Vascular Access In Patients Research Articles

Outcomes of Hemodialysis Vascular Access in Patients Initiating Dialysis With a Tunneled Catheter

The objective of this study was to determine factors that influence time to removal of tunneled hemodialysis catheter (THC), probability of repeated vascular access creation, and time to repeated vascular access. The Optum (Eden Prairie, Minn) Clinformatics database, which contains claims from a large managed care organization, from 2011 to 2016 was queried for patients who initiated hemodialysis with a THC. Time from initial arteriovenous fistula (AVF) or arteriovenous graft (AVG) to THC removal and time to repeated AVF or AVG were analyzed using Cox proportional hazards. Multivariate models included age, sex, race, diabetes, cardiac arrhythmia, congestive heart failure, peripheral vascular disease, and obesity as covariates. There were 8355 vascular accesses that met the inclusion criteria 6648 (77%) AVFs and 1940 (23%) AVGs. Median follow-up was 424 days (range, 1-2097 days). Patients undergoing AVF were younger and more likely to be male and white (Table). At 90 days, 20.3% (95% confidence interval [CI], 19.3%-20.3%) of AVFs vs 56% (95% CI, 53.7%-58.4%) of AVGs had the THC removed. At 180 days, 56.7% (95% CI, 55.4%-58.1%) of AVFs vs 68.4% (95% CI, 66.1%-70.6%) of AVGs had the THC removed. By day 315, 74% of patients with both AVFs and AVGs had the THC removed. Multivariate analysis demonstrated a significant interaction between vascular access type and age ≥70 years (P < .001). In the age group <70 years, patients who underwent AVG had a THC removal rate 46% higher than that of patients who underwent AVF. In the age group ≥70 years, patients who underwent AVG had a THC removal rate 88% higher than that of patients who underwent AVF. There were 1982 (23.7%) patients who underwent a second vascular access. Multivariate analysis demonstrated that AVG vs AVF (odds ratio, 0.70; 95% CI, 0.61-0.81) and age ≥70 years vs <70 years (odds ratio, 0.87; 95% CI, 0.78-0.98) were associated with a lower odds of second access. In patients who underwent a second access, multivariate analysis demonstrated that initial AVG was associated with longer time to second access (hazard ratio, 0.60; 95% CI, 0.54-0.68). Creation of AVG vs AVF significantly decreased the time to THC removal in dialysis-dependent patients, with a larger difference in patients aged ≥70 years vs <70 years. Initial AVG was associated with lower odds of second access and longer time to second access in those who underwent second access. These results contradict the dictum of “fistula first” and support the judicious use of AVG in achieving the more recent shift toward “catheter last.”TableDemographics by access typeFistula (n = 6486), No. (%)Graft (n = 1869), No. (%)P valueAge, years mean (SD)66.2 (13)69 (12)<.001Age ≥70 years2979 (46)1028 (55)<.001Male3920 (60)811 (44)<.001Race<.001 Asian216 (3)51 (3) Black1586 (24)677 (36) Hispanic859 (13)192 (10) White3663 (56)915 (49) Unknown168 (3)28 (1)Diabetes5257 (81)1565 (84).001Cardiac arrhythmia4688 (72)1400 (75).13Congestive heart failure5021 (77)1480 (79).073Peripheral vascular disease4406 (68)1322 (71).011Obesity2596 (40)694 (37).03SD, Standard deviation. Open table in a new tab

L’angioplastica intraoperatoria durante l’allestimento delle fistole arterovenose

Intraoperative angioplasty during the preparation of arteriovenous fistulasPurposeAutogenous arteriovenous fistula (AVF) has been shown to be the preferred vascular access in patients that are cand...

