Dynamic ultrasound-guided short-axis needle tip navigation technique vs. landmark technique for difficult saphenous vein access in children: a randomised study

The infrared-assisted peripheral intravenous catheterization in pediatric patients: A systematic review and meta-analysis

BACKGROUND

The peripheral intravenous catheter (PIVC) is an important strategy for the treating the illness of pediatric patients. However, the success rate of traditional PIVC method, such as the landmark technique, might be significantly variable and unstable. The near infrared-assisted PIVC might be another option and the results can be revealed by a systemic review and meta-analysis of randomized clinical trials (RCT).

METHODS

A systematic search and a meta-analysis for the RCT of near infrared-assisted PIVC on pediatric patients. The near infrared-assisted and traditional PIVC was compared to evaluate the first time success rate, number of attempts, and attempt duration. Seven RCT studies and total 1068 pediatric patients were enrolled in this meta-analysis. The subgroup analysis of vessel grade difficulty was also performed.

RESULTS

The near infrared-assisted PIVC showed a significantly higher odds ratio of first time success rate when compared to traditional PIVC. In addition, the number of attempts and attempt duration were significantly reduced in the group of near infrared-assisted PIVC. At last, the subgroup analysis of vessel grade difficultly showed that the first time success rate was borderline significantly increased in the subgroup of difficult vessel grade. In addition, the number of attempts was significantly reduced in the subgroup of difficult vessel grade.

CONCLUSIONS

The near infrared-assisted PIVC might be an option for the PIVC on pediatric patients. The advantages of increased first time success rate and decreased number of attempts and attempt duration should be considered by the clinicians and nurses.

Effectiveness and Safety of Measures to Prevent Infections and Other Complications Associated With Peripheral Intravenous Catheters: A Systematic Review and Meta-analysis

BACKGROUND

Peripheral intravenous catheters (PIVCs) contribute substantially to the global burden of infections. This systematic review assessed 24 infection prevention and control (IPC) interventions to prevent PIVC-associated infections and other complications.

METHODS

We searched Ovid MEDLINE, Embase, Cochrane Library, WHO Global Index Medicus, CINAHL, and reference lists for controlled studies from 1 January 1980-16 March 2023. We dually selected studies, assessed risk of bias, extracted data, and rated the certainty of evidence (COE). For outcomes with 3 or more trials, we conducted Bayesian random-effects meta-analyses.

RESULTS

105 studies met our prespecified eligibility criteria, addressing 16 of the 24 research questions; no studies were identified for 8 research questions. Based on findings of low to high COE, wearing gloves reduced the risk of overall adverse events related to insertion compared with no gloves (1 non-randomized controlled trial [non-RCT]; adjusted risk ratio [RR], .52; 95% CI, .33-.85), and catheter removal based on defined schedules potentially resulted in a lower phlebitis/thrombophlebitis incidence (10 RCTs; RR, 0.74, 95% credible interval, .49-1.01) compared with clinically indicated removal in adults. In neonates, chlorhexidine reduced the phlebitis score compared with non-chlorhexidine-containing disinfection (1 RCT; 0.14 vs 0.68; P = .003). No statistically significant differences were found for other measures.

CONCLUSIONS

Despite their frequent use and concern about PIVC-associated complications, this review underscores the urgent need for more high-quality studies on effective IPC methods regarding safe PIVC management. In the absence of valid evidence, adherence to standard precaution measures and documentation remain the most important principles to curb PIVC complications.

CLINICAL TRIALS REGISTRATION

The protocol was registered in the Open Science Framework (https://osf.io/exdb4).

The ultrasound-guided versus standard technique for peripheral intravenous catheter placement by nurses: A systematic review and meta-analysis

Aim

To comprehensively evaluate the efficacy of Ultrasound-guided technique for peripheral intravenous catheter placement by nurses in their daily practice.

Background

Peripheral intravenous catheter insertion is a common clinical procedure in healthcare settings. Ultrasound-guided peripheral intravenous placement has emerged in recent decades and was recognized as particularly useful in some specific patient groups.

