Difficult peripheral venous access: Clinical evaluation of a catheter inserted with the Seldinger method under ultrasound guidance

Asynchronous training for ultrasound-guided peripheral IV placement among critical care nurses

OBJECTIVE

Teaching ultrasound (US) guidance for placement of peripheral intravenous (PIV) catheters requires significant time for synchronous didactic and hands-on training. The investigators assessed the feasibility of an asynchronous model for critical care nurses to learn the novel skill of US-guided PIV placement. Secondary outcomes included the percentage of successful attempts and number of sticks per attempt for anatomy versus US-guided approaches.

METHODS

The investigators built a self-contained training cart for learners to practice and record their performance. Training occurred asynchronously. The learners recorded data from PIV attempts. Participants completed pre- and post-training surveys. Data from this prospective observational cohort was analyzed for descriptive and comparative statistics, using Kirkpatrick's Model for evaluation of this educational intervention.

RESULTS

During a 6 month period, 21 nurses completed the asynchronous training, with eight recording their PIV placements. 81.0% of the training occurred outside of a Monday to Friday 9AM-5PM period. There were 64 attempts by anatomy approach and 84 with US-guidance. The anatomic approach was successful in 35.9% of attempts with a mean of 1.5 sticks (SD 1.0, Range 1-5). The US-guided approach had a statistically significant greater rate of success (77.4%; p < 0.001) with a mean of 1.2 sticks (SD 1.2, range 1-2, p < 0.01). Participants reported increased confidence in US-guided PIV placement and enjoyment with this method of learning.

CONCLUSIONS

Asynchronous learning model with cart-based instruction and practice is a feasible means for nurses to learn US-guided PIV placement. Significant outcomes were seen across Kirkpatrick levels I-IV for educational outcome assessment.

Assessing the utility of ultrasound-guided vascular access placement with longer catheters in critically ill pediatric patients

BACKGROUND

Critically ill pediatric patients can have difficulty with establishing and maintaining stable vascular access. A long-dwelling peripheral intravenous catheter placement decreases the need for additional vascular interventions.

AIM

The study sought to compare longevity, catheter-associated complications, and the need for additional vascular interventions when using ultrasound-guided longer peripheral intravenous catheters comparing to a traditional approach using standard-sized peripheral intravenous catheters in pediatric critically ill patients with difficult vascular access.

METHODS

This single-center retrospective cohort study included children 0-18 years of age with difficult vascular access admitted to the pediatric intensive care unit between 01/01/2018-06/01/2021.

RESULTS

One hundred and eighty seven placements were included in the study, with 99 ultrasound-guided long intravenous catheters placed and 88 traditionally placed standard-sized intravenous catheters. In the univariate analysis, patients in the traditional approach were at a higher risk of intravenous failure compared to those in the ultrasound-guided approach (HR = 2.20, 95% CI [1.45-3.34], p = .001), with median intravenous survival times of 108 and 219 h, respectively. Adjusting for age, patients in the traditional approach remained at higher risk of intravenous failure (HR = 1.99, 95% CI: [1.28-3.08], p = .002). Adjusting for hospital length of stay, patients in the ultrasound-guided approach were less likely to have additional peripheral intravenous access placed during hospitalization (OR = 0.39, 95% CI [0.18-0.85] p = .017).

CONCLUSION

In critically ill pediatric patients with difficult vascular access, ultrasound-guided long peripheral intravenous catheters provide an alternative to traditional approach standard-sized intravenous catheters with improved longevity, lower failure rates, and reduced need for additional vascular interventions.

Asia-Pacific guidelines for standardization of appropriate selection, placement, and management of vascular access devices

Vascular access devices (VADs) are common and essential in the healthcare setting. However, several factors influence VAD selection and management. Wide variations in VAD practices and the degree of VAD awareness are noted across Asia-Pacific (APAC) countries. An international panel was convened that applied the ASA 2020 method to develop standard criteria for use of VADs in the APAC region. After a literature search, scenarios related to VAD use, care, and maintenance were developed according to the patient population, indication for insertion, and duration of use. These scenarios were rated on a scale of 1-5 (1 being strongly disagreed and 5 strongly agreed) by 11 expert members. A total of 48 clinical scenarios were developed: 23 in hospitalized patients, 3 in critical patients, 4 in cancer settings, 7 pertinent to VAD placement, and 11 for VAD maintenance. The multidisciplinary panel generated several recommendations for the use, care, and management of VADs across general hospitalized patients with or without difficult venous access, critically ill patients, patients with malignancy, patients with different stages of chronic kidney disease (CKD) with or without dialysis, and in other special populations through evidence-based standards. These recommendations may help in achieving uniformity in practice patterns and improving the quality of VAD care and quality of life of patients in APAC region.

