Insertion Attempts Research Articles

Use of Vein Finder to Overcome Factor Affecting Peripheral Intravenous Cannulation, Venipuncture, IV Insertion, and Blood Draws

To find a vein for intravenous insertion is quite difficult in most of the people. This difficulty is due to several factors, such as the demographic and clinical characteristics of the patients (age, sex, height, weight, ethnicity, IV drugs history, and medical history), health professional’s experience, device characteristics, site of insertion, and vein characteristics. Many insertion attempts has to be done due to difficulty in intravenous insertion. This makes the patient uncomfortable and frustrated leading to challenge for the health workers. It is also an expensive affair for the health institutions. Therfore to avoid the above problems medical practitioners should use the Vein Finder to locate the vein for intravenous insertion.

Safety, Efficacy, and Ease of Insertion of Gnana Laryngeal Airway (GLA-4): A Prospective Clinical Study Utilizing the Unique Laryngeal Mask Airway With a Suction Tubing.

Utilizing laryngeal mask airways to maintain patients' airways is advantageous because it enables the anesthesiologist to keep the patient spontaneously inhaling and is less traumatic to the airway than intubation. Newer designssuch as the Gnana laryngeal mask airway design permit real-time suctioning while the mask is on a patient. This is a prospective observational study of the efficacy of Gnana laryngeal airway 4 (GLA-4) in 50 patients undergoing colonoscopy. Induction and maintenance of anesthesia were provided with propofol; GLA-4 was applied to secure the airway; and correct placement was verified. Fifty patients were included in the study (44% female, 56% male, mean age: 56.5 years, mean BMI: 33.3). Twelve patients were assigned American Society of Anesthesiologists (ASA) class 2, and 38 were assigned ASA class 3. The first attempt of GLA-4 insertion was successful in 47 patients, and two attempts were required for the successful placement of the GLA-4 in two patients. The successful placement was not achieved in one patient. The average time to successful insertion was 27.1± 3.9s. The average volume of oropharyngeal secretions suctioned through the suction catheter was 9.96 ± 2.31 mL. No intraoperative or postoperative complications occurred in the 50 patients. There were no reports of sore throat, hoarseness, dysphagia, or cough immediately postop. GLA-4 can be inserted safely with adequate periglottic occlusion. This laryngeal mask is unique and desirable due to its ability to evacuate oropharyngeal secretions while in place to prevent laryngospasm. To establish the role of GLA-4 in broader clinical situations, additional clinical trials and studies are required.

Association between perioperative neuraxial local anesthetic neurotoxicity and arachnoiditis: a narrative review of published reports.

Arachnoiditis is a rare but devastating disorder caused by various insults, one of which is purported to be local anesthetic neurotoxicity following neuraxial blockade. However, the relationship between local anesthetics administered into the neuraxis and the development of arachnoiditis has not been clearly elucidated. We aimed to summarize the existing complex body of literature and characterize both the essential features and strength of any association between neuraxial local anesthetic neurotoxicity and arachnoiditis with a view toward mitigating risk, enhancing prevention, and refining informed consent discussions. We reviewed all published reports of arachnoiditis attributed to local anesthetic neurotoxicity following perioperative neuraxial anesthesia. This narrative review was based on a systematic search methodology, which included articles published up until December 2022. Thirty-eight articles were included, comprising 130 patients, over one-half of which were published prior to this century and inconsistent with modern practice. Neuraxial techniques included 78 epidurals, 48 spinals, and 5 combined spinal-epidurals, mostly for obstetrics. Reporting of essential procedural data was generally incomplete. Overall, at least 57% of patients experienced complicated needle/catheter insertion, including paresthesia, pain, or multiple attempts, irrespective of technique. The onset of neurological symptoms ranged from immediate to 8 years after neuraxial blockade, while the pathophysiology of arachnoiditis, if described, was heterogeneous. The existing literature attributing arachnoiditis to local anesthetic neurotoxicity is largely outdated, incomplete, and/or confounded by other potential causes, and thus insufficient to characterize the features and strength of any association.

