Caliber of the deep veins of the arm in infants and neonates: The VEEIN study (Vascular Echography Evaluation in Infants and Neonates)

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.

Point-of-care ultrasound for vascular access in neonates and children

Ultrasound plays a major role in neonatal/pediatric vascular access, both for venous access and for arterial access, not only just for the insertion of intravascular catheters, but also for many other issues related to this type of maneuver. This "global use of ultrasound" includes a systematic and consistent adoption of this technology for several steps of vascular access: (a) the pre-procedural assessment/evaluation of the vessels, (b) the ultrasound-guided puncture and cannulation of arteries and veins, (c) the real-time diagnosis of immediate, puncture-related complications, (d) the so-called "tip navigation" (i.e., real-time intra-procedural assessment of the direction and trajectory of the guidewire and/or of the catheter inside the vasculature), (e) the so-called "tip location" (i.e., intra-procedural or post-procedural assessment of the proper position of the tip of the catheter), and (f) the early diagnosis and/or management of most non-infective late complications.

CONCLUSION

Therefore, any vascular access expert (nurse or physicians) should have documented competency in the use of ultrasound. This knowledge should include the use of ultrasound for assessment of vessels, for catheter insertion, for proper placement of the tip, and for real-time detection of complications.

WHAT IS KNOWN

• Ultrasound is obviously useful for vascular access procedures in neonates and children.

WHAT IS NEW

• Recent evidence suggests that ultrasound is useful for many purposes in the field of vascular access (preprocedural scan, ultrasound-guided puncture, tip navigation, tip location, diagnosis of most non-infective complications). • Recent evidence also suggests that radiological methods no longer play any role in the insertion of vascular accesses in neonates and children.