Intravenous Therapy

Whole blood multiplex measurements using electrochemical aptamer-based biosensors

Simultaneous measurements of various molecules ("multiplex") using electrochemical biosensors typically require multiple electrode implementations, which for neonates, hemophiliacs, etc. is problematic. Here, we introduce the oxazine ATTO 700 into electrochemical aptamer-based biosensors to achieve "true" multiplex, continuous and real-time measurements of two different molecules in undiluted whole blood using a single electrode.

Subcutaneous edema as a potential cause of catheter failure in older inpatients receiving peripheral parenteral nutrition

Malnutrition is a common problem among hospitalized older patients. Peripheral parenteral nutrition (PN) can improve patient outcomes but can also lead to complications that affect future treatment. Older inpatients, in particular, are expected to be prone to these catheter-related complications. However, the impact of peripheral PN on older inpatients has been rarely investigated. In the current study, the impact of PN on short peripheral catheters (SPCs) was evaluated by comparing signs and symptoms at the time of catheter removal between 22 patients with PN and 27 without. In addition to external clinical assessment, sonographic investigations of the SPC site were performed. The prevalence of external signs and symptoms of complications was similar between the patients (all P > 0.05). However, subcutaneous edema was found by ultrasound in > 80% of patients with PN, compared with 55.6% of those without PN (P = 0.051). Unlike cases without PN, all patients with PN who presented with external signs and symptoms developed subcutaneous edema (P = 0.022). Multivariate analysis demonstrated that administration of PN was independently associated with subcutaneous edema (adjusted odds ratio = 6.88, 95% confidence interval = 1.083-75.486, P = 0.040). For several decades, phlebitis has been the primary focus of complications related to peripheral PN in clinical settings. However, our results imply that peripheral PN causes subcutaneous edema, which can lead to catheter failure in older inpatients. This study contributes to understanding the etiology of catheter failure during peripheral PN in this population.

The Prevalence and Associated Factors of Peripheral Intravenous Complications in a Thai Hospital

Complications of peripheral intravenous catheters (PIVCs) remain a major contributor to health care costs and are a patient safety problem. The objective of this cross-sectional descriptive study was to examine the prevalence of complications and factors associated with complications from peripheral intravenous fluid administration. The study was conducted at a tertiary care hospital in Thailand. The instruments were developed from the literature review. Data were analyzed using SPSS statistics, version 22. The study examined 441 patients with a total of 497 PIVC sites. Phlebitis (level 1 and 2 only) occurred at 2.41% of all sites; infiltration (level 1 and 2 only) occurred at 1.01% of all sites, and extravasation (mild and moderate only) occurred at 0.60% of all sites. Factors associated with the occurrence of infiltration complications included receiving intravenous (IV) crystalloids (P = .03) and receiving IV analgesic drugs (P = .001). Age was statistically significantly related to extravasation complications (P = .001). Nurses should be aware of possible complications from peripheral intravenous fluid administration, especially in older patients and those receiving IV crystalloids or analgesic drugs.

Peripheral intravenous catheter infection and failure: A systematic review and meta-analysis

BACKGROUND

Peripheral intravenous catheters are the most frequently used invasive device in nursing practice, yet are commonly associated with complications. We performed a systematic review to determine the prevalence of peripheral intravenous catheter infection and all-cause failure.

METHODS

The Cochrane Library, PubMed, CINAHL, and EMBASE were searched for observational studies and randomised controlled trials that reported peripheral intravenous catheter related infections or failure. The review was limited to English language and articles published from the year 2000. Pooled estimates were calculated with random-effects models. Meta-analysis of observation studies in epidemiology guidelines and the Cochrane process for randomised controlled trials were used to guide the review. Prospero registration number: CRD42022349956.

FINDINGS

Our search retrieved 34,725 studies. Of these, 41 observational studies and 28 randomised controlled trials (478,586 peripheral intravenous catheters) met inclusion criteria. The pooled proportion of catheter-associated bloodstream infections was 0.028 % (95 % confidence interval (CI): 0.009-0.081; 38 studies), or 4.40 catheter-associated bloodstream infections per 100,000 catheter-days (20 studies, 95 % CI: 3.47-5.58). Local infection was reported in 0.150 % of peripheral intravenous catheters (95 % CI: 0.047-0.479, 30 studies) with an incidence rate of 65.1 per 100,000 catheter-days (16 studies; 95 % CI: 49.2-86.2). All cause peripheral intravenous catheter failure before treatment completion occurred in 36.4 % of catheters (95 % CI: 31.7-41.3, 53 studies) with an overall incidence rate of 4.42 per 100 catheter days (78,891 catheter days; 19 studies; 95 % CI: 4.27-4.57).

INTERPRETATION

Peripheral intravenous catheter failure is a significant worldwide problem, affecting one in three catheters. Per peripheral intravenous catheter, infection occurrence was low, however, with over two billion catheters used globally each year, the absolute number of infections and associated burden remains high. Substantial and systemwide efforts are needed to address peripheral intravenous catheter infection and failure and the sequelae of treatment disruption, increased health costs and poor patient outcomes.

Safety and Efficacy of Midline vs Peripherally Inserted Central Catheters Among Adults Receiving IV Therapy: A Randomized Clinical Trial

Importance

Midline catheters (MCs) are widely used, but safety and efficacy compared with peripherally inserted central catheters (PICCs) has not been adequately evaluated.

Objective

To compare the safety and efficacy of MCs with PICCs among adult patients with an anticipated intravenous therapy lasting from 5 to 28 days.

Design, Setting, and Participants

This parallel, 2-group, open-label, randomized clinical trial (RCT) was conducted in Denmark from October 2018 to February 2022 at a single academic tertiary care center. Adult inpatients and outpatients were consecutively randomized.

Intervention

Patients were randomized in a 1:1 ratio to either the MC group or the PICC control group.

Main Outcomes and Measures

The primary outcome was catheter-related bloodstream infection (CRBSI), analyzed using the Fisher exact test. Secondary outcomes were symptomatic catheter-related thrombosis and catheter failure, including mechanical cause, phlebitis, infiltration, pain in relation to drug or fluid administration, and leaking from the puncture site. Incidence rate ratios (IRRs) were calculated to assess between-group failure rates over device dwell time using Poisson regression. An intention-to-treat analysis was performed.

Results

A total of 304 patients (mean [SD] age, 64.6 [13.5] years; 130 [42.8%] female) were included in the analysis, and 152 patients were allocated to each catheter group. The incidence of CRBSI was low, with 0 in the MC group and 1 in the PICC control group (P > .99). The MC group had a higher catheter-related complication rate (20 [13.2%] vs 11 [7.2%]), and an IRR of 2.37 (95% CI, 1.12-5.02; P = .02) for complications compared with the PICC control group. In a post hoc analysis stratified by catheter dwell time, no significant difference in complication rate (IRR, 1.16; 95% CI, 0.50-2.68; P = .73) was found between the 2 groups for catheters used less than 16 days.

Conclusions and Relevance

In this RCT with patients who received medium- to long-term intravenous therapy, the incidence of CRBSI was low, with no difference between MCs and PICCs. The use of MCs resulted in a higher incidence of catheter-related complications compared with use of PICCs. This finding should be balanced in the decision of type of catheter used at the individual patient level.

Trial Registration

ClinicalTrials.gov Identifier: NCT04140916.

Health-related quality of life and experience measures, to assess patients' experiences of peripheral intravenous catheters: a secondary data analysis

BACKGROUND

Peripheral intravenous catheters (PIVCs) are essential for successful administration of intravenous treatments. However, insertion failure and PIVC complications are common and negatively impact patients' health-outcomes and experiences. We aimed to assess whether generic (not condition-specific) quality of life and experience measures were suitable for assessing outcomes and experiences of patients with PIVCs.

METHODS

We undertook a secondary analysis of data collected on three existing instruments within a large randomised controlled trial, conducted at two adult tertiary hospitals in Queensland, Australia. Instruments included the EuroQol Five Dimension - Five Level (EQ5D-5L), the Functional Assessment of Chronic Illness Therapy - Treatment Satisfaction - General measure (FACIT-TS-G, eight items), and the Australian Hospital Patient Experience Question Set (AHPEQS, 12 items). Responses were compared against two clinical PIVC outcomes of interest: all-cause failure and multiple insertion attempts. Classic descriptives were reported for ceiling and floor effects. Regression analyses examined validity (discrimination). Standardised response mean and effect size (ES) assessed responsiveness (EQ5D-5L, only).

