Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients

Development of a clinical prediction rule to improve peripheral intravenous cannulae first attempt success in the emergency department and reduce post insertion failure rates: the Vascular Access Decisions in the Emergency Room (VADER) study protocol

INTRODUCTION

Peripheral intravenous cannula (PIVC) insertion is one of the most common clinical interventions performed in emergency care worldwide. However, factors associated with successful PIVC placement and maintenance are not well understood. This study seeks to determine the predictors of first time PIVC insertion success in emergency department (ED) and identify the rationale for removal of the ED inserted PIVC in patients admitted to the hospital ward. Reducing failed insertion attempts and improving peripheral intravenous cannulation practice could lead to better staff and patient experiences, as well as improving hospital efficiency.

METHODS AND ANALYSIS

We propose an observational cohort study of PIVC insertions in a patient population presenting to ED, with follow-up observation of the PIVC in subsequent admissions to the hospital ward. We will collect specific PIVC observational data such as; clinician factors, patient factors, device information and clinical practice variables. Trained researchers will gather ED PIVC insertion data to identify predictors of insertion success. In those admitted from the ED, we will determine the dwell time of the ED-inserted PIVC. Multivariate regression analyses will be used to identify factors associated with insertions success and PIVC failure and standard statistical validation techniques will be used to create and assess the effectiveness of a clinical predication rule.

ETHICS AND DISSEMINATION

The findings of our study will provide new evidence to improve insertion success rates in the ED setting and identify strategies to reduce premature device failure for patients admitted to hospital wards. Results will unravel a complexity of factors that contribute to unsuccessful PIVC attempts such as patient and clinician factors along with the products, technologies and infusates used.

TRIAL REGISTRATION NUMBER

ACTRN12615000588594; Pre-results.

Point-of-care ultrasound in paediatric emergency medicine

Point-of-care ultrasound (POC US) is an adjunct to clinical paediatric emergency medicine practice that is rapidly evolving, improving the outcomes of procedural techniques such as vascular access, nerve blocks and fluid aspiration and showing the potential to fast-track diagnostic streaming in a range of presenting complaints and conditions, from shock and respiratory distress to skeletal trauma. This article reviews the procedural and diagnostic uses, both established and emerging, and provides an overview of the necessary components of quality assurance during this introductory phase.

Design and application of model for training ultrasound-guided vascular cannulation in pediatric patients

Central vascular cannulation is not a risk-free procedure, especially in pediatric patients. Newborn and infants are small and low-weighted, their vascular structures have high mobility because of tissue laxity and their vessels are superficial and with small diameter. These characteristics, together with the natural anatomical variability and poor collaboration of small children, make this technique more difficult to apply. Therefore, ultrasound imaging is increasingly being used to locate vessels and guide vascular access in this population.

OBJECTIVE

(a) To present a model that simulates the vascular system for training ultrasound-guided vascular access in pediatrics patients; (b) to ultrasound-guided vascular cannulation in the model.

RESULTS

The model consisted of two components: (a) muscular component: avian muscle, (b) vascular component: elastic tube-like structure filled with fluid. 864 ecoguided punctures was realized in the model at different vessel depth and gauge measures were simulated, for two medical operators with different degree of experience. The average depth and diameter of vessel cannulated were 1.16 (0.42)cm and 0.43 (0.1)cm, respectively. The average number of attempts was of 1.22 (0.62). The percentage of visualization of the needle was 74%. The most frequent maneuver used for the correct location, was the modification of the angle of the needle and the relocation of the guidewire in 24% of the cases. The average time for the correct cannulations was 41 (35.8)s. The more frequent complications were the vascular perforation (11.9%) and the correct vascular puncture without possibility of introducing the guidewire (1.2%). The rate of success was 96%.

CONCLUSIONS

The model simulates the anatomy (vascular and muscular structures) of a pediatric patient. It is cheap models, easily reproducible and a useful tool for training in ultrasound-guided puncture and cannulation.

Effects of Needle and Catheter Size on Commercially Available Ultrasound Contrast Agents

OBJECTIVES

To investigate effects of needle and catheter size on in vitro ultrasound contrast agent (UCA) enhancement and concentrations using 4 commercially available UCAs.

METHODS

Definity (Lantheus Medical Imaging, North Billerica, MA), Optison (GE Healthcare, Princeton, NJ), SonoVue (Bracco SA, Geneva, Switzerland), and Sonazoid (GE Healthcare, Oslo, Norway) were investigated. The UCA was injected via a 1-mL syringe (BD, Franklin Lakes, NJ) into a 3-way stopcock (Smith Medical, Dublin, OH) and flushed with 10 mL of saline through an 18-cm infusion extension tube connected to either a 16-, 18-, 20-, 22-, or 24-gauge catheter (BD) or an 18-, 20-, 21-, or 25-gauge needle (BD). In vitro enhancement was determined in a flow phantom (ATS Laboratories, Bridgeport, CT), and microbubble concentrations were determined using an LSRII flow cytometer (BD Biosciences, San Jose, CA).

