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Peripheral intravenous cannulation (PIVC) in children is one of the most common procedures in acute care paediatrics. This can be difficult for experienced clinicians and daunting for those with limited paediatric experience. We aimed to evaluate the level of confidence of non-consultant hospital doctors (NCHDs) in PIVC and identify factors that impact on their level of confidence. This was a cross-sectional nationwide survey of NCHDs on the level of confidence in paediatric PIVC. Self-reported questionnaires explored clinical experience with PIVC, level of confidence, and potential factors impacting on confidence. Primary outcome was the level of confidence in PIVC. A survey response rate of 45% (202/450) was received from 12 Irish hospitals. Despite 89% (180/202) of NCHDs self-reporting average or above average success rates and 76% (155/202) having inserted ≥10 cannula within the preceding 3 months, self-reported confidence was low across the entire cohort. Only 48% (97/202) of NCHDs reported confidence scores >3 on 5-point scale and 37% (75/202) reported significant anxiety proceeding with PIVC. Level of confidence was increased with previous paediatric experience (p = 0.00004) and seniority of the doctor (p < 0.00001), whilst previous unsuccessful attempts by colleagues were strongly associated with decreased confidence (p = 0.009). Our study described the levels of confidence of NCHDs in PIVC. Although the experienced paediatric NCHDs are confident in PIVC, there still exists some degree of anxiety. These have implications for workforce educational planning and training to improve level of confidence which may lead to better patient care.

Background The use of enhancing agents in echocardiography has been shown to facilitate improved study quality. Despite the known benefits, its use remains limited by institutional policies. Methods We aimed to retrospectively evaluate if allowing sonographers to place a peripheral intravenous catheter and administer enhancing agent led to a decrease in time to complete outpatient transthoracic echocardiograms in comparison to using nursing personnel. Three separate protocols were employed. The ‘nurse driven protocol’ utilized nurses to place a peripheral intravenous catheter and inject enhancing agent. In a ‘mixed protocol,’ a nurse placed a peripheral intravenous catheter and the sonographer gave the enhancing agent. The ‘sonographer driven protocol’ involved the sonographer placing the peripheral intravenous catheter and delivering enhancing agent. Results A total of 232 echocardiograms were included for analysis. Patient characteristics across the three protocols were not statistically significant. The ‘mixed protocol’ had an average study time that was significantly less than the ‘nurse driven protocol’ (49.4 min ± 11.4 vs 54.6 min ± 12.9; p = 0.024). The ‘sonographer driven protocol’ also showed a significant reduction in study time (50.3 min ± 12.6) when compared to the ‘nurse driven protocol’ (p = 0.017). The additional task for the sonographer to place the peripheral intravenous catheter did not significantly increase the time to complete the study. Conclusion Allowing sonographers to administer enhancing agent reduced individual echocardiogram study times by approximately 5 min, supporting that a ‘sonographer driven protocol’ is more efficient with potential downstream economic benefits.

Peripheral intravenous lines are indispensable for emergency and intensive medical care. They have a high importance, especially in the context of primary care as well as in the early stages of treatment initiation. This requires in-depth knowledge of the persons being treated. This article describes the most important aspects of the indications, puncture and fixation techniques as well as special features in terms of management and hygiene.

To compare intraosseous access with peripheral venous access on adults out-of-hospital cardiac arrest (OHCA) patients’ clinical outcomes. A national retrospective multicentre study was conducted based on the French National Cardiac Arrest Registry. Comparison of patients (intraosseous vs. peripheral venous access) was conducted before and after a matching using a propensity score. The propensity score included confounding factors: age, time between the call (T0) to epinephrine (to take account of how quickly vascular access was achieved), the aetiology of OHCA, the shock and the patient initial rhythm at MMT arrival. A total of 1576 patients received intraosseous access, and 27,280 received peripheral intravenous access. Before matching, OHCA patients with intraosseous access were less likely to survive at all stages (return of spontaneous circulation (ROSC), 0-day survival and 30-day survival). No significant difference in neurological outcome was observed. After propensity score matching, no significant differences in 30-day survival rates (OR = 0.763 [0.473;1.231]) and neurological outcome (OR = 1.296 [0.973;1.726]) were observed. However, intraosseous patients still showed lower likelihood of short-term survival (ROSC and 0-day survival) even after propensity score matching was implemented. The populations we investigated were similar to those of other studies suggesting that intraosseous access is associated with reduced survival and poorer neurological outcome. Our findings suggest that intraosseous access is a comparably effective alternative to peripheral intravenous access for treating OHCA patients on matched populations.

