Peripheral Intravenous Access Research Articles

Near-infrared technology for improved PIVC placement: a clinical technology implementation model.

To share lessons learned from an evidence-based practice (EBP) initiative that implemented near-infrared (NIR) technology in a large US hospital system. A Clinical Technology Implementation Model (CTIM©) that can be adapted for use in other health institutions is presented. EBP implementation, including the adoption of new cutting-edge technologies, is crucial to improving patient care. Yet there are significant delays in changes to clinical practice, often due to organisational challenges that stifle the implementation process. The evidence-practice gap is increasingly evident in peripheral intravenous access (PIV). Implementation science offers new insights into the challenges of updating clinical practice, which can support EBP implementation. Recent literature on implementation science, change theory, PIV access, NIR technology, and patient outcomes were reviewed. A model that can help nurse managers implement technology that aligns with EBP is presented, drawing on experience from the adoption of NIR vein visualisation to enhance PIV access in a large US hospital system. A pervasive hesitancy in healthcare to embrace technology, coupled with the challenges of implementing a change to practice, has led to limited application of EBP PIV access guidelines and a stagnant standard of care. This article provides nurse managers with the tools necessary to successfully implement EBP, drawing on the experience from implementing NIR in a large US hospital. Nurse managers are uniquely positioned to lead the way in embracing technology to improve care and reduce the evidence-practice gap.

Controllo del dolore da venipuntura e accesso venoso periferico: tecniche farmacologiche e non

Venipuncture and peripheral intravenous access are the painful procedures more com- monly performed in children. The aim of this article is to present the techniques availa- ble and more commonly employed to decrease pain and distress during these procedures. Evidence shows that pharmacological techniques, such as the application of anaesthetic creams or topical anaesthesia, have the best pain-relieving effect. Nevertheless, considering that the painful experience during venipuncture and vascular access are related both to perceived pain and procedural anxiety, the integrated use of pharmacological and non-pharmacological techniques is warranted. In this sense, the appropriate preparation is a cornerstone of the procedure. In the article, brief management strategies, with easily implemented techniques to improve daily practice are provided.

Emergency medical team interventions in Poland during out-of-hospital deliveries: A retrospective analysis.

Emergency medical teams are a crucial component of healthcare systems, routinely providing essential care to pregnant patients in various situations. To evaluate the rate and outcomes of out-of-hospital deliveries attended by Emergency Medical Services (EMS) in Poland and identify areas for improvement in the care provided by emergency medical teams. This retrospective study was based on 41,335 EMS emergency calls to women in advanced pregnancy, of which 879 births were delivered directly by medical teams between January 2018 and December 2022. Data were obtained from the Polish National Monitoring Center for Emergency Medical Services, encompassing all EMS interventions in Poland. The study involved 879 EMS team interventions for pregnant women, with an average patient age of 29.87 years. Most patients were in their 2nd pregnancy (28.26%) and delivering for the 2nd time (25.77%). The postnatal condition of newborns, assessed using the Apgar score, was missing in 408 cases (46.52%) due to incorrect completion of documentation. Emergency Medical Services teams, predominantly P-type (basic) teams, handled 69.78% of deliveries, while S-type (specialist) teams were involved in 30.22% of cases. Medical procedures often performed during childbirth included manual assistance in spontaneous delivery, pulse oximetry, physical examination, examination of systemic blood pressure, obtaining peripheral intravenous access, and gynecological examination. Given the rate of encountered cases and the gaps identified in medical documentation, there is merit in potentially implementing a dedicated form to be completed by medical teams when caring for a pregnant patient. Ongoing training and enhancements in the range of assistance provided to the mother and newborn are imperative for ensuring appropriate care.

Practical use of the central venous access port for contrast-enhanced CT: comparison with peripheral intravenous access regarding enhancement and safety

To evaluate the efficacy of using the central venous (CV) port compared with peripheral intravenous access for contrast-material injection for contrast enhancement during the portal venous phase. Patients were divided into three groups: CV delay, CV routine, and peripheral access (PA) groups. Patients in the CV delay group underwent injection in the arm-down position with an additional delay, while those in the CV routine and PA groups underwent injections with the routine injection protocol for portal venous phase imaging. Contrast enhancement was evaluated by measuring the mean radiodensity (Hounsfield units) values for the aortic arch, abdominal aorta, inferior vena cava, portal vein, and spleen. The peak injection pressure was recorded and compared among the three groups. No complications related to power injection were observed during 119 contrast-material injections performed using the CV port device. The CV delay group showed significantly lower radiodensity values than the PA group (165.7±20.1 versus 181±19 HU [p<0.01] for the portal vein); however, no significant differences in mean radiodensity values were observed between the CV routine and PA groups (p>0.05). The median peak injection pressure was 73.5, 67, and 47 psi in the CV delay, CV routine, and PA groups, respectively (p<0.01). The CV port can be used for safe contrast-material injection while maintaining contrast enhancement on portal venous phase comparable to that achieved with peripheral intravenous access.