A COMPARISON OF MIDAZOLAM AND MINI DOSE SUXAMETHONIUM TO FACILITATE LARYNGEAL MASK AIRWAY INSERTION DURING PROPOFOL ANESTHESIA

This study aimed to compare the effectiveness of two different drug combinations used for general anesthesia during laryngeal mask airway (LMA) insertion. One group received Propofol-Midazolam (PM), and the other Propofol-Suxamethonium (PS). The study assessed pre-insertion conditions like mouth opening, gagging, coughing, patient movements, and laryngospasm, as well as hemodynamic parameters such as systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) in both groups. It also studied patient responses after LMA insertion, including apnea, cyanosis, desaturation (SpO₂ < 90%), aspiration/regurgitation, and airway injury. The primary objectives of the study were to compare the ease and success of LMA insertion when using Propofol with Midazolam and Propofol with low-dose suxamethonium and to compare variations in hemodynamic and the occurrence of complications during and after LMA insertion. The study included 110 male and female patients aged 18-40, classified as ASA 1 & 2, and scheduled for surgery under general anesthesia. The patients were randomly assigned to the PM and PS groups, and non-probability sampling was employed. In the PM group, patients were given intravenous midazolam (0.04 mg/kg) four minutes before induction with propofol (2.5 mg/kg), while in the PS group, patients received suxamethonium (0.1 mg/kg) 30 seconds after induction with propofol (2.5 mg/kg). Nalbuphine (0.1 mg/kg) was administered to all patients as an analgesic before surgery. The adequacy of anesthesia was assessed by the loss of response to verbal commands and the absence of excitatory movements. Patients were evaluated for their response to LMA insertion attempts, including the absence of excitatory movements, mouth opening, and the number of attempts required. Patient responses to gagging, coughing, movements, laryngospasm, desaturation, and apnea duration were noted. Hemodynamic changes before induction, as well as before and after LMA insertion, were recorded. Data was entered into SPSS version 15, and the mean standard deviation was calculated for age, weight, SBP, DBP, MAP, HR, SpO₂, and apnea duration. Qualitative and quantitative data were analyzed using the chi-square test and t-test, respectively, with significance set at a p-value < 0.05. Laryngeal masks were successfully inserted into the hypopharynx in the first attempt in 100% of patients in both the PM and PS groups. Gagging and patient movements were observed in only 4 (7.27%) out of 55 patients in the PM group. Hemodynamic variations more significant than 20% from baseline (before anesthesia induction) were compared before and after LMA insertion. Significant differences between the PM and PS groups were observed in SBP, DBP, MAP, and HR (p < 0.05). The apnea duration was 2.10 ± 1.51 minutes in the PM group and 1.01 ± 0.49 minutes in the PS group, with a significant p-value of 0.044. However, there were no cases of SpO₂ falling below 90% in either group. The study concluded that midazolam and a small dose of suxamethonium during propofol anesthesia were comparable in terms of ease and success of LMA insertion. The PM group exhibited better hemodynamic stability than the PS group, except for apnea duration, which was shorter in the PS group. There was no significant difference in SpO₂ levels between the two groups.

Wearable Mechatronic Ultrasound-integrated AR Navigation System for Lumbar Puncture Guidance.

As one of the most commonly performed spinal interventions in routine clinical practice, lumbar punctures are usually done with only hand palpation and trial-and-error. Failures can prolong procedure time and introduce complications such as cerebrospinal fluid leaks and headaches. Therefore, an effective needle insertion guidance method is desired. In this work, we present a complete lumbar puncture guidance system with the integration of (1) a wearable mechatronic ultrasound imaging device, (2) volume-reconstruction and bone surface estimation algorithms and (3) two alternative augmented reality user interfaces for needle guidance, including a HoloLens-based and a tablet-based solution. We conducted a quantitative evaluation of the end-to-end navigation accuracy, which shows that our system can achieve an overall needle navigation accuracy of 2.83 mm and 2.76 mm for the Tablet-based and the HoloLens-based solutions, respectively. In addition, we conducted a preliminary user study to qualitatively evaluate the effectiveness and ergonomics of our system on lumbar phantoms. The results show that users were able to successfully reach the target in an average of 1.12 and 1.14 needle insertion attempts for Tablet-based and HoloLens-based systems, respectively, exhibiting the potential to reduce the failure rates of lumbar puncture procedures with the proposed lumbar-puncture guidance.

Comparison of clinical performance of Baska mask and Ambu AuraGain in patients undergoing surgery: A single-blinded, randomised comparative trial.