Background Peripheral intravenous catheters (PIVCs) are the most widely used intravenous treatment tools for hospitalized patients. Compared to adult patients, PIVC fixation issues are more likely to occur in pediatric patients and can be more complex. However, research on PIVC fixation in pediatric patients is rare. This study aimed to investigate the pass rate for PIVC fixation in pediatric patients and the factors that influence pediatric nurses’ knowledge, attitude, and practice (KAP) concerning PIVC fixation. Methods An on-site investigation using a self-designed PIVC fixation standard inspection checklist for first insertion and routine maintenance in pediatric patients and a follow-up questionnaire survey investigating pediatric nurses’ KAP concerning PIVC fixation was conducted in a hospital in China between November 1 and December 31, 2019. Data were analyzed using SPSS 21.0. Results The pass rate for PIVC fixation in pediatric patients was 52.02%. The pediatric nurses’ knowledge, attitude and practice scores on PIVC fixation were 7.2 ± 1.36, 28.03 ± 2.42, and 31.73 ± 2.94, respectively. The multivariate linear regression analysis results show that department (where nurses are working in) and job position are the factors that influence knowledge score (B > 0, P 0, P 0, P Conclusion PIVC fixation in pediatric patients is affected by multiple factors. The level of pediatric nurses’ KAP on PIVC fixation needs to be improved. It is suggested that guidelines for PIVC fixation in pediatric patients be formulated and that training on PIVC fixation in pediatric patients be provided for pediatric nurses in an effort to raise the pass rate in terms of PIVC fixation in pediatric patients.

Objective We aimed to investigate the medical characteristics of helicopter hoist operations (HHO) in HEMS missions. Methods We designed a retrospective study evaluating all HHO and other human external cargo (HEC) missions performed by Swiss Air-Rescue (Rega) between January 1, 2010, and December 31, 2019. Results During the study period, 9,963 (88.7 %) HEMS missions with HHO and HEC were conducted during the day, and 1,265 (11.3 %) at night. Of the victims with time-critical injuries (NACA ≥ 4), 21.1 % (n = 400) reached the hospital within 60 min during the day, and 9.1 % (n = 18) at night. Nighttime missions, a trauma diagnosis, intubation on-site, and NACA Score ≥ 4 were independently and highly significantly associated with longer mission times (p n = 3,731, 37.5 %) while practicing recreational activities (n = 5,492, 55.1 %). In daytime HHO missions, the most common medical interventions performed were insertion of a peripheral intravenous access (n = 3,857, 38.7 %) and administration of analgesia (n = 3,121, 31.3 %). Conclusions Nearly 20 % of patients who needed to be evacuated by a hoist were severely injured, and complex and lifesaving medical interventions were necessary before the HHO procedure. Therefore, only adequately trained and experienced medical crew members should accompany HHO missions.

Children with medical complexity and associated neurologic impairment frequently face difficulties with venous access. Intermittently they require urgent intravenous administration of fluids and medication. To analyze the use of implanted port-a-caths in children with medical complexity who have neurologic impairment and difficult venous access. We performed a single-center observational study of port-a-caths placed by interventional radiologists in children with medical complexity with neurologic impairment. We analyzed peripheral intravenous access attempts, peripheral intravenous starts, peripheral intravenous complications, alternative temporary central venous access devices, port-a-cath insertions, catheter days, access days, port-a-cath-related complications, hospital admissions and emergency department visits. We compared the year pre port-a-cath to the year post port-a-cath. Twenty-one children with medical complexity with neurologic impairment (10 boys, 11 girls; median age 4.1 years; median weight 13.7 kg) underwent 26 port-a-cath insertions (median catheter days 787). In the year post port-a-cath compared to pre port-a-cath there was a highly significant reduction (P