Methods

Studies that had compared the ultrasound-guided and traditional approaches were eligible for inclusion and further analysis. The primary outcome was the success rate on the first intravenous insertion attempt. The secondary outcomes included the time needed for successful insertion, and the average number of attempts to establish the IV access. We systematically assess all studies using Cochrane Collaboration's Risk of Bias tool and the Newcastle-Ottawa Scale. We calculated the odds ratio and standardized mean difference with 95 % confidence intervals for the outcomes. Data were analyzed and visualized on Review Manager 5.3.4 and Stata 16.0.

Results

23 studies were included (17 randomized controlled trials and six cohort studies) with a population of 2051 patients offered ultrasound-assisted technique and 2479 treated with the conventional approach for comparison. The former approach was associated with a higher success rate on the first attempt in comparison (OR = 2.95, 95 % CI: 1.86, 4.69). This technique also took less time and less acupuncture to patients' skin (SMD = -0.62, 95 % CI: 1.01, -0.23; SMD = -0.55, 95 % CI: 0.92, -0.18). In the sub-group analyses, children were more likely to benefit from ultrasound guided technique. Ultrasound guided technique demonstrated consistent and significant benefits in emergency clinical settings. Hospitals from different geographical locations exhibited similar trends in the three outcomes. Year of publication and study design revealed inconsistent and insignificant outcomes.

Conclusions

Ultrasound-guided technique can be a safer, faster, and more effective alternative to the traditional approach for nurses to establish intravenous access across different clinical settings and age groups.

Effect of a thin-tipped short bevel needle for peripheral intravenous access on the compressive deformation and displacement of the vein: A preclinical study

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.

Ultrasound-Guided Short-Axis Out-of-Plane Approach With or Without Dynamic Needle-Tip Positioning for Peripheral Venous Catheterization in Pediatric Patients: A Systematic Review With Network Meta-Analysis

OBJECTIVES

To compare the efficacy of the ultrasound-guided approach with and without dynamic needle-tip positioning and the palpation technique regarding success for peripheral venous catheterization in children.

DESIGN

A systematic review with network meta-analysis.

SETTING

Databases of MEDLINE (via PubMed) and Cochrane Central Register of Controlled Trials.

PARTICIPANTS

Patients (<18 years) undergoing peripheral venous catheter insertion.

INTERVENTIONS

Randomized clinical trials were included to compare the following techniques: the ultrasound-guided short-axis out-of-plane approach with dynamic needle-tip positioning, the approach without dynamic needle-tip positioning, and the palpation technique.

MEASUREMENTS AND MAIN RESULTS

The outcomes were first-attempt and overall success rates. Eight studies were included in the qualitative analyses. According to the estimate of network comparison, dynamic needle-tip positioning was associated with higher first-attempt (risk ratio [RR] 1.67; 95% CI 1.33-2.09) and overall success rates (RR 1.25; 95% CI 1.08-1.44) than palpation. The approach without dynamic needle-tip positioning was not associated with higher first-attempt (RR 1.17; 95% CI 0.91-1.49) and overall success rates (RR 1.10; 95% CI 0.90-1.33) than palpation. Compared to the approach without dynamic needle-tip positioning, dynamic needle-tip positioning was associated with a higher first-attempt success rate (RR 1.43; 95% CI 1.07-1.92), but not a higher overall success rate (RR 1.14; 95% CI 0.92-1.41).

CONCLUSIONS

Dynamic needle-tip positioning is efficacious for peripheral venous catheterization in children. It would be better to include dynamic needle-tip positioning for the ultrasound-guided short-axis out-of-plane approach.

Ultrasound-Guided Cannulation of the Great Saphenous Vein in Neonates: A Randomized Study

OBJECTIVE

This prospective randomized controlled study aimed to compare the ultrasound-guided (USG) technique with the standard single-wall puncture technique for epicutaneo-caval catheter (ECC) placement in neonates.

