Ultrasound-guided "short" midline catheters for difficult venous access in the emergency department: a retrospective analysis

Complications related to short peripheral intravenous catheters in patients with acute stroke: a prospective, observational, single-cohort study

Patients with acute stroke often require venous access to facilitate diagnostic investigations or intravenous therapy. The primary aim of this study was to describe the rate and type of complications associated with the placement of a short peripheral catheter (SPC) in patients with acute ischemic or hemorrhagic stroke. A prospective, observational, single-cohort study was conducted at Niguarda Hospital, Italy, with enrolment in the Emergency Department. Adult patients with an ischemic or hemorrhagic stroke requiring an SPC were enrolled. Complications, such as infiltration, occlusion, phlebitis and dislodgment, were recorded daily. Descriptive statistics were used, and the incidence rate ratio (IRR) was estimated to assess the difference in complications, considering catheter calibre, dominant side, exit site, limb, and limb mobility, ictus type (ischemic/haemorrhagic), impairment deficit (language, motor, visual) and EA-DIVA score. A total of 269 participants and 755 SPC were analysed. Removal of SPC due to at least one local complication occurred in 451 (60%). Dislodgment was the major cause of SPC removal (31%), followed by infiltration (18%), occlusion (6%), and phlebitis (5%). The SPC calibre (22G), exit-site other than antecubital and forearm, visual deficit and EA-DIVA ≥ 8 were associated with a higher rate of SPC complications: IRR, 1.71 [1.31; 2.31]; 1.27 [1.01; 1.60], 1.38 [1.06; 1.80], 1.30 [1.04; 1.64], respectively. No other differences in complication rates were observed according to the insertion site, i.e. dominant side, left side, plegic/hyposthenic limb, or exit site. This study provides novel insights into the frequency and types of complications associated with SPC in patients with acute stroke. Compared to the literature, a higher dislodgment rate was observed, being the first cause of SPC removal, whereas no differences in the number of infiltrations, occlusions, and phlebitis were recorded.

Infiltration and Extravasation Risk with Midline Catheters: A Narrative Literature Review

Midline catheters have recently gained popularity in clinical use, with a common reason being the reduction of central venous catheter use and central line-associated bloodstream infections. At the same time, the number of nononcology vesicant medications has increased, and midline catheters are frequently being used for infusions of vesicant medications. The Infusion Nurses Society (INS) Vesicant Task Force identified midline catheter use as a possible risk factor for extravasation and concluded that a thorough literature review was necessary. This review highlights the variations in catheter terminology and tip locations, the frequency of infiltration and extravasation in published studies, and case reports of infiltration and extravasation from midline catheters. It also examines the many clinical issues requiring evidence-based decision-making for the most appropriate type of vascular access devices. After more than 30 years of clinical practice with midline catheters and what appears to be a significant number of studies, evidence is still insufficient to answer questions about infusion of vesicant and irritant medications through midline catheters. Given the absence of consensus on tip location, inadequate evidence of clinical outcomes, and importance of patient safety, the continuous infusion of vesicants, all parenteral nutrition formulas, and infusates with extremes in pH and osmolarity should be avoided through midline catheters.

Handheld Ultrasound Devices for Peripheral Intravenous Cannulation: A Scoping Review

Ultrasound-guided insertion of peripheral intravenous catheters (PIVCs) is recommended for patients with difficult intravenous access, but access to ultrasound equipment is often limited to specialty departments. Compact, affordable handheld ultrasound devices are available, but the extent of their clinical adoption and impact on patient outcomes is unknown. This scoping review aimed to explore evidence regarding handheld and pocket ultrasound devices for PIVC insertion. Databases were searched for studies published in English between January 2000 and January 2023 evaluating handheld or pocket ultrasound devices weighing ≤3 kg for PIVC insertion. Data were extracted using standardized forms and summarized using descriptive statistics. Seventeen studies reporting the use of handheld or pocket ultrasound devices were identified. Most studies were conducted in adult inpatient facilities; 3 included pediatrics, and 2 reported out-of-hospital use. Participants with difficult intravenous access featured in 9 studies. Ultrasound training programs were described in 12 studies, with competency defined by number of successful PIVC insertions. Five studies reported clinician and/or patient perspectives. Ultrasound for PIVC insertion is not widely accessible in nonspecialist areas, but more compact and affordable handheld models could provide a solution, especially for patients with difficult access. More research evidence using handheld ultrasound is needed.

Long peripheral cannula in COVID-19 patients: 769 catheter days experience from a semi-intensive respiratory COVID unit

BACKGROUND

In the daily management of peripheral venous access, the health emergency linked to the COVID-19 pandemic led to re-examining the criteria for choosing, positioning and maintaining the different types of peripheral venous access.

OBJECTIVES

This study aimed to observe the dwell time of long peripheral cannula (LPC, also known as mini-midline) in patients affected by COVID 19 related pneumonia. The secondary objective is to study any complications due to mini-midline insertion.

MATERIALS AND METHODS

We conducted a prospective observational study on COVID19 patients who arrived at our Semi-Intensive Respiratory Unit from territorial ED between January and April 2021, to whom were positioned an LPC at the time of admission following the SIPUA protocol (Safe Insertion of Peripheral Ultrasound-guided Access). We used Vygon™ Leader-Cath© 18G in polyethylene and 8 cm long catheter.

RESULTS

We enrolled 53 consecutive patients, reaching 769 catheter days. The procedure was performed without immediate complications in 37 patients out of 53 (69.8%). In 14 patients (26.4%), we observed a local hematoma (no one led to a failure or early removal of the device) and in two patients (3.7%) was not possible to draw blood. The average catheter dwell time was 14.5 days, from 3 to 41 days. In 42 patients (79.2%), the device was removed at the end of use. In 11 patients out of 53 (20.8%), the device was removed early due to complications: seven accidental removals, one obstruction, two vein thrombosis, and one superficial thrombophlebitis.

CONCLUSIONS

The ultrasound-guided implantation of an 18G LPC in COVID19 patients, regardless of the state of their venous heritage, would seem to be an excellent strategy for these patients, reducing the number of venipunctures and CVC implantation, as well as allowing multiple and high pressure (contrast) infusions.

Validity and reliability of the Turkish version of the Difficult Intravenous Access Scale for adult patients

Background

Difficult intravenous access is a condition that decreases the first-attempt success rate of intravenous catheterisation. It is important to evaluate patients with difficult vascular access using a standardised scale. This study was carried out to establish the Turkish validity and reliability of the 'Adult Difficult Intravenous Access Scale'.

Methods

The methodological descriptive study was carried out in the Adult Emergency Department. The research sample consisted of 100 patients over 18 years of age, who were conscious, whose condition was not critical or who did not require resuscitation. 'Case Report Form' and 'Adult Difficult Intravenous Access Scale' were used.

