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

First-Attempt Success in Ultrasound-Guided vs Standard Peripheral Intravenous Catheter Insertion: The EPIC Superiority Randomized Clinical Trial

Importance

Pediatric peripheral intravenous catheter (PIVC) insertion can be difficult and time-consuming, frequently requiring multiple insertion attempts and often resulting in increased anxiety, distress, and treatment avoidance among children and their families. Ultrasound-guided PIVC insertion is a superior alternative to standard technique (palpation and visualization) in high-risk patients.

Objective

To compare first-time insertion success of PIVCs inserted with ultrasound guidance compared with standard technique (palpation and visualization) across all risk categories in the general pediatric hospital population.

Design, Setting, and Participants

An open-label, pragmatic, superiority, randomized clinical trial was conducted in an Australian quaternary pediatric hospital. Children (ages 0-18 years) requiring PIVC insertion were included between July 2021 and December 2022. One catheter was studied per patient, and analysis was by intention to treat. Data analysis was performed from April to October 2023.

Intervention

Eligible children were randomly assigned (1:1 using computer-generated randomization and concealed allocation) to receive ultrasound-guided or standard PIVC insertion. Randomization was stratified by insertion difficulty (low, medium, or high risk) defined using a standardized tool.

Main Outcomes and Measures

The primary outcome was first-time insertion success. Secondary outcomes included number of insertion attempts, insertion failure, postinsertion complications, dwell time, patient and parent satisfaction, and health care costs.

Results

A total of 164 children were randomly assigned to ultrasound-guided insertion (n = 84) or standard care (n = 80), with 81 (96.4%) and 78 (97.5%) receiving their allocated intervention, respectively. The median (IQR) age was 24 (10-120) months, and 93 children (56.7%) were male. First-time insertion success was higher with ultrasound-guided PIVC insertion (72 children [85.7%]) compared with standard technique (26 children [32.5%]) (risk difference [RD], 53.6%; 95% CI, 41.7%-65.4%; P < .001). Ultrasound-guided insertion led to significantly greater first-time insertion success across all risk categories, with the following RDs: low risk, 30.8% (95% CI, 8.1%-53.5%); medium risk, 56.2% (95% CI, 37.1%-75.3%); and high risk, 69.6% (95% CI, 52.3%-87.0%). Ultrasound-guided PIVC insertion had higher immediate health care costs (between group difference in total mean cost per person, A$9.33; 95% credible interval, A$8.83-A$10.86 [US $5.83; 95% credible interval, $5.52-$6.78]).

Conclusion and Relevance

These findings suggest that ultrasound-guided PIVC insertion improves first-time insertion success across all risk categories in pediatrics, supporting the widespread adoption of ultrasound-guided PIVC insertion in children.

Trial Registration

anzctr.org.au Identifier: ACTRN12621000206820.

Quality Improvement Interventions for Peripheral Intravenous Catheter Nursing Practices: A Systematic Review

BACKGROUND

The use of peripheral intravenous catheters (PIVC) is a crucial nursing practice for ensuring patient safety.

PURPOSE

This systematic review assessed quality improvement (QI) articles focused on nursing insertion and management practices related to PIVCs.

METHODS

A comprehensive search was performed. The Quality Improvement Minimum Quality Criteria Set (QI-MQCS) was used to appraise the quality of QI studies by 2 independent reviewers.

RESULTS

A total of 27 studies were included. More than half of the studies did not meet the sustainability and spread QI-MQCS criteria. QI interventions focused on ultrasound-guided PIVC placement, PIVC dressing products or other catheter devices, and bundles for PIVC practices. The improvements in PIVC-related patient outcomes and nurses' capabilities were reported.

CONCLUSION

Further research is needed to identify detailed QI protocols for ensuring the sustainability and cost-effectiveness of interventions and to facilitate the application of QI in diverse types of hospitals.

