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Near-infrared Light Device Can Improve Intravenous Cannulation in Critically Ill Children

  • Author Footnotes
    † C.-Y. Sun and K.-C. Lee contributed equally to this article.
    Ching-Yun Sun
    Footnotes
    † C.-Y. Sun and K.-C. Lee contributed equally to this article.
    Affiliations
    Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

    Graduate Institute of Clinical Medical Science, Chang Gung University, College of Medicine, Kaohsiung, Taiwan
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  • Author Footnotes
    † C.-Y. Sun and K.-C. Lee contributed equally to this article.
    Kuan-Chiao Lee
    Footnotes
    † C.-Y. Sun and K.-C. Lee contributed equally to this article.
    Affiliations
    Department of Psychiatry, E-Da Hospital, Kaohsiung, Taiwan

    College of Medicine, I-Shou University, Kaohsiung, Taiwan
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  • I-Hsiu Lin
    Affiliations
    Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

    Graduate Institute of Clinical Medical Science, Chang Gung University, College of Medicine, Kaohsiung, Taiwan
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  • Chin-Ling Wu
    Affiliations
    Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

    Graduate Institute of Clinical Medical Science, Chang Gung University, College of Medicine, Kaohsiung, Taiwan
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  • Hsiao-Ping Huang
    Affiliations
    Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

    Graduate Institute of Clinical Medical Science, Chang Gung University, College of Medicine, Kaohsiung, Taiwan
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  • Yi-Yu Lin
    Affiliations
    Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

    Graduate Institute of Clinical Medical Science, Chang Gung University, College of Medicine, Kaohsiung, Taiwan
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  • Ya-Fen Hsu
    Affiliations
    Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

    Graduate Institute of Clinical Medical Science, Chang Gung University, College of Medicine, Kaohsiung, Taiwan
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  • Hong-Ren Yu
    Correspondence
    Corresponding author. Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, No. 123, Ta-Pei Road, Niao-Sung District, Kaohsiung, Taiwan.
    Affiliations
    Graduate Institute of Clinical Medical Science, Chang Gung University, College of Medicine, Kaohsiung, Taiwan

    Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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  • Author Footnotes
    † C.-Y. Sun and K.-C. Lee contributed equally to this article.
Open ArchivePublished:February 04, 2013DOI:https://doi.org/10.1016/j.pedneo.2012.12.012

      Background

      Vascular access in critically ill children can be a real challenge for medical staff.

      Methods

      To evaluate the effectiveness of a near-infrared light vein-viewing device for critically ill children, 60 pediatric inpatients were enrolled in a randomized prospective observation trial for intravenous cannulation. The patients' demographic data, mean time required to find the first available vessel, first-attempt success rate, mean number of attempts per patient, and the total time taken on the attempts per patient were compared.

      Results

      Less time was required to find the first available vessel in the near-infrared light device group compared with the control group (126.37 vs. 383.61 seconds; p = 0.027). In addition, the near-infrared light device group had a fewer number of attempts compared with the control group (median 1 vs. 2; p = 0.004), and also a shorter total time of attempts per patient compared with the control group (186.16 vs. 497.23 seconds; p = 0.014).

      Conclusion

      The use of a near-infrared light vein-viewing device for vascular access in critically ill children can decrease the total medical time and cost.