Results

The mean age of the patients was 57.54 ± 19.44 years, and 55% (n = 55) were female and 77% (n = 77) had a chronic disease. The factor loads of the scale items are between 0.366 and 0.852. The Cronbach's alpha coefficient was found to be 0.708.

Conclusions

The Turkish version of the scale is a valid and reliable scale for determining the risk of difficult intravenous access. The practical use of this scale by healthcare professionals will enable earlier diagnosis of patients with difficult vascular access.

Mono- and bi-plane sonographic approach for difficult accesses in the emergency department - A randomized trial

BACKGROUND

The insertion of peripheral intravenous (PIV) catheters is one of the most performed invasive procedures in acute healthcare settings. However, peripheral difficult vascular access (PDVA) is not uncommon and can lead to delays in administering essential medications. Ultrasound (US) has emerged as a valuable tool for facilitating PIV cannulation. Advancements in technology have introduced a technique known as bi-plane imaging, allowing the simultaneous display of both longitudinal and transverse views of vessels. We aimed to investigate whether the utilization of bi-plane imaging, as opposed to the single-plane approach, would yield superior results for PDVA in the emergency department (ED).

METHODS

This study was a single-center randomized controlled trial. We included adult patients admitted to the ED who required PIV cannulation. Patients were randomly assigned to undergo cannulation using either the mono-plane or bi-plane approach, both performed by skilled providers. The primary outcome of the study was to compare the first attempt success rates between the two techniques.

RESULTS

A total of 442 patients were enrolled, with 221 undergoing cannulation attempts using the mono-plane approach. Successful placement of a functioning PIV catheter was achieved in a single attempt for 313 out of 442 patients (70.8%). There was no significant difference in the success rates between the two study groups: 68.3% in the mono-plane group and 73.3% in the bi-plane group (p = 0.395). The median time required for a successful attempt differed between the groups, with 45 s (range 18-600) in the mono-plane group and 35 s (range 20-600) in the bi-plane group (p = 0.03).

CONCLUSIONS

Our study confirms that US is a highly effective tool for facilitating PIV cannulation in patients with PDVA presenting to the ED. However, our investigation into the use of bi-plane imaging did not reveal a significant improvement when compared to mono-plane imaging.

Long peripheral catheters in neonates: filling the gap between short peripheral catheters and epicutaneous-caval catheters?

INTRODUCTION

Non-critically ill neonates at times require venous access to provide peripherally compatible infusions for a limited period (more than 3 days). In such a situation, short peripheral cannulas are not appropriate as their average duration is about 2 days, while-on the other hand-epicutaneous-caval catheters may be too invasive. In these patients, insertion of long peripheral cannulas may be an effective option.

METHODS

In this observational retrospective study, we revised all "long" peripheral catheters (4 and 6 cm long) inserted by direct Seldinger technique in our neonatal intensive care unit when peripheral venous access was required for more than 3 days.

RESULTS

We inserted 52 2Fr polyurethane catheters, either 4 cm long (n = 25) or 6 cm long (n = 27) in 52 patients. Mean dwelling time was 4.17 days (range 1-12). Most devices were inserted in the cephalic vein (n = 18, 35%), and the rest in the saphenous vein (n = 11, 21%) and other superficial veins. There was no significant correlation between the duration of the device and type of infusion (p = 0.40). The main complications were infiltration (n = 16, 31%) and phlebitis (n = 8, 15%). The rate of removal due to complications was significantly higher (p < 0.01) in neonates with bodyweight <2000 g at the time of insertion.

CONCLUSION

In our experience, 2 Fr 4-6 cm long peripheral catheters may be a valid option for neonates requiring peripherally compatible infusions for more than 3 days. The limits of this study are the necessity of training in the technique of insertion and the small size of our sample. The longest dwell was observed in neonates weighing >2000 g at the time of LPC insertion.

Midline catheters in the operating room

Backgrounds

Among various vascular access devices, midline catheters (MCs) are commonly used in emergency departments, but rarely in operating rooms.

Aims

To evaluate the feasibility and safety of MCs in the operating room.

Materials and Methods

This was a retrospective study. The medical records of patients who underwent MC placement in the operating room from October 2020 to July 2022 were reviewed. The rates of successful catheter insertion as well as major and minor complications were assessed.

Results

Successful catheter insertions were achieved in 149 of 161 patients (92.5%). The median dwell time of midlines was eight days (IQR: 6-10 days). A major or minor complication occurred in 6.7% of the midlines. The rates of major complications of occlusion, upper extremity deep vein thrombosis (DVT), and catheter-related bloodstream infection were 1.3%, 0.7%, and 0%, respectively.

Conclusions

Placement of MCs in the operating room was feasible and safe. Also, the procedure provides an acceptable alternative for replacing central line catheters and peripherally inserted central catheters.

The Adult Difficult Intravenous Access (DIVA) Cognitive Aid: An Evidence-Based Cognitive Aid Prototype for Difficult Peripheral Venous Access

Difficult intravenous access (DIVA) is common, with imperfect solutions. Cognitive aids are widespread in anaesthesia; however, a standard DIVA cognitive aid is lacking. This article describes a cognitive aid for DIVA. It has been developed using evidence-based techniques for DIVA. The effects of heuristics, biases, and automatic thinking on procedural decision-making are briefly discussed. While often useful, shortcut decision-making can impair the performance of apparently simple tasks. Cognitive aids may lead to better outcomes by providing choice architecture. This resource is intended as a cognitive aid prototype for difficult peripheral venous access, incorporating both modern behavioural psychology principles and evidence-based medicine. It may be used as both an educational tool, or as a cognitive aid to assist in situations where DIVA is encountered or expected. The adult DIVA cognitive aid is intended for use in both elective and emergency scenarios by practitioners adequately trained in ultrasound-guided or ultrasound-assisted vascular access and Seldinger-based techniques. Clinical implementation and audit of the adult DIVA cognitive aid, or similar locally developed cognitive aids based on this prototype are recommended.

Comparative Effectiveness, Efficiency, and ED Nurse Preference Between Two Methods of Visualization for Midline Catheter Insertion: A Pilot Study

Introduction

Rapid and reliable peripheral IV access is essential for many patients admitted to the emergency department (ED) to ensure administration of life-saving medications, and successful intravenous cannulation can significantly affect patient care.

Objective

The objective of this study was to assess the impact of a continuous needle tracking system on the accuracy, speed, and quality of ultrasound-guided peripheral venous catheter insertions.