RESULTS

In total, 685 participants completed the EQ5D-5L at insertion and 526 at removal. The FACIT-TS-G was completed by 264 and the AHPEQS by 262 participants. Two FACIT-TS-G items and one AHPEQS item demonstrated ceiling effect. Instruments overall demonstrated poor discrimination, however, all-cause PIVC failure was significantly associated with several individual items in the instruments (e.g., AHPEQS, 'unexpected physical and emotional harm'). EQ5D-5L demonstrated trivial (ES < 0.20) responsiveness.

CONCLUSIONS

Initial investigation of an existing health-related quality of life measure (EQ5D-5L) and two patient-reported experience measures (FACIT-TS-G; AHPEQS) suggest they are inadequate (as a summary measure) to assess outcomes and experiences for patients with PIVCs. Reliable instruments are urgently needed to inform quality improvement and benchmark standards of care.

Cost-effectiveness of ravulizumab compared with eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria in the Netherlands

OBJECTIVES

The aim of this study was to evaluate the cost-effectiveness of ravulizumab compared with eculizumab for the treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH) in the Netherlands.

METHODS

A cost-effectiveness analysis was conducted based on a Markov cohort model simulating the course of patients with PNH with clinical symptom(s) indicative of high disease activity, or who are clinically stable after having been treated with eculizumab for at least the past six months. Costs, quality of life, and the incremental cost-effectiveness ratio (ICER) were estimated over a lifetime horizon from a Dutch societal perspective. Several additional analyses were performed, including a one-way sensitivity analysis, a probabilistic sensitivity analysis, and scenario analysis.

RESULTS

When compared with eculizumab, ravulizumab saves €266,833 and 1.57 quality adjusted life years (QALYs) are gained, resulting in a dominant ICER. Drug costs account for the majority of the total costs in both intervention groups. Cost savings were driven by the difference in total treatment costs of ravulizumab compared with eculizumab caused by the reduced administration frequency, accounting for 98% of the total cost savings. The QALY gain with ravulizumab is largely attributable to the improved quality of life associated with less frequent infusions and BTH events. At a willingness-to-pay threshold of €20,000/QALY, there is a 76.6% probability that ravulizumab would be cost-effective.

CONCLUSIONS

The cost reduction and QALY gain associated with the lower rates of BTH and less frequent administration make ravulizumab a cost-saving and clinically beneficial substitute for eculizumab for adults with PNH in the Netherlands.

Nurses' behavioural intentions towards intravenous fluid administration for pediatric patients: Application of the theory of planned behaviour

BACKGROUND

For pediatric patients, the demand for quality and safe Intravenous Fluid (IVF) therapy is huge. This is because, compared to adults, children have a lower tolerance for IVF therapy errors and present devastating physiological responses to errors. Nurses play a vital role in IVF administration; therefore, adequate knowledge, positive attitudes, positive perceived behavioural control, and good behavioural intentions are required to achieve effective and successful therapy, patient safety and prevention of complications, and overall positive patient outcomes. This study sought to assess the behaviour of nurses towards IVF administration for pediatric patients.

METHOD

A cross-sectional facility-based study was designed and randomly recruited 112 nurses. The theory of planned behaviour was used as a conceptual framework to assess nurses' behavioural intentions towards IVF administration for pediatric patients. Mean scores and their respective standard deviations, reliability tests, exploratory factor analysis, and linear logistic regression were all performed using SPSS version 27, with the level of significance set at 0.05.

RESULTS

Nurses' behavioural intentions for IVF administration for pediatric patients were influenced by their knowledge of standards and protocols for IVF use (β = 0.320; p = 0.01), attitudes (β = 0.339; p = 0.006) subjective norms (β 0.240; p = 0.003) and perceived behavioural control (β = 0.26; p = 0.001).

CONCLUSION

Nurses' behavioural intentions for IVF administration were significantly influenced by their knowledge of procedures and standards for IVF administration. Additionally, the nurses' subjective norms, perceived behavioural control, and attitude towards IVF administration have a significant effect on their behavioural intentions to administer IVFs to pediatric patients. For nurses to administer IVF effectively, safely, and successfully to pediatric patients, there is a need to enhance their knowledge of standards and guidelines for IVF administration. The nurses need to have good attitudes and positive support and influence from all others to be able to administer IVFs safely and successfully to their pediatric patients.

Factors determining success and the cost of materials used in securing intravenous access in an emergency setting: A prospective observational study

INTRODUCTION

Multiple failed attempts at securing intravenous catheter access cause increased patient dissatisfaction and higher costs. We aimed to identify the factors leading to multiple failed attempts and estimate the cost of resources wasted.

METHODS

Participants were recruited from the emergency department for a prospective, observational study. Healthcare workers inserting peripheral intravenous catheters were observed. Patient characteristics and the number of attempts needed were recorded.

RESULTS

Three hundred thirty-four patients were enrolled, and an average of 1.74 ± 1.026 (Range: 1 - 5) access attempts were needed per patient. Only 56.28% of the insertions were successful on the first attempt. On multivariate linear regression with attempts as the outcome variable, age (β = 0.01, 95%CI 0.004 - 0.014, p = 0.0006), catheter calibre (β 20G = -0.25, 95%CI -0.45 - -0.07, p = 0.008), visibility (β = 0.23, 95%CI 0.02 - 0.44, p = 0.026) and palpability (β = 0.44, 95%CI 0.21 - 0.66, p = 0.0001) of the vein were statistically significant predictors. The average total cost of materials required was $6.4 USD per patient, of which $1.76 USD was spent towards unsuccessfully inserted catheters that were consequently thrown away.

CONCLUSIONS

Our study shows that securing IV access often requires multiple attempts, with nearly 30% of the total cost amounting towards materials wasted. The risk of multiple attempts is highest for older patients with invisible and non-palpable veins.

Adverse effects related with norepinephrine through short peripheral venous access: Scoping review

Peripheral administration of norepinephrine is restricted due to the association of extravasation with tissue necrosis.

METHOD

Scoping review with the objective of describing the adverse effects related to the administration of norepinephrine through short peripheral venous access and the characteristics of drug administration in patients hospitalized in ICU, surgery, and emergency services.

RESULTS

12 studies with heterogeneous characteristics by size and type of population were included. The proportion of complications associated with peripheral norepinephrine administration was less than 12% in observational studies and it was less than 2% in those that used doses less than 0.13μg/kg/min, and concentrations less than 22.3μg/mL. The main associated complication was extravasation and there were no cases of tissue necrosis at the venipuncture site, some extravasation cases were treated with phentolamine, terbutaline or topical nitroglycerin. The drug administration time ranged between 1 and 528hours with a weighted mean of 2.78h.

CONCLUSION

The main adverse effect was extravasation, no additional complications occurred, phentolamine and terbutaline seem to be useful, and its availability is a necessity. It is essential for the nursing staff to carry out a close assessment and comprehensive care in patients receiving norepinephrine by peripheral route.

Subcutaneous versus intravenous tramadol for extremity injury with moderate pain in the emergency department: a randomised controlled noninferiority trial

BACKGROUND AND IMPORTANCE

Musculoskeletal trauma is a common presentation in the emergency department (ED). Tramadol as an analgesic has been recommended by pain management guidelines for musculoskeletal pain. Parenteral tramadol in the ED is commonly administered intravenously. Subcutaneously administered tramadol may have other advantages such as easier and faster preparation, avoids the need for intravenous (i.v.) access, and reduces the incidence of respiratory and gastrointestinal effects. However, studies comparing subcutaneous (s.c.) and i.v. tramadol for the management of acute moderate pain in patients with extremity injury are lacking.

OBJECTIVE

The objective of this study was to compare the clinical efficacy of s.c. tramadol vs. i.v. tramadol in patients with moderate pain due to extremity injury in the ED.

DESIGN, SETTINGS, AND PARTICIPANTS

This non-inferiority randomized controlled trial included adult patients presented to an academic, tertiary hospital ED with moderate pain (pain score of 4-6 on the visual analog scale) due to extremity injury. Intervention patients stratified to pain score were randomized to receive 50 mg of i.v. or s.c. tramadol.

