A systematic review and meta-analysis of new interventions for peripheral intravenous cannulation of children

Vein Visualisation Technology for Peripheral Intravenous Access in Paediatric Patients: A Clinical Decision-Making Tool

AIM

The aim of this study is to develop a clinical decision-making tool to guide utilisation of vein visualisation technologies and enhance chances of successful peripheral intravenous catheter (PIVC) insertion, using data collected from a vascular access team in a large paediatric medical centre in the United States.

DESIGN

Quantitative two-phase, cluster analysis design.

METHODS

The study consisted of the following two phases: (1) a quantitative retrospective chart review to evaluate clinician utilisation and preference for vein visualisation technologies and (2) a quantitative prospective design, including a post-discharge retrospective chart review, to confirm utilisation of vein visualisation technologies and factors influencing clinician decision-making.

RESULTS

A total of 16 groups were created based on the cluster analysis and expert clinician input. The results of first-attempt success analyses identified optimal device recommendations for each of the 16 patient groups. For patients older than 2 years old, the NIR device was more likely to result in first-attempt success regardless of BMI or access site and the NIR device was most optimal for almost all categories of paediatric patients regardless of BMI or access site. The transilluminator was found to be the most optimal device to use with younger patients (< 2 years old) who are underweight.

CONCLUSION

Vein visualisation technology is recommended by professional nursing organisations to improve PIV access. Yet, adoption of this useful technology to aid selection of an optimal vein for insertion and visualisation during insertion is limited. This is the first study to develop a clinical decision-making tool for vein visualisation technology in PIVC insertion.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Vein visualisation technology allows for a rapid, thorough assessment of patients' vasculature to determine an optimal site for PIVC placement beyond what is visible to the naked eye or achievable using traditional methods. The tool was designed to guide healthcare professionals towards successful first attempt PIVC insertions, thereby improving patient outcomes and efficiency of care.

PATIENT OR PUBLIC CONTRIBUTION

None.

The efficacy of technology-based devices on the first-attempt success rate for difficult intravenous access in pediatrics: A systematic review and network meta-analysis

INTRODUCTION

Previous studies have compared various technology-based devices, such as ultrasonography (USG), near-infrared (NIR), and transilluminator (TI), with standard care (SC) to facilitate peripheral intravenous cannulation (PIVC) in pediatric patients. This study aims to investigate the efficacy of these interventions on the first-attempt success rate (FASR) of PIVC in pediatric patients with difficult intravenous access (DIVA) using network meta-analysis (NMA).

METHODS

We conducted a comprehensive literature search in databases to identify randomized clinical trials comparing the effects of different devices on the FASR of PIVC from inception until August 2023. Pooled relative risks with 95% credible intervals were estimated using pairwise and network meta-analysis with random effects. To rank the efficacy of devices, we calculated the probabilities of the surface under the cumulative ranking curve (SUCRA).

RESULTS

A total of 18 studies were included in the final analysis. The results of pairwise meta-analysis showed that the use of devices increased the FASR for PIVC by 13% (RR: 1.13, 95% CI: [0.98, 1.30]) compared to SC. The ranking of interventions based on efficacy from highest to lowest was as follows: USG (SUCRA: 1), NIR (SUCRA: 0.6), SC (SUCRA: 0.3), and TI (SUCRA: 0.1), with a very low confidence estimate.

CONCLUSION

Based on our findings, the prioritization of device usage to increase the FASR of PIVC in pediatric patients with DIVA is as follows: USG, NIR, SC, and TI, respectively. However, due to inconsistencies in the network, existence of an overall high risk of bias in the included studies, and very low confidence estimate, further clinical trials are required.

The effect of transilluminator device on successful peripheral venous catheter placement in children: A systematic review and meta-analysis

Peripheral venous catheter placement (PVCP) is difficult for children due to the small diameter of their veins in adipose tissue. The transilluminator device (TD) is proposed as the effective method for PVCP. Therefore, this meta-analysis aimed to assess the effect of TD on first attempt success rate (FASR), mean the number of attempts (MNA), and mean duration of successful PVC placement (MDSPP) in children. In a systematic review and meta-analysis, an extensive search of online databases including PubMed, Scopus, Science Direct, Web of sciences, Cochrane, Clinical trial.gov, ProQuest, and Google scholar search engine was conducted. Keywords were combined and searched from the earliest records up to December 2021. The current meta-analysis was performed using STATA V.14.0 software. Six studies (four RCTs and two non-RCTs design) were included in the present meta-analysis. Analysis showed using of TD significantly led to FASR to 34% in studies with RCTs design (RR = 1.34; CI = 1.18-1.53) although, non-RCT studies did not indicate it (RR: 0.95; CI = 0.50-1.79). Also, one RCT (WMD = -0.24; CI = -0.4 -0.08) and two non-RCTs 0.05 (WMD = -0.05; 95% CI = -0.46-0.37) reported the MNA. Two RCTs (WMD: -24.30; CI = -53.50-4.89) and one non-RCT (WMD: -295.20; CI = -359.34 to -231.06) found TD decreased MDSSP. RCTs and non-RCTs studies showed different results in terms of some outcomes. Based on the results of four RCTs studies, the use of TD significantly increased the FASR of PVCP. The results of two non-RCTs also showed TD insignificantly decreased the FASR of PVCP. More evidence (RCT design) is required for decision-making about the effectiveness of TD on successful PVCP.

Effectiveness of near-infrared light devices for peripheral intravenous cannulation in children and adolescents: A meta-analysis of randomized controlled trials

OBJECTIVES

To examine the effectiveness of near-infrared light devices (NIR) on procedure time of successful cannulation, success rate at the first attempt, and pain scores among pediatric patients and explore potential covariates on the intervention effect.

BACKGROUND

Pediatric patients have encountered a high failure rate as compared with adult patients using traditional cannulation. NIR devices might help to access veins with an optimum viewing area and eliminate the number of attempts. However, methodological limitations and inconsistent results from previous reviews were found.

METHODS

A three-step comprehensive search was performed in nine databases. Meta-analysis, subgroup, and meta-regression analyses were conducted. Individual quality assessment and certainty of evidence were assessed using the Cochrane risk of bias tool and the Grading of Recommendations, Assessments, Development, and Evaluation criteria, respectively.