      Key Words

      1. Introduction

      Vascular access is frequently required for patients admitted to hospitals. Fluid supplements and administration of medication are mainly dependent on vascular access. However, under some conditions it can be a real challenge to insert an intravenous cannula even for experienced medical staff. Young age, dark skin, general anxiety, a critically ill condition, and chronic illnesses are all important factors that contribute to unsuccessful cannulation.
      • Cleary M.
      Peripheral intravenous cannulation.
      • Yen K.
      • Riegert A.
      • Gorelick M.H.
      Derivation of the DIVA score: a clinical prediction rule for the identification of children with difficult intravenous access.
      • Rosenthal K.
      Tailor your I.V. insertion techniques special populations.
      • Johnstone M.
      The effect of lorazepam on the vasoconstriction of fear.
      • Jacobson A.F.
      • Winslow E.H.
      Variables influencing intravenous catheter insertion difficulty and failure: an analysis of 339 intravenous catheter insertions.
      • Tekkesin M.S.
      • Olgac V.
      • Aksakalli N.
      • Alatli C.
      Odontogenic and nonodontogenic cysts in Istanbul: analysis of 5088 cases.
      It has been reported that successful intravenous placement requires an average of two venipunctures over 28 minutes for children.
      • Larsen P.
      • Eldridge D.
      • Brinkley J.
      • Newton D.
      • Goff D.
      • Hartzog T.
      • et al.
      Pediatric peripheral intravenous access: does nursing experience and competence really make a difference?.
      Vascular access is more difficult in critically ill children, and nurses working in a pediatric intensive care unit (PICU) often face the challenge of difficult venous access. Failure to establish an intravenous line increases the anxiety and pain of patients. It also leads to frustration and disappointment of the nursing staff. The additional cost and time spent by the staff on difficult venous access are also negative factors.
      Several strategies have been proposed to improve venous access. Recently, a near-infrared light source has been developed to view both superficial and deep veins, which reportedly reduces the number of needlesticks required to achieve venous access, although the results have been controversial (Figure 1).
      • Hess H.A.
      A biomedical device to improve pediatric vascular access success.
      • Perry A.M.
      • Caviness A.C.
      • Hsu D.C.
      Efficacy of a near-infrared light device in pediatric intravenous cannulation: a randomized controlled trial.
      In this study, we compared the first-attempt success rate for the insertion of peripheral intravenous catheters between those placed with and without the assistance of a near-infrared light vein-viewing device for critically ill children in a PICU.
      Figure thumbnail gr1
      Figure 1Visualization (A) without and (B) with the near-infrared light device (VeinViewer).

      2. Materials and Methods

      This study was conducted in a PICU at Kaohsiung Chang Gung Children's Hospital over a 1-year period from April 2010 to March 2011. The study protocol was approved by the institutional review board of Chang Gung Memorial Hospital, Taiwan. Sixty patients between the ages of 3 months and 17 years who were admitted to our PICU and who required vascular access were enrolled for the study in a 3-month prospective observation period. Pediatric Risk of Mortality (PRISM) III scores were used as a prognostic score to assess the gravity of the disease.
      • Pollack M.M.
      • Patel K.M.
      • Ruttimann U.E.
      PRISM III: an updated Pediatric Risk of Mortality score.
      All patients received an intravenous cannula insertion. The indications for intravenous cannulation included the need for fluid supplements and administration of medication. After informed consent had been obtained from their parents, the patients were divided into two groups: the near-infrared light vein-viewing device group (VeinViewer; Luminetx Corporation, Memphis, TN, USA) and the control group (without the use of the VeinViewer). A physician created two random allocation sequence lists (computer generated). The exclusion criteria included patients or families who did not agree to participate in this study, a rapidly progressive condition that needed resuscitation, and any other condition that did not give the medical staff enough time to prepare for this study.
      Five nurses with work experience ranging from 1 to 12 years were assigned to perform vascular access in both groups. All nurses received a 2-hour training session, and their ability to operate the device was validated by the device manufacturer. The basic clinical features and laboratory data of the patients were recorded. When performing vascular access, the nurses were asked to record the time required to find the first available vessel, the number of attempts needed to achieve success, and the total time needed to complete the procedure.

      2.1 Statistics

      The data presented are expressed as mean ± standard error. The chi-square test or Fisher's exact test was used to evaluate statistical differences in parametric items. The Mann–Whitney U-test was used to test the differences in nonparametric items. A p value less than 0.05 was considered statistically significant. All statistical tests were performed using SPSS 17.0 for Windows XP (SPSS, Inc., Chicago, IL, USA).