OUTCOMES MEASURE AND ANALYSIS

Primary outcome measure was the difference in the pain score reduction at 30 min after tramadol administration between the two groups. The noninferiority null hypothesis was that the therapeutic difference in terms of pain score reduction of more than 0.8 exists between the two treatment groups at the endpoint.

MAIN RESULTS

In total 232 patients were randomized to i.v. ( n  = 115) or s.c. ( n  = 117). Although 225 were analyzed in the per-protocol population (i.v. = 113; s.c. = 112). The baseline median pain score was 6 (IQR, 5-6). Median pain score reduction at 30 min after administration was 2 (IQR, 1-3) in the IV group vs. 2 (IQR, 1-2) in the s.c. group with a median difference of 0 (IQR, 0-0), which was below the prespecified noninferiority margin of 0.8. Adverse events in the i.v. group were higher compared to the s.c. group (33.6% vs. 8.9%, P  ≤ 0.001).

CONCLUSIONS

The s.c. tramadol is noninferior to i.v. tramadol in the treatment of moderate pain from extremity injuries.

Physicochemical Characteristics of Antimicrobials and Practical Recommendations for Intravenous Administration: A Systematic Review

Most antimicrobial drugs need an intravenous (IV) administration to achieve maximum efficacy against target pathogens. IV administration is related to complications, such as tissue infiltration and thrombo-phlebitis. This systematic review aims to provide practical recommendations about diluent, pH, osmolarity, dosage, infusion rate, vesicant properties, and phlebitis rate of the most commonly used antimicrobial drugs evaluated in randomized controlled studies (RCT) till 31 March 2023. The authors searched for available IV antimicrobial drugs in RCT in PUBMED EMBASE®, EBSCO® CINAHL®, and the Cochrane Controlled Clinical trials. Drugs' chemical features were searched online, in drug data sheets, and in scientific papers, establishing that the drugs with a pH of <5 or >9, osmolarity >600 mOsm/L, high incidence of phlebitis reported in the literature, and vesicant drugs need the adoption of utmost caution during administration. We evaluated 931 papers; 232 studies were included. A total of 82 antimicrobials were identified. Regarding antibiotics, 37 reach the "caution" criterion, as well as seven antivirals, 10 antifungals, and three antiprotozoals. In this subgroup of antimicrobials, the correct vascular access device (VAD) selection is essential to avoid complications due to the administration through a peripheral vein. Knowing the physicochemical characteristics of antimicrobials is crucial to improve the patient's safety significantly, thus avoiding administration errors and local side effects.

Nurses' knowledge and experience related to short peripheral venous catheter extravasation

BACKGROUND

The majority of hospitalized patients receive a Peripheral Venous Catheter (PVC) in the course of their treatment. Extravasation injury is a serious complication of intravenous treatment.

OBJECTIVE

This cross-sectional survey designed study aims to investigate nurses' knowledge and experience related to short peripheral venous catheter extravasation.

METHOD

The study sample included 145 nurses working in a university hospital in the west of Turkey. A questionnaire developed in accordance with the literature was used for data collection. The data were assessed by frequency and proportions.

RESULTS

Of the nurses included in this study, 26.2% reported they had experienced extravasation injury in a patient; 74.5% said they had received no instruction in the management of extravasation during their in-service training program; and 85.5% stated they did not keep a record of extravasation. 89.7% of the nurses reported infused medications as a cause of extravasation, and 81.4% reported catheter sites as a cause. Among the medications reported by the nurses as causing extravasation: 89.7% reported contrast agents; 84.8% TPN solutions; 71.0% cytotoxic agents; and 65.1% mannitol. The symptoms of extravasation reported by nurses included: swelling (97.9%), redness (97.2%), pain (92.4%), rise in temperature (65.5%), and ulceration (60.0%). In responding to the occurrence of extravasation, interventions reported by the nurses included: stopping the flow of fluid (98.6%), elevation (89.7%), cold application (76.6%), and aspiration of drug (40.7%).

CONCLUSION

Based on these results, it is recommended that guidelines are developed for the management of extravasation, that periodic in-service training programs are provided and that observational studies are carried out into the administration of vesicant drugs.

Precision and reliability study of hospital infusion pumps: a systematic review

BACKGROUND

Infusion Pumps (IP) are medical devices that were developed in the 1960s and generate fluid flow at pressures higher than that of normal blood pressure. Various hospital sectors make use of them, and they have become indispensable in therapies requiring continuity and precision in the administration of medication and/or food. As they are classified Class III (high risk) equipment, their maintenance is crucial for proper performance of the device, as well as patient and operator safety. The principal consideration of the pump is the volume infused, and the device demands great attention to detail when being calibrated. A lack of necessary care with this equipment can lead to uncertainty in volume and precision during the administration of substances. Because of this, it is essential to evaluate its reliability, to prevent possible failures at time of execution. This control aims at the quality of the intended infusion result, becoming an indication of quality.

METHODS

This systematic review summarizes studies done over the last 10 years (2011 to December 2021) that address the reliability and accuracy of hospital infusion pumps, in order to identify planning of maintenance and/or other techniques used in management of the equipment. The Prisma method was applied and the databases utilized were Embase, MEDLINE/Pubmed, Web of Science, Scopus, IEEE Xplore, and Science Direct. In addition, similar reviews were studied in Prospero and the Cochrane Library. For data analysis, softwares such as Mendeley, Excel, RStudio, and VOSviewer were used, and Robvis helped in plotting risk of bias results for studies performed with Cochrane tools.

RESULTS

The six databases selected produced 824 studies. After applying eligibility criteria (inclusion and exclusion), removing duplicates, and applying filters 1 and 2, 15 studies were included in the present review. It was found that the most relevant sources came from the Institute of Electrical and Electronics Engineers (IEEE) and that the most relevant keywords revolved around the terms ("device failure", "infusion pumps", "adverse effects", "complications", etc.). These results made clear that there remains substantial room for improvement as it relates to the study of accuracy and reliability of infusion.

CONCLUSIONS

We verified that the reliability and precision analysis of hospital infusion pumps need to be performed in a more detailed and consistent way. New developments, considering the model and IP specification, are intended, clearly explaining the adopted methodology.

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.

A Budget Impact Model of Maintenance Treatment of Chronic Inflammatory Demyelinating Polyneuropathy with IgPro20 (Hizentra) Relative to Intravenous Immunoglobulin in the United States

BACKGROUND

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare, progressive autoimmune disease causing peripheral nervous system dysfunction. Guidelines recommend immunoglobulin (IG) therapy as an immunomodulatory agent in CIDP. Drawbacks and unmet needs with intravenous immunoglobulin (IVIG) include adverse effects and wear-off effects, along with the burden of administration based on site of care. Subcutaneous administration of Hizentra, a subcutaneous immunoglobulin (SCIG) reduces patient burden by allowing self-administration outside the hospital setting and has fewer adverse events (AEs).

OBJECTIVE

We aimed to compare the expected cost of treatment and the budget impact of Hizentra compared with IVIG for maintenance treatment of CIDP in the United States.

METHODS

A decision tree model was developed to estimate the expected budget impact of maintenance treatment with Hizentra for US stakeholders. The model adopts primarily a US integrated delivery network perspective and, secondarily, a commercial perspective over a 1-year time horizon. Pharmacy costs were based on a payment mix of average sales price (73%), wholesale acquisition cost (2%), and average wholesale price (25%). Costs in the model reflect 2022 US dollars. In accordance with the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines and recommendations for budget impact modeling, no discounting was performed. The PATH clinical study of Hizentra maintenance in CIDP was used to determine clinical inputs for relapse rates at initial assessment (24 weeks) and at 52 weeks for Hizentra. The ICE clinical study of Gamunex maintenance in CIDP was the basis of relapse rates for Gamunex (and other IVIGs). Literature-based estimates were obtained for infusion costs by site of care, costs of IVIG infusion-related complications, and significant IVIG AE rates. Hizentra AE rates from the US Hizentra prescribing information were assessed but were not included in the model as the AEs in CIDP were mild, easily treated, and self-limited. Sensitivity analyses and scenario analyses were conducted to evaluate variations from the base case.

RESULTS

The model showed that a Hizentra starting dose of 0.2 g/kg is expected to result in annual cost savings of US$32,447 per patient compared with IVIG. For a hypothetical 25-million-member plan, the budget impact of a 10% market share shift from IVIG to Hizentra is expected to result in savings of US$2,296,235.

