Accidental arterial cannulation

Intravenous literature: Blaivas, M. (2009) Video analysis of accidental arterial cannulation with dynamic ultrasound guidance for central venous access. Journal of Ultrasound in Medicine. 28, p.1239-1244.

Abstract:

Objective. Accidental arterial cannulation during ultrasound-guided central venous cannulation is rarely reported and should be much less likely with dynamic guidance. Although accidental arterial penetration with the needle may occur periodically without notice and with little harm, actual arterial dilation and line placement may result in serious complications.

Methods. This series reports 6 such cases of accidental arterial cannulation and central line insertion under dynamic ultrasound guidance.

Results. Two of the arterial cannulations resulted in airway loss, with 1 of these ending in death. The remaining 4 arterial lines led to serious local complications. Ultrasound video analysis of each line placement or postplacement analysis was reviewed, and common pitfalls were extracted. In 3 cases, a central line went directly through the internal jugular vein (IJ) and into the carotid artery. In 1 case, a cordis introducer sheath traveled through the posterior wall of the common femoral vein and into the deep femoral artery branch below. Each patient was hypotensive and hypoxic, making traditional safety checkpoints such as aspiration of bright red blood and pulsatile flow from the syringe hub less reliable in identifying accidental arterial cannulation. All ultrasound-guided cannulations were performed by a standard short-axis approach with high-resolution linear array ultrasound transducers on modern equipment.

Conclusions. The short-axis approach, as seen in this series, can provide a false sense of security to the practitioner and allows for potentially dangerous accidental arterial cannulation. In the setting of critically ill patients, it may be prudent to not only visualize the entire path of the needle with the long-axis approach but also confirm correct cannulation by tracing the guide wire in the long axis before line placement.

Safety IV device demand grows

Intravenous products: InfectionControlToday.com report “A new market research report, “U.S. Infection Prevention Products & Services,” from Reportlinker.com projects that the total demand for infection prevention products and services will increase 4.5 percent annually through 2013. Growth will partially reflect the impact of new government legislation and changing health insurance reimbursement policies aimed at reducing the incidence of healthcare-acquired infections (HAIs). Gains will also be driven by efforts to reduce the incidence of HAIs in healthcare and life science institutions, prompting upgrades to standards involving patient and staff hygiene and protection, facility cleaning and disinfection, device and instrument sterilization and medical waste collection and disposal.

According to the report, safety-enhanced devices for IV and injectable drug delivery and in vivo fluid withdrawal, along with high-quality apparel, textiles and disinfectants for surgical procedures, will remain the top selling groups of infection prevention products. An increasing percentage of the syringes, catheters, IV administration sets, blood collection supplies and other disposable sharp instruments employed by the medical community will incorporate safety components designed to prevent accidental needlesticks and associated infections after use.”

Click here for the full story.

Zero BSI website launched

Intravenous news: InfectionControlToday.com report “As a market leader committed to educating the clinical community about patient and clinician safety, CareFusion is introducing the Getting to Zero BSI Web site to provide timely, evidence-based resources to help guide clinicians and their healthcare facilities and to speed their “Getting to Zero BSI” journey. The Web site contains a wealth of resources that explain the many means by which catheter-associated bloodstream infections (CA-BSIs) can occur as well as a variety of data-driven techniques that can be employed to help reduce them and to therefore facilitate a community of practice.”

Click here to view the website.

Safety IV cannula newsletter

Intravenous news: BBraun have published the summer 2009 edition of Safety News. Topics include Maidstone and Tunbridge Wells NHS Trust safety news and the launch of IV cannula packs into the George Eliot NHS Trust in Warwickshire. Click here to view the newsletter.

Click here for iv safety cannula product information.

Introduction

“As you may be aware, following first stage consultation back in December 2006 the European Commission considered that the protection of workers against blood-borne infections resulting from needlestick injuries should be improved. The Commission felt that too many European health sector workers were exposed to needlestick injuries and considered that Member States must make an effort to apply national legislation in this area.”

Click here to view the full newsletter.

Click here for iv safety cannula product information.

IV safety catheters

Intravenous products: IVTEAM welcome the publication of our second sponsored product page. This particular page is dedicated to safety IV catheters. You will find product information, a useful cannula insertion video, corporate information and contacts.

Click here to visit the product page.

Line infection prevention with Ethanol lock

Intravenous literature: Broom, J.K., O’Shea, S., Govindarajulu, S., Playford, G., Hawley, C.M., Isbel, N.M., Campbell, S.B., Mudge, D.W., Carpenter, S., Johnson, B.C., Underwood, N.P. and Johnson, D.W. (2009) Rationale and design of the HEALTHY-CATH trial: A randomised controlled trial of Heparin versus EthAnol Lock THerapY for the prevention of Catheter Associated infecTion in Haemodialysis patients. BMC Nephrology, 20(23).

Abstract:

Background - Catheter-related bacteraemias (CRBs) contribute significantly to morbidity, mortality and health care costs in dialysis populations. Despite international guidelines recommending avoidance of catheters for haemodialysis access, hospital admissions for CRBs have doubled in the last decade. The primary aim of the study is to determine whether weekly instillation of 70% ethanol prevents CRBs compared with standard heparin saline.

