Intravenous Catheter Insertion Research Articles

Deployment of a Time of Catheters: Experience Report

To date, there is no published, psychometrically validated, short peripheral intravenous catheter (PIVC) insertion skills checklist. Creating a valid, reliable, and generalizable checklist to measure PIVC skill is a key step in assessing baseline competence and skill mastery. Based on recognized standards and best practices, the PIVC Insertion Skills Checklist was developed to measure all the steps necessary for a best practice PIVC insertion. This includes the entire process from reading the prescriber's orders to documentation and, if the first attempt is unsuccessful, a second attempt option. Content validity was established using 3 infusion therapy experts. Evidence in support of response process validity is described. The PIVC Insertion Skills Checklist was used by 8 trained raters to assess the PIVC insertion skills, in a simulated environment, of 63 practicing clinicians working on medical and surgical units in a US teaching hospital. Internal consistency of the PIVC Insertion Skills Checklist was α = 0.84. Individual item intraclass correlation coefficients (ICCs) between rater and gold standard observations ranged from −0.01 to 1.00 and total score ICC was 0.99 (95% confidence interval, 0.99-0.99). The current study offers validity and reliability evidence to support the use of the PIVC Insertion Skills Checklist to measure PIVC insertion skill of clinicians in a simulated environment.

Peripheral Vascular Catheter Research: A Scoping Review

To date, there is no published, psychometrically validated, short peripheral intravenous catheter (PIVC) insertion skills checklist. Creating a valid, reliable, and generalizable checklist to measure PIVC skill is a key step in assessing baseline competence and skill mastery. Based on recognized standards and best practices, the PIVC Insertion Skills Checklist was developed to measure all the steps necessary for a best practice PIVC insertion. This includes the entire process from reading the prescriber's orders to documentation and, if the first attempt is unsuccessful, a second attempt option. Content validity was established using 3 infusion therapy experts. Evidence in support of response process validity is described. The PIVC Insertion Skills Checklist was used by 8 trained raters to assess the PIVC insertion skills, in a simulated environment, of 63 practicing clinicians working on medical and surgical units in a US teaching hospital. Internal consistency of the PIVC Insertion Skills Checklist was α = 0.84. Individual item intraclass correlation coefficients (ICCs) between rater and gold standard observations ranged from −0.01 to 1.00 and total score ICC was 0.99 (95% confidence interval, 0.99-0.99). The current study offers validity and reliability evidence to support the use of the PIVC Insertion Skills Checklist to measure PIVC insertion skill of clinicians in a simulated environment.

Using High Flow Flushing Technique (HFFT) as Initial Intervention for Malpositioned Peripherally Inserted Central Catheters (PICC's) in the Adult Population

To date, there is no published, psychometrically validated, short peripheral intravenous catheter (PIVC) insertion skills checklist. Creating a valid, reliable, and generalizable checklist to measure PIVC skill is a key step in assessing baseline competence and skill mastery. Based on recognized standards and best practices, the PIVC Insertion Skills Checklist was developed to measure all the steps necessary for a best practice PIVC insertion. This includes the entire process from reading the prescriber's orders to documentation and, if the first attempt is unsuccessful, a second attempt option. Content validity was established using 3 infusion therapy experts. Evidence in support of response process validity is described. The PIVC Insertion Skills Checklist was used by 8 trained raters to assess the PIVC insertion skills, in a simulated environment, of 63 practicing clinicians working on medical and surgical units in a US teaching hospital. Internal consistency of the PIVC Insertion Skills Checklist was α = 0.84. Individual item intraclass correlation coefficients (ICCs) between rater and gold standard observations ranged from −0.01 to 1.00 and total score ICC was 0.99 (95% confidence interval, 0.99-0.99). The current study offers validity and reliability evidence to support the use of the PIVC Insertion Skills Checklist to measure PIVC insertion skill of clinicians in a simulated environment.