RESULTS

Significant decreases in enhancement and microbubble concentrations were observed for all 4 UCAs (P < .001) when administration was performed through a 25-gauge needle. No statistically significant differences in enhancement or concentrations were observed between all catheter sizes and 18- to 21-gauge needles for SonoVue and Sonazoid. Definity and Optison administration through a 24-gauge catheter resulted in a significant loss of enhancement (P < .02), although these differences were not significant on flow cytometry.

CONCLUSIONS

Administration of commercial UCAs in a clinical scenario is possible with catheters or needles smaller than 20 gauge, although the minimal allowable size appears to be UCA specific.

Peripheral intravenous cannulation with support of infrared laser vein viewing system in a pre-operation setting in pediatric patients

BACKGROUND

Venous access, a prerequisite for anesthesiological and surgical intervention in pediatric patients, is often difficult to establish and potentially painful. AV300 uses near infrared laser light to improve visibility of peripheral veins and could help cannulating them. The aim of this study was to examine if use of Accuvein(®) AV300 vein viewer could facilitate venous cannulation in children.

METHODS

From January to March 2011, 238 consecutive pediatric patients (0-17 years) preceding surgical interventions were included. All participants including newborns, infants and children were allocated to groups [control group (124 patients) and intervention group (114 patients)] in a non-random way. Randomization was not feasible because data was acquired retrospectively from a clinical quality management project. In control group, peripheral IV cannulation was performed without supporting device, in intervention group with support of AV300. Time and number of attempts until successful venous cannulation were defined as primary end points.

RESULTS

Median time until successful cannulation was 2 min (range 0.1-20, quartiles: 25 %: 1; 75 %: 5) in the intervention group and 1 min (range 0.1-18, quartiles: 25 %: 0.2; 75 %: 2) in the control group (p < 0.01). Median number of attempts was higher in the intervention group (2; range 1-6, quartiles: 25 %: 1; 75 %: 3) than in the control group (1; range 1-6, quartiles: 25 %: 1; 75 %: 2, p < 0.01). Rate of cannulations successful at first attempt was 0.45 (51 of 114, 95 % CI 0.35-0.54) in the intervention group and 0.73 (90 of 124, 95 % CI 0.65-0.81) in the control group (p < 0.01).

CONCLUSIONS

In our study we were not able to reduce neither time nor number of attempts until a successful venous cannulation in children using the vein viewer. Given certain limitations of our study as the lack of randomization and no control for inter-operator variability, the conclusions drawn from it are also limited, but by our results laser-supported cannulation cannot be recommended for standard procedures.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01434537. Registered 29 July 2011.

Ultrasound Guided Intravenous Access by Nursing versus Resident Staff in a Community Based Teaching Hospital: A "Noninferiority" Trial

Objectives. Ultrasound (US) guidance is a safe and effective method for peripheral intravenous (IV) catheter placement. However, no studies have directly compared the success rate of emergency medicine (EM) residents and nurses at using this technique especially in community hospital settings. This prospective “noninferiority” study sought to demonstrate that nursing staff are at least as successful as EM residents at placing US guided IVs. Methods. A group of 5 EM residents and 11 nurse volunteers with at least two years' experience underwent training sessions in hands-on practice and didactic instruction with prospective follow-up. Two failed attempts on a patient using standard approach by an emergency department (ED) nurse were deemed to be “difficult sticks” and randomly assigned to either a nurse or resident, based on the day they presented. Results. A total of 90 attempts, consisting of trials on 90 patients, were recorded with a success rate of 85% and 86% for residents and nurses, respectively. With a p value of .305, there was no statistically significant difference in the success rate between the residents and nurses. Conclusion. Properly trained nursing staff can be as equally successful as EM residents in placing US guided intravenous lines.

Focused Simulation Training: Emergency Department Nurses’ Confidence and Comfort Level in Performing Ultrasound-Guided Vascular Access

Study objectives

The objective of this study is to assess Emergency Department (ED) nurses’ confidence, comfort level, and competency in performing ultrasound-guided vascular access after a focused ultrasound simulation training session.

Methods

A cross-sectional study at an academic medical center. A simulation-based ultrasound training module was used to train ED nurses in ultrasound-guided intravenous (IV) access. The training module consisted of didactics followed by hands-on practice on human models and Blue Phantom ultrasound training block model. All subjects completed a questionnaire after completing the training module.

Results

A total of 40 nurses were enrolled. All subjects successfully demonstrated competency during the training session by identifying upper extremity sonographic vascular anatomy on a human model and performing real-time ultrasound-guided IV access on Blue Phantom ultrasound training block model. On a scale of 1-10, the average confidence level in performing the ultrasound-guided vascular access was 6.9 [95% confidence interval (95% CI) 6.3-7.46], with 98% (95% CI, 92-102%) reporting no difficulty in recognizing upper limb vascular anatomy on ultrasound. Ninety-two percent (95% CI, 84-100%) agreed that focused training in ultrasound-guided IV access was adequate to learn the procedure.

Conclusions

After a focused simulation training session, ED nurses had a high level of comfort using ultrasound for vascular access. Despite having a moderate degree of confidence, ED nurses were accurate in identifying vascular anatomy and performing ultrasound-guided vascular access.

Predictors of difficult pediatric intravenous access in a community Emergency Department

Background

Successful intravenous (IV) placement is important in the care of the acutely ill and injured pediatric patient. There are little data that exist regarding predicators of difficult IV access in pediatric Emergency Department (ED) patients who present to community EDs.