Methods

A convenient sample study based on the study setting using simulated tissue was conducted with 49 US-based ED nurses to compare the insertion of a midline catheter using traditional ultrasound guidance versus an advanced needle-tracking technology along with ultrasound guidance. The purpose of this evaluation was to assess the impact of continuous needle tracking system. Informed consent was obtained from all individual participants involved in this study. All participants were made aware that the results may be published. There was no IRB approval for this study. All sources were properly disclosed within the text.

Results

The addition of the advanced needle-tracking technology significantly reduced total insertion attempts, insertion time, backwall penetrations, and redirects (probes to hit the target vein), while improving image clarity and confidence for participants.

Conclusion

The innovative needle-tracking system evaluated in this pilot study has the potential to improve emergent difficult vascular access. EDs should assess the value of this technology to potentially improve the management of difficult intravenous access patients in their settings.

European recommendations on the proper indication and use of peripheral venous access devices (the ERPIUP consensus): A WoCoVA project

Since several innovations have recently changed the criteria of choice and management of peripheral venous access (new devices, new techniques of insertion, new recommendations for maintenance), the WoCoVA Foundation (WoCoVA = World Conference on Vascular Access) has developed an international Consensus with the following objectives: to propose a clear and useful classification of the currently available peripheral venous access devices; to clarify the proper indication of central versus peripheral venous access; discuss the indications of the different peripheral venous access devices (short peripheral cannulas vs long peripheral cannulas vs midline catheters); to define the proper techniques of insertion and maintenance that should be recommended today. To achieve these purposes, WoCoVA have decided to adopt a European point of view, considering some relevant differences of terminology between North America and Europe in this area of venous access and the need for a common basis of understanding among the experts recruited for this project. The ERPIUP Consensus (ERPIUP = European Recommendations for Proper Indication and Use of Peripheral venous access) was designed to offer systematic recommendations for clinical practice, covering every aspect of management of peripheral venous access devices in the adult patient: indication, insertion, maintenance, prevention and treatment of complications, removal. Also, our purpose was to improve the standardization of the terminology, bringing clarity of definition, and classification.

Usefulness of Midline Catheters versus Peripheral Venous Catheters in an Inpatient Unit: A Pilot Randomized Clinical Trial

Canalization of vascular accesses is one of the most used techniques in hospitalization units. When talking about peripherally inserted catheters, we can differentiate between peripheral intravenous catheters (PIVC), midline catheters, and long peripheral catheters (LPC). Midline catheters are rarely used despite being recommended for intravenous therapies lasting more than six days. This research is a pilot study of a longitudinal clinical trial. It aims to compare the complications associated with intravenous therapy between the control group (CG) with a PIVC and the experimental group (EG) with a midline in an Internal Medicine Unit of a Spanish hospital for three months. In this study, 44 subjects participated, 25 in the CG and 19 in the EG. The duration of cannulation was longer in the experimental group (8.13 days vs. 3.22, p < 0.001), and the appearance of phlebitis was more significant in the control group (19 patients in CG and 25 patients in EG). Midlines have presented a longer duration of cannulation and fewer complications than the PIVC. This protocol was registered with ClinicalTrials.gov (NCT05512117).

Safety and efficacy of midline catheters versus peripheral intravenous catheters: A pilot randomized controlled trial

BACKGROUND

Despite pervasive need for peripheral intravenous catheters, insertion is often difficult, and approximately two thirds fail prematurely. Midline catheters are an alternative long peripheral catheter, inserted in the upper arm, ideal for patients with difficult access.

AIM

The aim of this study is to test feasibility of the protocol and compare the efficacy and safety of midline catheters to peripheral intravenous catheters.

DESIGN

A parallel-group, pilot randomized controlled trial of adult medical/surgical hospitalized patients, from a single Australian referral hospital.

METHODS

Participants with difficult vascular access (≤2 palpable veins) and/or anticipated ≥5 days of peripherally compatible intravenous therapy were recruited between May 2019 and March 2020. Participants were randomized to (1) peripheral intravenous catheter or (2) midline catheter. Primary feasibility outcome measured eligibility, recruitment, protocol adherence, retention and attrition. Primary clinical outcomes measured device insertion failure and post-insertion failure.

RESULTS

In total, n = 143 participants (71 peripheral intravenous catheters and 72 midline catheters) were recruited; n = 139 were analysed. Most feasibility criteria were met. Peripheral intravenous catheters had shorter functional dwell time, with higher incidence of post-insertion failure compared to midline catheters.

CONCLUSION

Midline catheters appear to be superior for patients with difficult vascular access or receiving prolonged intravenous therapy; a large, multi-centre trial to confirm findings is feasible.

Midline Catheters: Could They Replace a Central Vascular Access Device?

In the past 30 years, midline catheter use has grown rapidly. For several reasons, many providers and facilities are attempting to reduce the number of central venous catheters and subsequent central line-associated bloodstream infections (CLABSIs) by using midline catheters. Vessel preservation requires attention to all vascular access device (VAD)-associated complications and not only central line bloodstream infection. There is still much confusion about the appropriate tip location and the characteristics of fluids and medications that can safely be infused through a midline catheter residing in a peripheral vein. The Infusion Therapy Standards of Practice (the Standards) focuses on assessment of characteristics of infusion therapies that must be considered for VAD selection as an evidence-based list of fluids and medications for infusion through peripheral veins has yet to be established. This review of midline catheter studies evaluates the evidence regarding the substitution of a midline catheter for a central venous catheter. Many issues need to be addressed, such as studies that include an outcome list that mixes defined clinical complications (eg, thrombosis) with signs and symptoms of complications (eg, leaking). Another issue is basing a major change of clinical practice on retrospective chart reviews. Although a midline catheter may be appropriate for some patients, additional studies of a higher level of evidence are needed before this major practice change should occur.

Safety verification of a new peripheral intravenous catheter placed in the upper arm vein for administration of drugs with high irritant potential

Despite the widespread use of peripheral intravenous catheters, unscheduled catheter failure before completion of treatment occurs frequently. If a large vein is selected, catheter failures may be prevented despite administering a highly irritant drug. In this study, we attempted to use a catheter that can be placed in a large upper arm vein. The new catheter was 88 mm long but had no guidewire to reduce contamination risk. This study aimed to evaluate the safety of the first-in-human trial for the new catheter with the administration of highly irritant drugs. This study was conducted at a university hospital in Tokyo, Japan. Eight Japanese adults were hospitalized adults with planned administration of non-cancer drugs with high irritant potential using a peripheral catheter. A trained nurse catheterized with the new catheter in the upper arm using ultrasonography. The catheterization site was monitored by staff and a research nurse once every 24 hours for up to 7 days. No adverse events or catheter failure occurred and the catheter placement success rate was 100%. In two patients, a temporary occlusion alarm of the infusion pump occurred, possibly due to the flexion of the catheter base. The new peripheral intravenous catheter did not interrupt medical treatments as is common after placement, but safety administered the irritant drugs. However, because this catheter may be easily affected by the contraction of the muscle at the fixation position, the position and method of catheter fixation in the upper arm need to be carefully considered.

