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Emergency Nursing Resource: Difficult Intravenous Access

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Emergency Nurses Association © December 2011. Please email for approval to reproduce multiple copies.
Emergency Nursing Resource:
Difficult Intravenous Access
In emergency department patients with known or suspected difficult intravenous access, does
ultrasound-guided, intraosseous, subcutaneous rehydration therapy, warming, or alternative methods
improve intravenous access with fewer attempts, less pain, and/or improved patient satisfaction as
compared to traditional techniques?
Authored by the 2011 ENA Emergency Nursing Resources Development Committee:
Melanie Crowley, MSN, RN, CEN, MICN
Carla Brim, MN, RN, CEN, CNS
Jean Proehl, MN, RN, CEN, CPEN, FAEN
Susan Barnason, PhD, RN, APRN, CEN, CCRN, CNS, CS
Sherry Leviner, MSN, RN, CEN
Cathleen Lindauer, MSN, RN, CEN
Mary Naccarato, MSN, RN, CEN, CCNS
Andrew Storer, DNP, RN, ACNP, CRNP, FNP
Jennifer Williams, MSN, RN, CEN, CCRN, CNS
2011 ENA Board of Directors Liaison:
AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN
ENA’s Emergency Nursing Resources (ENRs) are developed by ENA members to provide emergency
nurses with evidence-based information to utilize and implement in their care of emergency patients
and families. Each ENR focuses on a clinical or practice-based issue, and is the result of a review and
analysis of current information believed to be reliable. As such, information and recommendations
within a particular ENR reflect the current scientific and clinical knowledge at the time of publication,
are only current as of their publication date, and are subject to change without notice as advances
In addition, variations in practice, which take into account the needs of the individual patient and the
resources and limitations unique to the institution, may warrant approaches, treatments and/or
procedures that differ from the recommendations outlined in the ENRs. Therefore, these
recommendations should not be construed as dictating an exclusive course of management, treatment
or care, nor does the use of such recommendations guarantee a particular outcome. ENRs are never
intended to replace a practitioner’s best nursing judgment based on the clinical circumstances of a
particular patient or patient population. ENRs are published by ENA for educational and informational
purposes only, and ENA does not approve or endorse any specific methods, practices, or sources of
information. ENA assumes no liability for any injury and/or damage to persons or property arising out of
or related to the use of or reliance on any ENR.
Publication Date: December 2011
Emergency Nurses Association © December 2011. Please email for approval to reproduce multiple copies.
Table of Contents
Background/Significance ....................................................................................................................... 1
Methodology ......................................................................................................................................... 1
Evidence Table and Other Resources .................................................................................................... 3
Summary of Literature Review .............................................................................................................. 3
Description of Decision Options/Interventions and the Level of Recommendation ..........................11
References ...........................................................................................................................................12
Acknowledgements .............................................................................................................................15
Emergency Nurses Association © December 2011. Please email for approval to reproduce multiple copies. 1
Establishing vascular access is one of the most common procedures carried out in the emergency
department (ED) and a high priority for the care of a critically ill and unstable patient. The condition of
the patient often plays a role in the likelihood of attaining vascular access. Conditions associated with
difficult vascular access include obesity, chronic illness, hypovolemia, intravenous (IV) drug abuse, and
vasculopathy (Blavias & Lyon, 2006; Chinnock, Thornton, & Hendey, 2007; Costantino, Parikh, Satz, &
Fojtik, 2005; Miles, Salcedo, & Spear, 2011; Nafiu, Burke, Cowan, Tutuo, Maclean, & Tremper, 2010).
Patients with difficult IV access are frequently subjected to repeated attempts by multiple practitioners.
Success rate and time to vascular cannulation are crucial to the optimal resuscitation of a critically-ill
patient. This can be a challenging to even the most experienced emergency nurse. Failure rates of
emergent IV access vary in the literature. Leidel, Kirchhoff, Bogner, Stegmaier, Mutschler, Kanz, and
Braunstein (2009) identify a failure rate ranging from 10 to 40%. Katsogridakis, Seshadri, Sullivan, and
Waltzman (2008) identifies success rates in multiple attempts for admitted patients at a children’s
hospital ranges from 23% for physicians, 44% for nurses to 98% for IV nurse clinicians. The average time
requirement for peripheral IV cannulation is reported at 2.5 to 13 minutes, with difficult IV access
requiring as much as 30 minutes (Leidel et al., 2009). The number of attempts at IV cannulation for the
pediatric patient ranges from 1 to 10 attempts (Katsogridakis et al., 2008). Utilization of anatomic
landmarks for peripheral IV access holds a 90% success rate (Costantino et al., 2005).
Central venous catheterization (CVC) is a common alternative approach to attain cannulation in patients
with difficult venous access. CVC cannulation provides vascular access for fluid resuscitation, and
additionally allows for hemodynamic monitoring. It is noted, however, that CVC cannulation presents
additional risks to the patient. Most common among these complications are venous thrombosis,
arterial puncture, catheter associated bloodstream infection, and pneumothorax (Leidel et al., 2009).
Given the time required to establish a central venous catheter, the increased risk to the patient, and the
skill required of the provider, other alternatives for vascular access are often desirable.
A delay in establishing vascular access can result in a delay in the administration of a fluids and/or
medications. Patients frequently experience delays in diagnosis and initiation of treatment. In addition,
multiple attempts at attaining vascular access result in frustration and a loss of productivity by the
treating team (Rauch, Dowd, Eldridge, Mace, & Schears, 2009).
This ENR was created based on a thorough review and critical analysis of the literature following ENA’s
Guidelines for the Development of the Emergency Nursing Resources. Via a comprehensive literature
search, all articles relevant to the topic were identified. The following databases were searched:
PubMed, Google Scholar, CINAHL, Cochrane - British Medical Journal, Agency for Healthcare Research
and Quality (AHRQ;, and the National Guideline Clearinghouse (
Searches were conducted using the search termsdifficult intravenous access,” “tools intravenous
access,” “heat,” “nitroglycerin,” “tourniquet,” ultrasound,” “light,” “illumination,” “subcutaneous
rehydration therapy,” and “hypodermoclysis,” using a variety of different search combinations. Searches
were limited to English language articles on human subjects from January 2003 October 2011. In
addition, the reference lists in the selected articles were scanned for pertinent research articles.
Research articles from ED settings, non-ED settings, position statements and guidelines from other
sources were also included in the review.
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Articles that met the following criteria were chosen to formulate the ENR: research studies, meta-
analyses, systematic reviews, and existing guidelines relevant to the topic of difficult IV access. Other
types of reference articles and textbooks were also reviewed and used to provide additional
information. The ENR authors used standardized worksheets, including the Reference Table, Evidence-
Appraisal Table, Critique Worksheet and AGREE Work Sheet, to prepare tables of evidence ranking each
article in terms of the level of evidence, quality of evidence, and relevance and applicability to practice.
Clinical findings and levels of recommendations regarding patient management were then made by the
Emergency Nursing Resource Development Committee according to the ENA’s classification of levels of
recommendation for practice, which include: Level A High, Level B. Moderate, Level C. Weak or Not
recommended for practice (Table 1).