      3. Results

      Sixty pediatric patients were entered into the study and randomly assigned to the control group or the study group. There were 30 patients in the near-infrared light device (study) group and 30 patients in the control group. Each nurse completed a minimum of one attempt and a maximum of 10 attempts per patient. The demographic data for the 60 patients are summarized in Table 1. There were no differences between the two groups in terms of basic demographic data including age, sex, body weight, body height, body mass index, and PRISM III score. Thus, body mass index and disease severity were both independent variables regarding the total time it took to achieve a successful vascular access and the success rate of vascular access.
      Table 1Demographic characteristics of the patients with and without use of the VeinViewer.
      CharacteristicStudy groupControl groupp
      Sex (M/F)15/1513/17NS
      Age (y)4.8 ± 0.94.5 ± 0.7NS
      BH (cm)103.80 ± 66.66100.38 ± 6.82NS
      BW (kg)18.36 ± 2.4418.25 ± 2.78NS
      BMI15.18 ± 0.6815.23 ± 0.79NS
      PRISM III score6.83 ± 0.716.20 ± 0.52NS
      Nurses working experience (y)5.84 ± 3.756.57 ± 4.12NS
      BH = body height; BMI = body mass index; BW = body weight; PRISM III score = Pediatric Risk of Mortality III score; NS = statistically nonsignificant.
      The primary outcome measure was the mean time it took to find the first available vessel, and the time was significantly shorter in the study group compared with the control group (126.37 vs. 383.61 seconds; p = 0.027) (Table 2). There were also a significantly fewer number of attempts in the study group compared with the control group (median 1 vs. 2; p = 0.004), and a significantly shorter total time of attempts per patient in the study group compared with the control group (186.16 vs. 497.23 seconds; p = 0.014). The study group had a higher first-attempt success rate for the insertion of the cannula into a peripheral vein as determined by easy flush with normal saline solution or successful blood return for laboratory analysis (study vs. control group = 56.7% vs. 33.3%), although the difference did not reach statistical significance. In general, the device was well received by the patients and staff. Only one nurse reported mild eye strain after using the device for a long time.
      Table 2Comparison between the patients with and without use of the VeinViewer.
      ItemsStudy groupControl groupp
      Mean time to find the first available vessel (s)126.37 ± 26.33383.61 ± 112.140.027
      First-attempt success rate56.7 % (17/30)33.3 % (10/30)0.059
      Median of attempts per patient (range)1 (1–5)2 (1–5)0.004
      Total time of attempts per patient (s)186.16 ± 38.82497.23 ± 123.310.014
      With regard to the cost-effectiveness of the near-infrared light device, we saved NTD109.31 (US$3.52) per patient, including a reduction of NTD57.71 (US$1.86) in material costs and NTD51.6 (US$1.66) in personnel costs. Therefore, in a PICU with 20 beds per ward, the total cost for peripheral intravenous line insertion is at least US$150, thus enabling a savings of NTD16,397 (US$528.51) per month in our medical budget.