STUDY DESIGN

A total of 100 neonates were included in this study. All enrolled neonates were randomly divided into two groups (n = 50): the USG group and the control group. The control group underwent standard single-wall puncture for ECC placement procedures, and the USG group underwent USG ECC placement procedures.

RESULTS

The first attempt success rates (62 vs. 38%; p = 0.016) and the total success rates (92 vs. 74%; p = 0.017) were higher in the USG group than in the control group. The procedure time was shorter in the USG group than in the control group: 351.43 (112.95) versus 739.78 seconds (369.13), p < 0.001. The incidence of adverse events was not significantly different between the two groups.

CONCLUSION

Compared with the standard single-wall puncture method, USG cannulation is superior for neonatal ECC placement, with a higher success rate, and decreases the total procedural time.

KEY POINTS

· Establishing ECCs in neonates is challenging and lead to multiple attempts and adverse events.. · Information on the efficiency of USG dynamic needle tip positioning for ECCs in neonates is lacking.. · Compared with the standard puncture method, USG cannulation is superior for neonatal ECC placement..

Ultrasound-guided PIVC insertion: a randomised controlled trial protocol

Ultrasound-guided insertion of peripheral intravenous catheters (PIVCs) is an alternative to traditional anatomical landmark-based insertion. However, data on its performance in paediatric patients of varying levels of difficult intravenous access are limited. The researchers hypothesise that ultrasound-guided PIVC insertion will increase first-attempt success compared with landmark technique. This randomised, parallel-group, single-centre, superiority trial commenced recruiting in July 2021, including hospitalised children (aged 0 (>37 weeks gestation) to 18 years) requiring a PIVC. It will recruit 180 children, stratified by degree of perceived difficulty, and centrally randomised into two groups (ratio 1:1). The primary outcome is first-attempt PIVC insertion success. Secondary outcomes include total number of PIVC insertion attempts, PIVC insertion failure, post-insertion complications, dwell time, patient/parent satisfaction, and healthcare costs. The current study will inform the superiority of ultrasound-guided PIVC insertion in comparison with landmark technique. Adoption by healthcare facilities might improve patient outcomes and decrease healthcare costs.

The Adult Difficult Intravenous Access (DIVA) Cognitive Aid: An Evidence-Based Cognitive Aid Prototype for Difficult Peripheral Venous Access

Difficult intravenous access (DIVA) is common, with imperfect solutions. Cognitive aids are widespread in anaesthesia; however, a standard DIVA cognitive aid is lacking. This article describes a cognitive aid for DIVA. It has been developed using evidence-based techniques for DIVA. The effects of heuristics, biases, and automatic thinking on procedural decision-making are briefly discussed. While often useful, shortcut decision-making can impair the performance of apparently simple tasks. Cognitive aids may lead to better outcomes by providing choice architecture. This resource is intended as a cognitive aid prototype for difficult peripheral venous access, incorporating both modern behavioural psychology principles and evidence-based medicine. It may be used as both an educational tool, or as a cognitive aid to assist in situations where DIVA is encountered or expected. The adult DIVA cognitive aid is intended for use in both elective and emergency scenarios by practitioners adequately trained in ultrasound-guided or ultrasound-assisted vascular access and Seldinger-based techniques. Clinical implementation and audit of the adult DIVA cognitive aid, or similar locally developed cognitive aids based on this prototype are recommended.