Methods - The study will follow a prospective, open-label, randomized controlled design. Inclusion criteria are adult patients with incident or prevalent tunneled intravenous dialysis catheters on three times weekly haemodialysis, with no current evidence of catheter infection and no personal, cultural or religious objection to ethanol use, who are on adequate contraception and are able to give informed consent. Patients will be randomized 1:1 to receive 3mL of intravenous-grade 70% ethanol into each lumen of the catheter once a week and standard heparin locks for other dialysis days, or to receive heparin locks only. The primary outcome measure will be time to the first episode of CRB, which will be defined using standard objective criteria. Secondary outcomes will include adverse reactions, incidence of CRB caused by different pathogens, time to infection-related catheter removal, time to exit site infections and costs. Prospective power calculations indicate that the study will have 80% statistical power to detect a clinically significant increase in median infection-free survival from 200 days to 400 days if 56 patients are recruited into each arm.

Discussion - This investigator-initiated study has been designed to provide evidence to help nephrologists reduce the incidence of CRBs in haemodialysis patients with tunnelled intravenous catheters. Trial Registration: Australian New Zealand Clinical Trials Registry Number: ACTRN12609000493246

Provisional pdf.

IRadimed MRI IV pump FDA clearance

IRadimed announces 510K Clearance of the New Non Magnetic MRidium MRI IV Pump with Integrated Masimo SET SpO2 Monitoring

Intravenous products: The United States Food and Drug Administration has granted IRadimed Corporation clearance of its new MRidium 3860+ MRI Infusion System with integrated Masimo SET SpO2 Monitoring. Transport to the MRI for Sedation, Critical Care, and Cardiac Patients to date has required multiple pieces of equipment, with hospital infusion pumps and SpO2 being typically not designed to be integrated and functional in the MRI. Clinicians no longer have to remember each time when they get to the door of the MRI to remove their standard hospital SpO2 equipment so that it does not become a dangerous projectile, or risk a patient burn, in the MR environment. IRadimed has innovatively combined two critically needed technologies for the MRI to increase productivity, patient safety, and ease of transport to, from, and within, the MRI.

The Innovative MRidium 3860+ MRI Infusion System is the first Non Magnetic IV Pump designed specifically for use in the MRI Environment with Integrated Masimo SET technology. “We chose the Masimo SET technology because it has such an excellent reputation in the marketplace. “Masimo’s systems are viewed by most as one of the best monitoring technologies in the world.” said Todd Weber, VP Sales and Marketing. Safety in the MR is the primary concern when it comes to meeting needs for required patient care. These risks are all well known, as essential IV and monitoring equipment can: fly into the bore, cause artifacts on the images, become un-reliable during crucial deliveries of medications and monitoring, or shut down completely when needed the most. Use of improper pulse oximeters has caused severe burns to patients due to the high RF fields involved within MR scanners. “It is critical to have products which have been designed with the utmost care and thorough insight of this harsh and potentially dangerous environment,” said Roger Susi, founder of IRadimed Corporation.

Click here for the full press release.

ChloraPrep® video with David Mitchell

Intravenous products: Enturia, makers of ChloraPrep®, the 2% chlorhexidine gluconate in 70% isopropyl alcohol skin antisepsis system have produced a fun animation (with the voice of David Mitchell) that examines the skin.

Infusion error deaths

Intravenous news: ISMP.org report “ISMP recently learned about the tragic deaths of two 6-year-old children stemming from severe postoperative hyponatremia. The fatal events occurred at two different hospitals. In at least one of these cases, it is clear that the rapid administration of plain D5W (dextrose 5% in water) postoperatively resulted in acute hyponatremia secondary to free water retention (also called water intoxication, which is described below). Postoperative children are at high risk for developing hyponatremia, and many fatalities from this disorder have been reported in the literature. When the serum sodium concentration rapidly falls below 120 mEq/L over 24 to 48 hours—as in the two events described below—the body’s compensatory mechanism is often overwhelmed and severe cerebral edema ensues, resulting in brainstem herniation, mechanical compression of vital midbrain structures, and death.”

Click here for the full article.

Simulated skills reduce CRBSI

Intravenous literature: Barsuk, J.H., Cohen, E.R., Feinglass, J., McGaghie, W.C. Wayne, D.B. (2009) Use of simulation-based education to reduce catheter-related bloodstream infections. Archives of Internal Medicine. 169(15), p.1420-3.

Abstract:

BACKGROUND: Simulation-based education improves procedural competence in central venous catheter (CVC) insertion. The effect of simulation-based education in CVC insertion on the incidence of catheter-related bloodstream infection (CRBSI) is unknown. The aim of this study was to determine if simulation-based training in CVC insertion reduces CRBSI.

METHODS: This was an observational education cohort study set in an adult intensive care unit (ICU) in an urban teaching hospital. Ninety-two internal medicine and emergency medicine residents completed a simulation-based mastery learning program in CVC insertion skills. Rates of CRBSI from CVCs inserted by residents in the ICU before and after the simulation-based educational intervention were compared over a 32-month period.

RESULTS: There were fewer CRBSIs after the simulator-trained residents entered the intervention ICU (0.50 infections per 1000 catheter-days) compared with both the same unit prior to the intervention (3.20 per 1000 catheter-days) (P = .001) and with another ICU in the same hospital throughout the study period (5.03 per 1000 catheter-days) (P = .001).

CONCLUSIONS: An educational intervention in CVC insertion significantly improved patient outcomes. Simulation-based education is a valuable adjunct in residency education.

OHPAT service review

Intravenous literature: Hitchcock, J., Jepson, A.P., Main, J. and Wickens, H.J. (2009) Establishment of an outpatient and home parenteral antimicrobial therapy service at a London teaching hospital: a case series. Journal of Antimicrobial Chemotherapy. 64(3), p.630-4.

