Difficult Peripheral Venous Access Research Articles

Inadvertent catheter misplacement into the subclavian artery during ultrasound-guided internal jugular venous catheterization: a case report

BackgroundUltrasound-guided central venous catheterization has become a standard procedure. However, mechanical complications are still reported.Case presentationAn 85-year-old woman presented with coagulopathic bladder tamponade. Ultrasound-guided right internal jugular venous catheterization was planned because of difficult peripheral venous access. A guidewire was advanced through a needle inserted at the midpoint of the right carotid triangle. The guidewire was identified in the short axis, but not in the long-axis ultrasound view, leading to inadvertent insertion of the catheter into the right subclavian artery through the internal jugular vein. Stent graft insertion was performed for perforation closure. The patient exhibited no symptoms of cerebral ischemia following stent graft insertion.DiscussionThis case demonstrated that the needle-sticking site should not be placed close to the clavicle for ultrasound-guided internal jugular venous catheterization, as it may not confirm the position of guidewire in the long-axis ultrasound view.

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 prototypeare recommended.

Two Cases of Extensive Venous Thrombosis Incidentally Discovered With Bedside Ultrasound for Intravenous Access.

Perioperative deep vein thrombosis (DVT) is a serious and increasingly common complication. While point-of-care ultrasound is commonly used in regional nerve blocks, central vascular access, and difficult peripheral vascular, access there are very few reports of DVT incidentally discovered by anesthesiologists. We report 2 cases of diagnosis of DVT that resulted from ultrasound for difficult peripheral venous access. In the course of ultrasound-guided procedures, anesthesiologists are in a position to incidentally discover DVT and potentially change management to reduce the likelihood of DVT leading to pulmonary embolism.

Early Results of Totally Implantable Central Venous Access Port Insertion Through a Supraclavicular Approach

Cancer patients usually require repeated venous punctures for chemotherapy or other reasons. Therefore, totally implantable venous access port (TIVAP) systems have been helpful for patients with difficult vascular access. The purpose of this study was to evaluate the safety and feasibility of the totally implantable venous access port (TIVAP) implanted using a supraclavicular approach. After identification of the anatomical landmarks (clavicular head of the sternocleidomastoid muscle) for a supraclavicular approach, the patient was anesthetized with 1% lidocaine. After puncturing the central vein with an 18-G needle, the Seldinger catheterization procedure was performed. Between March 2017 and February 2018, 89 totally implantable venous access ports (TIVAPs) were inserted in 89 consecutive patients (32 men and 57 women) with a mean age of 57.5 years (range, 19–89 years) through a supraclavicular approach. Successful totally implantable venous access port (TIVAP) implantation was achieved in 96.6% (86 of 89) of patients. In 2 patients, port catheter placement failed despite successful vascular puncture because a wire could not be passed after cannulation of the blood vessel. The other case of failed placement was due to development of pneumothorax during vascular puncture. Venous port-related complications such as bleeding, infection, thrombosis, malfunction, or catheter fracture did not occur within 2 postoperative weeks. Totally implantable venous access port (TIVAP) implantation through the supraclavicular approach can be performed safely and feasibly for oncologic patients with difficult central or peripheral venous access.

Defining risk factors associated with difficult peripheral venous Cannulation: A systematic review and meta-analysis

Peripheral venous catheterization is a common technique in hospitals which is not always successful, resulting in multiple punctures and degradation of the vessels. This scenario, which we have termed ‘difficult peripheral venous access’, is associated to delays in care, obtention of samples or diagnosis, as well as a higher use of central catheters.This study intends to identify risk factors associated to the incidence of ‘difficult peripheral venous access’ in adults at hospital.We designed a systematic review of published studies (protocol PROSPERO 2018 CRD42018089160). We conducted structured electronic searches using key words and specific vocabulary, as well as directed searches in several databases. After validity analysis, we selected 7 studies with observational methodology.We found great variability in the definition of ‘difficult peripheral venous access’ and in the variables proposed as risk factors. Statistically significant factors through studies include demographic and anthropometric variables (gender, Body Mass Index), as well as medical and health conditions (diabetes, renal insufficiency, parenteral drug abuse, cancer chemotherapy), together with variables related to the vein or vascular access (vein visibility and palpability, vessel diameter, previous history of difficulty). Some studies have also considered variables related to the professional performing the technique.Meta-analyses were carried out for gender and obesity as potential risk factors. Only obesity appeared as a statistically significant risk factor with OR of 1.48; 95% CI (1.03 to 1.93; p = 0.016). Methodological heterogeneity prevented the development of further meta-analyses.It is essential to design future studies with diverse hospital populations, in which a wide selection of potential risk factors can be studied in a unique analysis. Our work identifies the most relevant variables that should be included in those studies.