The effects of ultrasound guidance on first-attempt success for difficult peripheral intravenous catheterization: a systematic review and meta-analysis

Identifying patients at risk of difficult intravenous access (DIVA) and increasing the success rates of peripheral intravenous catheterization (PIVC), preferably on the first catheterization attempt, is of clinical importance. The aim of this study was to compare the use of dynamic ultrasound guidance for PIVC with the traditional technique of visualization and palpation in patients with predicted DIVA. A systematic review and meta-analysis comparing ultrasound-guided PIVC with the traditional technique was performed. Data were systematically collected through MEDLINE and EMBASE databases from inception to March 2021. Eligibility criteria included randomized controlled trials performed on patients meeting criteria for difficult catheterization comprising either (a) no palpable or visible veins, (b) previous history of difficult venous catheterization, (c) patient age less than 4 years, (d) suspicion of difficult catheterization by operator, or (e) two or more unsuccessful attempts using the traditional technique before enrollment were included. For all outcomes, a random-effects meta-analysis using the DerSimonian and Laird method was performed. The primary outcome was the first-attempt success rate, and the secondary outcomes were the overall success rate and the number of attempts for successful intravenous catheterization. Bias was assessed using the Revised Cochrane Risk of Bias tool. Seven studies with a total of 994 patients were included. Patients comprised both children and adults and settings included operating rooms, emergency departments, and intensive care units. Ultrasound guidance was associated with a higher first-attempt success rate (OR, 3.07; 95% CI, 1.66-5.65; P < 0.001). For the secondary outcomes, ultrasound guidance was associated with a higher overall success rate (OR, 3.02; 95% CI, 1.04-8.79; P = 0.04); however, this finding did not meet statistical significance in a sensitivity analysis (OR, 2.90; 95% CI, 0.71-11.93; P = 0.14). Ultrasound was not associated with a significantly different number of attempts compared with the traditional technique (difference in means, 0.14; 95% CI, -0.32 to 0.05; P = 0.15). The use of ultrasound guidance resulted in a three-fold increase in odds for the first-attempt success rate in patients with predicted DIVA compared with the traditional technique of PIVC.

Ultrasound-guided short-axis out-of-plane approach with or without dynamic needle tip positioning for arterial line insertion in children: A systematic review with network meta-analysis

The efficacy of the short-axis out-of-plane (SA-OOP) approach with and without dynamic needle tip positioning (DNTP) remains unclear. This systematic review with network meta-analysis aimed to compare the success rate of arterial line insertion in children using the SA-OOP approach with and without DNTP and the palpation technique. We searched MEDLINE (via PubMed) and the Cochrane Central Register of Controlled Trials. We included randomized controlled trials that compared two of the following techniques for arterial line insertion in children: (1) the ultrasound-guided SA-OOP approach with DNTP; (2) the ultrasound-guided SA-OOP approach without DNTP; and (3) the palpation technique. A network meta-analysis was performed. The outcomes were first-attempt and overall success rates. Eight studies were finally included in this network meta-analysis. The ultrasound-guided SA-OOP approach with DNTP was associated with increased first-attempt (relative risk RR = 3.45 [95% confidence interval (CI) 2.51-4.74]) and overall success rates (RR = 1.81 [1.41-2.32]) when compared with palpation. The same approach performed without DNTP was also associated with increased first-attempt (RR = 1.96 [1.59-2.42]) and overall success rates (RR = 1.25 [1.05-1.49]) when compared with palpation. The ultrasound-guided SA-OOP approach with DNTP was associated with increased first-attempt (RR = 1.76 [1.26-2.44]) and overall success rates (RR = 1.45 [1.10-1.91]) when compared with the same approach performed without DNTP. DNTP should be performed during the ultrasound-guided SA-OOP approach for arterial line insertion in children, as this can help increase first attempt and overall success rates.

Comparison of ultrasound-guided peripheral intravenous catheter insertion with landmark technique in paediatric patients: A systematic review and meta-analysis

BACKGROUND

Paediatric peripheral intravenous catheter (PIVC) insertion using traditional landmark insertion technique can be difficult.

AIM

To systematically review the evidence comparing landmark to ultrasound guidance for PIVC insertion in general paediatric patients.

STUDY DESIGN

Cochrane methodology to systematically search for randomised controlled trials comparing landmark to ultrasound-guided PIVC insertion.

DATA SOURCES

Cochrane Central Register of Controlled Trials, US National Library of Medicine, Cumulative Index to Nursing and Allied Health, Embase.