Table 1. Levels of Recommendation for Practice
Level A recommendations: High
Reflects a high degree of clinical certainty
Based on availability of high quality level I, II and/or III evidence available using Melnyk & Fineout-Overholt
grading system (Melnyk & Fineout-Overholt, 2005)
Based on consistent and good quality evidence; has relevance and applicability to emergency nursing practice
Is beneficial
Level B recommendations: Moderate
Reflects moderate clinical certainty
Based on availability of Level III and/or Level IV and V evidence using Melnyk & Fineout-Overholt grading
system (Melnyk & Fineout-Overholt, 2005)
There are some minor or inconsistencies in quality evidence; has relevance and applicability to emergency
nursing practice
Is likely to be beneficial
Level C recommendations: Weak
Level V, VI and/or VII evidence available using Melnyk & Fineout-Overholt grading system (Melnyk & Fineout-
Overholt, 2005) - Based on consensus, usual practice, evidence, case series for studies of treatment or
screening, anecdotal evidence and/or opinion
There is limited or low quality patient-oriented evidence; has relevance and applicability to emergency nursing
Has limited or unknown effectiveness
Not recommended for practice
No objective evidence or only anecdotal evidence available; or the supportive evidence is from poorly
controlled or uncontrolled studies
Other indications for not recommending evidence for practice may include:
o Conflicting evidence
o Harmfulness has been demonstrated
o Cost or burden necessary for intervention exceeds anticipated benefit
o Does not have relevance or applicability to emergency nursing practice
There are certain circumstances in which the recommendations stemming from a body of evidence should not
be rated as highly as the individual studies on which they are based. For example:
o Heterogeneity of results
o Uncertainty about effect magnitude and consequences,
o Strength of prior beliefs
o Publication bias
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Evidence Table and Other Resources
The articles reviewed to formulate the ENR are described in the Evidence Table. Other articles relevant
to difficult IV access were reviewed to serve as additional resources (Other Resources Table).
Summary of Literature Review
Difficult Intravenous Access: General Information
Difficult intravenous (IV) access is defined as multiple attempts and/or the anticipation of special
interventions being required to establish and maintain peripheral venous access (Kuensting, DeBoer,
Holleran, Shultz, & Steinmann, 2009). Gregg, Murthi, Sisley, Stein, and Scalea (2010) identify predictive
factors for difficult IV access as edema, obesity, and history of IV drug use. While the literature regarding
factors associated with difficult IV access in adults is limited, included are chemotherapy, diabetes, and
multiple prior hospitalizations (Lapostolle et al., 2007). It is further noted by Lapostolle et al. (2007), that
venous cannulation at the hands of a more experienced emergency care provider was associated with
an increased success rate. Smaller caliber IV catheters were more commonly associated with
cannulation failure (Lapostolle et al., 2007). This finding was postulated to be due to the choice of the
person inserting the IV catheter, and the anticipated ease or difficulty of insertion.
The literature on difficult IV access in children is more robust; however, there were no high quality
randomized controlled trials conducted in the ED setting identified in the literature search. In the
pediatric medical-surgical setting, Lininger (2003) identified that 53% of peripheral IV attempts (N = 249)
were successful on the first attempt, with an increase to 91% within four attempts. This led to the
implementation of a standard of practice at that institution that specified no more than four attempts
at IV cannulation were to be made by RN staff. The average time for venous access in the pediatric
patient is 33 minutes (Rauch et al., 2009). Nafiu et al. (2010) studied the relationship between body
mass index (BMI) and the ease of venous access in children ages 2 to 18 years. Obese children (BMI
greater than the 95th percentile) were more likely to have a failed attempt at first cannulation than their
lean controls and more likely to have two or more attempts at cannulation (Nafiu et al., 2010).
In 2008, Yen, Reigert and Gorelick studied IV access with an objective of developing a tool to predict
difficult IV access in children. In a study of 615 children, a 4-variable difficult IV access score was created
using 3 points for prematurity, 3 points for younger than 1 year, 1 point for 1-2 years of age, 2 points for
vein not palpable, and 2 points for vein not visible (Yen et al., 2008). Subjects with a difficult IV access
score of 4 or greater were more than 50% likely to have failed IV cannulation on the first attempt. This
tool is currently being validated.
Ultrasound-Guided Intravenous Access
Ultrasound guidance for venous access was initially studied for central access and shown to increase
success rates and decrease complications (Costantino et al., 2005; Stein, George, River, Hebig, &
McDermott, 2009). The use of ultrasound-guided techniques to gain venous access is widely studied in
the ED setting for both adult and pediatric populations. Ultrasound guidance provides real time 2-D
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image of blood vessels that appear as compressible circular structures (Walker, 2009). Characteristics
related to successful ultrasound-guided cannulation have been found to be larger vein diameter, while
depth did not affect success rate for veins less than 1.6 cm deep and patient characteristics such as age,
gender, race, body mass index or medical history did not impact success rate (Panebianco, Fredette,
Szyld, Sagalyn, Pines, & Dean, 2009). The literature provides guidance for several parameters to consider
for ultrasound-guided IV access.
Educational Considerations
Using ultrasound for IV access requires training for the user. The type and length of time for this training
varies in the literature. For physicians training is incorporated into residency training with up to sixteen
hours of didactic and over 100 ultrasound scans (Costantino et. al, 2005; Panebianco et. al, 2009). For
nursing staff and ED technicians training sessions include at least a 1-hour didactic with additional
hands-on training time (Bauman, Braude, & Crandall, 2007; Blaivas & Lyon, 2006; Chinnock et. al, 2007;
Schoenfeld, Boniface, & Shokoohi, 2010; Stein et. al, 2009; White, Lopez, & Stone, 2010). White et al.
(2010) recommended a 3-hour educational program to include didactic, simulation and hands-on
practice prior to beginning an ultrasound-guided IV access program.
Operator Characteristics
Studies have focused on various operators (e.g., physicians, nurses and ED technicians) as well as
different techniques. Two techniques used and studied include the dual-operator method in which one
user handles the ultrasound probe while a second user inserts the IV catheter and the single-user
method in which both activities are performed by one user. The dual-operator technique by emergency
physicians resulted in a 97% first attempt success rate compare to 33% for standard technique, with a
decrease in time to insertion of 13 minutes for ultrasound-guided compared to 30 minutes for control
(Costantino et al., 2005). Stein et al. conducted a randomized trial using the single-operator method
which did not yield a significant difference between the ultrasound-guided approach compared to
traditional methods for success rate, time to cannulation or patient satisfaction with the procedure
Operator experience with ultrasound does have an impact on the rate of successful cannulation.
Schoenfeld et al. (2010) demonstrated two independent factors associated with increasing success rate.
The number of previous ultrasound-guided IV attempts was important, as was the operator’s overall IV
experience. This reflects the two skills required to successfully cannulate a vein using ultrasound-guided
techniques: using the ultrasound to visually guide the catheter and successful cannulation of the vessel.