The Baska mask (BM) and the Ambu AuraGain (AAG) have shown promising results in recent trials but have not been compared. Therefore, we aimed to compare the clinical performance of the BM and the AAG for airway management of adult patients. In this randomised comparative study, patients aged 18-60 years and with an expected surgical duration of less than 2 h were enroled. Patients were randomly allocated to AAG (Group A, n = 37) and BM (Group B, n = 37) for airway management. After induction of anaesthesia, an allocated supraglottic airway device (SAD) was inserted. Oropharyngeal leak pressure (OLP), time taken to insert SAD, number of insertion attempts, leak fraction (LF), first-attempt success rate, overall success rate, ease of insertion, fiberoptic view of the glottis, and complications were compared. The data were analysed using Student's t-test, Mann-Whitney U test, and Fisher's exact tests. Baseline and demographic characteristics were comparable. OLP (31.32 ± 2.59 versus 27.54 ± 1.32 cmH2O) was higher (P < 0.001), and LF (6.19% ± 1.20% versus 7.24% ± 1.72%) was lower (P = 0.003) in the BM group. First-attempt and overall success rate, time taken to insert, number of insertion attempts, ease of insertion, and fibreoptic view of glottis through the SADs were statistically similar between groups. However, the incidence of sore throat (P = 0.007) and cough (P = 0.028) was higher with AAG. Clinical performance of BM was better than AAG as the former had higher OLP, lower LF and complications.

Factors impacting emergency department clinicians’ peripheral intravenous catheter practice: A qualitative analysis

BackgroundPeripheral intravenous catheters (PIVCs) are commonly used devices in emergency departments (EDs), and yet relatively little is known about factors influencing Australian clinicians’ adherence to the national PIVC quality and safety Standard. AimsTo explore attitudes and experiences of ED clinicians around PIVC insertion and care processes. MethodsThis study used an exploratory qualitative approach to analyse written responses to open-ended questions included in an online national (mixed data) survey. Snowballing methods were used to gather responses. Deductive analysis was used to analyse open-ended questions regarding practice and Standard adherence. ResultsThere were 340 written responses, mainly from nurses in public EDs, who reported suboptimal practices regarding idle catheters, lack of patient participation in care, antecubital fossa insertion, multiple insertion attempts, inadequate site preparation, poor documentation and insufficient review of PIVC. The main factors inhibiting ED clinicians from adhering to the Standard includes inadequate knowledge, perceptions of infeasibility, disbelief in evidence, ambiguous responsibilities, habitual practice, insufficient training, lack of recognition of good practice and inadequate engagement. ConclusionThe factors that impact ED clinicians’ PIVC Standard adherence are complex and multifactorial. Strategies and interventions are needed to facilitate the implementation of the Standard into daily practice and achieve sustainable behaviour change.

Peripheral vascular access as exclusive access mode in pediatric intensive care unit.

The type of vascular access (central or peripheral) in pediatric critical care depends on several factors, including the duration of treatment, the properties of the medication (osmolarity or vesicant), and the need for central pressure monitoring. The utilization of peripheral intravascular catheters (PIVCs) has shown a notable increase in the number of patients being treated. Extended dwell or midline catheters are another peripheral access option in addition to PIVCs. However, there are currently no established guidelines on their placement. The aim of this study is to estimate the duration of dwell time for PIVCs, analyze the specific parameters affecting it, and develop recommendations for switching to extended dwell and midline catheter placement as an alternative to peripheral access. The study enrolled patients aged 0-18 years admitted to the pediatric intensive care unit (PICU) for over 24 h and managed with peripheral access only over 2 years (2019-2021). A total of 484 patients met the specified criteria. Patients who had peripheral access exhibited a lower PRISM score and a shorter length of stay in the PICU, with mean values of 18 (SD: 8.5) and 9.5 (SD: 6.4) days, respectively, compared with patients who had central access with mean values of 8.9 (SD: 5.9) and 5.7 (SD: 3.6) days, respectively. The PIVC dwell time was found to be 50.1 h (SD: 65.3) and required an average of 1.6 insertion attempts. Patients with three or more insertions exhibited an increased odds ratio of 5.2 (95% CI: 3.1-8.5) for receiving an extended dwell or midline insertion. Increased dwell time was associated with female gender, 59.5 h (P < 0.001), first attempt insertion, 53.5 h (P < 0.001), use of 24 Ga bore, 56.3 h (P = 0.04), left-sided insertions, 54.9 (P = 0.07), less agitation, 54.8 h (P = 0.02), and less edema, 61.6 (P < 0.001). Decreased dwell time was associated with the use of vancomycin infusion at 24.2 h (P < 0.001) and blood transfusions at 29.3 h (P < 0.001). Extended catheters last longer than PIVCs in PICU patients. Extended catheter placement requires consideration of the length of treatment, as well as the overall body edema, the level of the patient's restlessness, and the need for vancomycin infusion or blood transfusions, as these factors reduce PIVC dwell time and expose the patients to painful insertions. For such cases, an extended dwell catheter may be a better option, even if the projected treatment time is less than 6 days.