Methods

We retrospectively analyzed all pediatric charts for the calendar year 2012 from a single community teaching hospital. We identified all cases with patients less than 18 years of age in whom an IV or IV medications were ordered. We defined difficult IV access as those requiring more than one attempt, or those where the IV team was required to place the IV. We identified patient, provider, and procedural characteristics. Data were analyzed using descriptive statistics and univariate logistic regression to determine the odds ratio (OR) for predictors of difficult IV access.

Results

We identified 652 patients, 607 (93%) without difficult access and 45 with difficult access. Increasing age [OR 0.94 (0.89-0.99) p = 0.017] was associated with decreased odds of difficult IV access. IVs attempted in the hand [OR 3.02 (1.06-8.58) p = 0.039] and lower extremity [OR 7.82 (2.27-26.91) p = 0.001)]) were associated with greater odds of difficult access than the antecubital fossa. Non-black/non-white race [2.37 (1.1-5.12) p = 0.028] was also associated with difficult IV access. Other factors (sex, IV catheter size, and so on) were not associated.

Conclusions

In this retrospective study of pediatric patients in a community ED, decreasing age, non-black/non-white race, and IV attempt location (hand and lower extremity vs. antecubital fossa) were associated with greater odds of difficult IV access.

Ultrasound or near-infrared vascular imaging to guide peripheral intravenous catheterization in children: a pragmatic randomized controlled trial

BACKGROUND

Peripheral intravenous catheterization in children is challenging, and success rates vary greatly. We conducted a pragmatic randomized controlled trial to determine whether the use of ultrasound or near-infrared vascular imaging to guide catheterization would be more effective than the standard approach in achieving successful catheter placement on the first attempt.

METHODS

We enrolled a convenience sample of 418 children in a pediatric emergency department who required peripheral intravenous catheterization between June 2010 to August 2012. We stratified them by age (≤ 3 yr and > 3 yr) and randomly assigned them to undergo the procedure with the standard approach, or with the help of either ultrasound or near-infrared vascular imaging. The primary outcome was the proportion of patients who had successful placement of a catheter on the first attempt.

RESULTS

The rate of successful first attempts did not differ significantly between either of the 2 intervention groups and the standard approach group (differences in proportions -3.9%, 95% confidence interval [CI] -14.2% to 6.5%, for ultrasound imaging; -8.7%, 95% CI -19.4% to 1.9%, for near-infrared imaging). Among children 3 years and younger, the difference in success rates relative to standard care was also not significant for ultrasound imaging (-9.6%, 95% CI -29.8% to 10.6%), but it was significantly worse for near-infrared imaging (-20.1%, 95% CI -40.1% to -0.2%). Among children older than 3 years, the differences in success rates relative to standard care were smaller but not significant (-2.3%, 95% CI -13.6% to 9.0%, for ultrasound imaging; -4.1%, 95% CI -15.7% to 7.5%, for near-infrared imaging). None of the pairwise comparisons were statistically significant in any of the outcomes.

INTERPRETATION

Neither technology improved first-attempt success rates of peripheral intravenous catheterization in children, even in the younger group. These findings do not support investment in these technologies for routine peripheral intravenous catheterization in children.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT01133652.

Ultrasound-Guided Peripheral Venous Access: A Meta-Analysis and Systematic Review

Objectives

The objective of this study was to determine through a systematic review of the literature and meta-analysis whether success rates, time to cannulation, and number of punctures required for peripheral venous access are improved with ultrasound guidance compared with traditional techniques in patients with difficult peripheral venous access.

Methods

We conducted a systematic search of MEDLINE, Web of Science, The Cochrane Library, ClinicalTrials.gov, Cumulative Index to Nursing, and Allied Health Literature. Studies were included if they met the following criteria: patients of any age identified as having difficult peripheral venous access; real-time ultrasound guidance was used for peripheral venous cannulation; and inclusion of at least one of these outcomes (success rates, time to successful cannulation and number of punctures required).

Results

Seven studies were selected for final analysis. Ultrasound guidance improved success rates when compared with traditional techniques [pooled odds ratio (OR) 3.96; 95% confidence interval (95% CI) 1.75-8.94]. No significant difference between ultrasound-guided techniques and traditional techniques was detected for time to cannulation or number of punctures required.

Conclusions

In patients with difficult peripheral venous access, ultrasound guidance increased success rates of peripheral venous placement when compared with traditional techniques. However, ultrasound guidance had no effect on time to successful cannulation or number of punctures required for successful cannulation.

