Placement Of Intravenous Cannula Research Articles

Intraoperative placement of intravenous cannula for maintaining the patency of ear-piercing hole during earlobe surgeries

Intraoperative placement of intravenous cannula for maintaining the patency of ear-piercing hole during earlobe surgeries

Effects of Quality Control Circle Activities for Intravenous Cannula Placement Using Deming Cycle Management: A Case-Controlled Study

The present study aimed to explore the effectiveness of quality control circle (QCC) activities under the guidance of the Deming cycle Management for improving intravenous (IV) cannula placement. A total of 1,035 patients who underwent IV cannula placement from March 2019 to June 2019 in the Department of Hepatobiliary Surgery and Department of Renal and Thoracic Surgery of our hospital were enrolled as the control group, and 1,437 patients who underwent IV cannula placement in the same places as above but from July 2019 to December 2019 were enrolled as the test group. A between-group comparison was performed on intangible and tangible outcomes (duration of IV cannula placement, complications, patient awareness rate of maintenance knowledge of IV cannula, patient satisfaction rate with nursing staff, nurse skills in IV cannula infusion, and maintenance). After QCC activities were implemented, the scores of 11 QCC members in the five aspects of QCC technique application, communication and coordination, sense of responsibility and honor, motivation, and problem-solving ability all improved compared with those before the activities (p < 0.05), and the duration of IV cannula placement in the test group was 70.22 ±48.33 h, which was longer (p < 0.05) than the 60.59±41.9 h of the control group. The test group had a significantly lower (p < 0.05) rate of complications (12.9%, 12.6%, and 1.3% for extravasation, phlebitis, and cannula obstruction, respectively) than the control group (30.0%, 11.4%, and 4.1% for blood oozing, phlebitis, and cannula obstruction respectively); the patient awareness rate of maintenance knowledge of IV cannula and patient satisfaction rate with nursing staff in the test group were 90% and 96.3%, respectively, which were significantly higher (p < 0.05) than the 82.4% and 81.5% in the control group. The scores of nurse skills in IV cannula infusion and maintenance in the test group were 90.5 ±1.3 and 93.6 ±2.0, respectively, which were significantly higher (p < 0.05) than the 85.5 ±2.7 and 81 ±1.0 in the control group. The implementation of QCC activities under the guidance of the Deming cycle Management in IV cannula placement improves the ability of the department’s nursing team to identify, analyze, and solve problems, which is favorable for continuous improvement of nursing quality, leading to an elongated duration of IV cannula placement, reduced rate of complications, and improved patient satisfaction rate with nursing services.

Intravenous cannula placement in children for induction of general anesthesia: Prospective audit and identification of success factors.

Approaches to pediatric induction of anesthesia vary widely. While oral sedative premedication and inhalational induction are common, total intravenous anesthesia is becoming increasingly popular. Total intravenous anesthesia without anxiolytic premedication, which is the most commonly used technique in our hospital, requires intravenous (IV) cannula placement in an awake child. To quantify the success rate of IV cannula placement in 1 or 2 attempts and to identify success factors and barriers. With ethical approval and written informed consent from participating anesthesiologists, a prospective audit of IV cannulation was undertaken over a 1-month period. The attending anesthesiologist captured basic demographics, IV insertion characteristics, setting, distraction techniques, the behavior of the child, number of attempts, and success/failure. A logistic regression model for successful IV cannulation was created. Anesthesiologists and procedural suite nurses participated in semi-structured interviews to identify success factors, barriers, and teaching approaches. Data from 984 cases were analyzed. IV induction was planned in 562 cases, and IV cannulation was successful in 90% of these patients. Anxiolytic premedication was given in 6% of cases. Observations indicated that 64% of children were pain- and reaction-free, and 90% experienced minimal or no reaction. Predictors for success included older child's age and child behavior at first encounter. Qualitative interview data from 13 participants suggested success factors included effective distraction, preparing the family for IV induction, parental presence, support of the operating room team, effective use of local analgesic cream, adapting the approach to the individual child, and the anesthesiologist's efficiency. Barriers included needle phobia, uncooperative child, anxious parents, ineffective use of analgesic cream, and unfavorable anatomy. Distraction techniques varied by age and developmental stage of the child. Cannulation for planned IV induction is feasible for most children, enabling increased use of total intravenous anesthesia as an institutional anesthetic strategy.

