IV medication errors in critical care
April 28, 2009
Intravenous literature: Camiré, E., Moyen, E. and Stelfox, H.T. (2009) Medication errors in critical care: risk factors, prevention and disclosure. CMAJ. 180(9), p.936-943.
Click here for the full text version.
Key points
- Medication reconciliation may improve patient safety in the intensive care unit, and an updated list of medications should be maintained, including long-standing medications, the reasons for starting new medications and their planned stop dates and the reasons for discontinuing or holding old medications.
- Engaging pharmacists in inpatient rounds in the intensive care unit may decrease the risk of adverse drug events.
Click here for the full text version.
Vascular access team business case
April 27, 2009
Intravenous conference: Deborah Bolton, Clinical Nurse specialist IV Therapy, Brighton trust, is presenting at the IPS IV Conference in September 2009. Deborah writes “This year there has been a huge rise in the number of people contacting me requesting a copy of a business case that I completed in order to expand my IV Therapy Team in Brighton”.
Deborah continues ‘Increasingly business cases are required when attempting to introduce anything new into organisations, whether it is a new member of staff, a change to practice or a new piece of kit. No one taught me how to do this, so my first effort took almost 2 years to complete! To avoid others having to go through this trauma, I have written and article and will be presenting ‘How to put a successful business case together’ This will include who you need to talk to, how to overcome the multitude of barriers easily and quickly and provide people with a simple template that can be used again and again”.
Click here for conference details.
Sonic flashlight in vascular access
April 27, 2009
Intravenous literature: Wang, D. et al (2009) Peripherally Inserted Central Catheter Placement With the Sonic Flashlight. Journal of Ultrasound in Medicine. 14, p.651-656.
Abstract:
Objective. We describe a case series constituting the first clinical trial by intravenous (IV) team nurses using the sonic flashlight (SF) for ultrasound guidance of peripherally inserted central catheter (PICC) placement.
Methods. Two IV team nurses with more than 10 years of experience with placing PICCs and 3 to 6 years of experience with ultrasound attempted to place PICCs under ultrasound guidance in patients requiring long-term IV access. One of two methods of ultrasound guidance was used: conventional ultrasound (CUS; 60 patients) or a new device called the SF (44 patients). The number of needle punctures required to gain IV access was recorded for each patient.
Results. In both methods, 87% of the cases resulted in successful venous access on the first attempt. The average number of needle sticks per patient was 1.18 for SF-guided procedures compared with 1.20 for CUS-guided procedures. No significant difference was found in the distribution of the number of attempts between the two methods. Anecdotal comments by the nurses indicated the comparative ease of use of the SF display, although the relatively small scale of the SF image compared with the CUS image was also noted.
Conclusions. We have shown that the SF is a safe and effective device for guidance of PICC placement in the hands of experienced IV team nurses. The advantage of placing the ultrasound image at its actual location must be balanced against the relatively small scale of the SF image.
Nexiva clinical trial
April 27, 2009
Intravenous literature: McNeill, E.E., Hines, N.L. and Phariss, R. (2009) A Clinical Trial of a New All-in-One Peripheral-Short Catheter. Journal of the Association for Vascular Access. 14(1), p.46-51.
Abstract:
The objectives of this survey were to: 1) understand current peripheral IV stabilization practices within our hospital and 2) evaluate the use of a new closed IV catheter system with a built-in stabilization platform. All medical-surgical patients within an 851-bed acute care hospital with peripheral-short catheters were evaluated within a 3-day period for catheter securement, dwell time, and signs of complications. Additionally, catheter restart data were collected from a renal telemetry unit for 2 weeks. Catheter and dressing protocols were then standardized to a new catheter system with a built-in stabilization platform (Nexiva™ Closed Catheter System) and an absorbent transparent dressing (SorbaView® 2000). After a 2-week trial of the new protocol, catheters were again evaluated for securement and restart data were again collected from the renal telemetry unit. Staff nurse (N = 42) opinions on the new catheter system and dressing combination were sought, as well as a vote on willingness to change to the new catheter system and dressing. Results demonstrate improvement in catheter stabilization (out to 96 hours of dwell-time), decreased restarts, a high clinical preference for the new catheter/dressing system, and a high willingness to convert to the new system. Results indicate that the new closed IV catheter system with a built-in stabilization platform and the transparent absorbent dressing evaluated in this survey may help to improve catheter securement and increase dwell-time. Research studies utilizing more rigorous randomized, controlled comparisons are warranted.