RESULTS

We included 18 randomized controlled trials (RCTs) with 5298 children and adolescents across nine countries. NIR light devices significantly reduce -29.43 s of procedure time and -0.47 attempts of peripheral intravenous cannulation compared with traditional methods. Subgroup analysis observed a significantly large effect size on procedure time using AccuVein with pre-procedure training at the clinics. However, NIR light devices do not significantly decrease the procedure time, first attempt success rate, and pain scores. Meta-regression identified sample size as a significant covariate that had an impact on the success rate at the first attempt.

CONCLUSIONS

The near-infrared light device can statistically significantly reduce the procedure time and the number of attempts. Given the low or very low certainty of the evidence, future well-designed RCTs are necessary.

A survey of paediatric difficult peripheral intravenous access in the emergency department and use of point-of-care ultrasound

Introduction/Purpose

Peripheral intravenous catheter (PIVC) insertion can be challenging in children, with point-of-care ultrasound (POCUS) known to increase success rates. The objective of this study was to survey how emergency department (ED) clinicians identify and escalate paediatric patients with difficult intravenous access (DIVA), specifically the use of POCUS.

Methods

This cross-sectional study was conducted in an Australian academic mixed ED that surveyed resident medical officers (RMOs), registrars, consultants and senior paediatric nurses. A 15 multiple-choice questionnaire evaluated clinicians experience with paediatric PIVC insertion, approach to identifying and managing DIVA and the use of POCUS or other adjuncts.

Results

Eighty clinicians (34.2% response rate) completed the survey. Poor vein palpability was rated the highest predictor of DIVA. Of the respondents, 19 consultants (86.4%), 28 registrars (90.3%) and 16 RMOs (64.0%) used POCUS as an adjunct for paediatric DIVA patients but 16 consultants (72.8%), 21 registrars (67.8%) and 20 RMOs (80.0%) would use this less than 25% of the time in clinical practice.

Discussion

This survey suggests more clinicians to prefer using objective factors when identifying paediatric DIVA patients, rather than subjectively using gestalt, which relies on clinician experience. Whilst clearly recognised as a useful tool in our study, POCUS was used infrequently for paediatric DIVA patients.

Conclusions

There is currently no consistent process for the identification and escalation of paediatric DIVA patients, including the use of adjuncts such as POCUS. Clinician awareness for these issues should be addressed, which should include the development of guidelines and clinician training in POCUS for PIVC insertion in children.

Literature review on the efficacy of near-infrared device in improving peripheral venous access time and number of attempts in pediatric patients

INTRODUCTION

The process of peripheral venous access (PVA) in children can be challenging for the patient and the clinician, as failed attempts often exceed the recommended two insertions, which can be painful. To speed up the process and increase success, near-infrared device (NIR) device technology has been introduced. This literature review aimed to investigate and critically evaluate the impact of NIR devices on the number of attempts and the time of the catheterization procedure in pediatric patients from 2015 to 2022.

METHODS

An electronic search was performed to identify studies in PubMed, Web of Science, Cochrane Library, and CINAHL Plus, from 2015 to 2022. After applying eligibility criteria, seven studies were considered for further review and evaluation.

RESULTS

The number of successful venipuncture attempts ranged from 1 to 2.41 in control groups and from 1 to 2 in NIR groups. The procedural time required for success ranged from 37.5 s to 252 s in the control group and from 28.47 s to 200 s in the NIR groups. The NIR assistive device could be successfully used in preterm infants and children with special health care needs.

CONCLUSIONS

While more research is needed to examine the training and application of NIR in preterm infants, some studies have shown improvement in placement success. The number of attempts and time required for a successful PVA may depend on several alternative factors, including general health, age, ethnicity, and knowledge and skills of healthcare providers. Future studies are expected to investigate how the level of experience of a healthcare provider performing venipuncture influences the outcome. More research is needed to explore additional factors that predict the success rate.

Association Between Profound Shock Signs and Peripheral Intravenous Access Success Rates in Trauma Patients in the Prehospital Scenario: A Retrospective Study

BACKGROUND

Hemorrhage is the leading cause of preventable death in trauma patients, and establishment of intravenous (IV) access is essential for volume resuscitation, a key component in the treatment of hemorrhagic shock. IV access among patients in shock is generally considered more challenging, although data to support this notion are lacking.

METHODS

In this retrospective registry-based study, data were collected from the Israeli Defense Forces Trauma Registry (IDF-TR) regarding all prehospital trauma patients treated by IDF medical forces between January 2020 and April 2022, for whom IV access was attempted. Patients younger than 16 years, nonurgent patients, and patients with no detectable heart rate or blood pressure were excluded. Profound shock was defined as a heart rate >130 or a systolic blood pressure <90 mm Hg, and comparisons were made between patients with profound shock and those not exhibiting such signs. The primary outcome was the number of attempts required for first IV access success, which was regarded as an ordinal categorical variable: 1, 2, 3 and higher and ultimate failure. A multivariable ordinal logistic regression was performed to adjust for potential confounders. Patients' sex, age, mechanism of injury and best consciousness level, as well as type of event (military/nonmilitary), and the presence of multiple patients were included in the ordinal logistic regression multivariable analysis model based on previous publications.

RESULTS

Five hundred thirty-seven patients were included, 15.7% of whom were recorded as having signs of profound shock. Peripheral IV access establishment first attempt success rates were higher in the nonshock group, and there was a lower rate of unsuccessful attempts in this group (80.8% vs 67.8% for the first attempt, 9.4% vs 16.7% for the second attempt, 3.8% vs 5.6% for the third and further attempts, and 6% vs 10% unsuccessful attempts, P = .04). In the univariable analysis, profound shock was associated with requirement for an increased number of IV attempts (odds ratio [OR], 1.94; confidence interval [CI], 1.17-3.15). The ordinal logistic regression multivariable analysis demonstrated that profound shock was associated with worse results regarding primary outcome (adjusted odds ratio [AOR], 1.84; CI, 1.07-3.10).

CONCLUSIONS

The presence of profound shock in trauma patients in the prehospital scenario is associated with an increased number of attempts required for IV access establishment.

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.

