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Medical Sciences	100%

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What You See (Sonographically) Is What You Get: Vein and Patient Characteristics Associated With Successful Ultrasound-guided Peripheral Intravenous Placement in Patients With Difficult Access

ACADEMIC EMERGENCY MEDICINE, Issue 12 2009
Nova L. Panebianco MD
Abstract Objectives:, Ultrasound (US) has been shown to facilitate peripheral intravenous (IV) placement in emergency department (ED) patients with difficult IV access (DIVA). This study sought to define patient and vein characteristics that affect successful US-guided peripheral IV placement. Methods:, This was a prospective observational study of US-guided IV placement in a convenience sample of DIVA patients in an urban, tertiary care ED. DIVA patients were defined as having any of the following: at least two failed IV attempts or a history of difficult access plus the inability to visualize or palpate any veins on physical exam. Patient characteristics (demographic information, vital signs, and medical history) were collected on enrolled patients. The relationships between patient characteristics, vein depth and diameter, US probe orientation, and successful IV placement were analyzed. Results:, A total of 169 patients were enrolled, with 236 attempts at access. Increasing vessel diameter was associated with a higher likelihood of success (odds ratio [OR] = 1.79 per 0.1-cm increase in vessel diameter, 95% confidence interval [CI] = 1.37 to 2.34). Increasing vessel depth did not affect success rates (OR = 0.96 per 0.1-cm increase of depth, 95% CI = 0.89 to 1.04) until a threshold depth of 1.6 cm, beyond which no vessels were successfully cannulated. Probe orientation and patient characteristics were unrelated to success. Conclusions:, Success was solely related to vessel characteristics detected with US and not influenced by patient characteristics or probe orientation. Successful DIVA was primarily associated with larger vessel, while vessel depth up to >1.6 cm and patient characteristics were unrelated to success. Clinically, if two vessels are identified at a depth of <1.6 cm, the larger diameter vessel, even if comparatively deeper, should yield the greatest likelihood of success. [source]

Emergency Nurses' Utilization of Ultrasound Guidance for Placement of Peripheral Intravenous Lines in Difficult-access Patients

ACADEMIC EMERGENCY MEDICINE, Issue 12 2004
Larry Brannam MD
Objectives: Emergency nurses (ENs) typically place peripheral intravenous (IV) lines, but if repeated attempts fail, emergency physicians have to obtain peripheral or central access. The authors describe the patient population for which ultrasound (US)-guided peripheral IVs are used and evaluate the success rates for such lines by ENs. Methods: This was a prospective observational study of ENs in a Level I trauma center with a census of 75,000, performing US-guided IV line placement on difficult-to-stick patients (repeated blind IV placement failure or established history). ENs were trained on an inanimate model after a 45-minute lecture. Surveys were filled out after each US-guided IV attempt on a patient. ENs could decline to fill out surveys, which recorded the reason for use of US, type of patient, and success. Successful cannulation was confirmed by drawing blood and flushing fluids. Descriptive statistics were used to evaluated data. Results: A total of 321 surveys were collected in a five-month period no ENs declined to participate. There were 280 (87%) successful attempts. Twelve (29%) of the 41 failure patients required central lines, 9 (22%) received external jugular IVs, and 20 (49%) had peripheral IV access placed under US guidance by another nurse or physician. Twenty-eight percent (90) of all patients were obese, 18% (57) had sickle cell anemia, 10% (31) were renal dialysis patients, 12% (40) were IV drug abusers, and 19% (61) had unspecified chronic illness. The remainder had no reason for difficult access given. There were four arterial punctures. Conclusions: ENs had a high success rate and few complications with use of US guidance for vascular access in a variety of difficult-access patients. [source]