European recommendations on the proper indication and use of peripheral venous access devices (the ERPIUP consensus): A WoCoVA project

Since several innovations have recently changed the criteria of choice and management of peripheral venous access (new devices, new techniques of insertion, new recommendations for maintenance), the WoCoVA Foundation (WoCoVA = World Conference on Vascular Access) has developed an international Consensus with the following objectives: to propose a clear and useful classification of the currently available peripheral venous access devices; to clarify the proper indication of central versus peripheral venous access; discuss the indications of the different peripheral venous access devices (short peripheral cannulas vs long peripheral cannulas vs midline catheters); to define the proper techniques of insertion and maintenance that should be recommended today. To achieve these purposes, WoCoVA have decided to adopt a European point of view, considering some relevant differences of terminology between North America and Europe in this area of venous access and the need for a common basis of understanding among the experts recruited for this project. The ERPIUP Consensus (ERPIUP = European Recommendations for Proper Indication and Use of Peripheral venous access) was designed to offer systematic recommendations for clinical practice, covering every aspect of management of peripheral venous access devices in the adult patient: indication, insertion, maintenance, prevention and treatment of complications, removal. Also, our purpose was to improve the standardization of the terminology, bringing clarity of definition, and classification.

Defining difficult intravenous access (DIVA): A systematic review

BACKGROUND

The term "difficult intravenous access" (DIVA) is commonly used but not clearly defined. Repeated attempts at peripheral intravenous catheter (PIVC) insertion can be a traumatic experience for patients, leading to sub-optimal clinical and economic outcomes. We conducted a systematic literature review (SLR) to collate literature definitions of DIVA, with the aim of arriving at an evidence-driven definition.

METHODS

The SLR was designed to identify clinical, cost, and quality of life publications in patients requiring the insertion of a PIVC in any setting, including studies on US-guidance and/or guidewire, and studies with no specific intervention. The search was restricted to English language studies published between 1st January 2010 and 30th July 2020, and the Ovid platform was used to search several electronic databases, in addition to hand searching of clinical trial registries.

RESULTS

About 121 studies were included in the SLR, of which 64 reported on the objectives relevant to this manuscript. Prevalence estimates varied widely from 6% to 87.7% across 19 publications, reflecting differences in definitions used. Of 43 publications which provided a definition of DIVA, six key themes emerged. Of these, themes 1-3 (failed attempts at PIV access using traditional technique; based on physical examination findings for example no visible or palpable veins; and personal history of DIVA) were covered by all but one publication. Following a failed insertion attempt, the most common number of subsequent attempts was 3, and it was frequently reported that a more experienced clinician would attempt to gain access after multiple failed attempts.

CONCLUSIONS

Considering the themes identified, an evidence-driven definition of DIVA is proposed: "when a clinician has two or more failed attempts at PIV access using traditional techniques, physical examination findings are suggestive of DIVA (e.g. no visible or palpable veins) or the patient has a stated or documented history of DIVA."

Standard Versus Long Peripheral Catheters for Multiday IV Therapy: A Randomized Controlled Trial

OBJECTIVES

In children, intravenous therapy (IVT) is generally administered via peripheral intravenous catheters (PIVCs) (2-6 cm in length). There is evidence that PIVCs are unreliable after 2 days. Long peripheral catheters (LPCs) (6-15 cm in length) could improve the delivery of IVT. The aim of this trial was to determine if LPCs could decrease catheter failure and the number of catheters in children receiving multiday IVT.

METHODS

This was an open-label randomized controlled trial conducted at Monash Children's Hospital in Melbourne, Australia. Participants were from the ages of 1 to 17 years, undergoing surgery and requiring >48 hours of postoperative IVT. Participants were randomly assigned to a 2.5-cm 22G PIVC or an 8-cm 22G LPC.

