Peripheral venous dilation using flow-mediated dilation response: A randomized crossover study

BACKGROUND

Venodilation is crucial in enhancing the success rate of peripheral intravenous cannulation. Flow-mediated dilation (FMD) is a vasodilatory response initiated by temporary ischemia followed by reperfusion. This crossover study aimed to test the hypothesis that FMD induces dilation of the peripheral veins of the forearm.

METHODS

Fifteen healthy volunteers underwent the FMD and control conditions in a randomized order. FMD involved a 5-min occlusion of blood flow in the brachial artery, followed by reperfusion, achieved by inflating and deflating a cuff placed on the upper arm. The control condition involved participants remaining at rest. The primary outcome measure was a change in the cross-sectional area of the cephalic vein post-intervention. The secondary outcomes included changes in venous diameter and perfusion index (PI).

RESULTS

FMD significantly increased the cross-sectional area of the cephalic vein compared with the control condition (relative change to baseline: 37.7% (31.4) vs 2.2% (11.7)), with a mean difference of 35.4% (95% confidence interval (CI): 16.4-54.5, p = 0.001). Both longitudinal and transverse diameters were significantly expanded with FMD compared to the control (relative change to baseline: 15.7% (15.4) vs 2.6% (3.6), p = 0.004; 18.9% (15.6) vs -0.0 (10.2), p = 0.003, respectively). Additionally, PI significantly increased with FMD compared with the control (relative change to baseline: 77.8% (56.9) vs 14.6% (36.0)), with a mean difference of 63.2% (95% CI: 31.2-95.2, p = 0.001).

CONCLUSION

FMD application induced dilation of the cephalic vein of the forearm. The findings suggest that FMD is an effective technique for dilating the venous area and potentially improving the success rate of peripheral intravenous cannulation.

Effect of a thin-tipped short bevel needle for peripheral intravenous access on the compressive deformation and displacement of the vein: A preclinical study

BACKGROUND

Peripheral intravenous catheter (PIVC) insertion often fails on the first attempt. Risk factors include small vein size and dehydration, causing vein deformation and displacement due to puncture resistance of the vessel. The authors developed a short, thin-tipped bevel needle and compared its puncture performance with needles of four available PIVCs using an ex vivo model.

METHODS

The PIVC with the thin-tipped short bevel needle was compared to four available PIVCs using an ex vivo model which simulated the cephalic vein of the human forearm. The ex vivo model consisted of a porcine shoulder and porcine internal jugular vein, and was used for evaluation of the rate of vein deformation and vessel displacement during needle insertion.

RESULTS

An ex vivo model was created with a vessel diameter of 2.7-3.7 mm and a depth of 2-5 mm. The thin-tipped short bevel PIVC needle was associated with a significantly lower compressive deformation rate and venous displacement compared to the needles of the other four PIVCs.

CONCLUSION

The thin-tipped short bevel needle induced lower compressive deformation and displacement of the vein than the conventional needles. This needle has the potential to improve the first-attempt success rate of peripheral intravenous catheterization in patients with difficult venous access.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of difficult intravenous access: a qualitative review

BACKGROUND

A perennial challenge faced by clinicians and made even more relevant with the global obesity epidemic, difficult intravenous access (DIVA) adversely impacts patient outcomes by causing significant downstream delays with many aspects of diagnoses and therapy. As most published DIVA strategies are limited to various point-of-care ultrasound techniques while other "tricks-of-the-trade" and pearls for overcoming DIVA are mostly relegated to informal nonpublished material, this article seeks to provide a narrative qualitative review of the iterature on DIVA and consolidate these strategies into a practical algorithm.

METHODS

We conducted a literature search on PubMed using the keywords "difficult intravenous access", "peripheral vascular access" and "peripheral venous access" and searched emergency medicine and anaesthesiology resources for relevant material. These strategies were then categorized and incorporated into a DIVA algorithm.

RESULTS

We propose a Vortex approach to DIVA that is modelled after the Difficult Airway Vortex concept starting off with standard peripheral intravenous cannulation (PIVC) techniques, progressing sequentially on to ultrasound-guided cannulation and central venous cannulation and finally escalating to the most invasive intraosseous access should the patient be in extremis or should best efforts with the other lifelines fail.

CONCLUSION

DIVA is a perennial problem that healthcare providers across various disciplines will be increasingly challenged with. It is crucial to have a systematic stepwise approach such as the DIVA Vortex when managing such patients and have at hand a wide repertoire of techniques to draw upon.

