Difficult Peripheral Venous Access: Recognizing and Managing the Patient at Risk

Abstract Nurses commonly face challenges placing peripheral intravenous (IV) lines in adults and children, a situation described as difficult venous access (DVA). Multiple venipuncture attempts can heighten patient anxiety and suffering, delay vital treatment, and increase costs. Numerous factors such as small, fragile or hidden veins can predispose patients to DVA, and collapsed veins due to dehydration are especially problematic. Several techniques can improve venous prominence, but when IV access cannot be achieved promptly, other routes of administration can be valuable. For rehydration fluids and certain drugs, subcutaneous administration may be a safe and effective alternative, providing cost and ease-of-use advantages.

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Peripheral venous access using the Seldinger wire technique and short cannulas in patients with difficult venous access: a case series

Vascular Access ◽

10.33235/va.7.1.12-15 ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Brendan SmithHanratty

Keyword(s):

Case Series ◽

Venous Access ◽

Peripheral Venous Access ◽

Difficult Venous Access

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Subcutaneous dexmedetomidine infusions to treat or prevent drug withdrawal in infants and children

Journal of Opioid Management ◽

10.5055/jom.2008.0024 ◽

2018 ◽

Vol 4 (4) ◽

pp. 187 ◽

Cited By ~ 20

Author(s):

Joseph D. Tobias, MD

Keyword(s):

Pediatric Patients ◽

Drug Withdrawal ◽

Subcutaneous Administration ◽

Pediatric Intensive Care ◽

Venous Access ◽

Subcutaneous Infusion ◽

Peripheral Venous Access ◽

Prolonged Sedation ◽

Dexmedetomidine Infusion ◽

Sedation Regimen

This retrospective study reports a cohort of pediatric patients in whom subcutaneous dexmedetomidine was used to treat or prevent drug withdrawal following prolonged sedation in the Pediatric Intensive Care Unit setting. There were seven patients ranging in age from 6 months to 3.75 years and in weight from 4.8 to 17.7 kg. The dexmedetomidine infusion before switching to subcutaneous administration varied from 0.8 to 1.4 μg/kg/h. Four of the patients had received dexmedetomidine in conjunction with an opioid as part of a sedation regimen during mechanical ventilation. In these four patients, the duration of the intravenous dexmedetomidine infusion varied from 4 to 10 days. In the three other patients, an intravenous dexmedetomidine infusion was used to treat withdrawal following the prolonged use of an opioid and/or a benzodiazepine. In these three patients, the duration of the intravenous dexmedetomidine varied from 3 to 5 days. Following the switch to subcutaneous dexmedetomidine, the infusion was gradually decreased by 0.1 μg/kg/h every 12 h. Subcutaneous access was maintained, and subcutaneous dexmedetomidine was administered for 4 to 7 days. No problems with the subcutaneous access were noted during treatment. No patient exhibited behavior suggestive of withdrawal during the use of subcutaneous dexmedetomidine. The maximum modified Finnegan score in the seven patients varied from 3 to 7. Our preliminary experience suggests that dexmedetomidine can be administered by subcutaneous infusion without difficulty or alteration of its efficacy. This approach allows the administration of dexmedetomidine when peripheral venous access becomes problematic and may facilitate the removal of central venous catheters in patients recovering from critical illnesses. It also offers the possibility of using dexmedetomidine in settings where peripheral venous access is not available such as home palliative care.

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Long peripheral catheters and midline catheters: Insights from a survey of vascular access specialists

The Journal of Vascular Access ◽

10.1177/1129729820966226 ◽

2020 ◽

pp. 112972982096622 ◽

Cited By ~ 1

Author(s):

Kirby R Qin ◽

Mauro Pittiruti ◽

Ramesh M Nataraja ◽

Maurizio Pacilli

Keyword(s):

Vascular Access ◽

Venous Access ◽

Common Indication ◽

Electronic Survey ◽

Peripheral Venous Access ◽

General Recommendation ◽

Peripheral Intravenous Access ◽

Intravenous Catheters ◽

Difficult Venous Access

Background: Peripheral intravenous access is no longer limited to the standard intravenous catheter (cannula). Devices varying in length, material and insertion technique, are increasingly accessible. There is substantial variability surrounding the nomenclature and use of these devices in the literature. We wished to understand the attitude of vascular access specialists towards the nomenclature and use of peripheral intravenous catheters (PIVCs), long peripheral catheters (LPCs) and midline catheters (MCs). Methods: A 15-question electronic survey was sent to members of the Association of Vascular Access (AVA) regarding the nomenclature and use of PIVCs, LPCs and MCs. Results: A total of 228 participants completed the survey. Approximately two-thirds of respondents use LPCs (65.8%) and MCs (71.9%) in their clinical practice. The most common indication for LPCs was difficult venous access (56.5%), while the most common indication for MCs was medium-term (1–4 weeks) intravenous therapy (62.7%). The majority of participants (57.9%) agreed with the following classification of peripheral intravenous devices: PIVCs: 2 to 6 cm in length, terminating distal to the axilla; LPCs: 6 to 15 cm in length, terminating distal to the axilla; MCs: 15–25 cm in length, terminating in the axilla. Participants suggested that the length of the catheter should be considered a general recommendation, as LPCs and MCs should be primarily differentiated by tip location. Conclusions: The majority of vascular access specialists from AVA have incorporated LPCs and MCs into their repertoire of peripheral venous access tools. We envisage that their use will increase as the clinical community becomes more familiar with these devices.

