Intravenous Cannula Insertion Research Articles

Supporting the use of sildenafil infusions in paediatric and neonatal intensive care – A compatibility study

ObjectiveIntravenous (IV) sildenafil, a phosphodiesterase type 5 inhibitor, is increasingly being used for the treatment of pulmonary hypertension (PH) in the paediatric population. Sildenafil (Revatio®) is approved for the treatment of pH in adults where it is administered as a bolus injection. However, in paediatrics it is used off-label and administered by continuous IV infusion. In the critically unwell child, limited IV access necessitates the administration of multiple IV infusions through a single IV lumen. The absence of compatibility data between sildenafil and other IV medications commonly used in this context necessitates the use of a dedicated IV line for sildenafil. The overall aim of this study was to establish the physical and chemical compatibility of sildenafil with commonly administered infusions in the paediatric and neonatal intensive care setting. DesignThis study evaluated the chemical and physical compatibility of binary and multiple combinations (n = 42) of sildenafil with adrenaline, noradrenaline, milrinone, vasopressin and heparin. These were tested using three diluents (NaCl 0.9%w/v, Glucose 5%w/v, and Glucose 10%w/v) and two environmental conditions (room temperature and 37 °C) frequently encountered in paediatric or neonatal intensive care units. Prior to drug combination analysis, HPLC methods were developed and optimised to allow for the quantification of drugs in accordance with current pharmaceutical guidance. Binary and multiple drug mixtures of sildenafil were examined for physical and chemical compatibility to establish compatibility. Measurements and main resultsOf the drug combinations not containing heparin, all were deemed compatible with the exception of the five drug mix of Sildenafil 800 μg/mL, Milrinone 200 μg/mL, Vasopressin 0.4Units/mL, Noradrenaline 60 μg/mL, Adrenaline 60 μg/mL at 37 °C, in 10%w/v glucose. All binary or multi drug combinations containing heparin were deemed incompatible. ConclusionsThis research provides support and information to clinicians looking to co-administer sildenafil with other IV medicines thus removing the requirement to subject their patients to multiple intravenous cannula insertion points where IV access is restricted. Article TweetNew evidence to support administration of sildenafil infusions in #PedsICU and #nicu– collaboration between @RCSIPharBioMol@FionaSOBrien1 and @OLCHCrumlin @RCSI_Irl @MoninneHowlett #CHI

Peripheral intravenous cannula insertion and use in a tertiary hospital emergency department: A cross-sectional study

IntroductionPeripheral intravenous cannula is often a first line invasive intervention for patients in the emergency department. It is used to facilitate blood sampling, deliver essential fluids, blood products and medication. However, the insertion and use of the peripheral intravenous cannula is not without complication. This study surveyed the number of peripheral intravenous cannulas inserted in the emergency department and identify the level of and reason for use. MethodsA cross-sectional study was conducted in the emergency department of a large tertiary hospital in Queensland. Descriptive and inferential statistics were used to describe peripheral intravenous cannula use and to explore associations. ResultsOf the 224 patients assessed, 159 (71%) had at least one peripheral intravenous cannula inserted in emergency department. Of the 159 peripheral intravenous cannulas inserted, 54 (34%) remained unused while the patient was in the emergency department. For patients classified as Australasian Triage Scale categories 3, 4 and 5, 40% of peripheral intravenous cannulas remained unused. Overall, poor documentation was observed with 29% of peripheral intravenous cannulas insertions not documented at all. ConclusionThis study identified a high proportion of unused peripheral intravenous cannulass in the emergency department and inadequate documentation. An intervention to promote best practice, raise awareness of the risks of peripheral intravenous cannulas use, possible alternatives therapies, and improve documentation is required.