Barriers to and attitudes towards the use of safety engineered devices for paediatric cannulation in emergency care

This article describes a report of the attitudes towards and barriers to the use of safety cannulas in paediatric patients. The evaluation was prompted by a lack of engagement from both doctors and nurses who continued to use non-safety-engineered devices (non-SEDs) after safety-engineered devices (SEDs) were introduced into a paediatric emergency department (ED). A survey was conducted among doctors and nurses working in the paediatric ED with questions focusing on the participants' clinical experience, views on safety, access to training and device preference, providing both quantitative and qualitative data. The findings highlighted several issues, including a difference in opinion between professional groups towards safe sharps. Significant differences in access to training and education between doctors and nurses were also identified; including those with up-to-date training appearing more likely to use a SED than those without. Recommendations including strategies for improving compliance have been proposed, with a plan to conduct a clinical audit to measure compliance at a later date.

Near-infrared system's efficiency for peripheral intravenous cannulation in a level III neonatal intensive care unit: a cross-sectional study

Venipuncture is a painful and invasive procedure for hospitalised newborns and represents a challenge for neonatal healthcare professionals. This study evaluated the most efficient cannulation method based on the proportion of success at the first attempt, standard care or near-infrared (NIR) device use, and pain assessment. An observational study with two arms was conducted in the neonatal intensive care unit (NICU) of a tertiary-care university hospital in Italy. All newborns undergoing peripheral vein cannulation and only nurses with more than 5 years of professional experience in the NICU were eligible for the first arm. Only newborns with a body weight of >2500 g at cannulation and all nurses working in the NICU were involved in the second arm. In the first arm of the study, no statistically significant differences between the NIR and control groups were found in terms of proportion of successful at the first attempt 60.6% (confidence interval [CI] 95%: 48.8; 72.4) vs. 56.1% (CI 95%: 44.1; 68.0) and the mean premature infant pain profile score 6.3 (CI 95%: 5.4-7.1) vs. 5.8 (CI 95%: 5.0-6.6). In the second arm, only among less experienced nurses (<1 year), we observed a significant increase in the proportion of success in the NIR group compared with the control group, nearly tripling the success rate (72.7% [54.1; 91.3] vs. 23.1% [0.2; 46.0]).  Conclusion: This study reported no differences between the NIR and control groups. The results also suggest that using a NIR device may be advantageous for healthcare professionals with less experience during first-time cannulation. What is Known: • Venipuncture is a painful procedure commonly used to place a peripheral venous catheter for administering nutrients or drugs. • Near-infrared light facilitates the visualisation of veins and consequently, the performance of cannulation in the paediatric population. What is New: • The near-infrared light device was not associated with fewer attempts and a lower premature infant pain profile score in placing venous access in newborns than the traditional method. • The near-infrared light device could help nurses with less professional experience place a peripheral venous catheter.

Peripheral intravenous catheter insertion and use of ultrasound in patients with difficult intravenous access: Australian patient and practitioner perspectives to inform future implementation strategies

Objective

To understand healthcare worker and patient experience with peripheral intravenous catheter (PIVC) insertion in patients with difficult intravenous access (DIVA) including the use of ultrasound (US).

Methods

Descriptive study using 1-on-1 semi-structured interviews conducted between August 2020 and January 2021. Purposeful sampling was used to recruit healthcare practitioners (HCPs) and patients with DIVA who had PIVC experience. Data were analysed using inductive thematic analysis. Interview data were than mapped to the implementation theory Behaviour Change Wheel to inform implementation strategies.

Results

In total 78 interviews (13 patients; 65 HCPs) were completed with respondents from metropolitan (60%), regional (25%) and rural/remote (15%) settings across Australia. Thematic analysis revealed 4 major themes: i) Harmful patient experiences persist, with patient insights not leveraged to effect change; ii) ‘Escalation’ is just a word on the front lines; iii) Heightened risk of insertion failure without resources and training; and iv) Paving the way forward–‘measures need to be in place to prevent failed insertion attempts. Themes were mapped to the behaviour change wheel and implementation strategies developed, these included: staff education, e-health record for DIVA identification, DIVA standard of care and DIVA guidelines to support escalation and ultrasound use.

Conclusion(s)

DIVA patients continue to have poor healthcare experiences with PIVC insertion. There is poor standardisation of DIVA assessment, escalation, US use and clinician education across hospitals. Quality, safety, and education improvement opportunities exist to improve the patient with DIVA experience and prevent traumatic insertions. We identified a number of implementation strategies to support future ultrasound and DIVA pathway implementation.

Comparison of ultrasound-guided peripheral intravenous catheter insertion with landmark technique in paediatric patients: A systematic review and meta-analysis

BACKGROUND

Paediatric peripheral intravenous catheter (PIVC) insertion using traditional landmark insertion technique can be difficult.

AIM

To systematically review the evidence comparing landmark to ultrasound guidance for PIVC insertion in general paediatric patients.

STUDY DESIGN

Cochrane methodology to systematically search for randomised controlled trials comparing landmark to ultrasound-guided PIVC insertion.

DATA SOURCES

Cochrane Central Register of Controlled Trials, US National Library of Medicine, Cumulative Index to Nursing and Allied Health, Embase.

DATA EXTRACTION

English-language, paediatric trials published after 2000, reporting first-attempt insertion success, overall PIVC insertion success, and/or time to insert were included. Central venous, non-venous and trials including only difficult intravenous access were excluded. Data were independently extracted and critiqued for quality using GRADE by three authors, and analysed using random effects, with results expressed as risk ratios (RR), mean differences (MD) and 95% confidence intervals (CI). Registration (CRD42020175314).

RESULTS

Of 70 titles identified, 5 studies (995 patients; 949 PIVCs) were included. There was no evidence of an effect of ultrasound guidance, compared to landmark, for first-attempt insertion success (RR 1.27; 95% CI 0.90-1.78; I2  = 88%; moderate quality evidence), overall insertion success (RR 1.14; 95% CI 0.90-1.44; I2  = 82%; low quality evidence), or time to insertion (mean difference -3.03 min; 95% CI -12.73 to 6.67; I2  = 92%; low quality evidence).

LIMITATIONS

Small sample sizes, inconsistent outcomes and definitions in primary studies precluded definitive conclusions.

