International consensus statement on the diagnosis and management of phaeochromocytoma and paraganglioma in children and adolescents

Phaeochromocytomas and paragangliomas (PPGL) are rare neuroendocrine tumours that arise not only in adulthood but also in childhood and adolescence. Up to 70-80% of childhood PPGL are hereditary, accounting for a higher incidence of metastatic and/or multifocal PPGL in paediatric patients than in adult patients. Key differences in the tumour biology and management, together with rare disease incidence and therapeutic challenges in paediatric compared with adult patients, mandate close expert cross-disciplinary teamwork. Teams should ideally include adult and paediatric endocrinologists, oncologists, cardiologists, surgeons, geneticists, pathologists, radiologists, clinical psychologists and nuclear medicine physicians. Provision of an international Consensus Statement should improve care and outcomes for children and adolescents with these tumours.

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

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

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.

The effects of ultrasound guidance on first-attempt success for difficult peripheral intravenous catheterization: a systematic review and meta-analysis

Identifying patients at risk of difficult intravenous access (DIVA) and increasing the success rates of peripheral intravenous catheterization (PIVC), preferably on the first catheterization attempt, is of clinical importance. The aim of this study was to compare the use of dynamic ultrasound guidance for PIVC with the traditional technique of visualization and palpation in patients with predicted DIVA. A systematic review and meta-analysis comparing ultrasound-guided PIVC with the traditional technique was performed. Data were systematically collected through MEDLINE and EMBASE databases from inception to March 2021. Eligibility criteria included randomized controlled trials performed on patients meeting criteria for difficult catheterization comprising either (a) no palpable or visible veins, (b) previous history of difficult venous catheterization, (c) patient age less than 4 years, (d) suspicion of difficult catheterization by operator, or (e) two or more unsuccessful attempts using the traditional technique before enrollment were included. For all outcomes, a random-effects meta-analysis using the DerSimonian and Laird method was performed. The primary outcome was the first-attempt success rate, and the secondary outcomes were the overall success rate and the number of attempts for successful intravenous catheterization. Bias was assessed using the Revised Cochrane Risk of Bias tool. Seven studies with a total of 994 patients were included. Patients comprised both children and adults and settings included operating rooms, emergency departments, and intensive care units. Ultrasound guidance was associated with a higher first-attempt success rate (OR, 3.07; 95% CI, 1.66-5.65; P < 0.001). For the secondary outcomes, ultrasound guidance was associated with a higher overall success rate (OR, 3.02; 95% CI, 1.04-8.79; P = 0.04); however, this finding did not meet statistical significance in a sensitivity analysis (OR, 2.90; 95% CI, 0.71-11.93; P = 0.14). Ultrasound was not associated with a significantly different number of attempts compared with the traditional technique (difference in means, 0.14; 95% CI, -0.32 to 0.05; P = 0.15). The use of ultrasound guidance resulted in a three-fold increase in odds for the first-attempt success rate in patients with predicted DIVA compared with the traditional technique of PIVC.

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

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

New dimension on potential factors of successful pediatric peripheral intravenous catheterization

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Does the use of infrared technology (AccuVein AV-500®) for Peripheral Intravenous Cannulation (PIVC) increase the success rate in nursing students? A randomized controlled trial

BACKGROUND

PIVC is one of the essential procedures of modern medicine, and is one of the most widely used and important treatments in the clinical setting. Nevertheless, it is one of the most difficult skills to teach in nursing education, and it is the skill which causes the most anxiety in nursing students.

OBJECTIVES

The aim of the study was to examine the effect of the teaching method using infrared technology on PIVC success, duration, and the level of psychomotor skills and knowledge in the acquisition of PIVC skills in nursing students.

METHODS

This was a pre-test post-test randomized experimental study with a control group. The research was conducted in the Skills and Simulation Laboratory of a Nursing Faculty of a university between December 2019 and February 2020 to examine the effects of teaching PIVC measurement via infrared light on students' success rate. A theory lesson on PIVC followed 15 days later by laboratory practical was carried out with all of the students included in the study. The PIVC Knowledge Evaluation Form as a pre-test. The researchers completed the PIVC Skills Performance Test from observation during the application of the checklist. Immediately after the procedure, the PIVC Knowledge Evaluation Form was applied as a post-test.

