Intravenous Access Research Articles

Intraosseous versus intravenous vascular access during cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of observational studies

IntroductionThis study is aimed to investigate the association of intraosseous (IO) versus intravenous (IV) route during cardiopulmonary resuscitation (CPR) with outcomes after out-of-hospital cardiac arrest (OHCA).MethodsWe systematically searched PubMed, Embase, Cochrane Library and Web of Science from the database inception through April 2020. Our search strings included designed keywords for two concepts, i.e. vascular access and cardiac arrest. There were no limitations implemented in the search strategy. We selected studies comparing IO versus IV access in neurological or survival outcomes after OHCA. Favourable neurological outcome at hospital discharge was pre-specified as the primary outcome. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I2 statistics. Time to intervention, defined as time interval from call for emergency medical services to establishing vascular access or administering medications, was hypothesized to be a potential outcome moderator and examined in subgroup analysis with meta-regression.ResultsNine retrospective observational studies involving 111,746 adult OHCA patients were included. Most studies were rated as high quality according to Newcastle-Ottawa Scale. The pooled results demonstrated no significant association between types of vascular access and the primary outcome (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27–1.33; I2, 95%). In subgroup analysis, time to intervention was noted to be positively associated with the pooled OR of achieving the primary outcome (OR: 3.95, 95% CI, 1.42–11.02, p: 0.02). That is, when the studies not accounting for the variable of “time to intervention” in the statistical analysis were pooled together, the meta-analytic results between IO access and favourable outcomes would be biased toward inverse association. No obvious publication bias was detected by the funnel plot.ConclusionsThe meta-analysis revealed no significant association between types of vascular access and neurological outcomes at hospital discharge among OHCA patients. Time to intervention was identified to be an important outcome moderator in this meta-analysis of observation studies. These results call for the need for future clinical trials to investigate the unbiased effect of IO use on OHCA CPR.

Use of catheter with 2-methacryloyloxyethyl phosphorylcholine polymer coating is associated with long-term availability of central venous port

Central venous port (CVP) is a widely used totally implantable venous access device. Recognition of risks associated with CVP-related complications is clinically important for safe, reliable, and long-term intravenous access. We therefore investigated factors associated with CVP infection and evulsion, including the device type. A total of 308 consecutive patients with initial CVP implantation between January 2011 and December 2017 were retrospectively reviewed, and the association of clinical features with CVP-related complications were analyzed. Intraoperative and postoperative complications occurred in 11 (3.6%) and 39 (12.7%) patients, respectively. The overall rate of CVP availability at six months was 91.4%. Malignancy and 2-Methacryloyloxyethyl phosphorylcholine (MPC) polymer-coated catheter use were negatively associated with the incidence of CVP infections. Accordingly, malignancy and MPC polymer-coated catheter use were independent predictors for lower CVP evulsion rate (odds ratio, 0.23 and 0.18, respectively). Furthermore, both factors were significantly associated with longer CVP availability (hazard ratio, 0.24 and 0.27, respectively). This retrospective study identified factors associated with CVP-related complications and long-term CVP availability. Notably, MPC polymer-coated catheter use was significantly associated with a lower rate of CVP infection and longer CVP availability, suggesting the preventive effect of MPC coating on CVP infection.

How to perform and interpret a first trimester transabdominal point-of-care ultrasound

A previously healthy 31-year-old gravida 1, para 0, presents to the ED for the evaluation of vaginal bleeding. The patient took a home pregnancy test that was positive and notes...

PaRamEDIc assessment of laCTate in OHCA and survival to hospital (PREDICT protocol)

Background: Studies suggest that blood lactate differs between survivors and non-survivors of out-of-hospital cardiac arrest who are transported to hospital. The prognostic role of lactate taken during out-of-hospital cardiac arrest remains unexplored. Aims: To measure the association between lactate taken during out-of-hospital cardiac arrest, survival to hospital and 30-day mortality. Methods: This is a feasibility, single-centre, prospective cohort study. Eligible for inclusion are patients aged ≥18 years suffering out-of-hospital cardiac arrest, receiving cardiopulmonary resuscitation, in the catchment of Newcastle or Gateshead hospitals, who are attended to by a study-trained specialist paramedic. Exclusions are known/apparent pregnancy, blunt or penetrating injury as primary cause of out-of-hospital cardiac arrest and an absence of intravenous access. Between February 2020 and March 2021, 100 participants will be enrolled. Primary outcome is survival to hospital; secondary outcomes are return of spontaneous circulation at any time and 30-day mortality.