Vascular Access Strategies in Intensive Care Units: Antimicrobial + Power Injectable Devices

To date, there is no published, psychometrically validated, short peripheral intravenous catheter (PIVC) insertion skills checklist. Creating a valid, reliable, and generalizable checklist to measure PIVC skill is a key step in assessing baseline competence and skill mastery. Based on recognized standards and best practices, the PIVC Insertion Skills Checklist was developed to measure all the steps necessary for a best practice PIVC insertion. This includes the entire process from reading the prescriber's orders to documentation and, if the first attempt is unsuccessful, a second attempt option. Content validity was established using 3 infusion therapy experts. Evidence in support of response process validity is described. The PIVC Insertion Skills Checklist was used by 8 trained raters to assess the PIVC insertion skills, in a simulated environment, of 63 practicing clinicians working on medical and surgical units in a US teaching hospital. Internal consistency of the PIVC Insertion Skills Checklist was α = 0.84. Individual item intraclass correlation coefficients (ICCs) between rater and gold standard observations ranged from −0.01 to 1.00 and total score ICC was 0.99 (95% confidence interval, 0.99-0.99). The current study offers validity and reliability evidence to support the use of the PIVC Insertion Skills Checklist to measure PIVC insertion skill of clinicians in a simulated environment.

Protecting the Vessels- Options for the Cystic Fibrosis Patient

To date, there is no published, psychometrically validated, short peripheral intravenous catheter (PIVC) insertion skills checklist. Creating a valid, reliable, and generalizable checklist to measure PIVC skill is a key step in assessing baseline competence and skill mastery. Based on recognized standards and best practices, the PIVC Insertion Skills Checklist was developed to measure all the steps necessary for a best practice PIVC insertion. This includes the entire process from reading the prescriber's orders to documentation and, if the first attempt is unsuccessful, a second attempt option. Content validity was established using 3 infusion therapy experts. Evidence in support of response process validity is described. The PIVC Insertion Skills Checklist was used by 8 trained raters to assess the PIVC insertion skills, in a simulated environment, of 63 practicing clinicians working on medical and surgical units in a US teaching hospital. Internal consistency of the PIVC Insertion Skills Checklist was α = 0.84. Individual item intraclass correlation coefficients (ICCs) between rater and gold standard observations ranged from −0.01 to 1.00 and total score ICC was 0.99 (95% confidence interval, 0.99-0.99). The current study offers validity and reliability evidence to support the use of the PIVC Insertion Skills Checklist to measure PIVC insertion skill of clinicians in a simulated environment.

Training and Implementation of PICC Team of the Hospital sãrio Libanãas - 2011

To date, there is no published, psychometrically validated, short peripheral intravenous catheter (PIVC) insertion skills checklist. Creating a valid, reliable, and generalizable checklist to measure PIVC skill is a key step in assessing baseline competence and skill mastery. Based on recognized standards and best practices, the PIVC Insertion Skills Checklist was developed to measure all the steps necessary for a best practice PIVC insertion. This includes the entire process from reading the prescriber's orders to documentation and, if the first attempt is unsuccessful, a second attempt option. Content validity was established using 3 infusion therapy experts. Evidence in support of response process validity is described. The PIVC Insertion Skills Checklist was used by 8 trained raters to assess the PIVC insertion skills, in a simulated environment, of 63 practicing clinicians working on medical and surgical units in a US teaching hospital. Internal consistency of the PIVC Insertion Skills Checklist was α = 0.84. Individual item intraclass correlation coefficients (ICCs) between rater and gold standard observations ranged from −0.01 to 1.00 and total score ICC was 0.99 (95% confidence interval, 0.99-0.99). The current study offers validity and reliability evidence to support the use of the PIVC Insertion Skills Checklist to measure PIVC insertion skill of clinicians in a simulated environment.

Achieving Hemostasis Post Insertion of a Peripherally Inserted Central Catheter

To date, there is no published, psychometrically validated, short peripheral intravenous catheter (PIVC) insertion skills checklist. Creating a valid, reliable, and generalizable checklist to measure PIVC skill is a key step in assessing baseline competence and skill mastery. Based on recognized standards and best practices, the PIVC Insertion Skills Checklist was developed to measure all the steps necessary for a best practice PIVC insertion. This includes the entire process from reading the prescriber's orders to documentation and, if the first attempt is unsuccessful, a second attempt option. Content validity was established using 3 infusion therapy experts. Evidence in support of response process validity is described. The PIVC Insertion Skills Checklist was used by 8 trained raters to assess the PIVC insertion skills, in a simulated environment, of 63 practicing clinicians working on medical and surgical units in a US teaching hospital. Internal consistency of the PIVC Insertion Skills Checklist was α = 0.84. Individual item intraclass correlation coefficients (ICCs) between rater and gold standard observations ranged from −0.01 to 1.00 and total score ICC was 0.99 (95% confidence interval, 0.99-0.99). The current study offers validity and reliability evidence to support the use of the PIVC Insertion Skills Checklist to measure PIVC insertion skill of clinicians in a simulated environment.

