Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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'When I was a house officer'
- Lewis G Morrison (24 August 2002)
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Warm hands make easier venipuncture
- John R.` Davies (24 August 2002)
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Re: 'When I was a house officer'
- Wallace I Sampson (25 August 2002)
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Critical Appraisal of the study
- Ket Sang Tai (25 August 2002)
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Healthcare professionals should consider if intravenous access is needed in the first place
- Gavin D. Barlow, Shanti Palniappan, Dilip Nathwani, Rahuh Mukherjee, Michael Jones (26 August 2002)
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Warming does make a difference
- Jeanette Beer (4 September 2002)
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Re: Warming does make a difference - several remarks
- Teresa T. Goodell (5 September 2002)
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Hand warming for insertion of intravenous cannulas
- Peter Faber (9 September 2002)
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How and when to warm before cannulation
- Robert K Peel, Stephen Wright (9 September 2002)
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Turf wars.
- Paul M Scott (12 September 2002)
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Novel method of bringing up veins for peripheral cannulation
- Eriko Morino, Stephanie Fulton (24 March 2007)
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Lewis G Morrison, Consultant Physician Roodlands Hospital Haddington EH41 3PF
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This study uses a relatively high tech solution to a common problem we encounter in clinical medicine in the Scottish climate; namely poor veins due to vasoconstriction. On the sage advice of the ward sister in my first house job those patients deemed to have 'impossible' veins could be rendered easy venflon 'fodder' by the low tech solution of placing their hands in a warm basin of water for a few minutes whilst either getting on with something else or performing some internal warming of my own (namely tea drinking). This was a triumph for anecdotal uncontolled trails with no funding necessary or conflict of interest in sight. |
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John R.` Davies, Consultant Anaesthetist, Royal Lancaster Infirmary, Lancaster LA1 4RP
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Sir, Lenhardt et al [1] are to be congratulated for showing the benefit of warming patients' hands before attempting venipuncture. But the device they use for warming is, no doubt, expensive. Those clinicians who wear disposable gloves while working have to learn to live with hot sweaty hands. I find that nervous patients with cold clammy hands will have hot sweaty hands with dilated veins when they arrive in the anaesthetic room, if they are given a pair of loose, disposable examination gloves to wear beforehand. Cost? Less than 10 pence (€0.16) each. Yours, Dr.John R.Davies Ref: 1 Lenhardt R, Seybold T, Kimberger O, Stoiser B, Sessler DI. Local warming and insertion of peripheral venous cannulas: single blinded prospective randomised controlled trial and single blinded crossover trial. BMJ 2002;325:409-10 |
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Wallace I Sampson, Editor, The Scientific Review of Alternative Medicine 841 Santa Rita Ave. Los Altos Calif. 94022, USA
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"When I was a practitioner'" in the early 1970s, in hematology/oncology, I recalled that the circulation to the hand and other sensitive areas was much greater than to the back, arm, and other areas. To increase blood flow I instituted the routine of immersing the hands in warm water before attempting venipuncture for chemotherapy, IVs, and phlebotomy. Previously invisible and "unhittable" veins became rapidly enlarged or visible. We were quite efficient. We spread the technique to associates by personal contact. In those days, we never thought of doing a blinded trial to prove such an obvious procedure. Our CVs are the shorter for that. |
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Ket Sang Tai, final year medical student University of Melbourne, 3010 VIC, Australia
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Why is the study done? Insertion of intravenous cannulas is the most commonly performed invasive medical procedure(1). Clearly, any improvement in efficiency in performing this procedure will potentially reduce cost and time. Is the study and design appropriate? The authors had a clearly focused objective and had chosen an appropriate study type. The methods, measurements and analysis were also very well designed and appropriate. However, the selection of patients was questionable. In this study, only patients who had physical status score of 1 or 2 were included. Are they representative of most inpatients in hospitals? Since most problems with insertion of intravenous cannulas are encountered in infants, children, obese patients and black people, are these people represented the study? Is patient allocation random? Is there any difference between the intervention and control group? Computer aided randomisation was used. The intervention and the control groups were not significantly different. However, some