Educational Training Using Transmitted Light Device on Nurses? Performance and Pain among Children Undergoing Peripheral Intravenous Cannulation

Background: Peripheral intravenous cannulation is frequently required for hospitalized children. Fluid supplements and administration of medication are mainly dependent on vascular access. Aim: Evaluate educational training using transmitted light device on nurses’ performance and pain among children undergoing peripheral intravenous cannulation Design: A quasi-experimental research design was used to conduct the study. Setting: The study was conducted at Pediatric Medical Departments of Benha University Hospital. Sample: A convenience sample of all available pediatric nurses (48) and (50) children received an intravenous cannula insertion at the time of the study. Tools: 1. Structured interview questionnaire for nurses to assess socio-demographic characteristics of the studied nurses, pediatric nurses' knowledge and observational checklist for nurse's performance.2. Structured interview questionnaire for children to assesses socio-demographic characteristics, medical history of studied children and Oucher pain rating scale. Results: A highly statistically significant difference observed between the studied nurses total knowledge and performance regarding to intravenous cannula insertion at pre- and post-intervention P= (

Comparison of Subclavian and Peripheral Intravenous Cannula Insertion in Critically Ill Patients Arriving in Emergency Department.

Introduction: Peripheral intravenous cannulation (PIVC) is a universal procedure to get venous access in hospital emergency settings. Sometimes, for critically ill patients in an emergency department, when we cannot get peripheral venous access, a central venous access could be established by percutaneous subclavian vein cannula insertion through a supraclavicular approach. This study will compare PIVC and percutaneous subclavian vein cannula insertion through supraclavicular approach, and determine which method is more effective and fast in critically ill patients arriving in the emergency department.Methods: This prospective, randomized clinical trial involved a total of 98 patients arriving in the emergency department in critical condition. Percutaneous subclavian vein cannula insertion through supraclavicular approach was attempted in 49 patients, and PIVC was attempted in other 49 patients. The timing of cannula insertion and the number of attempts for successful cannulation were compared for the two methods.Results: Percutaneous subclavian vein cannula insertion through supraclavicular approach was successful in 47 out of 49 patients (96%), and PIVC was successful in 38 out of 49 patients (78%). Average time of percutaneous subclavian vein cannula insertion through supraclavicular approach was 27.7 seconds (range 15-90 seconds), and the average time of PIVC was 68.64 seconds (range 25-150 seconds).Conclusion: Compared with PIVC, percutaneous subclavian vein cannula insertion through supraclavicular approach is faster and more effective to gain venous access in critically ill patients arriving in emergency department.

A Case of Acute Compartment Syndrome of Upper Limb in a Dengue Haemorrhagic Fever Patient Secondary to Intravenous Cannula Insertion

Dengue fever with its haemorrhagic complications is a common viral illness in Malaysia which can sometimes lead to high morbidity and mortality. We present a case report of a 27-year-old male who was admitted to our hospital with dengue haemorrhagic fever. He developed multiple hematomas and bruising in his right forearm and arm due to intravenous cannula insertion. Due to coexisting thrombocytopenia, the limb progressed to acute compartment syndrome and emergency fasciotomy was done and his limb was salvaged. This case illustrates an important potential complication of dengue fever and the importance of timing of surgery in the event of compartment syndrome.

Incidence, severity and risk factors of peripheral intravenous cannula-induced complications: An observational prospective study.

To determine the incidence, severity and risk factors of peripheral intravenous cannula-induced complications. Peripheral venous cannulation in hospitalised patients may cause complications such as phlebitis, infiltration, occlusion and dislodgement. A review of the literature reveals the discrepancy in their incidence and identification of a wide range of risk factors, whereas the data on the occurrence and degree of severity are insufficient. An observational prospective study. The study observed 1,428 peripheral intravenous cannula insertion among 368 adult patients hospitalised at the tertiary healthcare clinics. The data collection and analysis included patients' medical data and the data related to each cannula (including placement, monitoring and the reasons for removal), as well as the data on the type of administered medications and solutions. Reporting of this research adheres to the STROBE guidelines. Phlebitis ranked first among complications with occurrence of 44%, followed by infiltration of 16.3%, while the incidence of occlusion and catheter dislodgement was 7.6% and 5.6%, respectively. In assessing the occurrence of phlebitis, multivariate analysis highlighted the presence of comorbidity, current infection, catheter size, time in situ and the number of administrations of infusion solutions associated with risk, whereas 20-gauge catheter, two or more attempts at cannulation and administration of a high-risk solutions during the first day have been singled out with regard to infiltration. As for the severity, the most common was medium stage of phlebitis, whereas grade 2 was most commonly observed for infiltration. The incidence of infiltration, occlusion and dislodgment is almost congruent with the average incidence of previous studies. However, the incidence and degree of severity associated with the occurrence of phlebitis were significantly higher. The results of the study draw attention to vulnerable groups of patients, cannula-specific and pharmacological risk factors for the development of peripheral intravenous cannula-induced complications.