Validation of intraosseous delivery of valproic acid in a swine model of polytrauma

BackgroundIntraosseous (IO) drug delivery may be necessary in emergency situations when intravenous access is unattainable. Valproic acid (VPA) is a histone deacetylase inhibitor that has previously been shown to improve...

Comparison of Pain on Injection of Etomidate versus Etomidate-Lipuro in Patients Undergoing Elective Orthopedic Surgery: A Double-Blind Randomized Clinical Trial

Background: Etomidate is an efficient general anesthetic associated with injection pain. Etomidate-Lipuro is its lipid emulsion, suggested to have less adverse effects. We aim to compare the injection pain of etomidate vs. etomidate-lipuro. Methods: This double-blind randomized clinical trial investigated 46 hands (23 patients) undergoing elective orthopedic surgery referring to our hospital from May to September 2017. For each patient, intravenous (IV) access was put on both hands, on one of which 2 ml of etomidate (drug A) and on the other one, 2 ml of etomidate-lipuro (drug B) were infused simultaneously. Pain scores were compared between drug types by the Wilcoxon signed-rank test using the SPSS software. Results: Among 23 patients included in the study, 8 (34.8%) were female. Mean ± standard deviation (SD) of the patients’ age was 40.52 ± 13.07 years (range: 22-60 years). The type of drug injected to the right hand was drug A in 14 hands (60.9%) and drug B in 9 hands (39.1%). Mean ± SD of pain scores was 3.57 ± 3.30 for drug A (P < 0.001). The hand side (left/right) showed no significant effect on the pain scores (P = 0.535). Conclusion: This randomized clinical trial used each person as his/her own control (left/right hands). Given the results, etomidatelipuro showed significant superiority over etomidate regarding injection pain. In fact, most patients felt no pain, which suggests etomidate-Lipuro as an appropriate sedative.

Optimizing and Sustaining Timely Intravenous Access for Children Treated for Suspected Septic Shock in a Pediatric Emergency Department

Optimizing and Sustaining Timely Intravenous Access for Children Treated for Suspected Septic Shock in a Pediatric Emergency Department

Risk Factors for Central Venous Line Complications Versus Umbilical Veous Catheter in Premature Neonates Admitted to El Warak Centeral Hospital Neonatal Intesive Care Unit

peripherally inserted central catheters (PICCs) are routinely used in term and preterm infants to provide intravenous access for prolonged therapy and parenteral nutrition. They are known to reduce the complications associated with the conventionally used central catheters. PICCs can be conveniently inserted at the bedside without the need for surgical intervention. The point of the available investigation might have been with assess those danger figures to vital venous offering difficulties versus umber venous catheter over preterm neonates admitted to el Warak national clinic in neonatal seriousness Furthermore its result. This Prospective observational consider required been conveyed out in NICUs toward el Warak national clinic between December2018 Also december 2019, those ponder might have been conveyed out ahead 100 newborns ( preterm) that were admitted will nicu by diverse result in Also have focal embedded vascular catheter (Umbilical venous catheter Also vital veous cathter). Comes about of the study uncovered that crp Also PTT were altogether higher in CVC one assembly contrasted with UVC. However, TLC, platelets check Also HCT qualities were more level same time inr might have been higher On CVC gathering contrasted with UVC bunch without measurable hugeness distinction Also direct might have been the The greater part incessant condition around the two groups, In awful condition might have been All the more incessant over CVC assembly. However, there may be no huge Contrast the middle of the Assemblies in regards general condition. There might have been no noteworthy distinction in the occurrence about CABSI the middle of altogether preterm neonates who accepted a CVC alternately UVC Concerning illustration those elementary mode about venous get after conception. A prospective randomized regulated trial will be advocated will further aide act viewing essential venous get What's more diminishment from claiming spoiling.

Anesthesia for children with complete trisomy 18 (Edwards syndrome): A cohort review of 84 anesthesia encounters in nine patients.