RESULTS

Seventy-two children were randomly assigned, 36 received PIVCs, and 36 received LPCs. The median duration of IVT was 5.1 days and was similar between groups (P = .9). Catheter failure was higher for PIVCs than LPCs (66.7% vs 19.4%; relative risk [RR]: 3.4; P = .0001 or 187.9 vs 41.0 failures per 1000 catheter-days). Infiltration was the most common reason for PIVC failure (33.3% vs 2.8%; RR: 12.0; P = .001). LPCs exhibited superior life span (4.7 vs 3.5 days [median]; P = .01). Children with LPCs were twice as likely to complete therapy with a single catheter (80.6% vs 38.9%; RR: 2.1; P = .0006).

CONCLUSIONS

LPCs reduce catheter failure and total catheters in children. They should be considered as the first-line device for peripheral access in any child receiving prolonged IVT.

Comparison of 12-cm versus 6-cm long peripheral catheters in patients with difficult intravenous access (DIVA)

BACKGROUND

Long peripheral catheter is 6-15 cm long vascular device. The aim of the study was to compare the frequency of complications of two types of long peripheral catheters with different length inserted in DIVA patients.

METHODS

Under ultrasound navigation 2.7F 6.4 cm or 4Fr 12 cm long peripheral catheter was inserted. Complications of both long peripheral catheters were prospectively observed and their relationship to the patient's age, gender, selected vein, number of punctures and Barthel score system was evaluated.

RESULTS

Ninety-three 12 cm and fifty-five 6.4 cm long peripheral catheters were inserted. Median of dwelling time was 8 days for 6.4 cm and 9 days for 12 cm long peripheral catheter. There were 17 (26%) complications in 6.4 cm (38/1000 catheter days) and 15 (16%) in 12 cm catheter (17/1000 catheter days), p = 0.04. The complications of both peripheral catheters were not associated with the age of patients, gender, number of punctures and selected vein for insertion. Unlike 12 cm catheter, the complications of 6.4 cm long peripheral catheter were significantly associated with the result of Barthel scoring system (p = 0.003).

CONCLUSION

The frequency of complications was more common with 6,4 cm than with 12 cm catheter.

Long peripheral catheters for intravenous access in adults and children: A systematic review of the literature

BACKGROUND

Long peripheral catheters are peripheral intravenous catheters of 6-15 cm in length. They are commonly inserted into the forearm, antecubital fossa or upper arm using a direct Seldinger technique. They have proven to be valuable for peripheral intravenous catheters, particularly in patients with difficult intravenous access.

METHODS

We conducted a systematic review of studies reporting the use of long peripheral catheters. The following keywords were used: 'long', 'Seldinger', 'guidewire', 'peripheral', 'venous', 'intravenous', 'IV', 'vascular', 'cannula' and 'catheter'.

RESULTS

Three hundred forty-one publications were identified; 16 were included in the systematic review. There were 11 adult studies and 5 paediatric studies documenting 1288 long peripheral catheters in 1271 patients. Majority of studies (12/16) were conducted in acute care settings, (emergency department, n = 6; intensive care unit, n = 3; high dependency unit, n = 1; surgical unit, n = 2). The most frequently studied long peripheral catheter was 8 cm in length and 20 G in size. Nine studies recruited patients with difficult intravenous access; 11 studies used ultrasound guidance. Insertion success rate and mean procedural time ranged between 86% and 100% and 8 and 16.8 minutes, respectively. Average catheter duration ranged between 4 and 14.7 days (mean) and 1.1 and 9 days (median). Catheter failure occurred in 4.3-52.5% of long peripheral catheters, with leakage, infiltration and dislodgement being the most frequent causes of failure. In 3 randomised controlled trials, long peripheral catheters outperformed peripheral intravenous catheters in terms of duration and failure rate.

CONCLUSION

Long peripheral catheters are safe and reliable in both adults and children. In addition, long peripheral catheters may provide improved quality of care over peripheral intravenous catheters for multi-day intravenous therapy.

Nurse-Performed Ultrasound-Guided Technique for Difficult Peripheral Intravenous Access in Critically Ill Patients: A Randomized Controlled Trial

Highlights

Abstract

Purpose: The aim of this study was to compare nurse-performed ultrasound (US)-guided technique with standard of care (SOC) technique for difficult peripheral intravenous (PIV) access among patients admitted to the intensive care unit (ICU).

