Vessel Health and Preservation: The Right Approach for Vascular Access
Abstract
This Open access book offers updated and revised information on vessel health and preservation (VHP), a model concept first published in poster form in 2008 and in JVA in 2012, which has received a great deal of attention, especially in the US, UK and Australia.
The book presents a model and a new way of thinking applied to vascular access and administration of intravenous treatment, and shows how establishing and maintaining a route of access to the bloodstream is essential for patients in acute care today. Until now, little thought has been given to an intentional process to guide selection, insertion and management of vascular access devices (VADs) and by default actions are based on crisis management when a quickly selected VAD fails. The book details how VHP establishes a framework or pathway model for each step of the patient experience, intentionally guiding, improving and eliminating risk when possible. The evidence points to the fact that reducing fragmentation, establishing a pathway, and teaching the process to all stakeholders reduces complications with intravenous therapy, improves efficiency and diminishes cost. As such this book appeals to bedside nurses, physicians and other health professionals.
... Крім того, після проведеної терапії пацієнтам не потрібна зовнішня пов'язка у зоні порту та дозволено займатися звичайною діяльністю, наприклад приймати душ або плавати, після видалення голки. Завдяки цілком підшкірному розташуванню порт-системи непомітні, а тому пацієнти не комплексують з цього приводу [1][2][3]. Через низький рівень екстравазації та інфекції загальними показаннями для використання постійних венозних порт-систем є введення препаратів із місцевозапальною дією на ендотелій судин, як-от препарати для хіміотерапії та парентерального харчування [4]. ...
... Ускладнення встановлення центральних венозних порт-систем поділяються на перипроцедурні ранні (≤ 30 днів після імплантації) і відтерміновані (> 30 днів) [1][2][3]9]. Ускладнення можна розділити на незначні та серйозні. ...
... Ускладнення можна розділити на незначні та серйозні. Незначні ускладнення -це події, які не вимагають додаткового хірургічного або інтервенційного втручання чи застосування медикаментозної терапії > 24 год, тоді як серйозні ускладнення потребують хірургічного втручання, тривалої медикаментозної терапії, перебування в лікарні > 24 год або навіть можуть призвести до смерті [1][2][3]9]. Гемоторакс і пневмоторакс -це, най імовірніше, серйозні ускладнення, залежно від тяжкості. ...
Implanted central vascular access devices for intravenous administration of drugs are widely used in cancer patients who require long-term access, specific chemotherapy and parenteral nutrition. Installation of central vascular access devices solves the problem of venous access, but, unfortunately, it can lead to complications, including serious and irreversible ones. Here is a clinical case of cancer in a 49-year-old female patient who was implanted with a vascular access device for intravenous therapy. The incorrect and undiagnosed insertion of the vascular access device in the subclavian artery and also neoadjuvant polychemotherapy sessions led to myelomalacia with the subsequent development of myeloradiculopathy, the emergence and development of persistent neurological disorders. After radiological diagnosis and verification of this complication, percutaneous transluminal angioplasty with single stenting and removal of the central vascular access device was performed. The article presents complications with the insertion of central vascular access devices and discusses in detail a clinical case of complication and methods for its solution when this device is incorrectly implanted in the artery.
... Between each round, there was an interval of 7 -14 days. Prior to the first round, the collection of recommendations derived from the review of the CPG related to the prevention of PIVC complications was extracted [26][27][28]. A further potential benefit of the method is the meeting of geographically dispersed experts on a single panel while maintaining their anonymity [24]. ...
... First round of the questionnaire Between January -March 2020, we compiled an initial set of measures through a systematic review [26], the book Vessel Health and Preservation: The Right Approach for Vascular Access [27], and the Infusion Therapy Standard of Practice [28]. ...
... In this regard, health literacy in vascular access is needed for patient empowerment in self-care and shared decision-making for preventing PIVC failure and infections. In some countries, this is an emerging approach to research enquiry in others accepted as necessary and commonplace [27,41]. More studies are needed that integrate the patient experiences for improving decision-making related to the care of PIVCs. ...
... Multiple international vascular access experts and societies highlighted the importance of using vein-detecting technologies during the assessment of the patient's veins [28][29][30][31][32][33][34][35]. Most literature converges on the importance of ultrasound-guided PIVC insertion in DIVA patients, often considered the gold standard practice. ...
... Most literature converges on the importance of ultrasound-guided PIVC insertion in DIVA patients, often considered the gold standard practice. Ultrasound imaging allows the healthcare professional to locate a suitable vein, assess its size and select the proper catheter calibre, as well as continuously monitor needle progression through the skin layers until vein penetration is achieved [32][33][34]. While ultrasonography can be used in any anatomical region, it is an essential tool for veins above the antecubital fossa. ...
... Likewise, locating a vein per se is not a synonym for first-attempt success. Several studies have shown that the vein diameter is a predictor of easiness and first-attempt success in PIVC insertion [32,37,38]. Recent technology aims to apply the principles of electric stimulation treatment in peripheral veins before vein selection. ...
While previous studies suggest that patient risk factors such as advanced age and cancer disease are accountable for difficult intravenous access (DIVA), very few studies have studied how the coexistence of both risk factors impacts care outcomes. We aimed to compare DIVA status and peripheral intravenous catheter (PIVC) related care outcomes in adults and older adults with cancer. A retrospective analysis was conducted using an existing dataset from a large Action-Research project conducted with the nursing team from a surgical oncology ward in Portugal. Study findings show that one in every three older adults is at moderate to high risk of DIVA. Compared to younger adults, this cohort is less likely to experience first-attempt success in PIVC insertion (69.7% versus 82%; χ2(1) = 4.17, p = 0.046), a higher number of consecutive puncture attempts (t(198) = -2.67, p = 0.008) and PIVC-related adverse events (23.6% versus 13.5%). These findings support the importance of formally conducting DIVA assessment in oncology settings, using structured approaches and instruments, as well as introducing vein-locating technologies such as ultrasound imaging and electrical stimulation technology that promote efficient, safe, and sustainable nursing practice.
... 1,2 The most common method to choose a PIVC puncture site is to inspect and palpate superficial veins, looking for anatomical reference points. 3,4 Superficial veins in the upper limbs are mostly chosen for PIVC, since they are main options for inserting intravenous devices. 5,6 However, some factors make it harder to find veins by observation and palpation technique. ...
... All these aspects directly affect the assertiveness rates of cannulation and especially vascular health preservation. 4,7 In patients with difficult intravenous access, critical health status, and under emergency services and/or intensive care, ultrasound caused less peripheral cannulation attempts than the conventional technique. [8][9][10][11][12][13][14] Randomized clinical trials between both techniques also showed that, for emergency services, ultrasound had a higher success rate in patients with difficult venous access (76% insertion success rate [48/63] for puncture with ultrasound and 56% [33/59] for the conventional technique, increasing ultrasound success rates in 2.52 times [95% CI: 1.09-5.92]). ...
... Nurses from this group adopt the health and vascular preservation model in their clinical practice, which allows them to choose the best insertion site, the most appropriate device, and the best insertion technique. 4,26,27 A distinguishing feature of the present study, and one that certainly greatly increased first attempt success, was to analyze patients who were not clinically unstable at the time of evaluation for inclusion in the research. Also, to reduce the risk of bias, all patients underwent venous network classification prior to puncture. ...
Background:
Peripheral intravenous catheter (PIVC) insertion is the most common invasive procedure in the hospital setting. Ultrasound guided PIVC insertion in specific populations and settings has shown patient care benefits.
Objective:
To compare the success rate of first attempts of ultrasound guided PIVC insertion performed by nurse specialists with conventional PIVC insertion performed by nurse assistants.
Method:
Randomized, controlled, single-center clinical trial registered on the ClinicalTrials.gov platform under registration NTC04853264, conducted at a public university hospital from June to September 2021. Adult patients hospitalized in clinical inpatient units with an indication for intravenous therapy compatible with a peripheral venous network were included. Participants in the intervention group (IG) received ultrasound guided PIVC performed by nurse specialists from the vascular access team, while those in the control group (CG) received conventional PIVC by nurse assistants.
Results:
The study included a total of 166 patients: IG (n = 82) and CG (n = 84), mean age 59.5 ± 16.5 years, mostly women (n = 104, 62.7%) and white (n = 136, 81.9%). Success rate on the first attempt of PIVC insertion in IG was 90.2% and in CG was 35.7% (p < 0.001), with a relative risk of 2.5 (95% CI 1.88-3.40) for success in IG versus CG. Overall assertiveness rate was 100% in IG and 71.4% in CG. Regarding procedure performance time, the medians in IG and CG were 5 (4-7) and 10 (6-27.5) min respectively (p < 0.001). As for the incidence of negative composite outcomes, IG had lower rates compared to CG, 39% versus 66.7% (p < 0.001), generating a 42% lower probability of negative outcomes in IG, 0.58 (95% CI: 0.43-0.80).
Conclusion(s):
Successful first-try insertion was higher in the group receiving ultrasound-guided PIVC. Moreover, there were no insertion failures and IG presented lower insertion time rates and incidence of unfavorable outcomes.
... The vessel health and preservation (VHP) model guided synthesis of the study aim and research questions (20,21). Both a framework and clinical pathway developed via an integration of guidelines and functions, VHP provided a structured process to enable the systematic analysis of the study results with the goal of increasing quality indicators and reducing PIVC complications (20,21). ...
... The vessel health and preservation (VHP) model guided synthesis of the study aim and research questions (20,21). Both a framework and clinical pathway developed via an integration of guidelines and functions, VHP provided a structured process to enable the systematic analysis of the study results with the goal of increasing quality indicators and reducing PIVC complications (20,21). With education at its core, the model identifies key practice quadrants for the life of vascular access devices, as well as evidence-based recommendations to reduce the risk of PIVC complications to ensure patient safety. ...
