Association between Multiple IV attempts and Perceived Pain levels in the Emergency Department

Vascular access specialist teams versus standard practice for catheter insertion and prevention of failure: a systematic review

OBJECTIVE

Billions of vascular access devices (VADs) are inserted annually for intravenous therapy worldwide. However, their use is not without challenges. Facilitating the process and enhancing results, hospital authorities have created vascular access specialist teams (VASTs) with advanced competencies in the evaluation, insertion, care and management of VADs. The objective is to compare the effectiveness of VASTs versus standard practice regarding cannulation success and vascular access maintenance in hospitalised adults.

DESIGN

Systematic review, using the Mixed Methods Appraisal Tool.

DATA SOURCES

We conducted a structured data search on Cochrane Library, MEDLINE, Web of Science, Scopus and EBSCOhost up to 31 May 2023. We did not impose a time limit regarding the date of publication.

ELIGIBILITY CRITERIA

Studies were eligible for inclusion in the review if they were randomised and non-randomised trials and observational studies.

DATA EXTRACTION AND SYNTHESIS

We included studies that described or evaluated the activity of VASTs compared with clinical practitioners. The outcomes analysed were the success of the cannulation and the incidence of associated adverse effects.

RESULTS

The search strategy produced 3053 papers published between 1984 and 2020, from which 12 were selected for analysis. VASTs are heterogeneously described among these studies, which mainly focus on insertions, frequently for patients with difficult intravenous access. Some patients presented with specific needs or requirement for specific insertion technique or catheter type. Compared with usual practice, these studies indicate that the involvement of a VAST is associated with a higher effectiveness in terms of first attempt insertions and insertion success rates, and a reduction in catheter-associated adverse events. However, meta-analyses confirming this trend are not currently possible.

CONCLUSIONS

It seems apparent that VASTS contribute to improving the health of patients during the administration of intravenous. VASTs seem to increase the effectiveness of VAD insertion and care and reduce complications.

PROSPERO REGISTRATION NUMBER

CRD42021231259.

Automated angular measurement for puncture angle using a computer-aided method in ultrasound-guided peripheral insertion

Ultrasound guidance has become the gold standard for obtaining vascular access. Angle information, which indicates the entry angle of the needle into the vein, is required to ensure puncture success. Although various image processing-based methods, such as deep learning, have recently been applied to improve needle visibility, these methods have limitations, in that the puncture angle to the target organ is not measured. We aim to detect the target vessel and puncture needle and to derive the puncture angle by combining deep learning and conventional image processing methods such as the Hough transform. Median cubital vein US images were obtained from 20 healthy volunteers, and images of simulated blood vessels and needles were obtained during the puncture of a simulated blood vessel in four phantoms. The U-Net architecture was used to segment images of blood vessels and needles, and various image processing methods were employed to automatically measure angles. The experimental results indicated that the mean dice coefficients of median cubital veins, simulated blood vessels, and needles were 0.826, 0.931, and 0.773, respectively. The quantitative results of angular measurement showed good agreement between the expert and automatic measurements of the puncture angle with 0.847 correlations. Our findings indicate that the proposed method achieves extremely high segmentation accuracy and automated angular measurements. The proposed method reduces the variability and time required in manual angle measurements and presents the possibility where the operator can concentrate on delicate techniques related to the direction of the needle.

Using a LOng peripheral intraVEnous catheter with retractable guidewire to optimize first-insertion success for patients with Difficult IntraVenous Access in the emergency department (LOVE-DIVA): a study protocol for a randomized controlled trial

INTRODUCTION

First-insertion success rates for peripheral vascular access devices (PVADs) in patients with difficult venous access (DIVA) are low, which negatively affects staff workload, patient experience, and organizational cost. There is mixed evidence regarding the impact of a peripheral vascular access device with retractable coiled tip guidewire (GW; AccuCath™, BD) on the first-insertion success rate. The aim of this study is to investigate whether the use of long GW-PVADs, compared with standard PVADs, reduces the risk of first-time insertion failure, in patients admitted to emergency departments (EDs).

METHODS AND ANALYSIS

A parallel-group, two-arm, randomized controlled trial will be carried out in two Australian EDs to compare long GW-PVADs (5.8 cm length) against standard care PVADs (short or long). Patients ≥18 years of age meeting DIVA criteria will be eligible for the trial. The sample size is 203 participants for each arm. Web-based central randomization will be used to ensure allocation concealment. Neither clinicians nor patients can be blinded to treatment allocation. Primary outcome is the first-insertion success rate. Secondary outcomes include the number of insertion attempts, time to insert PVAD, all-cause failure, dwell-time, patient-reported pain, serious adverse events, complications, subsequent vascular access devices required, patient satisfaction, staff satisfaction, and healthcare costs. Differences between the two groups will be analyzed using Cox proportional hazards regression. Cost-effectiveness analysis will also be conducted. Intention-to-treat analysis will be used.

ETHICS AND DISSEMINATION

The study is approved by Metro South Ethics Committee (HREC/2022/QMS/82264) and Griffith University (2022/077). The findings will be published in a peer-reviewed journal.

TRIAL REGISTRATION

ACTRN12622000299707.