Tunneled Groshong® catheters
April 27, 2009
Intravenous literature: Pittiruti, M., Malerba, M., La Greca, A., Emoli, A., Nanni, L. and Cozza, T. (2009) A Retrospective Analysis of Our 15-year Experience with Bedside ‘Blind’ Positioning of Long-term Tunneled Groshong® Catheters, in the Pre-ultrasound Era. Journal of the Association for Vascular Access. 14(1), p.32-38.
Abstract:
Long-term tunneled Groshong catheters have been widely used in our institution since 1987, both in adult and pediatric patients, for different purposes (chemotherapy, parenteral nutrition, etc.). In the period 1987-2003, most of these catheters were inserted adopting the ‘blind’ percutaneous venipuncture of the internal jugular vein, by the so called ‘low lateral’ approach (Jernigan’s technique). Also, with the exception of selected pediatric cases, they have been inserted at the bedside, without intra-operative fluoroscopy. A retrospective analysis of 1848 tunneled Groshong catheters inserted at our institution over a 15 year period (1987-2003) showed that this protocol was particularly safe (low incidence of complications) and cost-effective (low costs: limited use of fluoroscopy and the operating room).
CVC and pacemaker risk
April 27, 2009
Intravenous literature: Pacana, C.L. and Durand, J-B. (2009) The Risk of Central Venous Catheter Placement Ipsilateral to the Permanent Pacemaker. Journal of the Association for Vascular Access. 14(1), p.28-30.
Abstract:
Purpose: The use of a central venous catheter is essential in the delivery of chemotherapy and other necessary intravenous treatments for oncology patients. This paper reviews the published reports of venous complications associated with an implanted cardiac pacemaker, and suggests some important considerations when planning to insert a central venous catheter through a peripheral approach.
Review of Literature: The subclavian venous system in the chest is the most common site for implanting pacemaker leads in patients with underlying heart problems. Venous complications after pacemaker implantation, such as stenosis, hematoma, thrombophlebitis, and thrombosis, can occur with or without the known associated local symptoms.
Discussion: No published case reports were found describing pacemaker leads displacement after insertion of central venous catheters, including peripherally inserted central catheters.
Implications for Clinical Practice: Prior to inserting a central venous catheter, a thorough assessment should include the patient’s history of any implanted medical device, in the context of understanding the clinical manifestations associated with the signs and symptoms of venous obstruction.
Intravenous (IV) therapy competencies
April 27, 2009
Intravenous literature: Jensen, R. (2009) Teaching Students about Intravenous Therapy: Increased Competence and Confidence. Journal of the Association for Vascular Access. 14(1), p.21-26.
Abstract:
Aim/Purpose: Graduate nurses require competency in IV therapy. Associate Degree in Nursing (ADN) programs offer elective IV education to provide additional information for interested students. After instituting such a course, students’ perceived comfort and knowledge of IV therapy were evaluated.
Review of Relevant Literature: Studies demonstrated that IV education for nurses in practice helped reduce complication rates. Dated research also indicated that nursing programs were reluctant to provide IV instruction that included advanced skills, such as catheter insertions. More recent literature involved teaching methodology.
Methods: A researcher-designed survey was distributed at the completion of an ADN program to evaluate perceived knowledge and comfort related to IV therapy, as well as information about IV education throughout the program.
Results: Students who participated in the workshop perceived having a higher level of comfort and knowledge of several IV content areas than those who participated in the course or had no elective IV education. Conversely, participants in the workshop and course felt more comfortable with central line dressing changes and IV insertions than students who did not take either IV educational offering.
Conclusions: The standard IV education appeared to provide adequate knowledge and comfort with IV therapy. However, optional IV education benefited students who wanted more in depth IV knowledge and skills.