Use of Peripheral Intravenous Access in Patients Undergoing Chemotherapy for Testicular Cancer.

Systemic chemotherapy, depending on the regimen, can be administered through peripheral intravenous (pIV) access or through central venous access devices (CVADs). There is no current best practice regarding optimal access for chemotherapy for patients with testicular cancer (TC). We retrospectively evaluated patients undergoing systemic chemotherapy for TC and compared baseline characteristics and complications of patients using pIV versus CVADs. We included patients with TC who underwent first-line systemic chemotherapy at the University of Colorado Hospitals from 2005 to 2020. Data were collected on demographics, cancer characteristics, type, duration of chemotherapy, pIV or CVAD use, and associated complication rates. We then performed univariate and multivariate regression analyses to compare complication rates and risk factors for each group. One hundred fifty-four patients met inclusion criteria. Ninety-two (60%) patients used CVADs, and 62 patients (40%) used pIV for their initial treatment. Only six (9.7%) of 62 patients transitioned from pIV to CVADs during therapy. Similarly, 10 of 92 (10.9%) patients with initial CVAD needed to transition to a different type of CVAD or to pIV (P = .81). There were a greater number of venous access-related complications (48 of 92 patients, 52.2%) and overall thrombotic events (33 of 92 patients, 35.9%) for the CVAD group (P > .001) when compared with the pIV group. We observed an association between the following factors and venous access-related complications during chemotherapy: higher stage TC, increased total chemotherapy cycles, and delayed therapy. Peripheral IV use for first-line nonvesicant chemotherapy in patients with TC appears to be well tolerated with high rates of therapy completion and lower rates of complications when compared with CVADs. These data support our preferred treatment approach and provide evidence that pIV access is a safe and effective way to deliver chemotherapy for patients with TC.

Outcomes with Tibial and Humeral Intraosseous Access Compared to Peripheral Intravenous Access in Out-of-Hospital Cardiac Arrest

Background The optimal initial vascular access strategy for out-of-hospital cardiac arrest (OHCA) remains unknown. Our objective was to evaluate the association between peripheral intravenous (PIV), tibial intraosseous (TIO), or humeral intraosseous (HIO) as first vascular attempt strategies and outcomes for patients suffering OHCA. Method This was a secondary analysis of the Portland Cardiac Arrest Epidemiologic Registry, which included adult patients (≥18 years-old) with EMS-treated, non-traumatic OHCA from 2018–2021. The primary independent variable in our analysis was the initial vascular access strategy, defined as PIV, TIO, or HIO based on the first access attempt. The primary outcome for this study was the return of spontaneous circulation (ROSC) at emergency department (ED) arrival (a palpable pulse on arrival to the hospital). Secondary outcomes included survival to: admission, discharge, and discharge with a favorable outcome (Cerebral Perfusion Category score of ≤2). We conducted multivariable logistic regressions, adjusting for confounding variables and for clustering using a mixed-effects approach, with prespecified subgroup analyses by initial rhythm. Results We included 2,993 patients with initial vascular access strategies of PIV (822 [27.5%]), TIO (1,171 [39.1%]), and HIO (1,000 [33.4%]). Multivariable analysis showed lower odds of ROSC at ED arrival (adjusted odds ratio [95% CI]) with TIO (0.79 [0.64–0.98]) or HIO (0.75 [0.60–0.93]) compared to a PIV-first strategy. These associations remained in stratified analyses for those with shockable initial rhythms (0.60 [0.41–0.88] and 0.53 [0.36–0.79]) but not in patients with asystole or pulseless electrical activity for TIO and HIO compared to PIV, respectively. There were no statistically significant differences in adjusted odds for survival to admission, discharge, or discharge with a favorable outcome for TIO or HIO compared to the PIV-first group in the overall analysis. Patients with shockable initial rhythms had lower adjusted odds of survival to discharge (0.63 [0.41–0.96] and 0.64 [0.41–0.99]) and to discharge with a favorable outcome (0.60 [0.39–0.93] and 0.64 [0.40–1.00]) for TIO and HIO compared to PIV, respectively. Conclusions TIO or HIO as first access strategies in OHCA were associated with lower odds of ROSC at ED arrival compared to PIV.

