Search

Intravenous catheters are multiple and essential for daily practice. They are also responsible for high morbidity and mortality. Simple or echo-guided peripheral venous catheters, midlines, PICCline, tunneled or non-tunneled central venous catheters, and implantable venous access device are currently at our disposal. Thus, catheter selection, duration and indications for use, and prevention and treatment of complications vary according to the situation. The objective of this update is to provide the clinician with an overview of knowledge and rules of good practice on the use of catheters.

Avulsion anterior cruciate ligament injuries are more common in pediatric patients. There are several methods of fixation available for these injuries (tibial intercondylar eminence fractures), such as the pullout suture technique, screw fixation, and suture anchor fixation. Currently, a pullout technique is widely used for fixation. We purpose a pullout technique method using a modified No. 16 intravenous catheter needle to suture the anterior cruciate ligament fiber instead of a suture hook or suture passer. We also use one anterior tibial tunnel for this arthroscopic pullout fixation technique to decrease the incidence of physeal injury in pediatric patients by using many tibial tunnels.

Background Microorganisms causing catheter-related bloodstream infections colonize to intravenous catheters (IVC)—particularly to connectors mounted to catheters. The aim of this study was to examine the colonization in 3-way stopcock (TWS) connectors and needleless connectors (NCs) that integrated into central, port, and peripheral venous catheters. Methods This random, experimental study consisted of 180 connectors that were inserted into the IVCs of patients in general surgery, reanimation intensive care, and daily chemotherapy units. Cultures of the connectors were obtained at least 48 hours after connecting to IVCs. Results This study showed that gram-negative, gram-positive, and other pathogens reproduced, although their colonization level was not high enough to develop an infection. When the results of colonization for patients using TWS and NC were compared, the peripheral venous catheters (using a TWS) resulted in a significantly higher increase in reproduction than in patients using NC (P ≤ .01) and no significant difference in the level of colonization in other types of connectors or catheters (P ˃ .05). Conclusions The study's results indicated no significant difference between NC and TWSs in terms of reproduction. It should also be noted that connectors integrated into IVC pose a risk in the development of catheter-related bloodstream infections.

We report a case of asymptomatic iatrogenic air bubbles in the left ventricle observed by coronary computed tomographic angiography. Air bubbles are rarely found in the left ventricle and could prove fatal should they migrate to the brain or coronary arteries. We believe that the cause is micro air bubbles in the tubing system between the intravenous catheter and power injector. Keywords: Iatrogenic air bubbles, Coronary computed tomographic angiography, Intravenous catheter, Power injector, Contrast medium, Patent foramen ovale

Peripheral veins often contain tortuosities and valves that hinder the effective passage of intravenous catheters to the full extent of catheter length. This report describes a methodology termed flick-spin that has proven efficacious for venous catheter passage in tortuous and valve-rich peripheral veins. The method relies on (1) applying longitudinal tension to the vessel in an attempt to straighten it, (2) rotating or spinning the catheter along its longitudinal axis, and (3) flicking the skin or visible vein just beyond the catheter tip, all during catheter advancement. Additionally, lateral pressure may also be applied to the vessel—ie, proximal to the catheter tip and during catheter advancement—to fine-tune catheter tip direction. The report contains multiple illustrations to communicate the anatomic, physiologic, and technical underpinnings of the technique, as well as instructions for troubleshooting common problems.

Objective The aim of this study was to assess the effect of inhalation aromatherapy with lavender essence on the pain severity of intravenous catheter insertion in hospitalized preschool children. Method A quasi-experimental study involving 60 participants using convenience sampling were assigned to control (n = 30) and aromatherapy (n = 30) groups. Children in the aromatherapy group inhaled 5 drops of the essence, while children in the control group inhaled 5 drops of distilled water, 20 min before venipuncture. Pain severity was measured using OUCHER scale 10 min after catheterization. Results Mean of pain severity between the aromatherapy and control groups demonstrated a significant difference immediately (P = 0.002) and 5 (P = 0.001) and 10 min (P = 0.01) after intravenous catheter insertion. Mean of pain severity in the three assessed time points had significant differences in aromatherapy and control groups (P = 0.001). Conclusion Aromatherapy with Lavender essence helped to reduce pain severity of intravenous catheter insertion in children.