Assessment of needle-tissue force models based on ex vivo measurements

Needle insertion is one of the most common procedures in clinical practice. Existing statistics reveal that success rates of needle insertions can be low, leading to potential complications and patient discomfort. Real-time imaging techniques like ultrasound and X-ray can assist in improving precision, but even experienced practitioners may face challenges in visualizing the needle tip. Researchers have proposed models of force interactions during needle insertions into biological tissue to enhance accuracy. This article presents an evaluation of the forces acting on intravenous needles during insertion into skin. The aim was to explore mathematical models, compare them with data from tests on animal specimens, and select the most suitable model for future research. The experimental setup involved conducting needle insertion tests on animal-originated cadavers, using the Brucker Universal Mechanical Tester device, which measured the force response during vertical movement of the needle. The research was divided into 2 stages. In Stage I, force measurements were recorded for both the insertion and extraction phases of the hypodermic needles. The measurements were conducted for several different needle sizes, speed and insertion angles. In Stage II, five different models were examined to determine how well they matched the experimental data. Based on the analysis of fit quality coefficients, the Gordon's exponential model was identified as the best fit to the measured data. The influence of needle size, insertion angle, and insertion speed on the measured force values was confirmed. Different insertion speeds revealed the viscoelastic properties of the tested samples. The presence of the skin layer affected the puncture force and force values for subsequent layers.

The effect of rose oil aromatherapy and hand-holding on pain due to peripheral intravenous catheter insertion

INTRODUCTION

The study aimed to evaluate the effectiveness of rose oil (Rosa Damascene Mill.) aromatherapy and hand-holding in reducing pain associated with peripheral intravenous catheter insertion.

METHODS

A comparative mixed-method design. A total of 126 patients were included in the study. For the study's quantitative data, sociodemographic characteristics of the patients and the Patient Interview Form for the qualitative data of the Numeric Rating Scale were used. In all patients included in the study, PIVC insertion was performed a single time by the same nurse using a standard procedure. Chi-square and Bonferroni tests were used for comparative statistics.

RESULTS

No statistically significant difference between the groups regarding age, gender, marital status, BMI, and education level (p>0.05). Pain scores: it was 2.40±1.78 in the rose oil group, 3.53±1.98 in the hand-holding group, and 4.88±1.56 in the control group. The difference between the groups regarding pain scores is statistically significant (p=0.001).

CONCLUSIONS

The study determined that rose oil aromatherapy and hand-holding interventions reduce pain during PIVC. However, rose oil aromatherapy was more effective on pain than the hand-holding intervention. (Clinical Trial ID: NCT05425849).

Factors determining success and the cost of materials used in securing intravenous access in an emergency setting: A prospective observational study

INTRODUCTION

Multiple failed attempts at securing intravenous catheter access cause increased patient dissatisfaction and higher costs. We aimed to identify the factors leading to multiple failed attempts and estimate the cost of resources wasted.

METHODS

Participants were recruited from the emergency department for a prospective, observational study. Healthcare workers inserting peripheral intravenous catheters were observed. Patient characteristics and the number of attempts needed were recorded.

RESULTS

Three hundred thirty-four patients were enrolled, and an average of 1.74 ± 1.026 (Range: 1 - 5) access attempts were needed per patient. Only 56.28% of the insertions were successful on the first attempt. On multivariate linear regression with attempts as the outcome variable, age (β = 0.01, 95%CI 0.004 - 0.014, p = 0.0006), catheter calibre (β 20G = -0.25, 95%CI -0.45 - -0.07, p = 0.008), visibility (β = 0.23, 95%CI 0.02 - 0.44, p = 0.026) and palpability (β = 0.44, 95%CI 0.21 - 0.66, p = 0.0001) of the vein were statistically significant predictors. The average total cost of materials required was $6.4 USD per patient, of which $1.76 USD was spent towards unsuccessfully inserted catheters that were consequently thrown away.

CONCLUSIONS

Our study shows that securing IV access often requires multiple attempts, with nearly 30% of the total cost amounting towards materials wasted. The risk of multiple attempts is highest for older patients with invisible and non-palpable veins.

The Effect of Cold Application to the Lateral Neck Area on Peripheral Vascular Access Pain: A Randomised Controlled Study

INTRODUCTION

Various types of vagus nerve stimulation are employed in the treatment of a range of conditions, including depression, anxiety, epilepsy, headache, tinnitus, atrial fibrillation, schizophrenia, and musculoskeletal pain. The objective of this study was to apply vagal stimulation to the neck area using standardised cold, and then analyse the level of vascular access discomfort experienced by individuals who underwent venous cannulation from the dorsal side of the hand prior to anaesthesia.

MATERIALS AND METHODS

A total of 180 patients, aged 18-75, who were scheduled to undergo elective surgery, were categorised into three distinct groups: the Sham group (Group S), the Control group (Group K), and the Cold group (Group M), with each group consisting of 60 individuals. Bilateral cold application to the lateral side of the neck was performed prior to the commencement of vascular access in Group M patients, followed by the subsequent opening of vascular access. The alterations in heart rate among patients was assessed subsequent to the application of cold and following the establishment of vascular access. The participants were instructed to assess their level of vascular access pain on a numerical pain scale (NRS) ranging from 0 to 10.