A Retrospective Analysis and Characterization of Female Patients with Bleeding Disorders Hemophilia B, Hemophilia B and Von Willebrand's Disease and Their Treatment Type at Banner MD Anderson Cancer Center

Introduction: Women with bleeding disorders experience bleeding in mucocutaneous tissues, uterine bleeding, and in muscles and joints. In men, bleeding of more than 1 or 2 bleeds per year is justification for starting prophylaxis with factor and non-factor replacement therapy. At Banner MD Anderson Cancer Center (BMDACC), women are offered prophylaxis according to the same standard. Uterine bleeding classified as excessive or disruptive to daily activity is considered bleeding requiring prophylaxis. Aim: Describe the number of women in the bleeding disorder database from June 2018 to December 2022 with Hemophilia A (HemA), Hemophilia B (HemB) and Von Willebrand Disease (VWD) with respect to number on prophylaxis to prevent bleeds. Specific factor levels and subtype of VWD were not gathered as part of this project. Rather, patients were offered prophylaxis based on symptoms of bleeding. Prophylaxis is defined as treatment to prevent bleeding associated with day-to-day activity, but not prior to planned procedures. The type of treatment was recorded, type of access if needed (peripheral intravenous access v. central venous access) and why treatment was started. Results: Among 101 female patients in the BMDACC bleeding disorder database, 64 had a diagnosis of HemA, HemB or VWD. Among HemA, 13 of 17 (76%) were on prophylaxis with factor replacement or emicizumab. Joint bleeding and pain were the most common reasons for starting prophylaxis in 6 of 13 patients and menorrhagia was the second most common in 3 patients. Among HemB, 2 of 4 (50%) were on factor replacement. Rectal bleeding and menorrhagia were reasons to start prophylaxis. Among VWD, 24 of 43 (56%) were on prophylaxis with one or more of the following treatments: factor replacement, desmopressin or antifibrinolytic replacement. Menorrhagia was the most common reason for starting prophylaxis in 13 of 24 patients and joint bleeding was the next most common in 4 patients. Additional reasons were trauma, mucocutaneous, urinary tract bleeding, and bleeding during pregnancy. Patients with VWD were much more likely to require central IV access in the form of a chest port-a-cath 14 of 43 (33%) than patients with HemA or HemB, of which no patients required central access. Patients with HemA or HemB were more likely to use factor replacement than VWD to prevent bleeding symptoms. Patients with VWD were more likely than patients with HemA or Hem B to have a diagnosis prior to age 18; VWD had 16 of 43 (37%), HemA had 3 of 17 (18%) and HemB had 0 of 4 (0%). Conclusions: Female patients with inherited bleeding disorders have bleeding symptoms that may require the initiation of routine treatment to prevent bleeding and should be offered treatment with hemostatic agents to prevent bleeding when bleeding frequency exceeds more than 1 or 2 bleeds per year. Heavy menstrual bleeding, joint bleeding, joint pain, gastrointestinal and genitourinary bleeding are reported in this patient population as reasons to start prophylaxis with hemostatic agents. Further study is underway to assess the efficacy of starting prophylaxis in these patients. In the Author's experience, once factor replacement is started, patients are pleased with the change in their health status after initiation of treatment and continue to be compliant with treatment recommendations although they may have difficulty in administering those treatments. Patients with VWD were much more likely than those with HemA or HemB to require placement of a central venous access device. Further study into this observation is needed to understand why this is so.