Trisomy 18 or Edwards syndrome is the second most common aneuploidy with a prevalence between 1/3000 and 1/10000 live births. The syndrome encompasses malformations of the central nervous, cardiac, respiratory, gastrointestinal, and genitourinary systems. Trisomy 18 carries a poor prognosis with 90% of patients not surviving beyond 1year of age; however, the current trend toward more aggressive supportive care may prolong survival. The limited anesthesia literature highlights the abnormal airway anatomy but generally describes uneventful airway management and perioperative course. Our goal was to review all anesthesia encounters recorded for eleven trisomy 18 patients treated at Children's Wisconsin during the study period to explore the frequency of anesthesia encounters and to improve our understanding of the perioperative risks. We performed a retrospective chart review of all patients with trisomy 18 who were treated at our institution between 2012 and 2017. Records were screened for anesthesia encounters, perioperative critical events and complications, enrollment in palliative care, code status, and time of death. Eleven children were identified. Children were born between 2001 and 2016. Two children never required anesthesia care. Nine patients had a total of 84 anesthesia encounters for 121 surgical or diagnostic procedures or emergent intubations. Critical events and perioperative complications included difficult mask ventilation (n=7), difficult intubation (n=15), and mechanical or pharmacological cardiopulmonary resuscitation (n=6). Five patients presented with difficult peripheral intravenous access. One patient died in the immediate postoperative period. On five occasions, patients required emergent intubation outside of the operating room. Difficult airway management and respiratory compromise were critical concerns during the perioperative period in our patient population, and the inability to ventilate could lead to cardiorespiratory arrest. This case series provides a comprehensive, longitudinal view of complete trisomy 18 patients in the perioperative period and adds information for counseling families and care providers.

Peripheral intravenous cannulae in neonates: To splint or not?

To determine the effect of splint on the dwell time of peripheral intravenous cannula in neonates. Level II Neonatal Intensive Care Unit (NICU). Consecutive babies with presumed need of peripheral intravenous access of at least 24 h. Enrolled subjects were randomized to "splint" or "splint-less" group. Insertion site was cleaned with Isopropyl alcohol and 2% Chlorhexidine and peripheral intravenous catheter was inserted under strict asepsis. Insertion sites was examined regularly for occurrence of complication which necessitated removal of the catheter. Out of 159 neonates, 80 were allotted to splint group and the rest to splint-less group. Mean dwell time of intravenous line in splint group was 27.68 ± 13.03 h which was significantly less than in splint-less group (32.87 ± 15.79 h, mean difference: 5.11 h, p value: 0.03). Subgroup analysis in preterms showed mean dwell time of 28.54 ± 14.86 h in splint group which was less than that of splint-less group (35.10 ± 16.24 h) (p value: 0.03). No such difference was noted in the term neonates. Subgroup analysis for catheters put across joints does not show difference in mean dwell times between splint and splint-less groups. Multivariate regression analysis did not identify any variable which independently affected the outcome. Use of splint does not prolong the dwell time of the catheter and is probably harmful in some neonates.

Reducing the time to successful intravenous cannulation in anaesthetised children with poor vein visibility using a near-infrared device: A randomised multicentre trial.

During inhalational induction of anaesthesia for children, severe respiratory events can occur but can be rapidly treated once intravenous access is in place. Reducing the time to successful cannulation during inhalational induction for children with poor vein visibility would improve safety. To study the effectiveness of a near-infrared (NIR) vascular imaging device (Veinviewer) to facilitate intravenous cannulation. A prospective, multicentre, randomised, open clinical trial. The operating rooms of three paediatric hospitals in Paris, France, from 1 October 2012 to 31 March 2016. Children up to the age of 7 years, with poor vein visibility requiring general anaesthesia. Inhalational anaesthesia was initiated and intravenous cannulation was performed with the standard approach or with the Veinviewer Vision. The primary outcome was the time to successful intravenous cannulation. A secondary outcome was the proportion of successful first attempts. The mean time to successful intravenous cannulation was 200 (95% CI, 143 to 295) seconds in the Veinviewer and 252 (95% CI, 194 to 328) seconds for the control group: hazard ratio 1.28 (1.02 to 1.60) (P = 0.03). The adjusted hazard ratio for known predictive factors was 1.25 (0.99 to 1.56) (P = 0.06). Success at the first attempt was 64.6% (102/158) in the 'Veinviewer' group vs. 55.6% (85/153) in the 'control' group (P = 0.10). The Veinviewer has limited value in reducing the time to successful intravenous cannulation during inhalational anaesthesia for young children with poor vein visibility. However, there is a strong trend to reducing the delay in some cases and, given its absence of side effects, it could be part of a rescue option for a difficult venous-access strategy. NCT01685866 (http://www.clinicaltrials.gov).

