BACKGROUND:A perennial challenge faced by clinicians and made even more relevant with the global obesity epidemic,difficult intravenous access(DIVA)adversely impacts patient outcomes by causing significant downstream ...BACKGROUND:A perennial challenge faced by clinicians and made even more relevant with the global obesity epidemic,difficult intravenous access(DIVA)adversely impacts patient outcomes by causing significant downstream delays with many aspects of diagnoses and therapy.As most published DIVA strategies are limited to various point-of-care ultrasound techniques while other“tricks-of-the-trade”and pearls for overcoming DIVA are mostly relegated to informal nonpublished material,this article seeks to provide a narrative qualitative review of the iterature on DIVA and consolidate these strategies into a practical algorithm.METHODS:We conducted a literature search on PubMed using the keywords“difficult intravenous access”,“peripheral vascular access”and“peripheral venous access”and searched emergency medicine and anaesthesiology resources for relevant material.These strategies were then categorized and incorporated into a DIVA algorithm.RESULTS:We propose a Vortex approach to DIVA that is modelled after the Difficult Airway Vortex concept:starting off with standard peripheral intravenous cannulation(PIVC)techniques,progressing sequentially on to ultrasound-guided cannulation and central venous cannulation and finally escalating to the most invasive intraosseous access should the patient be in extremis or should best efforts with the other lifelines fail.CONCLUSION:DIVA is a perennial problem that healthcare providers across various disciplines will be increasingly challenged with.It is crucial to have a systematic stepwise approach such as the DIVA Vortex when managing such patients and have at hand a wide repertoire of techniques to draw upon.展开更多
In orthopaedic patients, peripheral intravenous (IV) cannulation is a common procedure for various clinical purposes. This patient was introduced with a 17G cannula in the basilic vein of the dorsal venous arch of the...In orthopaedic patients, peripheral intravenous (IV) cannulation is a common procedure for various clinical purposes. This patient was introduced with a 17G cannula in the basilic vein of the dorsal venous arch of the left hand prior to knee replacement surgery. Post knee surgery patients use walking aids for mobilization. Cannula which has been placed at the dorsum of the hand has a potential to bend at the neck of the cannula when the wrist bend while holding the walking aid. Repeated bending can result in fatigue fracture of the cannula neck. In this patient at the time of cannula removal, it was noted the catheter part is broken and proximal migration. Ultrasound guided localization was done and removed with a venotomy under local anesthesia. It is advisable to place peripheral venous cannulas well away from the wrist joint, which will prevent catheter bending and fracture. This is a very important point to consider when placing cannulas in orthopaedic patients who undergo surgical procedures.展开更多
文摘BACKGROUND:A perennial challenge faced by clinicians and made even more relevant with the global obesity epidemic,difficult intravenous access(DIVA)adversely impacts patient outcomes by causing significant downstream delays with many aspects of diagnoses and therapy.As most published DIVA strategies are limited to various point-of-care ultrasound techniques while other“tricks-of-the-trade”and pearls for overcoming DIVA are mostly relegated to informal nonpublished material,this article seeks to provide a narrative qualitative review of the iterature on DIVA and consolidate these strategies into a practical algorithm.METHODS:We conducted a literature search on PubMed using the keywords“difficult intravenous access”,“peripheral vascular access”and“peripheral venous access”and searched emergency medicine and anaesthesiology resources for relevant material.These strategies were then categorized and incorporated into a DIVA algorithm.RESULTS:We propose a Vortex approach to DIVA that is modelled after the Difficult Airway Vortex concept:starting off with standard peripheral intravenous cannulation(PIVC)techniques,progressing sequentially on to ultrasound-guided cannulation and central venous cannulation and finally escalating to the most invasive intraosseous access should the patient be in extremis or should best efforts with the other lifelines fail.CONCLUSION:DIVA is a perennial problem that healthcare providers across various disciplines will be increasingly challenged with.It is crucial to have a systematic stepwise approach such as the DIVA Vortex when managing such patients and have at hand a wide repertoire of techniques to draw upon.
文摘In orthopaedic patients, peripheral intravenous (IV) cannulation is a common procedure for various clinical purposes. This patient was introduced with a 17G cannula in the basilic vein of the dorsal venous arch of the left hand prior to knee replacement surgery. Post knee surgery patients use walking aids for mobilization. Cannula which has been placed at the dorsum of the hand has a potential to bend at the neck of the cannula when the wrist bend while holding the walking aid. Repeated bending can result in fatigue fracture of the cannula neck. In this patient at the time of cannula removal, it was noted the catheter part is broken and proximal migration. Ultrasound guided localization was done and removed with a venotomy under local anesthesia. It is advisable to place peripheral venous cannulas well away from the wrist joint, which will prevent catheter bending and fracture. This is a very important point to consider when placing cannulas in orthopaedic patients who undergo surgical procedures.