1656. Evaluation of Using Oxacillin versus Vancomycin for Empiric Therapy of Late-Onset Neonatal Sepsis in NICU

Abstract Background Our Pediatric Antimicrobial Stewardship Program (PedASP) assessed methicillin-sensitive (MSSA) and methicillin-resistant S. aureus (MRSA) infections in neonatal intensive care unit (NICU) and created a NICU-specific antibiogram. Due to a rising trend of NICU MSSA infections seen in our 84-bed NICU, empiric therapy of late-onset neonatal sepsis (LONS) was modified from vancomycin to oxacillin in January 2021. We report the two-year results of using empiric oxacillin for LONS.Figure 1.Summary of S. aureus identified in LONS cases Methods We assessed MSSA versus MRSA isolated from blood and non-blood cultures in NICU between January 2019 and December 2022. Infants with weight less than 750 grams, previous MRSA infections, maternal MRSA colonization, or serious infections based on clinical judgement were advised to use empiric vancomycin. We examined the vancomycin eligibility criteria, antibiotic-pathogen mismatch rate, 30-day mortality, and frequency of peripheral intravenous (PIV) access loss after vancomycin or oxacillin administration. The cost-savings was estimated by comparing drug and lab costs associated with vancomycin and oxacillin use. Results LONS cases are summarized in Figure 1. There was no statistical difference in incidence of S. aureus bacteremia before and after protocol implementation (p=0.45). Antibiotic-pathogen mismatch rate was 0%. Cases of MRSA bacteremia increased from 0 to 3 post protocol initiation; all cases met vancomycin eligibility criteria. The 30-day mortality among MRSA infections increased from 0 to 1 case. Post protocol implementation, the PIV loss rate decreased from 4.7 to 3.3% (p=0.04), and vancomycin use decreased by 1154 doses while oxacillin use increased by 485 doses. Based on antibiotic use and 141 vancomycin levels averted, the estimated cost-savings was $140,229. Conclusion Our PedASP utilized local susceptibility data to change empiric antibiotics for LONS, reinforcing the benefit of using antibiogram to optimize antibiotic use in NICU. Implementing a NICU-specific antibiogram improved the effectiveness of antibiotic treatment and achieved significant cost savings. Disclosures All Authors: No reported disclosures

Bridging the Gap in Traditional PIVC Placement: An Evaluation of Operation STICK Vascular Access Outcomes.

Education and training is core to improving peripheral intravenous access outcomes. This study aimed to show that a vascular access training program (Operation STICK) in the emergency department (ED) improves the outcomes of traditionally placed peripheral intravenous catheters (PIVC). This was a pre-post quasi-experimental study of traditionally placed PIVCs at a large ED in southeastern Michigan, United States. A control group (non-OSTICK) was compared to an experimental group (OSTICK) using a 3:1 propensity score matched analysis. Groups were comprised of ED patients with traditional PIVC placements in two separate six-month periods: non-OSTICK PIVCs from April to September 2021 and OSTICK PIVCs (placed by an OSTICK graduate) from October 2022 to March 2023. The primary outcome was PIVC functionality. The secondary outcome was adherence to best practices. A total of 6512 PIVCs were included in the study; 4884 (75.0%) were in the non-OSTICK group, while 1628 (25.0%) were in the OSTICK group. 68.1% of OSTICK PIVCs and 59.7% of non-OSTICK PIVCs were placed by ED technicians (p < 0.001). 91.3% of OSTICK PIVCs were placed on the first attempt, and 98.5% were placed within two attempts. A subgroup analysis of admitted patients (2540 PIVCs; 553 (21.8%) OSTICK-trained and 1987 (78.2%) non-OSTICK-trained) revealed 87.6% of OSTICK PIVCs and 80.3% of non-OSTICK PIVCs were 20 gauge (p < 0.001). The median proportion of dwell time to hospital length of stay was 94% for OSTICK PIVCs, compared to 88% for non-OSTICK PIVCs (p < 0.001). This study underscores the value of education and training in enhancing vascular access outcomes. Implementing Operation STICK, a comprehensive vascular access training program, at a large ED has led to high first-stick success, adherence to best practice recommendations for site and device selection, and improved PIVC functionality for traditionally placed catheters.

A52Probing for Veins: A Cost-Effective, Reproducible Method for Teaching Ultrasound-Guided Peripheral Intravenous Access