Peripheral intravenous catheters in the care of oncology and haematology patients

Aim

To determine peripheral intravenous catheter (PIVC) characteristics, complications and risk factors among patients in cancer units.

Methods

A secondary analysis of a global, cross-sectional study (127 hospitals in 24 countries). Participants (≥18 years) admitted to cancer units were assessed once for PIVC characteristics and the presence of complications. Variables included patient demographics, device characteristics, treatment details, and device and/or site complications. PIVC characteristics were presented using qualitative descriptors; mixed-effects logistic regression models determined risk factors for PIVC complications.

Results

In total, 1,807 participants (1,812 PIVCs) were included; 12% (n=215) of PIVCs presented with complications. Risk factors included: insertion by doctors; insertion in ED and ambulance/other locations; poor PIVC dressing integrity; dwell time ≥49 hours; and administration of colloids/blood products and antiemetics.

Conclusions

At least one in ten PIVCs in cancer units present with complications; regular PIVC assessment and improved dressing integrity is likely to reduce risk and improve outcomes.

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.

Emergencies in obese patients: a narrative review

Obesity is associated to an increased risk of morbidity and mortality due to respiratory, cardiovascular, metabolic, and neoplastic diseases. The aim of this narrative review is to assess the physio-pathological characteristics of obese patients and how they influence the clinical approach during different emergency settings, including cardiopulmonary resuscitation. A literature search for published manuscripts regarding emergency and obesity across MEDLINE, EMBASE, and Cochrane Central was performed including records till January 1, 2021. Increasing incidence of obesity causes growth in emergency maneuvers dealing with airway management, vascular accesses, and drug treatment due to both pharmacokinetic and pharmacodynamic alterations. Furthermore, instrumental diagnostics and in/out-hospital transport may represent further pitfalls. Therefore, people with severe obesity may be seriously disadvantaged in emergency health care settings, and this condition is enhanced during the COVID-19 pandemic, when obesity was stated as one of the most frequent comorbidity. Emergency in critical obese patients turns out to be an intellectual, procedural, and technical challenge. Organization and anticipation based on the understanding of the physiopathology related to obesity are very important for the physician to be mentally and physically ready to face the associated issues.

Does the Midline Peripheral Intravenous Catheter Have a Place in Critical Care?

BACKGROUND

The goals of infusion therapy are to preserve vascular health and safely deliver needed treatment. Achieving these goals is challenging in critical care because of the complexity of the treatment required. Daily justification of retaining an existing central venous catheter also creates urgency to change to a peripheral vascular access device. The midline catheter has had a resurgence in use because of the need for a long-term peripheral vascular access device not linked to central catheter-associated bloodstream infection risk.

OBJECTIVE

To review the characteristics of midline catheters, the benefits and risks of midline catheters, and current evidence regarding midline catheter use in critical care.

RESULTS

Research related to midline catheters has greatly expanded the body of knowledge regarding vascular access device selection and midline catheter use.

DISCUSSION

Although the quality and results of research on vascular access devices vary widely, a more accurate safety profile is emerging to illustrate how midline catheter use can support the goals of infusion therapy.

CONCLUSIONS

Optimizing vascular access device selection requires recognition that every vascular access device can cause patient harm. Although the midline catheter appears to fill an important niche in infusion therapy, use of the midline catheter should be carefully evaluated. Midline catheters should not be used as a catheter-associated bloodstream infection prevention strategy, should be inserted to administer peripherally compatible solutions, and should be considered for short-term continuous vesicant therapy only in emergent situations until more definitive vascular access can be achieved.

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."

Experience in the use of midclavicular catheters: An inception cohort study

AIMS AND OBJECTIVES

To describe the outcomes of midclavicular catheters related to first insertion success rate, catheter dwell time, rate of catheter survival until the end of the treatment, and complication rates, as well as identify risk factors associated with early catheter removal.

BACKGROUND

Midclavicular catheters are peripheral venous catheters that are typically 20-25 cm in length.

DESIGN

Inception cohort study.

METHODS

We included all the midclavicular lines inserted in patients who met any of the following criteria: (a) difficult venous access; (b) administration of intravenous therapy expected to last between 6 and 30 days with non-irritant (pH=5-9) and/or non-vesicant drugs; or (c) contraindications to central venous catheter placement. The incidence of adverse events was calculated using percentages and episodes per 1,000 catheter days. Univariate and multivariate logistic regression analyses were performed to identify significant risk factors for unexpected catheter removal by calculating odds ratios. Catheter survival was assessed using Cox regression analysis. The STROBE guidelines were followed.

RESULTS

Overall, 2,275 midclavicular lines were placed in 1,841 participants. The insertion success rate was 99.4% and the mean catheter dwell time was 21.82 days. The rate of adverse events was .7 per 1,000 catheter days, the most common complications being thrombosis (.39) and catheter-associated bacteraemia (.14). No significant association was found between adverse events and the administration of irritant drugs. The incidence of unexpected removal was 6.7 per 1,000 catheter days. The multivariate analysis showed that both age ≤70 years and home therapy were associated with a lower likelihood of catheter failure.

CONCLUSIONS

Midclavicular catheters are associated with a high rate of insertion success and low rates of adverse events and unplanned removal.

RELEVANCE TO CLINICAL PRACTICE

Midclavicular lines are a safe alternative for intravenous therapy lasting more than 6 days, even with irritant drugs.

The Practice and Complications of Midline Catheters: A Systematic Review

OBJECTIVE

Midline catheters are considered "midway" regarding vascular access. The objective of this systematic review was to explore the current practice, dwell time, and complication rates of midline catheters.

DESIGN

Systematic review.

SETTING

Search on four databases, PubMed, CINAHL, Scopus, and Embase, were conducted for English language articles published after the year 2000.

MEASUREMENTS AND MAIN RESULTS

A total of 987 articles were identified, of which 31 manuscripts met the inclusion criteria and were selected for review. Quality assurance was performed based on the Newcastle-Ottawa score. Average dwell time and complication rates were calculated for studies involving adult patients and adjusted for sample size. This analysis included data from the placement of 18,972 midline catheters across five countries. Aside from two randomized control trials, most of the studies analyzed were cohort studies. One pediatric and two neonatal studies were included. The average dwell time was 16.3 days (n = 4,412). The adjusted mean infection rate was 0.28/1,000 catheter days, with 64% of studies not reporting any infection with midline catheter. The failure rate of midline catheters was 12.5%. Adjusted average rates of other significant complications included the following: deep vein thrombosis (4.1%), dislodgement (5.0%), occlusion (3.8%), phlebitis (3.4%), and infiltration (1.9%).