Materials and Methods: This was a randomized, prospective, open-label single-site study. ICU nurses completed a standardized training program for US-guided PIV access placement before patient enrollment. ICU patients with difficult PIV access were randomized to either nurse-performed US-guided technique or SOC technique. Primary outcome was success rate on the first attempt. Secondary outcomes were success rate after 2 attempts and frequency of complications after successful placement.

Results: A total of 60 patients were enrolled; 30 were randomized to receive US-guided technique, and 30 to SOC technique. Success rate on the first attempt was significantly higher with US-guided technique compared with SOC technique (70% vs 40%; P &lt; 0.05). Success rates after 2 attempts were 73.3% for US-guided technique and 46.6% for SOC technique (P = 0.065). Extravasation after successful placement occurred in 13.6% of patients with US-guided technique, and 28.6% of patients with SOC technique (P = 0.394).

Conclusions: Among ICU patients with difficult PIV access, US-guided PIV access placement by nurses who underwent standardized training was more successful than placement with SOC technique.

The clinical performance of midline catheters-An observational study

BACKGROUND

The use of peripheral venous catheters (PVCs) is hampered by short dwell time, and central venous catheters (CVCs) are often preferred for medium- to long-time intravenous treatment. Ultrasound techniques allow for easy catheter insertion into the major veins of the upper arm. A new generation of midline catheters, PowerGlide Pro, utilises a one-hand Seldinger technique and can be inserted by one single operator without assistance. This study aimed to evaluate the clinical performance of the PowerGlide Pro midline catheter.

METHODS

Consecutively inserted midline catheters were followed in a prospective, observational quality control study. Endpoints were dwell time, the incidence of premature catheter removal, causes of catheter removal and the dwell time and incidence rates of predefined subgroups representing potential effect modifiers.

RESULTS

Hundred midline catheters, of which 98 were accessible to follow-up, were inserted in 70 patients. Median dwell time was 8 days and 60 catheters were removed before the indication for intravenous therapy had ceased. The overall incidence for premature catheter removal was 71.8/1000 days and no significant effects of subgroups (sex, body mass index, catheter reinsertions, significant comorbidity, anticoagulant therapy, irritant infusions) were identified for either dwell time or the incidence rate for premature midline catheter removal. The most frequent reasons for premature catheter removal were pain during infusion, clotted catheter or signs of infection.

CONCLUSION

The median dwell time of the midline catheters was 8 days with substantial variation, whereas the incidence for premature catheter removal was 71.8/1000 catheter days. The majority of midline catheters were removed prematurely.

The Utility of Midline Intravenous Catheters in Critically Ill Emergency Department Patients

STUDY OBJECTIVE

Midline catheters are an alternative to more invasive types of vascular access in patients in whom obtaining peripheral access has proven difficult. Little is known of the safety and utility of midline catheters when used more broadly in critically ill patients in the emergency department (ED). These are long peripheral catheter, ranging from 10 to 25 cm in length, typically placed with assistance of ultrasound and the Seldinger's technique. We describe our experience with the use of midline catheters in the ED.

METHODS

We conducted a prospective observational case series of all patients who had a midline catheter insertion attempted in the ED. We prospectively captured data on indication, technique, location, catheter type, number of attempts, overall success or failure, vasoactive use, and complications (daily catheter patency, flow, site appearance, and dwell-time complications).

RESULTS

From January 28, 2016, to December 30, 2017, practitioners placed 403 midline catheters. Catheter insertion success was 99%, and the median number of attempts was 1 (interquartile range 1 to 1; minimum 1; maximum 3). The median number of days the catheter remained in place was 5 (interquartile range 2 to 8). Failure to aspirate occurred in 57 patients (14%; 95% confidence interval 11% to 18%). Overall, 10 patients (2.5%; 95% confidence interval 1.2% to 4.5%) experienced 10 insertion-related complications. During the study period, 49 patients (12%; 95% confidence interval 9% to 16%) experienced 60 dwell-time-related complications. Severe complications occurred in 3 patients (0.7%).

CONCLUSION

Midline catheters may present a feasible alternative to central venous access in certain critically ill ED patients.

