Vascular access device type for systemic anti-cancer therapies in cancer patients: A scoping review

BACKGROUND

Patients with cancer can expect to receive numerous invasive vascular access procedures for intravenous therapy and clinical diagnostics. Due to the increased incidence and prevalence of cancer globally there will be significantly more people who require first-line intravenous chemotherapy over the next ten years.

METHODS

Our objective was to determine the types of evidence that exist for the vascular access device (VAD) type for the delivery of systemic anti-cancer therapy (SACT) in cancer patients. We used JBI scoping review methodology to identify the types of VADs used for SACT and with a specific search strategy included articles from 2012-2022 published in the English language. We identify (i) type of VADs used for SACT delivery (ii) the type of insertion and post-insertion complications (iii) the geographical location and clinical environment (iv) and whether VAD choice impacts on quality of life (QOL). Findings were presented using the PAGER framework.

MAIN FINDINGS

Our search strategy identified 10,390 titles, of these, 5318 duplicates were removed. The remaining 5072 sources were screened for eligibility, 240 articles met the inclusion criteria. The most common design include retrospective study designs (n = 91) followed by prospective study designs (n = 31). We found 28 interventional studies with 21 registered in a clinical trial registry and identified no core outcome sets papers specific to VAD for SACT. The most prevalent publications were those that featured two or more VAD types (n = 70), followed by tunnelled intravenous VADs (n = 67). Of 38 unique complications identified, the most frequent catheter related complication was catheter related thrombosis (n = 178, 74%), followed by infection (n = 170, 71%). The county where the most publications originated from was China (n = 62) with one randomized controlled multicenter study from a comprehensive cancer centre. Of the thirty three studies that included QOL we found 4 which reported on body image. No QOL measurement tools specific to the process of SACT administration via VAD are available INTERPRETATION: Our findings suggest a systematic review and meta-analysis of VAD use for intravenous SACT can be considered. However, the development of a core outcome set for SACT should be prioritised. Funding for high quality programs of research for VAD in cancer are needed. Comprehensive cancer centres should lead this research agenda.

Effectiveness of near-infrared light devices for peripheral intravenous cannulation in children and adolescents: A meta-analysis of randomized controlled trials

OBJECTIVES

To examine the effectiveness of near-infrared light devices (NIR) on procedure time of successful cannulation, success rate at the first attempt, and pain scores among pediatric patients and explore potential covariates on the intervention effect.

BACKGROUND

Pediatric patients have encountered a high failure rate as compared with adult patients using traditional cannulation. NIR devices might help to access veins with an optimum viewing area and eliminate the number of attempts. However, methodological limitations and inconsistent results from previous reviews were found.

METHODS

A three-step comprehensive search was performed in nine databases. Meta-analysis, subgroup, and meta-regression analyses were conducted. Individual quality assessment and certainty of evidence were assessed using the Cochrane risk of bias tool and the Grading of Recommendations, Assessments, Development, and Evaluation criteria, respectively.

RESULTS

We included 18 randomized controlled trials (RCTs) with 5298 children and adolescents across nine countries. NIR light devices significantly reduce -29.43 s of procedure time and -0.47 attempts of peripheral intravenous cannulation compared with traditional methods. Subgroup analysis observed a significantly large effect size on procedure time using AccuVein with pre-procedure training at the clinics. However, NIR light devices do not significantly decrease the procedure time, first attempt success rate, and pain scores. Meta-regression identified sample size as a significant covariate that had an impact on the success rate at the first attempt.

CONCLUSIONS

The near-infrared light device can statistically significantly reduce the procedure time and the number of attempts. Given the low or very low certainty of the evidence, future well-designed RCTs are necessary.

Ultrasound-guided peripheral intravenous canulation by emergency nurses: A systematic review and meta-analysis

BACKGROUND

Peripheral intravenous cannulation is a common procedure in the emergency department. Nevertheless, failure rates during the first attempt are as high as 40% in adults and 65% in children. Evidence suggests that physician performed ultrasound-guided peripheral intravenous cannulation (USG-PIVC) is an effective alternative to the traditional method; however, there is insufficient data on the efficacy of the technique performed by nurses.