Implications for Practice: The best methods for teaching ADN students about IV therapy remains unknown. However, offering an elective course provides opportunities for interested students to increase their knowledge and comfort related to IV therapy prior to graduation.
Intravenous (IV) dressing care
April 27, 2009
Intravenous literature: Orsino, L., Bargelli, A., Cappucciati, L., Fanchin, G., Galati, G., Manzin, F., Marceca, F., Pignatelli, A., Peluffo, L., Vendemiati, S. and Verzè, A. (2009) Observational study of SorbaView® 2000, SorbaView® Ultimate and SecureView® Port AFZ Dressings used on Central Venous Catheters in Eleven Italian Oncology, Hematology and Pain Centers. Journal of the Association for Vascular Access. 14(1), p.14-19.
Abstract:
Observational study of SorbaView® 2000, SorbaView® Ultimate and SecureView® Port AFZ dressings used on Central Venous Catheters in 11 Italian Oncology, Hematology and Pain Centers.
Dressing care is one of the nursing challenges that is more and more frequent in the management of central venous catheters (CVCs). Our intention with this observational study was to study the efficacy and tolerability of the latest generation devices recently introduced in Italy. The study was performed on 435 patients; including 293 carriers of totally implantable CVCs and 142 carriers of tunneled and non-tunneled CVCs. In 90% of 311 patients with scheduled therapy of greater than seven days, the dressing adhered completely, at the end of seven days and up to 10 days. In 10% of all 435 patients the dressing became partially detached at between greater than one day and less than 10 days, but not enough to justify dressing change. Of the 10% that partially detached with dwell time greater than one day and less than four days, most occurred in Hematology. A cumulative total of 1,391 dressings were applied.
At the conclusion of the study, 84% of patients reported that they were satisfied with the use of the SorbaView 2000, SorbaView Ultimate and SecureView Port AFZ dressings.
Stephen Rowley on ANTT
April 23, 2009
Intravenous conference: Stephen Rowley, Lead Cancer Nurse UCLH and ANTT UK Lead is presenting at the IPS IV Conference in Harrogate. Stephen will be talking about implementing ANTT as an NHS Trust standard aseptic techniqe. Stephen explains “Since 2004, 76 of 175 Acute NHS Trusts in England have requested the ANTT implementation pack. A review of hospital data and experiences following ANTT implementation demonstrates ANTT is an effective framework for standardising and improving aseptic practice across large clinical workforces. Findings also suggest this can have a positve effect on helping reduce hospital acquired infection. The reasons why ANTT has been so widely adopted and is the NHS’s first standard defined aseptic technique are discussed. Future plans for the project will also be given”.
Click here for the conference details.
Measuring hand hygiene adherence
April 16, 2009
Intravenous news: The Joint Commission is releasing “Measuring Hand Hygiene Adherence: Overcoming the Challenges,” to help health care organizations target their efforts in measuring hand hygiene performance. The monograph is designed to address “everything you ever wanted to know about hand hygiene measurement but were afraid to ask.” The aim of the monograph is to broaden understanding of the issues and provide practical solutions for strengthening measurement and improvement activities.
The monogragh is the result of a two-year collaboration with major infection control leadership organizations in the United States and abroad. In addition to The Joint Commission, the participating organizations include:
- Association for Professionals in Infection Control and Epidemiology, Inc.
- The Centers for Disease Control and Prevention
- The Institute for Healthcare Improvement
- The National Foundation for Infectious Diseases
- The Society for Healthcare Epidemiology of America
- The World Health Organization
Click here to download the monograph
Baxter buy stake in Sigma IV pump
April 16, 2009
Intravenous products: Forbes.com report ‘Baxter International Inc. said Wednesday it bought a stake in Sigma International and will market one of the company’s infusion pumps, paying $100 million upfront in the deal.
Baxter will buy a 40 percent stake in Sigma of Medina, N.Y., and could pay an additional $130 million if the Spectrum pumps reach development, regulatory and commercial milestones, or buy the company outright. The deal is not expected to have a significant impact on Baxter’s results this year”.