BackgroundIt is unclear whether vasopressors can be safely administered through a peripheral intravenous (PIV). Systematic review and meta-analysis methodology was used to examine the incidence of local anatomic adverse events associated with PIV vasopressor administration in patients of any age cared for in any acute care environment.MethodsMEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials, and the Database of Abstracts of Reviews of Effects were searched without restriction from inception to October 2019. References of included studies and related reviews, as well as relevant conference proceedings were also searched. Studies were included if they were: (1) cohort, quasi-experimental, or randomized controlled trial study design; (2) conducted in humans of any age or clinical setting; and (3) reported on local anatomic adverse events associated with PIV vasopressor administration. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials or the Joanna Briggs Institute checklist for prevalence studies where appropriate. Incidence estimates were pooled using random effects meta-analysis. Subgroup analyses were used to explore sources of heterogeneity.ResultsTwenty-three studies were included in the systematic review, of which 16 and 7 described adults and children, respectively. Meta-analysis from 11 adult studies including 16,055 patients demonstrated a pooled incidence proportion of adverse events associated with PIV vasopressor administration as 1.8% (95% CI 0.1–4.8%,I2 = 93.7%). In children, meta-analysis from four studies and 388 patients demonstrated a pooled incidence proportion of adverse events as 3.3% (95% CI 0.0–10.1%,I2 = 82.4%). Subgroup analyses did not detect any statistically significant effects associated with stratification based on differences in clinical location, risk of bias or design between studies, PIV location and size, or vasopressor type or duration. Most studies had high or some concern for risk of bias.ConclusionThe incidence of adverse events associated with PIV vasopressor administration is low. Additional research is required to examine the effects of PIV location and size, vasopressor type and dose, and patient characteristics on the safety of PIV vasopressor administration.

Background The design of medical devices impacts upon the performance of healthcare professionals and patient safety. However, multiple devices serving the same function are often available. The purpose of this study was to use simulation as a means of examining the impact of differences in device design on (1) learning of, or attainment of behavioral fluency in, peripheral intravenous cannulation (PIVC); and (2) the generalization, or transfer, of learning on one device to performance of PIVC using an untrained device. Methods A total of 25 final cycle medical students participated in this study which used a randomized two-group design. Participants were randomly assigned to learn PIVC using either a closed PIVC device (a single device which consists of an intravenous cannula with a pre-attached extension tube; n = 14) or an open PIVC device (a two-piece device made up of an intravenous cannula and a separate extension tube which is attached following insertion of the cannula; n = 11). Task analyses were developed for the performance of PIVC using each device. Subsequently, simulation-based fluency training was delivered to both groups using their assigned PIVC device, and continued for each participant until the fluency criterion was achieved. Following achievement of fluency, participants were asked to perform PIVC using the untrained device (i.e., the PIVC device that they had not been trained on). Results All participants in both groups met the fluency criterion, and no significant differences were observed in the number of trials or total training required by groups to achieve fluency. Participants in both groups improved significantly from baseline (M = 11.69) to final training trial (M = 100). However, a significant decrement in performance (M = 81.5) was observed when participants were required to perform PIVC using the untrained device. Conclusions Participants achieved fluency in PIVC regardless of the device used. However, significant decrements in performance were observed when participants were required to perform PIVC using a novel device. This finding supports the need for careful consideration of devices purchased and supplied in the clinical setting, and the need for training prior to the introduction of novel devices or for new staff members.

The usefulness of ultrasound guidance in peripheral intravenous access placement has yet to be established in children. In this prospective comparative study, we investigated success rates of intravenous access placement with ultrasound guidance in a pediatric emergency department. After a failed first attempt with the conventional technique, the second and third attempts were conducted using either the ultrasound guidance (a real-time, dual operator method) or the conventional technique. The success rates within the two interventional attempts were then compared. From a total of 712 participants, those with a failed first attempt were allocated to the ultrasound guidance (n = 99) and conventional technique (n = 100) groups. The success rate was significantly lower for the ultrasound guidance (65%) than for the conventional technique (84%) group (p = 0.002, chi-square test). This remained significant after adjusting for confounders with multiple logistic regression analysis (odds ratio 2.60, 95% confidence interval 1.26-5.37, p = 0.001).Ultrasound-guided intravenous access placement using a real-time, dual operator method led to a significantly lower success rate than the conventional technique in children with one failed conventional attempt in the emergency department.UMIN000014730 What is Known: • Children experience a low success rate (about 60% with 1 attempt and about 90% with 4 attempts) for IV access placement. • Ultrasound guidance may lead to a decreased number of attempts and shorter procedural time with comparable overall IV success rate. What is New: • Ultrasound-guided IV placement (a real-time, dual operator method) actually led to a significantly lower IV success rate than the conventional technique in children in the emergency department. • Our result warrants further trials to determine the precise population who benefits from ultrasound guidance.