Human factor‐designed multimodal intervention reduces the rate of unused peripheral intravenous cannula insertion

Our objective was to examine the impact of a human factor-designed multimodal intervention on the proportion of unused peripheral i.v. cannula (PIVC) insertion in our ED. A pre- and post-multimodal intervention retrospective cohort study was conducted using a structured electronic medical record review within a single adult tertiary ED in Australia. Pre-intervention data was collected 30 days prior to the multimodal intervention, with 30 day post-intervention data collected 3 months after the intervention commenced. The rates of PIVC inserted, the unused rate and the unused but appropriately inserted cannulas were the main outcome measures. Intravenous cannula insertion rates decreased by 12.9% (95% confidence interval [CI] 12.19-13.61) between the pre-intervention (1413/4167 [33.9%]; 95% CI 32.5-35.4) and post-intervention cohort (928/4421 [21.0%]; 95% CI 19.8-22.2). An analysis of 754 cases (376 pre-intervention and 378 post-intervention) showed that 139 of 376 (37.0%; 95% CI 32.1-42.1) i.v. cannulas were unused pre-intervention, while 73 of 378 (19.3%; 95% CI 15.4-23.7) was unused post-intervention; an absolute reduction of 17.7% (95% CI 14.98-20.42). The relative risk of an unused i.v. cannula was 0.52 (95% CI 0.41-0.67). The proportion of unused but appropriately inserted i.v. cannulas remained unchanged in both cohorts, with a relative risk of 0.91 (95% CI 0.58-1.42). Our multimodal intervention successfully reduced the number of unused PIVCs inserted in the ED, with a reduction in overall and unused PIVC insertions without any change in appropriate insertions.

Elective replacement of intravenous cannula in neonates-a randomised trial.

Peripheral intravenous cannula (PIVC) insertion is one of the most common invasive procedures performed in neonates and is frequently associated with adverse events. There are no studies in the neonatal population looking at the possibility of reducing the risk of PIVC-related complications by elective replacement of PIVC. A randomised, non-blinded, control trial was conducted in a tertiary level neonatal unit in Melbourne, Australia, to examine rates of extravasation in neonates with elective replacement of PIVC as compared to standard practice. Neonates born at 32weeks of gestation or more were randomly assigned to have their PIVC replaced electively (every 72-96h) or when clinically indicated in a 1:1 allocation ratio after parental consent. Primary outcome studied was rate of extravasation. Secondary outcomes included rates of phlebitis, leakage or spontaneous dislodgement of PIVC. One hundred thirteen infants were enrolled. Extravasation was noted in 33 (60%) of standard practice group vs. 28 (48.3%) of elective replacement (RR 0.80, CI 0.57-1.13, p = 0.21) infants. Time to first extravasation was similar between the groups (hazard ratio 0.69, CI 0.42-1.15). Extravasation events per 1000 IV hours were also similar between groups. Similar results were seen by both intention to treat and per protocol analyses. There was an increase in leaking rates (HR1.98, CI 1.03-3.81, p = 0.04) in the elective group, while phlebitis and spontaneous dislodgement rates were similar to standard group.Conclusion: Elective replacement of PIVC in neonates is not associated with reduction in extravasation rates.Trial registration: This trial has been registered with the Australian and New Zealand Clinical Trials Register. Identifier: ACTRN12615000827538. What is Known: • The reported incidence of extravasation injury is as high as 70% in the neonatal and paediatric population and has an association with cannula dwell time. • Adult studies have done to look at the possibility of reducing intravenous cannula-related complications with routine replacement of the cannulas but no similar studies have been done in the neonatal population. What is New: • Routine replacement of intravenous cannula in neonates between 72 and 96h of use does not reduce the rate of extravasation injuries. • There might be some added complications associated with such a practice.

'What the hell is water?' How to use deliberate clinical inertia in common emergency department situations.