DATA EXTRACTION

English-language, paediatric trials published after 2000, reporting first-attempt insertion success, overall PIVC insertion success, and/or time to insert were included. Central venous, non-venous and trials including only difficult intravenous access were excluded. Data were independently extracted and critiqued for quality using GRADE by three authors, and analysed using random effects, with results expressed as risk ratios (RR), mean differences (MD) and 95% confidence intervals (CI). Registration (CRD42020175314).

RESULTS

Of 70 titles identified, 5 studies (995 patients; 949 PIVCs) were included. There was no evidence of an effect of ultrasound guidance, compared to landmark, for first-attempt insertion success (RR 1.27; 95% CI 0.90-1.78; I2  = 88%; moderate quality evidence), overall insertion success (RR 1.14; 95% CI 0.90-1.44; I2  = 82%; low quality evidence), or time to insertion (mean difference -3.03 min; 95% CI -12.73 to 6.67; I2  = 92%; low quality evidence).

LIMITATIONS

Small sample sizes, inconsistent outcomes and definitions in primary studies precluded definitive conclusions.

CONCLUSIONS

Large clinical trials are needed to explore the effectiveness of ultrasound guidance for PIVC insertion in paediatrics. Specifically, children with difficult intravenous access might benefit most from this technology.

Ultrasound for Pediatric Peripheral Intravenous Catheter Insertion: A Systematic Review

BACKGROUND AND OBJECTIVES

Establishing peripheral intravenous catheter (PIVC) access in infants and children is a common procedure but can be technically difficult. The primary objective was to determine the effect ultrasound had on first attempt PIVC insertion success rates in the pediatric population. Secondary objectives included overall success rates and subgroups analyses.

METHODS

A systematic review of articles using Medline, Embase, CENTRAL, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. Randomized trials evaluating ultrasound-guided PIVC insertion against the landmark approach in pediatric patients who reported at least 1 outcome of success rate (first attempt or overall) were included. Methodological quality of the literature was assessed using the Revised Cochrane risk-of-bias tool for randomized trials. A meta-analysis using a random-effects model was performed.

RESULTS

Nine studies with 1350 patients, from a total of 1033 studies, were included for analysis. Ultrasound showed a statistically significant improvement in PIVC insertion success on first attempt in 5 of 8 studies, with an overall success rate of 78% in the ultrasound group and 66% in the control group. The secondary outcome of overall success was improved by ultrasound in studies that allowed ≥3 attempts (pooled OR 3.57, 95% CI 2.05 to 6.21, P < .001, I2 = 0.0%).

CONCLUSIONS

This systematic review suggested that ultrasound improves pediatric PIVC first pass and overall success rates. Subgroup analysis showed improvement in PIVC success rates for patients with difficult intravenous access and a single operator, dynamic, short-axis ultrasound technique.

Establishing a risk assessment framework for point-of-care ultrasound

Point-of-care ultrasound (POCUS) refers to the use of portable ultrasound (US) applications at the bedside, performed directly by the treating physician, for either diagnostic or procedure guidance purposes. It is being rapidly adopted by traditionally non-imaging medical specialties across the globe. Recent international evidence-based guidelines on POCUS for critically ill neonates and children were issued by the POCUS Working Group of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). Currently there are no standardized national or international guidelines for its implementation into clinical practice or even the training curriculum to monitor quality assurance. Further, there are no definitions or methods of POCUS competency measurement across its varied clinical applications.

CONCLUSION

The Hippocratic Oath suggests medical providers do no harm to their patients. In our continued quest to uphold this value, providers seeking solutions to clinical problems must often weigh the benefit of an intervention with the risk of harm to the patient. Technologies to guide diagnosis and medical management present unique considerations when assessing possible risk to the patient. Frequently risk extends beyond the patient and impacts providers and the institutions in which they practice. POCUS is an emerging technology increasingly incorporated in the care of children across varied clinical specialties. Concerns have been raised by clinical colleagues and regulatory agencies regarding appropriate POCUS use and oversight. We present a framework for assessing the risk of POCUS use in pediatrics and suggest methods of mitigating risk to optimize safety and outcomes for patients, providers, and institutions.