CONCLUSIONS

The dwell times and failure rates of midline catheters compare favorably against published data on other types of catheters. Their infection rates are also lower than the reported rates of central venous catheters; however, they have a higher rate of mechanical complications. Active surveillance of infections due to midline catheters is recommended. More data are needed from pediatric and neonatal populations.

Standard Versus Long Peripheral Catheters for Multiday IV Therapy: A Randomized Controlled Trial

OBJECTIVES

In children, intravenous therapy (IVT) is generally administered via peripheral intravenous catheters (PIVCs) (2-6 cm in length). There is evidence that PIVCs are unreliable after 2 days. Long peripheral catheters (LPCs) (6-15 cm in length) could improve the delivery of IVT. The aim of this trial was to determine if LPCs could decrease catheter failure and the number of catheters in children receiving multiday IVT.

METHODS

This was an open-label randomized controlled trial conducted at Monash Children's Hospital in Melbourne, Australia. Participants were from the ages of 1 to 17 years, undergoing surgery and requiring >48 hours of postoperative IVT. Participants were randomly assigned to a 2.5-cm 22G PIVC or an 8-cm 22G LPC.

RESULTS

Seventy-two children were randomly assigned, 36 received PIVCs, and 36 received LPCs. The median duration of IVT was 5.1 days and was similar between groups (P = .9). Catheter failure was higher for PIVCs than LPCs (66.7% vs 19.4%; relative risk [RR]: 3.4; P = .0001 or 187.9 vs 41.0 failures per 1000 catheter-days). Infiltration was the most common reason for PIVC failure (33.3% vs 2.8%; RR: 12.0; P = .001). LPCs exhibited superior life span (4.7 vs 3.5 days [median]; P = .01). Children with LPCs were twice as likely to complete therapy with a single catheter (80.6% vs 38.9%; RR: 2.1; P = .0006).

CONCLUSIONS

LPCs reduce catheter failure and total catheters in children. They should be considered as the first-line device for peripheral access in any child receiving prolonged IVT.

Comparison of 12-cm versus 6-cm long peripheral catheters in patients with difficult intravenous access (DIVA)

BACKGROUND

Long peripheral catheter is 6-15 cm long vascular device. The aim of the study was to compare the frequency of complications of two types of long peripheral catheters with different length inserted in DIVA patients.

METHODS

Under ultrasound navigation 2.7F 6.4 cm or 4Fr 12 cm long peripheral catheter was inserted. Complications of both long peripheral catheters were prospectively observed and their relationship to the patient's age, gender, selected vein, number of punctures and Barthel score system was evaluated.

RESULTS

Ninety-three 12 cm and fifty-five 6.4 cm long peripheral catheters were inserted. Median of dwelling time was 8 days for 6.4 cm and 9 days for 12 cm long peripheral catheter. There were 17 (26%) complications in 6.4 cm (38/1000 catheter days) and 15 (16%) in 12 cm catheter (17/1000 catheter days), p = 0.04. The complications of both peripheral catheters were not associated with the age of patients, gender, number of punctures and selected vein for insertion. Unlike 12 cm catheter, the complications of 6.4 cm long peripheral catheter were significantly associated with the result of Barthel scoring system (p = 0.003).

CONCLUSION

The frequency of complications was more common with 6,4 cm than with 12 cm catheter.

Conventional central venous catheters as tunnelled mid-clavicular midline catheters: Description of novel application and outcome analysis

BACKGROUND

Long peripheral catheters are the ideal devices for intermediate venous access (1-4 weeks). However due to non-availability and cost constraints, these lines are not widely adapted in developing countries. In this clinical report we describe a technique of using conventional Central Venous Catheters as Midclavicular midlines for intermediate venous access and present the outcome analysis of such catheters in the last 2 years from our institute.

METHODS

A single lumen conventional central venous catheter (5 Fr, 20 cm) was introduced through the deep veins of the upper arm, 1 to 1.5 cm distal to the axillary crease. The catheter was tunnelled for a distance of 5 to 7 cm to exit from Dawson's green zone to reduce the incidence of Midline Associated Blood Stream Infection. Patients were followed up by trained staff nurses and outcome parameters were recorded.

RESULTS

Seventy six patients were enrolled and 72 patients underwent successful cannulation and completed the outcome analysis. Administration of intravenous antibiotics and chemotherapy were the commonest indications. The device served the intended duration of therapy in 66 (92%) patients for a median number of 12 (6-20) catheter days. Device related blood stream infection was 1.24/1000 catheter days and catheter related thrombosis rate was 8.3%.

CONCLUSION

Conventional Central Venous Catheters can be effectively used as tunnelled Midclavicular midline catheters in low resource settings. The successful outcome analysis has to be confirmed by larger studies.

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.

Midline or long peripheral catheters in difficult venous access conditions? A comparative study in patients with acute cardiovascular diseases

BACKGROUND

Midline catheters (MCs) are commonly inserted in patients with difficult venous access (DVA) needing peripheral access. Recently, the alternative placement of ultrasound-guided long peripheral catheters (LPCs) has spread. However, no study has compared the reliability of the 2 devices. This study aims to compare the safety and reliability of MCs and LPCs in DVA patients.

METHODS

A retrospective cohort study was conducted, enrolling 184 DVA patients. Polyurethane MCs and 2 lengths of polyethylene LPCs (8/10 cm and 18 cm) were compared. The independent effect of catheter type on uncomplicated catheter survival was determined through a Cox regression analysis.

RESULTS

The relative incidences of overall catheter-related complications (CRCs) were 15.84 of 1,000, 10.64 of 1,000, and 6.27 of 1,000 catheter-days for 8/10 cm-LPCs, 18 cm-LPCs, and MCs, respectively. The relative incidences of catheter-related bloodstream infections were 0.72 of 1,000 for both length LPCs and 0.48 of 1,000 catheter-days for MCs. Compared to MCs, a significant increase in CRC risk for 8/10 cm LPCs (hazard ratio [HR] 5.328; 95% confidence interval [CI] 2.118-13.404; P < 0.001) was found, along with a nonsignificant trend toward an increased risk for 18 cm-LCPs (HR 2.489; 95% CI 0.961-6.448; P = 0.060).

CONCLUSION

MCs allow for longer uncomplicated indwelling times than LPCs. The decision regarding which catheter to use should consider the planned duration of intravenous therapy, the patient's clinical condition, and the cost of the device.