Contribution to Emergency Nursing Practice •By providing the nurses working in the emergency department evidence that a change in practice will help them in their flow of work and contribute to getting their work done faster. Furthermore contributing in decreasing length of stay and decrease emergency department overcrowding. •By creating an easy way to make care provided to patients be more holistic, helping the emergency department nurses satisfy their patients more and be empowered as patient advocates. •By provided a new practice where the emergency department nurse would provide care in all aspects to safety for patient and themselves in light of reduction of sharp injuries, blood and body fluid exposure by using the vacationer system. Abstract Problem Laboratory tests are essential to diagnosis and treatment in the emergency department, but they can result in prolonged waiting times for patients, multiple needle pricks, and complaints about pain and discomfort. The goal of this project is to assess if a change in the blood collection process will lead to any improvement and benefit in care delivered with regard to time, patient comfort, and cost. Methods A feasibility study was conducted to evaluate the change in practice from cost, time, and applicability perspectives. Using an observational approach, data were collected about the management of a possible change in practice in the emergency department at American University of Beirut Medical Center. Trials of 2 proposed changes to practice were conducted and compared with the current practice. The nurses were trained in the proper use of blood withdrawal using a Vacutainer Luer adaptor. Results It was shown that intravenous line insertion and blood collection processes using the Vacutainer Luer adaptor were conducted in 46.2 seconds, which is less time spent than the current process but requires a small investment. Implications for Practice Allowing registered nurses to withdraw blood with the start of a peripheral intravenous line will significantly reduce length of stay and costs and enhance patient experience in the emergency department at American University of Beirut Medical Center.

Introduction. Starting the first case in the operating room (OR) on time leads to efficient scheduling; optimized use of time and resources. We assessed if a delayed start of the first case was occurring, if on- time completion at the end of each session was achieved, and identified delaying factors. Methods. An initial pilot study of twenty-six sessions found an average delay of 15.4 min. Based on ASC nurse and technician perceptions, one ASC nurse recorded delays as either late surgeon or patient arrival, extended patient interview, delay in anesthesia; equipment or OR delay. Data from the end time of sixty-three sessions were analyzed. Results. Of 63 sessions, 54% started past the scheduled start time. The average OR delay was 5.05 min. Seventeen sessions were late due to surgeon arrival, one from anesthesia arrival, three with difficult intravenous catheter insertion, one from an extended patient interview, five from equipment malfunctions; seven from OR delays. Thirty-three sessions concluded past scheduled end time; the average completion was 4.6 min past the scheduled end time. Conclusion. Late starts are minimized with physicians arriving on time, prompt assessment of equipment function and supply needs for each case after staff arrival, and the effective communication of physician arrival. First case on-time start is one factor, but turnover times and case durations are more influential in finishing a session late.

Background With the advancement of technology, methods such as clinical scenarios, role playing, video demonstration and simulation are now used to develop psychomotor skills in nursing education. Virtual reality and video-assisted teaching are useful technologies for the development of skills and self-confidence. In the literature, there is a lack of studies comparing the effects of the two methods. Objectives The aim of study is to compare the effect of the virtual simulator and video assisted teaching on the level of intravenous catheterization skills and self-confidence of nursing students. Thus, students are enabled to develop skills and work efficiently without the need for an instructor. Methods This study was a randomized controlled quasi-experimental study. A total of 60 students was included in the study (30 in the virtual simulator group and 30 in the video group). In the virtual simulator group, each student performed an intravenous catheter insertion in the virtual intravenous simulator. In the video group, each student watched a training video on the peripheral intravenous catheterization skill in a classroom setting. Each of the students' level of intravenous catheterization knowledge, psychomotor skill and self-confidence score was evaluated. Results Post-test knowledge scores was higher than pretest knowledge scores for both groups. There were no significant difference between the groups in terms of post-test scores. Students' scores of psychomotor skills were found to be higher in the virtual simulator group and self-confidence scores were similar in both groups. Conclusion Teaching with the virtual simulator contributed to the students' skills more than the method used in the video training. Both methods are effective in the development of knowledge and self-confidence related to intravenous catheterization.

Introduction The purpose of this study was to show that acceptable blood samples can be collected through intravenous (IV) catheters. Hemolysis of blood samples and appropriate methods of blood sample collection can be a topic of controversy in an emergency department and throughout a hospital. This investigation was conducted by laboratory personnel and ED nursing staff at a moderately sized hospital in the northwestern United States. Nearly 9,000 blood draws were collected and categorized between May and August 2011 to determine hemolysis rates. At the start of this project, there was some question about whether blood collected from IV catheter starts in the emergency department provided an acceptable laboratory sample. By the end of the project, it was clear that low rates of hemolysis were consistently achievable by each of the 3 methods investigated. Methods Information was collected electronically as part of the standard laboratory intake and processing of samples. The level of hemolysis in a blood sample was measured spectrophotometrically by automated laboratory equipment as part of the sample intake process. The data were then cataloged and presented monthly. Because of the simplicity of this project and the clarity of the results, only simple summary statistics were performed to assist in interpretation of the data. Results The rates of blood samples rejected because of hemolysis were as follows: 1.1% when collected from an IV catheter start, 0.8% when collected from an existing vascular access, and 0.1% when collected by venipuncture with a steel needle. Discussion The data show that low rates of samples rejected because of hemolysis are achievable by the collection of blood from an IV catheter start. With all 3 collection methods studied, the sample rejection rates because of hemolysis were well below the 2% level that has been cited as a benchmark best practice of the American Society of Clinical Pathology. The results of this investigation clearly support the use of blood samples collected from IV starts.

