC placement (17.8%) and seven related to arterial line placement (10.2%) were observed, none of which had outcome-relevant consequences. This case series suggests that mechanical issues of vascular access may frequently occur, underlining the need for special preparedness in prehospital, ED, ICU and OR environments.

New dimension on potential factors of successful pediatric peripheral intravenous catheterization

BACKGROUND

Peripheral intravenous catheterization (PIVC) is pivotal to pediatric medical care; however, it is a challenging technique for pediatricians, and the parameters affecting successful pediatric PIVC establishment have not been fully investigated.

METHODS

This prospective observational study collected data from pediatric patients aged less than 18 years who required PIVC. The participants were categorized into five groups for subgroup analysis: newborn, infant, toddler, pre-school, and student (children and adolescent). Data on demography, biochemistry, and PIVC executors were examined to elucidate the most powerful factors affecting the success of PIVC.

RESULTS

A total of 935 peripheral venous cannulations conducted within 1 year were studied. Age-subgroup analysis showed the highest failure rate (FR) of PIVC in the infant group (18.4%). No significant difference in BMI standard deviation score was noted among the groups (p-value = 0.430). Compared with those for the success group, more attempts, longer completion time, and more medical staff were needed for the failure group (all p-values < 0.05). A high serum procalcitonin level was correlated with an increased FR (p-value = 0.016). In addition, the success rate was positively associated with the seniority of the operators, except for the 3-year experienced R3 group (93.5%) showing a higher success rate than the 4-year experienced CR group (84.2%).

CONCLUSIONS

Difficulty in setting up PIVC was the greatest in infants and even greater than that in newborns. Even though seniority was a cardinal factor in successful PIVC, a high FR was still noted despite the lack of continuous and steady practice.

The effect of "pediatric peripheral intravenous access (PPIVA) pathway" on the success of vascular access in children

PURPOSE

Determine the affects of the developed "Pediatric Peripheral Intravenous Access (PPIVA) Pathway" on the success of the vascular access in children.

DESIGN AND METHODS

A quantitative approach was used using a quasi-experimental single-group post-test design involved pediatric patients. The patients who were first attempted for peripheral vascular access were subjected to the procedure in accordance with the "PPIVA Pathway". The data was collected via a form on which we recorded down the patients' characteristics alongside their procedural data, as well as the Difficult Intravenous Access (DIVA) Score. For statistical analysis, the R vers. 2.15.3 program was utilized.

RESULTS

The patients who applied to the pediatric observation clinic had a mean age of 8.14 ± 5.01 years. The DIVA total mean score of the patients was 1.73 ± 1.79. 89.1% (n = 163) of pediatric peripheral intravenous procedures were successfully completed on the first access. The logistic regression analysis model was found to be statistically significant to identify the factors that affect pediatric peripheral intravenous success on the first attempt (χ2 = 24.701; p < 0.001). A one-point increase in the DIVA score was found to reduce the likelihood of success on the first attempt by 56.1% [OR (95% CI) = 0.439 (0.280, 0.686), p < 0.001].

CONCLUSIONS

Using an algorithm to perform a peripheral intravenous intervention in children increases the likelihood of success on the first attempt.

PRACTICE IMPLICATIONS

Using PPIVA Pathway shall improve the provision of atraumatic care for children, as the success rate of pediatric peripheral intravenous access on the first attempt is high.

Development of a Peripheral Intravenous Access Training Program for Nurses in the Pediatric Intensive Care Units

PURPOSE

Obtaining vascular access in the pediatric population can be challenging, with insertion success rates varying widely based on patient and practitioner associated factors. Difficulty establishing peripheral intravenous access can delay treatment, which can be detrimental in emergent situations. Nurses who are trained in vascular access yield a much higher first attempt success rate, which decreases resource utilization, time to intervention, and complication rate. Fewer insertion attempts can also result in improved outcomes including decreased length of stay and better patient and family perception of pain.

DESIGN AND METHODS

The Vascular Access Service at our institution developed an extensive training program, which included three stages: didactic learning, simulation training, and insertion validation.