Click here for the full story on Forbes.com
Closed IV system award
April 16, 2009
Intravenous news: Newsok.com report on $100K in prizes given in Oklahoma business contest. The innovation Award winner was Innovative Solutions of Oklahoma State University. Innovative Solutions proposes to commercialize a patent-pending closed design Intravenous IV and syringe create a solution to a long-standing problem of systems that expose health care workers to blood-borne illnesses and patients to infection.
The Innovation Award recognizes the most feasible business plan with at least one member who plans to continue on to commercialize the technology. Innovative Solutions will receive $50,000 of in-kind services to advance the business.
Click here for the full story on Newsok.com
Intravenous history at IV conference
April 10, 2009
Intravenous conference: Dr Neil MacGillivray, Honorary Post Doctoral Fellow in Scottish History University of Edinburgh will present the inaugural Dr Thomas Latta Lecture for the Intravenous (IV) Therapy Programme at Infection Prevention 09.
While focussing on the pioneering work of Dr Thomas Latta the paper will also examine the social, political and medical upheaval which resulted from the arrival of cholera in Europe in 1831: medical men were assassinated in Russia and there were real fears of revolution in many European countries.
The response of the medical profession will be reviewed referring to the work of Dr William Brooke O’Shaughnessy and examining the general helplessness of the profession in the face of this new disease when the mainstay of treatment was bloodletting. Not only did the new disease result in the first cardiac catheterisation but also the first use of intravenous saline by Dr Thomas Latta.
Click here to view the full conference programme.
Martin Kiernan interview
April 9, 2009
Intravenous news: HealthExec TV present a video interview with Martin Kiernan, IPS President. “The MRSA target has been hit and C difficile rates are falling but Martin Kiernan, President of the Infection Prevention Society, urges trusts not to see this as the end but as the minimum that should be achieved.
In this interview, he advises on what more can be done to further reduce rates of avoidable infections – care bundles, leadership and the role of non-clinical staff such as commissioners are all raised as powerful factors”.
Click here to view the interview
IV conference – call for papers
April 8, 2009
Intravenous conference: The Infection Prevention Society (IPS) are pleased to invite submission of abstracts for free paper and poster presentations at Infection Prevention 09. In particular, IV nurses should consider presenting at the IV day on the 22nd September 2009. Two free paper sessions are availaable. If you are interested in presenting a paper please click here for more information.
Click here to view the Intravenous Therapy Programme for the 22nd September 2009.
The themes of this year’s conference are:
- Informing expert practice
- Promoting infection prevention excellence
- Sustaining systems for patient safety
Patient-to-patient HepB transmission
April 8, 2009
Intravenous literature: News-Medical.Net report “Patient-to-patient transmission of hepatitis B virus (HBV) can occur as the result of routine clinical practices incorrectly thought to be risk-free.
A review of 33 HBV outbreaks, published in the open access journal BMC Medicine, has shown that the most frequent HBV transmission routes are administration of drugs using multi-vial compounds and capillary blood sampling (e.g. for glucose monitoring) using non-disposable devices.
Simone Lanini led a team of researchers from the Istituto Nazionale per le Malattie Infettive Lazzaro Spallanzani, Rome, who performed a systematic review of HBV outbreaks published between 1992 and 2007 within the European Union and the United States. Lanini said, “HBV remains an important cause of liver disease in developed countries. Moreover, the virus has long been recognized as one of the most insidious viral agents within healthcare settings, and in fact a number of HBV outbreaks in healthcare are reported yearly in the USA and the European Union”.
The authors included 30 papers in their review, featuring information on 33 HBV outbreaks, involving 471 patients and 16 fatal cases. Sixteen out of the 33 outbreaks were from EU countries; the remaining 17 outbreaks were from the USA.
Read the full story on News-Medical.net
Hepatitis B doctor suspended
April 7, 2009
Intravenous news: FoxNews.com report “State regulators on Friday temporarily suspended the medical license of a doctor who health officials suspect is linked to a hepatitis B outbreak.
Nearly 3,000 of Dr. Parvez Dara’s patients have been warned to get tested after five cancer patients tested positive for the disease, which is transmitted through exposure to infected blood and can cause serious liver damage.