Peripheral intravenous catheterization (PIVC) is frequently required for various medical treatments. Over 1 billion PIVC operations are performed per year in the United States alone. However, this operation is characterized by a very low success rate, especially amongst pediatric patients. Statistics show that only 53% of first PIVC attempts are successful in pediatric patients. Since their veins are small and readily rupture, multiple attempts are commonly required before successfully inserting the catheter into the vein. This article presents and evaluates a novel venous entry detection method based on measuring the electrical bio-impedance of the contacting tissue at the tip of a concentric electrode needle (CEN). This detection method is then implemented in the design of a clinical device called smart venous entry indicator (SVEI), which lights up a LED to indicate the venous entry when the measured value is within the range of blood. To verify this detection method, two experiments are conducted. In the first experiment, we measured the bio-impedance during the insertion of a CEN into a rat's tail vein with different excitation frequencies. Then three classifiers are tested to discriminate blood from surrounding tissues. The experimental results indicate that with 100 kHz excitation frequency the blood bio-impedance can be identified with accuracy nearly 100%, demonstrating the feasibility and reliability of the proposed method for venous entry detection. The second experiment aims to assess the impact of SVEI on PIVC performance. Ten naive subjects were invited to catheterize a realistic baby arm phantom. The subjects are equally divided into two groups, where one group does PIVC with SVEI and the other group uses an ordinary IV catheter. The results show that subjects using SVEI can achieve much higher success rates (86%) than those performing PIVC in a conventional way (12%). Also, all subjects assisted by SVEI succeeded in their first trials while no one succeed in their first attempt using the conventional unassisted system. These results demonstrate the proposed detection method has great potential to improve pediatric PIVC performance, especially for non-expert clinicians. This supports further investment towards clinical validation of the technology.

To compare the patency duration of a peripheral intravenous cannula (PIVC) using either continuous infusion with 5% dextrose or intermittent flushing with 0.9% saline.Prospective comparative cohort study, including full-term newborn infants in whom PIVC were placed for the administration of antibiotics. In cohort 1 (n=48), 5% dextrose was infused at 3 ml h(-1); in cohort 2 (n=50), the cannula was flushed six times daily with 2 ml 0.9% saline. Primary outcome was the duration of PIVC patency. Secondary outcomes included the occurrence of complications, time required by the nursing staff and the cost of materials.Duration of PIVC patency was similar. However, significantly, more complications occurred in cohort 1 (P=0.02), and both cost and time were significantly lower in cohort 2 (P=0.001).Intermittent flushing and continuous infusion provide a similar duration of PIVC patency; however, intermittent flushing is associated with fewer complications, lower cost and reduced time.

Peripheral intravenous catheters (PIVCs) are the most commonly used invasive medical device, yet up to 50% fail. Many pathways to failure are mechanistic and related to fluid mechanics, thus can be investigated using computational fluid dynamics (CFD). Here we used CFD to investigate typical PIVC parameters (infusion rate, catheter size, insertion angle and tip position) and report the hemodynamic environment (wall shear stress (WSS), blood damage, particle residence time and venous stasis volumes) within the vein and catheter, and show the effect of each PIVC parameter on each hemodynamic measure. Catheter infusion rate has the greatest impact on our measures, with catheter orientation also playing a significant role. In some PIVC configurations WSS was 3254 times higher than the patent vein, and blood damage was 512 times greater, when compared to control conditions. Residence time is geometry-dependent and decreases exponentially with increasing insertion angle. Stasis volume decreased with increasing infusion rate and, to a lesser degree, insertion angle. Even without infusion, the presence of the catheter changes the flow field, causing low velocity recirculation at the catheter tip. This research demonstrates how several controllable factors impact important mechanisms of PIVC failure. These data, the first of their kind, suggest limiting excessive infusion rates in PIVC.