Repeated attempts at peripheral intravenous (PIV) access cause increased discomfort and delays in treatment for patients in hospital. The use of ultrasound can improve success in PIV access, benefitting patient experience. Medical professionals are increasingly expected to use ultrasound when landmark techniques fail [1]. We sought to improve confidence using ultrasound for PIV cannulation with low-cost simulation models made from ADAMgel [2] or tofu in multiple teaching sessions. We organized teaching sessions with multiple specialties at St Richard’s Hospital. A total of 48 members of staff have been taught over four sessions. Prior to the teaching session learners were asked to complete a survey identifying previous ultrasound experience and rating confidence using ultrasound for PIV access. The teaching session consisted of an introductory multimedia presentation with a video demonstration, then practical experience. Models consisted of water-filled balloons placed in ADAMgel (Aqueous Dietary Fibre Antifreeze Mix gel) or tofu to simulate human tissue and veins, Models used to deliver teaching sessions. After ADAMgel became available this has been used exclusively due to it being more reusable compared to the tofu modelsA: tofu model with ultrasound image underneath.B: ADAMgel model with ultrasound image underneath The initial survey identified only 29% of staff had previously used ultrasound for PIV access, and half of these (15% overall) had only used it once or twice a year. Using a five-point Likert scale, 74% of respondents rated their confidence in using ultrasound as one or two out of five. All respondents thought they would benefit from further teaching in PIV access. Feedback after teaching sessions was favourable, with 95% of respondents finding the session very useful and 95% also believing it would increase their use of ultrasound in clinical practice. After the session, more than half rated their confidence in ultrasound cannulation as four or five out of five. We have demonstrated that there is a desire from medical staff to increase their competency in ultrasound-guided PIV cannulation. Using low-cost, high-fidelity simulation models with a blended learning method, we can deliver teaching sessions to a large number of medical staff. We hope to continue this teaching in collaboration with our sister sites throughout Sussex to increase confidence with ultrasound-guided PIV cannulation in this region. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Radiopharmaceutical administration practices—Are they best practice?

BackgroundThe nuclear medicine community has stated that they are using best practices to gain venous access and administer radiopharmaceuticals, and therefore do not contribute to extravasations. We tested this hypothesis qualitatively and quantitatively by evaluating four different perspectives of current radiopharmaceutical administration practices: (1) clinical observations of nuclear medicine technologists on the job, (2) quality improvement (QI) projects, (3) a high-level survey of current practices in 10 acute care hospitals, (4) intravenous (IV) access site data for 29,343 procedures. These four areas were compared to the gold standard of pharmaceutical administration techniques.ResultsFrom clinical observations of radiopharmaceutical administrations in adult populations, technologists extensively used 24-gauge peripheral intravenous catheters (PIVCs) and butterfly needles. They also performed direct puncture (straight stick). Technologists predominantly chose veins in areas of flexion (hand, wrist, and antecubital fossa), rather than forearm vessels for IV access placement; in many circumstances, antecubital fossa vessels are chosen first, often without prior assessment for other suitable vessels. For selecting the injection vein, technologists sometimes used infrared vein finders but primarily performed blind sticks. Review of QI projects suggested that smaller gauge needles were contributing factors to extravasations. Additionally, the review of surveys from 10 hospitals revealed an absence of formalized protocols, training, knowledge, and skills necessary to ensure the safety/patency of IV devices prior to the administration of radiopharmaceuticals. Finally, findings from a review of IV access data for 29,343 procedures supported the observations described above.ConclusionsWe expect that nuclear medicine technologists have the best intentions when providing patient care, but many do not follow venous access best practices; they lack formal protocols, have not received the latest comprehensive training, and do not use the best placement tools and monitoring equipment. Thus, the presumption that most nuclear medicine technologists use best practices may not be accurate. In order to improve radiopharmaceutical administration and patient care, the nuclear medicine community should update technical standards to address the most recent peripheral IV access and administration best practices, provide technologists with vascular visualization tools and the proper training, develop and require annual vascular access competency, and provide active monitoring with center and patient-specific data to create ongoing feedback.

A national retrospective descriptiveanalysis ofcriticalcaretransfers in the private sector in South Africa.