WHAT IS KNOWN

• The use POCUS by traditionally non-imaging pediatric specialty physicians for both diagnostic and procedural guidance is rapidly increasing. • Although there are international guidelines for its indications, currently there is no standardized guidance on its implementation in clinical practice.

WHAT IS NEW

• Although standards for pediatric specialty-specific POCUS curriculum and training to competency have not been defined, POCUS is likely to be most successfully incorporated in clinical care when programmatic infrastructural elements are present. • Risk assessment is a forward-thinking process and requires an imprecise calculus that integrates considerations of the technology, the provider, and the context in which medical care is delivered. Medicolegal considerations vary across countries and frequently change, requiring providers and institutions to understand local regulatory requirements and legal frameworks to mitigate the potential risks of POCUS.

Techniques and Technologies to Improve Peripheral Intravenous Catheter Outcomes in Pediatric Patients: Systematic Review and Meta-Analysis

OBJECTIVE

Insertion and function of pediatric peripheral intravenous catheters (PIVCs) present challenges. We systematically reviewed techniques and technologies to improve PIVC outcomes (first-time insertion success, overall insertion success, time to insertion, dwell time, failure, and complications).

DATA SOURCES

Cochrane Central Register of Controlled Trials (CONTROL), Cumulative Index to Nursing and Allied Health (CINAHL), US National Library of Medicine, and Embase.

STUDY SELECTION

English-language pediatric trials published post 2010 reporting PIVC outcomes.

DATA EXTRACTION

Following Cochrane standards, two authors screened, extracted, and critiqued study quality (Grading of Recommendations Assessment, Development and Evaluation approach) data, random effects analysis, results expressed as risk ratios (RR), mean differences (MD) and 95% CIs.

RESULTS

Twenty-one studies (3237 children; 3098 PIVCs) were included. First-time insertion success significantly increased with ultrasound guidance (compared with landmark insertion; RR, 1.60; 95% CI, 1.02-2.50). Use of ultrasound guidance (compared with landmark insertion) did not improve overall PIVC insertion success (RR, 1.10; 95% CI, 0.94-1.28). There was no evidence of an effect of near-infrared (compared with landmark) on first-time insertion success (RR, 1.21; 95% CI, 0.91-1.59) or number of attempts (MD, -0.65; 95% CI, -1.59 to 0.29); however, it significantly reduced PIVC insertion time (MD, -132.47; 95% CI, -166.68 to -98.26) and increased first-time insertion success in subgroup analysis of patients with difficult intravenous access (RR, 2.72; 95% CI, 1.02-7.24).

LIMITATIONS

Few studies per intervention, small sample sizes, and inconsistent outcome measures precluded definitive conclusions.

CONCLUSIONS

Ultrasound and near-infrared appear to improve pediatric PIVC insertion. High-quality studies examining the full extent of techniques and technologies are needed. Registration: CRD42020175314.

A randomized controlled trial of ultrasound-assisted technique versus conventional puncture method for saphenous venous cannulations in children with congenital heart disease

Background

The study investigated the success rate of the great saphenous venous catheter placement performed by ultrasound-assisted technique compared with the conventional puncture method in infants and toddlers with congenital heart disease and aimed to assess the efficiency and feasibility of this method within the context of pediatric peripheral venous access.

Methods

We selected infants and toddlers who underwent congenital cardiac surgery in our medical center from June 1, 2020, to September 7, 2020, by convenience sampling. Children were stratified by the presence of the manifesting cardiac types (cyanotic or acyanotic heart disease). They were assigned to the conventional puncture method group or the ultrasound-assisted group through randomly blocked randomization. The primary outcome was the success rate of the first attempt. The second outcomes included the time to cannulation at the first attempt, the redirections of the first attempt, overall puncture time, and overall redirections of efforts. Besides, a binary logistic regression model was implemented to identify the possible variables related to the success rate of the first attempt.