Abstract:

BACKGROUND: Outpatient and home parenteral antimicrobial therapy (OHPAT) is becoming increasingly commonplace in the UK, enabling those patients who would previously have been obliged to remain in hospital for intravenous treatment to be managed as outpatients or in their own homes. The OHPAT service at St Mary’s Hospital, London, was established in 2004. This paper describes the types of infection, antimicrobial management and outcomes of patients referred to the service in the 3.5 years since its inception.

PATIENTS AND METHODS: All inpatients were eligible for OHPAT, provided that they had a serious infection requiring parenteral therapy, were well enough to leave hospital and fulfilled other criteria. We initially used an outpatient clinic model, but as the service developed, treatment was often delivered in patients’ homes, with the OHPAT team providing training and assessment of primary care staff.

RESULTS: Four hundred and sixty-seven patients were referred to the service between September 2004 and April 2008. Of these, 273 received 303 courses of OHPAT, 48 were discharged on oral therapy and 3 patients declined outpatient therapy; the remaining 143 patients were deemed unsuitable for inclusion, most commonly because the patient was too unwell for discharge (28.7%) or their social situation was inappropriate (14.7%). Causative organisms were identified in two-thirds of cases, with methicillin-resistant Staphylococcus aureus implicated in one-third of these. Mean treatment length was 24 days (range 1-165 days), with 7394 inpatient bed-days saved. Less than 5% of patients were readmitted within 28 days with infection- or drug-related problems. There were no cases of Clostridium difficile-associated diarrhoea during or after outpatient treatment, despite extensive use of cephalosporins and other broad-spectrum agents. Patients found the service highly satisfactory and felt that it had improved their quality of life during the treatment period.

CONCLUSIONS: The introduction of the OHPAT service at St Mary’s Hospital has proved to be of benefit to patients and hospital efficiency alike.

Nutritional support networks

Intravenous literature: Powell-Tuck, J. (2009) Teams, strategies and networks: developments in nutritional support; a personal perspective. Proceedings of the Nutrition Society. 68(3), p.289-95.

Abstract:

Chris Pennington was an archetypal team player, strategist and networker. Clinical nutritional support has progressed remarkably since the 1970s and it has been a privilege to work in this field over this period during which teamwork, strategy development and networking have been crucial. British experience has been characterised by groups of individuals of differing professions and specialties coming together to enable progress to be made. This approach was initially in the form of nutrition support teams orientated to patient-centred ward-based care, then as hospital strategic committees and the concept of the ‘patient journey’. Indeed, the formation of the British Association for Parenteral and Enteral Nutrition (now known as BAPEN) in 1992 required the statesmanlike burying of jealousies as societies came together into a multiprofessional association. With the understanding that disease-related malnutrition was highly prevalent it became apparent that it must be managed on a broad and organised clinical front. In the Organisation of Food and Nutritional Support in Hospitals a group of professionals developed for BAPEN concepts of hospital-wide organisation to tackle malnutrition that were based on previous reports, both national and international, and were made easily accessible from the BAPEN website, especially the ‘Malnutrition Universal Screening Tool’ and the National Institute for Health and Clinical Excellence nutrition guidelines. The coming together of six national clinical societies to develop evidence-based consensus guidelines for intravenous saline therapy (also on the BAPEN website) has shown that BAPEN can catalyse opinion well beyond its own nutritional constituency. In England Chris Pennington’s Scottish lead is being followed by developing a patient-centred strategic framework for a managed home parenteral nutrition and intestinal failure national network. In research, education or clinical practice the engines of progress have been teams, strategies and networks.

Subclavian venous catheterization

Intravenous literature: Czarnik, T., Gawda, R., Perkowski, T. and Weron, R. (2009) Supraclavicular approach is an easy and safe method of subclavian vein catheterization even in mechanically ventilated patients: analysis of 370 attempts. Anesthesiology. 111(2), p.334-339.

Abstract:

BACKGROUND: Central venous catheters are commonly inserted for hemodynamic monitoring, volume monitoring, administration of medications, long-term total parenteral nutrition, access for renal replacement therapy, cardiopulmonary resuscitation, and difficult peripheral catheterization. The primary outcome of this study was to define venipuncture, catheterization and entire procedure success rates, and finally complication rate of subclavian venous catheterization via the supraclavicular approach with special focus on mechanically ventilated patients. The secondary outcome was to potentially make recommendations regarding this technique of central venous catheterization in mechanically ventilated patients.

METHODS: The methodology of this prospective cohort study included subclavian venous catheterization via the supraclavicular approach. The technique of cannulation was the same for both the right and left sides, but the right claviculosternocleidomastoid angle was the preferred catheterization site. All procedures were performed by the first three authors, each of whom had different levels of experience. Each physician had performed at least 20 procedures before starting the study.

RESULTS: In the majority of patients, venipuncture occurred during the first attempt. In 362 patients, catheterization attempts were performed, in whom 311 catheterizations (85.6%) were successful during the first attempt. The overall subclavian venous catheterization via supraclavicular approach procedure complication rate reached 1.7% (95% confidence interval 0.6-3.6%). The overall subclavian venous catheterization via the supraclavicular approach procedure success rate reached 88.9% (95% confidence interval 85.1-91.9%, n = 359).

CONCLUSIONS: Subclavian venous catheterization via the supraclavicular approach is an excellent method of central venous access in mechanically ventilated patients. The procedure success rate and the significant complication rate are comparable to other techniques of central venous catheterization.