[Emerging challenges linked to vascular access, the strategy to adopt faced with the changing profile of hospitalised patients]

Peripheral venous catheters are the most commonly used vascular devices in hospitals. The ageing population and the increase in comorbidities makes their insertion more complex. A survey carried out in surgical units describes the factors contributing to failures. It is important to improve the identification of patients with difficult venous access, to offer access to various techniques and devices, as well as to the expertise of a specialised team.

Right Heart Catheterization-Background, Physiological Basics, and Clinical Implications

The idea of right heart catheterization (RHC) grew in the milieu of modern thinking about the cardiovascular system, influenced by the experiments of William Harvey, which were inspired by the treatises of Greek philosophers like Aristotle and Gallen, who made significant contributions to the subject. RHC was first discovered in the eighteenth century by William Hale and was subsequently systematically improved by outstanding experiments in the field of physiology, led by Cournand and Dickinson Richards, which finally resulted in the implementation of pulmonary artery catheters (PAC) into clinical practice by Jeremy Swan and William Ganz in the early 1970s. Despite its premature euphoric reception, some further analysis seemed not to share the early enthusiasm as far as the safety and effectiveness issues were concerned. Nonetheless, RHC kept its significant role in the diagnosis, prognostic evaluation, and decision-making of pulmonary hypertension and heart failure patients. Its role in the treatment of end-stage heart failure seems not to be fully understood, although it is promising. PAC-guided optimization of the treatment of patients with ventricular assist devices and its beneficial introduction into clinical practice remains a challenge for the near future.

A randomized trial of ultrasound-guided peripheral IV catheter placement in difficult access patients using a guidewire approach

OBJECTIVE

The purpose of this pilot study was to investigate whether use of a guidewire improves successful placement of ultrasound-guided peripheral IVs (PIV) in difficult intravenous access patients in the emergency department (ED).

METHODS

This was an unblinded, prospective, randomized trial performed by emergency medicine (EM) clinicians at a single academic ED. Eligible participants were randomized to ultrasound-guided PIV placement with or without the use of a guidewire. PIV access was obtained using the Accucath™ 20 gauge × 5.7 cm catheters by way of deployment or non-deployment of the guidewire. Primary outcome measure was first-pass success rate and secondary outcomes included number of attempts, complication rates, and clinician reported ease of insertion.

RESULTS

Seventy patients were enrolled and 69 were included in the final analysis. Thirty-four participants were randomized to use of guidewire and 35 to no guidewire. First-pass success rates were similar with and without guidewire use, 47.1% vs. 45.7%, (p = 0.9). There were no differences found in median number of attempts between the two techniques, 2 (IQR 1-2) vs 2 (IQR 1-2), (p = 0.60). The complication rates were similar, 15% vs. 29% (p = 0.25). Clinicians reported no difference in ease of insertion between methods on a 5-point Likert Scale, mean 2.6 vs 2.7 (p = 0.76).

DISCUSSION

In this pilot study comparing ultrasound-guided PIV placement in ED patients using an integrated guidewire versus no guidewire, there was no significant difference in first-pass success, number of attempts, or complication rates. This study provides preliminary data for further investigations.

Long peripheral catheters for deep arm vein venous access: A systematic review of complications

PURPOSE

Long peripheral catheters (LPCs) offer a quick, simple and cost-effective alternative for venous access in intensive care patients with difficult venous access, but the decision to use them must be balanced against an assessment of harm. The aim of this systematic review was to synthesise reports of complications associated with LPCs.

METHODS

The electronic databases MEDLINE, EMBASE and CINAHL were searched systematically for randomised controlled trials, cohort studies and case control studies published in the period 1966 to 24th July 2018 reporting LPC associated occlusion, catheter related blood stream infections, phlebitis and infiltration. Study quality was assessed using the Methodological Index for Non-Randomised Studies. The studies were described and participant characteristics; type of catheter; setting; average dwell time; and rates of occlusion, catheter related blood stream infection, phlebitis and infiltration were extracted as summary measures.

RESULTS

Five cohort studies and one randomised controlled study, comprising a total of 350 participants, fulfilled the inclusion criteria. Dwell time ranged from 1 to 15days and the reported complication rate was 3-14%. The most common complication was catheter occlusion (4%), followed by phlebitis (1%), infiltration (0.9%), and catheter related blood stream infection (0.3%). Significant heterogeneity, particularly in identification and reporting of complications, means results should be interpreted with caution.