Focus on peripherally inserted central catheters in critically ill patients

Venous access devices are of pivotal importance for an increasing number of critically ill patients in a variety of disease states and in a variety of clinical settings (emergency, intensive care, surgery) and for different purposes (fluids or drugs infusions, parenteral nutrition, antibiotic therapy, hemodynamic monitoring, procedures of dialysis/apheresis). However, healthcare professionals are commonly worried about the possible consequences that may result using a central venous access device (CVAD) (mainly, bloodstream infections and thrombosis), both peripherally inserted central catheters (PICCs) and centrally inserted central catheters (CICCs). This review aims to discuss indications, insertion techniques, and care of PICCs in critically ill patients. PICCs have many advantages over standard CICCs. First of all, their insertion is easy and safe -due to their placement into peripheral veins of the arm- and the advantage of a central location of catheter tip suitable for all osmolarity and pH solutions. Using the ultrasound-guidance for the PICC insertion, the risk of hemothorax and pneumothorax can be avoided, as well as the possibility of primary malposition is very low. PICC placement is also appropriate to avoid post-procedural hemorrhage in patients with an abnormal coagulative state who need a CVAD. Some limits previously ascribed to PICCs (i.e., low flow rates, difficult central venous pressure monitoring, lack of safety for radio-diagnostic procedures, single-lumen) have delayed their start up in the intensive care units as common practice. Though, the recent development of power-injectable PICCs overcomes these technical limitations and PICCs have started to spread in critical care settings. Two important take-home messages may be drawn from this review. First, the incidence of complications varies depending on venous accesses and healthcare professionals should be aware of the different clinical performance as well as of the different risks associated with each type of CVAD (CICCs or PICCs). Second, an inappropriate CVAD choice and, particularly, an inadequate insertion technique are relevant-and often not recognized-potential risk factors for complications in critically ill patients. We strongly believe that all healthcare professionals involved in the choice, insertion or management of CVADs in critically ill patients should know all potential risk factors of complications. This knowledge may minimize complications and guarantee longevity to the CVAD optimizing the risk/benefit ratio of CVAD insertion and use. Proper management of CVADs in critical care saves lines and lives. Much evidence from the medical literature and from the clinical practice supports our belief that, compared to CICCs, the so-called power-injectable peripherally inserted central catheters are a good alternative choice in critical care.

Ultrasound first, second, and last for vascular access

Vascular access is the most commonly performed invasive procedure in medicine. For more than 20 years, ultrasound has been shown to improve the success and decrease complications of central venous access; however, it is still not universally used for this procedure. Ultrasound may also be used to facilitate difficult peripheral vascular access, potentially avoiding other more invasive procedures such as central or intraosseus vascular access. This article reviews some of the indications and evidence for ultrasound-guided vascular access, provides tips for successful ultrasound guidance, and discusses barriers to adoption.

Advances in point-of-care ultrasound in pediatric emergency medicine

PURPOSE OF REVIEW

Point-of-care ultrasound (POCUS) has become an integral part of emergency medicine practice. Research evaluating POCUS in the care of pediatric patients has improved the understanding of its potential role in clinical care.

RECENT FINDINGS

Recent work has investigated the ability of pediatric emergency medicine (PEM) physicians to perform a wide array of diagnostic and procedural applications in POCUS ultrasound. Studies have demonstrated that PEM providers are able to identify an array of diseases, including intussusception, pyloric stenosis and appendicitis. Novel applications of ultrasound, such as a cardiac evaluation in the acutely ill patient or identification of skull fractures in the assessment of a patient with head injury, have shown excellent promise in recent studies. These novel applications have the potential to reshape pediatric diagnostic algorithms.

SUMMARY

Key applications in PEM have been investigated in the recent publications. Further exploration of the ability to integrate ultrasound into routine practice will require larger-scale studies and continued growth of education in the field. The use of ultrasound in clinical practice has the potential to improve safety and efficiency of care in the pediatric emergency department.

Towards a low-cost mobile subcutaneous vein detection solution using near-infrared spectroscopy

Excessive venipunctures are both time- and resource-consuming events, which cause anxiety, pain, and distress in patients, or can lead to severe harmful injuries. We propose a low-cost mobile health solution for subcutaneous vein detection using near-infrared spectroscopy, along with an assessment of the current state of the art in this field. The first objective of this study was to get a deeper overview of the research topic, through the initial team discussions and a detailed literature review (using both academic and grey literature). The second objective, that is, identifying the commercial systems employing near-infrared spectroscopy, was conducted using the PubMed database. The goal of the third objective was to identify and evaluate (using the IEEE Xplore database) the research efforts in the field of low-cost near-infrared imaging in general, as a basis for the conceptual model of the upcoming prototype. Although the reviewed commercial devices have demonstrated usefulness and value for peripheral veins visualization, other evaluated clinical outcomes are less conclusive. Previous studies regarding low-cost near-infrared systems demonstrated the general feasibility of developing cost-effective vein detection systems; however, their limitations are restricting their applicability to clinical practice. Finally, based on the current findings, we outline the future research direction.

Resource utilization and cost of inserting peripheral intravenous catheters in hospitalized children

OBJECTIVE

The goal of this study was to measure the costs and difficulty in placing peripheral intravenous (IV) catheters in hospitalized children; measures of resource utilization. We measured the costs and difficulty in placing peripheral intravenous (IV) catheters in hospitalized children. This common procedure has implications for the utilization of hospital resources.

METHODS

This was a prospective, large-scale observational study in 2 southeastern US pediatric teaching hospitals evaluating 592 children needing peripheral IV catheters in the inpatient setting. The median age was 2.25 years with an age range of 2 days to 18 years. Costs were estimated by using directly measured staff time and national salary data. Analyses included costs according to patient characteristics (age, weight, dehydration, and difficulty of stick attempts), and nurse characteristics (experience in years and anticipated difficulty).