Abstract PR036

Case Report: A 27 year old woman with Down’s syndrome and a cardiac history significant for a large ventricular septum defect, patent ductus arteriosus and Eisenmenger syndrome was scheduled for pleurodesis via left Video Assisted Thorascopic Surgery (VATS). She had persistent left pneumothorax with bullae that has failed conservative treatment. In view of difficult venous access and lack of patient cooperation for intravenous cannula placement, an inhalational induction was performed with Sevoflurane 4% and oxygen/air mixture with FiO2 of 0.6. Intravenous access was obtained after induction. Fentanyl 25mcg, Ketamine 40mg and Atracurium 40mg were given in preparation for double lumen tube insertion. Arterial line and central venous catheter were placed post intubation. Anaesthesia was maintained with Sevoflurane with end tidal concentrations ranging between 1.3 to 1.8. Systemic vascular resistance was maintained with Noradrenaline, with doses ranging from 0.05 to 0.14mcg/kg/min. To control pulmonary artery pressure, ventilation was performed with oxygen 60% and inhaled nitric oxide 20 ppm. An intercostal nerve block was performed by the surgeons at the end of the operation. Patient was successfully extubated at the end of the operation and weaned from Noradrenaline and inhaled nitric oxide. Her post operative recovery remained uneventful and was discharged home on post op day 7. Conclusion: A careful balance between the systemic vascular resistance and pulmonary vascular resistance is essential for the management of patients with Eisenmenger syndrome. In view of this patient having Down’s syndrome, previously described interventions for a patient with Eisenmenger syndrome needing one lung ventilation such as intravenous induction and placement of epidural catheter1 was challenging. Thus, we have described successful management of a patient with both Down syndrome and Eisenmenger syndrome with inhalational induction and maintenance; and intercostal nerve block for analgesia.

Quantification of hand hygiene compliance in anesthesia providers at a tertiary care center in northern India

Hand hygiene (HH) compliance continues to remain poor amongst anesthetists mainly because of multitasking and the need for repeated HH. We aimed to quantify HH compliance amongst anesthesia providers while performing anesthesia-related procedures inside operating rooms. The observations for HH before and after procedures, including placement of intravenous cannula, intubation, central line placement, arterial line placement, and neuraxial and peripheral nerve block, were made by a single observer in operating rooms where elective surgeries are carried out. The overall compliance of all health care workers was 39.6%. Resident physicians were less likely to be compliant than consultant physicians and there was significant variation in procedure-related HH with maximum compliance before neuraxial block (100%) followed by arterial line placement (93.7%), central line insertion (86.7%), and peripheral nerve block (80%) (P<.001). The compliance after performing the above procedures was <50% for all procedures.

Applications of Nitrous Oxide for Procedural Sedation in the Pediatric Population

The objective of this review was to provide a general descriptive account of the physical properties, end-organ effects, therapeutic applications, and delivery techniques of nitrous oxide (N2O) as used in the arena of procedural sedation. A computerized bibliographic search regarding the applications of nitrous for provision of sedation and analgesia during procedures with an emphasis on the pediatric population was performed. The end-organ effects of N2O have been well described in the operating room setting. Aside from its effects on the central nervous system of sedation and analgesia, N2O may alter intracerebral dynamics and alter cerebral blood flow and intracranial pressure especially in patients with altered intracranial compliance. Effects on ventilation include a dose-related depression of ventilatory function and control of upper airway patency. These effects are generally limited in the absence of comorbid diseases and potentiated by other sedative and analgesic agents. The more clinically significant respiratory effect of N2O on ventilatory function is a dose-dependent depression of the ventilatory response to hypoxemia. Hemodynamic effects include a mild direct depressant effect on myocardial function, which in the absence of comorbid cardiac disease is generally compensated by stimulation of the sympathetic nervous system. Nitrous oxide may potentially aggravate pulmonary hypertension. Additional physiologic effects on neurologic and hematologic function may result in inactivation of the enzyme, methionine synthetase. Recent concern has also been raised regarding the potential effects of N2O on immune function and its relationship to perioperative surgical site infections. Given differences in the solubility, N2O will diffuse into and significantly expand gas-filled cavities. Chronic exposure of health care works to N2O is also a concern. Although there are limited data in the literature to clearly substantiate concerns regarding the reproductive toxicity of occupational exposure to N2O, appropriate scavenging and use of other techniques are mandatory. Nitrous oxide has been shown to be effective for a variety of minor surgical procedures such as venipuncture, intravenous cannula placement, lumbar puncture, bone marrow aspiration, laceration repair, dental care, and minor dermatologic procedures. It is generally as effective as midazolam, with several studies demonstrating it to be more effective. However, its utility is not as great in severely painful procedures such as fracture reduction. Demonstrated advantages to parenteral sedation include a more rapid onset and a shorter recovery time with the majority of patients preferring it to over other agents or agreeing to its use for subsequent procedures. The literature also suggests increased success rates with simple procedures such as intravenous cannula placement when compared with placebo. In general, life-threatening adverse events have not been reported. Most common adverse effects include dysphoria and vomiting. For more painful procedures, combination with another agent may be used, and in all cases, topical or infiltrative local anesthesia is recommended. In general, N2O is a useful adjunct for procedural sedation. Given the variety of procedures performed in the pediatric patient, ongoing research is required to identify the most appropriate and effective use of this agent. This may be particularly relevant when evaluating its use for procedures associated with significant pain. In these scenarios, the combination of N2O with other agents needs to be evaluated. Given the potential for adverse effects, strict adherence to published guidelines regarding procedural sedation and monitoring is suggested.