Suction towards a vessel wall by hemodialysis catheters\u2014the establishment of a new experimental extracorporeal circulation system using pig veins

BackgroundHemodialysis catheters are commonly used for vascular access in patients undergoing blood purification therapies. However, the sudden dysfunction of catheters represents a serious problem, and while we know that the major causative factor is suction between the catheter and the vessel wall, it is very difficult to evaluate this in vivo. Therefore, we created a new experimental system to investigate this phenomenon ex vivo, using pig veins, which allowed us to quantitatively analyze the effect of suction.MethodsWe attempted to create a model system for quantitative evaluation using azygos veins from a pig. Four types of catheters were inserted into an extracted pig vein: true circle type 1, true circle type 2, semi-circle type 1, and semi-circle type 2. We then circulated 50% glycerol solution through the vein at a flow rate (Qv) from 100 to 1000 mL/min. Glycerol solution was also circulated within the catheters at a flow rate (Qb) from 100 to 200 mL/min. We measured the frequency of suction towards the vessel wall ten times, under each experimental schedule, at a Qb of both 100 and 200 mL/min. We then measured the pressure between the pre-Qb pump and the blood circuit, when the arterial side opening was positioned approximately in the center of the blood vessel to prevent catheter suction towards the vessel wall.ResultsSuction towards the vessel wall occurred 8/10 times with the true circle type 1 catheter and 10/10 times with the semi-circle type 2 catheter in the arterial pore of the catheter is only one, when Qb and Qv were 100 and 100 mL/min, respectively. Suction towards the vessel wall occurred 3/10 times with the semi-circle type 2 catheter, when Qb and Qv were 100 and 1000 mL/min, respectively. The true circle type 1 catheter showed a minimum pressure of − 58.6 ± 0.516 mmHg when Qb and Qv were 100 and 300 mL/min, respectively, while the true circle type 2 catheter showed a minimum pressure of − 137 ± 5.96 mmHg when Qb and Qv were 200 and 300 mL/min, respectively.ConclusionsWe successfully established a novel ex vivo evaluation system for catheters using a pig vein which allowed us to recreate the effect of suction from catheters towards a vessel wall in vivo.

Prevalence and correlates of central venous catheter use among haemodialysis patients in the Irish health system - a national study

BackgroundCentral venous catheters (CVC) are associated with substantial morbidity and mortality among patients undergoing haemodialysis (HD), yet they are frequently used as the primary vascular access for many patients on HD. The goal of this study was to determine the prevalence and variation in CVC use across centres in the Irish health system.MethodsData from the National Kidney Disease Clinical Patient Management System (KDCPMS) was used to determine CVC use and patterns across centres. Data on demographic characteristics, primary cause of end-stage kidney disease (ESKD), comorbid conditions, laboratory values and centre affiliation were extracted for adult HD patients (n = 1, 196) who were on dialysis for at least three months up to end of December 2016. Correlates of CVC use were explored using multivariable logistic regression.ResultsOverall prevalence of CVC use was 54% and varied significantly across clinical sites from 43% to 73%, P < 0.001. In multivariate analysis, the likelihood of CVC use was lower with increasing dialysis vintage, OR 0.40 (0.26–0.60) for 4 years vs 1 year vintage, rising serum albumin, OR 0.73 (0.59–0.90) per 5 g/L), and with cystic disease as a cause of ESKD, OR 0.38 (95% CI 0.21–0.6). In contrast, catheter use was greater for women than men, OR 1.77 (1.34–2.34) and for 2 out of 10 regional dialysis centres, OR 1.98 (1.02–3.84) and OR 2.86 (1.67–4.90) respectively compared to referent group).ConclusionsCatheters are the predominant type of vascular access in patients undergoing HD in the Irish health system. Substantial centre variation exists which is not explained by patient-level characteristics.

A prospective randomized study of bovine carotid artery biologic graft and expanded polytetrafluoroethylene for permanent hemodialysis access