OBJECTIVE

To examine the efficacy of the USG-PIVC technique performed by emergency department nurses.

METHODS

A literature review with meta-analysis was performed. The databases used were PubMed, Scopus and CINAHL. The search was conducted in March 2023. Two meta-analysis one of clinical trials about the effectiveness and one about the succession rate were performed.

RESULTS

20 studies were selected and analysed. The studies showed that USGPIVC performed by emergency nurses increased the probability of both the overall success and a successful first attempt compared to the standard technique. In addition, patients showed high satisfaction and lower complication rates. However, the procedure had no significant effect on the time or number of attempts required. A lower probability of success was obtained as regards peripheral intravenous cannulation when the standard technique was used, OR = 0.42 (95 %CI 0.25-0.70p < 0,05).

CONCLUSIONS

Ultrasound-guided peripheral intravenous cannulation performed by emergency nurses is a safe and effective technique.

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.

Efficacy of Ultrasound-Guided Peripheral Intravenous Cannulation versus Standard of Care: A Systematic Review and Meta-analysis

Peripheral intravenous cannulation (PIV) is a common and necessary procedure in the emergency department (ED). Patients with PIV access encounter significant treatment delay. Ultrasound guidance for PIV (USGPIV) cannulation is a modality to reduce delay of care in such patients, but its efficacy, when compared with cannulation by the standard of care (SOC), the landmark and palpation method, has not been well established. We performed a random effects meta-analysis of available literature that compared USGPIV with SOC cannulation. We searched PubMed, Scopus and EMBASE until October 2020 for eligible studies in adult patients. We excluded non-English language, non-full-text studies. Our primary outcome was rate of first successful cannulation. Other outcomes were number of attempts and patient satisfaction. After identifying 284 studies and screening 74 studies, we included 10 studies. There were 1860 patients, 966 (52%) in the USGPIV group and 894 (48%) who received the SOC. Sixty-six percent of patients were female. USGPIV cannulation was associated with a two-times higher likelihood of first successful cannulation (odds ratio: 2.1, 95% confidence interval [CI]: 1.65-2.7, p < 0.001, I² = 2.9%). While procedure length was similar in both groups, USGPIV was associated with a significantly smaller number of attempts (standardized mean difference [SMD]: -0.272, 95% CI: -0.539 to -0.004, p = 0.047) and significantly higher patient satisfaction (SMD: 1.467, 95% CI: 0.92-2.012, p < 0.001). There was low heterogeneity among our included studies, which were mostly randomized control trials. Our study confirmed that USGPIV cannulation offers a more effective modality, compared with SOC, to improve quality of care for patients with difficult PIV access.

The experience of patients at high risk of difficult peripheral intravenous cannulation: An Australian prospective observational study

INTRODUCTION

Peripheral intravenous cannulation (PIVC) insertion is challenging for some patients, leading to delays in care and workflow. A few easy-to-identify risk factors can differentiate difficult to cannulate (DIVA) patients.

METHODS

A prospective observational study of adults undergoing PIVC was undertaken. Nursing and medical staff inserted PIVC using their usual practices. Patient, PIVC characteristics, number of attempts and staff characteristics were captured. Indicators of high-risk-for-DIVA were: no vein seen, and/or no vein palpable, and/or a history of difficult PIVC. The experience and outcomes for high-risk-for-DIVA patients were compared to non-DIVA.

RESULTS

1084 adults with PIVCs inserted were observed; with (378 (34.9%)) qualifying as high-risk-for-DIVA. First attempt success was achieved for 831 (76.7%) patients overall, with high-risk-for-DIVA significantly less likely to require one attempt (61.1% vs 85.0%, p < 0.001). High-risk-for-DIVA were more likely to have: PIVC aborted, multiple attemptors, ultrasound -guidance, smaller gauge PIVC, and wrist or hand placement.