Critical care transfers (CCTs) are necessitated by the growing prevalence of high-acuity patients who require upgrade of care to multidisciplinary teams from less-equipped referring facilities. Owing to the high acuity of the critical care patient, specialised teams with advanced training and equipment are called upon to undertake these transfers. The inherent understanding of the potential effects, and therefore the needs of the critical care patient during transfer, are affected owing to the paucity of international, but more specifically, local data relating to CCTs. To describe a cohort of patients who underwent CCT by dedicated critical care retrieval services (CCRS) in the private sector in South Africa (SA). This retrospective, descriptive study sampled all paediatric and adult CCTs completed over a 1-year period (1 January 2017 - 31 December 2017) from the dedicated CCRS of two national emergency medical services in SA. All neonatal patients were excluded. Data were extracted from patient report forms by trained data extractors and subjected to descriptive analysis. A total of 1 839 patients were transferred between the two services. A total of 3 143 diagnoses were recorded, yielding an average of ~2 diagnoses per patient. The most prevalent primary diagnosis was cardiovascular disease (n=457, 25%), followed by infection (n=180, 10%) and head injury (n=133, 7%). Patients had an average of ~3 attachments, with the most prevalent being patient monitoring (n=2 856, 155%), peripheral intravenous access (n=794, 43%) and mechanical ventilation (n=445, 24%). A total of 2 152 instances of medication infusion or administration were required during transport, yielding an average of ~1 medication or infusion per patient transported. The most common medications recorded were central nervous system depressants (n=588, 32%), followed by analgesics (n=482, 26%) and inotropic or vasoactive agents (n=320, 17%). This study provides insight into the demographics, most prevalent diagnoses and interfacility transfer monitoring needs of patients being transported in SA by two private dedicated CCRS. The results of this study may be used to inform future specialised critical care transport courses and qualifications, equipment procurement and scopes of practice for providers undertaking critical care transfers.

Smart Glasses to Facilitate Ultrasound Guided Peripheral Intravenous Access in the Simulation Setting for Thai Emergency Medical Service Providers.

The ultrasound-guided peripheral venous access (USGPIV) was reported as difficult for novices to perform. Smart glasses equipped with teleconference systems can display real-time ultrasound images to sonographers and consultants which can increase the success rate of this procedure. The purpose of this study was to assess the effectiveness of employing smart glasses for USGPIV. A randomized, simulation study was conducted in emergency medical service (EMS) providers at Srinagarind Hospital, Thailand, from January to April 2023. We randomized participants into two groups which included participants who wore smart glasses during procedures requiring USGPIV (the smart glasses group) and participants who performed USGPIV with no smart glasses (the non-smart glasses group). After participating in USGPIV cannulation training, the simulations were carried out. The primary outcome was the first-attempt success rate, with secondary outcomes including the procedure time and subjective difficulty. Fifty participants were recruited for the study. The smart glasses group was superior to the non-smart glasses group both in terms of first-attempt success rate with no statistically significant (64% vs 60%; P = 0.460) and also demonstrated a shorter procedure time than the non-smart glasses group (25.5 sec vs 42.3 sec; P = 0.003). The participants reported the subjective difficulty score was higher in the smart glasses group (the visual analog scale, VAS = 8). In simulation scenarios, the smart glasses-assisted USGPIV could shorten the procedure time. However, our study did not find significant differences in the first pass success rate of USGPIV between the two groups.

Evaluation of extended-length cannula inserted using ultrasound guidance in patients with difficult IV access.

Historically, gaining peripheral intravenous (IV) access for patients with difficult intravenous access (DIVA) has been problematic and associated with increased complications, central venous access device insertion and reduced patient satisfaction. Consequently, extended-length peripheral intravenous catheters (PIVCs) have been developed, but to date no real-world data exploring their effectiveness with NHS patients has been published. This article reports on the results of introducing extended-length PIVCs, inserted using ultrasound guidance in patients with DIVA by a vascular access team. This began in 2019, across an adult tertiary hospital setting in the NHS with about 750 beds. The specialties at this hospital include, but are not limited to, emergency medicine; head and neck; vascular; diabetes and endocrinology; respiratory; care of the older person; stroke services; gastroenterology; and trauma and orthopaedics. The vascular access team recorded 1485 individual insertions between 2019 to 2022, with a mean dwell time of 6 days, a first attempt success rate of 91%, and a therapy completion rate of 75 and 78% for inpatient and outpatients respectively. Indications included administration of IV fluids, medication, blood products and access for investigations or procedures. Obtaining reliable IV access in patients with DIVA prevents treatment delays, cancelled or delayed procedures, both of which benefit patients and the healthcare organisation. The data presented in this study support the use of extended-length PIVCs in patients with DIVA and has led to the development of new referral pathways.

A survey of paediatric difficult peripheral intravenous access in the emergency department and use of point-of-care ultrasound.