RESULTS

The median cost of the pediatric IV insertions was $41, and 60% of the placements were obtained with the first nurse. Seventy-two percent of the children had a successful IV insertion in 1 to 2 attempts and accounted for 53% of total costs. However, the 28% of children who required > or = 3 IV attempts had a cost range of $69 to more than $125, and they consumed 43% of the total IV costs. This subset was often < 2 years old or dehydrated (P = .0002).

CONCLUSIONS

The insertion of peripheral IV catheters in an inpatient setting can be time intensive and requires significant skill. Our study suggests that resource utilization may improve when nurses and personnel proficient in starting peripheral IV catheters are used when the initial nurse has failed to obtain IV access. This systems improvement should result in shortened time to administration of parenteral therapies, positively improving outcomes and lessening length of stay, as well as improving patient/family satisfaction due to reduced perceptions of pain.

Predisposing factors for peripheral intravenous puncture failure in children

OBJECTIVE

To identify predisposing factors for peripheral intravenous puncture failure in children.

METHODS

Cross-sectional cohort study conducted with 335 children in a pediatric ward of a university hospital after approval of the ethics committee. The Wald Chi-squared, Prevalence Ratio (PR) and backward procedure (p≤0.05) tests were applied.

RESULTS

Success of peripheral intravenous puncture was obtained in 300 (89.5%) children and failure in 35 (10.4%). The failure rates were significantly influenced by: presence of clinical history of difficult venous access, malnourishment, previous use of peripherally inserted central venous catheter, previous use of central venous catheter, and history of phlebitis or infiltration. In the multivariate model, being malnourished and having previously been submitted to central venous catheterization were the predisposing factors for the failure.

CONCLUSION

The failure rate of 10.4% is similar to that identified in analogous studies and was influenced by characteristics of the children and intravenous therapy. In association with this, malnutrition and previous use of a central venous catheter were the most important variables influencing increase in peripheral intravenous puncture failure.

Assertividade e tempo de permanência de cateteres intravenosos periféricos com inserção guiada por ultrassonografia em crianças e adolescentes

Estudo randômico e controlado que objetivou verificar se a ultrassonografia vascular (USV) aumenta a assertividade na utilização do cateter intravenoso periférico e o tempo de permanência do cateter quando comparado ao método tradicional de punção. A coleta de dados ocorreu após aprovação do mérito ético, incluindo-se no estudo crianças e adolescentes submetidos a punção intravenosa periférica guiada pela USV, constituindo o grupo USV (GUSV), ou após avaliação clínica da rede venosa, denominado grupo controle (GC). Os valores de p<0,05 foram considerados significativos. A amostra foi constituída por 382 punções, 188 (49,2%) no GUSV e 194 (50,8%) no GC, realizadas em 335 crianças. Identificou-se assertividade em 73 (71,6%) cateteres do GUSV e em 84 (71,8%) do GC (p=0,970). O tempo de permanência do cateter apresentou mediana inferior a um dia nos dois grupos (p=0,121), não havendo diferença estatisticamente significativa. Concluindo-se que a USV não influenciou os resultados das variáveis dependentes investigadas. ClinicalTrials.govNCT00930254.

Ultrasonographically guided peripheral intravenous cannulation of children and adults: a systematic review and meta-analysis

STUDY OBJECTIVE

Peripheral intravenous cannulation is procedurally challenging and painful. We perform a systematic review to evaluate ultrasonographic guidance as an aid to peripheral intravenous cannulation.

METHODS

We searched MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, ClinicalTrials.gov, and Google.ca. We included randomized trials evaluating ultrasonographically guided peripheral intravenous cannulation and reporting risk of peripheral intravenous cannulation failure, number of attempts, procedure time, or time from randomization to peripheral intravenous cannulation. We separately analyzed pediatric and adult data and emergency department (ED), ICU, and operating room data. Quality assessment used the Cochrane Risk of Bias Tool.

RESULTS

We identified 4,664 citations, assessed 403 full texts for eligibility, and included 9 trials. Five had low risk, 1 high risk, and 3 unclear risk of bias. A pediatric ED trial found that ultrasonography decreased mean difference (MD) in the number of attempts (MD -2.00; 95% confidence interval [CI] -2.73 to -1.27) and procedure time (MD -8.10 minutes; 95% CI -12.48 to -3.72 minutes). In an operating room pediatric trial, ultrasonography decreased risk of first-attempt failure (risk ratio 0.23; 95% CI 0.08 to 0.69), number of attempts (MD -1.50; 95% CI -2.52 to -0.48), and procedure time (MD -5.95; 95% CI -10.21 to -1.69). Meta-analysis of adult ED trials suggests that ultrasonography decreases the number of attempts (MD -0.43; 95% CI -0.81 to -0.05). Ultrasonography decreased risk of failure (risk ratio 0.47; 95% CI 0.26 to 0.87) in an adult ICU trial.

CONCLUSION

Ultrasonography may decrease peripheral intravenous cannulation attempts and procedure time in children in ED and operating room settings. Few outcomes reached statistical significance. Larger well-controlled trials are needed.