On Friday, the state presented evidence about the conditions at the oncologist’s Toms River office. Investigators said they found blood on the floor of a room where chemotherapy was administered, blood in a bin where blood vials were stored, open medication vials and unsterile saline and gauze”.
Click here for the full story on FoxNews.com
TimestripIV
April 6, 2009
Intravenous products: SmallCapNews.co.uk report “Smart label company Timestrip has agreed a partnership deal with hospital supplies business Brenmoor Ltd that will see it introduce a new product to Brenmoor’s range of printable patient wristbands that are used widely within the NHS. This is the second product in the newly launched TimestripMedical range. Timestrip and Brenmoor have developed a detachable clip with fully integrated TimestripIV technology, which will be attached directly onto the clasp of the Brenmoor wristband. The process of attaching the clip to the wristband will also activate the TimestripIV.
TimestripIV has been designed to help hospitals comply with existing policy directives that stipulate the need to change Peripheral Intravenous Cannulae (PVCs) every 72 hours. The company announced the launch of TimestripIV on last week alongside an order from the Whittington Hospital to allow them to undertake an in-use assessment of the product.
Click here for the full story on SmallCapNews.co.uk
Medical Device Safety Calendar 2009
April 6, 2009
Intravenous news: The FDA report ‘FDA has received many reports of patient injuries and deaths when different device delivery systems are mistakenly connected to each other. These errors are often facilitated by fittings called Luer connectors, which allow different systems to be easily, but erroneously, connected.
The 2009 Medical Device Safety Calendar is one of FDA’s efforts to help educate healthcare professionals about these dangerous misconnections. The calendar provides a graphic depiction of a variety of misconnection cases, coupled with recommendations from The Joint Commission on ways to prevent these types of errors. We hope the calendar will be posted as a year-long reminder to staff that these errors can occur in any clinical setting. We also urge clinicians to use the case synopses and recommendations as on-going training materials. They can be downloaded free of charge by going to the website. Clinical facilities may also request copies of the calendar while supplies last.
For more information from the FDA watch the video below.
Click here to view a pdf of the calendar.
Click here for the this item on the FDA website.
Heparin error update from FDA
April 6, 2009
Intravenous news: The FDA report “The Institute for Safe Medication Practices (ISMP) points out that some multiple dose heparin vials have potentially confusing labels that could lead to dangerous overdoses. These vials, which contain 4 mL of heparin solution, are labeled “10,000 USP units/ 1 mL,” with the “10,000″ in larger print than the rest of the designation. Because of this, someone quickly reading the label could assume that the entire vial contains 10,000 units. Calculating the patient’s dose based on that mis-reading of the label could result in a fourfold overdose.
To help avoid this potential hazard, ISMP suggests that hospitals consider whether they need heparin in vials that contain more than 10,000 units per vial”.
For more information from the FDA watch the video below.
Read the ISMP Medication Safety Alert! Is It Really Needed? January 15, 2009.
Read the link on the FDA website.
Unintentional injection
April 6, 2009
Intravenous literature: News-Medical.net report that “Researchers find an increased rate of unintentional injection of epinephrine from auto-injectors for anaphylaxis (severe allergic reactions) and urge people who may need to administer the life-saving drug to themselves or others in an allergic emergency to receive regular coaching in its proper use.
The report is published this month in Annals of Allergy, Asthma & Immunology, the scientific journal of the American College of Allergy, Asthma and Immunology (ACAAI).
More than 50 million Americans suffer from some type of allergy. While an allergy often makes people miserable, it’s rarely dangerous, unless it results in an anaphylactic reaction, an allergic emergency. Fast-acting, self-administered epinephrine (adrenaline) auto-injectors are commonly prescribed for people who are at risk of anaphylaxis.
Systematically reviewing 26 reports published in peer-reviewed journals during the past 20 years, F. Estelle R. Simons, M.D., Department of Pediatrics and Child Health, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada, and colleagues in the United States, found that most of the 69 incidents of unintentional injection of epinephrine reported to date in the medical literature have occurred during the past 6 years”.