CONCLUSION

This analysis projects that Hizentra is likely associated with favorable economic benefit compared with IVIG in managing CIDP.

Integrated versus non-integrated peripheral intravenous catheters: a cross-sectional survey of nurse experiences

BACKGROUND

Integrated peripheral intravenous catheters (PIVCs) demonstrate clinical efficacy, however, device complexity and design differences may be a potential barrier to implementation.

AIMS

To assess nurse acceptability of integrated PIVC systems.

METHODS

A cross-sectional survey was nested within a multicentre randomised controlled trial. One hundred nurses caring for patients with integrated and non-integrated PIVCs completed a 17-item survey about key differences between devices (eg function and appearance, perceived patient comfort and skin injuries).

FINDINGS

Most nurses reported the integrated PIVC wings prevented device movement (80%), achieved patient comfort in areas of flexion (78%), and no patients developed skin injuries (100%). Nurses rated the ease of accessing and overall confidence using the integrated PIVC as significantly higher than the non-integrated design (P<0.001).

CONCLUSION

The integrated PIVC received positive feedback from nurses and had few barriers to implementation.

Short peripheral intravenous catheter securement with cyanoacrylate glue compared to conventional dressing: A randomized controlled trial

BACKGROUND

Short peripheral intravenous catheters (PIVCs) fail prior to completion of therapy in up to 63% of hospitalizations. This unacceptably high rate of failure has become the norm for the most common invasive procedure in all of medicine. Securement strategies may improve PIVC survival.

METHODS

We conducted a prospective, single-site, parallel, two-arm randomized controlled investigation with a primary outcome of catheter failure comparing securement with standard semi-permeable dressing and clear tape (SPD) to standard semipermeable dressing and clear tape with cyanoacrylate glue (SPD + CG). Adult emergency department patients with a short PIVC and anticipated hospital duration ⩾ 48 h were enrolled and followed until IV failure or completion of therapy for up to 7 days. Secondary outcomes included complications and cost comparisons between groups. Primary outcome was assessed by intention to treat and per protocol analyses.

FINDINGS

350 patients were enrolled between November 2019 and October 2020. PIVC survival for SPD + CG was similar to SPD group with the absolute risk difference of IV failure in the intention-to-treat (-5.8%, p = 0.065) population and improved in the per protocol (-8.1%, p = 0.04) population, respectively. Kaplan-Meier survival analysis indicated there was a significant benefit of the SPD + CG at greater than 2 days of hospitalization (p = 0.04). Prior to 48 h, there was no survival enhancement to either group (p = 0.98) in the intention to treat population. In a multivariable analysis with piecewise Cox regression, when the IV was functional greater than 48 h, the risk of IV failure in the SPD + CG was 43% less than the SPD group (adjusted hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.34 to 0.97; p = 0.04). Cumulative cost related to IV during hospitalization was similar between groups with a lower incremental rescue cost in the SPD + CG group.

INTERPRETATION

SPD combined with cyanoacrylate glue provides similar benefit to patients compared to SPD alone and potentially improves short PIVC survival when the IV was inserted >48 h. As this strategy is cost neutral, it could be considered in admitted patients, particularly those with longer anticipated hospital durations.

CE: Evidence-Based Practice for Peripheral Intravenous Catheter Management

ABSTRACT

Peripheral intravenous catheters (PIVCs) are among the most common invasive devices used in hospitalized patients, with over 300 million sold in the United States each year. However, about one-fourth of PIVCs are left in situ with no prescriber orders for IV medications or solutions, "just in case" they might be needed. PIVC insertion can be painful, is often unnecessary, and may increase a patient's risk of developing a bloodstream infection. This article reviews the evidence for the appropriate use of short PIVCs in hospitalized patients, assesses the ongoing need for PIVCs, provides recommendations for alternative options, and argues for promptly removing a PIVC that is no longer in use.

Ultrasound assessment of peripheral intravenous catheters by nurses in the pediatric intensive care unit

OBJECTIVE

Establish the feasibility of pediatric intensive care unit (PICU) nurse-directed ultrasound assessment (UA) of peripheral intravenous (PIV) catheters, compare the results of UA to traditional assessment (TA), and determine PIV survival after UA.

DESIGN

Prospective observational cohort study.

SETTING

PICU within a children's hospital.

PATIENTS

PICU patients with a PIV.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eight nurses performed UA on 131 PIVs in 85 patients. Median age was 3.0 years (IQR 1.0-13.8) and median weight was 15.0 kg (IQR 9.6-59.3). The most common PIV location was the arm (43%) and extravasation occurred in 15% of PIVs. Agreement between TA and UA was moderate with a Kappa of 0.47 (95% CI 0.28-0.66). Nursing confidence in the UA was significantly higher than TA (92% vs 21% very confident, p < 0.0001). In 106 PIVs with a UA that indicated the PIV was intravascular (i.e. negative UA), the median survival was 50.0 h (IQR 21.8-100.3).

CONCLUSIONS

Nurses can perform UA of PIV status in PICU patients and express greater confidence in the findings of UA than TA. Further study is necessary to determine the impact of UA on the rate of PIV complications.

Safety and efficacy of midline catheters versus peripheral intravenous catheters: A pilot randomized controlled trial

BACKGROUND

Despite pervasive need for peripheral intravenous catheters, insertion is often difficult, and approximately two thirds fail prematurely. Midline catheters are an alternative long peripheral catheter, inserted in the upper arm, ideal for patients with difficult access.

AIM

The aim of this study is to test feasibility of the protocol and compare the efficacy and safety of midline catheters to peripheral intravenous catheters.

DESIGN

A parallel-group, pilot randomized controlled trial of adult medical/surgical hospitalized patients, from a single Australian referral hospital.

METHODS

Participants with difficult vascular access (≤2 palpable veins) and/or anticipated ≥5 days of peripherally compatible intravenous therapy were recruited between May 2019 and March 2020. Participants were randomized to (1) peripheral intravenous catheter or (2) midline catheter. Primary feasibility outcome measured eligibility, recruitment, protocol adherence, retention and attrition. Primary clinical outcomes measured device insertion failure and post-insertion failure.

RESULTS

In total, n = 143 participants (71 peripheral intravenous catheters and 72 midline catheters) were recruited; n = 139 were analysed. Most feasibility criteria were met. Peripheral intravenous catheters had shorter functional dwell time, with higher incidence of post-insertion failure compared to midline catheters.

CONCLUSION

Midline catheters appear to be superior for patients with difficult vascular access or receiving prolonged intravenous therapy; a large, multi-centre trial to confirm findings is feasible.

ATTENTIV: Instrumented Peripheral Catheter for the Detection of Catheter Dislodgement in IV Infiltration

Intravenous (IV) infiltration is a common problem associated with IV infusion therapy in clinical practice. A multitude of factors can cause the leakage of IV fluids into the surrounding tissues, resulting in symptoms ranging from temporary swelling to permanent tissue damage. Severe infiltration outcomes can be avoided or minimized if the patient's care provider is alerted of the infiltration at its earliest onset. However, there is a lack of real-time, continuous infiltration monitoring solutions, especially those suited for clinical use for critically ill patients. Our design of the sensor-integrated ATTENTIV catheter allows direct detection of catheter dislodgement, a root cause of IV infiltration. We verify two detection methods: blood-tissue differentiation with a support vector machine and signal peak identification with a thresholding algorithm. We present promising preliminary testing results on biological and phantom models that utilize bioimpedance as the sensing modality. Clinical relevance- The sensor-embedded ATTENTIV catheter demonstrates potential to automate IV infiltration detection in lieu of using traditional infusion catheters and manual detection methods.

Procedure Code Utilization for Vascular Access Device Placement in the Inpatient Setting: A Retrospective Analysis

Vascular access (VA) is essential to inpatient care, and the documentation/coding practices for vascular access device (VAD) placement procedures remain unexplored. Accurate documentation may present benefits for patients, providers, and researchers. A retrospective analysis was performed in adult inpatients (2015 to 2020) using Cerner Real World Data™ to evaluate the utilization of CPT codes for VAD placement/replacement procedures. A total of 14,253,584 patient encounters were analyzed, 0.111 percent (n=15,833) of which received at least one VAD procedure code. Non-tunneled CVC procedures had the highest code rate (0.067 percent), while PIV/midline procedures were the least likely to be coded (0.004 percent). The annual proportion of code utilization increased from 10.9 percent in 2015 to 19.7 percent in 2020 (p<0.0001). Despite widespread use of VADs in the inpatient setting, the procedure coding rate was found to be remarkably low. Appropriate coding/documentation practices may ensure proper care by capturing VA-related patient history, and improve research quality and resource/staff allocation.