Near-infrared imaging in intravenous cannulation in children: a cluster randomized clinical trial

OBJECTIVE

Intravenous cannulation is a widespread medical procedure that can be difficult in children. Visualization of veins with near-infrared (NIR) light might support intravenous cannulation. Therefore, we investigated the effectiveness of an NIR vascular imaging system (VascuLuminator) in facilitating intravenous cannulation in children in the operating room.

METHODS

This was a pragmatic, cluster randomized clinical trial in all consecutive children (0-18 years) scheduled for elective surgery and in need of intravenous cannulation at a tertiary pediatric referral hospital. Daily operating rooms (770 patients) were randomized for allocation of the VascuLuminator or control group. The primary outcome was success at first attempt; the secondary outcome was time to successful cannulation.

RESULTS

Success at first attempt was 70% (171/246) with and 71% (175/245) without the use of the VascuLuminator (P = .69). Time to successful cannulation was 162 (± 14) seconds and 143 (± 15) seconds respectively (P = .26). In 83.3%, the vein of first choice was visible with the VascuLuminator.

CONCLUSIONS

Although it was possible to visualize veins with NIR in most patients, the VascuLuminator did not improve success rate or time to obtain intravenous cannulation. There are 3 possible explanations for this result: first, it could be that localization of the vein is not the main problem, and therefore visualization is not a solution; second, the type of system used in this study could be less than optimal; and, third, the choice of the patient population in this study could be inappropriate.

Greater saphenous vein location in a pediatric population

The purpose of this study was to assess the accuracy of a landmark technique for cannulation of the greater saphenous vein (GSV) near the medial malleolus. We performed bedside ultrasound in a convenience sample of 100 children, ages 3 to 16 years, to evaluate the anatomy of the GSV at the ankle. Despite the proposed constancy of the landmark technique regardless of patient age, the GSV location varied significantly with increasing patient age and weight. In children less than 10 years old or weighing less than 40 kg, the traditional landmark rarely predicted the precise location of the GSV.

Use of emergency ultrasound in United States pediatric emergency medicine fellowship programs in 2011

OBJECTIVES

The purpose of this study was to evaluate the use of and training in emergency ultrasound (US) in pediatric emergency departments (EDs) with pediatric emergency medicine (EM) fellowship programs. We hypothesized that emergency US use and pediatric EM fellow training have become widespread and that more structured training is being offered.

METHODS

A survey instrument was sent via e-mail to all 69 United States pediatric EM fellowship directors or associate directors in the spring of 2011. We used descriptive summary statistics and χ(2) tests to determine characteristics associated with having a formal emergency US training program for pediatric EM fellows.

RESULTS

The survey response rate was 87% (60 of 69). Among responding programs, 40 (67%) resided within a children's hospital (versus general ED). Fifty-one (85%) were designated level 1 pediatric trauma centers. Fifty-seven programs (95%) endorsed the use of emergency US in their EDs. Fifty-three (88%) provided at least some emergency US training to fellows, and 42 (70%) offered a structured emergency US rotation. Training has existed for a median of 3 years (interquartile range, 2-4 years). Twenty-eight programs (67%) with emergency US rotations provided fellow training in the both a general ED as well as a pediatric ED. There were no hospital or program level factors statistically associated with having a formal training program for pediatric EM fellows.

CONCLUSIONS

As of 2011, nearly all pediatric EDs with pediatric EM fellowship programs use emergency US. Pediatric EM fellowship programs provide emergency US training to their fellows, with a structured rotation being offered by most of these programs.

Placement of peripherally inserted central catheters in children guided by ultrasound: a prospective randomized, and controlled trial

OBJECTIVE

To compare the use of vascular Doppler ultrasound with vein visualization and palpation for positioning peripherally inserted central catheters in children and to determine the influence of these methods on the success of the first puncture attempt, catheter positioning, and time required for the accomplishment.

DESIGN

A prospective randomized, controlled trial was conducted in a university hospital after ethical approval and was carried out among children (from birth to 18 yrs).

SETTING

São Paulo Hospital, São Paulo, Brazil.

PATIENTS

The sample comprises 42 peripherally inserted central catheters insertions allocated randomly into two groups: 1) an ultrasound group with 21 peripherally inserted central catheters guided by ultrasound; and 2) a control group with 21 catheters, in which the peripherally inserted central catheters were inserted using vein visualization and palpation.

INTERVENTIONS

The procedure was performed by two trained nurses using a standard protocol for peripherally inserted central catheter insertion and ultrasound use. Ultrasound group equipment was ILook25 (Sonosite, Bothell, WA) with a 25-mm, 10- to 15-MHz linear array transducer that reaches a 4-cm depth.

MEASUREMENTS AND MAIN RESULTS

Success in the first puncture attempt was higher (p = .003) in the ultrasound group (90.5%) than in the control group (47.6%). The catheter positioning success rate was 85.7% in the ultrasound group and 52.4% in the control group (p = .019). The median time spent on the procedure for the ultrasound group was 20 mins, whereas it was 50 mins for the control group (p = .001).

CONCLUSION

The use of ultrasound increased the successful positioning of peripherally inserted central catheters in comparison with the venous anatomic landmark visualization and palpation technique and further optimized the time spent on the procedure.