Low-molecular-weight heparin administered by subcutaneous catheter is a safe and effective anti-coagulation regimen in selected inpatient infants and children with complex congenital heart disease.

Disadvantages of intravenous therapeutic unfractionated heparin, the first-line anti-coagulant agent in children with complex congenital heart disease, include unpredictable pharmacokinetics requiring frequent phlebotomies and the need for continuous intravenous access. To compare efficacy and safety of low-molecular-weight heparin administered by a subcutaneous indwelling catheter with intravenous unfractionated heparin. Clinical data from 31 inpatients prospectively enrolled to receive subcutaneous low-molecular-weight heparin were compared with those from a historical group of 44 inpatients receiving intravenous unfractionated heparin. Investigation of parents' satisfaction by telephone survey. The percentage of anti-factor Xa levels outside therapeutic range was lower in the subcutaneous low-molecular-weight heparin group compared with the percentage of activated partial thromboplastin times outside therapeutic range in the intravenous unfractionated heparin group (40% versus 90%, p < 0.001). Neither group had a major complication. Transient local reactions occurred in 19% of patients of the subcutaneous low-molecular-weight heparin group. The number of needle punctures and that of placement of indwelling catheters were significantly lower in the subcutaneous low-molecular-weight heparin compared with the intravenous unfractionated heparin group (p < 0.001). In total, 84.2% of parents in the subcutaneous low-molecular-weight heparin group reported a positive experience when asked about comparison with prior intravenous unfractionated heparin treatment. Subcutaneous low-molecular-weight heparin offers a safe anti-coagulation regimen for children with complex congenital heart disease providing more efficient therapeutic anti-coagulation and a reduction in needle punctures, thus causing less pain and anxiety in this children.

First-Attempt Success Rate of Ultrasound-Guided Peripheral IV Access using a Handheld Ultrasound Machine in a Simulation Model

Background: Although peripheral Intravenous (IV) cannulation is a routine procedure performed by nurses, IV access can be difficult to achieve, particularly in emergency patients who have critical illnesses. Ultrasound is used in this procedure to increase the success rate in novice practitioners. Objective: We aimed to determine the first-attempt success rate of ultrasound-guided peripheral IV (USGPIV) performed by emergency nurses in simulation model after having undergone training in the procedure. Materials and Methods: This was prospective descriptive study. The participants consisted of 61 emergency nurses at Srinagarind Hospital Emergency Department from January to April 2020. USGPIV cannulation training was provided by an emergency physician who is also a specialist in emergency ultrasound. After training, we calculated the number of attempts and time required to successfully complete USGPIV in a simulation model. Following this, participants responded to a questionnaire to evaluate their confidence in performing the procedure, as well as its feasibility and practical application. Data were analyzed using a Kolmogorov-Smirnov test, and p&lt;0.05 was considered to be significant. Results: Sixty-one emergency nurses were included. The first-attempt success rate of USGPIV was 85.25% (95% CI 0.761, 0.944), and the mean time required was 47.33+4.89 sec. (95% CI 37.547, 57.103). Fifty-nine participants (96.72%) completed the questionnaire. All items had a mean score of greater than 3 points, with confidence score being the highest. Conclusion: Emergency nurses with no previous experience with USGPIV were able to perform a simulated version of the procedure with a high first-attempt success rate after a short training session. Further studies should be conducted to evaluate nurses’ USGPIV competency in real patients. Keywords: Ultrasound, Peripheral IV cannulation, Emergency medicine, Emergency nurse

1st Attempt Success Rate of Ultrasound-Guided Peripheral IV Access of Emergency Medical Services Health Care Providers on the Pre-Hospital Simulation Model