RESULTS

A statistically significant difference (p = 0.035) was seen when comparing the pain ratings of patients during vascular access. The study revealed that the NRS values exhibited a statistically significant decrease in Group M compared to both Group K (p = 0.038) and Group S (p = 0.048). Group M had a higher prevalence of individuals experiencing mild pain compared to other groups, and the difference was statistically significant (p = 0.029). In Group M, the average heart rate following vagal stimulation exhibited a statistically significant decrease compared to the average heart rate observed at the beginning of the study (p < 0.05). Upon comparing the original heart rate measurements with the heart rate values following vascular access, it was observed that there was an elevation in heart rate for both Group S and Group K. Conversely, Group M exhibited a decrease in heart rate after vascular access when compared to the initial heart rate values.

CONCLUSIONS

In the present investigation, it was discovered that the application of cold to the neck region resulted in a drop in heart rate among the patients, which persisted throughout the process of vascular access. Furthermore, the level of pain experienced by these individuals was reduced during vascular access procedures.

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.

Performance of peripheral catheters inserted with ultrasound guidance versus landmark technique after a simulation-based mastery learning intervention

PROBLEM

Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is an effective method to gain vascular access in patients with difficult intravenous access (DIVA). While USGPIV success rates are reported to be high, some studies have reported a concerning incidence of USGPIV premature failures.

AIMS

The purpose of this study was to compare differences in USGPIV and landmark peripheral intravenous catheter (PIV) utilization and failure following a hospital-wide USGPIV training program for nurses.

METHODS

The authors performed a retrospective, electronic medical record review of all USGPIVs and PIVs inserted at a tertiary, urban, academic medical center from September 1, 2018, through September 30, 2019. The primary outcome was differences between USGPIV and PIV time to failure.

RESULTS

A total of 43,470 short peripheral intravenous catheters (PIVCs) were inserted in 23,713 patients. Of these, 7972 (16.8%) were USGPIV. At 30 days of follow-up, for PIVCs with an indication for removal documented, USGPIVs had higher Kaplan-Meier survival probabilities than PIVs (p < 0.001).

CONCLUSIONS

The use of simulation-based mastery associated with USGPIVs, demonstrated lower failure rates than standard PIVs after 2 days and USGPIVs exhibited improved survival rates in patients with DIVA. These findings suggest that rigorous simulation-based insertion training demonstrates improved USGPIV survival when compared to traditional PIVCs. SBML is an extremely useful tool to ensure appropriately trained clinicians acquire the necessary knowledge and skillset to improve USGPIV outcomes.

Comparison of feasibility between hypodermoclysis and intravenous hydration among palliative care patients in Thailand

BACKGROUND

Hypodermoclysis is a method of subcutaneous fluid administration. It has been used to treat palliative patients safely and effectively. However, the use of subcutaneous hydration is often overlooked.

AIM

This study aimed to compare the feasibility, pain experience and acceptability between subcutaneous and intravenous hydration in a hospital setting.

METHODS

A prospective, randomised clinical trial was conducted. Patients requiring fluid administration were randomly allocated an intravenous or subcutaneous route. Patients' pain score, satisfaction and acceptance levels were collected. The difficulty score of the needle insertion and acceptance scores from nurses were recorded.

FINDINGS

A total of 26 patients were enrolled. The difficulty scores and patients' pain scores were significantly lower in the subcutaneous group. The satisfaction and acceptance levels of the patients and nurses were similar in both groups. No systemic side-effects were found in either group.

CONCLUSION

Hypodermoclysis was acceptable and satisfying to patients and nurses. It was less painful than the intravenous route.

Simulation-Based Mastery Learning Improves Ultrasound-Guided Peripheral Intravenous Catheter Insertion Skills of Practicing Nurses

INTRODUCTION

Difficult intravenous (IV) access (DIVA) is frequently encountered in the hospital setting. Ultrasound-guided peripheral IV catheter (USGPIV) insertion has emerged as an effective procedure to establish access in patients with DIVA. Despite the increased use of USGPIV, little is known about the optimal training paradigms for bedside nurses. Therefore, we developed and evaluated a novel, sustainable, USGPIV simulation-based mastery learning (SBML) curriculum for nurses.

METHODS

This is a prospective cohort study of an USGPIV SBML training program for bedside nurses over a 12-month period. We evaluated skills and self-confidence before and after training and measured the proportion of the nurses achieving independent, proctor, and instructor status. Procedure logs and surveys were used to explore the nurse experience and utilization of USGPIV on real patients with DIVA 3 months after the intervention.

RESULTS

Two hundred thirty-eight nurses enrolled in the study. The USGPIV skill checklist scores increased from median of 6.0 [interquartile range = 4.0-9.0 (pretest) to 29.0, interquartile range = 28-30 (posttest), P < 0.001]. The USGPIV confidence improved from before (mean = 2.32, SD = 1.17) to after (mean = 3.85, SD = 0.73, P < 0.001) training (5-point Likert scale). Sixty-two percent of the nurses enrolled achieved independent status, 47.5% became proctors, and 11.3% course trainers. At 3-month posttraining, the nurses had attempted a mean of 35.6 USGPIV insertions with an 89.5% success rate.

CONCLUSIONS

This novel USGPIV SBML curriculum improves nurses' insertion skills, self-confidence, and progresses patient care through USGPIV insertions on hospitalized patients with DIVA.