ObjectiveArteriovenous grafts (AVGs) remain reliable substitutes for permanent hemodialysis access in scenarios that preclude the placement of native arteriovenous fistulas (AVFs). The majority of AVGs are constructed of expanded polytetrafluoroethylene (ePTFE), which is relatively inexpensive and readily available, but synthetic AVGs have poor patency rates. On the other hand, biologic grafts confer an advantage by virtue of their inherent similarity to the native human vasculature. However, evidence to support the current preference of synthetic conduits over biologic grafts in clinical practice is scarce. The aim of this protocol is to propose a contemporary re-evaluation and comparison between ePTFE and bovine carotid artery (BCA) grafts. MethodsThis prospective randomized controlled trial is being conducted at an academic hospital center. A total of 100 patients at least 18 years of age and undergoing AVG placement will be recruited and prospectively randomized into two parallel groups with a 1:1 allocation ratio. Patients eligible to receive AVF and those with a known allergic reaction or history of intolerance to any ePTFE or BCA component will not be included in the study. Moreover, patients with a recent active infection at the site of previous AVG placement and patients with a bleeding disorder, an active malignant disease, or a life expectancy <1 year or who refuse blood transfusion and pregnant women will be excluded. Patients will receive either BCA (experimental) or standard ePTFE grafts (control) in compliance with the National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines for AVG creation. Primary end points include primary, primary assisted, secondary, and functional patency at 1 year and 2 years after graft placement. Secondary outcomes include complications (pseudoaneurysms, infections, and steal syndrome) and reintervention rates during the first and second postoperative years. Outcomes will be assessed and documented every 6 months. ResultsOnce the study is completed, analysis of the data will be performed using univariate methods, and Kaplan-Meier and multivariate Cox proportional regression analyses will be employed to evaluate and to compare outcomes between BCA and ePTFE over time. ConclusionsThe creation of a functional and durable dialysis vascular access is crucial in the treatment of patients with end-stage renal disease and is a challenging quest for vascular surgeons. The proposed study compares the outcomes of synthetic and biologic AVG options in patients who are poor candidates for a native AVF. This will help derive contemporary evidence and improve the care of vascular access patients.

FLEXIBLE INTERCOSTAL GENERATOR FOR PACING AND DEFIBRILLATION

Extravascular (EV) implantable cardioverter defibrillators (ICD) are surgically implanted into the substernal space to provide effective defibrillation and circumvent problems of vascular access in patients with severe left ventricular dysfunction for primary or secondary prevention. Since these

3:45 PM Abstract No. 297 Custom 3D-printed ultrasound-compatible vascular access models: training medical students for vascular access

Commercially available US-guided vascular access models (CM) simulate anatomic and US-visible landmarks; however, they are expensive and do not simulate variant anatomy. The purpose of this study was to compare training efficacy between CM and a novel 3D-printed US-compatible vascular access model (3DPVAM) using a simulation experience (SE) directed at medical students. We hypothesized that student comfort with US-guided femoral artery (FA) access increases after SE, and that 3DPVAM and CM SE efficacy are comparable. A 3DPVAM of normal FA anatomy was developed from an anonymized CT exam. After IRB approval, students were randomized to 3DPVAM or FemoraLineMan CM (Simulab) SE. Students completed a pre-SE questionnaire ranking comfort with FA access on a Likert scale. A standardized SE was administered by IR faculty. Students completed a post-SE questionnaire ranking comfort with FA access on a Likert scale. Student questionnaire results were compared between 3DPVAM and CM groups using Chi-square, Wilcoxon signed-rank, and noninferiority analyses. 15 and 17 students were randomized to 3DPVAM and CM training, respectively. 93.3% of 3DPVAM trainees and 100% of CM trainees had never attempted FA access. 73.3% of 3DPVAM trainees and 76.5% of CM trainees did not feel confident performing FA access. After training and SE, most 3DPVAM and CM trainees agreed that the model was easy to use (93.3% and 94.1%, respectively) and helpful for practice (93.3% and 94.1%). In both groups, training increased subjective student confidence by 2 Likert points (3DPVAM p = 0.001; CM p = <0.0001). The subjective confidence increase in 3DPVAM trainees was noninferior to that in CM trainees (noninferiority margin 1 Likert point, p<0.0001). Generation of an inexpensive custom 3DPVAM and SE is feasible and produces comparable subjective training outcomes to CM. We aim to extend our SE to resident and fellow trainees and to assess objective improvements in the future. We also aim to develop complex 3DPVAMs of variant anatomy and other body regions with the goal of creating customizable models to improve vascular access outcomes and patient safety across multiple disciplines.