RESULTS

The procedure success rate of the experimental group was 90%, and that of the control group was 46%. Comparing PIVC skill scores between the groups, the difference was found to be statistically significant (Z = -2.741; p < 0.05). The groups' PIVC knowledge levels increased in a similar way.

CONCLUSION

Teaching with infrared technology contributes more to students' success in PIVC skills than does standard teaching. Both methods were effective in developing knowledge of PIVC.

Advanced Vascular Access in Small Animal Emergency and Critical Care

In canine and feline patients presenting in a state of hemodynamic collapse, obtaining vascular access can be challenging. Delays in achieving vascular access interfere with delivery of patient care. In human medicine, definitions of difficult vascular access are variable and include the need for multiple placement attempts or involvement of specialized teams and equipment. Incidence and risk factors for difficult vascular access have not been well studied in veterinary patients, which limits understanding of how best to address this issue. Alternatives to percutaneous peripheral or central intravenous catheterization in dogs and cats include venous cutdowns, umbilical access in newborns, corpus cavernosum access in males, ultrasound-guided catheterization, and intraosseous catheterization. In recent years, advances in ultrasonography and intraosseous access techniques have made these more accessible to veterinary practitioners. These vascular access techniques are reviewed here, along with advantages, limitations, and areas for future study of each technique.

Defining difficult intravenous access (DIVA): A systematic review

BACKGROUND

The term "difficult intravenous access" (DIVA) is commonly used but not clearly defined. Repeated attempts at peripheral intravenous catheter (PIVC) insertion can be a traumatic experience for patients, leading to sub-optimal clinical and economic outcomes. We conducted a systematic literature review (SLR) to collate literature definitions of DIVA, with the aim of arriving at an evidence-driven definition.

METHODS

The SLR was designed to identify clinical, cost, and quality of life publications in patients requiring the insertion of a PIVC in any setting, including studies on US-guidance and/or guidewire, and studies with no specific intervention. The search was restricted to English language studies published between 1st January 2010 and 30th July 2020, and the Ovid platform was used to search several electronic databases, in addition to hand searching of clinical trial registries.

RESULTS

About 121 studies were included in the SLR, of which 64 reported on the objectives relevant to this manuscript. Prevalence estimates varied widely from 6% to 87.7% across 19 publications, reflecting differences in definitions used. Of 43 publications which provided a definition of DIVA, six key themes emerged. Of these, themes 1-3 (failed attempts at PIV access using traditional technique; based on physical examination findings for example no visible or palpable veins; and personal history of DIVA) were covered by all but one publication. Following a failed insertion attempt, the most common number of subsequent attempts was 3, and it was frequently reported that a more experienced clinician would attempt to gain access after multiple failed attempts.

CONCLUSIONS

Considering the themes identified, an evidence-driven definition of DIVA is proposed: "when a clinician has two or more failed attempts at PIV access using traditional techniques, physical examination findings are suggestive of DIVA (e.g. no visible or palpable veins) or the patient has a stated or documented history of DIVA."

Predictive Factors for Anxiety during Blood Sampling and Insertion of Peripheral Intravenous Catheters in Paediatric Patients in Spain

INTRODUCTION

Invasive procedures for diagnosis purposes such as venepuncture and peripheral venous catheter insertion are painful procedures that cause great stress for paediatric patients. The objective of this study is to find out the factors that have an impact on the level of anxiety experienced by children undertaken these procedures.

DESIGN AND METHODS

Prospective study, 359 children between 2 and 15 years old were included, treated in a tertiary reference hospital in the region of Navarra (Spain). The impact of the variables recorded was analysed using a regressive analysis, the Wong-Baker and FLACC scales were used to measure the level of pain and the PACBIS scale to measure the level of stress and anxiety.

RESULTS

The average age of the participants was 7.93 years (SD: 4.04), with 51.8% (n = 186) boys and 48.2% (n = 173) girls. The mean value of pain recorded was 4.43 (SD:3.10). 45.7% (n = 123) of the venepuncture techniques was associated with minimum level of anxiety, including 11.1% of intravenous catheterization. Variables determining the anxiety has been detected such as age, sex, level of pain, parental conduct and time spent on the procedure.

CONCLUSIONS

Paediatric patients experience high levels of anxiety when undergoing painful procedures which are conditioned by multifactorial reasons. The increase in stress is directly related to the older age (>6 years old) of the patient, and statistically significant by the female gender, the longer duration of the technique and the parental block.