RESULTS

During the first three months of 2020, there were 54 ultrasound-guided peripheral IVs placed in the pediatric intensive care units, 100% of which were placed by the vascular access service. In the first three months of 2021, 63 ultrasound-guided peripheral IVs were placed, 100% of which were placed by pediatric intensive care unit nurses. Of those placed by pediatric intensive care unit nurses, 52 (82.5%) were placed following their ultrasound-guided peripheral IV training. First time insertion success rates were 86.5% with competency in a diverse patient population of widely varying ages.

CONCLUSIONS

Programs that include repeated simulation experiences may facilitate greater learning and thus increase the confidence of the nurses trained. Improving staff skills for vascular access has promoted independent bedside practice and contributed to a culture of quality and safety for the pediatric patient population.

A randomized controlled trial of ultrasound-assisted technique versus conventional puncture method for saphenous venous cannulations in children with congenital heart disease

Background

The study investigated the success rate of the great saphenous venous catheter placement performed by ultrasound-assisted technique compared with the conventional puncture method in infants and toddlers with congenital heart disease and aimed to assess the efficiency and feasibility of this method within the context of pediatric peripheral venous access.

Methods

We selected infants and toddlers who underwent congenital cardiac surgery in our medical center from June 1, 2020, to September 7, 2020, by convenience sampling. Children were stratified by the presence of the manifesting cardiac types (cyanotic or acyanotic heart disease). They were assigned to the conventional puncture method group or the ultrasound-assisted group through randomly blocked randomization. The primary outcome was the success rate of the first attempt. The second outcomes included the time to cannulation at the first attempt, the redirections of the first attempt, overall puncture time, and overall redirections of efforts. Besides, a binary logistic regression model was implemented to identify the possible variables related to the success rate of the first attempt.

Results

A total of 144 children in our medical center were recruited in the study. The success rate of the first attempt in the ultrasound-assisted group was higher than that of the conventional puncture method group in the stratification of cyanotic children (66.7% vs. 33.3%, P = 0.035). Among children of acyanotic kind, the difference in the success rate of the first attempt between the two groups was not significant (57.6% vs. 42.4%, P = 0.194). Overall puncture time (45.5 s vs. 94 s, P = 0.00) and the time to cannulation at the first attempt (41.0 s vs. 60 s, P = 0.00) in the ultrasound-assisted group was less than the conventional puncture method group. The ultrasound-assisted group also required fewer redirections of the first attempt (three attempts vs. seven attempts, P = 0.002) and fewer total redirections of efforts (two attempts vs. three attempts, P = 0.027) than the conventional puncture method group. The result of binary Logistic regression showed that the success rate of the first attempt was related to age (OR:1.141; 95% CI = 1.010–1.290, P = 0.034), the redirections of the first attempt (OR:0.698; 95% CI = 0.528–0.923, P = 0.012) and the saphenous venous width (OR:1.181; 95% CI = 1.023–1.364, P = 0.023).

Conclusions

The ultrasound-assisted technique improves the saphenous venous cannulation sufficiently in children with difficult peripheral veins. The younger age is associated with a higher likelihood of peripheral venous difficulty. The ultrasound-assisted methods can effectively screen peripheral veins, e.g., selecting thicker diameter peripheral veins, making puncture less uncomfortable, and improving success rates. This method can be used as one of the effective and practical ways of peripheral venipuncture in children, especially in difficult situations. It should be widely applied as one of the alternative ultrasound techniques in the operating room.

Trial registration

ChiCTR.org.cn (ChiCTR-2,000,033,368). Prospectively registered May 29, 2020.

Evaluation of the difficulty of peripheral venous cannulation during anesthesia induction in children: Is DIVA score sufficient?

BACKGROUND

The primary objective of the present study was to determine the rate and the independent predictors of the difficult peripheral intravascular access (PIVA) in the operating room (OR). The secondary objective was to validate the ability of the difficult intravenous access (DIVA) scoring system in the detection of difficult PIVA in the operating room.