Experience with arteriovenous fistula creation for maintenance hemodialysis in a tertiary hospital in South-Western Nigeria

End-stage renal disease (ESRD) is prevalent in our region. A major mode of treatment is by maintenance hemodialysis, and reliable vascular access is paramount for this to be successful. Arteriovenous fistula (AVF) creation offers permanent vascular access in patients with ESRD. We present our experience on AVF creation over a 10-year period. Our objective was to retrospectively review the outcome of all cases of AVF that have been created for ESRD patients at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife Nigeria between January 2006 and December 2015. The demographic characteristics, indications, clinical and intraoperative findings, operative complications and outcomes were filled into a pre-designed proforma. A total of 80 cases were reviewed. The age range was 17-80 years, with a mean of 49.03 ± 16.34 years. Males (85%) were more common than females (15%). Chronic glomerulonephritis and hypertension accounted for about 77.5% of etiology of ESRD in these patients. The left (non-dominant) upper limb was used in 88.1% of cases whereas 11.9% were created on the right upper limb. The distal radio-cephalic AVF (76.3%) was most commonly performed; with either the end (vein) to side (artery) (68.8%) or side-to-side (31.2%) anastomotic techniques employed. There was a primary failure in six patients (7.5%). Primary failure was more common in diabetics and thrombosis (7.5%) was the most common cause for primary failure. AVF creation has very good outcome in well-selected patients.

Two-stage forearm brachio-basilic loop arteriovenous graft for hemodialysis

Introduction. The autologous radio-cephalic arteriovenous fistula (AVF) is the best vascular access for patients on chronic hemodialysis. In some patients with inadequate blood vessels, it is necessary to create proximal AVF, or arteriovenous grafts. High percentage of primary graft failure is noted in cases where diameters of the brachial artery and the basilic vein are insufficient. The aim of this work was to introduce a new surgical technique for arteriovenous creation in patients with inadequate blood diameter. Case outline. The authors have proposed implantation of brachio-basilic polytetrafluoroethylene AV forearm loop graft in two acts. In the first act, the native brachio-basilic AVF was created in the distal region of the arm by side-to-end anastomosis. Three to four weeks after the first act, significant dilatation of brachial artery and basilic vein was noted (confirmed by the use of color duplex sonography technique). During the second act, polytetrafluourethylene graft was implanted by end-to-end anastomosis on the dilated basilica vein. Conclusion. AV graft that was created in two acts has sufficient blood flow without early or late complications. Primary patency was 30 months and secondary patency was 50 months. As an original method in the current literature, we recommend it in different clinical settings when there are no better alternatives for vascular access.

Trends in Vascular Access for Patients Undergoing Percutaneous Coronary Intervention in Australia: A Report From the Melbourne Interventional Group Cohort

Trends in Vascular Access for Patients Undergoing Percutaneous Coronary Intervention in Australia: A Report From the Melbourne Interventional Group Cohort

Bacteremia and thrombotic complications of temporary hemodialysis catheters: Experience of a single center in Morocco

Background: The use of central venous catheters is essential in hemodialysis care, but it is associated with infectious and thrombotic complications. The aim of this study is to determine rates and risk factors of hemodialysis catheter-related bacteremia and thrombotic complications from a Moroccan single center to set prevention policies. Materials and methods: The trial was designed as a prospective observational study including all patients who required a temporary hemodialysis catheter more than 48 h. Baseline demographic and clinical data including age, sex, causes of kidney failure, comorbidities, indication for insertion, catheter insertion sites, and duration of use were collected. Patients were followed up since the insertion of catheter to its removal. Results: A total of 126 hemodialysis catheters were inserted at different sites in 93 patients for the following reasons: the absence of vascular access in patients with end-stage renal disease in 55 cases (43.65%), vascular access dysfunction or infection in 45 cases (35.71%), and acute kidney injury in 26 (20.63%). During follow-up, 15 catheters (11.9%) were complicated by bacteremia, resulting in a rate of 6.68 per 1000 catheter days. Risk factors associated with catheter-related bacteremia were diabetes (odds ratio [OR] =26.018; P = 0.017) and advanced age (OR = 1.105; P = 0.045). Causative microorganisms were dominated by coagulase-negative staphylococci in 46.66%. Twenty-four thrombotic complications (19.04%) were documented with an incidence of 10.69/1000 catheter-days. Among these complications, 18 were dysfunction of catheter (14.28%, 8.01/1000 catheter-days) and 6 were vein thrombosis (4.76%, 2.67/1000 catheter-days). Lower serum albumin levels was the unique risk factor (OR = 0.801; P = 0.042). Conclusions: Early diagnosis of chronic kidney disease and creation of arteriovenous fistula may lower the incidence of catheter use in hemodialysis.