Peripheral intravenous catheter (PIVC) insertion can be challenging in children, with point-of-care ultrasound (POCUS) known to increase success rates. The objective of this study was to survey how emergency department (ED) clinicians identify and escalate paediatric patients with difficult intravenous access (DIVA), specifically the use of POCUS. This cross-sectional study was conducted in an Australian academic mixed ED that surveyed resident medical officers (RMOs), registrars, consultants and senior paediatric nurses. A 15 multiple-choice questionnaire evaluated clinicians experience with paediatric PIVC insertion, approach to identifying and managing DIVA and the use of POCUS or other adjuncts. Eighty clinicians (34.2% response rate) completed the survey. Poor vein palpability was rated the highest predictor of DIVA. Of the respondents, 19 consultants (86.4%), 28 registrars (90.3%) and 16 RMOs (64.0%) used POCUS as an adjunct for paediatric DIVA patients but 16 consultants (72.8%), 21 registrars (67.8%) and 20 RMOs (80.0%) would use this less than 25% of the time in clinical practice. This survey suggests more clinicians to prefer using objective factors when identifying paediatric DIVA patients, rather than subjectively using gestalt, which relies on clinician experience. Whilst clearly recognised as a useful tool in our study, POCUS was used infrequently for paediatric DIVA patients. There is currently no consistent process for the identification and escalation of paediatric DIVA patients, including the use of adjuncts such as POCUS. Clinician awareness for these issues should be addressed, which should include the development of guidelines and clinician training in POCUS for PIVC insertion in children.

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

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

The safety of intravenous peripheral administration of 3% hypertonic saline: A systematic review and meta-analysis

BackgroundThree percent hypertonic saline (3% HTS) is used to treat several critical conditions such as severe and symptomatic hyponatremia and increased intracranial pressure. It has been traditionally administered through a central venous catheter (CVC). The avoidance of peripheral intravenous infusion of 3% HTS stems theoretically from the concern about the ability of the peripheral veins to tolerate hyperosmolar infusions. The aim of this systematic review and meta-analysis is to assess the rate of complications associated with the infusion of 3% HTS using peripheral intravenous access. MethodsWe conducted a systematic review and meta-analysis to assess the rate of complications related to the peripheral infusion of 3% HTS. We searched several databases for available studies that met the criteria until February 24th, 2022. We included ten studies conducted across three countries examining the incidence of infiltration, phlebitis, venous thrombosis, erythema, and edema. The overall event rate was calculated and transformed using the Freeman-Tukey arcsine method and pooled using the DerSimonian and Laird random-effects model. I2 was used to evaluate heterogeneity. Selected items from Newcastle-Ottawa Scale2 were used to assess the risk of bias in each included study. ResultsA total of 1200 patients were reported to have received peripheral infusion of 3% HTS. The analysis showed that peripherally administered 3% HTS has a low rate of complications. The overall incidence of each of the complications was as follows: infiltration 3.3%, (95% C.I. = 1.8-5.1%), phlebitis 6.2% (95% C.I. = 1.1-14.3%), erythema 2.3% (95% C.I. = 0.3-5.4%), edema 1.8% (95% C.I. = 0.0-6.2%), and venous thrombosis 1% (95% C.I. = 0.0-4.8%). There was one incident of venous thrombosis preceded by infiltration resulting from peripheral infusion of 3% HTS. ConclusionsPeripheral administration of 3% HTS is considered a safe and possibly preferred option as it carries a low risk of complications and is a less invasive procedure compared to CVC.

Outcomes of Ultrasound Guided Peripheral Intravenous Catheters Placed in the Emergency Department and Factors Associated with Survival.

Patients with difficult peripheral intravenous (IV) access are common in emergency departments (EDs). Ultrasound-guided peripheral intravenous catheters (USIVs) are frequently used in this population; however, information regarding the effect of patient and IV characteristics on the dwell time (DT) and survival probability (SP) of USIVs is limited. Our study aimed to evaluate for associations between patient or IV characteristics and the DT and SP of USIVs. Retrospective analysis was performed on a database from an ED nurse (RN) USIV training program at an urban, academic hospital. Patients over 18 years with an USIV placed during the study period were included. Subject demographics, history, IV characteristics, insertion, and removal times were collected. Data were analyzed using descriptive statistics and univariable and multivariable Cox regression. USIV survival times for variates of interest were estimated using Kaplan-Meier curves for three censoring points. The final analysis cohort was 388 patients. Mean age was 56.6 years, 66.5% were female, mean BMI was 29.9 kg/m2, and 42.5% were obese (BMI ≥30). Median DT was 40.3 hours in admitted patients (N=340). SP for USIVs at 96 hours was 87.8%. A total of 21 of 340 (6.2%) USIVs failed. USIV location conferred a difference on DT in obese patients when dichotomized into upper arm versus antecubital fossa and forearm together (38.6 hours vs 44.6 hours, p=0.03). No factors were associated with a difference in USIV SP. Median USIV DT of 40.3 hours for admitted patients was higher than in previous studies. Only 7% of USIVs in our study failed. Overall, catheters survived longer than expected.