Low cost blood vein detection system based on near-infrared LEDs and image-processing techniques

Drawing blood and injecting drugs are common medical procedures, for which accurate identification of veins is needed to avoid causing unnecessary pain. In this paper, we propose a low-cost system for the detection of veins. The system emits near-infrared radiation from four light-emitting diodes (LEDs), with a charge-coupled device (CCD) camera located in the middle of the LEDs. The camera captures an image of the palm of the hand. A series of digital image-processing techniques, ranging from image enhancement and increased contrast to isolation using a threshold limit based on statistical properties, are applied to effectively isolate the veins from the rest of the image.

Risk Factors for Difficult Peripheral Intravenous Cannulation. The PIVV2 Multicentre Case-Control Study

BACKGROUND

Difficult peripheral intravenous cannulation (DPIVC) is associated with serious complications related to vascular access. These complications might be avoided if the risk factors were identified previously, enabling the detection of potentially difficult situations at an early stage. The aim of this study is to consider these risk factors, to determine the influence of the hospital setting, to examine the association between DPIVC and the different techniques of catheter insertion and to analyse the importance of the clinician's experience in this context.

METHODS

Case-control study following a previously published protocol, conducted in 48 units of eight public hospitals in Spain. Adult patients requiring a peripheral intravenous cannula were prospectively included in the study population during their hospital stay. Over a period of 11 months, for consecutive eligible patients, nurses in each participating unit recorded data on their assessment of the vascular access performed and the technique used. Variables related to these medical personnel were also recorded. One of the researchers reviewed the patients' clinical history to compile the relevant health variables and to characterise the healthcare process. The statistical analysis included association tests among the main study variables. The risk factors were analysed using bivariate logistic regression. The variables found to be statistically significant were included in a multivariate logistic regression model incorporating each of the healthcare environments identified.

RESULTS

The study population was composed of 2662 patients, of whom 221 (8.3%) presented with DPIVC. A previous history of difficulty, the presence of non-palpable veins, acute upper limb alterations and punctures in the ante-cubital fossa were found to be independent risk factors for DPIVC. Differences were found in the frequency of occurrence of DPIVC and in some risk factors, according to the healthcare context. The variables related to the characteristics of the hospital personnel did not influence the study event.

CONCLUSION

The present study identifies four independent risk factors for DPIVC that can be incorporated into algorithms aimed at preventing its occurrence and facilitating the referral of patients to vascular access specialist teams.

The Utility of Midline Intravenous Catheters in Critically Ill Emergency Department Patients

STUDY OBJECTIVE

Midline catheters are an alternative to more invasive types of vascular access in patients in whom obtaining peripheral access has proven difficult. Little is known of the safety and utility of midline catheters when used more broadly in critically ill patients in the emergency department (ED). These are long peripheral catheter, ranging from 10 to 25 cm in length, typically placed with assistance of ultrasound and the Seldinger's technique. We describe our experience with the use of midline catheters in the ED.

METHODS

We conducted a prospective observational case series of all patients who had a midline catheter insertion attempted in the ED. We prospectively captured data on indication, technique, location, catheter type, number of attempts, overall success or failure, vasoactive use, and complications (daily catheter patency, flow, site appearance, and dwell-time complications).

RESULTS

From January 28, 2016, to December 30, 2017, practitioners placed 403 midline catheters. Catheter insertion success was 99%, and the median number of attempts was 1 (interquartile range 1 to 1; minimum 1; maximum 3). The median number of days the catheter remained in place was 5 (interquartile range 2 to 8). Failure to aspirate occurred in 57 patients (14%; 95% confidence interval 11% to 18%). Overall, 10 patients (2.5%; 95% confidence interval 1.2% to 4.5%) experienced 10 insertion-related complications. During the study period, 49 patients (12%; 95% confidence interval 9% to 16%) experienced 60 dwell-time-related complications. Severe complications occurred in 3 patients (0.7%).

CONCLUSION

Midline catheters may present a feasible alternative to central venous access in certain critically ill ED patients.

Long Peripheral Catheters: A Retrospective Review of Major Complications

The risk of infectious and noninfectious complications associated with long peripheral catheters (LPCs) is unknown. In this retrospective study of 539 catheters, we found LPCs were often placed for the indications of difficult access and long-term antibiotics. Rates of deep vein thrombosis (1.7%) and catheter-related infection (0.6%) were low. LPCs may represent a novel and safe option for short-term venous access.

Mini-midline in difficult intravenous access patients in emergency department: A prospective analysis

BACKGROUND

"Difficult intravenous access" patients represent a challenge within an emergency department as they often require many attempts to insert a peripheral short cannula in the emergency room or during the whole hospitalization. This can lead to many problems in terms of patient discomfort, increase of cost, and prolonged treatment time.

OBJECTIVES

This study aimed to reduce the number of attempts needed for a short-cannula insertion or preventing insertion of a central vascular access by placing an ultrasound-guided long cannula during the emergency department visit.

MATERIAL AND METHODS

The insertion of mini-midline was monitored within an emergency room in 50 patients considered difficult intravenous access patients, who failed two attempts at peripheral venous access insertion and/or required the use of an alternative vascular device.

RESULTS

A total of 46 patients out of 50 were monitored. In 38 (82%) patients, the device was removed due to the end of the indication, and in six of them, it was replaced by a central venous catheter. Two devices were left inside even after discharge and were then removed at the end of indication. In eight (17%) patients, the device was removed due to accidental removal (4) and malfunction (4). In all the cases, the average duration of the insertion procedure was 10 min. The mean dwell time accounted to 7 and 9 days.

CONCLUSION

The insertion of a mini-midline as part of the first emergency room visit in selected patients is a rapid, safe, and cost-effective procedure, which can provide the patient with stable venous access during the all hospitalization time.

Infection free midline catheter implementation at a community hospital (2 years)

BACKGROUND

To reduce excess central line use and provide an option for difficult venous access patients through the introduction of a midline catheter.

METHODS

Design included prospective monitoring of the implementation of a quality improvement project. The setting was a 576 bed, urban, community, nonprofit, Magnet recognized, level 3 trauma center serving primarily adult patients. Midline and peripherally inserted central catheters were inserted by a specialty nursing team; care and maintenance of all devices were provided by front line staff.

RESULTS

Zero midline catheter infections were observed in the 24 months after implementation of the fixed length, power injectable device. Completion of therapy was 80%, the most frequently encountered complication was device dislodgement.

CONCLUSIONS

Adoption of a vascular access nurse led midline catheter program, coupled with device selection algorithms expanded the ability to select the right device for the patient, while decreasing excess central line usage without additional increased risks to the patient.