... As outlined in Figure 1, the VHP quadrants identify the functions required during the PIVC continuum (21). When used in combination, quadrant functions may contribute to a wider program of PIVC quality and patient safety. ...
Background
Peripheral intravenous catheter (PIVC) insertion is one of the most common clinical procedures worldwide, yet little data are available from Latin America. Our aim was to describe processes and practices regarding PIVC use in hospitalized patients related to hospital guidelines, characteristics of PIVC inserters, prevalence of PIVC complications, and idle PIVCs.Methods
In 2019 we conducted a multinational, cross-sectional study of adult and pediatric patients with a PIVC in hospitals from five Latin American countries: Argentina, Brazil, Chile, Colombia, and Mexico. We used two data collection tools to collect hospital guidelines and patient-specific data on the day of the study. The vessel health and preservation (VHP) model guided synthesis of the study aims/questions and suggested opportunities for improvement.ResultsA total of 9,620 PIVCs in adult (86%) and pediatric inpatients in 132 hospitals were assessed. Routine replacement 8–72 hourly was recommended for adults in 22% of hospitals, rather than evidence-based clinical assessment-based durations, and 69% of hospitals allowed the use of non-sterile tape rather than the international standard of a sterile dressing. The majority (52%) of PIVCs were inserted by registered nurses (RNs), followed by nursing assistants/technicians (41%). Eight percent of PIVCs had pain, hyperemia, or edema, 6% had blood in the extension tubing/connector, and 3% had dried blood around the device. Most PIVCs had been inserted for intravenous medications (81%) or fluids (59%) in the previous 24 h, but 9% were redundant.Conclusion
Given the variation in policies, processes and practices across countries and participating hospitals, clinical guidelines should be available in languages other than English to support clinician skills and knowledge to improve PIVC safety and quality. Existing and successful vascular access societies should be encouraged to expand their reach and encourage other countries to join in multinational communities of practice.
... In quanto procedura invasiva non è da ritenersi priva di complicazioni, le quali assumono una natura multifattoriale poiché dipendono dalle caratteristiche del paziente (comorbilità, età, stato del reticolo endovenoso), dalle variabili del VAD implementato (lunghezza, diametro della cannula, sede e sito di inserzione), dalle proprietà della sostanza infusa (agente irritante, vescicante e necrotizzante) e dalla tecnica utilizzata per il reperimento e il posizionamento del device (2). Quelle riscontrate con maggior frequenza in letteratura si associano alla tecnica con cui il device è stato impiantato e vengono classificate in complicazioni procedurali e postinserzionali: le prime incorrono a breve termine come la puntura accidentale dell' arteria nel 12% dei casi, la lesione del vaso, il coinvolgimento del nervo con incremento della percezione dolorifica, le infezioni catetere-correlate e l' embolia (8); le seconde invece nel lungo termine (giorni o settimane) come infezioni sistemiche, flebiti e tromboflebiti, infiltrazioni e stravasi, occlusioni e nel 69% dei casi dislocamenti accidentali della cannula (2,3). In entrambi i casi sarà necessario reperire un nuovo accesso venoso che esporrà il paziente ad ulteriori rischi potenziali, determinerà ritardi nell' esecuzione degli esami necessari alla diagnosi, aumenterà i tempi di inizio dei trattamenti e di degenza (8,9). ...
... Quelle riscontrate con maggior frequenza in letteratura si associano alla tecnica con cui il device è stato impiantato e vengono classificate in complicazioni procedurali e postinserzionali: le prime incorrono a breve termine come la puntura accidentale dell' arteria nel 12% dei casi, la lesione del vaso, il coinvolgimento del nervo con incremento della percezione dolorifica, le infezioni catetere-correlate e l' embolia (8); le seconde invece nel lungo termine (giorni o settimane) come infezioni sistemiche, flebiti e tromboflebiti, infiltrazioni e stravasi, occlusioni e nel 69% dei casi dislocamenti accidentali della cannula (2,3). In entrambi i casi sarà necessario reperire un nuovo accesso venoso che esporrà il paziente ad ulteriori rischi potenziali, determinerà ritardi nell' esecuzione degli esami necessari alla diagnosi, aumenterà i tempi di inizio dei trattamenti e di degenza (8,9). Le competenze dell' infermiere circa la scelta del device idoneo e il suo impianto con tecnica dedicata, divengono determinanti per la prevenzione e la riduzione delle complicazioni correlate alla pratica di incannulamento (6,10). ...
... La corretta gestione del patrimonio venoso è parte integrante del percorso di cura del paziente, preservarlo e trattarlo adeguatamente rientra nella valutazione clinica globale che l' infermiere è portato a effettuare con costanza durante la presa in carico (7,21); pertanto nell' esecuzione della procedura di incannulamento l' infermiere deve porsi come obiettivo clinico anche quello di garantire l' integrità del reticolo endovenoso del paziente. Ne consegue che il riconoscimento tempestivo di un DVA permette di implementare tecniche di reperimento della vena avanzate e di selezionare VAD alternativi (1,8). Le ultime linee guida pubblicate dall' Infusion Nurses Society (INS) dichiarano che la gestione di un assistito con DVA deve avvenire da parte di infermieri specializzati, in grado di impiegare un approccio proattivo nella valutazione delle necessità del paziente per selezionare il VAD più appropriato avvalendosi di tecniche alternative per la visualizzazione e il reperimento del vaso (6). ...
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.
... A escolha do acesso vascular central ( Fig. 1) depende da natureza da infusão a administrar (pH < 5 ou > 9, e osmolaridade > 600 mOsm/l), da existência de um "património vascular" diminuído (≤ 2 veias palpáveis/visíveis com dificuldade na punção), da necessidade de flebotomias frequentes (≥ 3 dia) e a duração do regime terapêutico (≥ 6 dias) (Moureau, 2019) (Chopra et al., 2015. El catéter venoso central totalmente implantado permite la administración segura de terapias antineoplásicas con bajo riesgo de complicaciones y un impacto positivo en la calidad de vida de la persona con patología oncológica. ...
... • Inserir o cateter em ambiente controlado (preferencialmente com ventilação mecânica de pressão positiva) do bloco operatório (DGS, 2015;Moureau, 2019 (Pittiruti et al., 2016). • Utilizar sempre a técnica de "Push-Pause" ou técnica turbulenta para a lavagem do lúmen do CVC, com a administração de ≥10 ml SF em pulsos (lentamente) de cerca de 1 ml (Martinez et al., 2018;Smith et al., 2017;Rupp & Karnatak, 2018;Moureau, 2019 (CDC, 2011;Pittiruti et al., 2016;Smith et al., 2017;Moureau, 2019). ...
... • Inserir o cateter em ambiente controlado (preferencialmente com ventilação mecânica de pressão positiva) do bloco operatório (DGS, 2015;Moureau, 2019 (Pittiruti et al., 2016). • Utilizar sempre a técnica de "Push-Pause" ou técnica turbulenta para a lavagem do lúmen do CVC, com a administração de ≥10 ml SF em pulsos (lentamente) de cerca de 1 ml (Martinez et al., 2018;Smith et al., 2017;Rupp & Karnatak, 2018;Moureau, 2019 (CDC, 2011;Pittiruti et al., 2016;Smith et al., 2017;Moureau, 2019). • Remover o CVC quando não for previsível a sua utilização (CDC, 2011;Pittiruti et al., 2016;Smith et al., 2017;Moureau, 2019). ...
Os tratamentos em oncologia têm vindo a aumentar, tanto em número como em complexidade. A existência de um acesso vascular central seguro e adequado à terapêutica a realizar é fundamental, promovendo a melhor prática no cuidado ao doente com cancro.O cateter venoso central totalmente implantado permite a administração segura de terapêuticas antineoplásicas com baixo risco de complicações e um impacto positivo na qualidade de vida da pessoa com patologia oncológica. Mais recentemente, o cateter central de inserção periférica sendo menos invasivo, tem demonstrado benefícios comprovados para o doente e para a gestão de cuidados de saúde. No entanto, ainda necessita de maior divulgação.
Apesar de existirem várias recomendações internacionais referentes à manutenção e otimização dos acessos vasculares centrais, ainda persistem dúvidas na prática clínica. Este facto, motivou esta pesquisa bibliográfica para desenvolver competências nesta área de intervenção.
... Short peripheral IV catheters (PIVC) are catheters measuring less than 7.5 cm in length. 1 An estimated 59%-86% of hospitalized patients receive at least one PIVC during their admission. [1][2][3][4] Despite their ubiquity, PIVC insertion may be challenging or ultimately unsuccessful in some patients, a condition known as difficult intravenous access (DIVA). ...
... Short peripheral IV catheters (PIVC) are catheters measuring less than 7.5 cm in length. 1 An estimated 59%-86% of hospitalized patients receive at least one PIVC during their admission. [1][2][3][4] Despite their ubiquity, PIVC insertion may be challenging or ultimately unsuccessful in some patients, a condition known as difficult intravenous access (DIVA). [5][6][7][8] An estimated 8%-59% of hospitalized patients are affected by DIVA. ...
... [33][34][35][36][37] There are also increasing concerns that repeated puncture attempts and recurring device failure precipitate venous depletion, and undermines overall vessel health. 1,38 These reports have led some authors to conclude that USGPIVs may only be appropriate for shortterm infusions or as a temporary bridge until more definitive vascular access can be established. [29][30][31] The purpose of this study was to compare the survival rate of USGPIVs to traditional PIVCs, following dissemination of a hospital-wide USGPIV simulation-based mastery learning (SBML) curriculum for nurses. ...
Problem
Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is an effective method to gain vascular access in patients with difficult intravenous access (DIVA). While USGPIV success rates are reported to be high, some studies have reported a concerning incidence of USGPIV premature failures.
Aims
The purpose of this study was to compare differences in USGPIV and landmark peripheral intravenous catheter (PIV) utilization and failure following a hospital-wide USGPIV training program for nurses.