Operator Techniques
The single-operator technique performed by nurses resulted in a 97% overall success rate (Walker,
2009). Of interest, the patients had undergone an average of 6.4 attempts prior to referral to this study,
and then required an average of 1.3 attempts to gain access with the ultrasound (Walker, 2009). The
anterior forearm was used for 69% of the sites with basilic veins accounting for 12% (Walker, 2009).
Emergency Nurses Association © December 2011. Please email for approval to reproduce multiple copies. 5
Blaivas and Lyon (2005) studied the effect of ultrasound use on nurses perceived difficulty of obtaining
IV access. The nurses participated in a class on ultrasound-guided techniques and then completed a
survey. Although not statistically significant, the success rate was 89% for short axis and 85% for long
axis. However, the study did indicate that the nurse’s perception of how difficult the access would be
statistically improved from “very hard” to “very easy” (p=0.0001; Blaivas & Lyon, 2005).
Chinnock, Thornton and Hendey (2007) studied the prediction of success for nurse initiated ultrasound-
guided IV access. The cannulation success rate for one-person technique was 66% and 72% for two-
persons. The overall cannulation success rate was 53% with a 63% success rate for ultrasound-guided
technique of which 83% were successful on the first attempt. The basilic vein had a better cannulation
success rate (70%) than the brachial vein (41%) (Chinnock et al., 2007).
Two studies focused on single user technique by ED technicians (Bauman et al., 2009; Schoenfeld et al.,
2010). Bauman et al. (2009) found similar success rates of 80.5% using ultrasound as compared to
traditional methods (70.6%). ED technicians gained access two times faster with ultrasound-guided
techniques than physicians or nurses utilizing standard technique (Bauman et al., 2009). Bauman et al.
(2009) also found a reduced number of skin punctures with ultrasound-guided techniques (1.6 vs. 2.6)
and significantly improved patient satisfaction with the procedure increasing from 4.4 to 7.7 (p=0.0001).
The Schoenfeld et al. (2010) study resulted in a 78.5% success rate, noting that user experience
significantly correlated (p<0.001) to success rate.
Pediatric Population
Ultrasound-guided technique has been found to useful in the pediatric population (Bair, Rose, Vance,
Andrada-Brown, & Kuppermann, 2008; Doniger, Ishimine, Fox, & Kanegaye, 2009). The study by Bair et
al. (2009) found the first attempt success for ultrasound-guided methods to be (35%) compared to
traditional methods of (29%) with a 6% difference between the groups. Although, the crossover group
who had failed traditional method had a 75% first attempt success rate with ultrasound-guided methods
(Bair et al., 2008). Doniger et al. (2009) performed a randomized control study with an overall success
rate of ultrasound-guided technique at 80% compared to traditional technique at 64%, although this
difference was not statistically significant (p=0.208)(2009). However, the ultrasound-guided group had
statistically significant improvements in overall time to access (p=0.001), number of attempts (p=0.004)
and number of needle redirections (p< 0.0001) compared to the control group (Doniger et al., 2009).
Alternatives to Invasive Access
The literature also described ultrasound-guided access in clinical settings other than the ED. In the pre-
operative area, Certified Registered Nurse Anesthetists using the single operator technique did not find
significant difference between traditional methods and ultrasound-guided methods (Aponte, Acosta,
Rigamonti, Sylvia, & Austin, 2007). Gregg et al. (2010) sought to avoid CVC placement in the intensive
care unit setting. The study was performed with a single physician using single operator technique and
resulted in a 71% first attempt success rate (Gregg et al., 2010). Costantino, Kirtz and Satz (2010)
concluded that ultrasound-guided methods are significantly superior for first attempt (p=0.006)
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compared to blind external jugular access, whereas, no difference was found when the external jugular
vein was visible.
Ultrasound-Guided Intravenous Access Conclusions
Ultrasound-guided IV access requires training sessions and can be performed using single-operator or
dual-operator method by physicians, nurses and ED technicians. For patients with known or suspected
difficult IV access, ultrasound-guided techniques improve success rate in a timely manner with improved
patient satisfaction.
Intraosseous Vascular Access
Intraosseous (IO) vascular access dates back as far as the 1920s when the sternum was described as a
potential site for transfusions (Fowler, Gallagher, Isaacs, Ossman, Pepe, & Wayne, 2007; Horton &
Beamer, 2008; MacKinnon, 2009; Paxton, Knuth, & Klausner, 2009). The IO route was later used by
military medical personnel during WWII when vascular access was needed for patients in shock and IV
cannulation was difficult or delayed (Fowler et al., 2007). Subsequently, the availability of plastic
catheters for peripheral and central IV access resulted in a decline in IO usage. IO access has been the
standard of care for over 20 years for the pediatric population when vascular access was difficult to
accomplish (Horton & Beamer, 2008). There are three different types of IO needle placement methods.
First, the manual needle is a hollow needle with a removable stylet. The second type is the impact
driven device, of which there are two types; one is designed for sternal access, the other is a spring-
loaded injector mechanism designed for the tibia. The third type is a battery-powered, drill-based
technology. The recent introduction of these various IO insertion devices has made the IO route an
option for vascular access in the adult population as well as the pediatric population (Langley & Moran,
2008; MacKinnon, 2009; Von Hoff, Kuhn, Burris, & Miller, 2008; Consortium on Intraosseous Vascular
Access in Healthcare Practice, 2010). Leidel et al. (2009) notes there are three lengths of IO needles
available for the drill device to accommodate the pediatric, adult, and obese patients.
The Consortium on Intraosseous Access in Healthcare Practice (2010) was attended by representatives
of multiple organizations with a goal of reviewing the evidence supporting use of the IO access method
wherever vascular access was deemed medically necessary and difficult to achieve. Among the
recommendations made by the Consortium is that IO access should be considered as an alternative to
peripheral or central IV access when an increase in patient morbidity or mortality is possible. Further,
for patients not requiring long-term vascular access or hemodynamic monitoring, IO access should be
the first alternative to failed peripheral venous access.
Frequently brought into question regarding IO access is which medications can be given via the IO route,
and are dosages equivalent to those given by other routes. The IO route is effective for the
administration of blood and blood products, fluid administration, drug delivery, and blood sampling
(Burgert, 2009; Paxton et al., 2009; Leidel et al., 2009). The efficacy of medication route administration
was studied by Von Hoff et al. (2008) in a Latin square crossover study with each subject serving as their
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own control. Each subject received a dose of morphine sulfate either through an implanted IO needle or
through a peripheral IV line, followed by a second dose at least 24 hours later given via the alternate
administration route. Serial blood sampling followed each administration to identify morphine sulfate
plasma concentrations. There were no significant differences between the IV and IO routes on plasma
morphine concentration vs. sampling time or pharmacokinetics (Von Hoff, et al., 2008). There was a
statistically significant difference in the volume of distribution in the central compartment thought to be
due to the deposition effect near the IO needle.