Purpose Anesthetics used to decrease pain during peripheral intravenous catheter insertion have been studied with equivocal results. This meta-analysis determined if lidocaine or bacteriostatic normal saline (BaNS) is more effective in reducing pain associated with peripheral intravenous catheter cannulation in adults. Methods PubMed, EMBASE, CINAHL, ProQuest Dissertation and Theses, and Web of Science databases were queried. Thirteen randomized controlled trials were analyzed. Results Mean sample was 119.9 (±82.0); combined N was 1,559. Mean effect size was z = 0.46 (confidence interval = 0.24-0.68) indicating lidocaine was more effective than BaNS in providing pain relief ( P Conclusion Cost-benefit issues and lidocaine drug shortages must be considered when making definitive practice recommendations.

Purpose: to investigate if nurses at neonatal units in Sweden have adopted national guidelines when neonates are exposed to intravenous catheter, capillary heel prick, venepuncture and injections, to identify the frequency of documentation of pharmacological and behavioural treatments and to compare the answers from the nurses with results from an earlier national survey completed by the chief neonatologists at the same units. Design and sample: Four nurses at a total of 44 neonatal units in Sweden, received questionnaires. A total number of 116 surveys were analysed (response rate 66 %). Main outcome and results: All units had written guidelines for prevention and treatment of pain. Behavioural treatments were used in every painful procedure in the study, but only1/5 used EMLA® often or always. There was a higher tendency to document the use of drugs than behavioural treatments. The chief neonatologist reported higher use of glucose than did nurses. Conclusions: Swedish national guidelines are not used consistently in some neonatal units. There is a considerably larger cohort of nurses who use behavioral treatments, rather than using drugs when painful procedures are performed. It was also evident that it was more common to document the use of drugs than behavioral treatments., NeoOpioid - smärtlindring i nyföddhetsperioden

Background Our program's most recent ACGME Resident Survey revealed that residents felt inadequately prepared to perform many required procedures without supervision. Moreover, current residents noted a poor understanding about which procedures are considered “essential” by the ACGME and independently voiced a desire for more dedicated training in emergent stabilization of critically ill children. Objective Improve procedural competency in pediatric residents through education, dedicated procedural time, and simulation. Methods Our program pursued the following methods: 1) Design and distribute a procedure passport for resident reference. This credit card sized tool delineates the 13 “essential” ACGME procedures and includes a target number of procedures to complete on certain rotations. 2) Develop a half day experience where residents work with a nurse completing procedures such as intravenous catheter placement, venipuncture, and bladder catheterization in the ED. 3) Organize intensive small-group sessions to emphasize bag valve mask ventilation and pediatric intubation. Each resident completes these half day simulated code experiences annually in addition to our monthly mock code curriculum. Results We obtained survey responses from residents about the utilization of the passport, and 47% felt it helped them better understand ACGME requirements. Additionally, 24% felt the passport helped them take initiative to complete procedures independently. Of the residents paired with nurses, 92% felt it was valuable. In addition to the previously listed procedures, residents also completed arterial draws, intraosseous lines, incisions and drainage, laceration repairs, and nasogastric tube placements. Conclusions A clear and tangible delineation of ACGME requirements helps educate and support residents independently completing procedures. Furthermore, increasing clinical time in areas with high procedural volume seems to be both well regarded and clinically beneficial. The expanded use of simulation has promise as an educational tool for procedural practice, and we are currently evaluating its utility as well as launching a procedural elective.

Biofilms are bacterial communities encapsulated within a self-secreted extracellular polymeric substance and are responsible for a wide range of chronic medical device related infections. Understanding and addressing the conditions that lead to the attachment and detachment of biofilms from biomedical surfaces (orthopaedic implants, sutures, intravenous catheters, cardio-vascular stents) has the potential to identify areas of the device that might be more prone to infection and predict how and when biofilms might dislodge. In this study, an integrated software methodology was devised to create image-based microscopic finite element models of real biofilm colonies of Staphylococcus aureus attached to a fragment of surgical suture. The goal was to predict how deformation of the suture may lead to the potential detachment of biofilm colonies by solving the equations of continuum mechanics using the finite element method for various loading cases. Tension, torsion and bending of the biomaterial structure were simulated, demonstrating that small strains in the suture can produce surface shear stresses sufficient to trigger the sliding of biofilms over the suture surface. Applications of this technique to other medical devices are discussed.