Background: Ultrasound guided peripheral intravenous access (USGPIV) has derived benefits for the Emergency and Pre-hospital Management. However, no studies have yet been conducted that have focused upon Emergency Medical Services (EMS) personnel in Thailand. Objective: To introduce USGPIV cannulation to the health care providers of Emergency Medical Services and to examine the success rates of the first attempts at PIV cannulation. Materials and Methods: This prospective observational study was conducted with 49 EMS providers in August 2020. All respondents had been participants in a USGPIV workshop. Afterwards, the participants’ skills were evaluated in a Pre-hospital simulation model, which was conducted in a moving ambulance. The data, which was recorded, noted the number of attempts required to successfully obtain USGPIV access, as well as the participants’ opinions about using ultrasound in this procedure. Results: Among the 49 participants, the first attempt success rate was found to be at 57.14%. The participants’ genders, their years of work experience, their experience of performing PIV with real patients, and the categories of the Emergency Medical Services health care providers were determined not to be factors that had contributed to the success rate of the first attempts at USGPIV. Our study demonstrated a “High” level of satisfaction with regard to performing USGPIV with this ultrasound device (4 out of 5). However, the participants noted that some elements of the environment in the ambulance may have affected the success rate of performing this procedure. Conclusion: In this study, the success rate of the first attempts was found to be lower than in other studies. However, in regard to this simulation, implementing this procedure represents the first step towards assisting Thai EMS personnel to perform ultrasound procedures. Keywords: Ultrasound, Peripheral IV cannulation, Emergency medicine, Emergency medical services, Emergency medical personnel

The impact of a notched peripheral intravenous catheter on the first attempt success rate in hospitalized adults: Block-randomized trial.

Peripheral intravenous cannulation is the preferred method to obtain vascular access, but not always successful on the first attempt. Evidence on the impact of the intravenous catheter itself on the success rate is lacking. Faster visualization of blood flashback into the catheter, as a result of a notched needle, is thought to increase first attempt success rate. The current study aimed to assess if inserting a notched peripheral intravenous catheter will increase first attempt cannulation success up to 90%, when compared to inserting a catheter without a notched needle. In this block-randomized trial, adult patients in the intervention group got a notched peripheral intravenous catheter inserted, patients in the control group received a traditional non-notched catheter. The primary objective was the first attempt success rate of peripheral intravenous cannulation. Intravenous cannulation was performed according to practice guidelines and hospital policy. About 328 patients were included in the intervention group and 330 patients in the control group. First attempt success was 85% and 79% for the intervention and control group respectively. First attempt success was remarkably higher in the intervention group regarding patients with a high risk for failed cannulation (29%), when compared to the control group (10%). This study was unable to reach a first attempt success of 90%, although first attempt cannulation success was higher in patients who got a notched needle inserted when compared to those who got a non-notched needle inserted, unless a patients individual risk profile for a difficult intravenous access.

Improving management of fever in neutropenic children with cancer across multiple sites.

To evaluate the effectiveness of a clinical pathway in achieving antibiotic administration in less than 60minutes for children with cancer, presenting with fever and neutropenia. Secondary objectives were to determine association between time to antibiotics (TTA) and other variables including fever duration, location of care and intravenous access types. Following introduction of the clinical pathway, we collected prospective data about management of all cases that did and did not use the pathway across multiple sites over 16months. A follow-up audit was conducted after 12months. We evaluated a total of 453 presentations. Use of the clinical pathway was significantly associated with achieving TTA in less than 60minutes (RR 0.69, 95% CI 0.56-0.85, p=<0.001). Despite varying use of the pathway over time, the median time to antibiotics was achieved in both the initial study period (57minutes) and sustained at follow-up (60minutes). TTA was also associated with types of intravenous access device and location of care and with length of stay. We did not find any association between TTA and any other variables. Clinical pathways improve fever management in this patient cohort. Ongoing education and auditing to identify factors which impact processes of care are necessary.