Comparison of the dilatory effect of three strategies on peripheral veins of the upper extremity in adults

BACKGROUND

Dilated veins are associated with increased success of peripheral intravenous cannulation, due to its improved visibility and palpability. Comparison of three strategies to achieve venodilation (tourniquet, electrical stimulation, or a combined strategy) on increase in venous size.

METHODS

A total of 54 volunteers participated in this cross-over observational study with healthy adults, measuring venous cross-sectional area and diameter at six different sites of the upper extremity. Measurements are performed with ultrasound after performing any dilation strategy, and compared with its non-dilated venous size. An increased cross-sectional area of 25 square millimetres was denoted as clinical relevant, which was detected with paired t testing, Wilcoxon signed rank testing or with ANOVA testing.

RESULTS

The cephalic vein is the greatest at all sites (t=12.43, df=39, P<0.001 for the crosssectional area), unless the largest increase in venous size was obtained in the basilic veins (t=12.11, df=39, P<0.001 for the cross-sectional area). The largest increase in venous size was obtained after electrical stimulation followed by tourniquet application at all measurement sites. Percentage-wise increased the basilic vein with 44% in cross-sectional area and 21% in diameter, which were 37% and 17% for the cross-sectional area and diameter of the cephalic vein.

CONCLUSIONS

In general, the largest sized veins are situated in the upper arm, of which the cephalic vein has the largest cross-sectional area and diameter. The combination of electrical stimulation followed by tourniquet application resulted in the greatest increase in venous size and is therefore considered as most effective to improve peripheral intravenous cannulation success.

The impact of a notched peripheral intravenous catheter on the first attempt success rate in hospitalized adults: Block-randomized trial

INTRODUCTION

Peripheral intravenous cannulation is the preferred method to obtain vascular access, but not always successful on the first attempt. Evidence on the impact of the intravenous catheter itself on the success rate is lacking. Faster visualization of blood flashback into the catheter, as a result of a notched needle, is thought to increase first attempt success rate. The current study aimed to assess if inserting a notched peripheral intravenous catheter will increase first attempt cannulation success up to 90%, when compared to inserting a catheter without a notched needle.

DESIGN

In this block-randomized trial, adult patients in the intervention group got a notched peripheral intravenous catheter inserted, patients in the control group received a traditional non-notched catheter. The primary objective was the first attempt success rate of peripheral intravenous cannulation. Intravenous cannulation was performed according to practice guidelines and hospital policy.

RESULTS

About 328 patients were included in the intervention group and 330 patients in the control group. First attempt success was 85% and 79% for the intervention and control group respectively. First attempt success was remarkably higher in the intervention group regarding patients with a high risk for failed cannulation (29%), when compared to the control group (10%).

CONCLUSION

This study was unable to reach a first attempt success of 90%, although first attempt cannulation success was higher in patients who got a notched needle inserted when compared to those who got a non-notched needle inserted, unless a patients individual risk profile for a difficult intravenous access.

Cost-utilization of peripheral intravenous cannulation in hospitalized adults: An observational study

Aim:

In modern healthcare there is increased focus on optimizing efficiency for every treatment or performed procedure, of which reduction of costs is an important part. With this study, authors aimed to calculate the cost of peripheral intravenous cannulation including all components that influence its price.

Methods:

This observational cost-utilization study was conducted between May and October 2016. Hospitalized adults were included in this study, who received usual care. Peripheral intravenous cannulation was carried out according to current hospital protocols, based on international standards for peripheral intravenous catheter insertion. Device costs were assumed equal to the number of attempts multiplied by the fixed supply costs and applicable costs for additional attempts, whereas personnel costs for both nurses and physicians were based on their hourly salary.

Results:

A total of 1512 patients were included in this study, with a mean of 1.37 (±0.77) attempts and a mean time of 3.5 (±2.7) min were needed for a successful catheter insertion. Adjusted mean costs for peripheral intravenous cannulation were estimated to be €11.67 for each patient, but costs increase as the number of attempts for successful cannulation increases. The cost for patients with a successful first attempt was lower, at approximately €9.32 but increased markedly to €65.34 when five attempts were needed.

Conclusion:

Prevention of multiple attempts may lower the costs, and furthermore, additional technologies applied by nurses to individual patients based on predicted difficult intravenous access will make the application of these additional technologies, in turn, more efficient.