QUALITY OF LIFE OF HEMODIALYSIS PATIENTS WITH ARTERIOVENOUS FISTULA

Objective: to study the basic quality of life in patients with chronic kidney disease and their relationship, with different numbers formed arteriovenous fistula.&#x0D; Materials and methods. Interviewed 56patients, who are treated with chronic hemodialysis department. To study the quality of life used (KDQOL-SF ™). Also used a questionnaire that enables presence fistula determine the impact on quality of life of patients.&#x0D; Results. Using statistical method cluster analysis, made differentiation studied three groups - clusters, which differ in different levels of the indicators of QOL, namely «Patients middle-manifestation of physical and psychological indicators of QOL» – 40%, «Patients with low the manifestation of physical and psychological QOL parameters «- 25% of subjects, and» Patients with high level of physical and psychological manifestations of QOL performance «- 35% sample of of the patients.&#x0D; Based on statistical comparative analysis revealed differences between the estimated quality of life in men and women. Role functioning due to physical condition in women is slightly lowered than men. In women, there is a greater level of pain than men. Men overall higher rate their health than women. Men are characterized by a higher level of social functioning than women.&#x0D; Conclusions. Patients with chronic hemodialysis age have difficulties in physical functioning and performance of daily affairs. Mental health by increasing the biological age becomes stronger and fitter.&#x0D; His attitude to the presence of fistula in upper limb showing men and women equally, that they feel discomfort and limitations in performing daily routine. The more surgeries performed to form vascular access in patients, the occurrence characteristically uncomfortable sensations in all aspects of life

Arteriovenous access banding revisited

The aim of this study is to validate the current applicability of arteriovenous access banding in high flow access (HFA) and/or haemodialysis access-induced distal ischaemia (HAIDI). This retrospective study was conducted at the GEV (Grupo de Estudos Vasculares) vascular access centre. The clinical records of consecutive patients undergoing banding for HAIDI and HFA symptoms, between June 2011 and January 2015, were reviewed until April 2015. All vascular access patients' consultation records and surgical notes were reviewed. We analysed and compared patients' age, gender, comorbidities, symptoms and intraoperative ultrasound control. We defined technical failure as recurrence of symptoms, requiring new banding. Excessive banding, access thrombosis, rupture and false aneurysm development were registered as complications. Primary clinical success was defined as improvement of symptoms or effective flow reduction after banding, with no need for reintervention. If one reintervention was necessary, we have defined it as secondary clinical success. Overall, 119 patients underwent banding: 64 (54%) with HAIDI and 55 (46%) with HFA. The HAIDI group was significantly older (65 ± 13 years compared with 56 ± 22 years, p = 0.001) and had significantly greater number of patients with diabetes (56% vs 24%, p = 0.004). Primary success was achieved in 85 patients (71.4%) and the secondary success rate was 84.9%. Older age (p = 0.016) and intraoperative ultrasound control (p = 0.012) were significantly associated with primary success. Our results do not corroborate the high incidence of thrombosis previously reported as associated with AV access banding and suggest that ultrasound control is crucial for preventing technical failure. The procedure was effective on both compared groups.