Implementation of “CODE SEPSIS” for septic patients at Al Wakra Hospital: A practice improvement initiative

Introduction: Sepsis is a major cause of hospitalization with a high mortality rate. Early recognition and management of sepsis have shown to improve mortality outcomes. A proactive alert system for improving the response of the interdisciplinary team may decrease the time to intervention and improve patient outcomes. Objective: The study evaluated the impact of an early alert system, “CODE SEPSIS”, on adherence to the sepsis management bundle and time to intervention among patients at risk for sepsis. Method: Patients presenting to the Emergency Department (ED) and meeting two or more criteria on the sepsis screening tool were intended to trigger an overhead alert known as CODE SEPSIS, which was activated based on the physician's decision. Data were retrospectively collected over a 3-month period for all hospitalized adult patients with confirmed sepsis (age above 18 years). We evaluated the time from ED presentation to diagnostic and treatment interventions. A data collection tool was designed to record information. Results: A total of 36 sepsis patients were identified, among which 18 were classified as CODE SEPSIS and 18 were classified as non-CODE SEPSIS. We found that the CODE SEPSIS group showed greater improvement than the non-CODE SEPSIS group from ED presentation to intravenous catheter insertion (37.3 to 31.5 minutes, 15.6%), fluid administration (41 to 39 minutes, 4.9%), microbiological workup (91 to 33 minutes, 63.7%), lactate level (69 to 66 minutes, 4.3%), prescribing antimicrobial therapy (92 to 44 minutes, 52%), and administration of antimicrobial therapy (88 to 46 minutes, 47.7%). Patients in the non-CODE SEPSIS group showed a 1-day decrease in length of hospital stay. Conclusion: The CODE SEPSIS alert system developed at Al Wakra Hospital promoted early and standardized management among patients at risk for sepsis, which may lead to improved patient outcomes.

Extravasation Risk Using Ultrasound‐guided Peripheral Intravenous Catheters for Computed Tomography Contrast Administration

Ultrasound-guided intravenous catheter (USGIV) insertion is increasingly being used for administration of intravenous (IV) contrast for computed tomography (CT) scans. The goal of this investigation was to evaluate the risk of contrast extravasation among patients receiving contrast through USGIV catheters. A retrospective observational study of adult patients who underwent a contrast-enhanced CT scan at a tertiary care emergency department during a recent 64-month period was conducted. The unadjusted prevalence of contrast extravasation was compared between patients with an USGIV and those with a standard peripheral IV inserted without ultrasound. Then, a two-stage sampling design was used to select a subset of the population for a multivariable logistic regression model evaluating USGIVs as a risk factor for extravasation while adjusting for potential confounders. In total, 40,143 patients underwent a contrasted CT scan, including 364 (0.9%) who had contrast administered through an USGIV. Unadjusted prevalence of extravasation was 3.6% for contrast administration through USGIVs and 0.3% for standard IVs (relative risk = 13.9, 95% confidence interval [CI] = 7.9 to 24.6). After potential confounders were adjusted for, CT contrast administered through USGIVs was associated with extravasation (adjusted odds ratio = 8.6, 95% CI = 4.6 to 16.2). No patients required surgical management for contrast extravasation; one patient in the standard IV group was admitted for observation due to extravasation. Patients who received contrast for a CT scan through an USGIV had a higher risk of extravasation than those who received contrast through a standard peripheral IV. Clinicians should consider this extravasation risk when weighing the risks and benefits of a contrast-enhanced CT scan in a patient with USGIV vascular access.