Intravenous cannula placement: getting it right

is a common procedure carried out within hospitals, with many patients being admitted requiring intravenous (IV) drug therapy, allowing rapid and accurate administration of medication (Endacott et al, 2009). However, the placement of an intravenous cannula can lead to a number of undesirable effects, with some of the most common being phlebitis and skin inflammation. It is important that any venous cannula is correctly secured to help prevent infection, phlebitis and cannula displacement. All nurses working in areas where IV therapy is administered have a duty to observe and react to evidence of phlebitis and inflammation. Many patients who are admitted into hospital require some form of IV therapy (via PVC), and for many different reasons. These include: intravenous antibiotic administration, intravenous pain relief and/or total parenteral nutrition (TPN). There are a number of intravenous delivery devices that can be used and these include: ■ Peripheral cannula ■ Peripheral midline catheter ■ Peripherally inserted central catheter ■ Skin tunnelled cuffed central catheter (Hickman line). The type of IV delivery device to be used is related to the type of fluid administered and the length of time intravenous therapy will last. Peripheral venous cannulas are indicated for short-term use only (Dougherty and Lister, 2008). If intravenous therapy is indicated for longer periods, then central venous access will be required. Likewise, central access is required if cytotoxic and/or hypertonic solutions are to be intravenously administered (Hankins et al, 2001; Royal College of Nursing (RCN), 2010). It is estimated that in the UK 20-80% of patients with a PVC develop phlebitis (Pandero et al, 2002). This broad range is in keeping with studies from other countries (Uslusoy and Mete, 2008), suggesting poor identification of phlebitis or poor reporting protocols. It is therefore essential for the nurse to be able to identify patients who are at risk of developing phlebitis. Furthermore, early recognition of its development will enable prompt intervention, with the aim of minimising disruption to treatment and optimising patient care. Peripheral catheter-related phlebitis is the inflammation of the tunica intima of a superficial vein that can lead to infection or thrombus formation if left untreated (RCN, 2010). This inflammation is the result of irritation of the tunica intima by the chemical solution infused, bacterial sources and/or mechanical forces. Chemical phlebitis is attributed to the type of drug or fluid being infused through the cannula. Researchers have concluded that factors such as pH and osmolarity of the substances have a significant effect on the incidence of phlebitis (Monreal et al, Intravenous cannula placement: getting it right