important factors, which might have effects on the results, were not considered. These factors include previous unpleasant experience with having cannula inserted and needle phobia. Are the patients, nurse anaesthetist and the resident blinded? Blinding is not always possible. The authors acknowledged that the nurse anaesthetist and the resident could feel that in some patients the hands were warmed. However, did the electric source have an on and off button that was observable to the patients, the nurse and the resident? Were the patients able to communicate with each other and with the performers of the cannula insertion? Were there any measure taken to ensure that the nurse anaesthetist and the resident had not got any information about the study? What is the result and is it applicable? The results are statistically significant. However, its practicality is questionable because: - The study only included patients with physical status score of less than two. Does this represent most patients in the ward? - It was not clear that how many of the very young, the very old, obese and black people were included in the study - The warming equipment used was obviously not cheap and not yet available commercially - Is the time spent in applying the warming equipment and in making sure the patients do not take it off justified? (Compared to time saved in performing cannulas insertion) Other alternatives: Are there better alternatives? What about using warm water(2) and wearing gloves? Can the same results achieved using these methods? References: 1. Rainer L, Tanja S, Oliver K, Brigitte S, Daniel S. Local warming and insertion of venous cannulas: single blinded prospective randomised controlled trial and the single blinded randomised trial. BMJ 2002; 325:409 2. Lewis G M. “When I was a house officer”. BMJ rapid response, 24 August 2002 Word count : 400 (excluding references) |
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Gavin D. Barlow, Clinical Research Fellow & Specialist Registrar in Infectious Diseases Infection Unit, East Block, Ninewells Hospital & Medical School, Dundee, UK. DD1 9SY, Shanti Palniappan, Dilip Nathwani, Rahuh Mukherjee, Michael Jones
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Editor, The study by Lenhardt et al highlights the process of inserting a peripheral intravenous catheter. Before healthcare professionals decide on the most appropriate technique to insert a catheter, however, we would encourage them to ask the question, does this patient need intravenous access in the first place? We recently found that 80% (N = 338) of patients admitted to a teaching hospital’s acute medical admissions unit over a 3-week period received a peripheral intravenous catheter as part of the admission process[1]. Of these, one-third remained unused by the post- on-call consultant ward round. Using criteria that gave inserting doctors the ‘benefit of the doubt’, one in nine catheterised patients still received an unnecessary catheter. Subsequently, none of these patients would have come to harm if they had not been catheterised. Based on these figures, at least 1000 patients per year will be inappropriately catheterised in our unit. The reason for this sub-optimal practice is likely to be multi- factorial. Inexperienced healthcare professionals may not have acquired the necessary clinical experience to risk-assess a patient’s need for intravenous access. Additionally, intravenous therapies, such as antibiotics, are often unnecessarily used. In UK healthcare, however, securing intravenous access before or on admission to hospital appears to have become a ritualistic practice. This may occur because healthcare professionals underestimate the adverse effect of catheter insertion. In one prospective study, for example, 13% of patients had pain at the catheter-site 10-days post-removal and 7% continued to have pain at 98- days[2]. Even if the catheter remains unused, 3% of patients will develop phlebitis[3]. Occasionally more serious skin or soft-tissue infection or rarely life-threatening hospital-acquired bacteraemia may occur[4]. Given the current clinical governance agenda in the UK, the increasing frequency of litigation for nosocomial infection and the potential financial and non -financial costs, the process of peripheral intravenous catheterisation is clearly an important risk-management issue. This common and important invasive procedure merits increased educational effort and further audit and research. Gavin Barlow, Clinical Research Fellow & Specialist Registrar in Infectious Diseases Gavin.Barlow1@tesco.net Shanti Palniappan, Senior House Officer Dilip Nathwani, Consultant Physician in Infectious Diseases & General Internal Medicine Infection Unit, East Block, Ninewells Hospital & Medical School, Dundee, UK. DD1 9SY Rahuh Mukherjee, Medical Student Michael Jones, Consultant Physician in Acute Medicine Ward 15, Ninewells Hospital & Medical School, Dundee DD1 9SY 1. Barlow GD, Palniappan S, Mukherjee R, Jones MC, Nathwani D. Unnecessary peripheral intravenous catheterisation on an acute medical admissions unit: A preliminary study. Eur J Intern Med 2002, in press 2. Lundgren A, Jorfeldt L, Ek AC. The care and handling of peripheral intravenous cannulae on 60 surgery and internal medicine patients: an observation study. J Adv Nurs 1993;18:963-71 3. Curran ET, Coia JE, Gilmour H, McNamee S, Hood J. Multi-centre research surveillance project to reduce infections/phlebitis associated with peripheral catheters. J Hosp Infect 2000;46:194-202 4. Mylotte JM, McDermott C. Staphylococcus aureus bacteremia caused by infected intravenous catheters. Am J Infect Control 1987;15:1-6 |