Cinco pasos para la disminución de las infecciones relacionadas con la asistencia sanitaria en prematuros grandes inmaduros. Estudio cuasiexperimental

ObjectivesAn evaluation is made of the impact of a series of five interventions on the incidence of hospital-related infections in a level iii neonatal unit. Material and methodsQuasi-experimental, pre-post intervention study, which included preterm infants weighing 1,500g at birth or delivered at <32 weeks gestation, admitted in the 12 months before and after the measures were implemented (January 2014). The measures consisted of: optimising hand washing, following a protocol for insertion and handling of central intravenous catheters, encouraging breastfeeding; applying a protocol for rational antibiotic use, and establishing a surveillance system for multi-resistant bacteria. The primary endpoint was to assess the incidence of hospital-acquired infections before and after implementing the interventions. ResultsThirty-three matched patients were included in each period. There was an incidence of 8.7 and 2.7 hospital-related infections/1,000 hospital stay days in the pre- and post-intervention periods, respectively (P<.05). Additionally, patients in the treatment group showed a statistically-significant decrease in days on mechanical ventilation, use of blood products, and vasoactive drugs. ConclusionsThe strategy, based on implementing five specific measures in a unit with a high rate of hospital-related infections, proved effective in reducing their incidence. This reduction could contribute to lowering the use of mechanical ventilation, blood products, and vasoactive drugs.

Improving pain management in neonates exposed to intravenous insertions: A quality improvement initiative

BackgroundFrom the time a neonate is admitted into the neonatal intensive care unit (NICU), they are exposed to several painful procedures especially, intravenous (IV) catheter insertions. An increase use of sucrose is essential to improve pain management in neonates exposed to IV insertions. The proper administration and storage location of sucrose plays an integral role in neonatal pain management. PurposeThe purpose of implementing the quality improvement (QI) project is to improve the quality of care within the neonatal population by improving neonatal nurses' beliefs, knowledge, and practices regarding neonatal pain. MethodsA quality improvement process to re-locate sucrose from the Pyxis (medication dispenser) to central supply unit to increase sucrose usage was completed along with distributing a 40-item pre and post questionnaire regarding neonatal pain to a convenience sample of nurses in a level II/III NICU in the Southeast Florida region. Pre and post intervention observation audits were also utilized to differentiate practice change throughout the QI initiative in the level II NICU. ResultsTwenty nurses agreed to participate in the QI initiative and completed both pre and post intervention questionnaires. Results reflect an increase in nurses' knowledge and beliefs and improved pain management practices. As a group, there was a significant difference between the utilization of sucrose two minutes prior to insertion of intravenous catheter (p < 0.05). The utilization of sucrose two minutes prior to insertion increased from 15% in the pre observations to 90% in the post observations. ConclusionThere is significant evidence that increased knowledge in neonatal pain management, the proper administration of sucrose including increased sucrose utilization will result in better pain management among neonates exposed to intravenous insertions.

General anesthesia of a Japanese infant with Barber-Say syndrome: a case report.

BackgroundBarber-Say syndrome (BSS) is a very rare congenital disorder characterized by macrostomia, cutis laxa, and other features. We report our experience of performing general anesthesia on a Japanese child with BSS.Case presentationA bilateral repair of the corners of the mouth under general anesthesia was planned for an 18-month-old male with macrostomia; the child was 75 cm in height and weighed 9.9 kg. As insertion of the peripheral intravenous catheter was difficult, it was inserted before the surgery by a pediatrician. The patient wore a mask and was ventilated manually after loss of consciousness with intravenous anesthesia. A mask for adults provided a superior fit and was effective in preventing air leakage from the corners of the mouth. After rocuronium was administered, the larynx was spread with a Macintosh laryngoscope. There was no laryngeal anatomical abnormality, and tracheal intubation was readily possible. The operation was completed without incident. Stiffening of both arms occurred for several seconds one hour after the operation ended, but the patient did not develop other complications.ConclusionsMask ventilation and the insertion of an intravenous catheter may be difficult in the general anesthesia of patients with BSS, and anesthetic management requires caution.

Video-based Assessment of Peripheral Intravenous Catheter Insertion in the Resuscitation Area of a Pediatric Emergency Department.