CVC guidelines for parenteral nutrition

Intravenous literature: Pittiruti, M., Hamilton, H., Biffi, R., MacFie, J. and Pertkiewicz, M. (2009) ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clinical Nutrition. 28(4), p.365-77.

Abstract:

When planning parenteral nutrition (PN), the proper choice, insertion, and nursing of the venous access are of paramount importance. In hospitalized patients, PN can be delivered through short-term, non-tunneled central venous catheters, through peripherally inserted central catheters (PICC), or – for limited period of time and with limitation in the osmolarity and composition of the solution – through peripheral venous access devices (short cannulas and midline catheters). Home PN usually requires PICCs or – if planned for an extended or unlimited time – long-term venous access devices (tunneled catheters and totally implantable ports). The most appropriate site for central venous access will take into account many factors, including the patient’s conditions and the relative risk of infective and non-infective complications associated with each site. Ultrasound-guided venepuncture is strongly recommended for access to all central veins. For parenteral nutrition, the ideal position of the catheter tip is between the lower third of the superior cava vein and the upper third of the right atrium; this should preferably be checked during the procedure. Catheter-related bloodstream infection is an important and still too common complication of parenteral nutrition. The risk of infection can be reduced by adopting cost-effective, evidence-based interventions such as proper education and specific training of the staff, an adequate hand washing policy, proper choices of the type of device and the site of insertion, use of maximal barrier protection during insertion, use of chlorhexidine as antiseptic prior to insertion and for disinfecting the exit site thereafter, appropriate policies for the dressing of the exit site, routine changes of administration sets, and removal of central lines as soon as they are no longer necessary. Most non-infective complications of central venous access devices can also be prevented by appropriate, standardized protocols for line insertion and maintenance. These too depend on appropriate choice of device, skilled implantation and correct positioning of the catheter, adequate stabilization of the device (preferably avoiding stitches), and the use of infusion pumps, as well as adequate policies for flushing and locking lines which are not in use.

Home intravenous antibiotic treatment

Intravenous literature: Sequeiros, I.M. and Jarad, N.A. (2009) Home intravenous antibiotic treatment for acute pulmonary exacerbations in cystic fibrosis – Is it good for the patient? Annals of Thoracic Medicine. 4(3), p.111-4.

Abstract:

There is a worldwide drive for the home management of chronic respiratory diseases. With the widespread use of home intravenous (IV) treatment for cystic fibrosis (CF) pulmonary exacerbations (PExs), evidence pointing to an inferior outcome of care for home-treated patients in comparison to hospital-treated patients is a cause of concern. Currently, patients who self-administer IV antibiotics at home are provided with equipment and instructions on the use of antibiotics. Policies vary; but in most UK centers, these patients are then followed up by the multidisciplinary team only on days 1, 7 and 14 of the treatment course. We aimed to review the current published literature in search for evidence for the value and the shortfalls of self-administered IV treatment at home for acute PExs in CF patients in comparison to conventional hospital treatment. We searched the electronic database system Medline for published papers regarding studies comparing home- and hospital-based IV antibiotic treatment for both adult and pediatric CF patients. Sixteen studies were identified and grouped into those that showed a similar outcome between home and hospital treatment and those that showed an inferior outcome for home management. Most studies were retrospective or inadequately powered to provide clear answers. Ideally, outcome of care for home treatment should be at least equal to outcome for hospital treatment. Extensive efforts should be made to standardize therapies preserving the advantages of home management and addressing the perceived reasons for an inferior outcome. Until further studies provide definitive answers, treatment at home should be reserved for adequately selected patients and individualized depending on the unique settings of each CF center and specific patients’ requirements. There is great need for a prospective randomized controlled trial comparing home and hospital treatments in order to clarify this matter.

Anaphylaxis following IV fluorescein

Intravenous literature: Bearelly, S., Rao, S. and Fekrat, S. (2009) Anaphylaxis following intravenous fluorescein angiography in a vitreoretinal clinic: report of 4 cases. Canadian Journal of Ophthalmology. 44(4), p.444-5.

Abstract:

OBJECTIVE: To assess the incidence of anaphylaxis following intravenous fluorescein angiography (IVFA) at 1 satellite clinic.

STUDY DESIGN: Observational case series.

PARTICIPANTS: Records from 1400 patients were reviewed.

METHODS: Consecutive vitreoretinal patients who underwent IVFA between 1998 and 2005 at 1 satellite office were included for retrospective analysis.

RESULTS: Anaphylaxis developed in 4 of 1400 (0.3%) patients within minutes after they had received intravenous fluorescein. In each case, the reaction was recognized promptly and treated with injectable epinephrine by the physician, and symptoms resolved quickly. The ambulance was called in all 4 cases. In the literature, reports of 21 cases of anaphylaxis and 7 deaths have been published in the past 55 years.

CONCLUSIONS: Although uncommon, anaphylaxis as a reaction to intravenous fluorescein does occur. As this is potentially life-threatening, prompt diagnosis and treatment are crucial. An emergency care plan should be available.

Skin preparation prior to blood donation

Intravenous literature: Webster, J., Bell-Syer, S.E. and Foxlee, R. (2009) Skin preparation with alcohol versus alcohol followed by any antiseptic for preventing bacteraemia or contamination of blood for transfusion. Cochrane Database of Systematic Reviews. 3.

Abstract:

Background - Blood for transfusion may become contaminated at any point between collection and transfusion and may result in bacteraemia (the presence of bacteria in the blood), severe illness or even death for the blood recipient. Donor arm skin is one potential source of blood contamination, so it is usual to cleanse the skin with an antiseptic before blood donation. One-step and two-step alcohol based antiseptic regimens are both commonly advocated but there is uncertainty as to which is most effective.