Objective The use of an intravenous catheter with a rest period has been recommended to avoid false-positive results for hyperprolactinaemia and false-negative results for hypocortisolaemia. We tested the relevance of this recommendation. Design Plasma cortisol and prolactin levels were determined before (T-15) and after a 15-min rest period (T0) in 119 patients, 38 males (M) and 81 females (F). 52 of the 119 patients were known (K; 30 females and 22 males) and 67 unknown (UK; 49 females and 18 males) to the unit. Results Prolactin was lower after rest in women (12.3 ± 22.7 ng/l vs 11.7 ± 22.5 ng/ml, P = 0.03), but not in men (6.2 ± 4.5 ng/ml at T-15 vs 5.8 ± 3.2 ng/ml at T0, P = 0.09), in the UK subgroup (10.6 ± 20.7 ng/ml at T-15 vs 10.1 ± 20.9 ng/ml at T0, P = 0.06) and in the K subgroup (10.1 ± 16.7 ng/ml at T-15 vs 9.7 ± 15.8 ng/ml at T0, P = 0.08). None of the patients with prolactin levels higher than 20 ng/ml at T-15 diminished its prolactin value below this cut-off value. Plasma cortisol levels were lower after rest in women (17.9 ± 5.9 μg/dl at T-15 vs 16.5 ± 6.1 μg/dl at T0, P P = 0.0003) but not in men (18 ± 4.4 μg/dl at T-15 vs 17.5 ± 5.8 μg/dl at T0, P = 0.47) and in the K subgroup (17.8 ± 4.6 μg/dl at T-15 vs 17 ± 5.4 μg/dl at T0, P = 0.13). At T0, 3.3% and 15% of patients presented values below the cut-off value of 10 μg/dl (276 nmol/l) and 17 μg/dl (470 nmol/l), respectively. Conclusion These results don’t justify intravenous catheterisation with a rest period for plasma prolactin determination in contrast with plasma cortisol determination.

Introduction Intravenous (IV) catheter placement is an extremely common painful procedure performed in all ages and healthcare settings, more often than not without anesthetic, despite clear research and guidelines demonstrating their effectiveness. This study examined differences in pain scores following topical anesthetic and placebo application, in a sample of healthy adult volunteers experiencing IV catheterization. Methods During this prospective, placebo-controlled, double-blind study, 43 subjects were randomized to receive LMX-4 on one hand and hand cream on the other 30 minutes prior to IV catheterization. Paired t-tests were used to measure the difference in pain scores between hands. Pain scores were reported utilizing a visual analog scale (0-10 cm) immediately after each stick. As a control, the difficulty of the IV stick was rated on a 0-10 cm scale and recorded by the nurse who started the IV. Results The mean pain score and standard deviation reported for the LMX-4 hand was 3.2 (SD=2.25, range, 0-8.5 cm), while the placebo hand was 4.67 (SD=2.25, range, 0.25-10 mm). The mean paired difference between LMX-4 and placebo hands was -1.37 (95% CI; -2.2, -0.49); subjects receiving LMX-4 reported clinically as well as statistically significant pain reductions (t=-3.17, p=0.003). When adjusted for difficulty of stick, pain scores continued to remain lower in the LMX-4 hand. Discussion These findings suggest that the topical use of LMX-4 anesthetic cream is a viable option for reducing the pain associated with IV catheter insertion in adults.

The objective of this study was to evaluate the LH and ovulatory response of dominant and subordinate dairy does following the introduction of males. A behavioral study was carried out to determine the individual success index (SI) of 35 anestrous does according to their ability to dominate other females. The 8 highest-ranking (highest SI) and the 8 lowest-ranking does (lowest SI) in terms of dominance were separated from the rest of the herd and placed together in the same pen, where a male was later introduced. Blood samples for plasma LH determinations were obtained from the 16 females at 30 min intervals from 0 to 6, 12 to 18 and 33 to 39 h after the introduction of the male, using an intravenous catheter. After day 8, plasma progesterone was also measured daily in order to determine the occurrence of ovulation. None of the does showed LH pulses during the sampling period prior to the introduction of the male. The dominant does showed significantly (p

Introduction Re-collection of hemolyzed blood specimens delays patient care in overcrowded emergency departments. Our emergency department was unable to meet a benchmark of a 2% hemolysis rate for the collection of blood samples. Our hypothesis was that hemolysis rates of blood specimens differ dependent on the blood collection technique by venipuncture or intravenous catheter draw. Methods A prospective, cross-over study of blood collection techniques in a 64,000 annual visit, community teaching hospital emergency department was conducted. Eleven experienced registered nurses with more than 2 years' ED experience completed a standardized phlebotomy retraining session. Registered nurses were randomly assigned to collect samples via intravenous catheters or venipuncture. After nurses collected 70 samples, they then collected samples via the other method. A standardized data collection form was completed. Blood samples were processed and assessed for hemolysis using standard procedures by laboratory technicians who were blinded to the collection method. Results A total of 853 valid samples were collected; 355 samples (41.6%) were drawn via venipuncture and 498 samples (58.4%) were drawn through an intravenous catheter. Of these, 28 intravenous catheter samples (5.6%) were found to be hemolyzed, whereas only 1 venipuncture sample (0.3%) was hemolyzed. This finding was significant (x2 Discussion Experienced ED nurses can reduce the number of hemolyzed specimens by collecting via venipuncture instead of through intravenous catheters. This practice should be considered as standard of care in the ED setting. Limitations: Total samples by nurse were affected by EMS patients arriving with existing intravenous lines, and nurse schedules affected total samples per nurse.