Use of Virtual Reality in the Education of Orthopaedic Procedures: A Randomised Control Study in Early Validation of a Novel Virtual Reality Simulator.

Background Virtual reality (VR) simulation is a potential solution to the barriers surgical trainees are facing. There needs to be validation for its implementation within current training. We aimed to compare VR simulation to traditional methods in acquiring surgical skills for a TFN-ADVANCED™ Proximal Femoral Nailing System (TFNA; DePuy Synthes, Auckland, New Zealand) femoral nailing system. Methods Thirty-one surgical trainees were randomised to two groups: traditional-training group (control group) and a VR-training group (intervention group) for insertion of a short cephalomedullary TFNA nail. Both groups then inserted the same TFNA system into saw-bone femurs. Surveys evaluated validity of the relevant activities, perception of simulation, confidence, stress and anxiety.The primary outcomes were tip-apex distance (TAD) and user anxiety/confidence levels. Secondary outcomes included number of screw- and nail-guidewire insertion attempts, the time taken to complete and user validity of the VR system. Results There was no statistical difference in TAD between the intervention and control groups (9mm vs 15mm, p=0.0734). The only TAD at risk of cut-out was in the control group (25mm). There was no statistical difference in time taken (2547.5ss vs 2395ss, p=0.668), nail guide-wire attempts (two for both groups, p=0.355) and screw guide-wire attempts (one for both groups, p=0.702). The control group versus intervention had higher anxiety levels (50% vs 33%) and had lower confidence (61% vs 84%). Interpretation There was no objective difference in performance on a saw-bone model between groups. However, this VR simulator resulted in more confidence and lower anxiety levels whilst performing a simulated TFNA. Whilst further studies with larger sample sizes and exploration of transfer validity to the operating theatre are required, this study does indicate potential benefits of VR within surgical training.

Frequency of Peripheral Intravenous Infiltration and Determination of Risk Factors in Children: A Cohort Study

Objective: Intravenous therapy is one of the most commonly used routes for drug administration. The aim of this study was to determine the frequency of peripheral intravenous infiltration and risk factors in children. Methods: This cross-sectional and cohort study was conducted in a university hospital in pediatric patients. An information form and the Infiltration Rating Scale were used. Data were obtained from patients, their parents, and patient records. Infiltration data was obtained by researchers through direct observation. Significance was assumed as p&amp;lt;0.05 at 95% confidence interval. Results: A total of 176 pediatric patients made up the study cohort. Most of the peripheral venous catheters were inserted by nurses and into upper extremities. The incidence of infiltration was 57.9%, and most of the infiltrates were first-degree. The development of infiltration was significantly associated with the medical specialty being attended (p=0.001) and the number of catheter insertion attempts (p=0.013). Conclusion: The specific medical specialty and the number of catheter insertion attempts were shown to play a significant role in the development of infiltration.

Midline Compared With Peripheral Intravenous Catheters for Therapy of 4 Days or Longer in Pediatric Patients