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Jeanette Beer, Research Sister Lincoln County Hospital LN2 5QY
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It was with interest that I read the paper by Lenhadt et al1, that local warming improves the success rate for peripheral cannula insertion. Working in a busy outpatient chemotherapy unit, insertion of peripheral cannulas is a core activity and can be extremely difficult particularly in those patients who have had repeated courses of chemotherapy. Until recently we asked patients to immerse their hands in warm water. This manoeuvre was not always successful as by the time the patient had returned to their chair and dried their hand, any benefit was rapidly reduced. This led us to investigate other forms of local warming methods, which included proprietary wheat filled bags. These can be readily purchased in many gift and health shops. A donation of a sack of wheat has enabled us to provide a number of wheat filled bags easily and cheaply. Removable cotton covers have also been made to facilitate laundering. Each bag measures approximately 150 cm x 50 cm and is heated in the microwave on high for 2 minutes. This method also reduces the number of attempts at cannulation. Our own in-house approach has provided us with an effective low cost option and has now been fully adopted. It may be that further research is needed to compare other methods used within different clinical areas to provide data for evidence based practice. Jeanette Beer
1 Rainer Lenhardt, Tanja Seybold, Oliver Kimberger, Brigitte Stoiser, Daniel I Sessler. Local warming and insertion of peripheral venous cannulas: single blinded prospective randomised controlled trial and single blinded randomised crossover trial. BMJ 2002;325:409-10. |
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Teresa T. Goodell, Clinical Nurse Specialist Providence St. Vincent Medical Center, Portland, Oregon, USA, 97225
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1) Bravo, Jeanette Beer! Leave it to nurses to figure out a cost- effective (and effective) intervention while the MDs are busy conducting a blinded randomized trial to confirm the usefulness of a low-risk, common- sense procedure. 2) Correction: intravenous cannulation is not the most common invasive medical procedure. It is the most common invasive NURSING procedure, which is also performed by physicians such as anesthesiologists, to be sure. By far, more IV cannulations are done by nurses on any given day than by physicians. 3) I, too, wonder why this study made it to the prestigious BMJ. Slow medical research day? I have a competing interest to report: I, as a nurse, support the nursing profession without which I would have no paycheck, and a lot of free time. |
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Peter Faber, Senior House Officer Aberdeen Royal Infirmary AB25 2ZN
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Editor – It was with interest I read the paper by Lenhardt et. al. [1], on local hand warming for insertion of peripheral venous cannulas. This paper does not sufficiently address hand warming as a ‘novel’ technique to facilitate venodilation and cannulation. The study by Lenhardt et al. [1] suffers from lack of detail on the skills and experience by the chosen phlebotomists/investigators (nurses and residents). The investigators may very well have become better at cannulation during the course of the study. The paper contains no information about how such a ‘learning effect’ may have biased the results on failure rates. The learning and time effect may statistically not have been the same within the hand warming and control group. Secondly, it is somewhat surprising not to find any information as to why 15 minutes was chosen as the optimal time for local hand warming. Lenhardt et. al. [1] do, however, address patients’ acceptability of the hand warming technique, which has previously only been anecdotally reported. Patient tolerability to local heating is widely variable and likely to cause discomfort in atopic individuals susceptible to heat rash. Lenhardt et. al. [1] do not mention that it is already well established in medical research, that venous cannulation and blood sampling can substitute for arterial samples after 10-15 min local hand warming to 68-70 oC [2,3]. For such purposes the cannula is often inserted in an anti-flow direction. Compared with intra-arterial cannulation, venous cannulation offers obvious advantages. The risk of compromising peripheral blood supply is abolished, the cannulation is often less painful, requires less skill and bleeding is easier controlled. Finally, it is, however, worth asking whether there is any gain in clinical efficiency and effectiveness as it takes 15 minutes to warm the hand, which should be conducted under supervision (anecdotally, patients take their hand out of the warming device, when left on their own). References: 1. Lenhardt R, Seybold T, Kimberger O, Stoiser B, Sessler DI. Local warming and insertion of peripheral venous cannulas: single blinded prospective randomised controlled trial and single blinded crossover trial. BMJ 2002;325:409-10 2. Amburad NN, Rabin D, Diamond MP, Lacy WW. Use of a heated superficial hand vein as an alternative site for the measurement of amino acid concentrations and for the study of glucose and alanine kinetics in man. Metabolism 1981; 30: 936-940 3. Elia M, Wood S, Khan K, Pullicino E. Ketone body metabolism in lean male adults during short-term starvation, with particular reference to forearm muscle metabolism. Clin Sci 1990; 78: 579-584 |