Minimally Invasive Technique of Direct Central Venous Access in Micro Preemies—a Case Series

Central venous line insertion and its maintenance in micro preemies carry significant risk for serious complications considering their small size and the skill involved in insertion. Hence, for uninterrupted and safe administration of essential medications and nutrition in these extreme preemies, we have come up with a minimally invasive technique of central venous access (MICVA technique) using peripherally inserted central catheter (PICC) of smaller caliber. We report a case series of 7 micro preemies who had difficult peripheral venous access because of their long stay in the neonatal intensive care unit (NICU) due to their extreme prematurity. We used a minimally invasive technique wherein under ultrasound guidance, the femoral vein was directly punctured with the splitting introducer needle (24G) available in a PICC set (28G/1Fr catheter with a stylet and splitting needle, Premicath, Vygon) (a size appropriate for micro preemies). Once the blood return was seen, the catheter was advanced up to the premeasured length, and then, the introducer needle was slowly withdrawn out and split. The catheter tip position was then checked with X-ray before starting any infusions. Throughout the procedure, non-pharmacological developmentally supportive care measures were followed. We did not encounter any serious complications except for a small hematoma which was encountered in 2 (28.6%) cases. The Premature Infant Pain Scale (PIPS) score measured for this minimally invasive technique was < 8 for all neonates. In our case series, using this technique (MICVA), we did not concur any serious complications. Local application of 2.5% Prilox cream with 25% oral dextrose and other non-pharmacological measures such as facilitated tuck, swaddling, nesting, and positioning significantly reduced pain and stress during the procedure. We recommend that this technique would be a safe approach in hemodynamically unstable neonates or in difficult venous access scenarios in extreme preterms. Invasive ventilatory support and use of benzodiazepines or opioids can be safely avoided with this technique.

Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine.

Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine.

Difficult Peripheral Venous Access in Children: An International Survey and Critical Appraisal of Assessment Tools and Escalation Pathways.

Peripheral venous cannulation is considered a routine procedure, yet 50% of first attempt insertions fail, necessitating repeat insertion attempts. Identification of children with difficult intravenous access (DIVA) can help promote prompt escalation to an appropriately skilled clinician. To describe current international practice regarding the identification and management of children with DIVA, and to systematically review clinical tools and clinical pathways for children with DIVA. A cross-sectional, international survey; followed by a systematic review and critical appraisal of clinical pathways using the Appraisal of Guidelines for Research Evaluation (AGREE) II checklist. A total of 148 clinicians from eight countries completed the survey. The majority were nurses (n = 92; 62%), practicing as vascular access specialists (n = 27; 18%). Twenty-three respondents (16%) reported using a DIVA tool, of which the DIVA Score was most common (n = 5; 22%). Five clinical pathways were identified from the survey and review. Based on the AGREE II domains, pathways generally scored well for scope and purpose, and for clarity of presentation areas. Information on the rigor of development and editorial independence was infrequently detailed. Based on AGREE II findings, one pathway was recommended for clinical practice, and four were recommended for use with modification. Resources for the identification and escalation of children with DIVA are not standardized or consistently used. Further work is needed to streamline processes for DIVA identification and escalation to the appropriate clinician, with technology-assisted insertion capability. This will enhance patient experiences and reduce harm from multiple insertion attempts. Multiple failed insertion attempts come at great cost to the child, family, and healthcare service. Early identification and management of the child with DIVA can ensure prompt escalation and management, improving the patient and family experience.

A new device for ultrasound-guided peripheral venous access.