Peripheral intravenous catheters (PIVCs) frequently fail during treatment causing therapy interruption, pain, recatheterization, and additional health care costs. Midline catheters (MCs) may improve functional dwell time and reduce failure compared with traditional PIVCs. To compare device failure of MCs with PIVCs. This was a pragmatic, randomized clinical superiority trial with an embedded internal pilot study conducted from July 2020 to May 2022. The study took place in a quaternary pediatric hospital in Brisbane, Queensland, Australia. Inclusion criteria were patients aged 1 to 18 years requiring peripherally compatible intravenous therapy for 4 days or longer. Patients were randomly assigned 1:1 to receive a PIVC or MC, stratified by age (≤5 years, >5 years). One catheter was studied per patient. The primary outcome was all-cause device failure, defined as premature cessation of device function. Secondary outcomes included number of insertion attempts, insertion failure, pain (on insertion), procedural time, patient/parent satisfaction (with insertion), device dwell time, device complications during dwell time, additional vascular access devices required to complete treatment, clinician satisfaction (at removal), and health care costs. Of the 128 patients randomly assigned to study groups, 127 patients (median [IQR] age, 7 [2-13] years; 71 male [56%]) had a device inserted, with 65 (51.2%) in the PIVC group and 62 (48.8%) in the MC group. All patients were included in the intention-to-treat analysis. Device failure was lower in patients in the MC group (10 [16.1%]) compared with those in the PIVC group (30 [46.2%]; odds ratio [OR], 0.22; 95% CI, 0.10-0.52; P <.001). MCs were associated with fewer insertion attempts (mean difference [MD], -0.3; 95% CI, -0.5 to 0; P = .04), increased dwell time (MD, 66.9 hours; 95% CI, 36.2-97.5 hours; P <.001), and fewer patients required additional vascular access devices to complete treatment in the MC group (4 [6.5%]) and PIVC group (19 [29.2%]; OR, 0.17; 95% CI, 0.05-0.52; P = .002). Compared with PIVCs, use of MCs was associated with greater patient (9.0 vs 7.1 of 10; P = .002) and parent (9.1 vs 8.2 of 10; P = .02) satisfaction and lower health care costs (AUS -$151.67 [US -$101.13] per person; 95% credible interval, AUS -$171.45 to -$131.90 [US -$114.20 to -$87.95]). Findings suggest that MC insertion for patients requiring peripherally compatible intravenous therapy for 4 days or longer should be prioritized to reduce the resource intensive, expensive, and burdensome sequelae of device failure. Australia New Zealand Clinical Trials Registry, ACTRN12620000724976.

A randomized comparative study to estimate the safety and effectiveness between laryngeal mask airway supreme and I-gel in patients undergoing elective surgeries

Background: Supreme laryngeal mask airway (SLMA) and i-gel airway devices are second generation supraglottic airway devices (SAD) and are good alternatives to intubation during elective surgeries. Aims and Objectives: This study was conducted with the objective of comparing the two SAD with respect to ease of insertion, number of attempts of insertion, insertion time, ease of gastric tube insertion, accompanying hemodynamic changes, incidence of adverse effects like regurgitation, lip and dental trauma, post-operative sore throat, dysphagia, and hoarseness. Materials and Methods: This study was conducted at M.G.M. Medical College and M.Y. hospital, Indore. Eighty patients belonging to ASA class 1 or 2, with Mallampati grading 1 or 2, between age group of 18–60 years and with BMI &lt;30 kg/m2 were selected for the study. After induction of anesthesia, one of the SAD’s (SLMA or i-gel) was inserted following randomization, and accordingly, the patients were divided into two groups of 40 each. Insertion parameters, hemodynamic, and respiratory parameters were noted. Patients were also observed for any possible complication at 1 h and 24 h postoperatively. Results: The Two groups showed no statistically significant difference in terms of demographic characteristics, insertion parameters, hemodynamic, or respiratory parameters (P&gt;0.05). Postoperatively, no significant complications were observed in terms of dental injury, laryngospasm. Ease of gastric tube insertion was found to be more in SLMA group than i-gel and the difference was statistically significant (P=0.0057). Incidence of sore throat after 1 h was found to be more in SLMA group than i-gel group (P=0.048). Conclusion: There was no significant difference between SLMA and i-gel in terms of insertion characteristics and hemodynamic changes. Ease of gastric tube insertion was found to be significantly more in SLMA group than i-gel. Incidence of post-operative sore throat at 1 h was more with SLMA as compared to i-gel.

Outcomes and evaluation of endoscopic retrograde cholangiopancreatography via Gastro-Laryngeal Tube in adult patients: a prospective randomised control study