Methods
The authors performed a retrospective, electronic medical record review of all USGPIVs and PIVs inserted at a tertiary, urban, academic medical center from September 1, 2018, through September 30, 2019. The primary outcome was differences between USGPIV and PIV time to failure.
Results
A total of 43,470 short peripheral intravenous catheters (PIVCs) were inserted in 23,713 patients. Of these, 7972 (16.8%) were USGPIV. At 30 days of follow-up, for PIVCs with an indication for removal documented, USGPIVs had higher Kaplan–Meier survival probabilities than PIVs ( p < 0.001).
Conclusions
The use of simulation-based mastery associated with USGPIVs, demonstrated lower failure rates than standard PIVs after 2 days and USGPIVs exhibited improved survival rates in patients with DIVA. These findings suggest that rigorous simulation-based insertion training demonstrates improved USGPIV survival when compared to traditional PIVCs. SBML is an extremely useful tool to ensure appropriately trained clinicians acquire the necessary knowledge and skillset to improve USGPIV outcomes.
... For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com inserted directly, and it is recommended in documents. [1] Despite the widespread usage of the PICC in neonatal nursing, there are side effects associated with it that detection of them will be lead to the prevention and reduction of these complications. Consequences such as perforation of arteries during emplacement, phlebitis, cardiac arrhythmia, nerve damage, blockage of the flow path in the catheter, hemorrhage, infection, clot formation and obstruction, thrombosis of superficial and deep veins, misplaced catheter and its displacement, air embolism and catheter embolism after its replacement, have been reported. ...
... This policy is in line with international standards for the care of premature neonates in the NICU. [1] The results demonstrated that septicemia and hemorrhage in the catheter site were significantly lower in exposure group, which means that using the PICC is a safe and better method of care in vulnerable neonates with lower gestational age and birth weight. In our study, complications such as phlebitis, cardiac tamponade, pericardial and pleural effusion, and ascites were not observed. ...
Background:
Peripherally Inserted Central Catheter (PICC), which is inserted through peripheral veins into the superior or inferior vena cava, is used to inject medications or parenteral nutrition in neonates with long-term hospitalization in the intensive care unit. In this study, we assessed the complications of PICC in neonates admitted to the intensive care unit in hospital.
Materials and methods:
In the present retrospective cohort, neonates admitted to the Neonatal Intensive Care Unit (NICU) of Valiasr Hospital during 2015-2018 had been divided into two groups with PICC and without it. Data included the occurrence of septicemia, tachycardia, perforation of large veins, pulmonary hypertension, cardiac tamponade, pericardial effusion, catheter site necrosis, hemorrhage, anemia, pleural effusion, ascites, phlebitis of catheter track and neonatal death, which were collected, using the comprehensive neonatal registry of Valiasr Hospital. Data analysis was performed with regression, mantel-haenszel and independent t-test.
Results:
Data from 174 neonates with PICC were compared to 207 infants with classic IV-Line. In the exposure group, the gestational age and birth weight were lower. Based on the results of the double logistic regression test, septicemia and hemorrhage in the injection site, independent of other variables, were related to the use of PICC and the risk of septicemia or hemorrhage in the injection site was significantly reduced if PCIC was used (p < 0.01).
Conclusions:
Using the PICC as a therapeutic procedure in hospitalized neonates in the NICU is a safe method. By improving its replacement skills among physicians and nurses, its side effects are minor and negligible.
... Currently, three methods are used: temporary jugular catheters, permanent catheters, and arteriovenous fistula (AVF) creation. 6 While AVF is preferred for its long-term use and low complication rates, 7 it has limitations, including a lengthy adaptation period and poor suitability for certain patients. 8 For patients requiring acute hemodialysis or those unsuitable for AVF, temporary or permanent tunnel catheters are recommended. ...
Background and Aim
One of the complications of using catheters is the occurrence of thrombosis, which can be dangerous for patients. The main objective of this study is to compare the effect of heparin, reteplase, and taurolock in the prevention of thrombosis in hemodialysis catheters.
Methods
The present study is a clinical trial, in which the effect of three drugs, heparin, reteplase, and taurolock, in the prevention of thrombosis in hemodialysis catheters, has been investigated. The research units were studied in two intervention and control groups. The stratified random allocation method was used to assign patients to five groups (control, Heparin 50, Heparin 1000, reteplase, and taurolock), with strata based on the patient's age (20–70 years), gender, and duration of dialysis. Within each stratum, patients were also assigned to groups using the randomized block permutation method and a random number table tool. To prevent bias, this study is triple‐blinded. This means that the patient, the thrombosis assessor, and the statistical analyst are unaware of the type of intervention received by the patient.
Results
Gender (p < 0.999), age distribution (p = 0.774), and duration of dialysis (p = 0.875) showed no statistically significant relationship with thrombosis. However, significant differences were observed among the five groups regarding thrombosis incidence. The relative risk of thrombosis in the Heparin 50, Heparin 1000, reteplase, and taurolock groups compared to the control group was 92.5%, 92.2%, 98.2%, and 89% lower, respectively.
Conclusion
Our study underscores the efficacy of heparin, reteplase, and taurolock in preventing thrombosis in hemodialysis catheters. While all three drugs demonstrated efficacy, the Heparin 50 group exhibited the highest relative risk reduction. These findings suggest that heparin, particularly at a low dose, should be considered a standard prophylactic treatment in hemodialysis patients.
... PIVCs are the most common invasive devices in acute care hospitals, with up to 90% of patients needing one or more during their hospital stay (Hill & Moureau, 2019). PIVCs are preferred for short-term delivery of intravenous (IV) fluids and medications. ...
Aim
To explore barriers and facilitators that influence adherence to evidence‐based guidelines for peripheral intravenous catheter care in different hospital wards.
Design
Sequential explanatory mixedmethod study design, with qualitative data used to elaborate on quantitative findings.
Method
Data were collected between March 2021 and March 2022 using the previously validated Peripheral Intravenous Catheter mini questionnaire ( PIVC‐miniQ ) on each ward in a tertiary hospital in Norway. Survey completion was followed by individual interviews with nurses from selected wards. The Pillar Integration Process was used to integrate and analyse the quantitative and qualitative findings.
Results
The PIVC‐miniQ screening assessed 566 peripheral intravenous catheters in 448 patients in 41 wards, and we found variation between wards in the quality of care. Based on the quantitative variation, we interviewed 24 nurses on wards with either excellent or not as good quality. The integration of the quantitative and qualitative findings in the study enabled an understanding of factors that influence nurses' adherence to the care of peripheral venous catheters. One main theme and four subthemes emerged. The main finding was that ward culture affects education practice, and this was evident from four subthemes: ( 1) Deviation from best practice , ( 2) Gaps in education and clinical training , (3) Quality variation between wards and ( 4) The importance of supportive leadership .
Conclusion
This mixed method study is the first study to explore reasons for variability in peripheral intravenous catheter quality across hospital wards. We found that ward culture was central to catheter quality, with evidence of deviations from best practice correlating with observed catheter complications. Ward culture also impacted nursing education, with the main responsibility for learning peripheral intravenous catheter management left to students' clinical training placements. Addressing this educational gap and fostering supportive leadership, including champions, will likely improve peripheral intravenous catheter care and patient safety.
Implications for the Profession and/or Patient Care
Nurses learn good peripheral intravenous catheter care in wards with supportive leaders and champions. This implies that the quality of nursing practice and patient outcomes are situational. Nurses need a strengthened emphasis on peripheral catheter quality in the undergraduate curriculum, and nurse leaders must emphasize the quality of catheter care in their wards.
Impact
The study findings impact nurse leaders who must commit to quality and safety outcomes by appointing and supporting local ward champions for promoting peripheral intravenous catheter care. This also impacts nursing education providers, as the emphasis on catheter care must be strengthened in the undergraduate nursing curriculum and continually reinforced in the hospital environment, particularly when guidelines are updated.
Reporting Method
The study adhered to the Good Reporting of A Mixed Method Study (GRAMM).
Patient or Public Contribution
A patient representative has been involved in planning this study.
... As per the Kidney Disease Outcomes Quality Initiative (KDOQI) 2019 vascular access guidelines, the arteriovenous (AV) fistula remains the venous access of choice in view of its low complication rates [2]. However, AV fistulas require six weeks for maturation and may not be possible in some patients with sclerotic vessels and long-term diabetes [3]. Tunneled catheters serve both as a bridge to the AV fistula and as primary and only access in some patients. ...
Introduction
Hemodialysis is a vital modality for patients with renal dysfunction, with venous access being a significant factor in its success. While arteriovenous fistulas are preferred, tunneled catheters serve as important alternatives, especially in challenging cases. Late-onset tunneled catheter dysfunction, often due to fibrin sheath formation, impedes hemodialysis efficiency. Streptokinase, a low-cost thrombolytic agent, has shown promise in resolving such complications, yet its efficacy in the Indian context remains unexplored.
Methods
We conducted a single-center interventional study at Mahatma Gandhi Mission (MGM) Hospital, Aurangabad, India, from May 2023 to October 2023. Ethical approval was obtained, and 10 eligible patients experiencing late-onset permanent tunnel catheter dysfunction were enrolled. Patients were treated with low-dose streptokinase, and outcomes were monitored for 60 days.
Results
Ten patients, evenly distributed by gender, participated, with a mean age of 48.2 ± 11.96 years. Diabetes was the predominant cause of chronic kidney disease (CKD) at 33% (3/10). All patients achieved the primary endpoint of blood flow rate (BFR) >300 ml/min post-streptokinase treatment, with an overall success rate of 100%. Group A had the highest average gain in catheter days (80.6 ± 7.59), followed by Group B (64 ± 1), while Group C showed variations in catheter days between the first (26.2 ± 6.8) and second insertion (32.5 ± 1.76). Eight patients maintained catheter patency during the 60-day follow-up. Adverse effects, primarily minor, were observed. The dosage rationale involved an eight-hour infusion at 4,000 units per hour.