      4. Discussion

      Vascular access is consistently one of the most distressing aspects of hospital admission for children. Children who are likely to be challenging for peripheral intravenous line insertion can often be identified by certain patient-related risk factors such as the patient's age (<3 years old),
      • Yen K.
      • Riegert A.
      • Gorelick M.H.
      Derivation of the DIVA score: a clinical prediction rule for the identification of children with difficult intravenous access.
      • Smith M.F.
      Emergency access in pediatrics.
      • Moller J.C.
      • Reiss I.
      • Schaible T.
      Vascular access in neonates and infants—indications, routes, techniques and devices, complications.
      body weight <5 kg,
      • Black K.J.
      • Pusic M.V.
      • Harmidy D.
      • McGillivray D.
      Pediatric intravenous insertion in the emergency department: bevel up or bevel down?.
      prematurity (<38 weeks' gestation),
      • Yen K.
      • Riegert A.
      • Gorelick M.H.
      Derivation of the DIVA score: a clinical prediction rule for the identification of children with difficult intravenous access.
      obesity,
      • Jacobson A.F.
      • Winslow E.H.
      Variables influencing intravenous catheter insertion difficulty and failure: an analysis of 339 intravenous catheter insertions.
      and dark skin.
      • Rosenthal K.
      Tailor your I.V. insertion techniques special populations.
      • Haas N.A.
      Clinical review: vascular access for fluid infusion in children.
      Other illness- and injury-related factors such as peripheral edema, hypothermia, dehydration, septic shock, vasoconstriction, chronic bedridden state, and long-term intravenous treatment for chronic conditions also contribute to vascular access difficulty.
      • Kuensting L.L.
      • DeBoer S.
      • Holleran R.
      • Shultz B.L.
      • Steinmann R.A.
      • Venella J.
      Difficult venous access in children: taking control.
      Approaches that enhance the visibility and palpability of peripheral veins have been reviewed.
      • Kuensting L.L.
      • DeBoer S.
      • Holleran R.
      • Shultz B.L.
      • Steinmann R.A.
      • Venella J.
      Difficult venous access in children: taking control.
      These include gentle slapping of the overlying skin, use of a proximal venous tourniquet, and warming the limb. Topical application of nitroglycerin ointment with a eutectic mixture of local anesthetics is effective in inducing local vasodilatation, improving the visibility of the veins of the hand. Veins can also be stabilized using a “trigger” method, in which the hand and index finger are used to stretch the skin and obstruct venous flow in a downward motion. All of these approaches are now widely used in clinical practice. Other techniques such as ultrasound and fluoroscopy may improve intravenous line insertion success rates; however, they have not been systematically investigated in children. Transillumination is another technology that can improve the visualization of nonpalpable, nonvisible veins in children. The VeinViewer uses near-infrared light over the patient's skin, called a vein viewer prototype (V-V-P), and has shown promising results. When comparing the results of V-V-P and ultrasound guided visualization of veins before phlebotomy, V-V-P has shown greater sensitivity in the detection of veins, and it can also aid in determining the direction of venous flux or reflux by projecting the image of refilling after compression of telangiectasias.
      • Miyake R.K.
      • Zeman H.D.
      • Duarte F.H.
      • Kikuchi R.
      • Ramacciotti E.
      • Lovhoiden G.
      • et al.
      Vein imaging: a new method of near infrared imaging, where a processed image is projected onto the skin for the enhancement of vein treatment.
      Applying the near-infrared light device into clinical practice may be helpful for the patients in pediatric emergency departments (ED) and pediatric inpatient hospitalizations,
      • Hess H.A.
      A biomedical device to improve pediatric vascular access success.
      and also assist in treating patients with varicose veins and telangiectasias.
      • Miyake R.K.
      • Zeman H.D.
      • Duarte F.H.
      • Kikuchi R.
      • Ramacciotti E.
      • Lovhoiden G.
      • et al.
      Vein imaging: a new method of near infrared imaging, where a processed image is projected onto the skin for the enhancement of vein treatment.
      In contrast to Perry et al's
      • Perry A.M.
      • Caviness A.C.
      • Hsu D.C.
      Efficacy of a near-infrared light device in pediatric intravenous cannulation: a randomized controlled trial.
      study, in which the benefits of using the VeinViewer for vascular access did not reach statistical significance in pediatric ED patients, we found statistically significant benefits in critically ill children. This difference may be explained by the following reasons. First, our staff had a longer training session (2 hours vs. 1 hour) conducted by the device manufacturer. Second, our patients were recruited from a PICU (vs. pediatric ED) and were more critically ill than those in Perry et al's study. Third, our patients were all ethnically Chinese with a relatively consistent skin color compared to Caucasians or blacks.
      The major disadvantage of a near-infrared light device is the cost of the equipment. In addition, we found that some staff required a longer time to adapt to this new technique. Taking a break to relieve eye strain was also needed after long periods of use.
      In conclusion, the use of a near-infrared light vein-viewing device for vascular access in critically ill children can decrease the total medical time and cost. The device was well received by our patients, their families, and staff.

      Acknowledgments

      This study was supported in part by grant CMRPG 8B0041 (Ching-Yun Sun) from Kaohsiung Chang Gung Memorial Hospital, Taiwan .

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