The objective was to describe the frequency of and factors associated with prolonged peripheral intravenous catheter (PIV) insertion in the resuscitation area of a pediatric emergency department (PED). Video-based study of a consecutive sample of nontrauma patients undergoing PIV insertion in the resuscitation area of a PED. Preexisting videos were the main data source. The primary outcome was patients with prolonged duration of PIV insertion (>90 seconds from start of first attempt to successful flush/blood draw). Logistic regression identified variables independently associated with prolonged PIV insertion. A total of 151 consecutive nontrauma patients underwent PIV insertion during a 2.5-month period. Sixty-nine patients (46%) had prolonged PIV insertion, including 14 for whom PED providers failed to insert PIVs. For patients with successful PIV insertion by PED providers, median duration was 48 seconds (interquartile range [IQR] = 23 to 295 seconds). Vascular access was ultimately achieved for 13 patients (93%) with initial insertion failure by the PED team (10 non-PED personnel, three intraosseous lines), with a median duration of 26.7 minutes (IQR = 19.9 to 34.2 minutes). Age ≤ 2 years (ORadj = 6.9; 95% confidence interval [CI] = 2.9 to 16.1) and musculoskeletal contractures (ORadj = 5.3; 95% CI = 1.6 to 17.2) were independently associated with prolonged PIV insertion. Prolonged PIV insertion is common in a PED resuscitation area. When PED providers could not insert a PIV, time to insertion was very long. Young patients and those with contractures were at particular risk for prolonged and failed PIV placement. When emergent vascular access is required, alternative approaches should be considered early for these patients.

Nursing Assistants, Medication Errors, and Patient Safety: A New Challenge in Iran.

Today, all over the world, university nursing programs are based on professional academic training (1). In many pioneering countries in nursing, to enter a nursing program, an applicant must have a two-year accreditation in other fields such as psychology or must be educated and trained in nursing for 4 years to qualify as a registered nurse (2). In Iran, individuals enter nursing school after passing the national university entrance exam. Nursing programs offer specific theoretical and practical courses that are based on the tasks that the nurses must be able to perform in hospitals or other nursing care facilities (1). A crucial area in nursing education is pharmacology, which is the teaching of theoretical and practical approaches by pharmacology experts. Knowing the mechanisms of action and providing appropriate nursing care before and after administering medicines are among the nurses’ main duties. However, studies have shown that medication errors are prevalent among nurses; a shortage of nursing staff, a high workload, and fatigue are among the influential factors. In Iran, similar to other countries, there is a nurse shortage (3). However, many countries have decreased this problem through the implementation of several strategies. Some countries reduced nurses’ workloads by training nurse assistants who are taught to perform primary care activities, such as bathing patients and helping patients with their elimination needs, dressing, and eating. Some countries have also presented nurse assistants with higher levels of training and then assigned them more complex responsibilities, such as suctioning, removing peripheral venous catheters, rewriting orders, caring for sores, and monitoring blood sugar levels, which must be done under the supervision of a nurse (4). Some countries have also started to train medication nursing assistants (MNAs), who are licensed nursing assistants (LNAs) who have completed a board-approved medication administration program that consists of at least 30 hours of theoretical content and 30 hours of clinical training. Candidates should also have a minimum of 5 years of work experience and possess crucial competencies in basic nursing skills and the English language. MNAs can administer medical orders only for stable patients (5). Recently, a curriculum for training nursing assistants was presented in Iran, and several private institutions have attempted to train nurse assistants. However, this program has received strong criticism because the theoretical and practical content of the program is not commensurate with the task descriptions defined for nursing assistants. Although the content of the program is very simple and requires only a short period to complete, the task descriptions contain several advanced nursing activities and procedures such as drug administration and insertion of intravenous catheters. These interventions require high levels of pharmacology and anatomy knowledge and skills. A recent study reported that nursing students who has passed the required theoretical and practical content for pharmacology are not competent in the process of providing medication therapy (6). In addition, in the current issue of Nursing and Midwifery Studies, Zare Ghamari et al. presented a study on the status of clinical pharmaceutical care education during a nursing internship program and reported that the quality of education is poor in several aspects of medication administration (7). Although the quality of education in Iran’s university programs with several expert instructors is low, the quality would be much lower in private institutions. How can high school graduates with no knowledge of or experience in healthcare or care-giving be taught to be nurse assistants with 1 month of theoretical training? Would not this increase medication errors? Are we putting patients at higher risk? Are we not threatening the status of the nursing profession in the healthcare system?