CONCLUSIONS

Large clinical trials are needed to explore the effectiveness of ultrasound guidance for PIVC insertion in paediatrics. Specifically, children with difficult intravenous access might benefit most from this technology.

The Effectiveness of the Buzzy Device for Pain Relief in Children During Intravenous Injection: Quasirandomized Study

BACKGROUND

Intravenous injection is the most common medical treatment and the main cause of pain in hospitalized children. If there is no appropriate health care for pain relief, the proportion of moderate and severe pain often exceeds 70%. With nonpharmaceutical-based pain management, Buzzy is recognized as an effective device for rapidly relieving injection pain in hospitalized children. However, Buzzy is not widely used in Asia and very few experimental studies in Asia have addressed the effectiveness of the Buzzy device at treating needle pain in hospitalized children.

OBJECTIVE

The main purpose of this study was to investigate the effectiveness of the Buzzy device for diminishing pain levels among hospitalized children in Taiwan.

METHODS

We applied a quasiexperimental design with random assignment. According to the time of admission, child participants were randomly assigned to treatment and nontreatment groups. The Buzzy device was applied as an intervention in this study. The samples size was 30 per group. The study participants were recruited from the pediatric ward of a medical center in northern Taiwan. The research data were collected longitudinally at three time points: before, during, and after intravenous injection. Three instruments were used for assessment: a demographic information sheet, the Wong-Baker Face Scale (WBFS), and the Faces Legs Activity Cry Consolability (FLACC) scale. The data were analyzed by descriptive analysis, the Mann-Whitney U test, the Wilcoxon signed-rank test, and the χ2 test.

RESULTS

A total of 60 hospitalized children aged 3 to 7 years participated in this study, including 30 participants in the treatment group and 30 participants in the nontreatment group. The average age of children in the treatment and nontreatment groups was 5.04 years and 4.38 years, respectively. Buzzy significantly mitigated pain in children during intravenous injection with a significant difference between the two groups in pain-related response (FLACC) and actual pain (WBFS) (Z=-3.551, P<.001 and Z=-3.880, P<.001, respectively). The children in the treatment group had a significantly more pleasant experience than those in the nontreatment group (Z=-2.387, P=.02). When Buzzy was employed, the children experienced less pain than they did during previous intravenous injections (Z=-3.643, P<.001).

CONCLUSIONS

The intervention of using the Buzzy device was effective in reducing pain levels of intravenous injection among hospitalized children. The specific focus on children in Asia makes a valuable contribution to the literature. For clinical application, the reliable pain relief measure of Buzzy can be used in other Asian children to help health care providers improve noninvasive care among children. For future applications, researchers could integrate Buzzy into therapy-related games and a technology-based app to increase the efficiency of use and provide more data collection functions.

Difficult intravenous access in a paediatric intensive care unit

INTRODUCTION

Multiple attempts during peripheral cannulation can have major consequences for patients, relatives, and healthcare professionals, therefore we set out to determine the extent of this problem in a paediatric intensive care unit (PICU).

OBJECTIVES

The main aim was to describe peripheral venous catheter (PVC) and peripherally inserted central catheter (PICC) cannulation in children in the PICU. Secondary objectives were to determine the success rate of the first cannulation attempt, to quantify patients with difficult venous access (DVA), and to explore the association between DVA and sociodemographic, technique and nursing-related characteristics.

METHOD

A cross-sectional descriptive study. Consecutive sampling was used to recruit patients aged 0-18 years admitted to the PICU who required peripheral venous cannulation. An ad hoc questionnaire was used for this purpose, including the presence of DVA as an independent variable.

RESULTS

A total of 163 venous cannulations were reported. A total of 55.8% (91) were performed in patients under 1 year of age. Of these, 38.7% (63) were successful on the first attempt and 36.8% (60) had DVA. When there was DVA, 85% (51) of patients had complications, median time to cannulation by short CVP was 30 minutes [15-53] and 2 or more nurses were required on 80% (48) of occasions.

CONCLUSIONS

We found a low success rate at first attempt and a high proportion of DVA. More nurses and time were employed during cannulation and complications increased if the patient had DVA. A statistically significant association was found between DVA and age, weight, poor perfusion, veins that were neither visible nor palpable, DIVA score ≥ 4, history of difficult intravenous access, complications, number of nurses and time spent.

Comparison of Standard Technique, Ultrasonography, and Near-Infrared Light in Difficult Peripheral Vascular Access: A Randomized Controlled Trial

OBJECTIVES

Successful placement of a peripheral intravenous catheter (PIVC) on the first attempt is an important outcome for difficult vascular access (DVA) patients. This study compared standard technique, ultrasonography (USG), and near-infrared light (NIR) in terms of success in the first attempt in patients with DVA.

METHODS

This was a prospective, randomized controlled study. The study was conducted in a tertiary care hospital. Emergency department patients who describe DVA history, have no visible or palpable veins, and were assessed by the nurse to have a difficult PIVC were included to study. The PIVC procedure was performed on patients by standard, USG, or NIR device techniques. For all approaches, the success of the first attempt was the primary aim. Total procedure time, the total number of attempts, and the need for rescue intervention were secondary aims.

RESULTS

This study evaluated 270 patients. The first attempt success rates for USG, standard, and NIR methods were 78.9%, 62.2%, and 58.9%, respectively. The rate of first attempt success was higher in patients who underwent USG (USG versus standard, P = .014; USG versus NIR, P = .004; standard versus NIR, P = .648). The total median (IQR) procedure time for USG, standard, and NIR methods was 107 (69-228), 72 (47-134), and 82 (61-163) seconds, respectively. The total procedure time was longer in patients undergoing USG (standard versus USG, P <.001; NIR versus USG, P = .035; standard versus NIR, P = .055). The total median (IQR) number of attempts of USG, standard, and NIR methods were 1 (1-1), 1 (1-2), and 1 (1-2), respectively. A difference was found among the groups regarding the total number of attempts (USG versus NIR, P = .015; USG versus standard P = .108; standard versus NIR, P = .307). No difference was found among groups in terms of the need for rescue methods.

CONCLUSION

It was found that USG increases the success of the first attempt compared with the standard method and NIR in patients with DVA.