Appropriate deliberate clinical inertia refers to the art of doing nothing as a positive clinical response. It includes shared decision-making to improve patient care with the use of clinical judgement. We discuss common clinical scenarios where the use of deliberate clinical inertia can occur. The insertion of peripheral intravenous cannulae, investigating patients with suspected renal colic and the investigation of low risk chest pain are all opportunities for the thoughtful clinician to 'stand there' and use effective patient communication to avoid low value tests and procedures. Awareness is key to identifying these opportunities to practice deliberate clinical inertia, as many of the situations may be so much a part of our environment that they are hidden in plain view.

Hot Off the Press: Peripheral Intravenous Cannula Insertion and Use in the Emergency Department.

This is a prospective before-after study comparing peripheral intravenous cannulation (PIVC) placement and usage rates following a 10-week-long multimodal intervention provided to medical and nursing staff working in a tertiary emergency department (ED). The intervention focused on improving appropriate use of PIVCs in an emergency setting by emphasizing to clinicians that a PIVC should only be placed if it was believed there was more than an 80% chance that it would be used. Patients were eligible for the study if they presented to the ED and were>18 years of age. Patients were excluded from the study if they were triage category 1, already had a PIVC placed in an ambulance, or were transferred from another hospital. Among the 4,172 patients included in the analysis, there was a 9.8% reduction in the number of PIVCs inserted (95% confidence interval [CI]= 6.8-12.87) and a 12% increase in PIVC usage (95% CI= 8.7%-17.0%) in the postintervention cohort.

Melatonin as an alternative sedation method during magnetic resonance imaging in preschool children with musculoskeletal problems.

The use of melatonin before the musculoskeletal MRI in preschool children is an effective, safe, and inexpensive alternative to standard sedation and general anesthesia in preventing motion artifacts. What is Known: • Magnetic resonance imaging (MRI) is a well-recognized diagnostic method to visualize synovial inflammation and changes of cartilage and bone in juvenile idiopathic arthritis. • MRI examination requires sedation or general anesthesia to ensure immobility in children who are uncooperative. What is New: • Melatonin without sleep deprivation is efficacious and safe alternative to conventional sedation and general anesthesia before the musculoskeletal contrast-enhanced MRI in preschool children with JIA with timely insertion of intravenous cannula.

Peripheral Intravenous Cannula Insertion and Use in the Emergency Department: An Intervention Study.

The objective was to examine cannulation practice and effectiveness of a multimodal intervention to reduce peripheral intravenous cannula (PIVC) insertion in emergency department (ED) patients. A prospective before and after study and cost analysis was conducted at a single tertiary ED in Australia. Data were collected 24 hours a day for 2 weeks pre- and post implementation of a multimodal intervention. PIVC placement and utilization within 24 hours were evaluated in all eligible patients. A total of 4,173 participants were included in the analysis. PIVCs were placed in 42.1% of patients' pre intervention and 32.4% post intervention, a reduction of 9.8% (95% confidence interval [CI] = 6.8 to -12.72%). PIVC usage within 24 hours of admission was 70.5% pre intervention and 83.4% post intervention, an increase of 12.9% (95% CI = 8.8% to 17.0%). Sixty-six patients were observed in the ED for cost analysis. The mean time per PIVC insertion was 15.3 (95% CI = 12.6 to 17.9) minutes. PIVC insertion cost, including staff time and consumables per participant, was A$22.79 (95% CI = A$19.35 to A$26.23). The intervention reduced PIVC placement in the ED and increased the percentage of PIVCs placed that were used. This program benefits patients and health services alike, with potential for large cost savings.

Lifespan and associated factors of peripheral intravenous Cannula among infants admitted in public hospitals of Mekelle City, Tigray, Ethiopia, 2016