CONCLUSION

Simple predictors for difficult PIVC are known, and were present in about one-third of adults in this cohort. Earlier identification and escalation of these patients to more experienced cannulators, those experienced with US, and/or placement in the wrist/hand with a small gauge PIVC, may assist in avoiding unnecessary cannulation attempts and delays.

Peripheral intravenous cannulation: reducing pain and local complications

Caring for patients with peripheral intravenous cannulas/catheters (PIVCs) is an important part of the nurse's role and insertion of PIVCs has traditionally been a post-registration nursing skill. With the introduction of the Nursing and Midwifery Council Standards of Proficiency for Registered Nurses in 2018, insertion of PIVCs is to be incorporated in pre-registration nursing programmes for all four fields of nursing practice. Although IV cannulation is a commonly performed clinical procedure, it is associated with significant risks and complications, which can cause pain for patients. This article outlines the factors that can cause pain for adult patients requiring a PIVC and recommends that the use of local anaesthetics be more widely considered when inserting a cannula. The identification, prevention and clinical management of commonly occurring painful local complications that can arise post-PIVC insertion are also discussed.

Using simulation to explore the impact of device design on the learning and performance of peripheral intravenous cannulation

BACKGROUND

The design of medical devices impacts upon the performance of healthcare professionals and patient safety. However, multiple devices serving the same function are often available. The purpose of this study was to use simulation as a means of examining the impact of differences in device design on (1) learning of, or attainment of behavioral fluency in, peripheral intravenous cannulation (PIVC); and (2) the generalization, or transfer, of learning on one device to performance of PIVC using an untrained device.

METHODS

A total of 25 final cycle medical students participated in this study which used a randomized two-group design. Participants were randomly assigned to learn PIVC using either a closed PIVC device (a single device which consists of an intravenous cannula with a pre-attached extension tube; n = 14) or an open PIVC device (a two-piece device made up of an intravenous cannula and a separate extension tube which is attached following insertion of the cannula; n = 11). Task analyses were developed for the performance of PIVC using each device. Subsequently, simulation-based fluency training was delivered to both groups using their assigned PIVC device, and continued for each participant until the fluency criterion was achieved. Following achievement of fluency, participants were asked to perform PIVC using the untrained device (i.e., the PIVC device that they had not been trained on).

RESULTS

All participants in both groups met the fluency criterion, and no significant differences were observed in the number of trials or total training required by groups to achieve fluency. Participants in both groups improved significantly from baseline (M = 11.69) to final training trial (M = 100). However, a significant decrement in performance (M = 81.5) was observed when participants were required to perform PIVC using the untrained device.

CONCLUSIONS

Participants achieved fluency in PIVC regardless of the device used. However, significant decrements in performance were observed when participants were required to perform PIVC using a novel device. This finding supports the need for careful consideration of devices purchased and supplied in the clinical setting, and the need for training prior to the introduction of novel devices or for new staff members.

Investigating the effect of local warming on vein diameter in the antecubital area in adults aged 20-40 years

BACKGROUND

peripheral intravenous cannulation is the most prevalent invasive procedure performed on patients admitted to hospital. The procedure is not always easy to undertake and can lead to problems for the patient and nurse. Alongside various procedures, local warming is one technique that could be used to increase the diameter of superficial veins. This prospective non-randomised trial aimed to determine the effect of local warming on vein diameter in the antecubital area in adults aged 20-40 years.

METHOD

the subjects included 55 volunteers who were in good health. The cephalic vein diameter of the right arm cubital area was measured for each participant using ultrasound guidance. The arm was warmed for 10 minutes using a heating device maintained at 42ºC. A second ultrasound scan was then undertaken immediately afterwards and cephalic vein diameter measured.

RESULTS

local warming increased the cephalic vein diameter in the cubital area by 0.43±0.4 mm. There was no significant relationship between change in cephalic vein diameter and participants' gender, age or body mass index.

CONCLUSION

the results indicate that the application of heat is an effective technique for venodilation and could be considered in emergencies or in cases when other veins are difficult to access.