Click here for the full story on Medical-News.net
Anaphylaxis after long-term IV
April 4, 2009
Intravenous literature: Chen, J., Song, X., Yang, P. and Wang J. (2009) Appearance of anaphylactic shock after long-term intravenous itraconazole treatment. Annals of Pharmacotherapy. 43(3), p.537-41.
Abstract:
OBJECTIVE: To report a rare but severe adverse effect of intravenous itraconazole, anaphylactic shock with hypotension and hypoxemia, in a female patient with acute lymphoblastic leukemia (ALL).
CASE SUMMARY: A 36-year-old woman with ALL received antifungal therapy for pulmonary fungal infections. On day 17 of itraconazole treatment, she developed hypotension and hypoxemia shock after intravenous administration of itraconazole 200 mg, which was eventually reversed by steroid treatment. On days 18 and 19, the patient developed the same type of shock 2 more times in the course of itraconazole administration. These 2 episodes of shock occurred more quickly after intravenous itraconazole administration (100 mg on day 18, 40 mg on day 19), and were reversed by stopping itraconazole and applying steroid treatment. In the modified antifungal therapy, intravenous administration of itraconazole was replaced by oral administration of voriconazole 200 mg twice daily. Shock did not recur after discontinuation of itraconazole treatment. The Naranjo probability scale showed a probable relationship between itraconazole treatment and shock occurrence.
DISCUSSION: Itraconazole is a widely used antifungal drugs and is well tolerated. However, long-term itraconazole treatment might lead to serious and even life-threatening adverse effects such as anaphylactic shock, as seen in our patient. T cell reduction caused by immunosuppression and itraconazole accumulation in patients with ALL are considered to be important causal factors for this delayed-type hypersensitivity reaction.
CONCLUSIONS: Anaphylactic shock represents a previously undocumented severe adverse effect associated with long-term itraconazole treatment; patients receiving this therapy and should be monitored closely.
Neck ultrasound following PICC placement
April 4, 2009
Intravenous literature: Schweickert, W.D., Herlitz, J., Pohlman, A.S., Gehlbach, B.K., Hall, J.B. and Kress, J.P. (2009) A randomized, controlled trial evaluating postinsertion neck ultrasound in peripherally inserted central catheter procedures. Critical Care Medicine. 37(4), p.1217-21.
Abstract:
OBJECTIVE: Insertion of peripherally inserted central catheters (PICCs) at the bedside may result in tip malposition. This study was designed to evaluate whether the addition of ultrasound (US) inspection of the ipsilateral neck provides immediate recognition of PICCs in aberrant position facilitating catheter reposition before completion of the procedure.
DESIGN: Randomized, controlled trial.
SETTING: University-affiliated hospital.
PATIENTS: Totally, 300 patients ordered for PICC placement.
INTERVENTIONS: Patients were randomized to either postinsertion US inspection of the ipsilateral neck (intervention, n = 151) or to usual practice (control, n = 149). In the intervention group, catheters detected by US to be traveling within the ipsilateral internal jugular vein (IJ), were further adjusted before procedural completion. All procedures included US localization of the peripheral vein and postprocedural chest radiograph to assess catheter tip position. The primary end point was defined as the rate of PICC tip malposition in the ipsilateral IJ as detected by postprocedure chest radiograph. The secondary end point was procedure duration.
MEASUREMENTS AND MAIN RESULTS: In the control arm, 140 of 149 PICC placement attempts (94%) were completed, including 11 procedures with catheter tips terminating in the ipsilateral IJ (7.9%). In the intervention arm, 142 of 151 attempts (94.7%, p = 0.98) were completed; one procedure resulted in a catheter tip in the ipsilateral IJ (0.7%, p = 0.007). Eleven intervention procedures included successful PICC repositioning during the initial procedure based on US detection of malposition. The median duration of the procedure in the control group was 8 minutes (6-10.5 minutes) and increased to 9.0 minutes (7-11 minutes) in the intervention group.