Catheter-based epicardial mapping is possible with two access methods: transthoracic pericardial access and transvenous access. Transthoracic pericardial access is based on the introduction of the catheters into the pericardial space using a percutaneous subxiphoid puncture and may at times require lengthy sequential mapping procedures. From the transthoracic pericardial approach major regions of the epicardium may also be inaccessible. Transvenous access uses the multielectrode (4-20 electrodes) catheters placed in the coronary veins thus increases the speed of the mapping procedure, however, leaves most of the epicardium inaccessible to direct measurement. The aim of this present study is to demonstrate that the reconstruction of the high-resolution maps using sparse measurements from different sites on the epicardium and on the multielectrode catheters is possible with a reasonably high accuracy in terms of locating the origin of the ventricular arrhythmia. In this study we investigated strategies for the reconstruction of epicardial potential distribution from recordings of intravenous and transthoracic epicardial mapping catheters, alone and in combination. For this purpose, we first examined the problem of best number of epicardial measurement sites (or best sampling resolution) using transthoracic mapping catheters and secondly studied the feasibility of the combined usage of both mapping approaches. In the prediction of the surrogate measurements at inaccessible sites from the measurements localized to the cardiac veins and sparse epicardial sites we evaluated two prediction methods: the Laplacian interpolation and statistical estimation, to overcome the sparsity of the measurements. We performed 14 dog experiments with various interventions to create a high-resolution epicardial potential map database. This database included a total of 592 beats which were recorded using a sock array placed on the ventricles of dog hearts. We found that 2 cm sampling resolution is quite feasible, which means that the time for the mapping procedure may be reduced considerably. Predictions from the combination of 21 intravenous catheter leads and 30 transthoracic catheter leads were better than when only 21 or 30 leads were used. The results of this study encourage further investigation and provide adequate evidence that an epicardial mapping approach based on the combined usage of transvenous and transthoracic pericardial access methods for the mapping of the outer surface of the heart is feasible and can provide adequate accuracy for clinical applications.

Objective Many children undergoing surgery for congenital heart disease have had prior operations. Reoperative sternotomy carries with it the risk of cardiac injury and the need for emergency peripheral cannulation. Unfortunately, in smaller children, many of the standard sites are occluded, stenosed, or too small for the smallest manufactured cannulas. Using a model, we evaluated the feasibility of using peripheral intravenous catheters for establishing cardiopulmonary support. Methods A model cardiopulmonary bypass circuit was created. Catheters of varying diameter and length were used to simulate arterial cannulation. With each catheter, flows were incrementally increased until a maximum arterial line pressure was achieved. Data were recorded. Results Catheter diameters increased from 24 to 14 gauge, and catheter lengths increased from 1 inch to 1.88 inches. Flow could not be established through the 24-gauge catheter without an unacceptably high arterial line pressure. From the next smallest catheter (22 gauge × 1 inch) to the largest catheter (14 gauge × 1.88 inches), maximum achievable flow rates ranged from 70 to 540 mL/min, respectively. Conclusions Peripheral arterial cannulation may be lifesaving in cases of complicated sternal re-entry in children. Intravenous catheters can be used when vessels are too small for standard cannulas. Flow rates that provide adequate support while maintaining acceptable arterial line pressures are achievable with peripheral intravenous catheters until central cannulation can be accomplished safely.

Catheter-based electrophysiological studies of the epicardium are limited to regions near the coronary vessels or require transthoracic access. We have developed a statistical approach by which to estimate high-resolution maps of epicardial activation from very low-resolution multi-electrode venous catheter measurements. This technique uses a linear estimation model that derives a relationship between venous catheter measurements and unmeasured epicardial sites from a set of previously recorded, high-resolution epicardial activation-time maps used as a training data set based on the spatial covariance of the measurement sites. We performed 14 dog experiments with various interventions to create an epicardial activation-time map database. This database included a total of 592 epicardial activation maps which were recorded using a sock array placed on the ventricles of dog hearts. We present five approaches, which examined sequential addition and removal of maps to select a generalized training set for the estimation technique. The selection consisted of choosing a subset of epicardial ectopic activation-time maps from the database of beats which resulted in estimation accuracy levels better than or at least similar to using all the maps in database. Our aim was to minimize the redundancy in the database and to be able to guide the eventual procedures required to obtain training data from open-chest surgery patients. The results from this study illustrated this redundancy and suggested that by including an optimal subset (around 100 maps) of the full database the estimation technique was able to perform as well as and even in some cases better than including all the maps in the database. The results also suggest that such an approach is feasible for providing accurate reconstruction of complete epicardial activation-time maps in a clinical setting and with fewer maps we can obtain similar reconstruction accuracy levels.