Effect of other venous access on cardiopulmonary resuscitation quality: A prospective, randomized, controlled trial

ABSTRACT This randomized controlled study aimed to prospectively evaluate the application effects of other venous access in patients undergoing cardiopulmonary resuscitation. A total of 212 patients who underwent respiratory and cardiac arrest were randomly divided into peripheral intravenous (IV) access group (IV group, n = 69), femoral vein catheterization group (FVC group, n = 72), and internal jugular vein catheterization group (IJVC group, n = 71). The puncture time, first administration time, pressure interruption time caused by the establishment of fluid pathway, endotracheal intubation time, complications, ROSC time, and ETCO2 were recorded. The time of establishing venous access was: IV<FVC<IJVC. The once puncture success rate of the FVC group was markedly higher than that in IV and IJVC groups (P < 0.01). There was no significant difference in ROSC time between the FVC, IV, and the IJVC group (P = 0.23). The ROSC time in the FVC group was higher than in the IV and IJVC groups (P < 0.01). The success rate of ROSC in the FVC group and IJVC group were better than that in the IV group (PVC>IJVC>IV, P = 0.04). There was no significant difference in EtCO2 between the FVC, IV group, and IJVC group (PVC>IJVC>IV, P = 0.17). Due to catheterization, the time of suspending chest compression in the FVC group was significantly lower than in the IJVC group (5s vs. 12s). The time of establishing an artificial airway in the IV (38s) and FVC (35s) group were significantly longer than that in IJVC (52s) group. Central venous catheterization is more effective than peripheral venous catheterization in cardiopulmonary resuscitation. Moreover, femoral vein access was more effective than internal jugular vein access.

Association Between Profound Shock Signs and Peripheral Intravenous Access Success Rates in Trauma Patients in the Prehospital Scenario: A Retrospective Study.

Hemorrhage is the leading cause of preventable death in trauma patients, and establishment of intravenous (IV) access is essential for volume resuscitation, a key component in the treatment of hemorrhagic shock. IV access among patients in shock is generally considered more challenging, although data to support this notion are lacking. In this retrospective registry-based study, data were collected from the Israeli Defense Forces Trauma Registry (IDF-TR) regarding all prehospital trauma patients treated by IDF medical forces between January 2020 and April 2022, for whom IV access was attempted. Patients younger than 16 years, nonurgent patients, and patients with no detectable heart rate or blood pressure were excluded. Profound shock was defined as a heart rate >130 or a systolic blood pressure <90 mm Hg, and comparisons were made between patients with profound shock and those not exhibiting such signs. The primary outcome was the number of attempts required for first IV access success, which was regarded as an ordinal categorical variable: 1, 2, 3 and higher and ultimate failure. A multivariable ordinal logistic regression was performed to adjust for potential confounders. Patients' sex, age, mechanism of injury and best consciousness level, as well as type of event (military/nonmilitary), and the presence of multiple patients were included in the ordinal logistic regression multivariable analysis model based on previous publications. Five hundred thirty-seven patients were included, 15.7% of whom were recorded as having signs of profound shock. Peripheral IV access establishment first attempt success rates were higher in the nonshock group, and there was a lower rate of unsuccessful attempts in this group (80.8% vs 67.8% for the first attempt, 9.4% vs 16.7% for the second attempt, 3.8% vs 5.6% for the third and further attempts, and 6% vs 10% unsuccessful attempts, P = .04). In the univariable analysis, profound shock was associated with requirement for an increased number of IV attempts (odds ratio [OR], 1.94; confidence interval [CI], 1.17-3.15). The ordinal logistic regression multivariable analysis demonstrated that profound shock was associated with worse results regarding primary outcome (adjusted odds ratio [AOR], 1.84; CI, 1.07-3.10). The presence of profound shock in trauma patients in the prehospital scenario is associated with an increased number of attempts required for IV access establishment.