No change in impedance upon intravascular injection of D5W

Electrical impedance increases following test injections of non-conducting solutions around nerves; however, this increase should diminish rapidly with intravascular needle placement, wherein the systemic circulation will dissipate the solution. For this observational study, we hypothesized that the impedance increases significantly at the perineural space after an injection of 5% dextrose in water (D5W), but that it does not increase correspondingly at the intravascular location After Ethics Research Board approval, electrical impedance was measured by a nerve stimulator displaying resistance, Stimuplex HNS 12, before and during (30 sec) an injection of D5W 3 mL: 1) during intravenous cannula placement using an insulated stimulating needle sheathed in its plastic cannula, MultiSet NanoLine with 18G needle; and 2) during needle placement (Pajunk 22G insulated) for an ultrasound-guided supraclavicular block in patients undergoing hand surgery. The impedance changes at each location were analyzed and compared. Data were collected from 16 patients. Baseline impedance was lower intravascularly (mean 16.5 +/- standard deviation 7.2 kOmega) compared with perineurally (23.5 +/- 8.3 kOmega) (P = 0.037). Peak impedance after intravascular D5W injection was 20.1 +/- 6.8 kOmega, which was not a significant change (P = 0.15). In contrast, peak impedance after perineural D5W injection was 58.6 +/- 29.1 kOmega, an increase of 35.1 +/- 26.4 kOmega (155 +/- 117%), and then it reached a plateau of 36.7 +/- 19.6 kOmega. The increase in impedance was significantly greater at the perineural location (P < 0.0001). The absence of a significant increase in impedance upon injection of D5W prior to injection of local anesthetic may provide useful information to warn of intravascular injection.

Evaluation of Efficacy of Intranasal Midazolam, Ketamine and Their Mixture as Premedication and its Relation with Bispectral Index in Children with Tetralogy of Fallot Undergoing Intracardiac Repair

We compared the efficacy of intranasal midazolam, ketamine and their mixture as premedication in children with tetralogy of Fallot (TOF) using bispectral index (BIS), sedation score and separation score at the time of separation from parent. Sedation score at the time of intravenous cannulation was also measured. Children with TOF physiology were randomly divided into three equal groups of 20 each. Group-A received intranasal ketamine (10 mg/Kg), Group-B received intranasal midazolam (0.2 mg/Kg), while Group-C received a mixture of ketamine (7.5 mg/Kg) and midazolam (0.1 mg/Kg) intranasally. After 30 minutes of premedication, sedation and separation score were noted. BIS values were recorded at 5 minutes intervals. A 4-point scale for sedation, separation and acceptance of intravenous cannulation was used. Sedation was good in midazolam group (group B-3.25 +/- 0.44), but the separation and acceptance of intravenous catheter was poor (2.9 +/- 0.31 and 2.85 +/- 0.37 respectively). Sedation scores in group A and C were excellent (3.75 +/- 0.44 and 3.80 +/- 0.41 respectively). Separation from parent was excellent in group A (ketamine) and group C (mixture) (group A- 3.90 +/- 0.28 and group C- 3.83 +/- 0.35 respectively). Children of both these groups allowed easy placement of intravenous cannula. At BIS values < 90, the sedation achieved was good. BIS values decreased with increase in sedation scores in groups who received intranasal midazolam and mixture containing ketamine and midazolam (group B and C respectively), while it remained high in children who received ketamine. We conclude that intranasal ketamine is better than intranasal midazolam. The combination of two is better than midazolam alone but provides no benefit as compared with ketamine alone.

Usefulness of intravenous Granisetron for prevention of neurally mediated hypotension upon head upright tilt testing