Doxorubicin, or “the red devil,” as patients affectionately call it because of its color as it flows through their intravenous catheters, is without a doubt one of the most widely prescribed and effective cytotoxic drugs, used in the treatment of cancer. However, its use has been limited by its

In-vitro hemolysis is a great challenge to emergency departments where blood is drawn from intravenous catheters (IVCs). Although high quality samples can be obtained by straight needle venipuncture, IVCs are preferred for various reasons. The aim of this study was to identify blood collection practices that reduce hemolysis while using IVC.The study was conducted at an emergency department where blood is drawn in ≥ 90% of patients from IVC. Hemolysis, measured spectrophotometrically, was compared between syringe and vacuum tubes. The following practices were tested in combination with vacuum collection; a Luer-slip adapter, a Luer-lock adapter, discard tubes and low vacuum tubes. Each intervention lasted 1 week and retrieved 154 to 297 samples. As reference, hemolysis was also measured in vacuum tubes retrieved from departments where only straight needle venipuncture is performed.Vacuum collection led to more hemolytic samples compared with syringe tubes (24% versus 16% respectively, p=0.008). No difference in hemolysis was observed between the Luer-slip and the Luer-lock adapter. The use of discard (17% hemolytic, p=0.045) and low vacuum tubes (12% hemolytic, p0.001) substantially decreased hemolysis. None of the interventions reduced the hemolysis rate to the level observed when drawing blood by straight needle venipuncture (3%, p0.02).In summary, both discard and low vacuum tubes reduce hemolysis while drawing blood from IVC. Of these practices the use of a low vacuum tube is preferred considering the less volume of blood and the amount of tubes drawn.

Therapeutic failure is a situation to be feared in severe infections due to staphylococci. In this article, we consider the difficulties faced is achieving a positive diagnosis in the context of such failures, and an approach to analysing their causes. The possible reasons for therapeutic failure must be considered systematically. The two principle causes are unquestionably the persistence in the patient of an infected, foreign body (intravenous catheter or prosthesis) and endovascular infections (thrombophlebitis or endocarditis). The rules for the prescription of antibiotics are followed, target concentrations are achieved and drug failures are a rarity today. This observation may be called into question by the emergence of strains with diminished sensitivity to glycopeptides. These therapeutic failures remain exceptional cases today.

Summary Fragmentation of an intravenous, polytetrafluoroethylene catheter occurred in three horses. The retained fragment was identified in the cervical region by radiography and in the jugular vein by ultrasonography. The retained fragment was removed successfully by jugular venotomy.

Many systems and techniques for continuous vascular access in small animals have been described. Problems with these systems have included (1) insufficient free movement, (2) sepsis, (3) high cost, (4) complicated construction, (4) thrombosis, and (5) dislocations of the intravenous catheter. The described operative techniques and a new experimental setup overcome these complications. The apparatus involves a swivel that is connected with an intravenously placed polyurethane catheter. A leather harness on the back of the animal is connected with the end of the swivel joint via a silicone tube in which the intravenous catheter runs to the swivel. The swivel, a modified conventional glass syringe, is positioned in ball bearings and a Johnson joint. The swivel, ball bearings, and Johnson joint are counterbalanced and can move up and down. When this system was used, the catheters functioned well for as long as 28 days, with a mean duration of 24.4 ± 1.8 days (n = 420). Five catheter dislocations resulted from harness failure, and three dislocations were caused by animals twisting. All animals gained weight (3.53 ± 0.37 gm/day (mean ± SEM)). The rotary portion of the swivel and the Johnson joint secure stressless movement of the animal, avoiding twisting and dislocation of the catheter, which overcomes typical problems of existing methods. The low thrornbogenicity of the polyurethane catheter also reduces complications. A further advantage is low cost, because prefabricated, reusable materials are used.

Intravenous catheter placement can save lives during the anesthetic experience. Utilization of catheters during ruminant swine anesthesia will make it possible to administer injectable anesthetics, rapidly access the cardiovascular system in response to unanticipated acutely life-threatening events, and perfuse the animal continuously with intravenous fluids that may help correct the blood Ph anomalies and organ perfusion problems that would otherwise complicate anesthetic procedures in these animals. This article discusses catheter selection, advantages of different sites, catheterization placement techniques, maintenance, and complications. To help the practitioner select the appropriate materials, several tables are included that indicate the manufacturer's name and suggested price for each item. Where appropriate, comments are made by the authors regarding advantages and disadvantages of each.

Intravenous anaesthesia encompasses intravenous induction and intravenous maintenance of anaesthesia. Children dislike needles, and therefore there is a tendency to first consider inhalational methods for induction of anaesthesia. However intravenous anaesthesia is indicated when a rapid sequence induction is needed and many paediatric anaesthetists find intravenous induction rapid and safe when an intravenous catheter is in place or can be inserted without undue trauma. Also some children do not tolerate smelly gaseous induction! Until recently, irrespective of induction technique, anaesthesia was maintained by inhalational agents. Since the recent introduction of intravenous agents with suitable pharmacokinetic profiles there is increased interest in using intravenous agents to maintain anaesthesia. This trend is enhanced by the development of computer controlled infusion pumps which can deliver the drug according to a pharmacokinetic model. This article reviews the impact of developmental physiology on intravenous drug distribution, metabolism and elimination in children and presents current practice and some recent advances in intravenous anaesthesia for paediatric practice.