Techniques and Technologies to Improve Peripheral Intravenous Catheter Outcomes in Pediatric Patients: Systematic Review and Meta-Analysis

OBJECTIVE

Insertion and function of pediatric peripheral intravenous catheters (PIVCs) present challenges. We systematically reviewed techniques and technologies to improve PIVC outcomes (first-time insertion success, overall insertion success, time to insertion, dwell time, failure, and complications).

DATA SOURCES

Cochrane Central Register of Controlled Trials (CONTROL), Cumulative Index to Nursing and Allied Health (CINAHL), US National Library of Medicine, and Embase.

STUDY SELECTION

English-language pediatric trials published post 2010 reporting PIVC outcomes.

DATA EXTRACTION

Following Cochrane standards, two authors screened, extracted, and critiqued study quality (Grading of Recommendations Assessment, Development and Evaluation approach) data, random effects analysis, results expressed as risk ratios (RR), mean differences (MD) and 95% CIs.

RESULTS

Twenty-one studies (3237 children; 3098 PIVCs) were included. First-time insertion success significantly increased with ultrasound guidance (compared with landmark insertion; RR, 1.60; 95% CI, 1.02-2.50). Use of ultrasound guidance (compared with landmark insertion) did not improve overall PIVC insertion success (RR, 1.10; 95% CI, 0.94-1.28). There was no evidence of an effect of near-infrared (compared with landmark) on first-time insertion success (RR, 1.21; 95% CI, 0.91-1.59) or number of attempts (MD, -0.65; 95% CI, -1.59 to 0.29); however, it significantly reduced PIVC insertion time (MD, -132.47; 95% CI, -166.68 to -98.26) and increased first-time insertion success in subgroup analysis of patients with difficult intravenous access (RR, 2.72; 95% CI, 1.02-7.24).

LIMITATIONS

Few studies per intervention, small sample sizes, and inconsistent outcome measures precluded definitive conclusions.

CONCLUSIONS

Ultrasound and near-infrared appear to improve pediatric PIVC insertion. High-quality studies examining the full extent of techniques and technologies are needed. Registration: CRD42020175314.

Infrared augmented reality device versus standard procedure for peripheral venous catheterisation in children less than 3 years old: A quasi-experimental cluster randomised controlled trial

AIM AND OBJECTIVE

The objective of this study was to evaluate the AccuVeinAV400® viewing device for peripheral venous catheter insertion in children on the first try.

BACKGROUND

Inserting a peripheral venous catheter is the most frequent invasive procedure carried out by healthcare professionals in hospitalised children. Several attempts are sometimes necessary, and veins can be damaged.

DESIGN

A quasi-experimental cluster randomised controlled trial based on the CONSORT 2010 guidelines.

METHODS

This randomised study comparing standard practice to the use of AccuVein400^® was carried out on children who were less than 3 years old, with difficult intravenous access (DIVA Score), hospitalised in three paediatric units and who needed cannulation.

RESULT

A total of 304 children were included (156 in the AccuVein arm and 148 in the standard arm). There was no significant difference between AccuVein and standard groups in age (respectively, 2.5 ± 0.9 years vs. 2.5 ± 0.8), or mean DIVA score (respectively 5.9 ± 1.3 vs. 5.5 ± 1.2). The success of cannulation on the first attempt was 40.38% in the AccuVein arm vs. 41.2% in the standard arm (p = .6). The caregiver's assessment of pain on the Face Legs Activity Cry Consolability scale was 4.8 ± 0.2 in the AccuVein arm vs. 5.0 ± 0.2 (p = .4).

CONCLUSIONS

The use of AccuVein400® did not lead to greater success in intravenous insertion at the first attempt in children under 3 years of age with difficult intravenous access.

RELEVANCE TO CLINICAL PRACTICE

This device can therefore be used according to the healthcare professionals' situation and needs. It is widely used in paediatric wards, and our study shows that it offers a support tool that reassures healthcare professionals and helps validate their choice of vein easiest to catheterise.

Difficult intravenous access in a paediatric intensive care unit

INTRODUCTION

Multiple attempts during peripheral cannulation can have major consequences for patients, relatives, and healthcare professionals, therefore we set out to determine the extent of this problem in a paediatric intensive care unit (PICU).

OBJECTIVES

The main aim was to describe peripheral venous catheter (PVC) and peripherally inserted central catheter (PICC) cannulation in children in the PICU. Secondary objectives were to determine the success rate of the first cannulation attempt, to quantify patients with difficult venous access (DVA), and to explore the association between DVA and sociodemographic, technique and nursing-related characteristics.

METHOD

A cross-sectional descriptive study. Consecutive sampling was used to recruit patients aged 0-18 years admitted to the PICU who required peripheral venous cannulation. An ad hoc questionnaire was used for this purpose, including the presence of DVA as an independent variable.

RESULTS

A total of 163 venous cannulations were reported. A total of 55.8% (91) were performed in patients under 1 year of age. Of these, 38.7% (63) were successful on the first attempt and 36.8% (60) had DVA. When there was DVA, 85% (51) of patients had complications, median time to cannulation by short CVP was 30minutes [15-53] and 2 or more nurses were required on 80% (48) of occasions.

CONCLUSIONS

We found a low success rate at first attempt and a high proportion of DVA. More nurses and time were employed during cannulation and complications increased if the patient had DVA. A statistically significant association was found between DVA and age, weight, poor perfusion, veins that were neither visible nor palpable, DIVA score≥4, history of difficult intravenous access, complications, number of nurses and time spent.

Selection and Insertion of Vascular Access Devices in Pediatrics: A Systematic Review

OBJECTIVE

To critically review the evidence for the selection and insertion of pediatric vascular access devices (VADs).

DATA SOURCES

Data were sourced from the US National Library of Medicine, Cumulative Index to Nursing and Allied Health, the Cochrane Library databases, Embase, and international clinical trial databases.

STUDY SELECTION

Clinical practice guidelines, systematic reviews, cohort designs, randomized control trials (RCTs), quasi RCTs, before-after trials, or case-control studies that reported on complications and/or risk as well as reliability of VADs in patients aged 0 to 18 years were included.

DATA EXTRACTION

Articles were independently reviewed to extract and summarize details on the number of patients and catheters, population, age of participants, VAD type, study method, indication, comparators, and the frequency of VAD failure or complications.