Patients' experiences in ultrasound-guided intravenous catheter insertion: A qualitative study

BACKGROUND

Peripheral intravenous catheter (PIVC) insertion is the most performed invasive procedure in healthcare. However, it often presents challenges in patients with non-visible or non-palpable veins, leading to unsuccessful cannulation attempts and associated complications. Ultrasound-guided PIVC insertion is a promising solution for patients with difficult venous access (DIVA). However, there remains a gap in the literature regarding patient experiences with this technique.

AIM

This study aimed to describe the characteristics and experiences of patients referred to a specialised DIVA team for ultrasound-guided PIVC insertion and compare their experiences with previous traditional cannulation.

METHOD

A qualitative study was conducted at an Australian 980-bed metropolitan tertiary referral centre. Thirteen patients were recruited through purposive sampling and interviewed post-ultrasound-guided cannulation. Data collection was conducted using one-on-one interviews followed by thematic analysis.

RESULTS

The study identified three major themes: the improved patient experience resulting from the expertise of the DIVA team with ultrasound cannulation; the impact of limited equipment and trained personnel on patient experience and outcomes; and the significance of acknowledging patients' prior cannulation experiences. Participants reported a stark contrast in their experiences between ultrasound-guided and traditional cannulation, with the former significantly reducing physical discomfort, stress and anxiety and improving success rates.

CONCLUSIONS

Ultrasound-guided PIVC insertion by trained clinicians significantly enhances the experience for patients with DIVA. However, challenges remain, including the availability of equipment and trained staff. The study highlights the need for policy changes and training in ultrasound-guided cannulation to improve patient care and outcomes. Future research should focus on broader and more diverse populations to validate these findings.

Effectiveness of the modified Seldinger technique for peripheral central catheter in newborns: a randomized clinical trial

OBJECTIVES

to evaluate the effectiveness of peripheral central catheterization by comparing the modified Seldinger technique and the conventional technique in critically ill newborns.

METHODS

randomized unmasked clinical trial conducted in a public children's hospital. Participation of 111 newborns with randomized allocation, 56 in the control group (conventional technique) and 55 in the experimental group (modified Seldinger). Success and absence of complications were evaluated as primary outcomes. The pain scale, difficulty in hemostasis, procedure time and number of punctures were considered secondary outcomes.

RESULTS

there was no statistical significance between groups, either for success (p=0.705) or absence of complications (p=0.347). A lower pain score, improved hemostasis, increased assertiveness with fewer punctures and reduced procedure time were not observed in the experimental group.

CONCLUSIONS

the modified Seldinger technique did not prove to be a more effective insertion technology compared to the conventional method. Brazilian Clinical Trial Registry: RBR-69vks36.

Registered Nurses' Association of Ontario (RNAO) best practice guideline on the assessment and management of vascular access devices

INTRODUCTION

Vascular access is the most common invasive procedure performed in health care. This fundamental procedure must be performed in a safe and effective manner. Vascular access devices (VADs) are often the source of infections and other complications, yet there is a lack of clear guidance on VADs for health providers across different settings. A Best Practice Guideline (BPG) was developed by the Registered Nurses' Association of Ontario (RNAO) to provide evidence-based recommendations on the assessment and management of VADs.

METHODS

RNAO BPGs are based on systematic reviews of the literature following the GRADE approach. Experts on the topic of vascular access were selected to form a panel. Systematic reviews were conducted on six research areas: education, vascular access specialists, blood draws, daily review of peripheral VADs, visualization technologies, and pain management. A search for relevant research studies published in English limited to January 2013 was applied to eight databases. All studies were independently assessed for eligibility and risk of bias by two reviewers based on predetermined inclusion and exclusion criteria. The GRADE approach was used to determine certainty of the evidence.

RESULTS

Over 65,000 articles were screened related to the six priority research questions. Of these, 876 full-text publications were examined for relevance, with 174 articles designated to inform nine recommendations in the BPG on the subject areas of: comprehensive health teaching, practical education for health providers, blood draws, daily review of peripheral VADs, visualization technologies, and pain management. In June 2021, the RNAO published the BPG on vascular access, which included the recommendations and other supporting resources.