Results

A total of 144 children in our medical center were recruited in the study. The success rate of the first attempt in the ultrasound-assisted group was higher than that of the conventional puncture method group in the stratification of cyanotic children (66.7% vs. 33.3%, P = 0.035). Among children of acyanotic kind, the difference in the success rate of the first attempt between the two groups was not significant (57.6% vs. 42.4%, P = 0.194). Overall puncture time (45.5 s vs. 94 s, P = 0.00) and the time to cannulation at the first attempt (41.0 s vs. 60 s, P = 0.00) in the ultrasound-assisted group was less than the conventional puncture method group. The ultrasound-assisted group also required fewer redirections of the first attempt (three attempts vs. seven attempts, P = 0.002) and fewer total redirections of efforts (two attempts vs. three attempts, P = 0.027) than the conventional puncture method group. The result of binary Logistic regression showed that the success rate of the first attempt was related to age (OR:1.141; 95% CI = 1.010–1.290, P = 0.034), the redirections of the first attempt (OR:0.698; 95% CI = 0.528–0.923, P = 0.012) and the saphenous venous width (OR:1.181; 95% CI = 1.023–1.364, P = 0.023).

Conclusions

The ultrasound-assisted technique improves the saphenous venous cannulation sufficiently in children with difficult peripheral veins. The younger age is associated with a higher likelihood of peripheral venous difficulty. The ultrasound-assisted methods can effectively screen peripheral veins, e.g., selecting thicker diameter peripheral veins, making puncture less uncomfortable, and improving success rates. This method can be used as one of the effective and practical ways of peripheral venipuncture in children, especially in difficult situations. It should be widely applied as one of the alternative ultrasound techniques in the operating room.

Trial registration

ChiCTR.org.cn (ChiCTR-2,000,033,368). Prospectively registered May 29, 2020.

Ultrasound guided peripheral IV placement: An observational study of the learning curve in pediatric patients

BACKGROUND

Ultrasound guided peripheral intravenous catheter placement (USGPIV) has demonstrated benefits in children including higher success rates and fewer attempts compared to the traditional technique. Little is known about the experience needed to establish competence with USGPIV in children. In adult patients, nurses with four USGPIV attempts had a subsequent 70% probability of success after training. The objective of this study is to measure the competency of nurses with USGPIV in children after training.

METHODS

Pediatric nurses completed 2 h of training on USGPIV, after which they used ultrasound at their discretion for children with difficult access. Data was collected prospectively via study forms and retrospectively from medical records. Mixed effects logistic regression models were used to estimate the probability of successful USGPIV placement.

RESULTS

Thirty-five nurses underwent training from the pediatric emergency department and intravenous access team. The overall USGPIV success rate was 70%. Participants with less nursing experience made more USGPIV attempts than those with more experience, but had similar success rates. Forty percent of participants performed ten or more attempts during the study period. Mixed effects logistic regression estimated that it took nine USGPIV attempts after training for learners to achieve a 70% probability of success for the subsequent attempt.

CONCLUSION

After training, 40% of participants adopted USGPIV into their practice. When developing training programs for USGPIV for children with difficult access, trainers can anticipate the experience needed to acquire this skill and the fact that not everyone trained will use this skill in their daily practice.

Comparison of Ultrasound Guided and Conventional Techniques for Peripheral Venous Catheter Insertion in Pediatric Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Ultrasound guided cannulation for peripheral venous insertion is a well-established methodology. However, there has never been a systematic review completed to synthesize evidence within the pediatric population. The current systematic review and meta-analysis was completed to compare the efficacy and safety profile of ultrasound guided peripheral cannulation against the conventional palpation technique within pediatric patients.

METHODS

A comprehensive search was conducted within the digital databases including Medline, EMBASE, ScienceDirect, Google Scholar and Cochrane library from inception until August 2021. A meta-analysis was then completed with random-effects model and reported pooled risk ratio (RR) or standardized mean difference (SMD) with 95% confidence interval (CI).