Comparison of Standard Technique, Ultrasonography, and Near-Infrared Light in Difficult Peripheral Vascular Access: A Randomized Controlled Trial

OBJECTIVES

Successful placement of a peripheral intravenous catheter (PIVC) on the first attempt is an important outcome for difficult vascular access (DVA) patients. This study compared standard technique, ultrasonography (USG), and near-infrared light (NIR) in terms of success in the first attempt in patients with DVA.

METHODS

This was a prospective, randomized controlled study. The study was conducted in a tertiary care hospital. Emergency department patients who describe DVA history, have no visible or palpable veins, and were assessed by the nurse to have a difficult PIVC were included to study. The PIVC procedure was performed on patients by standard, USG, or NIR device techniques. For all approaches, the success of the first attempt was the primary aim. Total procedure time, the total number of attempts, and the need for rescue intervention were secondary aims.

RESULTS

This study evaluated 270 patients. The first attempt success rates for USG, standard, and NIR methods were 78.9%, 62.2%, and 58.9%, respectively. The rate of first attempt success was higher in patients who underwent USG (USG versus standard, P = .014; USG versus NIR, P = .004; standard versus NIR, P = .648). The total median (IQR) procedure time for USG, standard, and NIR methods was 107 (69-228), 72 (47-134), and 82 (61-163) seconds, respectively. The total procedure time was longer in patients undergoing USG (standard versus USG, P <.001; NIR versus USG, P = .035; standard versus NIR, P = .055). The total median (IQR) number of attempts of USG, standard, and NIR methods were 1 (1-1), 1 (1-2), and 1 (1-2), respectively. A difference was found among the groups regarding the total number of attempts (USG versus NIR, P = .015; USG versus standard P = .108; standard versus NIR, P = .307). No difference was found among groups in terms of the need for rescue methods.

CONCLUSION

It was found that USG increases the success of the first attempt compared with the standard method and NIR in patients with DVA.

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."

Pre-operative peripheral intravenous cannula insertion failure at the first attempt in adults: Development of the VENSCORE predictive scale and identification of risk factors

STUDY OBJECTIVE

Our objective was to develop a clinical scale (the VENSCORE) to predict pre-operative peripheral intravenous cannula (PIVC) insertion failure at the first attempt in adults.

DESIGN

This was a prospective multicenter cohort study that included internal validation with bootstrapping.

SETTING

The operating rooms of 14 hospitals in southern France from June 2016 to June 2018.

PATIENTS

Consecutive adult patients aged 18 years or older were recruited upon arrival to the operating room, regardless of American Society of Anaesthesiology (ASA) physical status.

INTERVENTIONS

PIVC insertion on arrival to the OR.

MEASUREMENTS

PIVC insertion failure at the first attempt was the outcome of interest. Data collected included the number of PIVC insertion attempts and potential predictors of the risk of failure (including pre-operative patient characteristics and data relative to the procedure). Uni- and multivariable logistic analyses were performed. Based on these results, the VENSCORE scale was developed to predict the risk of failure of the first PIVC insertion.

MAIN RESULTS

In total, 3394 patients were included, and 27 were excluded because of protocol violations. The PIVC insertion failure rate at the first attempt was 20.3%. Based on multivariable analysis, a history of difficult PIVC insertions, high-risk surgery, poor vein visibility, and moderate to poor vein palpability were identified as risk factors for insertion failure at the first attempt. The area under the curve of the predictive model was 0.82 (95% confidence interval: 0.80-0.84). A VENSCORE value of 0 points was associated with a failure rate of 7%, versus 97% for a score of 6.

CONCLUSIONS

The four-item VENSCORE scale could be useful for prospectively identifying adults at risk of first PIVC insertion attempt failure.

The impact of multiple insertions on peripheral intravenous access in low-birth-weight infants in perinatology

Low-Birth-Weight (LBW) infants have very small veins, and there is a risk of needing multiple insertions to establish peripheral intravenous access. This study aimed to examine the impacts of multiple insertions during peripheral intravenous access in LBW infants. This cross-sectional study involved 216 respondents. Data were analyzed with the Spearman correlation. The results showed a significant relationship (p<α) between multiple insertions to establish peripheral intravenous access to LBW infants with increased pain, heart rate, respiratory rate, duration of crying, delayed treatment, duration of insertion, and high cost of care (p<0.001; r=0.358-0.836). Meanwhile, multiple insertions might decrease oxygen saturation and body temperature (p<0.001; r=0.358). In this study, multiple insertions were correlated with several negative impacts on the physiological function and discomfort of LBW infants. The study also highlights the effect on time of treatment precision and cost effectiveness. Recommendation: It is necessary to develop preventive measures to reduce the impact of multiple insertions to establish peripheral intravenous access in LBW infants.

Training the Trainers in Ultrasound-guided Access to Improve Peripheral Intravenous Catheter Placement among Children Presenting for Anesthesia

Supplemental Digital Content is available in the text.

Factors predicting difficult peripheral intravenous (PIV) catheter placement in children are known. Ultrasound guidance can decrease the number of attempts required for difficult PIV placement. However, the uptake of this technique among attending anesthesiologists at our institution remained low. This study aimed to reduce the incidence of PIV placement requiring greater than 3 attempts and reduce time to PIV placement by providing training in ultrasound guidance.

Pediatric Hand Injuries Requiring Closed Reduction at a Tertiary Pediatric Care Center

Background: Hand fractures and dislocations are common injuries in the pediatric population. This study aims to characterize the pediatric hand injuries that required closed reduction and identify those that required multiple reduction attempts. Methods: A retrospective cohort study was carried out in patients younger than 18 years of age with hand fractures or dislocations who underwent closed reduction in the emergency department (ED). Patients who ultimately required surgical reduction and fixation were not included. Results: Of the 310 hand injuries identified, 148 (114 fractures and 34 dislocations) underwent closed reduction in the ED; 7.4% of those required repeat reduction. Hand injuries that most often required repeat reduction included metacarpophalangeal joint dislocations (20.0%) and proximal phalanx neck (16.7%), metacarpal shaft (15.4%), metacarpal neck (6.2%), and proximal phalanx base (5.6%) fractures. No modifiable risk factors predicting the need for repeat reduction were identified. Conclusions: Some pediatric hand injuries are more likely to require repeat closed reduction by a hand surgeon. This retrospective study is the first step toward quality improvement as it provides opportunities for further research into the factors contributing to reductions that are unsuccessful at the first attempt. Identification of these factors and implementation of quality improvement measures are necessary to ensure the effective treatment of all pediatric hand injuries.

Prevalence of and factors associated with difficult peripheral venipuncture in adult surgical patients

OBJECTIVE

To determine the prevalence of difficult venous access in adult patients admitted to a surgical unit.

METHOD

This observational prospective cohort study included 235 patients from a Brazilian hospital. Clinical data were collected by direct observation and analyzed by descriptive, inferential statistics, and multiple binomial logistic regressions. Odds ratios were also calculated.

RESULTS

Most of the patients (66.4%) were men and self-reported as white (59.2%). The prevalence of difficult intravenous access was 32.8%. Predictors of peripheral intravenous cannula insertion failure were history of difficult intravenous access and nonvisibility of the vein.

CONCLUSION

History of difficult intravenous access and a nonvisible venous network were significant predictors of peripheral cannula insertion failure in adults undergoing clinical surgery. The prevalence of difficult intravenous access was 32.8%.

Nurse-Performed Ultrasound-Guided Technique for Difficult Peripheral Intravenous Access in Critically Ill Patients: A Randomized Controlled Trial

Highlights

Abstract

Purpose: The aim of this study was to compare nurse-performed ultrasound (US)-guided technique with standard of care (SOC) technique for difficult peripheral intravenous (PIV) access among patients admitted to the intensive care unit (ICU).

Materials and Methods: This was a randomized, prospective, open-label single-site study. ICU nurses completed a standardized training program for US-guided PIV access placement before patient enrollment. ICU patients with difficult PIV access were randomized to either nurse-performed US-guided technique or SOC technique. Primary outcome was success rate on the first attempt. Secondary outcomes were success rate after 2 attempts and frequency of complications after successful placement.

Results: A total of 60 patients were enrolled; 30 were randomized to receive US-guided technique, and 30 to SOC technique. Success rate on the first attempt was significantly higher with US-guided technique compared with SOC technique (70% vs 40%; P &lt; 0.05). Success rates after 2 attempts were 73.3% for US-guided technique and 46.6% for SOC technique (P = 0.065). Extravasation after successful placement occurred in 13.6% of patients with US-guided technique, and 28.6% of patients with SOC technique (P = 0.394).

Conclusions: Among ICU patients with difficult PIV access, US-guided PIV access placement by nurses who underwent standardized training was more successful than placement with SOC technique.

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.

Predicting Failure of Intravenous Access in Adults: The Value of Prior Difficulty

BACKGROUND

When intravenous access cannot be established using traditional methods of inspection/palpation, advanced methods are often required, leading to substantial delays in care. Knowing the likelihood of intravenous access failure can improve emergency department (ED) efficiency.

OBJECTIVE

Our aim was to validate prior need for an advanced technique to establish intravenous access as a predictor of failure to achieve access via traditional methods and to estimate the risk difference associated with this finding.

METHODS

We re-analyzed data collected for a clinical trial that randomized ED patients requiring intravenous access to one of two types of intravenous catheter; gauge size was selected by the inserter. The re-analysis pools data from both groups to examine predictors of failure to establish intravenous access by traditional methods, with failure defined as abandonment or use of an advanced technique (ultrasound guidance or external jugular vein catheterization). Confidence intervals for the difference between proportions were calculated using a normal binomial approximation.

RESULTS

We obtained data from 600 patients, with a median age of 52 years (interquartile range 36-63 years). We noted failure of traditional methods in 28 (4.7%) patients, including 17 of 109 (16%) with prior need for advanced techniques. The risk difference for prior need for advanced techniques versus no prior difficulty was 14% (95% confidence interval 7-22).

CONCLUSIONS

Patients with a prior need for advanced techniques were 14% more likely to have failure of intravenous access by traditional methods than those without prior difficulty.

Factors associated with peripheral intravenous cannulation first-time insertion success in the emergency department. A multicentre prospective cohort analysis of patient, clinician and product characteristics

OBJECTIVES

This study aimed to identify the incidence of and factors associated with peripheral intravenous catheter/cannula (PIVC) first time insertion success (FTIS) in the emergency department (ED).

DESIGN

Prospective cohort study.

SETTING

Two tertiary EDs in Western Australia.

PARTICIPANTS

879 ED patients.

PRIMARY OUTCOME

To identify factors affecting FTIS using univariate and multivariate logistic regression modelling. We created four models: patient factors only; clinician factors only; products and technology factors only and all factors model. We assessed each model's performance using area under the receiver operating characteristic curve.

RESULTS

A total of 1201 PIVCs were inserted in 879 patients. The mean age was 60.3 (SD 22) years with slightly more females (52%). The FTIS rate was 73%, with 128 (15%) requiring a second attempt and 83 (9%) requiring three or more attempts. A small percentage (3%) had no recorded number of subsequent attempts. FTIS was related to the following patient factors: age (for a 1-year increase in age: OR 0.99, 95% CI 0.983 to 0.998; p=0.0097); and target vein palpability: (always palpable vs never palpable: OR 3.53 95% CI 1.64 to 7.60; only palpable with tourniquet vs never palpable: OR 2.20, 95% CI 1.06 to 4.57; p=0.0014). Clinician factors related to FTIS include: clinicians with greater confidence (p<0.0001) and insertion experience (301-1000 vs <301: OR 1.54, 95% CI 1.02 to 2.34; >1000 vs <301: OR 2.07, 95% CI 1.41 to 3.04; p=0.0011). The final all factors model combining patient factors; clinician factors and product and technology factors has greater discriminative ability than specific factors models. It has a sensitivity of 74.26%, specificity of 57.69%, positive predictive value of 82.87% and negative predictive value of 44.85%.

CONCLUSION

A clinical decision, matching patients who have no palpable veins and are older, with clinicians with greater confidence and experience, will likely improve FTIS.

TRIALREGISTRATION NUMBER

ANZCTRN12615000588594; Results.

Prediction of Acute Postoperative Pain from Assessment of Pain Associated With Venous Cannulation

BACKGROUND

It has previously been reported that venous cannulation-induced pain (VCP) can be used to predict acute postoperative pain after laparoscopic cholecystectomy. Patients rating VCP at ≥2.0 VAS units had 3.4 times higher risk for moderate or severe pain. The purpose of this study was to evaluate if VCP scores of ≥2.0 VAS units are associated with higher risk for acute postoperative pain after various common surgical procedures.

METHODS

In a prospective clinical observational study, 600 male and female 18- to 80-year-old patients scheduled for elective surgery were included. The primary outcome measure was the difference in maximum postoperative pain intensity between low responders (VCP < 2.0) and high responders (VCP ≥ 2.0) to VCP. Secondary outcome measures were the difference in proportion of patients with moderate or severe postoperative pain between low and high responders, and potential influence of age, gender, and preoperative habitual pain.

RESULTS

Patients scoring VCP ≥2.0 VAS units reported higher acute postoperative pain intensity levels than those scoring VCP <2.0 VAS units (median 3.0 [interquartile range 0.0 to 5.0] vs. 0.2 [interquartile range 0.0 to 4.0], P = 0.001), and also had 1.7 times higher risk for moderate or severe postoperative pain (P = 0.005). Moderate or severe postoperative pain was reported by 38% of patients with VCP scores of ≥2.0 VAS units and by 26% with VCP scores of <2.0 VAS units (P = 0.005).

CONCLUSION

Scoring of VCP intensity before surgery, requiring no specific equipment or training, is useful to predict individual risks for moderate or severe postoperative pain, regardless of patient age or gender, in a setting involving different kinds of surgery.

Efficacy and patient satisfaction in the use of subcutaneous immunoglobulin immunotherapy for the treatment of auto-immune neuromuscular diseases

We reviewed the efficacy of SCIg administration in terms of muscle strength maintenance and patient satisfaction comparing with IVIg in the treatment of auto-immune neuromuscular diseases. A systematic review was conducted, and identified studies from databases (PUBMED, EMBASE, EBSCO, Web of Science and Google Scholar) which were analyzed. The methodological quality of the selected publications was evaluated using the Newcastle-Ottawa Scale. Data were extracted from a total of 11 studies Fixed and random-effect model meta-analyses were performed. For the maintenance of muscle strength, Overall Neuropathy Limitations Scale (ONLS) data from 100 patients diagnosed with multifocal mononeuropathy (MMN) or chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) were pooled together. Switching to subcutaneous immunoglobulin administration led to a significant improvement (fixed effects model, p = 0.002). In data collected using the Medical Research Council Scale for Muscle Strength data from 140 patients with a wider range of disorders, a small but significant improvement in overall strength was observed in the SCIg group (p < 0.0001). In addition, the results of two studies measuring health-related quality of life and patient satisfaction were pooled. Data from 49 patients suffering from MMN, CIDP, and a variety of different myopathies demonstrated a small but significant increase in the mean 36-Item Short Form Survey (SF-36) scores (p < 0.0001). A highly significant difference was revealed when comparing data from 119 patients' responses to the Life Quality Index questionnaire (LQI) assessing patient satisfaction (p < 0.0001). This is the first analysis showing that SCIg is more effective than IVIg in improving Patient Reported Outcomes in auto-immune neuromuscular disease. These results should permit a broad range of patients to self-administer immunoglobulin treatments at home, potentially improving patient acceptability while reducing hospital visits and healthcare costs for the treatment of chronic auto-immune neuropathies.

A Review of the Burden of Trauma Pain in Emergency Settings in Europe

Trauma pain represents a large proportion of admissions to emergency departments across Europe. There is currently an unmet need in the treatment of trauma pain extending throughout the patient journey in emergency settings. This review aims to explore these unmet needs and describe barriers to the delivery of effective analgesia for trauma pain in emergency settings. A comprehensive, qualitative review of the literature was conducted using a structured search strategy (Medline, Embase and Evidence Based Medicine Reviews) along with additional Internet-based sources to identify relevant human studies published in the prior 11 years (January 2006-December 2017). From a total of 4325 publications identified, 31 were selected for inclusion based on defined criteria. Numerous barriers to the effective treatment of trauma pain in emergency settings were identified, which may be broadly defined as arising from a lack of effective pain management pan-European and national guidelines, delayed or absent pain assessment, an aversion to opioid analgesia and a delay in the administration of analgesia. Several commonly used analgesics also present limitations in the treatment of trauma pain due to the routes of administration, adverse side effect profiles, pharmacokinetic properties and suitability for use in pre-hospital settings. These combined barriers lead to the inadequate and ineffective treatment of trauma pain for patients. An unmet need therefore exists for novel forms of analgesia, wider spread use of available analgesic agents which overcome some limitations associated with several treatment options, and the development of protocols for pain management which include patient assessment of pain.Funding: Mundipharma International Ltd.

Pain upon inserting a peripheral intravenous catheter: Size does not matter

BACKGROUND

Approximately 1.2 billion peripheral intravenous catheters are inserted across the world annually. It is known that intravenous cannulation may be a painful procedure, which affects cognitive abilities by increasing anxiety and discomfort.

AIM

We hypothesized that inserting a smaller sized peripheral intravenous catheter has a lower level of pain sensation compared to a larger sized catheter.

METHODS

This observational, cross-sectional study was conducted between May and October 2016, in which surgical patients, aged 18 years or older, were eligible to participate. Experienced anesthesiologists and nurse anesthetists routinely obtained peripheral intravenous access according to the standards of care. The primary outcome was pain (verbal numeric rating scale, 0-10) upon intravenous cannulation.

RESULTS

A total of 1063 patients were included and they were divided into four groups: group 1, 22 gauge (N = 29); group 2, 20 gauge (N = 447); group 3, 18 gauge (N = 531); and group 4, sized over 18 gauge (N = 56). Inserting an 18-gauged peripheral intravenous catheter resulted in the lowest pain score (3.2 ± 2.0). As a result of the multivariate linear analysis, five factors were significantly associated with pain upon inserting a peripheral intravenous catheter (sex, American Society of Anesthesiology classification, a patients risk profile on the A-DIVA scale, site of cannulation on the extremity, and whether or not the attempt was successful); however, the size of the inserted peripheral intravenous catheter had no significant relation to the primary outcome.

CONCLUSION

Inserting a smaller sized peripheral intravenous catheter did not result in a lower pain sensation. Moreover, to prevent pain upon inserting a peripheral intravenous catheter, an unsuccessful attempt must be avoided.

Risk factors for difficult peripheral venous cannulation in hospitalised patients. Protocol for a multicentre case-control study in 48 units of eight public hospitals in Spain

INTRODUCTION

Patients with difficult venous access experience undesirable effects during healthcare, such as delayed diagnosis and initiation of treatment, stress and pain related to the technique and reduced satisfaction. This study aims to identify risk factors with which to model the appearance of difficulty in achieving peripheral venous puncture in hospital treatment.

METHODS AND ANALYSIS

Case-control study. We will include adult patients requiring peripheral venous cannulation in eight public hospitals, excluding those in emergency situations and women in childbirth or during puerperium. The nurse who performs the technique will record in an anonymised register variables related to the intervention. Subsequently, a researcher will extract the health variables from the patient's medical history. Patients who present one of the following conditions will be assigned to the case group: two or more failed punctures, need for puncture support, need for central access after failure to achieve peripheral access, or decision to reject the technique. The control group will be obtained from records of patients who do not meet the above conditions. It has been stated a minimum sample size of 2070 patients, 207 cases and 1863 controls.A descriptive analysis will be made of the distribution of the phenomenon. The variables hypothesised to be risk factors for the appearance of difficult venous cannulation will be studied using a logistic regression model.

ETHICS AND DISSEMINATION

The study was funded in January 2017 and obtained ethical approval from the Research Ethics Committee of the Balearic Islands. Informed consent will be obtained prior to data collection. Results will be published in a peer-reviewed scientific journal.

Use of cutting-edge biomedical devices for intravenous cannulation in the health care of a patient: literature review

Introduction: Biomedical devices are tools used for locating invisible and impalpable peripheral veins. The purpose of this article is to give a systematic review and analysis of existing studies on the available biomedical devices used for locating peripheral veins and on their effectiveness in clinical practice. Methods: Databases CINAHL, Medline and ScienceDirect were used for the literature review and analysis. The search was performed with the following key words in English: devices, visualization, technology, cannulation, vein, nursing care, with Boolean operators 'AND' and 'OR'. The analysis included randomized and experimental clinical studies published in the English language in the period from 2000 to August 2016. From a total of 1,020 retrieved studies, 17 were included in the detailed analysis. Results: The results of the analysis have shown that the success rate of the first attempt of intravenous cannulation using biomedical devices in more than half of the studies was not significantly higher than when the process was performed using the conventional method. The success of the first attempt of intravenous cannulation mostly depends on the experience and skills of nurses. Biomedical devices are more helpful for novice nurses who do not perform cannulation on a daily basis, for beginners and nursing students. Discussion and conclusions: Based on research, we cannot affirm that biomedical devices significantly contribute to easier peripheral venous cannulation. Further research is required to validate the advantages of such an approach. However, this is limited due to the affordability issues of such biomedical devices.