The literature search revealed three studies which looked at several parameters that demonstrate the
usefulness of IO access. These included success rate of the IO access on first attempt, time to insertion
of the IO access, patient report of pain with insertion, and patient report of pain with fluid
Success Rate on First Attempt
Horton and Beamer (2008) found a 93% first time success rate but did not the specific parameters
defining success. Leidel et al. (2009) attained 90% first time success; success was measured as successful
administration of drugs or infusion solutions on first effort. The success rate of the IO access on first
attempt was reported by Paxton et al. (2009) as 80.6% in the proximal humerus. No determining factors
for success were identified in this study.
Time to Insertion
Horton and Beamer (2008) reported an insertion time of less than 10 seconds in 80.2% of subjects.
Measurement began at the time of needle to skin contact to needle placement in the IO space. Leidel et
al. (2009) reported a time of 2.3 + 0.8 minutes insertion time. Timing was measured by an independent
researcher who measured time from picking up the IO access device, preparing the set, prepping the
site, insertion of the IO needle, and administration of the first drug or fluid. Paxton et al. (2009) reported
a time of 1.5 minutes for IO insertion in the proximal humerus. Timing began with the skin preparation
before insertion and ended when the person completing the insertion deemed flow of the fluid was
Patient Report of Pain on Insertion
Paxton et al. (2009) assessed pain scores utilizing a visual analogue scale (VAS) on insertion of the IO
access device into the proximal humerus in adult patients with a Glasgow Coma Scale (GCS) score of 15
and reported an average score of 4.5. Horton and Beamer (2008) reported a mean pain score of 2.3 +
2.8 on IO insertion in pediatric patients with a GCS greater than 8. Leidel et al. (2009) did not study pain
on insertion.
Patient Report of Pain on Infusion
Paxton et al. (2009) assessed pain scores utilizing a VAS on infusion of fluids through the IO port in
patients with GCS score of 15 and reported an average score of 3.8 following lidocaine administration.
All patients were given a standard dose of 40 to 100 mg of lidocaine 2% through the IO needle prior to
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infusion of fluids or medications. Horton and Beamer (2008) reported a mean pain score of 3.2 + 3.5 on
infusion of fluids through the IO port in patients with a GCS greater than 8, without mention of
administration of lidocaine. Leidel et al. (2009) did not study pain on infusion of fluids.
Intraosseous Vascular Access Conclusions
In light of the evidence presented here, IO access provides vascular access in a timely manner when
faced with difficult IV access. This conclusion is supported by the consistent first attempt success rate
and rapid time to insertion.
Subcutaneous Rehydration Therapy
Also known as hypodermoclysis, subcutaneous rehydration therapy (SCRT) dates back to 1913
(Spandorfer, 2011) as an alternative for rehydration in mild to moderate dehydration when oral or IV
hydration is not feasible. The physiology behind SCRT stems from the sodium-potassium pump providing
an osmotic gradient. The subcutaneous tissue forms a thick matrix with hyaluronic acid (Allen, Etzwiler,
Miller, Maher, Mace, Hostetler, Smith, Reinhardt, Hahn, & Harb, 2009, Kuensting, 2011; Spandorfer,
2011). A recent innovation in SCRT involves the administration of hyaluronidase which modifies the
permeability of connective tissue, decreasing the viscosity of the cellular cement and promoting
absorption of injected fluids. By injecting hyaluronidase into the subcutaneous tissue, the permeability
of the matrix is increased and allows space for the infusion of fluid. The site selected for infiltration
should be an area where skin and the subcutaneous tissue can be pinched. The preferred site in children
is between the scapula (Kuensting, 2011) whereas in adults, the thighs, abdomen and arms can also be
used (Remington & Hultman, 2007). Fluid may be infused by gravity or by pump at a rate of 20 to 125
mL/h over a 24-hour period. Absorption of fluid is dependent on the osmotic gradient, not on the rate of
administration (Kuensting, 2011).
Allen et al. (2009) studied hyaluronidase facilitated SCRT in children ages 2 months to 10 years old
(N=51) to analyze rehydration and possible adverse events. The initial subcutaneous catheter was
placed upon first attempt 90.2% (46/51) with successful rehydration for 84.3% (43/51) patients. There
was one case of cellulitis at the site. The nurses who completed the procedure considered it easy to
perform for 96% (46/51) of patients with 90% (43/48) of the parents rating satisfied to very satisfied
with the procedure (Allen et al., 2009).
Remington and Hultman (2007) reviewed literature on SCRT and identified eight studies. When
comparing SCRT with IV administration from a safety perspective, the two were found to be
comparable. It is noted, however, subjects in these studies were elderly, with a mean age ranging from
71 to 85 years. The incidence of systemic adverse effects did not differ (Remington & Hultman, 2007).
Remington and Hultman showed more subjects improved clinically with IV administration than with
SCRT, but the difference was not statistically significant (81% IV, 57% SCRT, p=0.19). Site changes were
necessary on average every 2 days with SCRT and 2.8 days for IV administration (p=0.14) (Remington &
Hultman, 2007; Slesak, Schnurle, Kinzel, Jakob, & Dietz, 2003). Median duration of fluid administration
Emergency Nurses Association © December 2011. Please email for approval to reproduce multiple copies. 9
was six days with both SCRT and IV routes (Slesak et al., 2003). Nurses rated the feasibility of SCRT equal
with IV catheter (Remington & Hultman, 2007; Slesak et al., 2003). Nursing time to initiate SCRT was
significantly lower at 3.4 minutes versus 6.1 minutes for initiation of an IV catheter. A significant
difference was seen in the median volume of solution administered with 750 mL/day for SCRT and 1000
mL/day for IV administration (p=0.002; Slesak et al., 2003).
In summary, SCRT is a useful alternative for rehydration of mild to moderately dehydrated pediatric and
adult patients.
The use of heat to facilitate vasodilatation for IV insertion is widely practiced. Caution must be used with
this technique as burning may occur if not closely monitored and controlled. The U.S. Food and Drug
Administration (FDA) issued a patient safety warning in 2002 against the practice of using forced air
warmers without the blanket in a practice known as “hosing” because second and third degree burns
have resulted (FDA, 2002).
Studies specific to the ED setting are limited. Lenhardt, Seybold, Kimberger, Stoiser, and Sessler (2002)
conducted a randomized control study with a crossover trial of warming using a specific device to
facilitate IV cannulation in adult neurosurgery and hematology patients. The study compared passive
warming using a carbon fiber mitt and active warming when powered on and heated to 52˚C. The initial
study found that after 15 minutes of warming the success rate for IV cannulation was 94% (44/50) in the
active warming group compared to 72% (36/50) in the passive warming group (p=0.008). Additionally,
the cannulation required less time with active warming, 36 seconds compared to 62 seconds for passive
warming. The crossover trial applied warming for 10 minutes with a success rate of 95% for the active
warming group compared to the 73% passive warming group (p=0.001). The time required for successful
cannulation was 20 seconds shorter with active compared to passive warming (p=0.02; Lenhardt et al.,
Fink, Hjort, Wenger, Cook, and Cunningham conducted a randomized controlled study to compare dry
heat with moist heat (2009). Dry heat was 2.7 times more likely to result in successful IV insertion on
first attempt (p=0.039). The difference in mean insertion time between dry heat (98.5 seconds) and
moist heat (127.6 seconds) was large enough to be clinically meaningful. No significant difference in
patient anxiety was found between the heat modalities or between nurses or post-insertion patient
reported anxiety scores (p > 0.54). The conclusion recommended dry heat due to low cost, safety to
patients and feasibility. (Fink et al., 2009)
The use of EMLA Cream™ to decrease pain for pediatric patients is common practice which may result in
vasoconstriction of the vein.