Objectives - To assess the effects of cleansing the skin of blood donors with alcohol in a one-step compared with alcohol in a two-step procedure to prevent contamination of collected blood or bacteraemia in the recipient.

Search strategy - We searched the Cochrane Wounds Group Specialised Register (March 10 2009); The Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane Library 2009, Issue 1; Ovid MEDLINE – (1950 to February Week 4 2009); Ovid EMBASE – (1980 to 2009 Week 9); and EBSCO CINAHL – (1982 to February Week 4 2009). We also searched the reference lists of key papers.

Selection criteria - All randomised trials (RCTs) comparing alcohol based donor skin cleansing in a one-step versus a two-step process that includes alcohol and any other antiseptic for pre-venepuncture skin cleansing were considered. Quasi randomised trials were to have been considered in the absence of RCTs.

Data collection and analysis - Two review authors independently assessed studies for inclusion.

Main results - No studies (RCTs or quasi RCTs) met the inclusion criteria.

Authors’ conclusions - We did not identify any eligible studies for inclusion in this review. It is therefore unclear whether a two-step, alcohol followed by antiseptic skin cleansing process prior to blood donation confers any reduction in the risk of blood contamination or bacteraemia in blood recipients, or conversely whether a one-step process increases risk above that associated with a two-step process.

Click here for the full text article.

Local anesthetic techniques for IV insertion

Intravenous literature: McNaughton, C., Zhou, C., Robert, L., Storrow, A. and Kennedy, R. (2009) A randomized, crossover comparison of injected buffered lidocaine, lidocaine cream, and no analgesia for peripheral intravenous cannula insertion. Annals of Emergency Medicine. 54(2), p.214-20.

Abstract:

STUDY OBJECTIVE: We compare pain and anxiety associated with peripheral intravenous (IV) cannula insertion after pretreatment with no local anesthesia, 4% lidocaine cream, or subcutaneously injected, buffered 1% lidocaine.

METHODS: In a randomized, crossover design, 3 peripheral IVs were inserted in each of 70 medical students or nurses. In random order, insertion sites were pretreated with nothing, lidocaine cream, or injected, buffered lidocaine. After each IV insertion, subjects recorded pain, anxiety, and preference (as patient and provider) for each technique on a 10-point numeric rating scale. Higher scores indicated greater pain, anxiety, and preference.

RESULTS: Median pain scores (interquartile range [IQR]) were 7 (4 to without local anesthesia, 3 (2 to 5) with lidocaine cream, and 1 (1 to 2) with injected, buffered lidocaine. Median anxiety scores (IQR) were 4 (2 to 7) without local anesthesia, 2 (1 to 4) with lidocaine cream, and 2 (1 to 3) with injected, buffered lidocaine. There was no detectable difference in anxiety scores between lidocaine cream and injected, buffered lidocaine. Most IV placement attempts were successful, regardless of technique. Seventy percent of subjects indicated they would “always” request buffered lidocaine for peripheral IV insertion.

CONCLUSION: In adult health care providers, pain and anxiety associated with peripheral IV insertion is significantly reduced by using topical lidocaine cream or injected, buffered lidocaine. Injected, buffered lidocaine reduces IV insertion pain more than lidocaine cream, without affecting success. Adults desire the use of local anesthetic techniques for IV insertion for themselves and for their patients.

Guidelines for prehospital fluid resuscitation

Intravenous literature: Cotton, B.A., Jerome, R., Collier, B.R., Khetarpal, S., Holevar, M., Tucker, B., Kurek, S., Mowery, N.T., Shah, K., Bromberg, W., Gunter, O.L. and Riordan, W.P.Jr, EAST Practice Parameter Workgroup for Prehospital Fluid Resuscitation (2009) Guidelines for prehospital fluid resuscitation in the injured patient. Journal of Trauma-Injury Infection & Critical Care. 67(2), p.389-402.

Abstract:

Although the need and benefit of prehospital interventions has been controversial for quite some time, an increasing amount of evidence has stirred both sides into more frequent debate. Proponents of the traditional “scoop-and-run” technique argue that this approach allows a more timely transfer to definitive care facilities and limits unnecessary (and potentially harmful) procedures. However, advocates of the “stay-and-play” method point to improvement in survival to reach the hospital and better neurologic outcomes after brain injury. Given the lack of consensus, the Eastern Association for the Surgery of Trauma convened a Practice Management Guideline committee to answer the following questions regarding prehospital resuscitation: (1) should injured patients have vascular access attempted in the prehospital setting? (2) if so, what location is preferred for access? (3) if access is achieved, should intravenous fluids be administered? (4) if fluids are to be administered, which solution is preferred? and (5) if fluids are to be administered, what volume and rate should be infused?

Factor V Leiden

Intravenous literature: Weinstein, S.M. (2009) Factor V Leiden: impact on infusion nursing practice. Journal of Infusion Nursing. 32(4), p.219-223.

Abstract:

As one whose family has been affected by factor V Leiden since 1980, the author knows firsthand the impact of this disease process on patients, outcomes, and practice. In today’s healthcare environment, genetic screening for the factor V mutation is routine among pregnant women. Preoperative testing is often done on those “at risk.” This article addresses the genetics, the occurrence, the treatment, and practice implications.

Central catheter blood sampling

Intravenous literature: Mathew, A., Gaslin, T., Dunning, K. and Ying, J. (2009) Central catheter blood sampling: the impact of changing the needleless caps prior to collection. Journal of Infusion Nursing. 32(4), p.212-8.