The Urology Checklist towards a Structured Consultant-Led Ward Round

Objective: Formulating a comprehensive, practical, and urology-focused ward round checklist to enhance safety, efficiency and clear documentation for the Urology ward team when reviewing in-patients. Design: Identification of important parameters which should be addressed in every patient interaction. FIASCO – VH was coined for ease: • Fluid balance • Investigations • Intravenous access • Antibiotics • Analgesia • Stool • Catheter status • Observations • Venous thromboembolism (VTE) risk assessment • Home and follow up. Baseline measurement followed by implementation of the checklist and completion of three plan-do-study-act (PDSA) cycles. Setting: Single-centre district general hospital within the United Kingdom Participants: 279 ward round interactions with Urology inpatients Intervention: Implementation of the ward round checklist Main outcome measures: Adherence to parameters identified in the urology checklist Results: Stool (23.5%) and pain (30.6%) were worst assessed at baseline, with median 39.3% parameters assessed over all interactions. Significant improvement in assessed parameters after first (median 74.3%), second (median 84.0%), and third cycles (median 100%). These were associated with positive patient outcomes. There was discrepancy between factors verbally addressed and clinically documented (median 84.0% to 57.7% after second cycle). A dedicated third cycle reduced this gap (median 100% to 97%). 100% junior doctors surveyed believed the checklist has enabled addressing of factors which might have otherwise been missed. Conclusion: The use of a comprehensive, urology-focused, easy-to-memorise ward round checklist is feasible and led to sustained, well-documented improvements in all measured aspects of patients’ care, and perceived level of care by the team.

Quantifying Clinical Opportunities at the Navy Trauma Training Center.

Military-Civilian partnerships (MCPs), such as the Navy Trauma Training Center, are an essential tool for training military trauma care providers. Despite Congressional and military leadership support, sparse data exist to quantify participants' clinical opportunities in MCPs. These preliminary data from an ongoing Navy Trauma Training Center outcomes study quantify clinical experiences and compare skill observation to skill performance. Participants completed clinical logs after each patient encounter to quantify both patients and procedures they were involved with during clinical rotations; they self-reported demographic data. Data analyses included descriptive statistics and chi-square statistics to compare skills observed to skills performed between the first and second half of the 21-day course. A sample of 47 Navy personnel (30 corpsmen, 10 nurses, 3 physician assistants, 4 physicians) completed 551 clinical logs. Most logs (453/551) reflected experiences in the emergency department, where corpsmen and nurses each spent 102.0 hours, and physician assistants and physicians each spent 105.4 hours. Logs completed per participant ranged from 1 to 31, (mean = 8). No professional group was more likely than others to complete the clinical logs. Completion rates varied by cohort, both overall and by clinical role. Of emergency department logs, 39% reflected highest acuity patients, compared with 21% of intensive care unit logs, and 61% of operating room logs. Penetrating trauma was reported on 16.5% of logs. Primary and secondary trauma assessments were the most commonly reported clinical opportunities, followed by obtaining intravenous access and administration of analgesic medications. With few exceptions, logs reflected skill observation versus skill performance, a ratio that did not change over time. Prospective real-time data of actual clinical activity is a crucial measure of the success of MCPs. These preliminary data provide a beginning perspective on how these experiences contribute to maintaining a skilled military medical force.

Intraosseus route for thrombolysing acute stroke is safe and successful.

Use of intraosseous route in thrombolysis of acute stroke patients remains a rare entity. Here, we describe the first such case within UK of a 55-year-old female patient of acute stroke who was thrombolysed with Alteplase administered through intraosseous (IO) route. She initially presented to A&E with severe dysarthria dysphasia and left sided weakness with an NIHSS-8. Failing acquisition of an intravenous access an IO vascular access was secured and thrombolysis was administered She improved remarkably and had no complications. The challenge faced in this case, of acquiring an effective access within the time frame and safely administering the Alteplase without any local or systemic complications was well met with a favourable outcome. IO is an established method of obtaining vascular access in children and adults in acute emergency situations. It can be used for effective thrombolysis in acute stroke patients.

The Anesthetic Challenges of Caring for a Pediatric Patient With Incontinentia Pigmenti: A Case Report

Incontinentia pigmenti (IP) is a rare X-linked dominant disorder. We present a case of an infant with IP who was brought to the operating room for panretinal diode photocoagulation under general anesthesia. The anesthesia team was unable to obtain intravenous access even with instruments such as a vein finder and ultrasound. Anesthesia for IP patients also poses challenges such as prevention of the oculocardiac reflex, obesity and airway management, and preemptive measures for intravenous access due to skin manifestations. Patients with IP may present with many challenges for the anesthesiologist during all phases of anesthetic management.