Incidence, causes, and timing of peripheral intravenous catheter failure related to insertion timing in the treatment cycle in patients with hematological malignancies: A prospective descriptive study

AIM

We aimed to reveal detailed descriptive data on peripheral intravenous catheter (PIVC) failure related to insertion timing during the treatment cycle, in patients with lymphoma, leukemia, and myeloma.

METHODS

We conducted a prospective descriptive study to investigate the incidence of PIVC failure, defined as PIVC removal prior to completing infusion therapy. This was judged by ward nurses for adult patients requiring PIVC insertion for chemotherapy. A research nurse confirmed the timing and determined the causes of PIVC failure using ultrasonographic imaging. Descriptive data were collected in the hematology and oncology ward of a tertiary hospital in Japan.

RESULTS

We recruited 85 patients (with 303 PIVCs), and analyzed 67 patients (with 280 PIVCs). Of these, 118 PIVCs (42%) were inserted during the chemotherapeutic dosing period of the treatment cycle, and 106 (38%), during the rest period. The incidence of cumulative PIVC failure was 43.2% of all analyzed PIVCs (89.97 per 1,000 PIVC days). Of the PIVCs in patients with lymphoma, those inserted during the dosing period were less likely to show PIVC failure (32% vs. 57%, p < .001). Conversely, those inserted after the treatment cycle were more likely to show PIVC failure (22% vs. 7%, p = .002).

CONCLUSION

This study demonstrated that the incidence of PIVC failure in patients with hematological malignancies was unacceptably high. Conceivably, the incidence of PIVC failure varies by the onset time of side effects in the treatment cycle. This should be considered when using PIVCs and selecting optimal vascular access devices for patients with hematological malignancies.

Risk Factors for the Onset of Frozen Shoulder in Middle-Aged and Elderly Subjects Within 1 Year of Discharge From a Hospitalization That Involved Intravenous Infusion: A Prospective Cohort Study

AIM

To investigate the incidence of frozen shoulder and risk factors for the onset of frozen shoulder in middle-aged and elderly subjects within 1 year of discharge from a hospitalization that involved intravenous infusion in Zhangjiagang Second People's Hospital.

METHODS

A total of 1,900 subjects who were discharged from a hospitalization that involved intravenous infusion in the hospital between May 2020 and September 2020 met the inclusion criteria for this study: 950 subjects had a mean daily duration of intravenous infusion ≤ 2 h (low exposure) and 950 subjects had a mean daily duration of intravenous infusion ≥3 h (high exposure). Subjects were followed up by telephone at 6 months ± 1 week and 12 months ± 1 week after discharge the incidence of frozen shoulder.

RESULTS

The cumulative incidence rate of frozen shoulder within 1 year of discharge was 5.2%. Multivariate logistic regression analysis revealed the risk of frozen shoulder was higher in subjects with a mean daily duration of intravenous infusion ≥3 h compared to ≤ 2 h (OR = 3.082, 95% CI 1.919-4.949, P < 0.001); subjects hospitalized for 11-30 days had a higher risk of frozen shoulder compared to those hospitalized for 10 days or less (OR = 6.836, 95%CI 4.363-10.709, P < 0.001); subjects who were overweight/ obese (BMI ≥ 25 kg/m²) had a higher risk of frozen shoulder compared to those of normal weight (BMI 18.5-24.9 kg/m²) (OR = 2.166, 95%CI 1.376-3.410, P = 0.001); subjects in the 56-70-year-old age group had a higher risk of developing frozen shoulder compared to those in the 40-55-year-old age group (OR = 1.977, 95%CI 1.154-3.387, P = 0.013); diabetes increased the risk of frozen shoulder (OR = 3.009, 95%CI 1.826-4.959, P < 0.001). The 71-85 years old age group and hypertension were statistically significant in univariate analysis but not in multivariate analysis (P > 0.05).

CONCLUSION

Compared with middle-aged and elderly in the general population, middle-aged and elderly subjects who received intravenous infusion during a hospitalization had a higher cumulative incidence rate of frozen shoulder within 1 year after discharge. Independent risk factors for the onset of frozen shoulder included mean daily duration of intravenous infusion ≥3 h, length of hospital stay 11-30 days, BMI ≥ 25 kg/m², age 56-70 years, and diabetes.

Pulmonary Embolization of Radiolucent Intravenous Cannula: Endovascular Retrieval

Fracture and embolization of peripheral intravenous cannula is very rare. Although endovascular retrieval is the standard of care for most of the embolized intravascular devices, endovascular management of embolized peripheral intravenous cannula is technically difficult due to its radiolucent nature and it is not described previously in the literature. We describe the clinical presentation, imaging findings, and endovascular management in a middle aged male who had fractured peripheral intravenous cannula which was embolized into the pulmonary artery branch. Technical nuances associated with retrieval of this radiolucent little plastic tube have been discussed.

Hypoxia driven opioid targeted automated device for overdose rescue

Opioid use disorder has been designated a worsening epidemic with over 100,000 deaths due to opioid overdoses recorded in 2021 alone. Unintentional deaths due to opioid overdoses have continued to rise inexorably. While opioid overdose antidotes such as naloxone, and nalmefene are available, these must be administered within a critical time window to be effective. Unfortunately, opioid-overdoses may occur in the absence of antidote, or may be unwitnessed, and the rapid onset of cognitive impairment and unconsciousness, which frequently accompany an overdose may render self-administration of an antidote impossible. Thus, many lives are lost because: (1) an opioid overdose is not anticipated (i.e., monitored/detected), and (2) antidote is either not present, and/or not administered within the critical frame of effectiveness. Currently lacking is a non-invasive means of automatically detecting, reporting, and treating such overdoses. To address this problem, we have designed a wearable, on-demand system that comprises a safe, compact, non-invasive device which can monitor, and effectively deliver an antidote without human intervention, and report the opioid overdose event. A novel feature of our device is a needle-stow chamber that stores needles in a sterile state and inserts needles into tissue only when drug delivery is needed. The system uses a microcontroller which continuously monitors respiratory status as assessed by reflex pulse oximetry. When the oximeter detects the wearer’s percentage of hemoglobin saturated with oxygen to be less than or equal to 90%, which is an indication of impending respiratory failure in otherwise healthy individuals, the microcontroller initiates a sequence of events that simultaneously results in the subcutaneous administration of opioid antidote, nalmefene, and transmission of a GPS-trackable 911 alert. The device is compact (4 × 3 × 3 cm), adhesively attaches to the skin, and can be conveniently worn on the arm. Furthermore, this device permits a centralized remotely accessible system for effective institutional, large-scale intervention. Most importantly, this device has the potential for saving lives that are currently being lost to an alarmingly increasing epidemic.

Evaluation of Intravenous Diphenhydramine Use in Patients with Sickle Cell Vaso-Occlusive Crisis

Purpose: To compare the incidence of oversedation between oral and parenteral diphenhydramine therapy for treatment of opioid-induced pruritus in patients with sickle cell disease vaso-occlusive crisis (SCD VOC). Methods: This retrospective, single-center, cohort study included patients greater than or equal to 18 years old with sickle cell disease admitted for vaso-occlusive crisis who received either intravenous or oral diphenhydramine for opioid-induced pruritus. Patients were identified through ICD-9 and ICD-10 codes from June 1, 2016 through July 1, 2017. Rates of oversedation were compared between the 2 formulations. Secondary endpoints included length of stay, amount and duration of diphenhydramine, rate of acute chest and indication for IV therapy. Results: Fifty unique patients were included in the analysis representing 121 admissions. Seven patients received both formulations on separate admissions and were included in both groups. Twenty-nine percent of patients in the IV diphenhydramine group experienced oversedation (12/42) versus 13% in the oral diphenhydramine group (2/15, P = .312). The average number of admissions was significantly higher in the IV versus oral group (2.45 vs 1.20; P = .005) with average and median length of stay also significantly higher in the IV versus oral group (30.57, 16.0 vs 10.67, 10.0; P = .003). Conclusion: While there was no statistically significant difference in the rates of oversedation with use of IV versus oral diphenhydramine formulations, patients with SCD VOC who received IV diphenhydramine had more frequent admissions and a longer length of stay. Clinicians may consider oral diphenhydramine preferentially in appropriate patients over IV administration.