BackgroundPeripheral Intravenous cannula (IV) is the most common vascular access device used to administer medications with the exception of medication or fluid with high or low PH or hyperosmolarity which may cause severe damage to small veins. The insertion of a peripheral intravenous cannula in newborn infants can be difficult. Appropriate veins with sufficient capacity to insert a cannula become less available throughout the hospital stay. Once a peripheral intravenous cannula is inserted, it is desirable that its patency can be maintained as long as possible. This study was aimed to assess the lifespan and associated factors of peripheral intravenous cannula among infants admitted in public hospitals of Mekelle city, Tigray, Ethiopia, 2016.MethodsThe method used was a prospective cohort study. 178 study subjects were recruited using systematic random sampling technique. The data was collected by structured questionairre and observational checklist.ResultsMore than half of infants (94) had a short cannula lifespan (below 30 h). Multivariable logistic regression analysis showed that Pediatric intensive care unit (PICU) [AOR = 6.93; 95% CI (1.56,30.71)], clinical experience (3-5 years) [AOR = 0.168; 95% CI (0.060-0.469)], insertion site (arm) [AOR = 0.126;95% CI (0.046-0.349)], reason for removal (dislodgement and complication) [AOR = 8.15; 95% CI (2.49,26.63) [AOR = 10.48;95% CI (3.08,35.65)], medication [AOR = 0.17;95% CI (0.37,0.784)], corticosteroids [0.164; 95% CI (0.034,0.793)] and blood transfusion [AOR = 0.12; 95% CI (0.028-0.509)] were the statistically significant variables associated with the lifespan of a peripheral intravenous cannula.ConclusionsUntimely removal of peripheral intravenous cannulas was higher in infants and demographic. Cannulation and health care factors had significant effects on the lifespan of a peripheral intravenous cannula.

Peripheral cannulae in oncology: nurses’ confidence and patients’ experiences

The insertion and care of peripheral intravenous cannulae (PIVCs) is a role performed by clinical staff that is fundamental to oncology. Previous research indicates nurses' confidence and experience could mediate successful first attempt insertion, increasing the longevity of PIVCs and improving the patient experience. The aim of this audit was to provide a snapshot of care and maintenance of PIVCs, patients' experiences and nurses' confidence at a specialist cancer hospital. An audit tool assessing PIVC care practices (n = 51) and a patient experience questionnaire (n = 65) were completed. A questionnaire assessing nurses' confidence and training needs was completed by 36 nurses. The findings raise some concerns about clinical practice when inserting PIVCs and ongoing care, with 80% adherence to cannulation policies. Almost half of insertion procedures failed at the first attempt and 17% of nurses lacked confidence in PIVC insertion and in recognising or responding to common complications. Patient satisfaction was high for ongoing PIVC care (95%), although some reported increased pain and anxiety after PIVC insertion, with some unresolved concerns. This audit highlights several important areas for improvement in relation to PIVC insertion and maintenance and the need for greater adherence to clinical guidelines/policy and additional training were identified.

Predicting and preventing peripheral intravenous cannula insertion failure in the emergency department: Clinician 'gestalt' wins again.

Failed attempts at peripheral i.v. cannula (PIVC) insertion in the ED are common. The psychological, physical and economic impact of these failures is significant. We sought to explore whether clinicians of differing experience levels can predict their own likelihood (clinician 'gestalt') of first-time cannula insertion success on any given patient. Data analyses from a prospective self-reported study assessing risk factors for first-time insertion success in a tertiary adult ED. We constructed and compared two simple theoretical clinical decision algorithms in an attempt to improve first-time PIVC insertion success rates. This best algorithm identified a subgroup of 18% of the total PIVC population at higher risk of failure. This 18% comprised 57% of all PIVC failures, and implementation would result in a relative risk reduction of PIVC failure by 31%. When applied to our sample population, an algorithm relying on clinician gestalt to identify patients at high risk of PIVC failure had the greatest potential impact. These patients would be referred to expert PIVC inserters prior to, rather than after, failed attempts.

Plastic in patient study: Prospective audit of adherence to peripheral intravenous cannula monitoring and documentation guidelines, with the aim of reducing future rates of intravenous cannula-related complications.