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

Using a Near Infrared Device to Improve Successful Venous Access in Children with Special Health Care Needs

BackgroundChildren with special health care needs (CSHCN) are predicted to be at particular risk for difficult peripheral venous access (PVA). Near infrared (NIR) technology is a noninvasive method that reveals vessels that are otherwise not visible to the eye. Our primary objective was to determine whether PVA success improved with NIR when compared with traditional visualization/palpation, specifically in CSHCN. MethodsA retrospective analysis of all patients requiring PVA insertions by the vascular access team at a 350-bed tertiary children's hospital from July 2013 until June 2014 were included. Independent variables included age, gender, ethnicity, CSHCN status and modality used (NIR, ultrasound guidance, transillumination, or none). The primary outcome was subjective difficulty, PVA success, and number of attempts required. The effect of NIR and CSHCN was analyzed using χ2 test. ResultsData were gathered on 7896 PVA placements in children. Out of these, 6071 children were deemed to have special health care needs. CSHCN had subjectively difficult access 88% of the time compared with non-CSHCN at 74.7% (P < 0.0001). CSHCN status lowered intravenous access success rates from 91.4% to 87.5% (P < 0.0001). The use of NIR significantly increased intravenous access success rates when compared with visualization or palpation (26% vs 19.6%; P < 0.0001). Modality had a statistically significant effect on the number of attempts (P < 0.0001), but only a slight clinical significance (NIR, up to 1-4 attempts and ultrasound or transillumination combined, 1-6 attempts). ConclusionsNIR decreases the number of attempts and improve overall success rates in acquiring PVA in CSHCN. Further studies on maximizing PVA success in this patient population are warranted.

Ultrasound-Guided Peripheral Venous Catheterization in Emergency Services

Peripheral venous catheterization is difficult to achieve in some patients, which can delay diagnosis and treatment, causing problems for the patient and frustration for health professionals. 1 Miles G Salcedo A Spear D Implementation of a successful registered nurse peripheral ultrasound-guided intravenous catheter program in an emergency department. J Emerg Nurs. 2012; 38: 353-356 Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Venous catheterization is one of the most frequently used techniques in emergency care settings. Nonetheless, catheter insertion has a 10% to 40% overall failure rate, 2 Leidel BA Kirchhoff C Bogner V et al. Is the intraosseous route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department?. Patient Saf Surg. 2009; 3 (http://www.pssjournal.com/content/3/1/24. Accessed February 3, 2016): 24 Crossref PubMed Google Scholar and although attempts have been made to define the patient characteristics that contribute to the difficulty of cannulation, 3 Lapostolle F Catineau J Garrigue B et al. Prospective evaluation of peripheral venous access difficulty in emergency care. Intensive Care Med. 2007; 33: 1452-1457 Crossref PubMed Scopus (118) Google Scholar the only relationship that has been established is between certain disease conditions and the difficulty of intravenous (IV) access. Patients with diabetes or heart conditions have more fragile veins, 4 Walsh G Difficult peripheral venous access: recognizing and managing the patient at risk. J Assoc Vasc Access. 2008; 13: 198-203 Abstract Full Text Full Text PDF Scopus (39) Google Scholar and the patient’s clinical status, pain level, or state of anxiety can affect the difficulty of implementing this technique. 5 Yen K Riegert A Gorelick MH Derivation of the DIVA score: a clinical prediction rule for the identification of children with difficult intravenous access. Pediatr Emerg Care. 2008; 24: 143-147 Crossref PubMed Scopus (140) Google Scholar Other characteristics that affect IV catheterization in the general population are obesity or being underweight 6 Sebbane M Claret PG Lefebvre S et al. Predicting peripheral venous access difficulty in the emergency department using body mass index and a clinical evaluation of venous accessibility. J Emerg Med. 2013; 44: 299-305 Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar and repeated venous administration of prescription drugs. 7 Fields JM Dean AJ Todman RW et al. The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity. Am J Emerg Med. 2012; 30: 1134-1140 Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar Studies analyzing the ultrasound-guided catheterization technique have shown that a high percentage of the patients for whom this technique has been used have chronic diseases 8 Schoenfeld E Boniface K Shokoohi H ED technicians can successfully place ultrasound-guided intravenous catheters in patients with poor vascular access. Am J Emerg Med. 2011; 29: 496-501 Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar or high body mass index. 9 Elia F Ferrari G Molino P et al. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. Am J Emerg Med. 2012; 30: 712-716 Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar Laia Salleras-Duran is Registered Nurse, Emergency Department, Hospital of Figueres, Fundació Salut Empordà, Girona, Spain. Concepció Fuentes-Pumarola is Professor, Nursing Department, University of Girona, Girona, Spain. Núria Bosch-Borràs is Registered Nurse, Hospital of Figueres, Fundació Salut Empordà, Girona, Spain. Xavier Punset-Font is Registered Nurse, Hospital of Figueres, Fundació Salut Empordà, Girona, Spain. Francesc-Xavier Sampol-Granes is Registered Nurse, Hospital of Figueres, Fundació Salut Empordà, Girona, Spain.