ABSTRACT Objectives In conventional endoscopic retrograde cholangiopancreatography (ERCP), the patient lies prone or in a semi-prone position under deep sedation and maintains spontaneous ventilation. Sedative-induced respiratory depression and unprotected airway compromise patients’ safety. The gastro-laryngeal tube (G-LT) is a novel reusable supraglottic airway device with two separate ports for endoscopy and ventilation. This study attempts to evaluate the performance characteristic of G-LT. Methods One hundred and forty patients undergoing ERCP were enrolled and randomized. In Group G, patients underwent ERCP with G-LT, whereas Group S patients underwent ERCP conventionally. G-LT insertion attempts, esophageal visualization times, vital parameters, propofol consumption, endoscopists’ and anesthesiologists’ satisfaction scores, time to achieve Modified Aldrete Score of ≥ 9, and complications were recorded. Results Both groups showed similar demographic parameters and 100% procedure completion rates. G-LT group showed shortened esophageal visualization times (4.71 ± 1.687 s vs 7.37 ± 1.515 s) and increased propofol consumption (423.14 ± 106.982 mg vs 178.00 ± 100.125 mg). Group G showed better endoscopic maneuvrability and lesser hemodynamic variability. Sore throat, dysphagia, and mucosal trauma were higher in the G-LT group. Conclusion G-LT provides less intra-procedural hemodynamic changes, quicker esophageal visualization, and better scope maneuvrability at the cost of higher propofol consumption, sore throat, dysphagia, and mucosal trauma. Trial Registration Clinical Trial Registry of India CTRI/2021/06/034212 (Registered on: 14/06/2021)

Nasogastric Tube Insertion in Intubated Patients: Comparison of Three Different Positions; Standard Sniffing Position, Additional Flexion of the Neck, and Standard Sniffing Position with Lateral Neck Pressure.

Our study aimed to evaluate two modified nasogastric tube (NGT) insertion techniques in intubated patients compared to the conventional method in respect of first attempt success rate, time taken for insertion, and complications. In this prospective interventional study, patients with orotracheal intubation requiring NGT insertion were randomly allocated into three groups by SNOS Group A (control group- standard sniffing position, n = 40), Group B (additional flexion of the neck, n = 40), Group C (standard sniffing position with lateral neck pressure, n = 40). The number of attempts for successful NGT insertion, time for insertion, and complications were compared. Modified positions showed a high first-attempt success rate in Group B (55%) and Group C (85%) as compared to conventional Group A (32.50%) (P < 0.001). On intergroup analysis of modified groups (B and C), Group C was superior to Group B in 1st attempt success rate with a significant P value of 0.003. In intubated patients, NGT insertion in standard sniffing position with lateral neck pressure has the highest first attempt success rate followed by additional flexion of neck position. Both the modified positions are better positions for NGT insertion in intubated patients.

Ultrasound-guided PIVC insertion: a randomised controlled trial protocol.

Ultrasound-guided insertion of peripheral intravenous catheters (PIVCs) is an alternative to traditional anatomical landmark-based insertion. However, data on its performance in paediatric patients of varying levels of difficult intravenous access are limited. The researchers hypothesise that ultrasound-guided PIVC insertion will increase first-attempt success compared with landmark technique. This randomised, parallel-group, single-centre, superiority trial commenced recruiting in July 2021, including hospitalised children (aged 0 (>37 weeks gestation) to 18 years) requiring a PIVC. It will recruit 180 children, stratified by degree of perceived difficulty, and centrally randomised into two groups (ratio 1:1). The primary outcome is first-attempt PIVC insertion success. Secondary outcomes include total number of PIVC insertion attempts, PIVC insertion failure, post-insertion complications, dwell time, patient/parent satisfaction, and healthcare costs. The current study will inform the superiority of ultrasound-guided PIVC insertion in comparison with landmark technique. Adoption by healthcare facilities might improve patient outcomes and decrease healthcare costs.

Comparison of ultrasound-guided and palpation-inserted peripheral venous cannula in -patients before primary hip or knee arthroplasty: study protocol for a randomized controlled trial

BackgroundMore than 2 billion peripheral vascular cannulas are introduced globally each year. It is the most frequently performed invasive procedure in medicine worldwide. There is a group of patients with difficult intravenous access (DIVA). In experts’ hands, ultrasound-guided vascular access appears to be a significantly better method. Investigators hypothesize that UGVA is superior also in short-term patency of cannula and even for blood draw through cannula. Repeated cannula pricks in the operating room setting not only puts a lot of stress on the patient and medical staff, but they also waste OR time.MethodsThis investigator-initiated prospective randomized monocentric controlled trial is designed to randomly allocate 200 patients undergoing elective primary total joint arthroplasty of hip or knee to one of two groups as follows: Group C (control group) – peripheral venous cannula insertion by palpation or Group USG (intervention) – cannula insertion by ultrasound-guided vascular access. Our primary endpoint is to compare the number of attempts for ultrasound-guided insertion of the peripheral venous cannula with common palpation insertion of the peripheral venous cannula in overweight/obese patients (BMI ≥ 25). The secondary endpoint is a failure rate of the peripheral venous cannula to administer intravenous therapy up to 5 days postoperatively. Tertiary endpoints include a portion of long PVCs that are able to ensure blood draw up to 5 days postoperatively, time needed to insert PVC in each group, number of needle tip redirections in both groups, and reinsertion of PVC needed in both groups for any reason.DiscussionThis study is pragmatic and is looking for clinically relevant data. After completion, it will answer the question of whether it is clinically relevant to use ultrasound-guided vascular access in the context of not only short-term benefit of insertion, but also up to 5 days after insertion. Also, if this method can ensure blood draw through a peripheral vein cannula, it can save resources in the perioperative period — valuable especially considering the ongoing shortage of medical staff worldwide. If this hypothesis is confirmed, this finding could contribute to more widespread implementation of ultrasound-guided peripheral vascular access in the perioperative period.Trial registrationClinicalTrials.gov NCT05156008. Registered on 13.12.2021.