METHODS

In this prospective observational study, patients between 0 and 18 years old who were operated in the pediatric hospital were evaluated. Peripheral intravenous cannulation performed during inhalation induction in 1008 patients were recorded. The following data were collected: demographic characteristics, the presence of a chronic disease, the DIVA score, operating room temperature, the area of PIVA application, the duration of PIVA and the number of PIVA attempts. The independent determinants of the difficult PIVA were determined with multivariate logistic regression.

RESULTS

A total of 1008 patients (82% boys) with a median age of 4 (range 0.04-17 years) were included in the study. The median number of PIVA attempts was 1 whereas the median duration for successful PIVA was 15 s (range 4-2100). PIVA was successful at the first attempt in 75.3% of patients. Among patients who required more than two PIVA attempts, the most common adjunctive method was to seek help from another operator (80.8%). In the multivariable logistic regression model, only the presence of chronic disease, being underweight, and DIVA score ⩾4 (OR 6.355, CI 4.57-9.486) remained to be the significant determinants of difficult PIVA.

CONCLUSION

The success rate of anesthesiologist-performed PIVA at the first attempt in the OR was 75.3%. Having a chronic disease, a DIVA score ⩾4 and being underweight appeared as the independent predictors for difficult PIVA.

External validation of the DIVA and DIVA3 clinical predictive rules to identify difficult intravenous access in paediatric patients

BACKGROUND

Intravenous (IV) peripheral access is often a difficult procedure in the paediatric ED, causing pain and significant distress. Clinical prediction tools including reproducible variables have been developed to help clinicians identify children at risk of difficult IV access, likely to need additional resources/interventions to maximise success at first attempt. We aimed to externally validate the Difficult IntraVenous Access (DIVA) and DIVA3 scores developed for this purpose.

METHODS

Cross-sectional study of children undergoing IV cannulation by nurses in a tertiary-care paediatric ED. Data were collected at the time of the procedure in a clinical report form.

RESULTS

Of 440 children included (56.8% males; median age 4.7 years (IQR 1.5-9.5)), 23.4% had a difficult IV access (defined as requiring >1 attempt). Diagnostic accuracy measures for a DIVA cut-off ≥4 and their 95% CIs were sensitivity 24.3% (16.4% to 33.7%), specificity 92.6% (89.2% to 95.1%), positive and negative predictive value 50.0% (35.3% to 64.5%) and 80.0% (75.7% to 83.9%), respectively. The same measures for the DIVA3 were 22.3% (14.7% to 31.6%), 93.5% (90.3% to 95.9%), 51.1% (35.8% to 66.3%) and 79.8% (75.4% to 83.6%). The area under the receiver operating characteristic curve was 0.652 (95% CI 0.591 to 0.712) for the DIVA and 0.649 (95% CI 0.589 to 0.709) for the DIVA3 score. In patients with DIVA and DIVA3 <4, nurses' prediction of greater difficulty in IV placement and moderate/severe dehydration were common independent predictors of difficult IV at multivariate analysis. Only nurses' prediction of greater difficulty in IV placement were associated with higher odds of difficult cannulation for both DIVA/DIVA3 scores ≥4.

CONCLUSION

We externally validated the DIVA and DIVA3 showing a similar accuracy compared with the DIVA derivation cohort and between DIVA and DIVA3. We identified factors that can help refine further the risk of difficult IV access and support decision making on the best strategy to maximise the chances of cannulation success on first attempt.

A Comparative Study of Blood Sampling From Venipuncture and Short Peripheral Catheters in Pediatric Inpatients

This prospective, comparative study examined blood test results, hemolysis rates, and patient perceptions related to 2 blood sampling methods in pediatric inpatients (N = 95). Blood specimens were drawn via venipuncture and a short peripheral catheter used for fluid administration. Results revealed no significant differences in potassium and glucose levels. No clinically significant difference in hemoglobin was noted. Hemolysis rates were 4% for venipuncture samples and 15% when drawn from peripheral catheters. One catheter became occluded after a blood draw. Patients/parents rated distress and dissatisfaction with venipuncture as significantly greater compared with short peripheral catheter blood sampling (P < .001).