The role of ultrasound guidance for vascular access.

Ultrasound-guided cannulation of the internal jugular vein has become a standard practice over recent years. Despite known benefits, ultrasound is less frequently used for other vascular applications probably because these are technically demanding and require more experience. The authors of this review focus on pitfalls of ultrasound guidance: most important practical aspects as well as nonroutine vascular applications are discussed. Ultrasound guidance increases the first-pass and overall success rates and reduces the risk of complications of central venous catheterization through the subclavian and femoral routes, as well as arterial and difficult peripheral venous access. Ultrasound is also useful to detect catheter malposition and complications. Technical improvements and new modifications of old ultrasound-guided techniques may result in better outcomes. Growing evidence suggests that routine utilization of ultrasound guidance is beneficial for all types of vascular access. The presence of a skilled operator and proper technique are, however, required to achieve success and avoid complications.

Use a Guidewire for Difficult Peripheral Venous Access

In a prospective study, investigators at an academic emergency department compared outcomes between a convenience sample of 100 patients with difficult venous access who underwent peripheral vein cannulation with a guidewire-associated catheter and 100 such patients who underwent the procedure with a standard …

Ultrasound-guided peripheral venous access: a meta-analysis and systematic review.

The objective of this study was to determine through a systematic review of the literature and meta-analysis whether success rates, time to cannulation, and number of punctures required for peripheral venous access are improved with ultrasound guidance compared with traditional techniques in patients with difficult peripheral venous access. We conducted a systematic search of MEDLINE, Web of Science, The Cochrane Library, ClinicalTrials.gov, Cumulative Index to Nursing, and Allied Health Literature. Studies were included if they met the following criteria: patients of any age identified as having difficult peripheral venous access; real-time ultrasound guidance was used for peripheral venous cannulation; and inclusion of at least one of these outcomes (success rates, time to successful cannulation and number of punctures required). Seven studies were selected for final analysis. Ultrasound guidance improved success rates when compared with traditional techniques [pooled odds ratio (OR) 3.96; 95% confidence interval (95% CI) 1.75-8.94]. No significant difference between ultrasound-guided techniques and traditional techniques was detected for time to cannulation or number of punctures required. In patients with difficult peripheral venous access, ultrasound guidance increased success rates of peripheral venous placement when compared with traditional techniques. However, ultrasound guidance had no effect on time to successful cannulation or number of punctures required for successful cannulation.

Peripheral venous access in the obese patient.

Sir, Intravenous (IV) cannulation, a common procedure in anaesthetic practice, can at times be difficult and frustrating. We report a 46-year-old male, 109 kg, who was scheduled for repair of incisional hernia (related to previous right nephrolithotomy via a subcostal incision) in whom establishing peripheral IV access proved difficult. The patient had undergone several previous surgeries for genitourinary and kidney-related complaints. No peripheral veins were visible or palpable in the extremities. Venous cut-downs had been done in both lower limbs during previous surgeries. The right cephalic vein was visible in the delto-pectoral groove and was successfully cannulated. After establishing standard monitoring, anaesthesia was induced with fentanyl and thiopentone. Tracheal intubation was facilitated with rocuronium. The patient was positioned in left lateral position for surgery. This resulted in positional slowing of the crystalloid infusion rate. The operation table was tilted ≈20° head-down (to make neck veins prominent), and the right external jugular vein was cannulated. The surgery lasted 3 h and the recovery and post-operative course were uneventful. Predictive factors for difficult venous access include obesity, chronic illness, hypovolaemia, history of IV drug abuse, vasculopathy,[1,2,3] oedema, chemotherapy, diabetes and multiple prior hospitalizations.[4] Obtaining IV access can be tedious and time-consuming procedure in the obese. The veins on the dorsum of the hand and the deep brachial vein may be neither visible nor palpable in the obese patient. However, veins on the volar aspect of the wrist may be used for venous cannulation. The external jugular vein is another option but may be difficult to find in the short, thick neck of the obese patient. Placing the obese patient in Trendelenburg position (to make the vein prominent) may not be tolerated because of respiratory embarrassment. The cephalic vein crosses the surface of the anatomical snuff box, superficial to the radial styloid. This vein is referred to as the ‘houseman's friend’ because of its consistent location at this site and its straight course that allows placement of a large bore IV cannula.[5] It communicates with the basilic vein via the median cubital vein at the elbow. Superiorly, the cephalic vein passes between the deltoid and the pectoralis major muscles before it empties into the axillary vein. The cephalic vein is often visible through the skin in the deltopectoral groove and is a potential site for venous access in the obese [Figure 1]. This vein is worth looking for in an obese patient with a difficult peripheral venous access. Loukas et al.,[6] in a cadaveric study, found that the cephalic vein was found emerging superficially in the lateral portion of the deltopectoral triangle in 80% of specimens. In the remaining 20% cases, the cephalic vein was located deep to the deltopectoral fascia and fat. The length of the cephalic vein within the deltopectoral triangle ranged from 3.5 to 8.2 cm (mean 4.8 ± 0.7 cm). The morphometric analysis revealed a mean cephalic vein diameter of 0.8 ± 0.1 cm (range 0.1–1.2 cm).[6] Ultrasound-guided peripheral venous access is also a valuable aid in patients with a known difficult venous access. Nevertheless, knowledge of the potential sites for IV access can improve the success rate for IV line placement in the obese. Figure 1 The cephalic vein (in the deltopectoral groove) and the external jugular vein cannulated (18 gauge cannula) in an obese patient