Abstract:

Little is known about the association between central catheter needleless connectors and bacteremia. In a cohort study on 91 patients, central catheter blood samples were collected using 3 methods–old cap (the existing cap), new cap (after replacing the old cap with a new sterile cap), and peripheral methods–from each patient and their correlation was examined. The old cap method identified 36 positive bacteremia cases. However, only 17 cases were verified by the new cap method, yielding a positive predictive value of 47.2% (17/36). The 19 false-positive cases indicated old cap contamination. This study recommends that changing the needleless cap before drawing blood samples would be an ideal practice for obtaining more specific and reliable results in diagnosing bacteremia.

Infiltration and extravasation prevention and management

Intravenous literature: Doellman, D., Hadaway, L., Bowe-Geddes, L.A., Franklin, M., LeDonne, J., Papke-O’Donnell, L., Pettit, J., Schulmeister, L. and Stranz, M. (2009) Infiltration and extravasation: update on prevention and management. Journal of Infusion Nursing. 32(4), p.203-11.

Abstract:

Infiltration and extravasation are risks of intravenous administration therapy involving unintended leakage of solution into the surrounding tissue. Consequences range from local irritation to amputation. While immediate action using appropriate measures (ie, dilution, extraction, antidotes, and supportive treatments) can decrease the need for surgical intervention, many injuries may be prevented by following established policy and procedures. However, timely surgical intervention, when necessary, can prevent more serious adverse outcomes. Clinicians should be prepared to act promptly when an event occurs. Thorough incident documentation helps determine whether infusion care meets the standard of practice and is a keystone to medicolegal defense.

Blood collection safety in Africa

Intravenous news: Afrique en ligne report “US officials have signed a pact with a leading global technology company launching an initiative to help protect the health of healthcare personnel and patients in African countries, the US State Department said.

The Memorandum of Understanding was signed in Washington Tuesday by Ambassador Elizabeth Bagley, the U.S. Department of State Special Representative for Global Partnerships, and Gary M. Cohen, Executive Vice President of Becton, Dickinson and Company (BD).

Through this partnership, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) will work with BD to improve blood collection safety in clinics and hospitals in sub-Saharan Africa.”

Click here for the full report.

Closed needlefree connector

Intravenous products: IVTEAM are pleased to bring you the first of a number of sponsored product pages. This particular page is dedicated to closed needlefree connectors. You will find video of the products and a number of studies related to the devices in question.

Click here to visit the product page.

Central line tip location anatomy

Intravenous literature: Ellis, H. (2009) The superior mediastinum. Anaesthesia and Intensive Care Medicine. 10(8), p.360-361.

Abstract:

The mediastinum is the area of the thorax that lies between the two pleural sacs. It is further divided by an imaginary line passing from the manubriosternal junction (angle of Louis) in front and the T4/T5 vertebral junction behind into a superior and inferior compartment. The inferior mediastinum contains the heart, within its pericardial sac, together with the descending aorta and lower oesophagus. The contents of the superior mediastinum comprise the retrosternal structures, the remnant of thymus and the great veins. These are made up as follows: the right and left brachiocephalic veins form from the internal jugular/subclavian junction behind each sternoclavicular joint. The right passes directly downwards; the left passes obliquely to join the right at the level of the first right costomanubrial junction to form the superior vena cava. This is joined by the vena azygos and drains into the right atrium. Posteriorly, the superior mediastinum contains the trachea (the right vagus descends on its right border). The trachea itself lies immediately in front of the oesophagus, which lies on the bodies of T1–T4. The left recurrent laryngeal nerve lies in the tracheo-oesophageal groove on its left side, while the thoracic duct lies on the left of the oesophagus. The aortic arch commences from the ascending aorta and arches posterolaterally to the left over the pulmonary trunk and left pulmonary artery. It is crossed by the left phrenic nerve and the left vagus nerve. The latter gives off the left recurrent laryngeal nerve. The aortic arch gives off from its upper margin the brachiocephalic, left common carotid and left subclavian arteries. These do not give off branches until they have left the thorax.

Hypertonic saline in critical care

Intravenous literature: Strandvik, G.F. (2009) Hypertonic saline in critical care: a review of the literature and guidelines for use in hypotensive states and raised intracranial pressure. Anaesthesia. 64(9), p.990-1003.

Abstract:

Hypertonic saline has been in clinical use for many decades. Its osmotic and volume-expanding properties make it theoretically useful for a number of indications in critical care. This literature review evaluates the use of hypertonic saline in critical care. The putative mechanism of action is presented, followed by a narrative review of its clinical usefulness in critical care. The review was conducted using the Scottish Intercollegiate Guidelines Network method for the review of cohort studies, randomised-controlled trials and meta-analyses. The review focuses specifically on blood pressure restoration and outcome benefit in both haemorrhagic and non-haemorrhagic shock, and the management of raised intracranial pressure. Issues of clinical improvement and outcome benefit are addressed. Hypertonic saline solutions are effective for blood pressure restoration in haemorrhagic, but not other, types of shock. There is no survival benefit with the use of hypertonic saline solutions in shock. Hypertonic saline solutions are effective at reducing intracranial pressure in conditions causing acute intracranial hypertension. There is no survival or outcome benefit with the use of hypertonic saline solutions for raised intracranial pressure. Recommendations for clinical use and future directions of clinical research are presented.