Idle peripheral intravenous cannulation: an observational cohort study of pre-hospital and emergency department practices

BACKGROUND

Unused ('idle') peripheral intravenous catheters (PIVC) are those not used within 24 hours of insertion. There is little data on cannulation practices and idle PIVC rates in emergency settings, especially the pre-hospital environment.

METHODS

This was an observational cohort study set in south-east Queensland, Australia using data from a large tertiary level emergency department (ED) and the local statutory ambulance service. Demographic, clinical and PIVC data were collected over two periods; 9 February-18 March 2017 and 5 January-4 February 2018. Adult patients were included if they were allocated an Australasian triage scale (ATS) category between 2 and 5, and had a PIVC inserted in the pre-hospital setting or ED. PIVC use was defined as idle if no fluids, medications or contrast were administered intravenously within 24 hours of insertion. Comparisons between pre-hospital and ED practice and idle PIVC status were undertaken using descriptive statistics and logistic regression.

RESULTS

A total of 1249 patients with a PIVC (372 pre-hospital; 877 ED) were included. Overall, 366 PIVCs (29.3%; 95% CI 26.9%-31.9%) remained idle at 24 hours. In the pre-hospital group, 147 (39.5%) PIVCs inserted were not used pre-hospital, and 74 (19.9%) remained idle. In comparison, 292 (33.3%) PIVCs placed in the ED remained idle. ED staff more frequently inserted PIVCs in the antecubital fossa than paramedics (65.5% vs. 49.7%), where forearm PIVC insertion was more common pre-hospital than in ED (13.7% vs. 7.4%). Nursing staff inserted idle PIVCs at a rate of (35.1%) compared to doctors (29.6%) and paramedics (19.9%). Having a PIVC inserted in the ED was the only factor significantly (p ≤ .001) predicting an idle outcome (Odds Ratio: 2.4; 95% CI 1.7-3.3).

CONCLUSION

One-third of PIVCs inserted within the emergency setting remained idle, suggesting unnecessary risk and costs. Pre-hospital and ED PIVC insertion practices differed, with idle PIVCs 2.4 times more prevalent if inserted in the ED than pre-hospital and with greater use of antecubital insertion. Reasons for these differences are not well understood and requires more targeted research.

Potential of high dimensional radiomic features to assess blood components in intraaortic vessels in non-contrast CT scans

Background

To assess the potential of radiomic features to quantify components of blood in intraaortic vessels to non-invasively predict moderate-to-severe anemia in non-contrast enhanced CT scans.

Methods

One hundred patients (median age, 69 years; range, 19–94 years) who received CT scans of the thoracolumbar spine and blood-testing for hemoglobin and hematocrit levels ± 24 h between 08/2018 and 11/2019 were retrospectively included. Intraaortic blood was segmented using a spherical volume of interest of 1 cm diameter with consecutive radiomic analysis applying PyRadiomics software. Feature selection was performed applying analysis of correlation and collinearity. The final feature set was obtained to differentiate moderate-to-severe anemia. Random forest machine learning was applied and predictive performance was assessed. A decision-tree was obtained to propose a cut-off value of CT Hounsfield units (HU).

Results

High correlation with hemoglobin and hematocrit levels was shown for first-order radiomic features (p < 0.001 to p = 0.032). The top 3 features showed high correlation to hemoglobin values (p) and minimal collinearity (r) to the top ranked feature Median (p < 0.001), Energy (p = 0.002, r = 0.387), Minimum (p = 0.032, r = 0.437). Median (p < 0.001) and Minimum (p = 0.003) differed in moderate-to-severe anemia compared to non-anemic state. Median yielded superiority to the combination of Median and Minimum (p(AUC) = 0.015, p(precision) = 0.017, p(accuracy) = 0.612) in the predictive performance employing random forest analysis. A Median HU value ≤ 36.5 indicated moderate-to-severe anemia (accuracy = 0.90, precision = 0.80).

Conclusions

First-order radiomic features correlate with hemoglobin levels and may be feasible for the prediction of moderate-to-severe anemia. High dimensional radiomic features did not aid augmenting the data in our exemplary use case of intraluminal blood component assessment.

Trial registration Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12880-021-00654-9.

Reducing the incidence of phlebitis in medical adult inpatients with peripheral venous catheter care bundle: a best practice implementation project

BACKGROUND

One major complication of the insertion of a peripheral venous catheter (PVC) is phlebitis, often resulting in delay of treatment, increased healthcare costs and prolonged hospitalization.

AIMS

The current study sought to evaluate the effectiveness of a standardized PVC care bundle in increasing the compliance of PVC care and assessment and reduce the occurrences of phlebitis rates.

METHODS

A pre and postimplementation audit approach was used in this study and adopted the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice program. This study was carried out in three phases over a 10-month period, from March 2017 to December 2017 across three medical wards in a hospital in Singapore with a sample size of 90 patients. The study involved educating nurses on phlebitis assessment, implementing a PVC care bundle and monitoring compliance. An audit tool comprising four criteria from the Joanna Briggs Institute Practical Application of Clinical Evidence System was developed.

RESULTS

One-month and 3-month postimplementation findings revealed significant improvement in Criteria 1, 3 and 4 (P < 0.001) but no significant improvement in Criterion 2 (P > 0.05). Six-month postimplementation findings showed significant improvement in all four criteria (P < 0.05). An interesting finding was that the number of reported occurrences of phlebitis increased after implementing the PVC care bundle.

DISCUSSION

The increase in phlebitis rates could be attributed to the care bundle facilitating prompt and early identification of phlebitis. Despite the initial increase in occurrences 1 month post implementation, the general effectiveness of the care bundle in reducing occurrences of phlebitis was seen 6 months post implementation. The effectiveness of the care bundle to reduce phlebitis rates may be even more evident across a longer implementation period.

CONCLUSION

The current study showed that the implementation of a standardized PVC care bundle can significantly enhance the assessment and identification process of phlebitis and can aid in reducing the incidence of phlebitis. The nurses' compliance in practicing the PVC care bundle was determined by the post and preimplementation audits, thus, the audit approach was beneficial in translating evidence into practice.

Vascular access care in patients with multimorbidity

BACKGROUND

More than half of patients with multimorbidity require intravenous therapy during their hospital stay. The aims of this study are to describe difficult intravenous access (DIVA) and vascular access care provided to this patient population and to explore the differences between easy and DIVA groups.

METHODS

A cohort study was conducted in patients with multimorbidity admitted to 2 hospitals between March and November 2013. The variables used to describe vascular care included choice and placement of devices, catheter swell time, and occurrence of adverse events. The incidence of adverse events was expressed as number cases per 1000 catheter days and χ², Student's t, or Mann-Whitney U tests were used to compare the care provided between both groups. Odds rates were calculated to determine the risk of complications associated with DIVA.

RESULTS

We recruited 135 patients, of whom 34.8% were women. Overall, 59.3% had DIVA. A total of 224 catheters were inserted, patients with difficult access requiring a mean of 1.71 catheters and those with easy access 1.58 catheters. Two or more attempts were required to place catheters in 23% of cases in the difficult access group versus 2.50% in the easy access group. Mean catheter dwell time was 3.84 days and 3.99 days, and the adverse event rate was 111/1000 and 83.6/1000 catheter days, respectively. The odds ratio for complications was 1.596.

CONCLUSIONS

Multimorbid patients with DIVA have a higher rate of complications as well as requiring more catheters and more placement attempts.

Methodological Quality Assessment with the AGREE II Scale and a Comparison of European and American Guidelines for the Treatment of Lyme Borreliosis: A Systematic Review

BACKGROUND

Most European and American countries recently updated their guidelines on Lyme borreliosis (LB). The aim of this study was to provide a comparative overview of existing guidelines on the treatment of LB in Europe and America and to assess the methodological quality of their elaboration.