RESULTS

VAD selection and insertion decision-making in general hospitalized and some specialized patient populations were well evidenced. The use of single-lumen devices and ultrasound-guided techniques was also broadly supported. There was a lack of RCTs, and for neonates, cardiac patients, patients with difficult venous access, midline catheters, catheter-to-vein ratio, and near-infrared devices, the lack of evidence necessitated broadening the review scope.

LIMITATIONS

Limitations include the lack of formal assessment of the quality of evidence and the lack of RCTs and systematic reviews. Consequently, clinical decision-making in certain pediatric populations is not guided by strong, evidence-based recommendations.

CONCLUSIONS

This is the first synthesis of available evidence for the selection and insertion of VADs in pediatric patients and is important for determining the appropriateness of VADs in pediatric patients.

Effect of two tourniquet techniques on peripheral intravenous cannulation success: A randomized controlled trial

OBJECTIVES

Peripheral intravenous (IV) cannulation is the most common procedure performed in the emergency department (ED). Elastic tourniquets (ETs) and blood pressure cuffs (BPCs) are frequently used for venodilation. Although BPCs lead to increased venodilation and decreased compressibility, it is unclear whether this translates into a meaningful patient-centered outcome. This study aimed to determine whether one method is superior for success on the first attempt.

METHODS

This was a prospective, single-blinded, randomized controlled trial in the ED of a tertiary care center. A convenience sample of adult patients was randomly assigned to an ET or BPC with a cover concealing the type of tourniquet. The primary outcome was success rate on the first attempt. Secondary outcomes were number of attempts, number of providers, and rate of rescue techniques.

RESULTS

Of the 121 patients enrolled, 119 qualified for analysis. In the ET group, 42 of 59 patients (71%) had successful IV cannulation on first attempt compared with 43 of 60 (72%) in the BPC group (P = .95). The number of attempts (P = .87), number of nurses (P = .67), and use of rescue techniques (P = .32) did not differ significantly. A history of difficult IV access and site other than the antecubital vein were associated with decreased success.

CONCLUSIONS

ETs and BPCs performed similarly in providing venodilation for successful peripheral IV cannulation. History of difficult IV access and IV site are important factors in determining the likelihood of success.

Vascular access specialist teams for device insertion and prevention of failure

BACKGROUND

Most people admitted to hospitals worldwide require a vascular access device (VAD). Hundreds of millions of VADs are inserted annually in the USA with reports of over a billion peripheral intravenous catheters used annually worldwide. Numerous reports suggest that a team approach for the assessment, insertion, and maintenance of VADs improves clinical outcomes, the patient experience, and healthcare processes.

OBJECTIVES

To compare the use of the vascular access specialist team (VAST) for VAD insertion and care to a generalist model approach for hospital or community participants requiring a VAD in terms of insertion success, device failure, and cost-effectiveness.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1); Ovid MEDLINE (1950 to 7 February 2018); Ovid Embase (1980 to 7 February 2018); EBSCO CINAHL (1982 to 7 February 2018); Web of Science Conference Proceedings Citation Index - Science and Social Science and Humanities (1990 to 7 February 2018); and Google Scholar. We searched the following trial registries: Australian and New Zealand Clinical Trials Register (www.anzctr.org.au); ClinicalTrials.gov (www.clinicaltrials.gov); Current Controlled Trials (www.controlled-trials.com/mrct); HKU Clinical Trials Registry (www.hkclinicaltrials.com); Clinical Trials Registry - India (ctri.nic.in/Clinicaltrials/login.php); UK Clinical Trials Gateway (www.controlled-trials.com/ukctr/); and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (www.who.int/trialsearch). We searched all databases on 7 February 2018.

SELECTION CRITERIA

We planned to include randomized controlled trials (RCTs) that evaluated the effectiveness of VAST or specialist inserters for their impact on clinical outcomes.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane and used Covidence software to assist with file management.

MAIN RESULTS

We retrieved 2398 citations: 30 studies were eligible for further examination of their full text, and we found one registered clinical trial in progress. No studies could be included in the analysis or review. We assigned one study as awaiting classification, as it has not been accepted for publication.

AUTHORS' CONCLUSIONS

This systematic review failed to locate relevant published RCTs to support or refute the assertion that vascular access specialist teams are superior to the generalist model. A vascular access specialist team has advanced knowledge with regard to insertion techniques, clinical care, and management of vascular access devices, whereas a generalist model comprises nurses, doctors, or other designated healthcare professionals in the healthcare facility who may have less advanced insertion techniques and who care for vascular access devices amongst other competing clinical tasks. However, this conclusion may change once the one study awaiting classification and one ongoing study are published. There is a need for good-quality RCTs to evaluate the efficacy of a vascular access specialist team approach for vascular access device insertion and care for the prevention of failure.

Ultrasound-guided intravenous access in adults using SonoStik®, a novel encapsulated sterile guidewire: A prospective cohort trial

Purpose:

We evaluated the performance of an encapsulated guidewire designed for single-handed use with ultrasound-guided vascular access (SonoStik) with Seldinger technique, as compared with conventional intravenous catheters placed under ultrasound guidance in healthy subjects.

Methods:

This is a prospective cohort trial in healthy subjects in which each subject served as his/her own control by having a SonoStik ultrasound intravenous cannulation placed in one arm and a conventionally placed, standard ultrasound intravenous cannulation placed in the other arm. The basilic vein was used because it is a non-visible and non-palpable vein. Emergency department technicians with extensive experience in ultrasound-guided intravenous access performed the procedures. The first-attempt success rate of intravenous-guided intravenous by using the SonoStik was compared to the standard ultrasound intravenous cannulation in adult healthy subjects. The secondary outcomes including time of procedure, technicians’ and subjects’ satisfaction, and complications were compared in both arms of the study.

Results:

A total of 24 volunteers with a mean age of 22.7 years were enrolled. Four emergency department technicians with extensive prior experience with ultrasound-guided intravenous access but with no prior experience using the SonoStik device performed the procedures. The first-attempt success was 83.3% with the use of SonoStik ultrasound intravenous cannulation compared to 95.8% with the standard ultrasound intravenous cannulation. There was a mean of 1.14 insertions per each successful placement in the SonoStik group compared to 1.04 insertions by using the standard catheters (mean differences = –0.1; 95% confidence interval = –0.6 to 0.4). There were no complications in either SonoStik or the standard ultrasound intravenous cannulation group. The mean time of insertion using SonoStik was slightly longer compared to standard ultrasound intravenous cannulation (143.3 vs 109.7 s).

