It remains unknown what impact saline flushing might have on venous physiology and injury.
Repeated vigorous flushing could cause endothelial injury, clot formation and catheter failure.
Flushing frequency (hourly vs. 5 hourly) did not impact catheter failure over 5 hours.
Frequent flushing increased prothrombin time, suggesting extrinsic coagulation factor consumption.
Sub-clinical thromboses formed adjacent to ~80% of PIVCs, irrespective of flushing frequency.
Abstract
Background:
Peripheral intravenous venous catheters (PIVCs) are associated with a postinsertion failure incidence of 40%, yet the common maintenance and preventive strategy of saline flushing is poorly understood at a physiological level.
Methods:
We developed a human model of bilateral cephalic vein cannulation to study the impact of varied PIVC flushing frequency (high frequency, HF; low frequency, LF) over 5 hours on catheter failure (primary outcome), coagulation, platelet aggregation, and local tissue injury. Ultrasound was used in a subset to assess vascular diameter/catheter to vein, blood flow velocity, and thrombus formation.
Results:
Out of 34 catheters in 17 adult participants, 1/17 (6%) LF catheters failed, which was not significantly different from HF catheters (0/17). Platelet function, activated partial thromboplastin time, and tissue factor were also not different (P > 0.05). However, prothrombin time (PT) increased with HF versus LF after 5 hours (P < 0.05). Ultrasound demonstrated luminal thromboses in veins experiencing both HF (6/7) versus LF (5/7) conditions after 5 hours with nonsignificant changes in vascular diameter and blood flow velocity over time.
Conclusions:
Although no difference in PIVC failure was observed between HF and LF flushing conditions over 5 hours, greater flushing frequency increased PT time, suggesting delayed activation or consumption of extrinsic coagulation factors. This study also demonstrated feasibility in assessment of luminal thromboses, which were remarkably prevalent after PIVC placement, and changes in vascular diameter and blood flow. This manuscript illustrates that the development of a sensitive human model will be of great use for exploring the impact of interventions on reducing PIVC failure in the future.
The DIVA scoring tool has previously been validated in the pediatric ED setting.
Our project applied DIVA to an inpatient pediatric sample.
DIVA may not predict likelihood of PIV success in the inpatient setting.
Abstract
Background:
First-attempt success rate for placing pediatric peripheral intravenous (PIV) catheters ranges from to 24% to 52%. Multiple attempts can increase risk of deleterious outcomes. It is essential to screen pediatric patients appropriately to identify those who will require additional resources for successful PIV placement.
Methods:
A convenience sample of hospitalized pediatric patients 0 to 18 years of age on a general care unit was used in this performance improvement project. Prior to attempting PIV access, nurses completed a data collection tool that included elements of established difficult intravenous access (DIVA) tools as well as first-attempt successful PIV placement. The primary outcome measure was to determine if each DIVA scoring tool is accurate in predicting the need for additional resources to achieve successful first-attempt PIV placement. The secondary outcome measure was to compare the predictive value of each DIVA scoring tool among an inpatient pediatric population. Following data exploration and cleaning, a correlation analysis was performed with logistic regression to assess DIVA score effectiveness in predicting success of PIV insertion on the first attempt.
Results:
Out of 133 children, 167 PIV attempts were analyzed with 150 PIV attempts included in the final data analysis. Of the 150 PIV attempts analyzed, 60% (n = 90) were successful on the first attempt. Performance of prediction for first-time insertion success was comparable among all 4 DIVA scoring tools.
Conclusions:
None of the 4 DIVA scoring tools were superior in predicting first-time PIV placement among hospitalized children. Vein palpability was more predictive, although not statistically significant.
Compare effectiveness of chemical disinfectants in reducing S. aureus.
Five disinfectants reduced the bacterial load, especially chlorhexidine solutions.
Focus on Brazilian clinical practice of needleless connector disinfection.
Abstract
Purpose:
This study aimed to gain further knowledge about the comparative effectiveness of chemical disinfectants in reducing the bacterial load of NCs inoculated with S. aureus.