CONCLUSION

The vascular access BPG provides high quality guidance and updated recommendations, and can serve as a primary resource for health providers assessing and managing VADs.

The effect of a pushing technique with normal saline on peripheral intravenous catheter placement success in paediatric haematology and oncology: A randomized controlled trial

PURPOSE

The aim of the present study is to determine the effect of the pushing technique with saline on the success of peripheral IV catheter placement in a paediatric haematology and oncology sample.

METHODS

The randomized controlled trial was conducted among 60 paediatric haematology and oncology patients aged between 0 and 17. The participants were randomly assigned to two peripheral intravenous catheter placement groups (intervention group, n:30, control group, n:30). Each patient was evaluated with the Difficult Intravenous Access (DIVA) score before being included in the study. Each patient was assessed using the Personal Information Form for Children and Catheter Registration Form.

RESULTS

The average age of the children was 86.4 months (SD = 60.0); 36.7% were female. The pushing technique with saline significantly increased the success of placing a peripheral IV catheter on the first attempt in the intervention group compared to the control group (F = 42.391, p = 0.000). The number of attempts during peripheral IV catheter placement significantly decreased in the intervention group compared with the control group (t = -5.676, p = 0.000). Complications were less in the intervention group compared with the control group (χ2 = 24.438, p = 0.000). The procedure time was significantly shorter in the intervention group compared with the control group (t = -4.026, p = 0.000).

CONCLUSION

The pushing technique with saline is an effective method to increase the first attempt success rate, decrease the number of attempts, reduce the procedure time, and reduce the complications during peripheral intravenous catheter placement procedures in paediatric haematology and oncology patients with difficult intravenous access.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov (NCT05685290 & date of first recruitment: January 3, 2023) https://clinicaltrials.gov/ct2/show/NCT05685290.

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.

See It Best: A Propensity-Matched Analysis of Ultrasound-Guided versus Blind Femoral Artery Puncture in Balloon-Expandable TAVI

Background: Currently, transcatheter aortic valve implantation (TAVI) is the standard procedure recommended for patients over 75 years of age with symptomatic aortic valve stenosis. Percutaneous transfemoral (TF) access is the main route used to perform the procedure. Among periprocedural complications, access-related ones are the most frequent, potentially leading to prolonged in-hospital stays and transfusions. Methods: We performed a retrospective analysis of prospectively collected data on consecutive patients undergoing TF-TAVI with the latest generation balloon-expandable transcatheter valve between 2013 and 2022. Results: A total of 600 patients were analyzed, differentiating the population between ultrasound-guided and blind common femoral artery puncture. Valve Academic Research Consortium 3 (VARC-3)criteria were used to report at 30 days and follow-up. In our propensity-matched comparison of the two groups, we found a strong reduction in access-related complications in the echo-guided group, particularly in terms of reduction of major and minor bleedings. We also found a significant trend in reduction of local complications, such as pseudoaneurysms, hematomas, arterio-venous fistulas, dissection of the femoral or iliac arteries, and stenosis. Conclusions: Although there is a lack of consensus on the role of ultrasound-guided puncture, we found better outcomes for patients having an echo-guided puncture of the main access, particularly with regard to access-related complications, early mobilization, and early discharge home.

Outcomes of a Comprehensive Ultrasound Guided Peripheral IV Insertion (USGPIV) Training Program in a Pediatric Emergency Department

INTRODUCTION

Timely and reliable peripheral intravenous cannulation is an imperative skill in a pediatric emergency department. Utilization of point-of-care ultrasound guidance has proven to significantly improve first-attempt peripheral intravenous cannulation insertion rates in pediatric patients. We sought to develop, implement, and evaluate an ultrasound-guided peripheral intravenous training program for emergency nurses in a tertiary care pediatric center.