Conclusion
Streptokinase emerges as cost-effective and efficacious for maintaining the patency of late-onset tunnel catheter dysfunction in resource-limited settings, particularly in younger patients. Caution is advised for older individuals with prolonged CKD.
... Intravenous treatment in the community provided through clinical models including home nursing programs and outpatient infusion centres has grown markedly in the last decade, with the recent COVID 19 pandemic further increasing demand [1]. Peripherally inserted central catheters (PICCs) are medium to long-term vascular access devices recommended for consumers undergoing intravenous treatment at home or outpatient facilities [2]. These devices are commonly used to facilitate community treatment for those with serious infection and cancer [3] who are the most common diagnostic groups who receive a PICC [4][5][6] Under these clinical models, health consumers have a PICC inserted and receive treatment from a nurse at home or attend an outpatient infusion centre. ...
Background
Peripherally inserted central catheters (PICCs) are common vascular access devices inserted for adults undergoing intravenous treatment in the community setting. Individuals with a PICC report challenges understanding information and adapting to the device both practically and psychologically at home. There is a lack of research investigating the supportive care needs of individuals with a PICC to inform nursing assessment and the provision of additional supports they may require to successfully adapt to life with a PICC. The aim of this study was to identify the supportive care needs of adults with cancer or infection living with a PICC at home.
Method
Qualitative, semi-structured interviews were used to identify supportive care needs of adults living with a PICC at home. Participants were recruited from cancer and infectious diseases outpatient units. Two researchers independently analysed transcripts using content analysis.
Results
A total of 15 participants were interviewed (30–87 years old). There were 5 males and 10 females interviewed, 9 participants had a cancer diagnosis and most lived in a metropolitan area. Many participants lived with a partner/spouse at home and three participants had young children. Participants identified supportive care needs in the following eight categories (i (i) Adapting daily life (ii) Physical comfort (iii) Self-management (iv) Emotional impact (v) Information content (vi) Understanding information (vii) Healthcare resources and (viii) Social supports.
Conclusions
Adults living with a PICC at home report a broad range of supportive care needs. In addition to practical and information needs, health consumers may also require support to accept living with a device inside their body and to assume responsibility for the PICC. These findings may provide nurses with a greater understanding of individual needs and guide the provision of appropriate supports.
... Specific to PIVC insertion and care, Carr et al. (2019) showed that less confident clinicians had lower success in first-time PIVC insertions, which lead to multiple insertion attempts resulting in an increased risk of patient harm. Nurses with high confidence had a positive impact on patient satisfaction, quality, and safety, as well as decreasing risk of PIVC infection (Alexandrou & Moureau, 2019). ...
Background and Purpose: It has been shown that nurse confidence predicts peripheral intravenous catheter (PIVC) insertion success. However, intravenous cannulation is a challenging skill for entry to practice students. To date, there is no well-validated measure of nursing student self-confidence in learning and performing PIVC insertion. To address this measurement gap, we created and validated the Nursing Student PIVC Insertion Self-Confidence Scale. Methods: This study employed a descriptive, cross-sectional design. Three cohorts of undergraduate entry-to-practice students at a Canadian university were recruited and assessed during their studies. Two hundred and eighty-one students completed the scale at the first data collection point and 146 at the second point. The structure of the tool was analyzed by exploratory factor analysis to extract factors and confirmatory factor analysis (CFA) was employed for validation. Results: CFA revealed a three-factor scale (PIVC Cannulation Confidence, PIVC Preparation and Securement Confidence, and PIVC Learning Confidence). It has 15 items with satisfactory goodness of fit indices. Conclusions: The Nursing Student PIVC Insertion Self-Confidence Scale is a valid and reliable scale to measure nursing students' confidence in learning about and performing PIVC insertions.
... Research indicates that over 73% of patients may contract a healthcare-associated infection (HAI) due to the presence of a PVC [5]. Additionally, some studies suggest that retaining an unused catheter in a patient may increase the risk of developing potentially avoidable complications by more than 25% [6]. The most relevant complications that require catheter replacement include phlebitis, obstruction, infiltration and extravasation [4,7]. ...
Background
The use of peripherally inserted central catheters and midline catheters is growing due to their potential benefits. These devices can increase patient safety and satisfaction while reducing the use of resources. As a result, many hospitals are establishing vascular access specialist teams staffed by nurses who are trained in the insertion and maintenance of these catheters. The objective of the study is to evaluate previously to the implementation whether the benefits of introducing ultrasound-guided peripheral venous catheters, midline catheters and peripherally inserted central catheters compared to current practice by a vascular access specialist team outweigh their costs.
Methods
Cost-benefit analysis from the perspective of the healthcare provider based on administrative data. The study estimates the reduction in resources used when changing the current practice for the use of ultrasound-guided midline and PICC catheters, as well as the additional resources required for their use.
Results
The use of an ultrasound-guided device on peripherally inserted central carheter, results in a measurable resource reduction of approximately €31. When 3 peripheral venous catheters are replaced by an ultrasound-guided peripherally inserted central catheter, the saving is €63. Similarly, the use of an ultrasound-guided device on a midline catheter, results in a reduction of €16, while each ultrasound-guided midline catheter replacing 3 peripheral venous catheters results in a reduction of €96.
Conclusion
The benefits of using ultrasound-guided midline and PICC catheters compared to current practice by introducing a vascular access specialist team trained in the implantation of ultrasound-guided catheters, outweigh its cost mainly because of the decrease in hospital stay due to the lowered risk of phebitis. These results motivate the implementation of the service, adding to previous experience suggesting that it is also preferable from the point of view of patient safety and satisfaction.
... Some manufacturers limit their systems to be used exclusively with their products, limiting the use of this method of confirmation in certain hospital settings as they may not have access to these specific products. 38 This method appears to be a suitable replacement for post-procedural CXR confirmation as it has been proven to be safe and accurate. As with TOE, this technique cannot be used to exclude the presence of a pneumothorax. ...
Background:
Mechanical central venous catheter (CVC) placement complications are mostly malposition or iatrogenic pneumothorax. Verification of catheter position by chest X-ray (CXR) is usually performed postoperatively.
Objectives:
This prospective observational study assessed the diagnostic accuracy of peri-operative ultrasound and a 'bubble test' to detect malposition and pneumothorax.
Method:
Sixty-one patients undergoing peri-operative CVC placement were included. An ultrasound protocol was used to directly visualise the CVC, perform the 'bubble test' and assess for the presence of pneumothorax. The time from agitated saline injection to visualisation of microbubbles in the right atrium was evaluated to determine the correct position of the CVC. The time required to perform the ultrasound assessment was compared to that of conducting the CXR.
Results:
Chest X-ray identified 12 (19.7%) malpositions while ultrasound identified 8 (13.1%). Ultrasound showed a sensitivity of 0.85 (95% confidence interval [CI]: 0.72 to 0.93) and a specificity of 0.5 (95% CI: 0.16 to 0.84). The positive and negative predictive values were 0.92 (95% CI: 0.80 to 0.98) and 0.33 (95% CI: 0.10 to 0.65), respectively. No pneumothorax was identified on ultrasound and CXR. The median time for ultrasound assessment was significantly shorter at 4 min (interquartile range [IQR]: 3-6 min), compared to performing a CXR that required a median time of 29 min (IQR: 18-56 min) (p < 0.0001).
Conclusion:
This study showed that ultrasound produced a high sensitivity and moderate specificity in detecting CVC malposition.
Contribution:
Ultrasound can improve efficiency when used as a rapid bedside screening test to detect CVC malposition.
... Research indicates that over 73% of patients may contract a healthcare-associated infection due to the presence of a peripheral venous catheter [5]. Additionally, some studies suggest that retaining an unused catheter in a patient may increase the risk of developing potentially avoidable complications by more than 25% [6]. The most relevant complications that require catheter replacement include phlebitis, obstruction, infiltration and extravasation [4,7]. ...
Background: The use of peripherally inserted central catheters and midline catheters is growing due to their potential benefits. These devices can increase patient safety and satisfaction while reducing the use of resources. As a result, many hospitals are establishing vascular access specialist teams staffed by nurses who are trained in the insertion and maintenance of these catheters. Objective: Evaluate ex-ante whether the benefits of replacing peripheral venous catheters, peripherally inserted central catheters and midline catheters with ultrasound-guided peripherally inserted central catheters and midline catheters by a vascular access specialist team outweigh their costs. Methods: Cost-benefit analysis from the perspective of the healthcare provider based on administrative data. The study estimates the reduction in resources used when replacing peripherally inserted central catheters, midline catheters and peripheral venous catheters with ultrasound-guided peripherally inserted central catheters and midlines, as well as the additional resources required for their use. Results: Each ultrasound-guided peripherally inserted central catheter replacing a peripherally inserted central catheter, results in a measurable resource reduction of approximately €31. When 3 peripheral venous catheters are replaced by an ultrasound-guided peripherally inserted central catheter, the saving is €63. Similarly, each ultrasound-guided midline catheter replacing a midline, results in a reduction of €16, while each ultrasound-guided midline catheter replacing 3 peripheral venous catheters results in a reduction of €96. Conclusion: The benefits of replacing peripheral venous catheters, peripherally inserted central catheters and midline catheters by introducing a vascular access specialist team trained in the implantation of ultrasound-guided peripherally inserted central catheters and midline catheters, outweigh its cost mainly because of the decrease in hospital stay due to the lowered risk of healthcare-associated infections. These results motivate the implementation of the service, adding to previous experience suggesting that it is also preferable from the point of view of patient safety and satisfaction.
... In this pre-clinical study, the measured primary outcomes were: (i) the number of tasks and goals achieved; (ii) procedure execution time; (iii) type and frequency of errors (as per Table 1). The tasks were listed by the research team in accordance with current standards of care in PIVC and recommendations from industrial manufacturers [25][26][27][28]. Table 1. ...