RESULTS

In total, 9 studies were analyzed, which included 1,312 participants, and the majority of studies (5 out 9 studies) were considered high quality. Amongst efficacy outcomes, first attempt success rate had a pooled RR of 1.53 (95% CI: 1.14-2.04), overall success rate had a pooled RR of 1.13 (95% CI: 1.01-1.26), number of attempts before successful cannulation had a pooled SMD of -1.93 [95%CI: -3.44 to -0.42], time taken for successful cannulation had a pooled SMD of -0.46 [95%CI: -1.20 to 0.28], needle redirections before successful cannulation had a pooled SMD of -1.26 [95%CI: -2.47 to -0.06]. Amongst safety outcomes, venous extravasation had a pooled RR of 1.59 (95% CI: 0.99-2.54) and phlebitis had an RR of 0.31 (95% CI: 0.07-1.50).

CONCLUSION

Within pediatric patients, ultrasound guided peripheral venous cannulation is more efficacious when compared to the conventional palpation technique.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021275305, identifier: CRD42021275305.

Comparison of dynamic needle tip positioning versus conventional long-axis in-plane techniques for ultrasound-guided internal jugular venous catheterization: a randomized controlled trial

BACKGROUND

Continuous visualization of the needle tip is essential for successful ultrasound-guided central venous catheterization, and the dynamic needle tip positioning (DNTP) technique enables it. The aim of this randomized, dual-center trial was to compare the first-attempt success rate of ultrasound-guided internal jugular catheterization between the DNTP and conventional long-axis in-plane (LAX-IP) techniques.

METHODS

Patients undergoing cardiac surgery at two tertiary teaching hospitals were randomly allocated to either the DNTP or LAX-IP group. Internal jugular venous catheterization was performed by four anesthesiologists. The primary outcome was the first-attempt success rate of central venous catheterization. Procedural time and complications related to catheterization were compared as secondary outcomes.

RESULTS

In total, 142 patients were analysed. The first-attempt success rate was significantly higher in the DNTP group (59/72, 81.9%) than in the LAX-IP group (46/70, 65.7%; odds ratio, 2.37; 95% confidence interval 1.09-5.15; P=0.028). In addition, the needle was redirected less frequently in the DNTP group than the LAX-IP group (P=0.026). Procedural time was comparable between the groups. No significant differences were observed in complications related to catheterization, including posterior wall puncture, carotid artery puncture, or hematoma.

CONCLUSIONS

The DNTP technique resulted in a significantly higher success rate on the first attempt at internal jugular venous catheterization and required less frequent redirection of the needle during the procedure than the conventional LAX-IP technique.

Ultrasound-guided techniques for peripheral intravenous placement in children with difficult venous access

Peripheral intravenous placement in children can be challenging. Different techniques have been used to improve first pass success rates in children with known history of difficult venous access including surface landmarking, local warming, transillumination, ultrasonography, epidermal nitroglycerin, central venous access, intraosseous placement, and venous cutdown. Among these, ultrasound guidance has garnered the most interest among anesthesiologists. The cumulative literature surrounding the utility of ultrasound-guided peripheral intravenous placement in children with and without difficult venous access has shown mixed results. Literature on the utility of ultrasound guidance for peripheral intravenous placement in children under deep sedation or anesthesia is limited but encouraging. This review summarizes the overall evidence for ultrasound-guided peripheral intravenous placement in children with difficult venous access under deep sedation or general anesthesia. Furthermore, five subtly varying approaches to ultrasound-guided peripheral intravenous placement with their advantages and disadvantages will be discussed. One of these five approaches is Dynamic Needle Tip Positioning. Utilizing a short axis out of plane ultrasound view, this promising technique allows for accurate needle tip localization and may increase the success rate of peripheral intravenous placement, even in small children, under deep sedation, or general anesthesia.