Vascular access conversion and patient outcome after hemodialysis initiation with a nonfunctional arteriovenous access: a prospective registry-based study

BackgroundLittle is known about vascular access conversion and outcomes for patients starting hemodialysis with nonfunctional arteriovenous (AV) access. We assessed mortality risk associated with nonfunctional AV access at hemodialysis initiation, taking subsequent changes in vascular access into account.MethodsWe studied the 53,092 incident adult hemodialysis patients included in the French REIN registry from 2005 through 2012. AV access placed predialysis was considered nonfunctional when dialysis began with a central venous catheter. Information about vascular access changes was obtained from treatment modality updates.ResultsAt hemodialysis initiation, AV access was functional for 47% of patients and nonfunctional for 9%; 44% had a catheter alone. After a 3-year follow-up, 63% of patients beginning hemodialysis with a nonfunctional AV access had changed to a functional one, 4% had had a transplant, 19% had died before any vascular access change, and 13% still used a catheter. Cox proportional hazard models with vascular access treated as a time-dependent variable showed an adjusted mortality hazard ratio (95% confidence interval) for patients with nonfunctional AV access who subsequently converted to functional access of 0.95 (95% CI 0.89–1.03) compared with the reference group with functional AV access since first hemodialysis, versus 1.43 (95% CI 1.31–1.55) for those who did not convert.ConclusionsAmong patients starting hemodialysis with a nonfunctional AV access, a substantial percentage may never experience successful vascular access conversion. Poor survival seems to be limited to these patients, while those who subsequently convert to functional AV access have similar mortality risk compared to patients with such access since hemodialysis initiation. Every effort should be made to obtain functional AV access in all suitable patients.

Impact of Indoxyl Sulfate on Progenitor Cell-Related Neovascularization of Peripheral Arterial Disease and Post-Angioplasty Thrombosis of Dialysis Vascular Access.

Patients with chronic kidney disease (CKD) have an increased risk of vascular disease, which is associated with considerable health care costs. Vascular disease in CKD differs clinically and pathobiologically from that in patients with normal renal function. Besides the traditional risk factors, retention of uremic toxins contributes to the pathogenesis of vascular disease in patients with CKD. Indoxyl sulfate is a protein-bound uremic toxin and is inefficiently removed by conventional dialysis. Accumulating evidence suggests that indoxyl sulfate is a vascular toxin involved in atherosclerosis, arteriosclerosis, vascular calcification and vascular repair. Clinically, indoxyl sulfate is associated with total and cardiovascular mortality in patients with CKD. Recent studies have indicated that in addition to coronary and cerebral arteries, indoxyl sulfate plays a role in peripheral artery disease (PAD) and dialysis graft thrombosis. Emerging evidence suggests that indoxyl sulfate is implicated via novel mechanisms, including progenitor cell-related neovascularization and tissue factor-related hypercoagulability. These findings raise the possibility that strategies targeting serum indoxyl sulfate may have the potential to improve the outcomes of PAD and dialysis vascular access in patients with CKD.

Tip Design of Hemodialysis Catheters Influences Thrombotic Events and Replacement Rate

Central venous tunnelled hemodialysis catheters (CVTC) are used for initial vascular access in patients with renal failure. Tip design of the CVTC may play an important role in catheter function and complication rates, influencing adequate hemodialysis treatment of these patients. This prospective, observational cohort study compared the function and complication rates of two CVTCs in patients with end stage renal disease (ESRD) within a follow-up period of 24 months. The study included patients with ESRD who received either a CVTC with a split tip (ST) or a shotgun tip (SG). All patients underwent dialysis within 24h of intervention. Blood flow was documented initially (Qb0) and was followed up after 6 (Qb6), 12 (Qb12), and 24 (Qb24) months. Analysis of blood flow and complication rates within the follow-up period was performed by questionnaires. In total, 185 patients were included, of whom 93 received a ST CVTC and 92 a SG CVTC. Baseline parameters did not differ significantly between groups. CVTC blood flow was not significantly different between the two devices. Thrombolytic therapy with Alteplase was used significantly more often in the ST group (29%) than in the SG group (16%) (p<0.05). The CVTC replacement rate was significantly higher in the ST group (19.3%) compared with the SG group (8.7%) (p<0.05). The tip design of CVTC (split or shotgun) appears to be irrelevant for long-term blood flow during dialysis treatment. However, patients may benefit from SG catheters over ST catheters where replacement rates and thrombolytic treatment are concerned.