Guaranteeing peripheral venous access is one of the cornerstones of modern healthcare. Recent evidence shows that the lack of adequate clinical devices can result in the provision of substandard care to patients who require peripheral intravenous catheterization (PIVC). To address this challenge, we aimed to develop a PIVC pack for adult patients and assess the usability of this new device.
Methods:
Following a mix-method design, the PIVC pack development and usability assessment were performed in two phases with the involvement of its potential end-users (nurses). In phase one (concept and semi-functional prototype assessment), focus group rounds were conducted, and a usability assessment questionnaire was applied at each stage. In phase two (pre-clinical usability assessment), a two-arm crossover randomised controlled trial (PIVC pack versus traditional material) was conducted with nurses in a simulated setting. Final interviews were conducted to further explore the PIVC pack applicability in a real-life clinical setting.
Results:
High average usability scores were identified in each study phase. During the pre-clinical usability assessment, the PIVC pack significantly reduced procedural time (Z = -2.482, p = 0.013) and avoided omissions while preparing the required material (Z = -1.977, p = 0.048). The participating nurses emphasised the pack's potential to standardise practices among professionals, improve adherence to infection control recommendations, and enhance stock management.
Conclusions:
The developed pack appears to be a promising device that can assist healthcare professionals in providing efficient and safe care to patients requiring a PIVC. Future studies in real clinical settings are warranted to test its cost-effectiveness.
... After the PIVC bundle was completed, to avoid a more prescriptive nature and allow for appropriate clinical judgment [20], the research team included short guiding statements for each EII based on existing evidence in international guidelines and standards of care [29][30][31]. Likewise, as a matter of external validation and to ensure the PIVC bundle's relevance and clinical applicability, the research team conducted an online session to present and discuss the results of the Delphi consensus study with the surgical ward's nurses and manager. ...
Contrary to many international settings, there are no clinical guidelines for peripheral intravenous catheter (PIVC) insertion and maintenance in Portugal. We sought to derive an international consensus on a PIVC bundle that could guide Portuguese nurses' clinical decision-making in this scope.
Methods:
Two international vascular access specialist groups participated in an online Delphi panel. During the first round, specialists (n = 7) were sent a summary report from a previous observational study conducted in a surgical ward in Portugal. Based on the report findings, specialists were asked to provide five to eight PIVC insertion and maintenance interventions. Then, another set of specialists (n = 7) scored and revised the recommendations until a consensus was reached (≥70% agreement). The PIVC bundle was made available and discussed with the surgical ward's nurses.
Results:
After three rounds, a consensus was achieved for five evidence-informed interventions: (i) involve the person and assess the peripheral venous network; (ii) maintain an aseptic no-touch technique; (iii) ensure proper catheter dressing and fixation; (iv) perform catheter flush & lock; (v) test the peripheral venous catheter's functionality and performance at each shift.
Conclusion:
The final version of the PIVC bundle achieved consensus among international experts. Despite the positive feedback provided by the ward nurses, future studies are warranted to assess its effectiveness in standardizing PIVC care delivery and its potential implications for care outcomes in Portuguese clinical settings.
... All the modalities have their own merits and demerits. To date, arteriovenous fistula is known as the best modality for hemodialysis access due to its long term use and low level of complications [2,3]. ...
Background
End-Stage Renal Disease (ESRD) is a significantly increasing condition warranting renal replacement therapy. Gaining vascular access for catheter placement for this procedure is of paramount importance. These can be done by temporary and permanent cuffed tunnelled catheters. The present study aims to analyze the outcome of permanent hemodialysis catheters and their efficacy in the case of patients suffering from end-stage renal disease.
Materials and methods
A cross-sectional study was conducted on 32 patients who underwent permanent tunnelled catheter intervention along with details of follow-up from January 1st, 2021 till December 31st, 2021.
Results
Among 32 patients, the mean age of the patient was 50.25 ± 18.10 years with 62.5% females. The site of insertion was right 27(84.37%) and left internal jugular vein in 4 (12.50%) and 1 patient (3.12%) in the left common femoral vein. Bleeding the peri-catheter site was observed in 4 (12.5%), infection was found among 2 patients (6.25%), thrombosis in the catheter in 7 (21.87%) patients. Indication for the procedure was due to failure of arteriovenous fistula in 21 (65.62%), lack of maturation of the AVF in 9 (28.12%) and patients awaiting transplantation in 2 (6.25%). The mean months of follow-up of the patients were 5.9 months (SD 4.4 months, range 1 month–12 months). Total 25 (78.1%) of the catheters were patent till the time of follow-up. Seven (21.9%) of the patients required manipulation once after which they also had functioning permanent catheters. The mean month on which manipulation was required was 4.1 months (SD 2.3months, range one month to seven months).
Conclusion
Permanent cuffed tunnelled catheter has good patency and can be an alternative to an arteriovenous fistula.
... All the modalities have their own merits and demerits. To date, arteriovenous fistula is known as the best modality for hemodialysis access due to its long term use and low level of complications [2,3]. ...
Background
End-Stage Renal Disease (ESRD) is a significantly increasing condition warranting renal replacement therapy. Gaining vascular access for catheter placement for this procedure is of paramount importance. These can be done by temporary and permanent cuffed tunnelled catheters. The present study aims to analyze the outcome of permanent hemodialysis catheters and their efficacy in the case of patients suffering from end-stage renal disease.
Materials and methods
A prospective cross-sectional study was conducted on 32 patients who underwent permanent tunnelled catheter intervention along with details of follow-up from January 1st 2021 till December 31st 2021.
Results
Among 32 patients, the mean age of the patient was 50.25 ± 18.10 years with 62.5% females. The site of insertion was right 27(84.37%) and left internal jugular vein in 4 (12.50%) and 1 patient (3.12%) in the left common femoral vein. Bleeding the peri-catheter site was observed in 4 (12.5%), infection was found among 2 patients (6.25%), thrombosis in the catheter in 7 (21.87%) patients. Indication for the procedure was due to failure of arteriovenous fistula in 21 (65.62%), lack of maturation of the AVF in 9 (28.12%) and patients awaiting transplantation in 2 (6.25%). The mean months of follow-up of the patients were 5.9 months (SD 4.4 months, range 1 month–12 months). Total 25 (78.1%) of the catheters were patent till the time of follow-up. Seven (21.9%) of the patients required manipulation once after which they also had functioning permanent catheters. The mean month on which manipulation was required was 4.1 months (SD 2.3months, range one month to seven months).
Conclusion
Permanent cuffed tunnelled catheter has good patency and can be an alternative to an arteriovenous fistula.
... Therefore, it was expected that the head nurses would possess a greater knowledge of PIVC fixation. Receiving systematic training on intravenous therapy techniques can help nurses fix PIVCs with standard methods and significantly reduce the occurrence of iatrogenic complications, thereby improving patient satisfaction and ensuring patient safety [23][24][25]. Thus, nursing managers should improve the level of knowledge of PIVC fixation among pediatric nurses and create more opportunities for nurses to receive further health education. ...
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 < 0.05); department is also a factor that influences attitude score (B > 0, P < 0.05); and department and nursing hierarchy are the factors that influence practice score (B > 0, P < 0.05).
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.
... The position of the catheter tip plays an important role in the low incidence of both mechanical and chemical complications, such as catheter kinking, infiltration and phlebitis, which are less common in large veins with high blood flow (Anderson, 2004;Gorski & Czaplewski, 2004;Moureau, 2019). ...
Aims and objectives
To describe the outcomes of midclavicular catheters related to first insertion success rate, catheter dwell time, rate of catheter survival until the end of the treatment, and complication rates, as well as identify risk factors associated with early catheter removal.
Background
Midclavicular catheters are peripheral venous catheters that are typically 20–25 cm in length.
Design
Inception cohort study.
Methods
We included all the midclavicular lines inserted in patients who met any of the following criteria: (a) difficult venous access; (b) administration of intravenous therapy expected to last between 6 and 30 days with non-irritant (pH=5–9) and/or non-vesicant drugs; or (c) contraindications to central venous catheter placement. The incidence of adverse events was calculated using percentages and episodes per 1,000 catheter days. Univariate and multivariate logistic regression analyses were performed to identify significant risk factors for unexpected catheter removal by calculating odds ratios. Catheter survival was assessed using Cox regression analysis. The STROBE guidelines were followed.
Results
Overall, 2,275 midclavicular lines were placed in 1,841 participants. The insertion success rate was 99.4% and the mean catheter dwell time was 21.82 days. The rate of adverse events was .7 per 1,000 catheter days, the most common complications being thrombosis (.39) and catheter-associated bacteraemia (.14). No significant association was found between adverse events and the administration of irritant drugs. The incidence of unexpected removal was 6.7 per 1,000 catheter days. The multivariate analysis showed that both age ≤70 years and home therapy were associated with a lower likelihood of catheter failure.
Conclusions
Midclavicular catheters are associated with a high rate of insertion success and low rates of adverse events and unplanned removal.
Relevance to clinical practice.
Midclavicular lines are a safe alternative for intravenous therapy lasting more than 6 days, even with irritant drugs.
... 21 In addition, there is greater investment and professional labor, since it is necessary to remove the dressing for traction, make a new bandage and request a new x-ray, which can delay the release of the catheter for treatment initiation. 22 Thus, each traction intervention for repositioning can pose risks to the patient. A study demonstrates that, during dressing manipulation, there may be a risk of cutaneous trauma due to detachment of the film, as well as accidental displacement of the catheter. ...
Introduction: The measurement recommended in literature for a peripherally inserted central catheter presents considerable rates of poor positioning in the neonatal population.
Objective: To evaluate the effectiveness of the modified measurement method for a peripherally inserted central catheter in newborns, with respect to the positioning of the catheter tip.