A randomized controlled trial comparing the AccuVein AV300 device to standard insertion technique for intravenous cannulation of anesthetized children

OBJECTIVES AND AIMS

To evaluate the efficacy of the AccuVein AV300 device in improving the first-time success rate of intravenous cannulation of anesthetized pediatric patients.

BACKGROUND

The AccuVein AV300 device was developed to assist venepuncture and intravenous cannulation by enhancing the visibility of superficial veins. It uses infrared light to highlight hemoglobin so that blood vessels are darkly delineated against a red background.

METHODS/MATERIALS

Patients were randomized to cannulation with the AccuVein AV300 device or standard insertion by experienced pediatric anesthesiologists. An observer recorded the number of skin punctures and cannulation attempts required, and the time between tourniquet application and successful cannulation or four skin punctures, whichever came first.

RESULTS AND CONCLUSIONS

There were 146 patients with a median age of 4.6 years (range, 0.18-17.1 years), 46.6% were male, 80.8% were light skin colored, and 15.7% were younger than 2 years. The first-attempt success rates were 75% (95% CI, 63.8-84.2%) using AV300 and 73% (95% CI, 61.9-81.9%) using the standard method (P = 0.85). Patients with dark or medium skin color were 0.38 times less likely to have a successful first attempt than patients with light skin color. The difference between the two treatment groups in number of skin punctures and the time to insertion was not significant. Although the AV300 was easy to use and improved visualization of the veins, we found no evidence that it was superior to the standard method of intravenous cannulation in unselected pediatric patients under anesthesia.

Bedside ultrasound education in pediatric emergency medicine fellowship programs in the United States

OBJECTIVES

As the use of bedside ultrasound becomes more prevalent in pediatric emergency departments, the need for a national curriculum for fellows' training in pediatric emergency medicine (PEM) has increased. The objectives of this study were to describe the current state of bedside ultrasound education among existing PEM fellowship programs and to explore the interest in a national curriculum.

METHODS

A 20-question survey was sent to all 57 PEM fellowship directors in the United States in February 2011. Weekly reminders were sent for 4 weeks.

RESULTS

The response rate was 58% (33/57). Although 91% of respondents reported having an ultrasound machine available, only 16% reported an ultrasound curriculum designed specifically for PEM. Another 25% reported no curriculum, and 28% use a curriculum designed for general emergency medicine physicians. Most (>83%) directors thought an ultrasound curriculum for PEM fellows should include the focused assessment with sonography for trauma, bladder size assessment, soft tissue foreign body localization, skin and soft tissue infection evaluation, guidance for central and peripheral line insertion, and arthrocentesis. Some directors (40%-68%) thought that cardiac ultrasound, thoracic ultrasound, abdominal ultrasound, lumbar puncture guidance, fracture reduction, nerve blocks, and testicular ultrasounds should also be included. Forty-two percent plan to create a bedside ultrasound curriculum in the next 5 years, and 40% reported the lack of a national curriculum as a barrier to creating a curriculum.

CONCLUSIONS

Bedside ultrasound use in pediatric emergency departments is very common, and PEM fellowship directors would welcome the development of a standard curriculum.

The use of near-infrared light for safe and effective visualization of subsurface blood vessels to facilitate blood withdrawal in children

Obtaining access to blood vessels can be difficult, especially in children. Visualization of subsurface blood vessels might be a solution. Ultrasound and visible light have been used to this purpose, but have some drawbacks. Near-infrared light might be a better option since subsurface blood vessels can be visualized in high contrast due to less absorption and scattering in tissue as compared to visible light. Our findings with a multispectral imaging system support this theory. A device, the VascuLuminator, was developed, based on transillumination of the puncture site with near-infrared light. The VascuLuminator was designed to meet the requirements of compact and safe use. A phantom study showed that the maximum depth of visibility (5.5mm for a 3.6mm blood vessel) is sufficient to visualize blood vessels in typical locations for peripheral venous and arterial access. A quantitative comparison of the VascuLuminator and to two other vessel imaging devices, using reflection of near-infrared light instead of transillumination, was conducted. The VascuLuminator is able to decrease failure at first attempt in blood withdrawal in pediatric patients from 10/80 (13%) to 1/45 (2%; P=.05).

Efficacy of VeinViewer in pediatric peripheral intravenous access: a randomized controlled trial

Peripheral venous access in infants and children is technically challenging, because their veins are small and located deep in subcutaneous tissue, which makes them difficult to palpate or visualize. The VeinViewer® (Luminetx Corporation, Memphis, TN, USA) is a near-infrared light device that delineates the running course of subcutaneous veins. In this study, we investigated whether the use of the VeinViewer® in infants and children facilitated peripheral venous access, especially in difficult cases. This study was a randomized, controlled trial of a convenience sample of pediatric patients between the ages of 1 month and 16 years who required peripheral venous access in the pediatric ward. Prior to randomization, difficult intravenous access (DIVA) score, a four-variable clinical prediction rule for first-attempt success, was estimated. We compared the first-attempt success rates and procedural times between the VeinViewer® group and a control group. We evaluated 111 patients: 54 in the VeinViewer® group and 57 in the control group. Patient demographics and factors related to the success of vein access were similar for both groups. The overall first-attempt success rate was 69.4%: i.e., 77/111 in the VeinViewer® group and 38/57 in the control group, a difference that was not statistically significant. However, the first-attempt success rate increased from 5/20 in the control group to 14/24 in the VeinViewer® group for difficult veins with a DIVA score greater than 4 (p=0.026). There were no significant differences in procedural time between the two groups.