Peripheral intravenous catheter insertion in the Emergency Department

Growing research suggests that a large number of peripheral intravenous catheters (PIVCs) inserted in the Emergency Department (ED) are unused. The aim of this study was to assess the proportion of unused ED inserted PIVCs in a before-and-after interventional study. Additional aims were to ascertain indications for PIVC insertion in the ED and to increase the appropriateness of PIVC insertion. A prospective interventional study was conducted. Data were collected on 150 cases in the pre- and a further 150 cases in the post-intervention phase. During the intervention phase strategies were implemented to increase appropriate PIVC insertion in the ED. Interventions included introduction of insertion and removal stickers, new venepuncture devices, changing the intravenous (IV) trolley layout, and an educational campaign. Results from this study demonstrate that the number of PIVCs used (50 vs. 28) remained unchanged, however the number of PIVC insertions initiated by nursing staff reduced significantly (p=0.049). With regard to the indication for PIVC insertion, the implementation of the interventions was associated with significantly fewer PIVCs being inserted for routine blood collection (p=0.006) and for PIVCs inserted for a potential need of medication and intravenous fluid administration (p=0.03). There was a significant reduction in the number of PIVCs inserted following the intervention (74 vs. 50: p=0.005). This study demonstrated a high proportion of unused PIVCs in the ED. A composite intervention strategy was developed and significantly reduced the "just-in-case" PIVCs inserted.

Molecular Comparison of Bacterial Communities on Peripheral Intravenous Catheters and Matched Skin Swabs.

Skin bacteria at peripheral intravenous catheter (PIVC) insertion sites pose a serious risk of microbial migration and subsequent colonisation of PIVCs, and the development of catheter related bloodstream infections (CRBSIs). Common skin bacteria are often associated with CRBSIs, therefore the bacterial communities at PIVC skin sites are likely to have major implications for PIVC colonisation. This study aimed to determine the bacterial community structures on skin at PIVC insertion sites and to compare the diversity with associated PIVCs. A total of 10 PIVC skin site swabs and matching PIVC tips were collected by a research nurse from 10 hospitalised medical/surgical patients at catheter removal. All swabs and PIVCs underwent traditional culture and high-throughput sequencing. The bacterial communities on PIVC skin swabs and matching PIVCs were diverse and significantly associated (correlation coefficient = 0.7, p<0.001). Methylobacterium spp. was the dominant genus in all PIVC tip samples, but not so for skin swabs. Sixty-one percent of all reads from the PIVC tips and 36% of all reads from the skin swabs belonged to this genus. Staphylococcus spp., (26%), Pseudomonas spp., (10%) and Acinetobacter spp. (10%) were detected from skin swabs but not from PIVC tips. Most skin associated bacteria commonly associated with CRBSIs were observed on skin sites, but not on PIVCs. Diverse bacterial communities were observed at skin sites despite skin decolonization at PIVC insertion. The positive association of skin and PIVC tip communities provides further evidence that skin is a major source of PIVC colonisation via bacterial migration but microbes present may be different to those traditionally identified via culture methods. The results provide new insights into the colonisation of catheters and potential pathogenesis of bacteria associated with CRBSI, and may assist in developing new strategies designed to reduce the risk of CRBSI.

Application of an Evidence Based Framework to Improve Vascular Access Performance Outcomes

Peripheral intravenous catheter (PIVC) insertion and subsequent care have been highlighted as areas for improvement in the management of intravascular devices; however, only the fundamentals of PIVC care are routinely taught to registered nurses in Australia. In 2013, a vascular access-focused elective postgraduate course, Peripheral Intravenous Access and Care (8035NRS) was commenced for students enrolled in any of the Griffith University master's degree programs. It was developed with the intent to translate research knowledge into practice by providing access to the latest research findings and current best practices in peripheral intravenous access. Topics covered preinsertion, insertion, and postinsertion care and were developed for the online environment, which is known to be conducive to individual student learning styles. Learning activities included viewing short videos delivered by local and international clinical researchers. This course is the first known university-provided, postgraduate academic course on this subject in Australia, and possibly 1 of the few available internationally. The course succeeded in its aim of increasing knowledge and skills about safe, evidence-based PIVC insertion and care to registered nurses. Its development and implementation at the postgraduate level may be regarded as a strategy to provide a greater understanding regarding scope and relevance for nursing practice and for informed decision making on optimum integration at the undergraduate level. This ultimately will increase positive patient outcomes and the patient experience of vascular access.