CONCLUSION

There is a lack of intervention specific and adequately powered randomised controlled trials investigating LPCs in an intensive care setting. Until the results of such studies are available, LPCs should be used as an alternative to ultrasound-guided PVCs in well monitored acute care environments.

Long peripheral catheters: Is it time to address the confusion?

Long peripheral catheters are 6–15 cm peripheral dwelling catheters that are inserted via a catheter-over-needle or direct Seldinger (catheter-over-guidewire) technique. When inserted in the upper extremity, the distal tip terminates before reaching the axilla, typically no further than the mid-upper arm. This is distinct from a midline catheter, which is inserted via a modified Seldinger technique and terminates at the axilla. The nomenclature of this catheter is confusing and inconsistent. We have identified over a dozen labels in the literature, all describing the same device. These include ‘15 cm catheter’, ‘catheter inserted with a Seldinger method’, ‘extended dwell/midline peripheral catheter’, ‘Leaderflex line’, ‘long catheter’, ‘long IV catheter’, ‘long peripheral cannula’, ‘long peripheral catheter’, ‘long peripheral venous catheter’, ‘long polyurethane catheter’, ‘midline cannula’, ‘mini-midline’, ‘peripheral intravenous catheter’, ‘Seldinger catheter’, ‘short midline catheter’, ‘short long line’ and ‘ultrasound-guided peripheral intravenous catheter’. The purpose of this editorial is to achieve some level of standardisation in the nomenclature of this device. Is it time to address the confusion? We suggest adopting ‘long peripheral catheter’. However, we encourage discussion and debate in reaching a consensus.

Ultrasound-guided intravenous access in adults using SonoStik®, a novel encapsulated sterile guidewire: A prospective cohort trial

Purpose:

We evaluated the performance of an encapsulated guidewire designed for single-handed use with ultrasound-guided vascular access (SonoStik) with Seldinger technique, as compared with conventional intravenous catheters placed under ultrasound guidance in healthy subjects.

Methods:

This is a prospective cohort trial in healthy subjects in which each subject served as his/her own control by having a SonoStik ultrasound intravenous cannulation placed in one arm and a conventionally placed, standard ultrasound intravenous cannulation placed in the other arm. The basilic vein was used because it is a non-visible and non-palpable vein. Emergency department technicians with extensive experience in ultrasound-guided intravenous access performed the procedures. The first-attempt success rate of intravenous-guided intravenous by using the SonoStik was compared to the standard ultrasound intravenous cannulation in adult healthy subjects. The secondary outcomes including time of procedure, technicians’ and subjects’ satisfaction, and complications were compared in both arms of the study.

Results:

A total of 24 volunteers with a mean age of 22.7 years were enrolled. Four emergency department technicians with extensive prior experience with ultrasound-guided intravenous access but with no prior experience using the SonoStik device performed the procedures. The first-attempt success was 83.3% with the use of SonoStik ultrasound intravenous cannulation compared to 95.8% with the standard ultrasound intravenous cannulation. There was a mean of 1.14 insertions per each successful placement in the SonoStik group compared to 1.04 insertions by using the standard catheters (mean differences = –0.1; 95% confidence interval = –0.6 to 0.4). There were no complications in either SonoStik or the standard ultrasound intravenous cannulation group. The mean time of insertion using SonoStik was slightly longer compared to standard ultrasound intravenous cannulation (143.3 vs 109.7 s).

Conclusion:

This study demonstrated that emergency department technicians skilled in ultrasound-guided intravenous access could successfully place SonoStik 83.3% of the time in vessels that were unable to be palpated or visualized. Compared to standard ultrasound intravenous cannulation, the odds ratio of successful cannulation with SonoStik was 0.91 (95% confidence interval = 0.04–17.5). In all cases, the time required to successfully insert SonoStik was less than 4 min from tourniquet application to catheter advancement to hub, with a mean time of less than 2.5 min.

A Nurse-Led Ultrasound-Enhanced Vascular Access Preservation Program

: Insertion of peripheral iv catheters is a common practice in medical-surgical care settings. The frequency with which attempts are made to insert catheters causes rapid peripheral vessel depletion (a reduction in the number of usable veins), leading to the overuse of unnecessary central line catheters. Reducing central line-associated bloodstream infections is a national health care priority. In this quality improvement report, the authors describe the implementation of a nurse-led vascular access preservation program using ultrasound technology as a method to reduce the use of nonessential peripherally inserted central catheters.