CONCLUSIONS: Bedside PICC placement morbidity can be reduced via US inspection of the ipsilateral neck for PICC tip malposition in the IJ. This modality can guide catheters to be successfully repositioned during the initial procedure.
Antibiotic treatment for Lyme disease
April 4, 2009
Intravenous literature: Cameron, D.J. (2009) Insufficient evidence to deny antibiotic treatment to chronic Lyme disease patients. Medical Hypotheses. 72(6), p.688-91.
Abstract:
BACKGROUND: The severity, length of illness, and cost of chronic Lyme disease (CLD) have been well described. A number of oral, intravenous, and intramuscular antibiotics have been prescribed for CLD. Surprisingly few antibiotic schedules prescribed for the treatment of CLD have been evaluated in randomized double-blind placebo-controlled clinical trials (RCTs). Physicians have increasingly turned to clinical treatment guideline (CPG) panels to judge the mixed results of the evidence. Two CPG panels have looked at the evidence only to reach opposite conclusions: (1) antibiotic therapy for CLD is not effective and (2) antibiotic therapy for CLD is effective. Physicians have been advised by guideline developers to use clinical discretion in diagnosing and treating CLD. Nevertheless, many health insurers – relying exclusively upon only one CPG – have a policy of automatically denying antibiotics to CLD patients regardless of the specifics of each case or the recommendations of the patient’s physician.
HYPOTHESES: This paper examined the eight limitations of the evidence used to conclude that antibiotics therapy for CLD is not effective in forming the following hypothesis: insufficient evidence to deny antibiotic treatment to CLD patients.
EVIDENCE FOR THE HYPOTHESIS: There are eight limitations that support the hypothesis: (1) the power of the evidence is inadequate to draw definite conclusions, (2) the evidence is too heterogeneous to make strong recommendations, (3) the risk to an individual of facing a long-term debilitating illness has not been considered, (4) the risk to society of a growing chronically ill population has not been considered, (5) treatment delay has not been considered as a confounder, (6) co-infections have not been considered as a confounder, (7) the design of RCTs did not address the range of treatment options in an actual practice, and (8) the findings cannot be generalized to actual practice.
IMPLICATIONS OF THE HYPOTHESES: This hypothesis suggests that physicians should consider the limitations of the evidence before denying antibiotic treatment for CLD. Physicians who deny antibiotic treatment to CLD patients might inform their patients that there are some clinicians who disagree with that position, and then offer to refer them for a second opinion to a doctor who could potentially present a different point of view. The hypothesis also suggests that health care insurers should consider the limitations of the evidence before adopting policies that routinely deny antibiotic treatment for CLD patients and should expand coverage of CLD to include clinical discretion for specific clinical situations.
More intravenous news at IVTEAM
Portable ultrasound
April 4, 2009
Intravenous literature: Johnson, M.A., McKenzie, L., Tussey, S., Jacobs, H. and Couch, C. (2009) Portable ultrasound: A cost-effective process improvement tool for PICC placement. Nursing Management. 40(1), p.47-50.
Abstract not available
Ultrasound-guided peripheral IV placement
April 3, 2009
Intravenous literature: Doniger, S.J., Ishimine, P., Fox, J.C. and Kanegaye, J.T. (2009) Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients. Pediatric Emergency Care. 25(3), p.154-9.
Abstract:
OBJECTIVES: We hypothesized that the use of ultrasound guidance would improve the success rate of peripheral intravenous catheter placement in pediatric patients with difficult access in a pediatric emergency department (ED). Our secondary hypotheses were that ultrasound guidance would reduce the number of attempts, the number of needle redirections, and the overall time to catheter placement.
METHODS: This was a prospective randomized study of pediatric ED patients younger than 10 years old requiring intravenous access, presenting between August 2006 and May 2007. Inclusion criteria were 2 unsuccessful traditional attempts at peripheral intravenous access or history of difficult access. Exclusion was critical illness or instability. Patients were randomized to undergo peripheral intravenous catheter placement using continued traditional approaches or real-time, dual-operator ultrasound-guided technique. Measured outcomes were success of cannulation, number of attempts, number of needle redirections, and overall time to catheter placement.