An instructive case of presumed brown snake (Pseudonaja spp.) envenoming

Context. Several species of medically important Australian elapid snakes are frequently involved in human envenoming. The brown snake group (Pseudonaja spp., 9 species) is most commonly responsible for envenoming including life-threatening or fatal cases. Several Pseudonaja spp. can inflict human envenoming that features minor local effects, but may cause serious systemic venom disease including defibrination coagulopathy, thrombocytopenia, micro-angiopathic hemolytic anemia (MAHA) and, rarely, paralysis. Pseudonaja envenoming is typically diagnosed by history, clinical assessment including occasional active clinical bleeding noted on physical examination (e.g. from venipuncture sites, recent cuts, etc.), and laboratory detection of coagulopathy (prolonged activated partial thromboplastin time [APTT]/INR, elevated D-dimer, afibrinogenemia and thrombocytopenia). Lack of verified identity of the envenoming snake species is a common problem in Australia and elsewhere. Identification and confirmation of the envenoming Australian snake taxon is often attempted with enzyme sandwich immunoassay venom detection kits (SVDKs). However, the SVDK has limited utility due to unreliable specificity and sensitivity when used to detect venoms of some Australian elapids. Antivenom (AV) remains the cornerstone of treatment, although there is debate concerning the recommended dose (1 vs. 2 or more vials) necessary to treat serious Pseudonaja envenoming. Envenomed patients receiving timely treatment uncommonly succumb, but a proportion of seriously envenomed patients may exhibit clinical or laboratory evidence of myocardial insult. Case details. An 88-year-old woman presented her dog to a veterinarian after it had sustained a bite by a witnessed snake, reportedly an eastern brown snake (Pseudonaja textilis, Elapidae). The woman became suddenly confused, and lost consciousness at the veterinary office. After transport to hospital, she denied any contact with the snake, but developed large haematomas at intravenous (i.v.) catheter insertion sites; blood tests revealed a severe defibrination coagulopathy, consistent with envenoming by a brown snake. An SVDK-tested urine sample was negative. A non-contrast CT of her head showed a minor subacute infarction of the left corona radiata. A twelve-lead ECG was normal, but her troponins were mildly elevated (39 ng/L). A diagnosis of brown snake envenoming was made and she received 2 vials of brown snake AV i.v., without adverse incident. Thirty min post AV her Glasgow Coma Score (GCS) had improved from 13 to 15 (normal). At 3.5 h post AV all bleeding from i.v. sites ceased, although her troponin T level peaked at 639 ng/L, supporting a diagnosis of non-ST elevated myocardial infarction (NSTEMI). Discussion. Severe brown snake envenoming may occur in the absence of a perceived bite, and AV is temporally associated with improvement in clinical findings and coagulopathy. However, severe envenoming by this species can be complicated by cardiovascular events that in the circumstance of incomplete or absent history may confuse the primary diagnosis and affect patient outcome.

Paracetamol (acetaminophen) for prevention or treatment of pain in newborns.

Paracetamol (acetaminophen) for prevention or treatment of pain in newborns.

One million global catheters PIVC worldwide prevalence study: building alliances to put vascular access device management and infection prevention on the world stage from Australia to the Democratic Republic of Congo

Background Despite the existence of numerous guidelines for peripheral intravenous catheter (PIVC) insertion and care, outcomes for peripheral catheters are reportedly sub-optimal. Furthermore, little is known about PIVC outcomes in developing nations. Optimising infection control of PIVCs is a unique challenge for developing and least developed countries. Following devastating events in 2002, the Centre Medical Evangelique de Nyakunde in Democratic Republic of Congo is slowly rebuilding hospital capacity and tackling the challenges of infection control in difficult conditions.