Method: A randomized clinical trial, conducted in a Neonatal Intensive Care Unit in south Brazil. The sample comprised the number of catheter insertion procedures in newborns, being randomized in the control group by applying the traditional measure and in the experimental group by applying a modified measure. The sample included 155 procedures, with 88 procedures included in data analysis. The data collection period was from September 2018 to September 2019.
Results: The group-related variable was considered a risk factor for tip location. The control group was 28.87 times more likely to have the tip’s initial location peripheral than the experimental group, and 44.80 times more likely that the location would be intracardiac than in the experimental group.
Conclusions: The modified measurement method proved to be more effective for the central location of the tip. The need for new assessments of this method in future research studies is highlighted.
Central venous access devices (CVADs), including peripherally inserted central catheters (PICCs) and cuffed tunnelled catheters, play a crucial role in modern medicine by providing reliable access for medication and treatments directly into the bloodstream. However, these vital medical devices also pose a significant risk of catheter-related bloodstream infections (CRBSIs) alongside associated complications such as thrombosis or catheter occlusion. To mitigate these risks, healthcare providers employ various strategies, including the use of locking solutions in combination with meticulous care and maintenance protocols. KiteLock 4% catheter lock is a solution designed to combat the triple threat of infection, occlusion and biofilm. This locking solution is described as the only locking solution to provide cover for all three complications.
Objective
to build, evaluate and test two clinical simulation scenarios for the planning and management of infusion therapy by nurses.
Methods
methodological study, with construction of scenarios based on the NLN Jeffries Simulation Theory and the theoretical model Vessel Health Preservation; evaluation of the scenario design by judges, with calculation of the Modified Kappa Coefficient (MKC); testing scenarios with the target audience. Results: scenarios built for: 1. Patient assessment and vascular device selection; and 2. Identification and management of deep vein thrombosis. In the evaluation by judges, testing of validated scenarios in relation to educational practices and simulation design, the items evaluated presented MKC values ≥ 0.74.
Conclusion
two evidence-based scenarios related to infusion therapy were constructed, with high levels of agreement among judges regarding their design. In testing with nurses, good results were obtained regarding the design and structuring of educational practice.
Descriptors:
Educational Measurement; Nursing Education; Vascular Access Devices; Simulation Training; Patient Care Planning
Objective
to build, evaluate and test two clinical simulation scenarios for the planning and management of infusion therapy by nurses.
Methods
methodological study, with construction of scenarios based on the NLN Jeffries Simulation Theory and the theoretical model Vessel Health Preservation; evaluation of the scenario design by judges, with calculation of the Modified Kappa Coefficient (MKC); testing scenarios with the target audience. Results: scenarios built for: 1. Patient assessment and vascular device selection; and 2. Identification and management of deep vein thrombosis. In the evaluation by judges, testing of validated scenarios in relation to educational practices and simulation design, the items evaluated presented MKC values ≥ 0.74.
Conclusion
two evidence-based scenarios related to infusion therapy were constructed, with high levels of agreement among judges regarding their design. In testing with nurses, good results were obtained regarding the design and structuring of educational practice.
Descriptors:
Educational Measurement; Nursing Education; Vascular Access Devices; Simulation Training; Patient Care Planning
case series on outcomes of tunnelled haemodialysis Cathter without fluoroscopic guidance in a resource limited settings in a government setup.
Citation: Borgonovo, F.; Quici, M.; Gidaro, A.; Giustivi, D.; Cattaneo, D.; Gervasoni, C.; Calloni, M.; Martini, E.; La Cava, L.; Antinori, S.; et al. Physicochemical Characteristics of Antimicrobials and Practical Recommendations for Intravenous Administration: A Systematic Review. These authors contributed equally to this work. Abstract: Most antimicrobial drugs need an intravenous (IV) administration to achieve maximum efficacy against target pathogens. IV administration is related to complications, such as tissue infiltration and thrombo-phlebitis. This systematic review aims to provide practical recommendations about diluent, pH, osmolarity, dosage, infusion rate, vesicant properties, and phlebitis rate of the most commonly used antimicrobial drugs evaluated in randomized controlled studies (RCT) till 31 March 2023. The authors searched for available IV antimicrobial drugs in RCT in PUBMED EMBASE ® , EBSCO ® CINAHL ®, and the Cochrane Controlled Clinical trials. Drugs' chemical features were searched online, in drug data sheets, and in scientific papers, establishing that the drugs with a pH of <5 or >9, osmolarity >600 mOsm/L, high incidence of phlebitis reported in the literature, and vesicant drugs need the adoption of utmost caution during administration. We evaluated 931 papers; 232 studies were included. A total of 82 antimicrobials were identified. Regarding antibiotics, 37 reach the "caution" criterion, as well as seven antivirals, 10 antifungals, and three antiprotozoals. In this subgroup of antimicrobials, the correct vascular access device (VAD) selection is essential to avoid complications due to the administration through a peripheral vein. Knowing the physicochemical characteristics of antimicrobials is crucial to improve the patient's safety significantly, thus avoiding administration errors and local side effects.
This article aims to provide an overview of the range of long- and short-term vascular access devices (VADs) used in most healthcare settings for the administration of intravenous therapies or to deliver medical interventions. This article will describe the devices in use and the rationale for correct device selection; and how to reduce the risk of catheter related complications. Within the article, there is a discussion on the optimal care and maintenance procedures necessary to help ensure that VAD dwell complications free and until treatment is complete. This ensures patient safety, satisfaction, and an improved patient experience.
Background:
Peripheral intravenous cannulation is one of the most fundamental and common procedures in medicine. Securing a peripheral line is occasionally difficult with the landmark method. Ultrasound guidance has become a standard procedure for central venous cannulation, but its efficacy in achieving peripheral venous cannulation is unclear.
Objectives:
To evaluate the effectiveness and safety of ultrasound guidance compared to the landmark method for peripheral intravenous cannulation in adults. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 29 November 2021.
Selection criteria:
We included randomised controlled trials (RCTs) and quasi-RCTs (RCTs in which participants are systematically allocated based on data such as date of birth or recruitment) comparing the effects of ultrasound guidance to the landmark method for peripheral intravenous cannulation in adults.
Data collection and analysis:
We used standard Cochrane methods. Our primary outcomes were first-pass success of cannulation, overall success of cannulation, and pain. Our secondary outcomes were procedure time for first-pass cannulation, procedure time for overall cannulation, number of attempts, patient satisfaction, and overall complications. We used GRADE to assess the certainty of the evidence. Placing a peripheral intravenous line in individuals can be classed as 'difficult', 'moderate', or 'easy'. We use the terms 'difficult participants', 'moderate/moderately difficult participants' and 'easy participants' as shorthand to characterise the difficulty level in placing a peripheral line using the landmark method. We used the original studies' definitions of difficulty levels of peripheral intravenous cannulation with the landmark method. We analysed the results in these subgroups: 'difficult participants', 'moderate participants', and 'easy participants'. We did this because we expected the effect of ultrasound-guided peripheral venous cannulation to be largest in participants classed as 'difficult' and smaller in participants classed as 'moderate' and 'easy'. MAIN RESULTS: We included 14 RCTs and two quasi-RCTs involving 2267 participants undergoing peripheral intravenous cannulation. Participants were classed as 'difficult' in 12 studies (880 participants), 'moderate' in one study (401 participants), and 'easy' in one study (596 participants). Two studies (390 participants) did not restrict by landmark method difficulty level. The overall risk of bias assessments ranged from low to high. We judged studies to be at high risk of bias mainly because of concerns about blinding for subjective outcomes. In difficult participants, ultrasound guidance increased the first-pass success of cannulation (risk ratio (RR) 1.50, 95% confidence interval (95% CI) 1.15 to 1.95; 10 studies, 815 participants; low-certainty evidence), and the overall success of cannulation (RR 1.40, 95% CI 1.10 to 1.77; 10 studies, 670 participants; very low-certainty evidence). There was no clear difference in pain (mean difference (MD) -0.20, 95% CI -1.13 to 0.72; 4 studies, 323 participants; very low-certainty evidence; numerical rating scale (NRS) 0 to 10 where 10 is maximum pain). Ultrasound guidance increased the procedure time for first-pass cannulation (MD 119.9 seconds, 95% CI 88.6 to 151.1; 2 studies, 219 participants; low-certainty evidence), and patient satisfaction (standardised mean difference (SMD) 0.49, 95% CI 0.07 to 0.92; 5 studies, 333 participants; very low-certainty evidence; NRS 0 to 10 where 10 is maximum satisfaction). Ultrasound guidance decreased the number of cannulation attempts (MD -0.33, 95% CI -0.64 to -0.02; 9 studies, 568 participants; very low-certainty evidence). Ultrasound guidance showed no clear difference in the procedure time for overall cannulation (MD -24.9 seconds, 95% CI -323.1 to 273.3; 8 studies, 413 participants; very low-certainty evidence) and overall complications (RR 0.64, 95% CI 0.37 to 1.10; 5 studies, 431 participants; low-certainty evidence). In moderate participants, ultrasound guidance increased the first-pass success of cannulation (RR 1.14, 95% CI 1.02 to 1.27; 1 study, 401 participants; moderate-certainty evidence). No studies assessed the overall success of cannulation. There was no clear difference in pain (MD 0.10, 95% CI -0.47 to 0.67; 1 study, 401 participants; low-certainty evidence; NRS 0 to 10 where 10 is maximum pain). Ultrasound guidance increased the procedure time for first-pass cannulation (MD 95.2 seconds, 95% CI 72.8 to 117.6; 1 study, 401 participants; high-certainty evidence). Ultrasound guidance showed no clear difference in overall complications (RR 0.83, 95% CI 0.38 to 1.82; 1 study, 401 participants; moderate-certainty evidence). No studies assessed the procedure time for overall cannulation, number of cannulation attempts, or patient satisfaction. In easy participants, ultrasound guidance decreased the first-pass success of cannulation (RR 0.89, 95% CI 0.85 to 0.94; 1 study, 596 participants; high-certainty evidence). No studies assessed the overall success of cannulation. Ultrasound guidance increased pain (MD 0.60, 95% CI 0.17 to 1.03; 1 study, 596 participants; moderate-certainty evidence; NRS 0 to 10 where 10 is maximum pain). Ultrasound guidance increased the procedure time for first-pass cannulation (MD 94.8 seconds, 95% CI 81.2 to 108.5; 1 study, 596 participants; high-certainty evidence). Ultrasound guidance showed no clear difference in overall complications (RR 2.48, 95% CI 0.90 to 6.87; 1 study, 596 participants; moderate-certainty evidence). No studies assessed the procedure time for overall cannulation, number of cannulation attempts, or patient satisfaction. AUTHORS' CONCLUSIONS: There is very low- and low-certainty evidence that, compared to the landmark method, ultrasound guidance may benefit difficult participants for increased first-pass and overall success of cannulation, with no difference detected in pain. There is moderate- and low-certainty evidence that, compared to the landmark method, ultrasound guidance may benefit moderately difficult participants due to a small increased first-pass success of cannulation with no difference detected in pain. There is moderate- and high-certainty evidence that, compared to the landmark method, ultrasound guidance does not benefit easy participants: ultrasound guidance decreased the first-pass success of cannulation with no difference detected in overall success of cannulation and increased pain.