Long peripheral catheters for deep arm vein venous access: A systematic review of complications

PURPOSE

Long peripheral catheters (LPCs) offer a quick, simple and cost-effective alternative for venous access in intensive care patients with difficult venous access, but the decision to use them must be balanced against an assessment of harm. The aim of this systematic review was to synthesise reports of complications associated with LPCs.

METHODS

The electronic databases MEDLINE, EMBASE and CINAHL were searched systematically for randomised controlled trials, cohort studies and case control studies published in the period 1966 to 24th July 2018 reporting LPC associated occlusion, catheter related blood stream infections, phlebitis and infiltration. Study quality was assessed using the Methodological Index for Non-Randomised Studies. The studies were described and participant characteristics; type of catheter; setting; average dwell time; and rates of occlusion, catheter related blood stream infection, phlebitis and infiltration were extracted as summary measures.

RESULTS

Five cohort studies and one randomised controlled study, comprising a total of 350 participants, fulfilled the inclusion criteria. Dwell time ranged from 1 to 15days and the reported complication rate was 3-14%. The most common complication was catheter occlusion (4%), followed by phlebitis (1%), infiltration (0.9%), and catheter related blood stream infection (0.3%). Significant heterogeneity, particularly in identification and reporting of complications, means results should be interpreted with caution.

CONCLUSION

There is a lack of intervention specific and adequately powered randomised controlled trials investigating LPCs in an intensive care setting. Until the results of such studies are available, LPCs should be used as an alternative to ultrasound-guided PVCs in well monitored acute care environments.

Long peripheral catheters: Is it time to address the confusion?

Long peripheral catheters are 6–15 cm peripheral dwelling catheters that are inserted via a catheter-over-needle or direct Seldinger (catheter-over-guidewire) technique. When inserted in the upper extremity, the distal tip terminates before reaching the axilla, typically no further than the mid-upper arm. This is distinct from a midline catheter, which is inserted via a modified Seldinger technique and terminates at the axilla. The nomenclature of this catheter is confusing and inconsistent. We have identified over a dozen labels in the literature, all describing the same device. These include ‘15 cm catheter’, ‘catheter inserted with a Seldinger method’, ‘extended dwell/midline peripheral catheter’, ‘Leaderflex line’, ‘long catheter’, ‘long IV catheter’, ‘long peripheral cannula’, ‘long peripheral catheter’, ‘long peripheral venous catheter’, ‘long polyurethane catheter’, ‘midline cannula’, ‘mini-midline’, ‘peripheral intravenous catheter’, ‘Seldinger catheter’, ‘short midline catheter’, ‘short long line’ and ‘ultrasound-guided peripheral intravenous catheter’. The purpose of this editorial is to achieve some level of standardisation in the nomenclature of this device. Is it time to address the confusion? We suggest adopting ‘long peripheral catheter’. However, we encourage discussion and debate in reaching a consensus.

Peripherally inserted central catheter, midline, and “short” midline in palliative care: Patient-reported outcome measures to assess impact on quality of care

Objectives:

A prospective, observational study was conducted in our palliative care unit to assess the impact of peripherally inserted central catheters (PICCs), midline, and “short” midline catheters on the quality of care in cancer and non-cancer patients. The secondary objective was to assess pain and distress during vascular access device insertion.

Methods:

Patients were recruited if they underwent insertion of a PICC, midline, or “short” midline catheter as part of their standard care. The Palliative care Outcome Scale was used to assess changes in quality of care after vascular access device positioning. A numerical rating scale was used to measure pain intensity during catheter insertion.

Results:

Of the 90 patients enrolled, 52.2% were male with a mean age of 73.0 ± 13 years. Among these patients, 64.4% patients underwent “short” midline insertion, 26.7% PICC, and 8.9% midline catheter. The patients’ mean baseline Palliative care Outcome Scale score was 15.7 ± 5.6. Three days after vascular access device positioning, the patients’ mean Palliative care Outcome Scale score was 11.5 ± 5.5 (p < 0.0001). Mean pain score during vascular access device insertion was 1.26 ± 1.63, and mean procedural distress score was 1.78 ± 1.93.

Conclusion:

These findings suggest that medium-term intravenous catheters can have a favorable impact on quality of care and the procedures for these vascular access device insertions are well tolerated. Further research on the performance of different vascular access devices and their appropriateness in palliative care should be encouraged.

A new device for ultrasound-guided peripheral venous access

BACKGROUND

In patients with difficult peripheral venous access, alternative techniques require expertise and are invasive, expensive, and prone to serious adverse events. This brought us to designing a new venous catheter (JLB® Deltamed, Inc.) for the cannulation of medium and large bore veins; it is echogenic, and available in different lengths (60 / 70 / 80 mm) and Gauges (14 / 16 / 17 / 18).

METHODS

We led a multi-center observational convenience sampling study to evaluate safety and effectiveness of JLB. Data was collected from June 2015 to February 2018. Inclusion criteria were age ⩾ 18, difficulty in obtaining superficial venous access in the veins of the arm, need for rapid infusion, or patient's preference.

RESULTS

We enrolled 1000 patients, mean age 66.8 years. In total, 951 (95.1%) had the device placed in internal jugular vein, 28 in basilic or cephalic vein, 15 in femoral vein, 5 in axillary vein (infra-clavicular tract), and 1 in the external jugular vein. The procedure was performed by attending physicians or emergency medicine residents under US guidance. Mean procedure time (from disinfection to securing) was approximately 240 s. Mean attempts number was 1.21. Early complications (<24 h) occurred in four patients, consisting in two soft tissue hematoma, one phlebitis, and one atrial tachyarrhythmia. No major complications (such as pneumothorax) were reported. Mean indwelling time was 168 h (7 days); early occlusion/dislocation occurred in four cases.

CONCLUSION

According to preliminary data, the application of JLB appears to be safe, cost-effective, and rapid to place bedside.

Standard long IV catheters versus extended dwell catheters: A randomized comparison of ultrasound-guided catheter survival

INTRODUCTION

Establishing peripheral intravenous (IV) access is a vital step in providing emergency care. Ten to 30% of Emergency Department (ED) patients have difficult vascular access (DVA). Even after cannulation, early failure of US-guided IV catheters is a common complication. The primary goal of this study was to compare survival of a standard long IV catheter to a longer extended dwell catheter.

METHODS

This study was a prospective, randomized comparative evaluation of catheter longevity. Two catheters were used in the comparison: [1] a standard long IV catheter, the 4.78 cm 20 gauge Becton Dickinson (BD); and [2] a 6 cm 3 French (19.5 gauge) Access Scientific POWERWAND™ extended dwell catheter (EDC). Adult DVA patients in the ED with vein depths of 1.20 cm-1.60 cm and expected hospital admissions of at least 24 h were recruited.