Huff, Hamlin, Wolski, McClure, and Eliades evaluated the effect of heat
with EMLA Cream™ to facilitate IV cannulation (2009). The vein size was measured using ultrasound
technology prior to EMLA Cream™ application, one hour after application of EMLA Cream™, and 2
minutes after heat applied. The vein measurements over time were statistically significant (F=2.58,
Refer to the ENA Emergency Nursing Resource, Needle-Related Procedural Pain in Pediatric Patients in the Emergency
Department (Crowley et al., 2010) for a thorough review of needle-related pain management in this population.
Emergency Nurses Association © December 2011. Please email for approval to reproduce multiple copies. 10
p=.000), indicating approximately 51% variance in vein measurement which was attributed to EMLA
Cream™ and or heat when other conditions are stable. The average vein measurement at baseline was
0.243 cm, after EMLA Cream ™ 0.205 cm and with heat 0.253 cm. The difference in vein visualization
was also statistically significant (F=2.58, p=.000). The study had an 80% first cannulation success rate
(Huff et al., 2009).
In summary, controlled warming to facilitate IV cannulation is a low-cost adjunct to improve cannulation
success rate in a timely manner.
Alternative Methods
Noting the frustration experienced by healthcare professionals when faced with establishing IV access in
the ED, several groups have devoted time to identifying tools to assist with IV access. Near infrared light
illuminates the skin without ionizing radiation and produces a 2-D image of blood filled structures (Perry,
Caviness & Hsu, 2011). The literature was limited to pediatric populations. Perry et al. (2011) found the
nursing staff (N=14) felt the device was beneficial for 90% for those patients who had difficult IV access.
Further, 70% of the nurses surveyed found the device helpful for dehydrated patients and 80% in the
chronically ill population. However, there was no significant difference in the first attempt success rate
between standard IV techniques (N=62, 79%) and the infrared device (N=61, 72.1%; Perry et al., 2011).
Transillumination of veins using fiber optics in pediatric patients in another method studied
(Katsogridakis et al., 2008). Transillumination did not improve first attempt success (p=0.53), rather, use
of a safety catheter (p=0.01), vein visibility (p=0.01) and palpability (p=0.02) were better predictors of
first attempt success (Katsogridakis et al., 2008).
A Vein Entry Indicator Device (VEID™) is a small box with a pressure sensor that fits onto an IV cannula.
When a change in pressure in the needle indicates penetration of the vessel, a continuous beep sounds
and reduces the likelihood of exiting the back wall of the vein. The VEID was studied by Simhi, Kachko,
Bruckheimer, and Katz (2008) and found to help reduce the number of attempts at IV cannulation. The
VEID is not currently available in the United States.
In summary, these alternative methods may be useful adjuncts for patients with difficult IV access.
Emergency Nurses Association © December 2011. Please email for approval to reproduce multiple copies. 11
Description of Decision Options/Interventions and the Level of Recommendation
Conclusions and recommendations about alternatives to venous access in the patient with difficult IV
access in the ED:
1. Ultrasound-Guided Intravenous Access
i. Ultrasound-guided IV access is a viable option for patients with known difficult access
for both adult and pediatric populations. Level A High.
ii. Ultrasound-guided IV access is a technique that can effectively be performed by
physicians, nurses and ED technicians. Level A High.
iii. Ultrasound-guided techniques may result in improved patient satisfaction. Level C
iv. When the external jugular access is not visible, ultrasound-guided peripheral access is
significantly more successful than external jugular access. Level C Weak.
2. Intraosseous Vascular Access
i. Intraosseous venous access is significantly more expeditious than standard IV access and
should be considered early when known or suspected difficult IV access exists. Level A
ii. In alert patients, pain with intraosseous access insertions is rated as minor. Level A
iii. Lidocaine administration prior to medication infusion reduces the pain felt by alert
patients. Level C Weak.
3. Subcutaneous Rehydration Therapy
i. SCRT is an alternative to peripheral IV insertion for the mildly to moderately dehydrated
pediatric and elderly patients. Level B Moderate.
4. Warming
i. Application of heat improves IV success rate and decreases time required to gain access.
Level B Moderate.
a. Dry heat may be more effective than moist heat. Level C Weak
ii. For pediatric patients, heat may counteract the vasoconstriction associated with EMLA
Cream™. Level C Weak.
5. Alternative Methods
i. The use of infrared light, transillumination, and the VEID may be beneficial for
pediatric patients with difficult IV access, dehydration or a chronic illness. Level C
Emergency Nurses Association © December 2011. Please email for approval to reproduce multiple copies. 12
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Emergency Nurses Association © December 2011. Please email for approval to reproduce multiple copies. 15
ENA would like to acknowledge the following members of the 2011 Institute for Emergency Nursing
Research (IENR) Advisory Council for their review of this document:
Gordon Gillespie, PhD, RN, CEN, CPEN, CCRN, FAEN
Mary Kamienski, PhD, APRN, CEN, FAEN
Anne Manton, PhD, RN, APRN, FAEN, FAAN
Lisa Wolf, PhD, RN, CEN
... Tuttavia in un range di casistica che si aggira tra il 24% (11) e il 30% (12) del totale dei pazienti che accedono in ospedale per sottoporsi a trattamenti diagnostici e terapeutici, il reperimento di un accesso vascolare può risultare particolarmente difficoltoso e non riuscire con successo al primo tentativo. L' Emergency Nurses Association (ENA) definisce l' accesso vascolare difficile [Difficult Venous Access (DVA) o Difficult Intravenous Access (DIVA)] una condizione clinica che comporta l'esecuzione di due o più tentativi fallimentari di incannulamento della vena, come la necessità di ricorrere a tecniche di supporto per poter individuare i vasi non visibili con la sola tecnica della palpazione oppure come la scelta di procedere al posizionamento di un CVC ad inserzione centrale o di non ricorrere ad alcun accesso vascolare (13)(14)(15). In letteratura sono stati evidenziati alcuni fattori di rischio che ricorrono con frequenza negli assistiti con DVA e che possono indirizzare gli infermieri in un riconoscimento tempestivo: assenza di vasi visibili e palpabili rispettivamente nel 49.7% e 54.7% dei casi, l' 83.7% ha riferito precedenti episodi di difficoltà nel reperimento della vena, il 29.8% presenta indici di massa corporea [Body Mass Index (BMI)] > 30 Kg/m 2 con ispessimento dello strato sottocutaneo che ostacola l' identificazione del vaso (16), il 21.9% ha diagnosi di diabete ed è sottoposto a trattamento di dialisi che ha comportato un progressivo danneggiamento del reticolo vasale (13,15,17), il 5.4% è stato sottoposto a chemioterapie e/o a trattamenti con farmaci ad azione irritante e lo 0.9% conduce stili di vita scorretti come l'abuso di droghe per via parenterale (13). ...