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Extravascular Administration of Factor IX: Potential for Replacement Therapy of Canine and Human Hemophilia B

Thrombosis and Haemostasis ◽

10.1055/s-0038-1656082 ◽

1997 ◽

Vol 77 (05) ◽

pp. 0944-0948 ◽

Cited By ~ 20

Author(s):

Darla Liles ◽

Charles N Landen ◽

Dougald M Monroe ◽

Celeste M Lindley ◽

Marjorie s Read ◽

...

Keyword(s):

Gene Therapy ◽

Vitamin K ◽

Absorption Rate ◽

Venous Access ◽

Factor Ix ◽

Hemophilia B ◽

Current Therapy ◽

Home Therapy ◽

Routes Of Administration ◽

Plasma Compartment

SummaryCurrent therapy for hemophilia B requires large intravenous doses of factor IX (F.IX) given in the clinic or at home. Although home therapy is possible for many patients, it is often complicated by factors such as the lack of good venous access. Very little is known about extravascular routes for administering proteins like F.IX (57 kD) or other vitamin K-dependent procoagulant factors into the circulation. Questions about the absorption rate from extravascular administration as well as plasma recovery and bioavailability have arisen recently with the growing availibility of highly purified procoagulant proteins and increased interest in gene therapy of hemophilia B. Therefore, a group of studies were undertaken to determine the absorption rate, plasma recovery, and bioavailability of high purity, human plasma-derived F.IX concentrates administered via extravascular routes in hemophilia B dogs and in one human hemophilia B subject. Five hemophilia B dogs were given human F.IX via either a subcutaneous (SC), intramuscular (IM), intra- peritoneal (IP) or intravenous (IV) route. In a subsequent study, a single SC administration of human F.IX was compared to an identical IV dose of F.IX in the human hemophilia B subject. All extravascular routes of F.IX administration in both the canine and human gave lower levels of circulating plasma F.IX than the IV route, however all routes resulted in measurable F.IX activity. Of the extravascular routes, the IM injection in the canine resulted in a bioavailibility of 82.8%, while the SC injection resulted in a bioavailability of 63.5%. F.IX reached the plasma compartment by all extravascular routes used, confirming that F.IX can be absorbed extravascularly. The duration of measurable F.IX activity following extravascular administration is prolonged beyond that typically seen with IV administration. These data show that significant levels of F.IX may be obtained via SC injection in canine and ‘ human hemophilia B subjects and further highlight the potential of extravascular routes of administration for future experimental and clinical uses of F.IX and other procoagulant proteins.

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Ultrasound‐based criteria for adequate peripheral venous access in therapeutic apheresis procedures

Journal of Clinical Apheresis ◽

10.1002/jca.21930 ◽

2021 ◽

Author(s):

Eric Salazar ◽

Faaria Gowani ◽

Francisco Segura ◽

Heather Passe ◽

Lamesha Seamster ◽

...

Keyword(s):

Venous Access ◽

Peripheral Venous Access

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Peripheral Inotropes in Critically Ill Children: Is It Safe?

Global Pediatric Health ◽

10.1177/2333794x211022250 ◽

2021 ◽

Vol 8 ◽

pp. 2333794X2110222

Author(s):

Ravi K. Mooli ◽

Kalaimaran Sadasivam

Keyword(s):

Central Venous Access ◽

Pediatric Intensive Care ◽

Venous Access ◽

Critically Ill Children ◽

Middle Income ◽

Central Lines ◽

Middle Income Countries ◽

Peripheral Venous Access ◽

Vasoactive Medications

Many children needing pediatric intensive care units care require inotropes, which are started peripherally prior to securing a central venous access. However, many hospitals in low- and middle-income countries (LMIC) may not have access to central lines and the vasoactive medications are frequently given through a peripheral venous access. Aim: The aim of our study was to describe the role of peripheral vasoactive inotropes in children. Methods: Children requiring peripheral vasoactive medications were included in this study. We retrospectively collected data at 2 time points on use and complications of peripheral vasoactive medications. Results: Eighty-four children (51 pre-COVID era and 33 COVID pandemic) received peripheral vasoactive medications. Only 3% of children (3/84) developed extravasation injury, all of whom recovered completely. Conclusions: Results from our study suggest that extravasation injury due to peripheral inotrope infusion is very low (3%) and it may be safely administered in children at a diluted concentration.

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