METHODS

A systematic search was carried out in MEDLINE, Google Scholar, and the national databases of scientific societies from 2014 to 2020. Quality was assessed by two independent reviewers using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

RESULTS

Twelve guidelines were included. The scores for the AGREE II domains (median ± IQR) were: overall assessment 100 ± 22, scope and purpose 85 ± 46, stakeholder involvement 88 ± 48, rigour of development 67 ± 35, clarity of presentation 81 ± 36, applicability 73 ± 52 and editorial independence 79% ± 54%. Cohen's weighted kappa showed a high agreement (K = 0.90, 95%CI 0.84-0.96). Guidelines were quite homogeneous regarding the recommended molecules (mostly doxycycline in the first intention and ceftriaxone in the second intention), their duration (10 to 28 days), and their dosage. The differences were due to the lack of well-conducted comparative trials. The International Lyme and Associated Diseases Society (ILADS) guidelines were the only ones to suggest longer antibiotics based on an expert consensus.

CONCLUSION

European and American guidelines for the treatment of LB were quite homogeneous but based on moderate- to low-evidence studies. Well-conducted comparative trials are needed to assess the best molecules, the optimal duration and the most effective doses.

Innovative approaches to teaching vascular access to nursing students in the COVID-19 era

PURPOSE

For the student nurse, peripheral venous cannulation is one of the most stressful skills to be learned. Although some healthcare employers/establishments offer courses on vascular access and infusion nursing as part of their onboarding programs, ultimately educational institutions should share the responsibility to ensure that graduating nurses can provide safe infusion therapies.

METHODS

An innovative vascular access and infusion nursing (VAIN) curriculum was created and mapped onto the entry to practice undergraduate nursing program at McGill University in Montréal, Québec, Canada. This presented an opportunity to implement new teaching approaches.

RESULTS

Students experienced multiple new teaching approaches including multimedia and experiential learning and live simulation to ensure acquisition of knowledge and psychomotor skills. The teaching approaches had to be rapidly modified with the advent of the COVID-19 pandemic.

CONCLUSIONS

The VAIN curriculum emphasizes simulation and directed practice, seeking to increase competence, confidence, and knowledge. The pandemic underscored the need for flexibility and creativity in content delivery.

Impact of a Peripheral Vascular Access Service on Device Use

BACKGROUND

More than 1 billion peripheral vascular access devices are inserted annually worldwide with potential complications including infection, thrombosis, and vasculature damage. Vasculature damage can necessitate the use of central catheters, which carry additional risks such as central catheter-associated bloodstream infections. To address these concerns, one institution used expert nurses and a consult request system with algorithms embedded in the electronic medical record.

OBJECTIVES

To develop a uniform process for catheter insertion by means of a peripheral vascular access service dedicated to selecting, placing, and maintaining all inpatient peripheral catheters outside of the intensive care units.

METHODS

Descriptive analysis and χ2 analysis were done to describe the impact of the peripheral vascular access service.

RESULTS

In 2018, 6246 consults were reviewed. Of these, 26% did not require vascular access. Similarly, in 2019, 7861 consults were reviewed, and 35.3% did not require vascular access. Use of central catheters decreased from 21% in 2017 to 17% in 2018 and 2019.

CONCLUSIONS

The peripheral vascular access service allowed patients to receive appropriate peripheral vascular access devices and avoid unnecessary peripheral catheter placements. This may have preserved patients' peripheral vasculature and thus prevented premature central catheter placement and contributed to an overall decrease in central catheter days. With the peripheral vascular access service, peripheral vascular access devices were selected, placed, and maintained by experts with a standardized process that promoted a culture of quality and patient safety.

Measuring the Validity and Reliability of the Vascular Access Complication Staging and Treatment Instrument in a Pediatric Population

A multiphase study designed with Delphi and observational components was conducted to establish the preliminary validity and reliability of the 2018 Vascular Access Complication Staging and Treatment Instrument in pediatric and neonatal populations from a single, free-standing academic children's hospital. The instrument uses objective measurement criterion to determine the severity of swelling and tissue damage to inform treatment decisions. The results of the study provided preliminary empirical evidence to support a pediatric and neonatal intravenous complication staging instrument to assess degree of swelling and severity of tissue injury. The study also offered preliminary evidence that the instrument was perceived by the nurses who participated in the study to be efficient and easy to use.

Positioning of Vascular Access in Pediatric Patients: An Observational Study Focusing on Adherence to Current Guidelines

Venous access devices (VADs) play an important role in different clinical contexts. In pediatric subjects, VAD placement is more complicated than in adults due to children’s poor cooperativity and reduced vascular access. Adherence to guidelines for the placement of VADs could prevent the occurrence of complications, but data in the literature are general and not exhaustive, especially with regard to the pediatric population. The objective of this study was to assess adherence to guidelines for the placement of VADs in a pediatric setting. A retrospective observational study was conducted in the general ward of a pediatric hospital in the northern region of Italy. Data related to consecutive admissions in the period from 1 January to 31 December 2019 were collected according to the availability of clinical documentation. A cohort of 251 subjects was considered, yielding a total of 367 VADs. Device permanence in situ and the effective administration of intravenous therapy were associated with an increased risk of complications, while adherence to guidelines was an important protective factor. Adherence to guidelines for the placement of VADs is an independent and positive predictive factor for the prevention of complications due to the presence of a vascular device.

The impact of the catheter to vein ratio on peripheral intravenous cannulation success, a post-hoc analyses

Background

Intravenous cannulation is usually the first procedure performed in modern healthcare, although establishing peripheral intravenous access is challenging in some patients. The impact of the ratio between venous diameter and the size of the inserted catheter (catheter to vein ratio, CVR) on the first attempt success rate can be of added value in clinical. This study tries to give insight into the consideration that must be made when selecting the target vein and the type of catheter, and proved the null hypothesis that an optimal CVR would not be associated with increased first attempt cannulation success.

Methods

This was a post-hoc analyses on adult patients admitted for peripheral intravenous cannulation. Intravenous cannulation was performed according to practice guidelines, by applying the traditional landmark approach. The CVR was calculated afterwards for each individual patient by dividing the external diameter of the inserted catheter by the diameter of the target vein, which was multiplied by 100%.

Results

In total, 610 patients were included. The median CVR was 0.39 (0.15) in patients with a successful first attempt, whereas patients with an unsuccessful first attempt had a median CVR of 0.55 (0.20) (P<0.001). The optimal cut-off point of the CVR was 0.41. First attempt cannulation was successful in 92% of patients with a CVR<0.41, whereas as those with a CVR>0.41 had a first attempt success rate of 65% (P<0.001).

Conclusion

This first introduction of the CVR in relation to cannulation success should be further investigated. Although, measuring the venous diameter or detection of a vein with a specific diameter prior to cannulation may increase first attempt cannulation success.

Oral Doxycycline Compared to Intravenous Ceftriaxone in the Treatment of Lyme Neuroborreliosis: A Multicenter, Equivalence, Randomized, Open-label Trial

BACKGROUND

Lyme neuroborreliosis (LNB) is often treated with intravenous ceftriaxone even if doxycycline is suggested to be noninferior to ceftriaxone. We evaluated the efficacy of oral doxycycline in comparison to ceftriaxone in the treatment of LNB.

METHODS

Patients with neurological symptoms suggestive of LNB without other obvious reasons were recruited. The inclusion criteria were (1) production of Borrelia burgdorferi-specific antibodies in cerebrospinal fluid (CSF) or serum; (2) B. burgdorferi DNA in the CSF; or (3) an erythema migrans during the past 3 months. Participants were randomized in a 1:1 ratio to receive either oral doxycycline 100 mg twice daily for 4 weeks, or intravenous ceftriaxone 2 g daily for 3 weeks. The participants described their subjective condition with a visual analogue scale (VAS) from 0 to 10 (0 = normal; 10 = worst) before the treatment, and 4 and 12 months after the treatment. The primary outcome was the change in the VAS score at 12 months.

RESULTS

Between 14 September 2012 and 28 December 2017, 210 adults with suspected LNB were assigned to receive doxycycline (n = 104) or ceftriaxone (n = 106). The per-protocol analysis comprised 82 patients with doxycycline and 84 patients with ceftriaxone. The mean change in the VAS score was -3.9 in the doxycycline group and -3.8 in the ceftriaxone group (mean difference, 0.17 [95% confidence interval, -.59 to .92], which is within the prespecified equivalence margins of -1 to 1 units). Participants in both groups improved equally.