... Ne deriva un tempo complessivo per svolgere l'intera procedura che si aggira tra un minimo di 13 minuti ed un massimo di 30 minuti considerando l'impianto di un CVP (12). Attualmente in caso di DVA si procede con l' esecuzione di ripetuti tentativi di incannulamento, coinvolgendo membri del team più esperti o ricorrendo al medico anestesista reperibile (12) il quale dopo aver tentato ulteriormente di reperire un accesso per via periferica procederà con il posizionamento di un CVC ad inserzione centrale (14). Questo approccio espone l'assistito con accesso vascolare difficile ad un rischio maggiore di insorgenza di infezioni catetere-correlate (1), ad un incremento della percezione del dolore e del discomfort (11,19,20) e progressivamente ad deterioramento progressivo del reticolo endovenoso per traumi vasali da ripetute venipunture. ...
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INTRODUZIONE: L’ accesso vascolare difficile si manifesta nel 30% degli assistiti che necessitano un accesso vascolare. E’ una condizione clinica che determina l’esecuzione di molteplici tentativi di incannulamento della vena. La gestione è affidata ad un team infermieristico dedicato con competenze avanzate nell’impianto di cateteri venosi periferici (CVP), PICC e Midline tramite tecnica ad ultrasuoni. OBIETTIVO:Effettuare un’analisi della letteratura indagando outcome e benefici della gestione di questi assistiti da parte di un team infermieristico con competenze avanzate negli accessi vascolari. METODI: Sono state consultate le banche dati PubMed, CINAHL, EMBASE, Cochrane Library, ILISI e Web of Science ed i siti ufficiali dell’ INS e del GAVeCeLT. RISULTATI: Sette studi sono stati inclusi. Il team è composto in media da 15 infermieri e 4 medici specialisti. Emerge un tasso di successo della procedura al primo tentativo dell’88-100% ed una riduzione del 90% e 70 % dei tassi di CLABSI e infezioni catetere-correlate. In media il 44.1% dei device sono stati rimossi per termine del trattamento. L’ attesa del device idoneo si è ridotta dell’ 80%. Il tasso medio di soddisfazione è risultato dell’ 88.23% (score medio registrato 8.56/10) ed una media di 2.85/10 per il dolore percepito. Le aziende hanno riportato una riduzione media di 261.358,27 euro/anno sulle spese aziendali. CONCLUSIONI: Un team dedicato per gli accessi vascolari difficili rappresenta una risorsa fondamentale per l’ erogazione di cure di qualità grazie ad una gestione tempestiva, una riduzione dei tassi di complicazioni, un’ ottimizzazione del timing assistenziale e delle spese aziendali.
... [11]Up to 90% of patients who visit the emergency room (ER) would need a PIVC at some point throughout their treatment. [12] Cannula selection and placement are increasingly in the hands of nurses, especially in specialized settings including oncology units, emergency rooms, critical care units, and medical imaging.Peripheral intravenous cannulation is estimated to take 2.5 to 13min on average, with problematic IV access taking up to 30min. [13] Patients admitted to the hospital for treatment, need long-duration intravenous cannulation for administering medication but to avoid infection from cannulation, the CDC ("Centres for Disease Control") (2011) recommendations avoiding intravenous catheters recommend changing the cannula every 72-96 hours. ...
... 10,11 International organisations (e.g. Infusion Nurses Society, 12 Emergency Nurses' Association of the USA, 13 The Australian Commission on Quality and Safety in Healthcare, 14 Royal College of Nursing 15 and Association of Anaesthetists of Great Britain and Ireland Safe Vascular Access 2016 16 ) all recommend the use of technology to improve PIVC first-attempt insertion success. Despite positive findings regarding ultrasound guidance to improve first-attempt insertion success in adults, particularly those identified as DIVA, evidence in paediatric patients appears inconclusive. ...
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Background: Paediatric peripheral intravenous catheter (PIVC) insertion using traditional landmark insertion technique can be difficult. Aim: To systematically review the evidence comparing landmark to ultrasound guidance for PIVC insertion in general paediatric patients. Study design: Cochrane methodology to systematically search for randomised controlled trials comparing landmark to ultrasound-guided PIVC insertion. Data sources: Cochrane Central Register of Controlled Trials, US National Library of Medicine, Cumulative Index to Nursing and Allied Health, Embase. Data extraction: English-language, paediatric trials published after 2000, reporting first-attempt insertion success, overall PIVC insertion success, and/or time to insert were included. Central venous, non-venous and trials including only difficult intravenous access were excluded. Data were independently extracted and critiqued for quality using GRADE by three authors, and analysed using random effects, with results expressed as risk ratios (RR), mean differences (MD) and 95% confidence intervals (CI). Registration (CRD42020175314). Results: Of 70 titles identified, 5 studies (995 patients; 949 PIVCs) were included. There was no evidence of an effect of ultrasound guidance, compared to landmark, for first-attempt insertion success (RR 1.27; 95% CI 0.90-1.78; I2 = 88%; moderate quality evidence), overall insertion success (RR 1.14; 95% CI 0.90-1.44; I2 = 82%; low quality evidence), or time to insertion (mean difference -3.03 min; 95% CI -12.73 to 6.67; I2 = 92%; low quality evidence). Limitations: Small sample sizes, inconsistent outcomes and definitions in primary studies precluded definitive conclusions. Conclusions: Large clinical trials are needed to explore the effectiveness of ultrasound guidance for PIVC insertion in paediatrics. Specifically, children with difficult intravenous access might benefit most from this technology.
Background: A perennial challenge faced by clinicians and made even more relevant with the global obesity epidemic, difficult intravenous access (DIVA) adversely impacts patient outcomes by causing significant downstream delays with many aspects of diagnoses and therapy. As most published DIVA strategies are limited to various point-of-care ultrasound techniques while other "tricks-of-the-trade" and pearls for overcoming DIVA are mostly relegated to informal nonpublished material, this article seeks to provide a narrative qualitative review of the iterature on DIVA and consolidate these strategies into a practical algorithm. Methods: We conducted a literature search on PubMed using the keywords "difficult intravenous access", "peripheral vascular access" and "peripheral venous access" and searched emergency medicine and anaesthesiology resources for relevant material. These strategies were then categorized and incorporated into a DIVA algorithm. Results: We propose a Vortex approach to DIVA that is modelled after the Difficult Airway Vortex concept starting off with standard peripheral intravenous cannulation (PIVC) techniques, progressing sequentially on to ultrasound-guided cannulation and central venous cannulation and finally escalating to the most invasive intraosseous access should the patient be in extremis or should best efforts with the other lifelines fail. Conclusion: DIVA is a perennial problem that healthcare providers across various disciplines will be increasingly challenged with. It is crucial to have a systematic stepwise approach such as the DIVA Vortex when managing such patients and have at hand a wide repertoire of techniques to draw upon.