Introduction: Ultrasound-guided intravenous (UGIV) insertion performed by nurses has been shown to be more effective than the blind approach for patients with difficult intravenous (IV) access in the emergency department (ED). While both the single-operator (SO) (where a single operator holds the IV and probe) and dual-operator (DO) (where a second operator holds the probe) techniques have been described, the DO is more resource-intensive, requiring a second operator to be present. The objective of this study is to compare the first-attempt cannulation success rates between a SO and DO technique in ED patients with predicted difficult access. Methods: We conducted a randomized controlled non-inferiority trial using a convenience sample of adult ED patients. Participating ED nurses received a one-hour UGIV training session including didactic and practical training on simulated arms. Patients were enrolled if they met any of three criteria for difficult access: (1) history of difficult access, (2) no visible or palpable veins, or (3) two failed blind attempts. Patients requiring active resuscitation, lack of suitable veins on US, or those unable to consent or comply with the procedure were excluded. Eligible patients were randomized to the SO or DO technique and a maximum of two UGIV attempts were allowed. The primary outcome was first-attempt success rate. Additional outcomes included overall success rate, number of attempts, time to successful cannulation, patient pain scores, operator ease of use scores, and complications 30 minutes after insertion. The chi-square test was used to compare success rates between groups and t-tests used for all other secondary outcomes. Results: 42 eligible patients have been approached for our study. 14 were excluded due to lack of visible veins on US or due to ongoing resuscitation. A total of 33 UGIV attempts were performed on 28 patients (17 in SO group, 16 in DO group). There was no statistically significant difference in first attempt success rates between the SO group of 76.5% (95% CI [50.1% to 93.2%]) and the DO group of 68.8% (95% CI [41.3% to 89%]) (p=0.62). There were also no statistically significant differences between the SO and DO groups in time to cannulation (140 vs 165 seconds, p=0.36), patient preference on a 10-point scale (7.0 vs 7.9, p=0.49), patient pain score (6.3 vs 6.6, p=0.87) or nursing ease of use (5.3 vs 6.5 p=0.23) respectively. There were no complications noted in either arm of the study. Conclusion: To date, the SO technique appears to be non-inferior to the DO technique for successful UGIV cannulation. Our results support the use of the SO technique, reducing the need for additional nursing resources when performing this procedure.

Malpositioning of the percutaneously placed central venous line (PCVL) or percutaneously inserted central catheter (PICC) in infants is not a rare occurrence. It has been occasionally observed that these lines spontaneously correct themselves. This prospective study was done to study the incidence of malposition and spontaneous correction. Using a modification of the standard method, 187 catheters were placed with 98.9 % success. Seven of these were initially malpositioned. All seven corrected themselves within a day when left in and used as a peripheral intravenous line. In many centers malpositioned catheters are taken out and replaced, which imposes great stress on the critically ill infant. Our study suggests that to avoid this stress the catheter should be left in place, since spontaneous correction may occur.

Many patients who present to the emergency department require placement of a peripheral intravenous line, which frequently causes pain and anxiety. We compare pain and anxiety associated with peripheral intravenous cannula insertion after pretreatment with no local anaesthesia or subcutaneously injected, buffered 2% lidocaine.

The pharmacokinetics of adriamycin in patients with malignant tumours of the liver were studied after peripheral intravenous treatment and after regional administration of the drug either by the arterial route or by the portal vein, with or without hepatic artery ligation. The plasma concentration of adriamycin after intravenous as well as after intrahepatic administration followed a three-compartment open model. The results in the present study confirm previous reports of a large inter-individual variation of the pharmacokinetics of adriamycin. After intravenous administration the individual variations in AUC/mg/m2 and Cp,max/mg/m2 (dose normalized area under plasma concentration time curve and dose normalized maximum plasma concentration, respectively) were more than 5-fold. The area under the plasma concentration time curve (AUC) was on the average 1.5 times higher after the peripheral intravenous administration than after intrahepatic administration. The reduction of maximum plasma concentration (Cp,max) of adriamycin after intrahepatic administration was even more pronounced than the reduction in AUC (mean value Cp,max iv/Cp,max ihep = 1.7). The plasma concentration of adriamycinol did not exceed 20 ng/ml. The AUC values of adriamycinol were 20% (median value) of the AUC values of adriamycin, indicating the importance of adriamycinol in the adriamycin therapy.