CONCLUSIONS

Oral doxycycline is equally effective as intravenous ceftriaxone in the treatment of LNB.

CLINICAL TRIALS REGISTRATION

NCT01635530 and EudraCT 2012-000313-37.

Optimizing the Effectiveness of Short Peripheral Catheters

Hospitalized adult patients often require more than 1 short peripheral catheter (SPC) to complete the prescribed intravenous (IV) therapy attributed to catheter failure and the practice of routinely replacing SPCs. The purpose of this quality improvement project was to increase the number of SPCs that dwell for the complete duration of the IV therapy in hospitalized adult patients using a bundled approach. Implementation of an engineered securement device (ESD), education pertaining to modifiable risk factors, and changing the practice to removal on clinical indication were methods used to reduce the number of SPC insertions and catheter failures. This study was conducted at a rural Midwestern hospital using a convenience sample (N = 405) and an observational, descriptive cohort design in 6 phases between September 2019 and March 2020. After the practice changes, there was a reduction of SPC replacement (24%), catheter failures (24% to 13%), SPCs per patient (M = 2.9-2.2; P = .045), SPC insertions (4000 per year), and catheter-related bloodstream infections (0.26 per 1000 catheter days to 0.0), as well as a significant increase of SPCs remaining in situ (M = 2.6-3.8 days; P < .001), resulting in an estimated cost savings of at least $285,000. The results demonstrated that the risk of failure significantly increased when SPCs were inserted in the wrist (P = .007) and upper arm (P = .026) and significantly reduced when inserted in the forearm (P = .39). Study findings suggest that using an ESD, promoting SPC insertion in the forearm, avoiding the wrist and upper arm, and changing practice to removal when clinically indicated reduced the number of SPC insertions and rate of catheter failures.

Does non-invasive blood pressure measurement increase the complications and decrease indwelling time of peripheral intravenous catheters: A cohort study

AIMS AND OBJECTIVES

To explore the efficacy of non-invasive blood pressure monitors on reducing clinical complications of peripheral intravenous catheters in renal transplant recipients.

BACKGROUND

A peripheral intravenous catheter is a regular route of medication administration, but the incidence of complications such as infiltration, occlusion and phlebitis perpetuates in the clinical setting.

DESIGN

This was a cohort study.

METHODS

Patients were placed naturally into observation group or control group according to whether or not the two procedures (non-invasive blood pressure monitoring and peripheral intravenous catheters indwelling) were on the same arm. Univariate test and Cox regression model were used to estimate relative risk factors. The STROBE checklist was used to guide the submission.

RESULTS

We identified 177 kidney recipient patients during the perioperative period with 440 peripheral intravenous catheters. There were incidences of 112 (25.5%) phlebitis, 137 (31.1%) occlusion and 150 (31.8%) infiltration. There was no significant difference between incidence of phlebitis, occlusion and infiltration between the observation group and the control group (p > .05). The observation group peripheral intravenous catheters indwelling time was 97.03 ± 6.76 hr, while it was 89.22 ± 9.55 hr for the control group. However, this difference was not significant between the two groups (p > .05). Cox risk regression showed that only a high BMI was a risk factor for peripheral intravenous catheters indwelling time.

CONCLUSION

Non-invasive blood pressure monitoring did not increase complications or shorten PIVCs indwelling time among renal transplant recipients. BMI represented an independent risk factor for the peripheral intravenous catheters indwelling time.

RELEVANCE TO CLINICAL PRACTICE

It is not a prohibition to take non-invasive blood pressure measurement when having a peripheral intravenous catheter, especially in some special circumstances in the clinical practice or when good prevention procedures are implemented.

Standardization and Chemical Characterization of Intravenous Therapy in Adult Patients: A Step Further in Medication Safety

BACKGROUND

Intravenous drug administration is associated with potential complications, such as phlebitis. The physiochemical characteristics of the infusate play a very important role in some of these problems.

AIM

The aim of this study was to standardize the dilutions of intravenous drugs most commonly used in hospitalized adult patients and to characterize their pH, osmolarity and cytotoxic nature to better guide the selection of the most appropriate vascular access.

METHODS

The project was conducted in three phases: (i) standardization of intravenous therapy, which was conducted using a modified double-round Delphi method; (ii) characterization of the dilutions agreed on in the previous phase by means of determining the osmolarity and pH of each of the agreed concentrations, and recording the vesicant nature based on the information in literature; and (iii) algorithm proposal for selecting the most appropriate vascular access, taking into account the information gathered in the previous phases.

RESULTS

In total, 112 drugs were standardized and 307 different admixtures were assessed for pH, osmolarity and vesicant nature. Of these, 123 admixtures (40%), had osmolarity values >600 mOsm/L, pH < 4 or > 9, or were classified as vesicants. In these cases, selection of the most suitable route of infusion and vascular access device is crucial to minimize the risk of phlebitis-type complications.

CONCLUSIONS

Increasing safety of intravenous therapy should be a priority in the healthcare settings. Knowing the characteristics of drugs to assess the risk involved in their administration related to their physicochemical nature may be useful to guide decision making regarding the most appropriate vascular access and devices.

Local complications of intravenous access - an often underestimated entity

Context:

Obtaining intravenous (IV) access is one of the very frequent invasive procedures performed in hospital care settings. This has several complications some of which are serious in nature. However, the incidence and seriousness of these complications as well as the burden of this complication on patient management are often underestimated. Identification of susceptible patients and the risk factors are important to ensure better outcomes.

Aims:

The aim of this study was to document the various local complications of intravenous access and to identify the risk factors associated with it.

Settings and Design:

Prospective observational study with three hundred and one surgical patients. Study duration of 1 year.

Methods and Material:

Indication of IV access, site, size of IV cannula used, category of personnel involved as well as local complications at access site were documented. Dressing at cannula site were changed every 72 h or earlier. Cannula and site of access were changed in case of any complication.

Statistical Analysis Used:

Results analysed using SPSS software (IBM Inc). Frequency calculated as average and percentage. Chi-square test used for statistical significance. Relative risk calculated.

Results:

Females, overweight, diabetics and smokers were found at more risk. Requirement of major surgery, IV access by paramedical personnel, IV access over joints and when kept beyond 3 days were found to have more complications. 5.7% of patients had serious complications requiring surgical intervention.

Conclusions:

Our study shows that local complications at IV access site are very common with occurrence in more than fifty percent patients. Several risk factors are identified. Not all demographic and clinical risk factors are readily modifiable. However many of the complications can easily be minimized by following basic precautions.

Adaptive randomised controlled non-inferiority multicentre trial (the Ketodex Trial) on intranasal dexmedetomidine plus ketamine for procedural sedation in children: study protocol

INTRODUCTION

Up to 40% of orthopaedic injuries in children require a closed reduction, almost always necessitating procedural sedation. Intravenous ketamine is the most commonly used sedative agent. However, intravenous insertion is painful and can be technically difficult in children. We hypothesise that a combination of intranasal dexmedetomidine plus intranasal ketamine (Ketodex) will be non-inferior to intravenous ketamine for effective sedation in children undergoing a closed reduction.

METHODS AND ANALYSIS

This is a six-centre, four-arm, adaptive, randomised, blinded, controlled, non-inferiority trial. We will include children 4-17 years with a simple upper limb fracture or dislocation that requires sedation for a closed reduction. Participants will be randomised to receive either intranasal Ketodex (one of three dexmedetomidine and ketamine combinations) or intravenous ketamine. The primary outcome is adequate sedation as measured using the Paediatric Sedation State Scale. Secondary outcomes include length of stay, time to wakening and adverse effects. The results of both per protocol and intention-to-treat analyses will be reported for the primary outcome. All inferential analyses will be undertaken using a response-adaptive Bayesian design. Logistic regression will be used to model the dose-response relationship for the combinations of intranasal Ketodex. Using the Average Length Criterion for Bayesian sample size estimation, a survey-informed non-inferiority margin of 17.8% and priors from historical data, a sample size of 410 participants will be required. Simulations estimate a type II error rate of 0.08 and a type I error rate of 0.047.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Clinical Trials Ontario for London Health Sciences Centre and McMaster Research Ethics Board. Other sites have yet to receive approval from their institutions. Informed consent will be obtained from guardians of all participants in addition to assent from participants. Study data will be submitted for publication regardless of results.

TRIAL REGISTRATION NUMBER

NCT0419525.