METHODS

Twelve emergency nurses underwent a training program that consisted of an interactive asynchronous learning module followed by 8 hours of training by a vascular access clinical instructor. Data was collected on each ultrasound-guided peripheral intravenous insertion via survey methodology.

RESULTS

Complete data for a total of 210 ultrasound-guided peripheral intravenous were recorded over the 9-month period. A total of 65.2% (137/210) of patients who received an ultrasound-guided peripheral intravenous had known difficult intravenous access on history. A total of 89.5% (188/210) of patients had a difficult intravenous access of ≥4. The mean difficult intravenous access score for the patients in which ultrasound-guided peripheral intravenous insertions were attempted was 4.78 (95% confidence interval, 4.55-5.01). A total of 193 of 210 (91.9%) of ultrasound-guided peripheral intravenous were attained successfully. On the first attempt, 86.5% (167/193) ultrasound-guided peripheral intravenous were attained, and 98.96% (191/193) were attained within the first 2 attempts.

CONCLUSION

We found that implementing a comprehensive ultrasound-guided peripheral intravenous training program for emergency nurses in a pediatric tertiary care center led to a high first-pass success rate in attaining peripheral intravenous cannulations. It also facilitates vascular access in patients with known difficult intravenous access. Consideration should be made to implementing point-of-care ultrasound intravenous training programs to improve pediatric vascular access in the emergency department, particularly in patients with known difficult intravenous access.

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.

Improving difficult peripheral intravenous access requires thought, training and technology (DART3): a stepped-wedge, cluster randomised controlled trial protocol

BACKGROUND

Peripheral intravenous catheters (PIVCs) are the most used invasive medical device in healthcare. Yet around half of insertion attempts are unsuccessful leading to delayed medical treatments and patient discomfort of harm. Ultrasound-guided PIVC (USGPIVC) insertion is an evidence-based intervention shown to improve insertion success especially in patients with Difficult IntraVenous Access (BMC Health Serv Res 22:220, 2022), however the implementation in some healthcare settings remains suboptimal. This study aims to co-design interventions that optimise ultrasound guided PIVC insertion in patients with DIVA, implement and evaluate these initiatives and develop scale up activities.

METHODS

A stepped-wedge cluster randomized controlled trial will be conducted in three hospitals (two adult, one paediatric) in Queensland, Australia. The intervention will be rolled out across 12 distinct clusters (four per hospital). Intervention development will be guided by Michie's Behavior Change Wheel with the aim to increase local staff capability, opportunity, and motivation for appropriate, sustainable adoption of USGPIVC insertion. Eligible clusters include all wards or departments where > 10 PIVCs/week are typically inserted. All clusters will commence in the control (baseline) phase, then, one cluster per hospital will step up every two months, as feasible, to the implementation phase, where the intervention will be rolled out. Implementation strategies are tailored for each hospital by local investigators and advisory groups, through context assessments, staff surveys, and stakeholder interviews and informed by extensive consumer interviews and consultation. Outcome measures align with the RE-AIM framework including clinical-effectiveness outcomes (e.g., first-time PIVC insertion success for DIVA patients [primary outcome], number of insertion attempts); implementation outcomes (e.g., intervention fidelity, readiness assessment) and cost effectiveness outcomes. The Consolidated Framework for Implementation Research framework will be used to report the intervention as it was implemented; how people participated in and responded to the intervention; contextual influences and how the theory underpinning the intervention was realised and delivered at each site. A sustainability assessment will be undertaken at three- and six-months post intervention.

DISCUSSION

Study findings will help define systematic solutions to implement DIVA identification and escalation tools aiming to address consumer dissatisfaction with current PIVC insertion practices. Such actionable knowledge is critical for implementation of scale-up activities.

TRIAL REGISTRATION

Prospectively registered (Australian and New Zealand Clinical Trials Registry; ACTRN12621001497897).