Development of a clinical prediction rule to improve peripheral intravenous cannulae first attempt success in the emergency department and reduce post insertion failure rates: the Vascular Access Decisions in the Emergency Room (VADER) study protocol

INTRODUCTION

Peripheral intravenous cannula (PIVC) insertion is one of the most common clinical interventions performed in emergency care worldwide. However, factors associated with successful PIVC placement and maintenance are not well understood. This study seeks to determine the predictors of first time PIVC insertion success in emergency department (ED) and identify the rationale for removal of the ED inserted PIVC in patients admitted to the hospital ward. Reducing failed insertion attempts and improving peripheral intravenous cannulation practice could lead to better staff and patient experiences, as well as improving hospital efficiency.

METHODS AND ANALYSIS

We propose an observational cohort study of PIVC insertions in a patient population presenting to ED, with follow-up observation of the PIVC in subsequent admissions to the hospital ward. We will collect specific PIVC observational data such as; clinician factors, patient factors, device information and clinical practice variables. Trained researchers will gather ED PIVC insertion data to identify predictors of insertion success. In those admitted from the ED, we will determine the dwell time of the ED-inserted PIVC. Multivariate regression analyses will be used to identify factors associated with insertions success and PIVC failure and standard statistical validation techniques will be used to create and assess the effectiveness of a clinical predication rule.

ETHICS AND DISSEMINATION

The findings of our study will provide new evidence to improve insertion success rates in the ED setting and identify strategies to reduce premature device failure for patients admitted to hospital wards. Results will unravel a complexity of factors that contribute to unsuccessful PIVC attempts such as patient and clinician factors along with the products, technologies and infusates used.

TRIAL REGISTRATION NUMBER

ACTRN12615000588594; Pre-results.

Advanced intravenous access: technique choices, pain scores, and failure rates in a local registry

BACKGROUND

When an intravenous (IV) catheter is needed and the common approach of inspection and palpation fails, an advanced access technique becomes necessary. Our objectives were to estimate pain scores, operator times, success rates, and complication rates when advanced techniques are used in a clinical setting.

METHODS

We enrolled patients who had a need for advanced IV access and were able to give informed consent to participate in our study. We collected data on operator type, technique, initial success, number of attempts, skin punctures, operator time, pain scores, and complications. We estimated confidence intervals for proportions using normal binomial approximation or exact calculation.

RESULTS

The registry documented 154 attempts in 116 patients. The median time from triage to establishment of an IV line was 203 minutes; multiple advanced attempts were required in 24% of cases. Most attempts (95%) used either ultrasound-guided cannulation of a peripheral vein (PUG) (108) or cannulated the external jugular vein (EJ) (38). These 2 methods yielded similar pain scores (4.3-4.5), but PUG required more skin punctures (1.6 vs 1.2) and longer operator time (17.7 vs 11.9 minutes). The only complication was IV line failure, occurring in 6% (95% confidence interval, 0%-18%) of EJ approaches and 27% (95% confidence interval, 18%-38%) of the PUG scenarios.

CONCLUSION

Most attempts to establish IV access used PUG or the EJ. External jugular vein cannulation was achieved more quickly, with fewer skin punctures and a lower rate of postinsertion failure, than PUG.

Predictors of difficult pediatric intravenous access in a community Emergency Department

Background

Successful intravenous (IV) placement is important in the care of the acutely ill and injured pediatric patient. There are little data that exist regarding predicators of difficult IV access in pediatric Emergency Department (ED) patients who present to community EDs.

Methods

We retrospectively analyzed all pediatric charts for the calendar year 2012 from a single community teaching hospital. We identified all cases with patients less than 18 years of age in whom an IV or IV medications were ordered. We defined difficult IV access as those requiring more than one attempt, or those where the IV team was required to place the IV. We identified patient, provider, and procedural characteristics. Data were analyzed using descriptive statistics and univariate logistic regression to determine the odds ratio (OR) for predictors of difficult IV access.

Results

We identified 652 patients, 607 (93%) without difficult access and 45 with difficult access. Increasing age [OR 0.94 (0.89-0.99) p = 0.017] was associated with decreased odds of difficult IV access. IVs attempted in the hand [OR 3.02 (1.06-8.58) p = 0.039] and lower extremity [OR 7.82 (2.27-26.91) p = 0.001)]) were associated with greater odds of difficult access than the antecubital fossa. Non-black/non-white race [2.37 (1.1-5.12) p = 0.028] was also associated with difficult IV access. Other factors (sex, IV catheter size, and so on) were not associated.

Conclusions

In this retrospective study of pediatric patients in a community ED, decreasing age, non-black/non-white race, and IV attempt location (hand and lower extremity vs. antecubital fossa) were associated with greater odds of difficult IV access.