Efficacy of spinal anesthesia—ultrasound guided versus landmark-based, in patients undergoing spinal anesthesia: a prospective cross-sectional study

Abstract Objective: This research aims to assess the effectiveness and practical value of ultrasound imaging (US group) in minimizing the discomfort and potential hazards associated with spinal anesthesia compared to traditional landmark-based (LM group) approaches. Materials and Methods: In this prospective, randomized comparative investigation, 80 patients were enrolled to undergo spinal anesthesia using either the landmark-based or ultrasound-guided method, with an equal distribution of 40 patients in each respective group. The study recorded various parameters, including evaluation duration, count of needle insertion attempts, instances of redirection, duration of spinal anesthesia, overall procedure time (comprising assessment and administration of spinal anesthesia), and measurement of intrathecal space depth. Patient comfort was evaluated employing a visual analog scale (VAS). Results: Demographic characteristics, including age, gender, and body mass index, exhibited no notable differences. The overall procedure time was approximately 2–3 min for the LM group and 3–4 min for the US group, with a statistically significant difference (P &lt; 0.0001). The initial successful needle insertion rate was considerably more critical in the US group (52.5%) than in the LM group (10%). The distance from the skin to the subarachnoid space was notably more remarkable in the US group, with a statistically significant distinction from the LM group (P = 0.034). The successful spinal needle placement rate was 77.5% in the US group, significantly surpassing the LM group’s rate of 25% (P &lt; 0.05). Regarding patient comfort assessed using the VAS, the US group demonstrated significantly greater comfort levels than the LM group. In the US group, every patient reported a VAS score of &lt;4, whereas only 27.5% achieved the same level of comfort in the LM group. Conclusion: Our study provides evidence supporting the utility of pre-procedural ultrasound evaluation of the subarachnoid space as an effective tool for achieving successful lumbar punctures in patients receiving spinal anesthesia. Compared to the traditional landmark technique, this approach reduces the number of attempts required while enhancing patient comfort.

Efficacy and safety comparison of esketamine-propofol with nalbuphine-propofol for upper gastrointestinal endoscopy in children: a multi-center randomized controlled trial.

Anesthetics such as propofol, esketamine and nalbuphine are used during the upper gastrointestinal endoscopy to achieve and maintain the desired sedation level. The aim of the study was to evaluate the effectiveness and safety of propofol-nalbuphine and propofol-esketamine in children. A multi-centered study was performed at three tertiary class-A hospitals. Children between 3 and 12 years old undergoing diagnostic painless upper gastrointestinal endoscopy were included and randomly divided into esketamine or nalbuphine group to estimate the primary outcome of successful endoscope insertion. The patients were given esketamine 0.5 mg/kg and propofol 2 mg/kg intravenously in esketamine group, with nalbuphine 0.2 mg/kg and propofol 2 mg/kg in the nalbuphine group. The primary outcome was success rate for the first attempt of endoscope insertion in each group. Secondary outcomes included the safety of both anesthesia regimens and gastroenterologist's satisfaction. We used the Face, Leg, Activity, Cry and Consolability (FLACC) scale to evaluate the level of pain before and during the procedure and the Pediatric Anesthesia Emergence Delirium (PAED) scale to assess the level of agitation and delirium after awakening from anesthesia. Among 246 patients, 200 were randomly included in the final intention-to-treat analysis, with 100 patients in each group. The success rate for the first attempt of endoscope insertion in the esketamine group was higher than the nalbuphine group (97% vs. 66%; P < 0.01). The heart rate and mean arterial pressure after intraoperative administration in the esketamine group were higher than those in the nalbuphine group, while the delirium incidence during awakening was higher in esketamine group (all P < 0.05). The success rate for the first attempt of endoscope insertion of children undergoing upper gastrointestinal endoscopy in the esketamine group was higher than the nalbuphine group, propofol-related hemodynamic changes were reduced accordingly, while the incidence of esketamine-related adverse effects could be high. Chinese Clinical Trial Registry: ChiCTR2000040500.