RESULTS: Fifty patients were enrolled, with 25 patients randomized to each group. The overall success rates for the ultrasound-guided group were 80% and for the traditional-attempts group, 64%, with a difference in proportions of 16% (95% confidence interval, -9% to 38%, P = 0.208). The ultrasound-guided group required less overall time (6.3 vs 14.4 minutes, difference of -8.1 minutes [95% confidence interval, -12.5 to -3.6], P = 0.001), fewer attempts (median, 1 vs 3; P = 0.004), and fewer needle redirections (median, 2 vs 10; P G 0.0001) than traditional approaches.
CONCLUSIONS: In a sample of pediatric ED patients with difficult access, ultrasound-guided intravenous cannulation required less overall time, fewer attempts, and fewer needle redirections than traditional approaches.
Implantable port complications
April 3, 2009
Intravenous literature: Dickinson, M.G., Scholvinck, E.H., Boonstra, A., Vonk-Noordegraaf, A., Snijder, R.J. and Berger, R.M. (2009) Low complication rates with totally implantable access port use in epoprostenol treatment of pulmonary hypertension. Journal of Heart & Lung Transplantation. 28(3), p.273-9.
Abstract:
BACKGROUND: Among patients with advanced pulmonary arterial hypertension (PAH) who are receiving epoprostenol treatment, complications due to the delivery system are known to be a cause of serious morbidity and mortality. In this study, we aimed to outline the complications associated with the use of a totally implantable access port (TIAP) and their consequences in continuous intravenous epoprostenol treatment.
METHODS: One hundred eleven pulmonary hypertension (PH) patients treated with epoprostenol through a totally implantable access port (TIAP) between May 1998 and July 2006 at three Dutch PH referral centers were retrospectively studied.
RESULTS: During a mean follow-up period of 946 +/- 719 days, TIAP-related complications included local port site infections, bloodstream infections, port site skin perforations and incorrect port placement, with incidence rates of 0.11, 0.15, 0.06 and 0.04 per patient-year, respectively. Fatal, serious, moderate and minor consequences of these complications had incidence rates of 0.01, 0.50, 0.09 and 0.01 per patient-year, respectively. The median complication-free survival was 371 days. Staphylococcus aureus was the dominant infectious agent. The median TIAP life duration was 677 days. Female patients showed significantly longer first TIAP survival (p = 0.004).
CONCLUSIONS: The use of a TIAP showed long-lasting port survival and relatively low complication rates. Our data suggest that the TIAP is well suited for continuous intravenous epoprostenol delivery in patients with pulmonary hypertension.
Nurse charged with murder
April 3, 2009
Intravenous news: The New York Times report on a “A nurse has been charged with murdering five patients at a clinic in Lufkin, Tex., by injecting bleach into their veins while they were undergoing kidney dialysis, local authorities said Thursday.
The arrest of the nurse, Kimberly Saenz, 35, this week appeared to resolve the mystery surrounding a spike in deaths and sudden illnesses at the DaVita Dialysis clinic a year ago. State records show 19 people died at the clinic in the five months before Ms. Saenz was fired in late April 2008; that number was well above the state’s average rate.
The police say they have found evidence linking Ms. Saenz to at least five of those deaths, including three on a single day — April 1, 2008. She is also charged with sickening five other patients, who survived despite having doses of bleach added to their intravenous tubes during dialysis. If convicted, Ms. Saenz faces the death penalty”.
Click here for the full story from the New York Times.
Shaving skin before IV
April 1, 2009
Intravenous news: Researchers have found that shaving an area of skin over the jugular vein before the insertion of a catheter is the best course to reduce the risk of infection.
Intravenous catheters are commonly used to administer ongoing fluid therapy, give medications and take blood samples. However, they do carry risks, in particular thrombosis and infection. Even healthy skin carries bacteria that could cause problems if introduced with the catheter, so it is important to disinfect the site beforehand. A study at Glasgow University looked at techniques used to prepare the skin for inserting catheters.
Equine Science Update reports that they took swabs from the skin overlying the jugular veins before and after clipping or shaving the hair and after disinfection. Well it is April 1st 