RESULTS

120 patients were enrolled. Ultimately, 70 patients were included in the survival analysis, with 33 patients in the EDC group and 37 patients in the standard long IV group. EDC catheters had lower rates of failure (p = 0.0016). Time to median catheter survival was 4.04 days for EDC catheters versus 1.25 days for the standard long IV catheter. Multivariate survival analysis also showed a significant survival benefit for the EDC catheter (p = 0.0360).

CONCLUSION

A longer extended dwell catheter represents a viable and favorable alternative to the standard longer IVs used for US-guided cannulation of veins >1.20 cm in depth. These catheters have significantly improved survival rates with similar insertion success characteristics.

The incidence of symptomatic upper limb venous thrombosis associated with midline catheter: Prospective observation

Aim:

The evaluation of the incidence of symptomatic upper limb venous thrombosis (ULVT) associated with midline catheters in patients admitted to the hospital.

Methods:

The frequency of symptomatic ULVT diagnosed in a group of patients with midline catheters confirmed by sonographic examination in hospitalised patients at Faculty Hospital over the period of 1 year.

Results:

Four hundred thirty-nine midline catheters were inserted in 430 patients (250 women and 180 men) during year 2015. Nine patients had two midline catheters. The average age of the patient was 68 years (range: 19–96 years). The median time of midline catheter introduction into a vein was 10 days (range: 1–112 days). Symptomatic thrombosis was diagnosed in 20 patients (4.5%), 3.3/1000 catheter days. It was associated with gender (male) and midline insertion in the cephalic vein.

Conclusion:

The risk of upper limb symptomatic thrombosis associated with midline catheters during a stay in the hospital should be taken into consideration when indicating optimal venous access.

Use of 8-cm 22G-long peripheral cannulas in pediatric patients

INTRODUCTION

Medium-term intravenous access in children is normally achieved by means of repeated multiple peripheral intravenous cannula insertions or peripherally inserted central catheters. Long peripheral cannulas might offer an alternative to these devices in children. Our aim was to clarify whether long peripheral cannulas provide reliable medium-term intravenous access avoiding the need for multiple peripheral intravenous cannulations or peripherally inserted central catheter insertion in children undergoing surgery.

METHODS

Following ethical approval, we prospectively collected data in children requiring medium-term intravenous access. The 22G-8-cm-long peripheral cannulas were inserted with a Seldinger technique in a peripheral vein. Position was checked by flushing and aspirating the catheter. Results are reported as mean ± standard deviation.

RESULTS

A total of 18 children were included. Indications for medium-term intravenous therapy included perforated appendicitis (n = 14), infected central venous port (n = 2), fungal infection (n = 1) and septic arthritis (n = 1). In all, 15 (83%) patients underwent the procedure under general anaesthetic. The procedure failed in an 8-year-old patient. Insertion time was 8 ± 3.7 min. Age at insertion was 6.3 ± 4.9 years. Duration of intravenous therapy was 6.4 ± 5.1 days. About 13 (76%) patients completed the treatment with no complications. Three (17%) lines occluded by day 3 needed removal; one (7%) line needed removal on day 3 because of redness/pain noted around the insertion site.

CONCLUSION

Long peripheral cannulas represent a valid option for medium-term intravenous access in children undergoing surgery. Majority of patients will be successfully treated with one long peripheral cannula for the duration of their treatment without the need for further cannulation.

Ultrasound-guided placement of long peripheral cannulas in children over the age of 10 years admitted to the emergency department: a pilot study

OBJECTIVES

Most children admitted to the emergency department (ED) require peripheral venous access (PVA), which is often difficult to perform or is unsuccessful. Ultrasound guidance helps with the placement of peripheral short cannulas (SC), but it has a limited cannula duration and a high risk of developing complications. The aim of this study was to compare success rates, dwell times and complications of peripheral venous long cannulas (LCs) inserted under ultrasound guidance with those of SCs in children.

METHODS

We prospectively studied all children older than 10 years of age admitted to our paediatric ED requiring PVA for an expected therapy of more than 5 days. In children with difficult intravenous access (DIVA), after two unsuccessful attempts of 'blind' placement of SCs, LCs (20 G, 8 cm) were inserted in the deep veins of arms using ultrasound guidance and the direct Seldinger technique.

RESULTS

LC placement (n=20) was successful in 100% of the cases. LC dwell time was 9.2±6.0 days, and most catheters were electively removed because they were no longer indicated. SC (n=20) placement showed a shorter dwell time duration, 3.2±2.1 days (p<0.0001), with complications occurring in 70% of the cases compared with 25% of cases in patients with LC (p=0.002). No local or major infectious complications were reported with LC placement.

CONCLUSIONS

Ultrasound-guided placement of LC was associated with a low risk of catheter failure and complications compared with the 'blind' placement of SC. LC placement may be considered a valid option in patients with DIVA requiring PVA in paediatric ED or in children who are candidates for infusion therapy expected to last longer than 5 days.

Utilizing CT with Maximum Intensity Projection Reconstruction Bypassing CTA Improves Time to Groin Puncture in Large Vessel Occlusion Stroke Thrombectomy

Background and Purpose

Prior to thrombectomy for proximal anterior circulation large vessel occlusion (LVO) stroke, recent trials have utilized CT angiography (CTA) for vascular imaging immediately following noncontrast CT (NCCT) for decision-making, but thin-section NCCT with automated maximum intensity projection (MIP) reconstruction also has high accuracy in demonstrating the site of an occluding thrombus. We hypothesized that performing thin-section NCCT with MIP alone prior to thrombectomy improves the time to groin puncture (GP) compared to performing CTA after NCCT.

Materials and Methods

We performed a retrospective cohort study of anterior circulation LVO thrombectomy at our tertiary care academic medical center. All stroke patients evaluated with thin-section NCCT (0.625 mm) with automated MIP reconstructions alone and those who had additional CTA were included. We excluded transfer patients, in-hospital strokes, posterior circulation strokes, and patients that were evaluated with stroke imaging other than NCCT or CTA prior to thrombectomy. The study groups were compared for duration from NCCT to GP and total stroke imaging duration.

Results

From March 2008 through August 2015, 34 thrombectomy patients met the inclusion/exclusion criteria - 13 in the NCCT and 20 in the NCCT+CTA group. The total stroke imaging duration was shorter in the NCCT group than in the NCCT+CTA group (2 min [1-6] vs. 28 min [23-65]; p < 0.001). The NCCT-only group had a shorter time from NCCT to GP (68 min [32-99] vs. 104 min [79-128]; p = 0.030).

Conclusion

Avoiding advanced imaging for patients with anterior circulation LVO in whom thin-section NCCT with MIPs reveals a hyperdense sign significantly shortens the imaging-to-GP time.