Background Peripheral intravenous catheterization (PIVC) is pivotal to pediatric medical care; however, it is a challenging technique for pediatricians, and the parameters affecting successful pediatric PIVC establishment have not been fully investigated. Methods This prospective observational study collected data from pediatric patients aged less than 18 years who required PIVC. The participants were categorized into five groups for subgroup analysis: newborn, infant, toddler, pre-school, and student (children and adolescent). Data on demography, biochemistry, and PIVC executors were examined to elucidate the most powerful factors affecting the success of PIVC. Results A total of 935 peripheral venous cannulations conducted within 1 year were studied. Age-subgroup analysis showed the highest failure rate (FR) of PIVC in the infant group (18.4%). No significant difference in BMI standard deviation score was noted among the groups (p-value = 0.430). Compared with those for the success group, more attempts, longer completion time, and more medical staff were needed for the failure group (all p-values <0.05). A high serum procalcitonin level was correlated with an increased FR (p-value = 0.016). In addition, the success rate was positively associated with the seniority of the operators, except for the 3-year experienced R3 group (93.5%) showing a higher success rate than the 4-year experienced CR group (84.2%). Conclusions Difficulty in setting up PIVC was the greatest in infants and even greater than that in newborns. Even though seniority was a cardinal factor in successful PIVC, a high FR was still noted despite the lack of continuous and steady practice.
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Aim: this analysis investigates the concept of violence against nurses by patients and visitors in the emergency department. It aims to differentiate, clarify, and clearly identify this specific concept, which will facilitate more apt measurement and reporting, ultimately to contribute violence reduction measures. Background: Due to contextual factors, occupational risk and patient characteristics, violence against nurses by patients and visitors in the emergency department varies from other types of violence against other healthcare staff, METHODS: This study employed Walker & Avant's concept analysis technique. Results: The analysis found that violence against nurses by patients and visitors in the emergency department is primarily an occurrence of interpersonal violence based on the working relationship; whereby the patient and/or visitor becomes an assailant, and a nurse becomes a target in the absence of capable guardianship. There is also an intentional use of physical force or power, that results in or has a high chance of causing harm. Conclusion: A clearer understanding of the antecedents, attributes, and consequences of violence against nurses by patients and visitors arising from this concept analysis provides a framework that will assist in the understanding, measurement, reporting, and prevention of violence, but also inform future research. Implications for nursing management: Nursing managers are encouraged to adopt strategies that act on the factors related to attributes and antecedents that will serve to reduce the occurrence of intentional violent acts.
Introduction Multiple attempts during peripheral cannulation can have major consequences for patients, relatives, and healthcare professionals, therefore we set out to determine the extent of this problem in a paediatric intensive care unit (PICU). Objectives The main aim was to describe peripheral venous catheter (PVC) and peripherally inserted central catheter (PICC) cannulation in children in the PICU. Secondary objectives were to determine the success rate of the first cannulation attempt, to quantify patients with difficult venous access (DVA), and to explore the association between DVA and sociodemographic, technique and nursing-related characteristics. Method A cross-sectional descriptive study. Consecutive sampling was used to recruit patients aged 0-18 years admitted to the PICU who required peripheral venous cannulation. An ad hoc questionnaire was used for this purpose, including the presence of DVA as an independent variable. Results A total of 163 venous cannulations were reported. A total of 55.8% (91) were performed in patients under 1 year of age. Of these, 38.7% (63) were successful on the first attempt and 36.8% (60) had DVA. When there was DVA, 85% (51) of patients had complications, median time to cannulation by short CVP was 30 minutes [15-53] and 2 or more nurses were required on 80% (48) of occasions. Conclusions We found a low success rate at first attempt and a high proportion of DVA. More nurses and time were employed during cannulation and complications increased if the patient had DVA. A statistically significant association was found between DVA and age, weight, poor perfusion, veins that were neither visible nor palpable, DIVA score ≥ 4, history of difficult intravenous access, complications, number of nurses and time spent.
The field of emergent vascular access has evolved extensively since its earliest days and will undoubtedly continue to evolve as clinicians and organizations explore new devices, modified techniques, and novel approaches to meet the demands of an increasingly complex clinical landscape. This chapter will explore some of the nascent concepts in emergent vascular access that have surfaced over the last few decades, focusing on areas expected to yield improvements in the ways in which vascular access can be achieved for patients in a variety of acute care settings.
Peripheral intravenous cannulation (PIV) is a common and necessary procedure in the emergency department (ED). Patients with PIV access encounter significant treatment delay. Ultrasound guidance for PIV (USGPIV) cannulation is a modality to reduce delay of care in such patients, but its efficacy, when compared with cannulation by the standard of care (SOC), the landmark and palpation method, has not been well established. We performed a random effects meta-analysis of available literature that compared USGPIV with SOC cannulation. We searched PubMed, Scopus and EMBASE until October 2020 for eligible studies in adult patients. We excluded non-English language, non-full-text studies. Our primary outcome was rate of first successful cannulation. Other outcomes were number of attempts and patient satisfaction. After identifying 284 studies and screening 74 studies, we included 10 studies. There were 1860 patients, 966 (52%) in the USGPIV group and 894 (48%) who received the SOC. Sixty-six percent of patients were female. USGPIV cannulation was associated with a two-times higher likelihood of first successful cannulation (odds ratio: 2.1, 95% confidence interval [CI]: 1.65–2.7, p < 0.001, I² = 2.9%). While procedure length was similar in both groups, USGPIV was associated with a significantly smaller number of attempts (standardized mean difference [SMD]: –0.272, 95% CI: –0.539 to –0.004, p = 0.047) and significantly higher patient satisfaction (SMD: 1.467, 95% CI: 0.92–2.012, p < 0.001). There was low heterogeneity among our included studies, which were mostly randomized control trials. Our study confirmed that USGPIV cannulation offers a more effective modality, compared with SOC, to improve quality of care for patients with difficult PIV access.
Ultrasonography use in the emergency department (ED) has been well established. The use of ultrasonography that falls into the traditional practice of the emergency nurse is peripheral intravenous (IV) access. Benefits of using ultrasonography for peripheral IV access include decreasing patient throughput, cost reduction, decreasing complications, increased patient and emergency medicine physician satisfaction, and emergency nurse autonomy. Review of the literature demonstrates no discernable differences in ability and efficacy with ultrasound (US)-guided peripheral IV access when comparing data from studies about emergency medicine physicians, certified registered nurses anesthetists, emergency department technicians, physician assistants, and emergency registered nurses. In 2006, Duke University Hospital Emergency Department started a US-Guided Peripheral IV Access program for emergency nurses. Similar patient populations have been observed and the same types of complications have been encountered as described in the literature. Future goals include perfecting nurses' vein selection, and to study skill mastery with US-guided peripheral IV access.