Needle length for immunization

Intravenous literature: Koster, M.P., Stellato, N., Kohn, N. and Rubin, L.G. (2009) Needle Length for Immunization of Early Adolescents as Determined by Ultrasound. Pediatrics. 124(2), p.667-672.

Abstract:

OBJECTIVE: To determine the appropriate needle length for intramuscular injection of vaccines to early adolescents by measuring muscle depth at the deltoid injection site.

METHODS: Students from Nassau County, New York, and patients attending an adolescent clinic were invited to participate. Height, weight, and arm circumference were measured. BMI percentiles were obtained. Depths of muscle and bone underlying the deltoid injection site were measured by using ultrasonography while the deltoid area was bunched or flattened. A sufficiently long needle length was defined as greater than or equal to the skin-to-muscle depth plus 5 mm (based on measurement, no needle used). Too long was considered greater than or equal to skin-to-bone depth.

RESULTS: The age range of the 141 subjects was 11 to 15 years. Fifty-five percent were female. Twenty-six percent weighed <40 kg, and 20% were between 60 and 108 kg. The mean and median BMI percentiles were 58th and 62th, respectively, with 6% of the subjects at <10th percentile and 28% of subjects at >85th percentile. Using the bunch technique, we found that a 25-mm (1-in) needle is acceptable in 86% of subjects; in the subgroup of 60 kg, it is acceptable in 100% of subjects. A 16-mm (-in) needle is acceptable in 88%; in the subgroup of <60 kg, it is acceptable in 98% of subjects. Using the flatten technique, a 25-mm needle is acceptable in 39%; in the subgroup of 60 kg, it is acceptable in 93% of subjects. A 16-mm needle is acceptable in 92%; in the subgroup of <60 kg, it is acceptable in 96% of subjects.

CONCLUSIONS: For intramuscular immunization of early adolescents, a 16-mm needle is appropriate for those weighing <60 kg, and a 25-mm needle is appropriate for those weighing 60 to 70 kg, using either technique.

IV device identification

Intravenous news: The Institute for Safe Medication Practices report “A patient with a low potassium level was due to receive three sequential, hour-long infusions of highly concentrated potassium chloride 20 mEq in minibags. A primary IV of 0.9% sodium chloride was infusing so the patient’s nurse attached a secondary IV set to the first potassium chloride minibag, connected it to the primary line, and began infusing the solution via a pump. She came back to the patient’s room when the second dose was due and noticed the potassium solution was flowing quickly into the drip chamber. She then realized the solution was flowing into the primary IV bag rather than the patient”.

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Purple not an IV or enteral standard

Intravenous news: The Institute for Safe Medication Practices report “Purple is not an official standard for either enteral feeding equipment or PICC lines.” They describe “an epileptic patient who was supposed to receive oral KEPPRA (levetiracetam) liquid via a PEG tube instead received it IV via a Bard PowerPICC (peripherally inserted central catheter) line. An oral Baxa amber syringe that held the levetiracetam did not connect properly to the hub of the PICC line, however it could be held easily against the opening for the injection. It’s possible that the experienced nurse who incorrectly gave the drug IV was confused by a purple color system available from Covidien for enteral feeding equipment. The color is identical to the purple coloring used for the patient’s Bard PowerPICC line. Learn more about preventing errors like this in your facility in the newsletter”.

Click here for the newsletter.

Click here for more information from ASPEN.

Biopatch CHG update

Intravenous products: FoxBusiness.com report that “Ethicon Inc., a  Johnson & Johnson Company, today announced that BIOPATCH((R)) Protective Disk with CHG (chlorhexidine gluconate) will include new design elements and updated packaging to make it easier for surgeons, nurses and other healthcare providers to apply the product correctly around catheters to reduce the risk of catheter-related bloodstream infections (CRBSIs). Distribution of BIOPATCH((R)) with the enhanced design and packaging began on August 10, 2009 and the product will be available nationwide by mid-August.

The enhanced design and packaging for BIOPATCH((R)) includes easy-to-follow instructions and clearly marked “up” arrows to signify correct application with respect to skin orientation of the product. This new design is intended to provide clear and immediate guidance on the application of BIOPATCH((R)) with each use. In addition, BIOPATCH((R)) packaging now features color-coded elements designed to instantly identify the size and center-hole diameter of the product.”

Click here to view the full press release.

Heparin liability lawsuit

Intravenous news: SunJournal.com report “Dennis Quaid and his wife sued the makers of heparin Tuesday after their newborn twins were inadvertently given massive doses of the blood thinner at a hospital.

The product liability lawsuit, filed in Chicago, seeks more than $50,000 in damages. It claims that Baxter Healthcare Corp., based in Deerfield, Ill., was negligent in packaging different doses of the product in similar vials with blue backgrounds. The lawsuit also says the company should have recalled the large-dosage vials after overdoses killed three children at an Indianapolis hospital last year.”

Click here for the full story.