CONCLUSION

The VeinViewer® facilitated peripheral venous access for pediatric patients with difficult veins, which enhanced first-attempt success rates.

International evidence-based recommendations on ultrasound-guided vascular access

PURPOSE

To provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access.

METHODS

An international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations.

RESULTS

The recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter's tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications.

CONCLUSIONS

These definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.

Ultrasound guidance allows faster peripheral IV cannulation in children under 3 years of age with difficult venous access: a prospective randomized study

OBJECTIVES

Ultrasound-guided peripheral venous access (USG-PIVA) presents many advantages over the reference 'blind' technique in both adults and children in emergency situations.

AIM

To compare USG-PIVA with the blind technique in children <3 years undergoing general anesthesia.

METHODS

After obtaining the approval of the ethics committee and informed consent from the parents, we included all children <3 years scheduled to undergo general anesthesia [surgery, magnetic resonance imaging (MRI)], who presented difficult venous access. The children were randomized into two groups: the US group (USG-PIVA) and the B group (blind). The primary endpoint was time to cannulation (from tourniquet placement to successful IV cannulation), compared between USG-PIVA group and B group by intention-to-treat analysis. Secondary outcomes were success rate at the first puncture, number of punctures, and diameter of the catheters. Cannulations requiring >15 min were considered as failures. In case of failure in group B, USG-PIVA was attempted for a further 15 min.

RESULTS

Twenty children were included in each group. Groups were comparable for sex, age, and BMI. Significant differences were observed in median time to cannulation (63.5 s vs 420.5 s, USG-PIVA vs B respectively, P < 0.001); median number of punctures (1 vs 2.5, USG-PIVA vs B, P = 0.004); and success rate at first cannulation (85% vs 35%, USG-PIVA vs B, P = 0.0012). In contrast, overall success rate did not differ significantly between groups (90% vs 85%, USG-PIVA vs B, P = 0.63).

CONCLUSIONS

Ultrasound-guided peripheral venous access leads to faster peripheral IV access and should therefore be recommended in children presenting with difficult venous access.

Predictive factors for difficult intravenous cannulation in pediatric patients at a tertiary pediatric hospital

BACKGROUND

It is generally believed that certain patient characteristics (e.g., Body Mass Index and age) predict difficulty of intravenous cannulation in children, but there is not much literature evaluating these risk factors. In this study, we investigated predictive factors for success rate at first attempt and time needed for intravenous cannulation.

METHODS/MATERIALS

In a prospective cohort study, we observed characteristics of intravenous cannulations in pediatric patients at the operating room (n = 1083) and the outpatient care unit (n = 178) of a tertiary referral pediatric hospital. Time to successful intravenous cannulation, success at first attempt, and potential predictors for difficult cannulation (age, gender, skin color, BMI or weight-to-age z-score, the child being awake or anesthetized, operator profession and surgical specialty) were recorded. Regression models were constructed to find significant predictors.

RESULTS

Success at first attempt was 73% and 81%, respectively. In the operating room age, operator and surgical specialty were predictive for a successful first attempt and time to successful cannulation. No significant predictive factors were found for the outpatient care unit. BMI or weight-to-age was not related to difficult intravenous cannulation.

CONCLUSIONS

This study shows that in one-fifth to one-third of the patients, intravenous cannulation required more than one attempt. It is difficult to predict with accuracy the difficulty of intravenous cannulation solely with easily obtainable patient characteristics.

Bedside ultrasound in pediatric critical care: a review

OBJECTIVE

Bedside ultrasound, as performed by the intensivist, is gaining in popularity and has become a powerful tool to understand the physiological state of the critically ill patient and to decrease procedural risks. This review assesses clinical applications of bedside ultrasound in the pediatric intensive care unit.

DESIGN

A literature review was conducted to identify English language studies in Pubmed as of June, 2010, using combinations of the following search terms: 'pediatric,' 'ultrasound,' 'critical care,' and 'intensive care.' Examination of reference lists of these studies yielded additional studies. Studies were reviewed by both authors.

SETTING

Intensive care unit, emergency department, or operating rooms, as relevant to application of bedside ultrasound in the pediatric intensive care unit.

PATIENTS/SUBJECTS

Pediatric patients (age 0-18 yrs) with adult patients (>18 yrs) in relevant studies utilizing bedside ultrasound by the treating clinician.

INTERVENTIONS

Bedside ultrasound by treating clinician.

MEASUREMENTS

Variable, per individual studies. MAIN RESULTS/CONCLUSIONS: Bedside ultrasound, as practiced by the pediatric intensivist, has the potential to improve pediatric critical care medicine, but data supporting its use is limited. Further studies are needed to explore applications, with specific emphasis on the training and experience of ultrasound operators. There is a need for a standardized educational curriculum, and questions remain as to the optimal mode of education and quality assurance of ultrasound operators.