Ultrasound-assisted peripheral vascular access in a paediatric ED

EMERGENCY MEDICINE AUSTRALASIA, Issue 2 2010
Ed Oakley
Abstract Objectives: To assess the implementation and utility of US for assisting peripheral venous access in a paediatric ED. Methods: A prospective, observational study of a convenience sample comparing the landmark and US-guided technique for peripheral vascular access in children from July 2006 to February 2007. Clinicians involved under went 3 months of training in US physics and with practical models. Clinicians estimated the degree of difficulty of insertion (using a Likert scale) before each line placement. Data including time of procedure and success or failure were collected, using a standardized clinical record form, by an observing researcher. Results: A total of 84 patients were enrolled. There were 61 line placement episodes in the landmark group (with 253 attempts), and 38 in the US group (with 90 attempts). US recorded slightly higher success per attempt overall (42% vs 38%, P= 0.08), and performed better in the patients with difficult access (success 35% vs 18%, P= 0.003). US attempts took longer than landmark attempts (2 min 15 s vs 4 min, P < 0.001). Conclusion: The US guidance may improve the success rate of peripheral vascular access in children rated to have difficult or very difficult vascular access. [source]

Laparoscopic pancreatic surgery: a review of present results and future prospects

HPB, Issue 4 2010
Omer S. Al-Taan
Abstract Pancreatic surgery is still associated with a relatively high morbidity and mortality compared with other specialties. This is a result of the complex nature of the organ, the difficult access as a result of the retroperitoneal position and the number of technically challenging anastomoses required. Nevertheless, the past two decades have witnessed a steady improvement in morbidity and a decrease in mortality achieved through alterations of technique (particularly relating to the pancreatic anastomoses) together with hormonal manipulation to decrease pancreatic secretions. Recently minimally invasive pancreatic surgery has been attempted by several centres around the world which has stimulated considerable interest in this approach. The majority of the cases attempted have been distal pancreatectomies, because of the more straightforward nature of the resection and the lack of a pancreatic ductal anastomosis, but more recently reports of laparoscopic pancreaticoduodenectomy have started to appear. The reports of the series to date have been difficult to interpret and although the results are claimed to be equivalent or better than those associated with a traditional approach a careful examination of the literature and comparison with the best results previously reported does not presently support this. In the present review we examined all the reports of pancreatic procedures performed laparoscopically and compared the results with those previously achieved at open surgery. [source]

Restoration of Extensive Erosion Areas Using an Indirect Composite Technique

JOURNAL OF ESTHETIC AND RESTORATIVE DENTISTRY, Issue 1 2000
JAMES S. KNIGHT DDS
ABSTRACT Cervical erosion defects, particularly those of extensive size that are located in an area where control of the operative field is difficult, can present a significant restorative challenge. This article describes an indirect restorative technique to solve this problem. Following tooth preparation, an indirect restoration is luted to the tooth and the margins are finished and polished. Using an indirect technique minimizes operative field isolation time and the total chairside time required to restore the tooth. Clinical cases are presented to illustrate this technique. CLINICAL SIGNIFICANCE An indirect composite restoration provides a useful treatment option when restoring extensive erosion defects in areas of difficult access. [source]

What You See (Sonographically) Is What You Get: Vein and Patient Characteristics Associated With Successful Ultrasound-guided Peripheral Intravenous Placement in Patients With Difficult Access

Subcutaneous Transposition of the Superficial Femoral Artery for Arterioarterial Hemodialysis: Technique and Results

ARTIFICIAL ORGANS, Issue 12 2008
Octavio J. Salgado
Abstract We report the use of subcutaneous transposition of the femoral artery (STFA) for placement of both inflow and outflow needles in 14 hemodialysis (HD) adult patients with difficult access. Follow-up time was 318 months during which a total of 3215 arterioarterial HD sessions were done. Kt/V values ranged between 0.71 and 1.59. Elevated access recirculation and dialysis outflow pressures were common findings to all patients. Complications were: (i) two episodes of bleeding secondary to puncture-related arterial wall laceration, repaired by stitching; (ii) three episodes of thrombosis in two patients, all successfully declotted; (iii) three puncture-related complications needing placement of a vein interposition graft, namely, aneurysm, pseudoaneurysm, and arterial stenosis; and (iv) one case of arterial ligation because of suppurative puncture site infection, without subsequent distal ischemia signs or claudication. The use of STFA should only be reserved for patients in urgent need for vascular access with no remaining options. [source]