Introduction: Pemphigus foliaceus is a serious and rare autoimmune skin disorder presenting much like exfoliative dermatitis with blisters or erosions, as well as scaly or crusty regions. Current treatment includes high dose corticosteroids, immunosuppressive drugs, and, in patients refractory to treatment, intravenous immune globulin (IVIG). In patients with systemic skin conditions, long-term vascular access is a great challenge. Successful initiation and completion of therapy requires selection of the proper insertion site, device composition, method of securement, and dressing interval. In patients where the traditional insertion sites such as the upper arm, axillary, jugular, or femoral regions have non-intact skin, assessment of the surrounding region for a single puncture subcutaneous tunnel maneuver is warranted. Case Report: The patient was a 67-year-old man who presented to the Emergency Department at the recommendation of his primary care physician because he had a systemic rash, fever, and chills. The skin lesions were confluent, crusted, erythematous bullae that were diffused with skin sloughing. The patient was diagnosed with pemphigus foliaceus and prescribed a 14-day course of intravenous rituximab. The nursing staff were unable to establish peripheral venous access and the Vascular Access Service was consulted for a peripherally inserted central catheter placement. There was a small area of intact skin on the medial aspect of the left upper extremity. The plan was made to enter the skin in this intact region and using ultrasound guidance subcutaneously tunnel the needle to the basilic vein for infection prevention purposes. Conclusion: For catheter placement in patients with systemic skin integrity disorders, pseudo-needle tunneling to create a safe exit site location, an antimicrobial catheter, and subcutaneous securement will provide the optimal outcome for prolonged intravenous antibiotic administration.
Introduction: Providing the appropriate device at the appropriate time based on a patient’s intravenous needs is the key to successful vascular access care. The evolution of vascular access device requirements from the prehospital environment to the intensive care unit include peripheral, intraosseous, arterial, and central catheter placement. A documented daily needs assessment of vascular access devices to downgrade, remove, insert, or consolidate will provide best outcomes with regards to vessel preservation, and the associated risks of infection and thrombosis.Case Report: The patient was an 87-year-old male with a history of congestive heart failure, asthma, diabetes mellitus, chronic obstructive pulmonary disease, and chronic kidney disease (CKD) brought to the hospital by the Emergency Medical Service for hypoglycemia. The paramedics placed a 20-gauge peripheral intravenous (PIV) catheter in the left forearm and treated the patient with a 50% dextrose solution. Three days later, the patient was found in his hospital room unresponsive and pulseless in asystole. The patient was intubated, and emergent central vascular access was achieved with a 15-gauge, 25-mm intraosseous needle to the left proximal tibia. The was found to be in acute renal failure and the medical team placed a dialysis catheter to the right jugular vein. Due to the difficulties in establishing central venous access, the vascular access service was consulted for central and arterial access placement. A triple lumen central venous catheter was placed to the right axillary vein in the deltopectoral groove, and an arterial catheter to the right axillary artery in the upper extremity.Conclusion: From the prehospital environment to the Intensive Care Unit, a patient’s vascular access requirements can fluctuate. Clear knowledge of the venous and arterial anatomy in conjunction with the selection of the appropriate access device will ensure best clinical outcomes.KeywordsPeripheral intravenous catheterIntraosseous catheterAcute dialysis catheterCentral venous catheterArterial catheterAxillary artery
Introduction: As many as 25% of all healthcare-associated infections (HAIs) are linked with medical devices such as urinary and central line catheters. The need for central access devices should be assessed on a day-to-day basis to decrease the risk of patients developing central line bloodstream infections. While bloodstream infections can develop from any vascular access device ranging from a peripheral intravenous catheter to a central line catheter, it makes sense to relocate catheters from an area of high risk such as the femoral vein in the inguinal crease, or a jugular vein proximal to a tracheostomy, to regions of lower risk such as the chest or the upper extremities.Case Report: The patient was an 89-year-old woman who presented to the Emergency Department after falling on her back at home. A computed tomography revealed a subdural hematoma in her right cerebral hemisphere with a left-sided shift of 4 mm. The patient became unstable, and a central venous catheter was placed to her right common femoral vein. The patient was brought to the Operating Room for a right-sided burr hole evacuation due to the expanding subdural hematoma. Following successful evacuation of the hematoma, the patient was moved to the Neurology Step-Down Intensive Care Unit, where a request was made for peripheral venous access to remove the femoral central catheter due to a rising white blood cell count. The patient was referred to the Vascular Access Service for placement of two peripheral intravenous (PIV) catheters for antibiotics, medication administration, and phlebotomy.Conclusion: In patients requiring central venous catheter removal with poor caliber peripheral access, the placement of ipsilateral ultrasound-guided midlines to the superficial and deep vasculature is a viable temporary solution.KeywordsUltrasound-guided peripheral intravenous catheterMidline catheterIpsilateral venous catheter placementDowngrading central accessBridging device
Introduction: Ultrasound use for vascular access is a critical assistive device for assessment of vessel options, real-time needle guidance, and detection of post-procedural complications. Ultrasound guidance assists with avoiding the insertion-related complication of arterial puncture to all site locations. The major risk factors for central line complications include inexperience of the inserter and the number of attempts made. But despite best efforts arterial puncture, although rare, does occur at a rate of less than 1% even in the hands of the most experienced clinician. Arterial puncture remains a risk in pediatrics and neonates for both peripheral and central access with specific early and late diagnostic indicators. It is vital that the clinician not only be well versed and trained in assessment and insertion techniques, but also possess the knowledge to diagnose and intervene in a timely manner with insertion-related complications.Case Report: The patient was a 2-year-old boy with a history of cystic fibrosis (CF) who presented to the Emergency Department with a 3-week history of cough and an O2 saturation of 95% on room air. He had last been hospitalized 1 month ago for a CF exacerbation and underwent bronchoscopy and wash out with medication. The patient’s cough had persisted and worsened, with a concomitant history of vomiting. The Vascular Access Service and an anesthesiologist were consulted for placement of a peripherally inserted central catheter (PICC) for administration of a 2-week course of piperacillin-tazobactam and amikacin. A post-procedural chest radiograph for PICC tip positioning demonstrated the catheter to be to the left of the mediastinum indicating an inadvertent arterial catheter placement. The catheter was transduced with an arterial waveform and immediately removed.Conclusion: In the age of ultrasound guidance, arterial puncture should never occur. But in the rare circumstance in which it is suspected, it is important to assess critically and recognize the early and late signs of arterial cannulation to prevent potentially serious patient harm.KeywordsUltrasound guidanceInadvertent arterial catheterizationInadvertent arterial punctureVascular access complicationCystic fibrosis
O objetivo foi construir e validar o conteúdo de um formulário de coleta de dados para avaliar o conhecimento e as práticas de enfermeiros sobre as técnicas de inserção do cateter central de inserção periférica (PICC). Trata-se de um estudo metodológico que adotou procedimentos psicométricos para construção e validação de conteúdo. Foi realizada uma revisão da literatura pautada nas recomendações das diretrizes da Infusion Nurse Society (ISN), no Guia para cateter intravenoso (MAGIC) e no documento Saúde e preservação dos vasos: a abordagem certa para o acesso vascular (AVA). O formulário possui 68 itens que foram validados por 9 juízes seguindo a classificação dos sistemas de experts proposto por Jasper e com base nas respostas dos juízes, foi calculado o índice de validade de conteúdo (IVC). A primeira versão possuía 68 itens, após ter sido avaliada pelos Juízes, originou-se uma segunda versão com 78 itens. Todos os itens do formulário tiveram o IVC de 100%. Assim, o formulário pode contribuir para a avaliação utilizada nos cursos de habilitação de PICC e para a avalição dos enfermeiros das instituições de saúde.
Background
Peripheral intravenous catheter (PIVC) insertion often fails on the first attempt. Risk factors include small vein size and dehydration, causing vein deformation and displacement due to puncture resistance of the vessel. The authors developed a short, thin-tipped bevel needle and compared its puncture performance with needles of four available PIVCs using an ex vivo model.
Methods
The PIVC with the thin-tipped short bevel needle was compared to four available PIVCs using an ex vivo model which simulated the cephalic vein of the human forearm. The ex vivo model consisted of a porcine shoulder and porcine internal jugular vein, and was used for evaluation of the rate of vein deformation and vessel displacement during needle insertion.
Results
An ex vivo model was created with a vessel diameter of 2.7–3.7 mm and a depth of 2–5 mm. The thin-tipped short bevel PIVC needle was associated with a significantly lower compressive deformation rate and venous displacement compared to the needles of the other four PIVCs.