Lyme disease resource center

Intravenous literature: Medscape.com have developed a Lyme Disease Resource Center (Click here). Topics covered in the resource center include:

• Ten Clinical Pearls for the Diagnosis and Management of Lyme Disease  - Don’t miss these 10 tips on Lyme disease in a video blog from Paul G. Auwaerter, MD, MBA. Topics include symptoms, diagnostic testing, the scientific evidence on long-term antibiotic use, and more. Medscape Infectious Diseases, July 2009
• Lyme Disease: Issues and Controversies  - In this video blog, Paul G. Auwaerter, MD, MBA discusses the controversies related to Lyme disease and recommends care that is based on the evidence — not allegations. Medscape Infectious Diseases, July 2009
• In the Lymelight: Law and Clinical Practice Guidelines - In an unprecedented move, IDSA and the AG have entered into a legal agreement that necessitates a rethinking of the guidelines. Southern Medical Journal, June 2009
• A Case of Ascending Paralysis: the Signs and Symptoms of Tick Paralysis - A hiker is presented to the ED with flu-like symptoms and a tick is found. What are the signs and symptoms of tick paralysis and how can it be treated? American Academy of Emergency Medicine, March 2009
• Chronic Lyme Disease and the “Axis of Evil” - Lyme disease is a controversial clinical conundrum. Over the past decade, two opposing views have emerged, one from the Infectious Diseases Society of America (IDSA) and the other represented by the International Lyme and Associated Diseases Society (ILADS). Future Microbiology, December 2008
• Lyme Borreliosis, Erythema Migrans and Annular Skin Lesions - A 68-year-old female enters the ED complaining of three weeks of intermittent low grade temperature in addition to chills, myalgias, arthralgias, and rash. Can Lyme borreliosis be the problem? American Academy of Emergency Medicine, November 2008
• Southern Tick-Associated Rash Illness: Erythema Migrans Is Not Always Lyme Disease - A 48-year-old Caucasian male working in South Carolina as a home inspector reported a tick bite about six weeks before presentation. Southern Medical Journal, July 2008
• Risk Maps for Range Expansion of the Lyme Disease Vector, Ixodes scapularis, in Canada Now and With Climate Change - A Lyme disease tick vector has an expanding geographic range that will cause the disease to emerge in new areas. What potential do risk maps hold in predicting the occurrence of this vector? International Journal of Health Geographics, May 2008
• Late Diagnosis of Early Disseminated Lyme Disease: Perplexing Symptoms in a Gardener - Learn why the timely diagnosis of early disseminated Lyme disease is sometimes delayed. Journal of the American Board of Family Medicine, May 2008
• Chest Pain in a Military Recruit - A basic military trainee who presents with cardiac manifestations of Lyme disease. Southern Medical Journal, February 2008

Click here for the Medscape page.

CLABSI prevention evidence-base

Weinstein, R.A. and Smith, S.L. (2009) An Evidence-Based Approach to the Prevention of Central Line-Associated Bloodstream Infections in Hospitalized Patients. Medscape CME.

Target Audience:

This activity is intended for surgeons, infectious disease specialists, hospitalists, critical care specialists, emergency department physicians, physician assistants, and nurses/nurse practitioners who care for patients at risk for central line associated bloodstream infections.

Goal:

The goal of this activity is to provide evidence-based information on prevention of catheter-related bloodstream infections, including central line associated bloodstream infections in hospitalized patients.

Introduction:

“Central venous catheters or central lines (defined as a vascular infusion device that terminates at or close to the heart or in one of the great vessels) are used in inpatient and outpatient clinical settings to provide long-term venous access for patients with a wide variety of illnesses and conditions. The following are considered great vessels: aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocepahic veins, internal jugular veins, subclavian veins, external iliac veins, common femoral veins. A catheter introducer is considered an intravascular catheter and the umbilical artery in a neonate is considered a great vessel. Pacemaker wires are not considered central lines; they are not used to infuse or withdraw fluids.

Approximately 48% of patients in intensive care units (ICUs) have a central line, accounting for 15 million central line-days per year. Central lines disrupt the integrity of the skin, making patients vulnerable to bacterial and fungal infections, including central line-associated bloodstream infections (CLABSI). The Centers for Disease Control and Prevention (CDC) defines CLABSI as an infection in a patient who had a central line in place within the 48-hour period before the onset of infection.

An estimated 250,000 to 500,000 CLABSI occur in US hospitals each year. CLABSI are an important cause of morbidity and excess cost of care for hospitalized patients. Studies of CLABSI that control for the underlying severity of illness suggest that the attributable mortality rate is 4% to 20%. Put another way, an estimated 500 to 4000 patients die annually from CLABSI in the United States, and the reported range for patient care cost attributed to CLABSI is $3700 to $29,000 per episode”.

Click here to view the article.

AccuVein vein viewer gains CE mark

Intravenous products: AccuVein LLC, maker of the AV300, the world’s first hand-held, non-contact vein illumination device,  announced today that its medical device now carries a CE Mark, enabling the Company to commence European sales of AccuVein’s AV300.

“Receiving approval to ship the AV300 to Europe is an important step in bringing this beneficial device to healthcare practitioners around the globe,” said Stephen P. Conlon, President of AccuVein. “Furthermore, Europe provides a significant growth opportunity for AccuVein allowing us to build upon our successful launch in the United States.”

Click here for the full press release.

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Antimicrobial needlefree connector

Intravenous products: ICU Medical describe the new antimicrobial needlefree device. On the ICU Medical website they state “The new Antimicrobial CLAVE is the only antimicrobial connector with dedicated internal fluid path technology. The same features that make the CLAVE the least likely to transmit bacteria over any other brand, now has the added feature of an antimicrobial additive.

CLAVE is the only connector which has been proven to reduce intraluminal catheter colonization in a randomized clinical trial. The reversed, split-septum technology and dedicated internal fluid path are the heart of what makes the CLAVE least likely to transmit bacteria than any other brand.

ICU Medical developed the Antimicrobial CLAVE to enhance the dedicated internal fluid path and further reduce the risk of bacterial ingress into the catheter. Ionic silver has been infused into all fluid path contact components which includes the internal cannula and split septum seal.”

Click here to view more information on the ICU Medical website.