Conclusion:

This study demonstrated that emergency department technicians skilled in ultrasound-guided intravenous access could successfully place SonoStik 83.3% of the time in vessels that were unable to be palpated or visualized. Compared to standard ultrasound intravenous cannulation, the odds ratio of successful cannulation with SonoStik was 0.91 (95% confidence interval = 0.04–17.5). In all cases, the time required to successfully insert SonoStik was less than 4 min from tourniquet application to catheter advancement to hub, with a mean time of less than 2.5 min.

Pediatric Vascular Access Peripheral IV Algorithm Success Rate

PURPOSE

Determine if the pediatric peripheral vascular access algorithm (PPVAA) led to differences in first-attempt and overall peripheral intravenous (PIV) success, staff attempting PIV access per episode and overall attempts and first PIV attempt success by provider.

DESIGN/METHODS

A two-cohort pre-/post-implementation comparative design involved pediatric nurses and patients. The PPVAA included four components: a patient comfort plan, PIV grading score, nurses' self-assessed IV access capability and nurse decision to stop-the-line. Two sample t-test or Wilcoxon rank sum test and Pearson's chi-square test were used to evaluate differences between groups and measures.

RESULTS

Healthcare providers (N=96) attempted 721 PIV insertions (pre-PPVAA, n=419 and post-PPVAA, n=302). Of 78 nurse providers, mean (SD) age was 37.4 (11.0) years and 20.0% self-assessed PIV capability as expert. Of children, mean age was 8.3 (7.0) years. Post-PPVAA, first-attempt (p=0.86) and overall (p=0.21) success did not change, though fewer staff were needed per episode to initiate PIV; p=0.017. Overall rate of success after one attempt in the post-PPVAA period compared to pre-PPVAA was reduced (p=0.002), reflecting greater awareness to stop-the-line. Compared to pre-PPVAA, advanced practice nurses and non-clinician providers were more likely to achieve success on first attempt.

CONCLUSIONS

The PPVAA did not increase first-attempt or overall PIV success; however, it decreased overall IV attempts and the number of staff attempting access per episode.

PRACTICE IMPLICATIONS

The multi-component PPVAA provided a guide for nurses during PIV and assisted decision making to stop attempts in difficult cases.

Effectiveness of ultrasound-guided peripheral intravenous cannulation in pediatric patients aged under three years: a systematic review protocol

REVIEW QUESTION

The objective of this systematic review is to identify, evaluate and synthesize evidence of effectiveness on ultrasound-guided peripheral intravenous cannulation in pediatric patients aged under three years.Specially, the review question is: In pediatric patients aged under three years, what is the effect of ultrasound-guided peripheral intravenous cannulation on the first attempt and on the overall success rate, time to cannulation and number of attempts for successful cannulation compared with the traditional blind approach?

Impact of Ultrasound on Short Peripheral Intravenous Catheter Placement on Vein Thrombosis Risk

Approximately 90% of hospitalized patients have a short peripheral intravenous catheter (SPC) placed. Methods of inserting the catheter have evolved over time and now include the use of ultrasound (US)-guided procedures for placement. Little is known about the impact that US-guided procedures have on the vein. This study compared the rate of venous thrombosis in patients with and without US-guided catheter placement. This prospective, single-blind, observational study assessed for venous thrombosis in 153 veins from 135 patients. Veins were evaluated by a research nurse blinded to the method of placement between 48 and 72 hours after the SPC was placed. The Fisher exact test showed a significant difference between vessel compressibility and catheter insertion method (P = .0012). The proportion of noncompressible veins was significantly greater when US was used in comparison with freehand SPC insertion. The Mantel-Haenszel chi-square value of 10.34 (P = .0013) showed that US insertion technique is associated with a higher likelihood of noncompressible veins. This pilot study provides compelling evidence that the use of US to assist with catheter placement is associated with a higher rate of noncompressible veins at day 2 or 3. Further studies are needed with a larger sample to determine the generalizability of the results from this pilot study.

Low-Cost Bicycle Lights vs. Cold Lights for Visualizing Neonatal Veins

OBJECTIVE

Difficult intravenous (IV) access can compromise patient care in neonatal practice, and transillumination is often used to improve the visibility of veins. Current devices are expensive, prone to bacterial contamination and unaffordable in low-resource settings. We conducted a study comparing the quality of transillumination provided by "cold lights" that are currently in use with low-cost (<£1) red silicone LED bicycle lights.

METHODS

Photographs of the hands and feet of neonates were taken with parental consent: first without transillumination (control group), second by transillumination with a cold light, and third with a bicycle light. Thirty photographs were sent in a survey to pediatric doctors who were blinded to the method of transillumination. Survey respondents then rated the visibility of the veins (easily visible, moderately visible, barely visible and invisible).

RESULTS

Completed surveys of 114 respondents were included in the analysis. The majority (94.8%) of respondents rated the veins moderately to easily visible with the bicycle light compared with 87.6% with the cold light, and 42.6% in the control group with no transillumination. There was a strong evidence of an improvement in visibility with bicycle lights compared with cold lights (p < 0.001).

CONCLUSION

Low-cost red silicone LED bicycle lights were found to improve visibility of veins in neonates. Given their quality of transillumination, portability and reduced cost, they may provide a useful method of transillumination in all settings, but particularly in low-income settings, where there is currently no affordable alternative.

Teaching medical students ultrasound-guided vascular access - which learning method is best?

Introduction

Ultrasound is recommended to guide insertion of peripheral intravenous vascular cannulae (PIVC) where difficulty is experienced. Ultrasound machines are now common-place and junior doctors are often expected to be able to use them. The educational standards for this skill are highly varied, ranging from no education, to self-guided internet-based education, to formal, face-to-face traditional education. In an attempt to decide which educational technique our institution should introduce, a small pilot trial comparing educational techniques was designed.

Methods

Thirty medical students were enrolled and allocated to one of three groups. PIVC placing ability was then observed, tested and graded on vascular access phantoms.

Results

The formal, face-to-face traditional education was rated best by the students, and had the highest success rate in PIVC placement, the improvement statistically significant compared to no education (p = 0.01) and trending towards significance when compared to self-directed internet-based education (p<0.06).

Conclusions

The group receiving traditional face-to-face teaching on ultrasound-guided vascular access, performed significantly better than those not receiving education. As the number of ultrasound machines in clinical areas increases, it is important that education programs to support their safe and appropriate use are developed.

Utility of near-infrared light devices for pediatric peripheral intravenous cannulation: a systematic review and meta-analysis

We investigated the utility of near-infrared (NIR) light devices for peripheral intravenous cannulation (PIVC) in pediatric patients. We searched three databases, MEDLINE, EMBASE, and the Cochrane CENTRAL. Randomized controlled trials that compared PIVC using NIR light devices and the "traditional" method (with no assistive device) were included. The primary outcome was a failure rate at the first attempt, and the effect size was measured by the risk ratio for failure. Subgroup analysis was performed according to control group risk for failure at first attempt as an indicator of difficult procedure (low vs. high). Eleven studies were included in the meta-analysis. There was no significant difference in the primary outcome between the two methods (risk ratio 1.03, confidence interval 0.89-1.20, I ² = 48 %). In a subgroup analysis, the subgroup difference between subsets of low and high control group risk was significant (I ² = 83 %). In the subset of the high control group risk, using NIR light devices showed a lower risk for failure than the traditional method (risk ratio 0.81, confidence interval 0.64-1.01, I ² = 0 %).

CONCLUSION

Using NIR light devices did not have an impact on overall failure rate at the first attempt at PIVC in pediatric patients. What is Known: • Near-infrared light devices have been used to help vascular access especially for the pediatric patients. But, their utilities reported in previous studies were conflicting. What is New: • From this study, we could not find out overall benefit of using near-infrared light devices for pediatric peripheral intravenous cannulation. But, this device might be useful for the patients in a difficult condition of successful cannulation.

Association of Anaesthetists of Great Britain and Ireland: Safe vascular access 2016

Safe vascular access is integral to anaesthetic and critical care practice, but procedures are a frequent source of patient adverse events. Ensuring safe and effective approaches to vascular catheter insertion should be a priority for all practitioners. New technology such as ultrasound and other imaging has increased the number of tools available. This guidance was created using review of current practice and literature, as well as expert opinion. The result is a consensus document which provides practical advice on the safe insertion and removal of vascular access devices.

Video-based Assessment of Peripheral Intravenous Catheter Insertion in the Resuscitation Area of a Pediatric Emergency Department

OBJECTIVE

The objective was to describe the frequency of and factors associated with prolonged peripheral intravenous catheter (PIV) insertion in the resuscitation area of a pediatric emergency department (PED).

METHODS

Video-based study of a consecutive sample of nontrauma patients undergoing PIV insertion in the resuscitation area of a PED. Preexisting videos were the main data source. The primary outcome was patients with prolonged duration of PIV insertion (>90 seconds from start of first attempt to successful flush/blood draw). Logistic regression identified variables independently associated with prolonged PIV insertion.

RESULTS

A total of 151 consecutive nontrauma patients underwent PIV insertion during a 2.5-month period. Sixty-nine patients (46%) had prolonged PIV insertion, including 14 for whom PED providers failed to insert PIVs. For patients with successful PIV insertion by PED providers, median duration was 48 seconds (interquartile range [IQR] = 23 to 295 seconds). Vascular access was ultimately achieved for 13 patients (93%) with initial insertion failure by the PED team (10 non-PED personnel, three intraosseous lines), with a median duration of 26.7 minutes (IQR = 19.9 to 34.2 minutes). Age ≤ 2 years (ORadj = 6.9; 95% confidence interval [CI] = 2.9 to 16.1) and musculoskeletal contractures (ORadj = 5.3; 95% CI = 1.6 to 17.2) were independently associated with prolonged PIV insertion.

CONCLUSIONS

Prolonged PIV insertion is common in a PED resuscitation area. When PED providers could not insert a PIV, time to insertion was very long. Young patients and those with contractures were at particular risk for prolonged and failed PIV placement. When emergent vascular access is required, alternative approaches should be considered early for these patients.

Ultrasound or near-infrared vascular imaging to guide peripheral intravenous catheterization in children: a pragmatic randomized controlled trial

BACKGROUND

Peripheral intravenous catheterization in children is challenging, and success rates vary greatly. We conducted a pragmatic randomized controlled trial to determine whether the use of ultrasound or near-infrared vascular imaging to guide catheterization would be more effective than the standard approach in achieving successful catheter placement on the first attempt.

METHODS

We enrolled a convenience sample of 418 children in a pediatric emergency department who required peripheral intravenous catheterization between June 2010 to August 2012. We stratified them by age (≤ 3 yr and > 3 yr) and randomly assigned them to undergo the procedure with the standard approach, or with the help of either ultrasound or near-infrared vascular imaging. The primary outcome was the proportion of patients who had successful placement of a catheter on the first attempt.

RESULTS

The rate of successful first attempts did not differ significantly between either of the 2 intervention groups and the standard approach group (differences in proportions -3.9%, 95% confidence interval [CI] -14.2% to 6.5%, for ultrasound imaging; -8.7%, 95% CI -19.4% to 1.9%, for near-infrared imaging). Among children 3 years and younger, the difference in success rates relative to standard care was also not significant for ultrasound imaging (-9.6%, 95% CI -29.8% to 10.6%), but it was significantly worse for near-infrared imaging (-20.1%, 95% CI -40.1% to -0.2%). Among children older than 3 years, the differences in success rates relative to standard care were smaller but not significant (-2.3%, 95% CI -13.6% to 9.0%, for ultrasound imaging; -4.1%, 95% CI -15.7% to 7.5%, for near-infrared imaging). None of the pairwise comparisons were statistically significant in any of the outcomes.

INTERPRETATION

Neither technology improved first-attempt success rates of peripheral intravenous catheterization in children, even in the younger group. These findings do not support investment in these technologies for routine peripheral intravenous catheterization in children.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT01133652.