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Robert K Peel, Specialist registrar in Renal and General Internal Medicine The General Infirmary at Leeds,Great George Street, Leeds, LS1 3EX, Stephen Wright
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We read with interest the paper by Lenhardt et al which supported the use of a carbon fibre warming mitten to aid the insertion of peripheral venous cannulae1. This novel approach proved effective in increasing both the speed and success rate of this common and important procedure. Their paper however raises a number of questions. Firstly, the warmed mitten was compared to a control group that does not represent usual clinical practice as the protocol did not include any of the techniques commonly used in establishing venous access: namely gentle tapping of the vein, repeated clenching and relaxing of the fist and hanging the arm down below the level of the heart. Perhaps this would explain their poor initial success rate in the control group - would one not expect to succeed more than 72% of the time with an 18 gauge cannula in ASA 1 and 2 neurosurgical patients? Secondly, is it practical? 15 minutes or even 10 minutes of warming could well be incorporated into the routine in the holding-bay prior to elective surgery but is it realistic in a busy admissions ward, emergency department or general medical ward. Furthermore, the authors claim that even modest reductions in the time required could be clinically important but is it really a time saver? Would not the 26 seconds saved on average per patient be spent in simply setting up and positioning the warming mitten? The regular use of such a devise is likely to increase rather than decrease the overall time spent on venous cannulation. Finally, they make no reference to cross-infection risk, the regular use of the mitten without some form of disposable liner would risk cross- infection and the risk of catheter-related infection associated with peripheral venous cannulae is well documented2. For these reasons we doubt that this technique will be widely acceptable but agree that warming by whatever method - immersion in warm water for example - is useful to bear in mind where peripheral venous cannulation is difficult and where the alternative may be the insertion of a central venous line. 1. Lenhardt R et al. Local warming and insertion of peripheral venous cannulas: single blinded prospective randomised controlled trial and single blinded randomised crossover trial. BMJ 2002;325:409-13. 2. Hirschmann H et al. The Influence of hand hygiene prior to insertion of peripheral venous catheters on the frequency of complications. J Hosp Infect 2001 Nov;49(3):199-203. To our knowledge we have no competing interests to declare. |
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Paul M Scott, SpR Radiology Churchill Hospital Oxford
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Surprisingly, to me at least, as a radiologist I now cannulate more patients per day (as a result of intravenous contrast administration for CT and MRI exams) than I did when working in internal medicine. I find it easier than I used to do and there is no doubt that I am more skilled at this procedure than I was ten years ago as a House Officer. In other words experience improves success rate. I commend Lenhardt et al, for undertaking their study and disagree with those respondents who belittle the importance of succesful first time cannulations and of the procedure itself. I suspect had I been cannulating them ten years ago they might have come to view this "simple" procedure with trepidation. Finally, were a relative of mine to require cannulation, I would have no particular concern regarding whether a nurse, doctor, radiographer or passer-by inserted the cannula. I would like them to succeed first time. |
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Eriko Morino, SHO Anaesthetics St Helier Hospital, Carshalton, Stephanie Fulton
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I commend the authors for carrying out this study as I agree wholeheartedly with pre-optimization of conditions in attempting peripheral venous cannulation. During a nightshift recently I was asked to cannulate elderly lady - all members of the surgical team had attempted cannulation with no success - when i saw her she had a tissued 22G cannula placed in the left shoulder! I looked everywhere for a vein - I tried tapping, flicking, rubbing, warming her hands etc with no avail. On her bed side table was a GTN spray - and hesitated for one moment before giving the dorsum of the hand a little spray. Within ten seconds the vasodilatory properties began to appear and I had a choice of three most forgiving veins. I have tried this method two or three times now and it always seems to be effective in the most dire circumstances. I'm not saying all house officers should carry a GTN spray on-call - it is just an observation that it is worth persevering to obtain adequate vasodilation for peripheral venous cannulation. Competing interests: None declared |
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