James Rippey

Insertion of peripheral intravenous cannulae in the Emergency Department: factors associated with first-time insertion success

Background We sought to identify the reasons for peripheral intravenous cannulae insertion in the emergency department (ED), and the first-time insertion success rate, along with patient and clinician factors influencing this phenomenon. Methods A prospective cohort study of patients requiring peripheral cannulae insertion in a tertiary ED. Clinical and clinician data were obtained. Results A total 734 peripheral intravenous cannula (PIVC) insertions were included in the study where 460 insertions were analysed. The first-time insertion success incidence was 86%. The antecubital fossa (ACF) site accounted for over 50% of insertions. Multivariate logistic regression modelling to predict first-time insertion success for patient factors found: age <40 versus 80+ years, emaciated versus normal patient size, having a visible or palpable vein/s, and ACF versus forearm insertion site to be statistically significant. Statistically significant clinician factors predicting success were: higher number of prior cannulation procedures performed, and increased clinician perception of the likelihood of a successful insertion. When patient and clinician factors were combined in a logistic regression model, emaciated versus normal, visible vein/s, ACF versus forearm site, higher number of prior PIVC procedures performed and increased clinician perceived likelihood of success were statistically associated with first-time insertion success. Conclusions Peripheral intravenous cannulation insertion success could be improved if performed by clinicians with greater procedural experience and increased perception of the likelihood of success. Some patient factors predict cannulation success: ‘normal’ body weight, visible vein/s and cubital fossa placement; venepuncture may be a cheaper alternative for others if intravenous therapy is not imperative.

Development of a clinical prediction rule to improve peripheral intravenous cannulae first attempt success in the emergency department and reduce post insertion failure rates: the Vascular Access Decisions in the Emergency Room (VADER) study protocol.

Introduction Peripheral intravenous cannula (PIVC) insertion is one of the most common clinical interventions performed in emergency care worldwide. However, factors associated with successful PIVC placement and maintenance are not well understood. This study seeks to determine the predictors of first time PIVC insertion success in emergency department (ED) and identify the rationale for removal of the ED inserted PIVC in patients admitted to the hospital ward. Reducing failed insertion attempts and improving peripheral intravenous cannulation practice could lead to better staff and patient experiences, as well as improving hospital efficiency. Methods and analysis We propose an observational cohort study of PIVC insertions in a patient population presenting to ED, with follow-up observation of the PIVC in subsequent admissions to the hospital ward. We will collect specific PIVC observational data such as; clinician factors, patient factors, device information and clinical practice variables. Trained researchers will gather ED PIVC insertion data to identify predictors of insertion success. In those admitted from the ED, we will determine the dwell time of the ED-inserted PIVC. Multivariate regression analyses will be used to identify factors associated with insertions success and PIVC failure and standard statistical validation techniques will be used to create and assess the effectiveness of a clinical predication rule. Ethics and dissemination The findings of our study will provide new evidence to improve insertion success rates in the ED setting and identify strategies to reduce premature device failure for patients admitted to hospital wards. Results will unravel a complexity of factors that contribute to unsuccessful PIVC attempts such as patient and clinician factors along with the products, technologies and infusates used. Trial registration number ACTRN12615000588594; Pre-results.

Creating thoracic phantoms for diagnostic and procedural ultrasound training

The use of pleural and lung ultrasound is being performed increasingly by respiratory and critical care clinicians around the world. This article describes how to create cheap and reliable lung and pleural phantoms for teaching. The phantoms described replicate the appearance of normal ventilating lung, pneumothorax (including the contact or lung point), pulmonary oedema, pleural effusion and empyema. The pleural effusion phantom can be used to teach procedural ultrasound (pleurocentesis).

An affordable and easily constructed model for training in ultrasound-guided vascular access.

Purpose This paper describes a simple and inexpensive method to make high-fidelity simulators for use in ultrasound-guided vascular access teaching. The phantoms can be created to reflect the ultrasound appearance and feel of central or peripheral arteries and veins. Different clinical states such as hypovolaemia may be readily displayed using the phantoms. Methods The article and associated videos describe the production, appearance and use of phantoms for central vascular access, for peripheral venous access and for peripheral arterial access. Key ingredients are readily accessible and include chicken breasts, modelling balloons and thin walled latex or silicone tubing. Results The phantoms are easily and rapidly constructed and may be used repeatedly in a training session. As the needle passes through the phantom and vessel wall, the ultrasound appearance and tactile sensation is very similar to that of human tissue and vessels. Conclusions Using this method, simple and inexpensive phantoms can be created. These are ideal for use in training for ultrasound-guided vascular access. Links to videos describing the phantom construction process, their appearance and the teaching techniques utilised by the authors are found in the text.