Improving difficult peripheral intravenous access requires thought, training and technology (DART3): a stepped-wedge, cluster randomised controlled trial protocol

BackgroundPeripheral intravenous catheters (PIVCs) are the most used invasive medical device in healthcare. Yet around half of insertion attempts are unsuccessful leading to delayed medical treatments and patient discomfort of harm. Ultrasound-guided PIVC (USGPIVC) insertion is an evidence-based intervention shown to improve insertion success especially in patients with Difficult IntraVenous Access (BMC Health Serv Res 22:220, 2022), however the implementation in some healthcare settings remains suboptimal. This study aims to co-design interventions that optimise ultrasound guided PIVC insertion in patients with DIVA, implement and evaluate these initiatives and develop scale up activities.MethodsA stepped-wedge cluster randomized controlled trial will be conducted in three hospitals (two adult, one paediatric) in Queensland, Australia. The intervention will be rolled out across 12 distinct clusters (four per hospital). Intervention development will be guided by Michie’s Behavior Change Wheel with the aim to increase local staff capability, opportunity, and motivation for appropriate, sustainable adoption of USGPIVC insertion. Eligible clusters include all wards or departments where > 10 PIVCs/week are typically inserted. All clusters will commence in the control (baseline) phase, then, one cluster per hospital will step up every two months, as feasible, to the implementation phase, where the intervention will be rolled out. Implementation strategies are tailored for each hospital by local investigators and advisory groups, through context assessments, staff surveys, and stakeholder interviews and informed by extensive consumer interviews and consultation. Outcome measures align with the RE-AIM framework including clinical-effectiveness outcomes (e.g., first-time PIVC insertion success for DIVA patients [primary outcome], number of insertion attempts); implementation outcomes (e.g., intervention fidelity, readiness assessment) and cost effectiveness outcomes. The Consolidated Framework for Implementation Research framework will be used to report the intervention as it was implemented; how people participated in and responded to the intervention; contextual influences and how the theory underpinning the intervention was realised and delivered at each site. A sustainability assessment will be undertaken at three- and six-months post intervention.DiscussionStudy findings will help define systematic solutions to implement DIVA identification and escalation tools aiming to address consumer dissatisfaction with current PIVC insertion practices. Such actionable knowledge is critical for implementation of scale-up activities.Trial registrationProspectively registered (Australian and New Zealand Clinical Trials Registry; ACTRN12621001497897).

The parent, child and young person experience of difficult venous access and recommendations for clinical practice: A qualitative descriptive study.

Explore the parent and child/young person experience of difficult venous access and identify ideas and preferences for changes to clinical practice. Peripheral intravenous catheter insertion is one of the most common invasive procedures in hospitalised paediatric patients. Multiple insertion attempts in paediatric patients are common and associated with pain and distress. Little research has explored the parent and child/young person experience of difficult venous access nor sought to identify their suggestions to improve clinical practice. Qualitative description. A purposive sampling approach was used to identify children and young people with experience of difficult venous access and their parents. Semi-structured interviews were conducted, with sample size based on data saturation. Transcripts were analysed using thematic analysis. There were 12 participants, seven parents and five children/young people (five parent/child dyads and two individual parents). Analysis of the data revealed three main themes: (1) Distress-before, during and after (2) Families navigating the system: the challenging journey from general clinician to specialist and (3) Difficult venous access impacts both treatment and life outside the hospital A pre-determined theme, (4) Recommendations for good clinical practice is also described. Multiple attempts to insert a peripheral intravenous catheter are a source of substantial distress for children/young people, leading to treatment avoidance. Effective interpersonal skills, providing choice and avoiding frightening language are important to minimise distress. Clinicians without specialist training should assess each child's venous access experience and consider immediate referral to a specialist if they have a history of difficult venous access. Cultural change is required so clinicians and healthcare services recognise that repeated cannulation may be a source of psychological distress for children/young people.