SUMMARY Infection remains a significant cause of morbidity and mortality in cardiac transplant patients. Skin infections are not uncommon in these patients. Although usually caused by secondary dissemination after initial infection of another organ system, some skin infections may be primary infections, such as bacterial infections caused by the use of intravenous catheters or fungal infections in severely immunosuppressed patients. Nevertheless, the presence of skin lesions in a transplant patient may indicate infection in a primary site or another deep-seated focus of infection.

Introduction In response to the needs of our patients for infusion of IV medications and fluids and our staff needing to maintain long-term catheters, we continually look for the best catheter available to meet the needs of these two groups. Previous placement and use of a wide variety of tunnelled catheters have identified one continuing, and as yet unsolved, problem. Long-term catheters in this facility are placed in oncology and haematology patients for two primary reasons: 0) to enable the prescribed therapy to be delivered, and (2) to permit the withdrawal of blood for sampling purposes whenever the patient's condition dictates. The main area for concern about the use of longterm catheters, highlighted by both patients and staff, is a continuing, intermittent inability to withdraw blood through the lumen of indwelling catheters. As a consequence of this, the patient may have to undergo multiple venipunctures in order to obtain a blood sample. If blood withdrawal through the lumen of IV catheters is restricted (in order to preserve functionality of the catheters), then the catheters used at our facility fulfill only part of their intended function. Our commitment to our patients is to proVide a continuously improving standard of care, so reviewing all newly available products is an important aspect of the service we provide as an IV team. To that end, an evaluation of a valved intravenous catheter (Catheter Innovations, Inc., Salt Lake City, UT) has been ongoing for the past several months.

The effects of desipramine treatment (0.56-10.0 mg/kg per day) on cocaine self-administration were compared to saline treatment in five rhesus monkeys. Cocaine (0.050 or 0.100 mg/kg per inj) and food (1 g banana pellets) self-administration were maintained on an FR 4 (VR 16:S) reinforcement schedule. Desipramine (or an equal volume saline control solution) was infused over 1 h each day through the second lumen of an intravenous catheter. After 5 days of baseline saline treatment, seven doses of desipramine each were administered for 5 days in an ascending order. Cocaine self-administration increased (P less than 0.01) or remained equivalent to base-line levels in 4 of 5 subjects during the first 15 days of desipramine treatment (0.56 to 1.78 mg/kg per day). Three monkeys continued to self-administer cocaine equivalent to or significantly above base-line levels (P less than 0.01) during days 16-30 of desipramine treatment (3.2-7.86 mg/kg per day). The highest desipramine dose (10 mg/kg per day) significantly suppressed cocaine self-administration in only one of these three monkeys (P less than 0.01). Desipramine treatment (3.2-10.0 mg/kg per day) suppressed cocaine self-administration (P less than 0.01) without a concomitant suppression of food-maintained responding in one of five subjects. A generalized suppression of both cocaine and food-maintained responding (P less than 0.01) during desipramine treatment occurred in one monkey that took the highest base-line levels of cocaine (6.3 +/- 1.03 mg/kg per day). Food-maintained responding remained equivalent to or significantly above (P less than 0.01) base-line levels in four of five monkeys during desipramine treatment. A transient decrease in food self-administration at desipramine doses of 1.78-5.62 mg/kg per day occurred in one monkey (P less than 0.01). Thirty days of desipramine treatment at the highest doses (5.62, 7.86 and 10.0 mg/kg per day for 10 days each) also did not suppress cocaine self-administration in a monkey that took an average of 4 mg/kg per day of cocaine during saline base-line treatment. These primate data are concordant with the extant clinical literature on the inconsistent effects of desipramine treatment; i.e., both stimulation of cocaine use and inconsistent or incomplete attenuation of cocaine abuse during desipramine maintenance have been reported.

Intravenous fluid therapy is valuable as primary or ancillary therapy for many conditions in calves. The first step in developing an intravenous fluid plan is determination of the volume needed to replace the fluid deficit, estimated on the basis of clinical signs. The parenteral solution to be used is chosen to be similar in electrolyte composition to the fluid lost. Abnormalities of specific electrolytes, acid-base balance, and energy metabolism can be addressed during volume replacement; this requires an understanding of the pathophysiology of the primary clinical abnormality. The fluid delivery system is composed of an administration set and an intravenous catheter. The administration set allows sterile delivery and regulation of the rate of administration. An intravenous catheter is selected, inserted, and maintained to minimize the potential for catheter-related complications.

Infections related to cardiac implantable electronic devices (CIEDs) are increasing in prevalence and carry substantial morbidity and mortality. Complications involving peripheral intravenous catheters resulting in CIED infections have not yet been investigated and may pose an important risk factor. We report 5 cases of CIED infection related to documented complications of peripheral vascular devices.