Methods:
Disinfection of needleless connectors was undertaken in vitro against Staphylococcus aureus comparing 70% isopropyl alcohol (IPA), 70% ethanol, 0.5% and 2% chlorhexidine in 70% IPA applied with gauze, and 70% IPA single-use cap (Site-Scrub®).
Results:
All disinfectants reduced the bacterial load (P < 0.001), especially the chlorhexidine solutions. Mechanical friction should follow guidelines.
Conclusion:
This study found that all tested disinfectants effectively reduced the bacterial load and more clinical studies must be developed with a focus on the Brazilian clinical practice of needleless connector disinfection.
Early identification of patients with a history of injectable drug use is vital.
Interprofessional collaboration is needed to increase safe completion of IV therapy.
Stratifying risks and realistic protocols are required in care settings for PWID.
In-patient use of illicit drugs may be 40% or higher.
Development of new tamper evident technology is urgently needed.
Abstract
Background:
The use of injectable drugs and alcohol increased during the months of lockdown and continual uncertainty of the worldwide response to the COVID-19 virus and its variants. As the world adjusts to living with multiple transmissible viruses, the health care system needs a comprehensive approach to care for people who inject drugs. Although the problem of injectable drug use is wide-ranging, this article will focus on the intersection of the person who injects drugs and the health care system.
Methods & Findings:
After an initial case involving a person who injects drugs requiring 42 days of intravenous antibiotics, the hospital began to develop plans to care for this patient population. Finding gaps in the research, a team at the hospital developed a Substance Use Risk Reduction Program that included a risk assessment scale, an interprofessional communication plan, and a set of protocols, then trialed these components between 2017 and 2019. The program successfully screened and collaborated care for patients with a history of injectable drug use. The goals to increase safety were addressed through the protocols that included tamper-evident technology and frequent observations by the staff. The risks of blood stream infection and overdose while a patient was in the hospital were reduced by using the risk reduction protocols. In addition, repudiated costs were decreased by thousands of dollars because of early planning for transfer from inpatient to outpatient, skilled nursing facility, or long-term acute care for the completion of intravenous therapy.
In the past decade, cyanoacrylate glue has been progressively introduced into the clinical practice of venous access devices used for different purposes. Glue has been used to increase device stabilisation (to reduce the risk of catheter dislodgement), to seal the exit site (to both reduce local bleeding and decrease the risk of bacterial contamination) and to close skin incisions required for the insertion of tunnelled catheters or totally implanted venous ports. For many of these purposes, the efficacy and cost-effectiveness of cyanoacrylate glue has been demonstrated, while some indications are still controversial. This article reports on 10 years of clinical experience with cyanoacrylate glue in a large university hospital, and provides a narrative review of the scientific evidence on the benefits of glue in venous access that has been accumulating over the past decade.
Observational studies have found that placement of peripheral intravenous cannulas (PIVCs) in the antecubital fossa (ACF) is associated with increased risks of infection, including healthcare-associated Staphylococcus aureus bacteraemia (HA-SAB). Avoiding placement of the PIVC in the ACF area along with other preventive measures such as aseptic technique, staff education on documentation, standardised insertion packs and alerts for timely removal, may reduce the overall risk of acquiring an HA-SAB. Aim: To implement a multimodal awareness programme on ACF cannulas and the risk of infection, and to reduce PIVC-associated HA-SAB in one hospital in Australia. Method: The authors performed a baseline digital survey to identify root causes for clinical decision making related to PIVCs and to raise awareness of the project. The authors performed weekly audits and provided feedback on four key wards over 12 weeks. Simple linear regression was used to look at the trend of ACF cannulation rates overtime. HA-SAB rates were calculated per 10000 occupied bed days. Findings: Improved insertion documentation was observed during the intervention period. The ACF cannulation rates decreased by 0.03% per day during the study, although this did not quite reach statistical significance (P=0.06). There were no PIVC-associated SAB events during the intervention period. The SAB rates decreased by 0.02% per day over the period of the study.