Improving PICC use and outcomes in hospitalised patients: an interrupted time series study using MAGIC criteria

Background

Although important in clinical care, reports of inappropriate peripherally inserted central catheter (PICC) use are growing.

Objective

To test whether implementation of the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) can improve PICC use and patient outcomes.

Design

Quasi-experimental, interrupted time series design at one study site with nine contemporaneous external controls.

Setting

Ten hospitals participating in a state-wide quality collaborative from 1 August 2014 to 31 July 2016.

Patients

963 hospitalised patients who received a PICC at the study site vs 6613 patients at nine control sites.

Intervention

A multimodal intervention (tool, training, electronic changes, education) derived from MAGIC.

Measurements

Appropriateness of PICC use and rates of PICC-associated complications. Segmented Poisson regression was used for analyses.

Results

Absolute rates of inappropriate PICC use decreased substantially at the study site versus controls (91.3% to 65.3% (−26.0%) vs 72.2% to 69.6% (−2.6%); P<0.001). After adjusting for underlying trends and patient characteristics, however, a marginally significant 13.8% decrease in inappropriate PICC use occurred at the study site (incidence rate ratio 0.86 (95% CI 0.74 to 0.99; P=0.048)); no change was observed at control sites. While the incidence of all PICC complications decreased to a greater extent at the study site, the absolute difference between controls and intervention was small (33.9% to 26.7% (−7.2%) vs 22.4% to 20.8% (−1.6%); P=0.036).

Limitations

Non-randomised design limits inference; the most effective component of the multimodal intervention is unknown; effects following implementation were modest.

Conclusions

In a multihospital quality improvement project, implementation of MAGIC improved PICC appropriateness and reduced complications to a modest extent. Given the size and resources required for this study, future work should consider cost-to-benefit ratio of similar approaches.

Ultrasound-Guided Peripheral Intravenous Line Placement: A Narrative Review of Evidence-based Best Practices

Peripheral intravenous line placement is a common procedure in emergency medicine. Ultrasound guidance has been demonstrated to improve success rates, as well as decrease complications and pain. This paper provides a narrative review of the literature focusing on best practices and techniques to improve performance with this procedure. We provide an evidence-based discussion of preparation for the procedure, vein and catheter selection, multiple techniques for placement, and line confirmation.

The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method

Use of peripherally inserted central catheters (PICCs) has grown substantially in recent years. Increasing use has led to the realization that PICCs are associated with important complications, including thrombosis and infection. Moreover, some PICCs may not be placed for clinically valid reasons. Defining appropriate indications for insertion, maintenance, and care of PICCs is thus important for patient safety. An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use of PICCs. After systematic reviews of the literature, scenarios related to PICC use, care, and maintenance were developed according to patient population (for example, general hospitalized, critically ill, cancer, kidney disease), indication for insertion (infusion of peripherally compatible infusates vs. vesicants), and duration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days). Within each scenario, appropriateness of PICC use was compared with that of other venous access devices. After review of 665 scenarios, 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days. Midline catheters and ultrasonography-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days. In critically ill patients, nontunneled central venous catheters were preferred over PICCs when 14 or fewer days of use were likely. In patients with cancer, PICCs were rated as appropriate for irritant or vesicant infusion, regardless of duration. The panel of experts used a validated method to develop appropriate indications for PICC use across patient populations. These criteria can be used to improve care, inform quality improvement efforts, and advance the safety of medical patients.

Navigating venous access: a guide for hospitalists

Venous access is the foundation for safe and effective hospital-based care. Inpatient providers must have a deep knowledge of the different types of venous access devices (VADs), their relative indications, contraindications, and appropriateness. However, such knowledge is difficult to come by and usually only gleaned through years of clinical experience. To bridge this gap, we provide an in-depth summary of the relevant anatomical considerations, physical characteristics, advantages, and disadvantages of VADs commonly used in the hospital setting. In doing so, we seek to improve the safety and share the science of vascular access with frontline clinicians. To aid decision-making, we conclude by operationalizing the available data through algorithms that outline appropriate vascular access for the hospitalized patient.