At approximately 8:00 am on March 2, 1999, N was prepped for surgery at Hospital. Dr. L was the physician responsible for administering anesthesia. N's arms were extended away from his body and secured to arm boards. Intravenous (IV) catheters were placed. H, a nurseanesthetist, placed a Bair Hugger over N then placed a blanket over the Bair Hugger. H also taped the blanket to the arm boards. Midway through the surgical procedure, Dr. L left the operating room (OR). Nurse anesthetist H was assigned to monitor N's anesthesia during that period. At 11:05 am, T, another nurse-anesthetist, relieved H. N's surgery ended shortly afterwards without complication. However, when T removed the blanket and the Bair Hugger from N's arms, T discovered that the IV catheter in N's left arm had extravasated and that N had developed compartment syndrome. While N was still receiving anesthesia in the OR, Dr. D, a vascular surgeon, performed an emergency fasciotomy to relieve the pressure in N's left arm. Four days later, Dr. D performed a skin graft in which he removed a section of skin from N's thigh and placed it on N's left arm. N sued Dr. L and Nurse Anesthetists L and H for medical malpractice, claiming they were negligent in failing to properly monitor his arm and the IV site.

BACKGROUND/OBJECTIVES: Intravenous catheter (IVC) tips are often cultured when IVC lines are removed from febrile patients to help determine if the patient has a line-related bloodstream infection (BSI). We wanted to determine the reliability and cost-effectiveness of IVC tip cultures in predicting bacteremia and BSI in our institution. METHODS: We perform surveillance for and maintain a database of all bloodstream infections in our 400 bed facility. Centers for Disease Control and Prevention (CDC) definitions are used. We reviewed all (339) IVC tip cultures obtained from January 1-June 30, 2005. Positive tip cultures were defined as greater then 15 colony-forming units (cfu) via the semi-quantitative roll plate method. Positive tip cultures were compared with our BSI database to determine if the culture was associated with a bloodstream infection. IVC tip cultures without a blood culture done within 24 hours of the tip culture were excluded from analysis (119 (35%)). Positive tip cultures with an associated positive blood culture were examined to determine if CDC BSI criteria were met and the patient was in our database. Cost information was obtained from the laboratory. RESULTS: Of 339 IVC tips cultured, 59 (17%) were deemed positive. 222 (65%) of tip cultures were associated with a blood culture done within 24 hours either before or after the tip culture. 246 (73%) cultures were negative for both IVC tip and blood. 13 cultures were positive for both the IVC tip and blood. Of these, 1 had a positive blood culture after the positive tip culture within 24 hours but with a different organism. Twelve had positive blood cultures before the tip culture. The predictive value of a positive tip culture (PVP) was 0/15 = 0%. The predictive value of a negative culture was 246/280 = 88%. The cost to the laboratory of processing a negative tip culture is $71, while the cost of processing a positive culture is $124. The annualized cost of IVC tip cultures in the adult critical care units is $33,142. The estimated cost hospital-wide is $54,392. CONCLUSIONS: Our data do not support the use of IVC tip cultures for the prediction of bacteremia or BSI. Discontinuation of the practice could save the hospital thousands of dollars per year. On the basis of these findings, our institution has stopped performing routine culture of IVC tips. This change has been accepted without objections.

Study objectives: Before graduation, medical schools expect their students to successfully perform basic procedures either on a patient or on a model. In addition, many medical schools are developing systems that track the type and number of procedures performed by their students. This study describes the number of times certain basic procedures were performed by medical students rotating on a mandatory emergency medicine clerkship as documented in their personal digital assistant (PDA) Patient Encounter Log System (PELS). Methods: Starting in July 2003, all fourth-year medical students began rotating through a new 4-week emergency medicine clerkship. During this clerkship, students were taught and performed the following basic procedures: airway maintenance (AM), central venous catheter insertion (CVCI), intravenous catheter insertion (IVI), laceration repair (LR), and lumbar puncture (LP). Students were expected to document all performed procedures into their PDA-based PELS. PELS cumulates the type and number of procedures performed. After completion of the clerkship, every student was expected to download their PELS data into the central base run by the medical school's Center for Research in Medical Education. Data were collected from the first 5 emergency medicine clerkships. Results: Fifty-five students downloaded PELS data (Table). Conclusion: A mandatory fourth-year emergency medicine clerkship provides medical students the opportunity to perform many basic procedures at least once before graduation. A PDA system that facilitates students' documentation of basic procedures can provide data necessary for the successful completion of medical school. Future data from this instrument can also be used to assess the clinical and procedural experience of a fourth-year emergency medicine clerkship compared with third-year clerkships.Table, abstract 154.No. of Times Procedure PerformedProcedure012345+Total Students% at Least 1AM1131910845598.2CVCI152774115590.9IVI52396575598.2LR161396205598.2LP1224134115578.2