OBJECTIVES: To compare the acceptance, feasibility, and adverse effects of subcutaneous (SC) and intravenous (IV) rehydration in dehydrated geriatric patients and clinical changes exhibited by the patients. DESIGN: A prospective, randomized, open clinical trial. SETTING: Hospital geriatric wards during a period of 20 months. PARTICIPANTS: Ninety-six patients with a mean age ± standard deviation of 85.3 ± 6.7 with signs of mild to moderate dehydration needing parenteral fluids. INTERVENTION: Geriatric patients were randomly allocated to receive SC or IV infusions of half-normal saline-glucose solutions as long as clinically necessary. MEASUREMENTS: A standardized patient record form was used to document the observed adverse effects. Using a Likert-like scale based on the German school marks system with scores ranging from 1 = very good to 6 = very bad, patients were asked to score their discomfort; nurses and doctors scored the feasibility of the intervention. Changes in laboratory and clinical findings (including patients' orientation and activities of daily living using the Barthel Index) and adverse effects were recorded. RESULTS: Forty-eight patients were randomized into each group. Median duration of fluid administration was 6 days (SC and IV, P = .33). Median volume was 750 mL/day (SC) and 1,000 mL/day (IV, P = .002). In 13 patients, the therapy had to be changed from SC to IV (SC/IV subgroup): 11 times because of the exigency of an IV drug application and twice because of poor resorption. In 17 patients, there was a change from IV to SC (IV/SC subgroup), mainly because of impossibility of further peripheral IV punctures (8 times) and permanent removal of the IV cannula (5 times). The patients of the IV/SC subgroup scored their discomfort significantly worse (median 5.5 vs all other groups median 2, P = .017). This corresponded with the scoring of feasibility by the nurses (IV/SC: median 4.25 vs all other groups median 2, P = .009) and by the doctors (IV/SC: median 4 vs all other groups: median 2, P = .001). Both methods of rehydration caused only few systemic adverse reactions; acute cardiac failure occurred twice in the SC group versus four times in the IV group (P = .68) and hyponatremia once in the SC group versus twice in the IV group (P = 1.0). Some patients experienced local side effects (SC, n = 29 vs IV, n = 24; P = .41), mainly to a mild extent (SC, n = 25 vs IV, n = 24; P = 1.0). Major local side effects (large edema, phlebitis, cellulitis, erythema and strong pain) occurred in nine SC and eight IV (P = 1.0) patients. The clinical and laboratory changes during therapy were similar in both trial arms. CONCLUSIONS: Rehydration by hypodermoclysis is equally well accepted by geriatric patients as the IV therapy and offers a similarly easy feasibility. Additionally, in confused patients and in those in whom IV punctures are difficult to achieve, it represents the far superior method. Both techniques are comparably safe and effective.
The purpose of this study was to investigate whether the application of heat placed to a child's potential intravenous (IV) site after the application of EMLA Cream™ decreases vasoconstriction, therefore promoting atraumatic care in the hospitalized pediatric patient. Venipuncture in children is a painful and frequently performed procedure. While use of EMLA Cream™ to reduce pain on insertion is a common practice with pediatric patients, no studies had measured venous size in relation to EMLA Cream™ and heat application. A descriptive quantitative design was used to examine the use of EMLA Cream™ and application of heat to facilitate venipuncture for peripheral venous cannulation. A convenience sample of 30 hospitalized Caucasian children, eight to twelve years old, participated. Vascular ultrasound directly measured the vein prior to and 1 hour after EMLA Cream™ application, as well as 2 minutes after heat application. Mean vein measurements were 0.243 cm prior to EMLA Cream™, 0.205 cm after EMLA Cream™ applied for 1 hour, and 0.253 cm after two minutes of heat. There was a significant increase in vein visualization from pre-application of heat to post application of heat with a success rate of 80% with the first time attempt of IV insertion. Therefore, application of heat counteracts the adverse effect of vasoconstriction that occurs with EMLA Cream™ application, potentially increasing peripheral venous cannulation success rates.
In summary, hyaluronidase augmented SCRT is becoming an accepted alternative for children with mild to moderate dehydration when ORT has failed and intravenous access is difficult. While use of a nasogastric tube is an accepted alternative, this technique is invasive and usually requires restraining of the child's extremities and can lead to complications. The use of oral ondansetron has enhanced ORT, but it is not always successful. Hyaluronidase augmented SCRT has provided an additional alternative for parenteral therapy, but knowledge of its indications and expectations for use is required. This article provides the ED nurse with some clinical knowledge of hyaluronidase augmented SCRT and its key differences from IVT (Table). Further study of nursing considerations with this method of parenteral therapy in children is strongly recommended.
Subcutaneous (SC) rehydration therapy (SCRT), originally referred to as "hypodermoclysis," shows promise as an alternative to intravenous (IV) fluid administration for treatment of dehydration. A simple, safe, and effective technique, SCRT is indicated for treatment of mild-to-moderate dehydration. Augmentation of SCRT with administration of a recombinant human formulation of the hyaluronidase enzyme at the infusion site gives rise to SC fluid administration rates up to 5-fold faster than those achieved without the enzyme, making the technique more clinically practical. Unlike older, animal-derived forms of hyaluronidase, recombinant human hyaluronidase has a lower chance of allergic reactions with repeated dosing. Clinical trials have demonstrated that recombinant human hyaluronidase effectively and safely facilitates fluid delivery in adults and children and is well accepted by parents and clinicians. In the emergency department setting, SCRT may be an appropriate alternative to IV fluid administration in certain situations because it is less invasive and generally less painful, while still permitting administration of appropriate volumes of rehydration fluids. Subcutaneous rehydration therapy appears to be particularly useful in patients who present with mild-to-moderate dehydration and have had failed attempts at oral rehydration. The SC route also provides benefits in patients with small, collapsed, or difficult-to-visualize veins or in those who may be agitated or distressed by IV catheterization. Continued research will further clarify the role of recombinant human hyaluronidase-facilitated SCRT in the rehydration treatment algorithm.
To determine whether the use of a near-infrared light venipuncture aid (VeinViewer; Luminetx Corporation, Memphis, Tenn) would improve the rate of successful first-attempt placement of intravenous (IV) catheters in a high-volume pediatric emergency department (ED). Patients younger than 20 years with standard clinical indications for IV access were randomized to have IV placement by ED nurses (in 3 groups stratified by 5-year blocks of nursing experience) using traditional methods (standard group) or with the aid of the near-infrared light source (device group). If a vein could not be cannulated after 3 attempts, patients crossed over from one study arm to the other, and study nurses attempted placement with the alternative technique. The primary end point was first-attempt success rate for IV catheter placement. After completion of patient enrollment, a questionnaire was completed by study nurses as a qualitative assessment of the device. A total of 123 patients (median age, 3 years) were included in the study: 62 in the standard group and 61 in the device group. There was no significant difference in first-attempt success rate between the standard (79.0%, 95% confidence interval [CI], 66.8%-88.3%) and device (72.1%, 95% CI, 59.2%-82.9%) groups. Of the 19 study nurses, 14 completed the questionnaire of whom 70% expressed neutral or unfavorable assessments of the device in nondehydrated patients without chronic underlying medical conditions and 90% found the device a helpful tool for patients in whom IV access was difficult. First-attempt success rate for IV placement was nonsignificantly higher without than with the assistance of a near-infrared light device in a high-volume pediatric ED. Nurses placing IVs did report several benefits to use of the device with specific patient groups, and future research should be conducted to demonstrate the role of the device in these patients.