The authors conducted a randomized, prospective, controlled trial of three different dressings for peripheral intravenous catheters in 301 acutely ill medical inpatients. Catheters were dressed with dry clean gauze or one of two brands of transparent plastic. The gauze dressings remained in place significantly longer (47 hours median) than either Uniflex (39 hours) of Tegaderm (32 hours) transparent plastic dressings (p = 0.026). Catheters were removed for complications (inflammation, mechanical failure, or infiltration) in 35% of the gauze group, compared with 58% of the Uniflex group and 48% of the Tegaderm group (p = 0.015). Not only were inflamed venipuncture sites seen less often with gauze, inflammation occurred later (p = 0.002) and with lesser severity. Dry gauze dressings resulted in longer catheter life, lower complication rates, and less expense than transparent plastic dressings for peripheral intravenous catheters.

Glucose is the primary substrate for energy during parenteral alimentation of LBW infants. Hyperglycemia may result in glucosuria and osmotic diuresis when excessive glucose is infused. Tolerance for glucose was studied in 35 appropriate for gestational age well LBW infants (birth wt. M = 1216 gms, gestational age M = 30 wks) between 3-38 days of age. Infants received glucose: 8,11, or 14 mg/Kg/min for 3 hours by continuous peripheral intravenous infusion. Plasma glucose and insulin, and timed urine glucose and volume were measured (MtS.E.M.). A steady state (S-S) of plasma glucose was noted by one hour at all infusion rates. There were significant increases in S-S plasma glucose (p

We evaluated prospectively the effect of 11 variables on the survival of PVL. PVL were monitored from the time of cannula placement to discontinuation. Sites were inspected hourly for clinical signs of infiltration. 151 PVL were studied in patients whose median age was 1 month (range 0.1-8.7 months). 58% of PVL infiltrated. The time to infiltration was 36.3 ± 33.5 (mean ± SD) hrs (median:40 hrs;range 10-187 hrs). No difference existed in non-infiltrated vs infiltrated PVL for patient age, sex, weight, cannula type/gauge, site, infusion device, IV drugs, administration rate, or potassium/dextrose solution concentration. Infiltration frequency was > in blacks than whites (p=0.03), and with lower controller head heights (p=0.01). Infiltration probability was significant for, steel > teflon cannulas (p=0.02), IV drug > no drug (p=0.03), and with increasing cannula gauge (p=0.05). No difference in the time to infiltration existed for 5% vs 10% dextrose, potassium ≤ 20 mEq/L vs > 20mEq/L, and gravity controlled vs positive pressure infusion devices. No tissue sloughing or necrosis occurred. Only 13% of infiltrated PVL were associated with an audible infusion device alarm. We conclude: 1) black infants, decreasing controller head height, increasing cannula gauge, use of steel needles, and IV drug administration increases the probability of and decreases the time to infiltration, and 2) present infusion device alarms do not reliably detect infiltration in infants.

Growth retardation occurs in approximately 20% of children and adolescents with Crohn's disease (CD). Total parenteral and peripheral intravenous alimentation have reversed this growth retardation, but these methods necessitate prolonged hospitalization. Six consecutive prepubertal patients with CD, all 2 SD below normal); one had a falling growth velocity but remained in the low normal range. Three of these pts were completely growth arrested for >1 yr. After therapy, growth velocities increased to 6.5 ±2.0 cm/yr in 5 pts, which is within the normal range. One pt grew only 1.8 cm/yr which subsequently increased to 5.5 cm/yr after 4 wks of peripheral intravenous alimentation. These results indicate that oral calorie/protein supplementation in conjunction with medical therapy is an effective method for reversing growth retardation in prepubertal CD patients.