Difficult peripheral venous access: Clinical evaluation of a catheter inserted with the Seldinger method under ultrasound guidance

PurposeA preliminary observational study was undertaken to evaluate the risk of failure of ultrasound-guided peripheral intravenous catheterization of a deep arm vein for a maximum of 7 days, after peripheral intravenous (PIV) cannulation failure. MethodsThis prospective study included patients referred to the intensive care unit for placement of a central line, a polyurethane cannula commercialized for arterial catheterization was used for peripheral venous cannulation. Catheter length and diameter were chosen based on preliminary ultrasound measurements of vein diameter and skin-vein distance. ResultsCatheterization was successful for all 29 patients. Mean vein diameter was 0.42 ± 0.39 cm; mean vein depth was 0.94 ± 0.52 cm. Mean catheter duration was 6 (median 7) days. Two occluded catheters were removed prematurely. No thrombophlebitis, catheter infection, or extravasation was observed. ConclusionOur results suggest that catheters inserted with the Seldinger method are adapted to prolonged peripheral deep-vein infusion. Ultrasound can play a role in catheter monitoring by identifying early thrombosis formation.

Midline catheter use in an obesity case of difficult peripheral venous access with threatened premature delivery

Midline catheter use in an obesity case of difficult peripheral venous access with threatened premature delivery

Peripheral venous access with ultrasound guidance

Peripheral venous cannulation is a routine procedure. The method is usually easy, however, occasionally it may prove to be difficult or even impossible to perform. Ultrasound can visualize deep veins that are undetectable by palpation and it makes possible to cannulate these veins under direct visual control. Authors routinely use ultrasound for difficult peripheral venous access. In this report they present 3 cases and discuss the practical aspects of ultrasound-guided peripheral venous access. Venous circulation of the arm is briefly reviewed, and ultrasound guidance techniques are discussed with regards to sterility aspects. Furthermore, authors describe a new technique wich they use efficiently for cannulating patients with poor peripheral venous access.

Systemic Fibrinolysis Through Intraosseous Vascular Access in ST-Segment Elevation Myocardial Infarction

In emergency situations, intraosseous cannulation represents an alternative route of vascular access when peripheral vein insertion is difficult. We present the first documented case of intraosseous systemic fibrinolysis in a patient with ST-segment elevation myocardial infarction. In this case, repetitive episodes of ventricular fibrillation occurred soon after first contact with emergency care providers. Given that the patient had difficult peripheral venous access, an intraosseous catheter was inserted. Fibrinolytics and antiarrhythmic drugs were administered though this line, resulting in resolution of coronary ischemia and electrical instability, without complications. Intraosseous cannulation represents a novel route for administration of systemic fibrinolysis in cases of difficult peripheral venous access in the out-of-hospital setting.

Difficult Peripheral Venous Access: Recognizing and Managing the Patient at Risk

Nurses commonly face challenges placing peripheral intravenous (IV) lines in adults and children, a situation described as difficult venous access (DVA). Multiple venipuncture attempts can heighten patient anxiety and suffering, delay vital treatment, and increase costs. Numerous factors such as small, fragile or hidden veins can predispose patients to DVA, and collapsed veins due to dehydration are especially problematic. Several techniques can improve venous prominence, but when IV access cannot be achieved promptly, other routes of administration can be valuable. For rehydration fluids and certain drugs, subcutaneous administration may be a safe and effective alternative, providing cost and ease-of-use advantages.