Use of ultrasound by registered nurses—a systematic literature review

BACKGROUND In Western Australia (WA), most stable patients undergoing haemodialysis receive treatment in a satellite setting where no doctors are on-site during treatment hours, so nurses must make critical decisions about fluid removal. Some patients regularly experience adverse events during dialysis (intradialytic), often due to excessive ultrafiltration goals, with intradialytic hypotension being particularly challenging. Ultrasound of the inferior vena cava has been previously demonstrated being a rapid and non-invasive method for volume assessment on haemodialysis patients, thus could hold valuable information for the treating nurse. AIM This paper examines the existing literature in regards to the use of ultrasound measurements of the inferior vena cava in patients on haemodialysis for objective assessment of their intravascular volume status by renal nurses. METHOD A systematic literature review was performed within medical and nursing databases including CINAHL Plus with Full Text, SCOPUS, Web of Science and MEDLINE. RESULTS Renal nurses are conscious of the significance of intradialytic hypotension and have only limited options for its prevention. Ultrasound of the inferior vena cava could add another objective dimension for intravascular volume assessment and prevention of intradialytic hypotension, but to date renal nurses have not been using this technique. CONCLUSIONS Ultrasound of the inferior vena cava has the potential to assist in defining the ultrafiltration goal for that particular dialysis session, thus reducing the risk of intradialytic hypotension. Additionally, it has potential to change current renal nursing practice when added to clinical nursing assessment methods. Further studies are required to validate this assessment tool carried out by a renal nurse compared with a skilled ultrasonographer.

Upper extremity deep vein thrombosis: a complication of an indwelling peripherally inserted central venous catheter

We report a case of peripherally inserted central venous catheter (PICC)‐associated deep vein thrombosis (DVT). Ultrasound images and video of subclavian thrombus are presented. PICC line‐associated DVT, particularly in cancer patients is not uncommon. Point‐of‐care Emergency Department ultrasound can readily diagnose this complication and device removal is not always necessary.

Ultrasonography of sternal fractures

This paper describes the use of clinician‐performed ultrasound to detect sternal fractures in trauma patients. It is a pictorial essay that describes the ultrasound technique, the normal anatomy and ultrasound findings, variants, potential pitfalls and the appearance of fractures when they occur in both children and adults.

Teaching medical students ultrasound-guided vascular access - which learning method is best?

Introduction Ultrasound is recommended to guide insertion of peripheral intravenous vascular cannulae (PIVC) where difficulty is experienced. Ultrasound machines are now common-place and junior doctors are often expected to be able to use them. The educational standards for this skill are highly varied, ranging from no education, to self-guided internet-based education, to formal, face-to-face traditional education. In an attempt to decide which educational technique our institution should introduce, a small pilot trial comparing educational techniques was designed. Methods Thirty medical students were enrolled and allocated to one of three groups. PIVC placing ability was then observed, tested and graded on vascular access phantoms. Results The formal, face-to-face traditional education was rated best by the students, and had the highest success rate in PIVC placement, the improvement statistically significant compared to no education (p = 0.01) and trending towards significance when compared to self-directed internet-based education (p<0.06). Conclusions The group receiving traditional face-to-face teaching on ultrasound-guided vascular access, performed significantly better than those not receiving education. As the number of ultrasound machines in clinical areas increases, it is important that education programs to support their safe and appropriate use are developed.

Reasons for Removal of Emergency Department–Inserted Peripheral Intravenous Cannulae in Admitted Patients: A Retrospective Medical Chart Audit in Australia

It has been reported that the peripheral intravenous cannula (PIVC) is the first choice of vascular access device for patient treatment in the emergency department (ED). The number of PIVC insertions in our Australian ED is more than 35,000 per year. Concern arises when ED-inserted PIVCs are used exclusively for blood sampling because this may lead to unused PIVCs being left in situ after patients are transferred to the ward, increasing risk of infection. The rate of unused or idle PIVCs inserted in the ED has been reported at 45%-50%. PIVC insertions in the ED have been identified as a cause for phlebitis and bacteremia, leading to their premature failure. Analysis of 5 years of prospective data from 2 hospitals in Australia found a high incidence of catheter-related Staphylococcus aureus bloodstream infections with 39.6% of such infections associated with PIVCs inserted in the ED. As a result, routine PIVC replacement should be considered after 24 hours for PIVCs inserted under emergent conditions 6 and after 96 hours for those inserted under nonemergent conditions. These worrying statistics prompted the design of the current study that was performed to investigate how and why PIVCs are used in the ED, and during the subsequent hospital admission, as well as the documented rationale for removal of ED-inserted PIVCs by ward staff. To our knowledge, there is no prior study investigating this phenomenon.

Ultrasound for knee effusion: lipohaemarthrosis and tibial plateau fracture

Knee trauma and effusion are common Emergency Department presentations. This article outlines the clinicians sonographic approach to knee effusion detection and localisation. A case where lipohaemarthrosis was detected with ultrasound is demonstrated, and the characteristic appearance of this pathology discussed. The sonographic detection of the associated tibial fracture is also demonstrated.