ARTERIOVENOUS FISTULA IN A PATIENT WITH ABERRANT RADIAL ARTERY

Abstract Arteriovenous fistula is the most commonly used vascular access in patients on maintenance hemodialysis. Operating surgeon has to be aware about the normal anatomy of vessels as well as variations in the course of the vessels. Here wereport a case of radiocephalic arteriovenous fistula constructed in aberrant radial artery. This is the first case of arteriovenous fistula with aberrant radial artery to be reported in world literature.

AIUM Practice Parameter for the Performance of Ultrasound Vascular Mapping for Preoperative Planning of Dialysis Access

AIUM Practice Parameter for the Performance of Ultrasound Vascular Mapping for Preoperative Planning of Dialysis Access

A randomized controlled trial assessing the use of ultrasound for nurse-performed IV placement in difficult access ED patients

ObjectiveThis study analyzed outcomes associated with nurse-performed ultrasound (US)–guided intravenous (IV) placement compared to standard of care (SOC) palpation IV technique on poor vascular access patients. MethodsThis was a randomized, prospective single-site study. Phase 1 involved education/training of a cohort of nurses to perform US-guided IVs. This consisted of a didactic module and hands-on requirement of 10 proctored functional IVs on live subjects. Phase 2 involved patient enrollment. emergency department patients meeting strict criteria of poor access were randomized to US-guided or SOC palpation arm. A functional IV placed by a study nurse was considered successful. Unsuccessful placement implied the study nurse failed, and a rescue IV was attempted. Time to IV placement was the total time required to obtain a functional IV and, if needed, a rescue IV. ResultsA total of 124 subjects were enrolled; 63 were randomized to the US-guided arm, and 61 were randomized into the SOC arm; 2 patients were excluded, leaving 59 patients. Success rate was 76% for the US-guided arm and 56% for the SOC arm (P=.02). Compared to the SOC arm, the odds ratio for success for the US-guided arm was 2.52 (95% confidence interval, 1.09-5.92). The mean time to IV placement for the US-guided arm was 15.8 and 20.7 minutes for the SOC arm (P=.75). ConclusionIn difficult access patients, nurses were more successful in obtaining IV access using US guidance than palpation SOC technique. Lengthier placement times were observed more frequently when the SOC IV technique was used.

Intraosseous vascular access in disasters and mass casualty events: A review of the literature.

The intraosseous (IO) route of vascular access has been increasingly used to administer resuscitative fluids and drugs to patients in whom reliable intravenous (IV) access could not be rapidly or easily obtained. It is unknown that to what extent the IO route has been used to gain vascular access during disasters and mass casualty events. The purpose of this review was to examine the existing literature to answer the research question, "What is the utility of the IO route compared to other routes for establishing vascular access in patients resulting from disasters and mass casualty events?" Keyword-based online database search of PubMed, CINAHL, and the Cochrane Database of Systematic Reviews. University-based academic research cell. Included evidence were randomized and nonrandomized trials, systematic reviews with and without meta-analysis, case series, and case reports. Excluded evidence included narrative reviews and expert opinion. Not applicable. Of 297 evidence sources located, 22 met inclusion criteria. Located evidence was organized into four categories including chemical agent poisoning, IO placement, while wearing chemical protective clothing (PPE), military trauma, and infectious disease outbreak. Evidence indicates that the IO route of infusion is pharmacokinetically equal to the IV route and superior to the intramuscular (IM) and endotracheal routes for the administration of antidotal drugs in animal models of chemical agent poisoning while wearing full chemical PPE. The IO route is superior to the IM route for antidote administration during hypovolemic shock. Civilian casualties of explosive attacks and mass shootings would likely benefit from expanded use of the IO route and military resuscitation strategies. The IO route is useful for fluid resuscitation in the management of diarrheal and hemorrhagic infectious disease outbreaks.