N mediated hypotension is a common clinical problem that can be diagnosed by head-up tilt (HUT) table testing.1–3 In patients with neurally mediated syncope, sympathetic stimulation is believed to cause ventricular hypercontractility, which activates mechanoreceptor C-fibers located within the ventricles.4 Mechanoreceptor activation elicits the release of serotonin (5-HT), which impinges on 5-HT3 receptors on the afferent vagus nerve at the position of the right ventricle and propagates the stimulus to the dorsal vagal nucleus of the brain stem.4,5 This results in vagal overdrive and sympathetic withdrawal, which causes hypotension, bradycardia, and syncope.4 In animal models of neurally mediated syncope, 5-HT3 stimulation has been shown to cause bradycardia and hypotension.6–8 Paroxetine (SmithKline Beecham, Philadelphia, Pennsylvania), a selective serotonin reuptake inhibitor, has been evaluated in humans with 61.8% of patients being successfully treated (38.2% placebo group) after 1 month of therapy.9 However, paroxetine is believed to work indirectly by specifically increasing serotonin levels for 5-HT2 receptor stimulation rather than antagonism at the 5-HT3 receptor. We recently reported that granisetron, a 5-HT3 receptor antagonist, can inhibit the Bezold-Jarisch reflex (bradycardia and hypotension preceded by sympathetic stimulation) in a hemorrhagic rabbit model.10 Whether granisetron can prevent neurally mediated hypotension in humans undergoing HUT is unknown. The present study evaluates whether the specific 5-HT3 receptor antagonist granisetron can prevent neurally mediated hypotension in patients induced by HUT. • • • Patients with $2 episodes of syncope or presyncope of unexplained etiology who underwent diagnostic HUT and had a positive test for neurally mediated hypotension were evaluated for study inclusion. Patients were excluded from the study if they: (1) were on b blocker or selective serotonin reuptake inhibitors, (2) had prestudy systolic blood pressures (BP) ,90 mm Hg, (3) contraindications to isoproterenol or granisetron therapy, and (4) had an implanted permanent pacemaker. The study protocol was approved by the Institutional Review Board at Hartford Hospital, and informed consent was obtained from all patients. After an overnight fast and after cardioactive or vasoactive drugs known to cause hypotension or syncope were discontinued for 5 half-lives, HUT was performed between 8 and 10 A.M. to minimize confounding diurnal variation. After small gauge intravenous cannula placement, the patient was allowed to rest quietly in the supine position for 20 minutes. A physiologic recorder continuously monitored heart rate. BP was determined every minute by automatic cuff and confirmed with manual determinations when the patient became symptomatic. The tilt protocol consisted of a 70 upright tilt for 30 minutes. If the patient did not develop syncope or presyncope, the table was lowered to the supine position and an isoproterenol infusion was initiated and titrated upwards between 1 and 2 mg/min until a heart rate of 100 beats/min or an increase in heart rate of .25% from baseline occurred. Upon achieving the target heart rate, the isoproterenol infusion rate was maintained while the patient was retilted at 70 for 15 minutes. A positive response to upright tilt (with or without concomitant isoproterenol infusion) was defined as a sudden loss of consciousness or the development of impending faint in association with a decrease in systolic BP to ,70 mm Hg. Patients who developed a syncopal or presyncopal response during initial or isoproterenol HUT were given intravenous granisetron over 5 minutes. The first 9 consecutive patients received 40 mg/kg and the final 8 consecutive patients received 160 mg/kg of granisetron. The repeat HUT commenced 5 minutes after the granisetron infusion concluded. If isoproterenol HUT was used to induce syncope and/or presyncope, the full tilt protocol (initial first, then isoproterenol) was repeated to assess the impact of granisetron on the time to onset of syncope or presyncope, ability to prevent the recurrence of syncope or presyncope, and effect on hemodynamic (heart rate and BP) and electrocardiographic parameters. In the 160 mg/kg group, the QT and RR intervals were measured 4 minutes after the granisetron infusion concluded. Data are expressed as means 6 SD. A Student’s t test was used to compare continuous variables. A p value of ,0.05 was considered significant. Patient (n 5 17) demographics and clinical characteristics are summarized in Table I. In the total cohort, 47% of patients responded to granisetron therapy, whereas 44% and 50% of patients in the 40 mg/kg dose group and 160 mg/kg dose group had suppression of HUT induced syncope, respectively. The response From the Department of Pharmacy and Division of Cardiology, Hartford Hospital, Hartford; University of Connecticut School of Pharmacy, Storrs; University of Connecticut School of Medicine, Farmington, Connecticut; and Chinese University of Hong Kong, Shatin, Hong Kong. Dr. White’s address is: Drug Information Center, 80 Seymour Street, Hartford Hospital, Hartford, Connecticut 06102–5037. Email: cmwhite@harthosp.org. Manuscript received September 14, 1999; revised manuscript received and accepted December 8, 1999.

Sclerosing Thyroid Cysts Using a Polytef Intravenous Cannula

<h3>To the Editor.</h3> —In a previous issue of theArchives, Treece et al¹reported the clinical application of tetracycline hydrochloride for sclerosing of recurrent thyroid cysts with uniformly successful results. However, in the January issue of theArchives, Ryan and Dwarakanathan,²in their letter, and Treece,³in his reply, described the untoward effects of this therapy, which were extreme pain occurring almost immediately in the area of injection and recurrent nerve palsy. Both Ryan and Dwarakanathan²and Treece³stated that these adverse effects were attributed to the extravasation of tetracycline into the surrounding tissue. We would like to describe an alternate procedure for sclerosing thyroid cysts using a polytef (Teflon) intravenous cannula placement unit to prevent the extravasation of the drug. <h3>Report of a Case.</h3> —A 75-year-old woman was found to have a 2.5×3.5cm nodule in the right lobe of the