PRACTICE IMPLICATIONS

Healthcare professionals should work on some of the variables and apply measures aimed to mitigate anxiety levels. For example, reducing the duration of the procedure, training parents, and distracting techniques.

The association of intraosseous vascular access and survival among pediatric patients with out-of-hospital cardiac arrest

INTRODUCTION

In pediatric out-of-hospital cardiac arrest (OHCA) the effect of intraosseous (IO) or intravenous (IV) access on outcomes is unclear.

METHODS

We analyzed prospectively collected data of non-traumatic OHCA in the Resuscitation Outcomes Consortium registry from 2011 to 2015. We included EMS-treated patients ≤17 years of age, classified patients based on vascular access routes, and calculated success rates of IO and IV attempts. After excluding patients with obvious non-cardiac etiologies and those with unsuccessful vascular access or multiple routes, we fit a logistic regression model to evaluate the association of IO vascular access (reference IV access) with the primary outcome of survival, using multiple imputation to address missing data. We analyzed a subgroup of patients at least 2 years of age.

RESULTS

There were 1549 non-traumatic OHCA: 895 (57.8%) patients had an IO line attempted with 822 (91.8%) successful; 488 (31.5%) had an IV line attempted with 345 (70.7%) successful (difference 21%, 95% CI 17 to 26%). Of the 761 patients included in our logistic regression, 601 received IO (30 [5.2%] survived) and 160 received IV (40 [25%] survived) vascular access. Intraosseous access was associated with a decreased probability of survival (adjusted OR 0.46; 95% CI 0.21-0.98). Patients at least 2 years of age showed a similar association (adjusted OR 0.36; CI 0.15-0.86).

CONCLUSIONS

Intraosseous access was associated with decreased survival among pediatric non-traumatic OHCA. These results are exploratory and support the need for further study to evaluate the effect of intravascular access method on outcomes.

Procedural Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Point-of-care ultrasound can improve efficacy and safety of pediatric procedures performed in the emergency department. This article reviews ultrasound guidance for the following pediatric emergency medicine procedures: soft tissue (abscess incision and drainage, foreign body identification and removal, and peritonsillar abscess drainage), musculoskeletal and neurologic (hip arthrocentesis, peripheral nerve blocks, and lumbar puncture), vascular access (peripheral intravenous access and central line placement), and critical care (endotracheal tube placement, pericardiocentesis, thoracentesis, and paracentesis). By incorporating ultrasound, emergency physicians caring for pediatric patients have the potential to enhance their procedural scope, confidence, safety, and success.

Difficult intravenous access as an independent predictor of delayed care and prolonged length of stay in the emergency department

OBJECTIVES

Difficult intravenous access (DIVA) is common in the emergency department (ED). We investigated the extent to which DIVA is associated with care delay outcomes including time to first laboratory draw, therapies, imaging, and ED disposition.

METHODS

An observational retrospective cohort analysis of patients with DIVA treated between 2018 and 2020 at 2 urban academic EDs was performed. DIVA was defined as patients requiring ultrasound-guided intravenous access placed by physicians or advanced practice providers (APPs) as opposed to landmark-based intravenous placement by nurses. ED throughput variables and disposition time were compared. We correlated DIVA with time to administration of intravenous pain medications, fluids, imaging contrast, laboratory results, and ED disposition.

RESULTS

A total of 108,256 subjects with 161,122 total encounters were included. DIVA occurred in 4961 (3.1%) of ED visits. Patients with DIVA were more likely to be female (3.5% vs 2.6% for males, odds ratio [OR] 1.34, 95% confidence interval [CI]: 1.27-1.42), self-identify as black (OR 1.78, 95% CI: 1.66-1.91), and have higher acuity of illness (P < 0.001). Among pediatric patients, DIVA occurred most often in the first year of life at a rate of 3.25%. In adults, DIVA occurred in 2 age peaks; at 35 years (4.02%), and at 63 years (3.44%). In all workflow metrics, the presence of DIVA was associated with significant delays in median time to completion: 50 minutes for pain medication administration, 36 minutes for intravenous fluid administration, 29 minutes for laboratory results, 57 minutes for intravenous contrast administration, and 87 minutes for discharge orders.

CONCLUSION

DIVA was associated with increased time to therapies, diagnostic studies, imaging completion, and ED disposition. A more expeditious approach to achieving intravenous access in patients with predicted DIVA could improve ED throughput and patient care overall.