Peripheral intravenous cannula (PIVC) insertion is a universal intervention for inpatients and is associated with multiple complications. Effective, simple, reproducible interventions specific to PIVC complication prevention are few and often extrapolated from central venous catheter complication prevention strategies. The objective of this study is to improve compliance with documentation and monitoring PIVC guidelines in the medical ward of a secondary care center. This study is a prospective run-in audit of adherence to PIVC documentation and monitoring guidelines between the dates of August 30-November 14, 2014, with data recollection from December 25, 2014-January 30, 2015, after intervention implementation. Three interventions were implemented. The Plastic in Patient (PIP) strip is a dedicated column on the journey board, identifying inpatients with PIVCs, prompting assessment of indication at daily multidisciplinary meetings. PIP row is a prompt in the medical admission proforma to review PIVC indication. PIP poster is a visual cue on PIVC trolleys highlighting PIVC management practices. Baseline demographics were similar in the pre- and postintervention groups. Documentation significantly improved in the postintervention group (36.4 vs 50%, P = .025). Early identification of nonindicated PIVCs improved in the postintervention group (88.8% vs 97.1%, P = .018) and a trend toward a reduced PIVC-related early phlebitis rate (3.7% vs 0, P = .08). Simple, cost-effective interventions result in improvements in adherence to practice guidelines. Our results suggest a trend toward reduction in phlebitis rates.

Reducing Staphylococcus aureus bloodstream infections associated with peripheral intravenous cannulae: successful implementation of a care bundle at a large Australian health service

Healthcare-associated Staphylococcus aureus bacteraemia (HA-SAB) results in morbidity, mortality, and increased healthcare costs, and these infections are frequently regarded as preventable. To implement a multi-modal prevention programme for improved processes regarding peripheral intravenous cannula (PIVC) insertion and maintenance, in order to reduce PIVC-associated HA-SAB events in a large Australian health service. Baseline clinical practice was evaluated for a 12-month pre-intervention period. Measures to reduce HA-SAB risk were introduced between January and September 2013: staff education, improved documentation (including phlebitis scoring), and availability of standardized equipment. Post-intervention auditing was performed during the 27 months following intervention. Baseline and post-intervention HA-SAB and PIVC-associated infection rates were compared. Interrupted time-series and Bayesian change-point analyses were applied to determine the impact of interventions and timing of change. Significantly improved documentation regarding PIVC insertion and management was observed in the post-intervention period, with fewer PIVCs left in situ for ≥4 days (2.6 vs 6.9%, P<0.05). During the baseline period a total of 68 HA-SAB events occurred [1.01/10,000 occupied bed-days (OBDs)] and 24 were PIVC-associated (35% of total, rate 0.39 per 10,000 OBDs). In the post-intervention period, a total of 83 HA-SAB events occurred (0.99 per 10,000 OBDs) and 12 were PIVC-associated (14.4% of total, rate 0.14 per 10,000 OBDs). PIVC-associated SAB rates were 63% lower in the post-intervention period compared to baseline (P=0.018) with a change point observed following full bundle implementation in October 2013. A successful multi-modal hospital-wide campaign was introduced to reduce PIVC-associated SAB rates. Evaluation of cost-effectiveness and sustainability is required.

A prospective quality improvement study in the emergency department targeting paediatric sepsis

ObjectiveQuality improvement sepsis initiatives in the paediatric emergency department have been associated with improved processes, but an unclear effect on patient outcome. We aimed to evaluate and improve emergency department...

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

IntroductionPeripheral 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...

You’ve been bleeped: patient with a fever

Patients with a fever on the ward might have been admitted with infection that is not improving or admitted for another reason and developed a hospital acquired infection. An infection is not the only differential for a patient with fever so keep an open diagnostic mind. Whatever the cause of the patient’s fever, a high temperature is often the first presentation of a serious illness or serious deterioration so you need to be adept with your clinical assessment and speedy when instigating an initial management plan. #### Scenario It is Sunday morning. You are the foundation year one doctor (FY1) on call covering the general medical wards at a busy district general hospital. You are finishing the insertion of an intravenous cannula for a patient, when you are bleeped by ward 15. Bleep “Is that the FY1 on call for medicine? My name is Nicole, I’m a nurse on ward 15. I’m calling about a woman called Peggy Lee who I’m worried about because she has spiked a temperature of 39oC. She is 61 years old and has pneumonia. Can you come and review her?” ### How should you react to this bleep on the phone? A new or recurring fever is a common bleep. The definition of a fever is a temperature greater than 37.8°C measured with an oral or auricular thermometer, or 38.2°C measured with a rectal thermometer. Fever is one part of the systemic inflammatory response syndrome (SIRS). This syndrome is the body’s reaction to a large number of insults, and is a potential signal of major disease. Fever on its own is not enough to diagnose SIRS—two or more of the following features must be present1: