Investigation of vasculature characteristics to improve venepuncture techniques in hospitalized elderly patients

Spiced RCT: Success and Pain Associated with Intravenous Cannulation in the Emergency Department Randomized Controlled Trial

BACKGROUND

Peripheral venous cannulation is one of the most common procedures in medicine. A larger cannula allows higher rates of fluid to be provided if needed in a deteriorating patient; however, it is also perceived that larger-gauge cannula placement is associated with increased pain and procedural difficulty.

OBJECTIVE

This study aimed to compare the pain and procedural difficulty experienced during insertion between 18-gauge (18G) and 20-gauge (20G) cannulas.

METHODS

We conducted a single-blinded, randomized controlled trial on adult patients who required peripheral IV cannulation within a tertiary hospital emergency department between April and October 2018. Patients were randomized to either the 18G or 20G cannula group. The primary outcomes of the study-pain experienced by patients and procedural difficulties experienced by clinical staff-were recorded on two separate 10-cm visual analog scales. Other outcomes include first-attempt success rate, operator designation, complications, and the intent and actual use of the IV cannula were documented on preformatted questionnaires.

RESULTS

Data from 178 patients were included in the analysis. Eighty-nine patients were allocated to each cannula group. There were no statistically or clinically significant differences between mean pain score (0.23; 95% CI 0.56-1.02; p = 0.5662) and mean procedural difficulty score (0.12; 95% CI 0.66-0.93; p = 0.7396). between the two groups. There was no difference in first-attempt success rate (73 of 89 vs. 75 of 89; p = 0.1288), complications (2 of 89 vs. 1 of 89) between the 20G group and 18G group, respectively.

CONCLUSIONS

There was no significant difference between the 18G or 20G cannula for either pain experienced by patients or procedural difficulty experienced by clinicians.

Venous dilation effect of hot towel (moist and dry heat) versus hot pack for peripheral intravenous catheterization: a quasi-experimental study

BACKGROUND

Heat application before peripheral intravenous catheterization is recommended for venous dilation. Hot pack application enlarges the venous diameter in healthy adults; however, hot towels (moist and dry heat) are used often in some medical cases. However, it is unclear whether hot towel application promotes venous dilation better than hot pack application. This study compared the venous dilation effect of using a hot towel (moist and dry heat) to a hot pack before applying the tourniquet at an access site for peripheral intravenous catheterization.

METHODS

Eighty-eight healthy females aged 18-29 years were recruited for this quasi-experimental study. They underwent three types of heat applications (hot pack, moist hot towel, and dry hot towel [moist hot towel wrapped in a dry plastic bag], all of which were warmed to 40 ± 2 °C and performed for 7 min) to their forearm and tourniquet application for 30 s after each heating. Venous diameter and depth were measured using ultrasonography, and venous palpability and visibility (venous assessment score) was observed as venous dilatation effects. In addition, the skin temperature, stratum corneum hydration, and subjective evaluation of the warmth were measured.

RESULTS

There were no significant differences in venous diameter and assessment scores after intervention between the dry hot towel and the hot pack groups, and the effect size was negligible (Cohen's d < 0.20). However, these measurements were significantly lower for the moist hot towel than for the other two heat applications (P < .001). Although there was no significant difference in skin temperature and warmth rating score between the dry hot towel and the hot pack, these were significantly lower for the moist hot towel than for the other two heat applications (P < .001). The amount of change in stratum corneum hydration of the dry hot towel was not significantly different from that of the hot pack; however, that of the moist hot towel was significantly larger than that of the other two heat applications (P < . 001.) CONCLUSIONS: A method in which a towel warmed in hot water is wrapped in a dry barrier may be an alternative to a hot pack.

TRIAL REGISTRATION

This study was registered with University Hospital Medical Information Network in Japan (Registration No.: UMIN000048308. Registered on July 7, 2022).

Superficial venous morphometry in the antecubital fossa: An autonomous robotic ultrasound-based analysis

BACKGROUND

The antecubital fossa is an important site for venepuncture and intravenous procedures. The size and location of a vein can affect the success of venepuncture and intravenous access. Several studies have investigated the superficial vein morphometry, but they had small sample sizes or focused on specific populations or groups. Therefore, we conducted a prospective study with large participants in general population to analyse the morphology of the antecubital superficial vein and identify the association of sex, age and body mass index (BMI) with the size and location of the vein.

METHODS

This study collected images of superficial veins prospectively using autonomous robotic ultrasound on the antecubital area between October and November 2020. We measured the superficial vein depth, vertical diameter and horizontal diameter at the antecubital area, extracted population characteristics (sex, age and BMI), and analysed a relationship between the vein dimensions and the characteristics.

RESULTS

In this study, data from 461 participants (201 males and 260 females) with mean age of 41.1 years were produced. The mean vein depth, mean vertical diameter and mean horizontal diameter (±standard deviation) were 4.81 (±2.17), 3.01 (±1.10) and 4.46 (±1.60) mm, respectively. We found significant differences in vein dimensions between males and females, with males having larger vertical and horizontal diameters than females (p < 0.001). The study also revealed significant differences in vein depth and dimensions among age groups and BMI subgroups (p < 0.001).

CONCLUSIONS

These findings revealed that the superficial vein in the antecubital area was oval, with a larger horizontal diameter than vertical diameter. Morphometry revealed differences in sex, age and BMI. Understanding variations in vein dimensions among different subgroups can help medical professionals improve success rate of venous access and patient safety.

Do Tapping and Massaging during Tourniquet Application Promote Dilation of Forearm Cutaneous Veins? A Pilot Quasi-Experimental Study

Successful insertion of a peripheral intravenous catheterization requires that veins be sufficiently dilated. This study aimed to clarify the venous dilation effect of including tapping or massaging to the application of a tourniquet at the cutaneous veins of healthy adults' forearms. This was a quasi-experimental study of 30 healthy adult volunteers. Each participant underwent all three venous dilation procedures, which included the tourniquet application (Control condition), the tourniquet application and tapping the participant's forearm (Tapping condition), as well as the tourniquet application combined with massaging the participant's forearm (Massage condition). To clarify the venous dilation effects, venous indices were measured, namely the venous diameter (mm), depth (mm), and palpation score. After applying all venous dilation procedures, the venous diameter and palpation score significantly increased. However, no significant difference was observed between the control condition and each intervention condition. The depth in the control and tapping conditions decreased significantly in contrast to the Massage condition. Moreover, a subgroup (nine participants with a venous diameter less than 3 mm after the control condition) had similar results. This study found that additional tapping or massaging after tourniquet application could be less effective in promoting dilation in the forearm veins of healthy adults. Future studies should examine the efficacy and effectiveness of venous dilation in a wide target population while considering intervention methods.

Safety of Venipuncture Sites at the Cubital Fossa as Assessed by Ultrasonography

Objective

The aim of the present observational study was to identify safe and suitable venipuncture sites for nursing in the clinical setting using ultrasonography to measure the depth and cross-sectional area of each superficial vein before and after tourniquet application as well as the distance between each superficial vein and the median nerve or brachial artery.

Methods and Results

Twenty healthy volunteers (21.8 [0.6] y) were recruited. The visible rate of each superficial vein before and after tourniquet application was 65% for the basilic vein, 90% to 95% for the median cubital vein, and 65% to 80% for the cephalic vein. The cross-sectional area of the median cubital vein after tourniquet application was significantly larger than that of the basilic vein and cephalic vein. The distance between the basilic vein or median cubital vein and median nerve was significantly smaller than that between the cephalic vein and median nerve. The distance between the basilic vein or median cubital vein and brachial artery was significantly smaller than that between the cephalic vein and brachial artery.

Conclusions

These results demonstrated that the cephalic vein at the cubital fossa is a relatively safe venipuncture site because of its distance from the median nerve and brachial artery. When puncturing the cephalic vein is difficult because it is not visible, the median cubital vein at the cubital fossa may be selected for venipuncture due to its cross-sectional area and visibility; however, care is needed to avoid penetrating the vein because the median nerve and brachial artery are located underneath.

Factors affecting superficial vein visibility at the upper limb in healthy young adults: A cross-sectional observational study

OBJECTIVE

Venipuncture is an invasive procedure, and repeated puncture attempts may be uncomfortable or even traumatic for patients. Vein visibility is one of the most influential variables for the failure of venipuncture; however, the factors affecting vein visibility remain unclear. The present study was conducted to identify the factors influencing vein visibility at the upper limb in healthy young adults.

METHODS

Twenty-seven healthy volunteers were included. All measurements were performed at the right arm, right cubital fossa, and right forearm. The depth and cross-sectional area of superficial veins were measured by ultrasonography. Skin color was assessed by a spectrophotometer and quantified according to Commission International d'Eclairage L*a*b* values.

RESULTS

Invisible superficial veins were significantly deeper and had a larger cross-sectional area than visible superficial veins. Skin color b* of invisible superficial veins was significantly higher than that of visible superficial veins. Vein depth, skin color b*, and gender markedly affected superficial vein visibility at the upper limb. The cutoff for vein depth was 2.3 mm (area under the curve = 0.91).

CONCLUSION

The present results confirmed that vein depth, skin color b*, and gender strongly influenced vein visibility at the upper limb. The cutoff for vein depth was 2.3 mm.

Making It Stick: Developing and Testing the Difficult Intravenous Access (DIVA) Tool

: Background: Establishing peripheral IV access for infusions is one of the most common invasive procedures performed in the hospital setting, but it isn't always successful on the first attempt. Multiple attempts delay treatment and cause stress in patients and nurses. The literature reports that venipuncture skills are among the most challenging for novice nurses to master.

OBJECTIVES

The goal of this quality improvement (QI) initiative was to develop, validate, and refine a simple evidence-based tool that novice nurses can use in the clinical setting to better identify those patients with preexisting conditions or anatomical variances that result in difficult IV access.

METHODS

Novice nurses employed in an urban medical center were enrolled in a vascular access education program with didactic and skill-enhancement components. Based on evidence found in the literature, the QI team developed and piloted a difficult intravenous access (DIVA) tool tailored to the adult patient population served by this institution. Following an initial trial, the tool was further refined and retested with a larger group of novice nurses. In the first phase, there were 94 IV insertion attempts; in the second, there were 971 attempts, for a total of 1,065. The two samples were analyzed independently using descriptive statistics, and Pearson product moment correlation coefficients were calculated to examine the relationship between the DIVA tool and the various factors that could affect the establishment of IV access.

RESULTS

Analysis of the first sample showed moderate positive correlations between DIVA tool scores and five variables: tough skin (scars, tattoos, or both), vein not palpable with tourniquet, vein not visible with tourniquet, IV drug use, and chronic renal failure. Analysis of the second sample showed high positive correlations between DIVA tool scores and the two vein visibility variables; moderate positive correlations between DIVA tool scores and chronic renal failure, altered fluid status, diabetes, IV drug use, tough skin (scars, tattoos, or both), and only one arm available; and low positive correlations between DIVA tool scores and frail and/or elderly skin and chemotherapy. Analysis of the degree of correlation between DIVA tool scores and the total number of IV insertion attempts per patient showed a moderate correlation (r = 0.32). All correlations were significant at P < 0.01. Eighty percent of the novice nurses who used the pilot tool and 84% who used the modified tool rated it as a good indicator of the degree of difficulty of IV access.

CONCLUSIONS

The DIVA tool gave novice nurses a reliable indication of the probable difficulty of an IV insertion and resulted in a change in the IV policy standard at the institution, which now limits the number of peripheral IV insertion attempts to two per nurse and four per patient, bringing current policy into alignment with the 2016 Infusion Therapy Standards of Practice. Use of the revised and validated DIVA tool has the potential to enhance patient comfort and satisfaction and effect significant change in nursing practice.

The Efficacy and Safety of the Fentanyl Iontophoretic Transdermal System (IONSYS®) in the Geriatric Population: Results of a Meta-Analysis of Phase III and IIIb Trials

Background and Objectives

Acute postoperative pain management in the geriatric patient can be challenging, including their response to medications. The purpose of this analysis was to evaluate whether the efficacy and safety profile of fentanyl iontophoretic transdermal system (ITS) (IONSYS^®) was similar in geriatric (≥65 years) and non-geriatric (<65 years) patients.

Methods

Efficacy and safety data from three randomized, double-blind, placebo-controlled trials and four randomized, open-label, active-comparator trials were utilized for this analysis. Efficacy was assessed via the patient global assessment (PGA) and the investigator global assessment (IGA) scales. The PGA and IGA are categorical 4-point scales (excellent, good, fair, or poor) with treatment success defined as excellent or good. Safety was evaluated via adverse events.

Results

A total of 1763 patients were assigned to the fentanyl ITS treatment group. Of the 1763 patients in the fentanyl ITS group, 499 patients were ≥65 years of age; 65.1% were 65–74 years of age, 31.7% were 75–84 years of age, and 3.2% were ≥85 years of age. In the fentanyl ITS treatment groups, there were no statistically significant differences between the non-geriatric and geriatric patients in terms of patients reporting success on the PGA at 24 h (80.0 vs. 83.0%, respectively; p = 0.3415). There were no statistically significant differences between the groups in success rates on the IGA at study discharge (82.8 vs. 87.5%, respectively; p = 0.1195). The safety profile was similar between the age groups.

Conclusions

Overall, efficacy and safety of the fentanyl ITS were similar between the geriatric and non-geriatric patients.