Conclusion
The thin-tipped short bevel needle induced lower compressive deformation and displacement of the vein than the conventional needles. This needle has the potential to improve the first-attempt success rate of peripheral intravenous catheterization in patients with difficult venous access.
This review addresses the use of vascular catheterization in small laboratory animals in biomedical research with
an emphasis on the technological aspects of the method. The use of vascular catheters for blood sampling, drug
delivery or biomonitoring improves the quality of the study (reliability and reproducibility of results) and promotes
compliance with modern bioethical standards. The key factors that determine the success of the surgery and the
entire study are considered with an up-to-date approach. In particular, recommendations are given on the choice
of the vessel and the type and size of the catheter, depending on the characteristics of the animal and the study
objectives. Catheterization of the external jugular vein of a rat is described in detail, and the fundamental stages
of the procedure are the same for all major vessels of rodents. Much attention is paid to potential complications
of vascular catheterization, care for catheterized animals in the postoperative period, as well as measures for
maintaining the patency of the catheter and its proper functioning. The main limitations for the widespread use of
catheterization in research are insufficient qualification of the surgeon and the need to use surgical equipment and
microsurgical instruments
Establishing emergent vascular access is a complicated process, including many different considerations. Providers must consider multiple aspects of patient care, including the need for vascular access, comorbid conditions, advance directives, and the likely clinical course for patients following the initial vascular access attempt. Patients undergoing emergent intervention, evaluation, and treatment require an individualized approach to establishing vascular access, considering myriad factors derived from the patient’s unique presentation as well as the provider’s own subjective experience, the physical environment in which care is provided, understanding of the vascular access process, and the provider’s ability to complete the task at hand. This chapter describes an approach that will help providers to tailor their decision-making process for each patient requiring emergent vascular access rather than relying upon a strictly algorithmic approach.
Purpose: The purpose of this quality improvement study was to examine the impact of a Vascular Access Clinical Nurse Specialist (VA-CNS) on patient and organizational outcomes.
Description of the Project/Program: The VA-CNS role was created and implemented at an acute care hospital in Thunder Bay, Ontario, Canada. The VA-CNS collected data on clinical activities and interventions performed from April 1 to March 29, 2019. The dataset and its associated qualitative clinical outcomes were analyzed using deductive content analysis. Furthermore, a cost analysis was performed by the hospital accountant on these clinical outcomes.
Outcome: Over a 1-year period, there were 547 patients protected from an unwarranted peripherally inserted central catheter (PICC) insertion among 302 patient consultations for the VA-CNS. A total of 322 ultrasound-guided peripheral intravenous catheters were inserted and 45 PICC insertions completed at the bedside. The cost associated with the 547 patients not receiving a PICC line result in an estimated savings of $113,301. The VA-CNS role demonstrated a positive payback of $417,525 to the organization.
Conclusion: The results of this quality improvement project have demonstrated the positive impacts of the VACNS on patient and organizational outcomes. This role may be of benefit and worth its adoption for other health systems with similar patient populations.
Objectives
To evaluate the effectiveness of needle-free connectors to maintain Central Venous Catheter—CVC patency.
Background
Loss of patency is a common complication associated with CVC. For patients, this can be stressful and painful, and can result in a delay in infusion therapy. Pressure-activated anti-reflux needle-free connectors are one of the most modern devices; however, no studies have compared this connector with the open-system three-way stopcock in terms of the incidence of CVC occlusion.
Methods
This study is a prospective before and after intervention study. From March to August 2018, an observation phase was conducted with the three-way stopcock as the standard central venous catheter hub and closure system (phase 1). After implementation of needle-free connectors (phase 2), post-intervention observations were made from September 2019 to January 2020 (phase 3).
Results
Of 199 CVCs analyzed, 41.2% (40/97) occluded in at least one lumen in the first phase, and 13.7% (14/102) occluded after introducing the technological device, absolute risk reduction 27.5% (95% confidence interval 15.6%–39.4%). The lumens supported by needle-free connectors showed a higher probability of maintaining patency compared with three-way stopcocks. No differences were observed in the rate of infection.
Conclusions
Pressure-activated anti-reflux needle-free connectors are effective and safe devices suitable for the management of vascular access in cardiac patient care. Staff training, even on apparently simple devices, is essential to avoid the risk of infection.
Background
Assessing competency in the speciality of vascular access is still limited, and few valid and reliable tools are available. Therefore, this study aimed to develop and validate three different tools for assessing competency in managing the care of short peripheral cannulas (SPCs), midlines, peripherally inserted central catheters (PICCs), centrally inserted central catheters (CICCs), and arterial catheters (ACs) (tool one), placing SPCs (tool two), placing PICCs and midlines (tool three).
Methods
A two-phase and multi-method design was adopted. Phase one was implemented to develop the initial pool of items for each tool, starting from a literature overview. Panel discussions were adopted for developing the items. In phase two, the developed items were tested for content and face validity, involving a panel of 10 experts. Once obtained adequate content validity, a cross-sectional data collection was implemented to enroll three samples of healthcare workers who had to assess their competency through the developed tools. Dimensionality was assessed by performing a principal component analysis (PCA) and assessing internal consistency (Cronbach’s α).
Results
Tool one had 26 items, and the dimensionality was given by placement, risk assessment, procedure conformity and traceability, and patient education to self-care. Tool two had 35 items; its principal components were: risk evaluation, identification, clinical assessment and orientation to self-care, placement, and procedure registration shaped the competency of placing SPCs. Tool three had 31 items; its principal components were: risk assessment, placement, conformity to standards and procedure traceability, education, and orientation to self-care were the essential elements for adequately placing midlines and PICCs. Cronbach’s α values ranged between 0.806 and 0.959.
Conclusions
The three developed tools reflected the core elements of competency in each application area, representing an initial framework that could be useful in future research and educational projects. Cross-national investigations are required to corroborate the described results.
Pompe disease is an autosomal recessive glycogen storage disorder resulting in progressive glycogen accumulation expressed in infancy with cardiomyopathy and skeletal myopathy. Without treatment by enzyme replacement therapy (ERT), life expectancy is less than 2 years. The cross-reactive immunologic material (CRIM) positive or negative status is the basis for the response to ERT. CRIM-negative patients mount an immune response to ERT, making this the most dangerous presentation. The following case study describes the 5-year course of the first successful treatment of an in utero CRIM-negative Pompe disease patient with prophylactic immune tolerance induction (ITI) and administration of ERT given within the first 2 days of life followed by ultrasound guided vascular access that facilitated by bi-weekly infusions and extensive phlebotomy.
Aim:
To clarify the characteristics of expert nurses' assessments when selecting an insertion site for a peripheral venous catheter (PVC).
Methods:
Participants were 11 competent (control group) and 13 expert nurses. Using a simulated patient, we recorded the procedures participants followed when selecting a site for a PVC insertion. The researchers interviewed the nurses after the procedure by asking targeted questions about the site selection to clarify the factors influencing that selection. During the interview, a video of that nurse's procedure was observed, and each step performed during the procedure was investigated.
Results:
We identified three assessment characteristics specific to expert nurses that influenced their PVC site selection: (a) focusing on a patient's unique characteristics and choosing the appropriate procedure for that individual; (b) avoiding complications and paying attention to the patient's daily self-care needs; and (c) carefully considering the patient's fear and fatigue during site selection and catheter insertion. Other assessments, based on the general knowledge and skill acquired by nurses in selecting a PVC site, were common to both groups: arm selection based on the patient's preference and site selection to avoid nerve injuries or complications. The control group's approach was assessed on the basis of their confidence in selecting a site for a PVC insertion.
Conclusions:
Expert nurses assessed the patient's individual characteristics and daily self-care needs and helped mitigate the patient's anxiety. Our findings provide a basis for educational programs that share how expert nurses assess sites for a PVC insertion.
Background
Peripherally inserted central catheters and centrally inserted central catheters have numerous benefits but can be associated with risks. This meta-analysis compared central catheters for relevant clinical outcomes using recent studies more likely to coincide with practice guidelines.
Methods
Several databases, Ovid MEDLINE, Embase, and EBM Reviews were searched for articles (2006–2018) that compared central catheters. Analyses were limited to peer-reviewed studies comparing peripherally inserted central catheters to centrally inserted central catheters for deep vein thrombosis and/or central line–associated bloodstream infections. Subgroup, sensitivity analyses, and patient-reported measures were included. Risk ratios, incidence rate ratios, and weighted event risks were reported. Study quality assessment was conducted using Newcastle–Ottawa and Cochrane Risk of Bias scales.
Results
Of 4609 screened abstracts, 31 studies were included in these meta-analyses. Across studies, peripherally inserted central catheters were protective for central line–associated bloodstream infection (incidence rate ratio = 0.52, 95% confidence interval: 0.30–0.92), with consistent results across subgroups. Peripherally inserted central catheters were associated with an increased risk of deep vein thrombosis (risk ratio = 2.08, 95% confidence interval: 1.47–2.94); however, smaller diameter and single-lumen peripherally inserted central catheters were no longer associated with increased risk. The absolute risk of deep vein thrombosis was calculated to 2.3% and 3.9% for smaller diameter peripherally inserted central catheters and centrally inserted central catheters, respectively. On average, peripherally inserted central catheter patients had 11.6 more catheter days than centrally inserted central catheter patients ( p = 0.064). Patient outcomes favored peripherally inserted central catheters.
Conclusion
When adhering to best practices, this study demonstrated that concerns related to peripherally inserted central catheters and deep vein thrombosis risk are minimized. Dramatic changes to clinical practice over the last 10 years have helped to address past issues with central catheters and complication risk. Given the lower rate of complications when following current guidelines, clinicians should prioritize central line choice based on patient therapeutic needs, rather than fear of complications. Future research should continue to consider contemporary literature over antiquated data, such that it recognizes the implications of best practices in modern central catheterization.
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