Obtaining peripheral vascular access in

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1 The Art nd Science of Infusion Nursing Arine Ferreir Mchdo Avelr, PhD, RN Mri Angélic Sorgini Peterlini, PhD, RN Mvilde d Luz Gonçlves Pedreir, PhD, RN Ultrsonogrphy-Guided Peripherl Intrvenous Access in Children A Rndomized Controlled Tril ABSTRACT A prospective, rndomized controlled tril compred the success of peripherl venipuncture in peditric ptients using vsculr ultrsound nd stndrd lndmrk methods nd the occurrence of infiltrtion nd phlebitis. The smple ws composed of 382 venipunctures; 188 (49.2%) were performed with vsculr ultrsound, nd 194 (50.8%) were performed using the stndrd lndmrk method. No significnt difference (P =.059) ws found between either method in the success of peripherl venipuncture. A higher frequency of infiltrtion ws found (P =.025) in the vsculr ultrsound group. Key words: child, ptient sfety, peditric nursing, peripherl venous ctheteriztion, ultrsound Author Affilition: Escol Pulist de Enfermgem, Universidde Federl de São Pulo, São Pulo, Brzil. Arine Ferreir Mchdo Avelr, PhD, RN, is n djunct professor t the Escol Pulist de Enfermgem of the Universidde Federl de São Pulo, where she conducts reserch involving intrvenous therpy nd ptient sfety. Mri Angélic Sorgini Peterlini, PhD, RN, is n ssocite professor t the Escol Pulist de Enfermgem of the Universidde Federl de São Pulo, where she lso is involved in reserch relted to intrvenous therpy nd ptient sfety. Mvilde d Luz Gonçlves Pedreir, PhD, RN, is n ssocite professor t the Escol Pulist de Enfermgem of the Universidde Federl de São Pulo, where she conducts reserch involving intrvenous therpy, ptient sfety, nd peditric intensive cre. This reserch ws supported by grnts / nd / from Brzil s Ntionl Council of Technologicl nd Scientific Development. The uthors hve no conflicts of interest to disclose. Corresponding Author: Arine Ferreir Mchdo Avelr, PhD, RN, Ru Embu, 206 pto. 91, São Pulo, Brzil (rine.mchdo@unifesp.br). DOI: /NAN Obtining peripherl vsculr ccess in peditric ptients is complex, timeconsuming procedure tht is prticulrly difficult in smll children. 1,2 Young children, including infnts nd toddlers, hve more subcutneous tissue thn older children nd dults. In ddition, their veins re smller cliber nd re difficult to visulize nd plpte, which contribute to low rte of insertion success on the first ttempt. 2,3 Studies conducted with children hve shown filure rtes for the procedure tht rnge from 9% to 36%, result in severl ttempts, nd in some cses, contribute to relted complictions, such s hemtom nd stress. 1,4-9 Peditric nurses, who re responsible for chieving better results during peripherl ctheter insertion in children, strive to improve prctice. 10 One potentil innovtion for incresing successful venipunctures could be the use of vsculr ultrsound, which hs lredy proved efficcious for centrl vsculr ccess. 11 Only few studies hve exmined the use of ultrsonogrphy for peripherl vsculr ccess in children, nd the results differ with regrd to success rtes. 4,12-14 Two rndomized trils were performed in children with history of difficult ccess or of previous unsuccessful ttempts t insertion using the trditionl stndrd lndmrk method. The first study ws unble to demonstrte cliniclly importnt benefit in sttic, ultrsoundided ctheter insertion technique, 12 but the second study concluded tht ultrsonogrphy-guided ctheter insertion improved overll success rtes by 16% compred with the stndrd lndmrk method. However, no significnt difference in success rtes (P =.208) ws observed in children with difficult ccess. 4 Two nonrndomized studies concluded tht ultrsonogrphy-guided peripherl venipuncture in children could be significnt benefit, reducing the number of insertions nd potentilly reducing insertionrelted pin nd the risk of infection. 13,14 This study nlyzed whether the use of ultrsound during the 320 Copyright 2015 Infusion Nurses Society Journl of Infusion Nursing

2 routine insertion of peripherl ctheters nd site identifiction would increse the insertion success rte nd reduce the incidence of infiltrtion nd phlebitis compred with the stndrd lndmrk method for ctheter insertion. METHODS Study Design A prospective, rndomized controlled tril ws performed in 25-bed peditric surgicl unit in teching hospitl in Brzil, following the pprovl of the ethicl merits of the reserch by its institutionl review bord. The study, Peripherl Intrvenous Puncture Guided by Vsculr Ultrsound, is registered with Trils.gov (#NCT ). The ims, methods, benefits, discomforts, nd potentil risks of the interventions were described to ll subjects nd their prents or gurdins, ccording to the frmework of the World Medicl Assocition s Declrtion of Helsinki. 15 Written informed consent ws obtined from ll prents/gurdins nd subjects 12 yers of ge nd older who greed to prticipte in the reserch. 16 Selection of Prticipnts All children dmitted to the peditric surgicl unit who required peripherl vsculr ccess were eligible for the study with the exception of ptients who were younger thn 24 hours old or older thn 18 yers, s well s ptients who needed emergency tretment. Consent ws obtined from ll of the 335 children who met the inclusion criteri nd their prents or gurdins. The method of venipuncture ws ssigned rndomly to 1 of 2 groups by computerized rndomiztion progrm. For the experimentl group (EG), venipuncture ws guided by ultrsound. In the control group (CG), the venipuncture ws performed using the stndrd ntomicl lndmrk technique with venous plption nd visuliztion. The smple comprised 382 insertions 188 (49.2%) in the EG nd 194 (50.8%) in the CG performed in 335 children between 12 dys nd 17 yers of ge who met the study s inclusion criteri. The insertions were completed in the presence of prents or gurdins. Before dt collection, nurses were trined in the stndrds for peripherl vsculr ccess, ctheter mintennce, ssessment of the insertion site, nd ultrsound use. Introduction of ultrsound use into nursing prctice, equipment opertion, nd imge interprettion trining ws provided to ll peditric nurses in the unit by group of experts in infusion therpy nd ultrsonogrphy. 17 Before the procedure, ll of the children nd their prents took prt in n orienttion bout venipuncture nd ultrsound, using n eductionl mnul nd toy therpy nd simulted ultrsound equipment. Intervention Portble equipment with 25-mm liner trnsducer operting t frequency of 10 MHz ws used for ultrsonogrphic imging. One nurse operted the equipment nd exmined vessels in trnsverse nd longitudinl directions with 90-degree ngle of the trnsducer, then chose the vein to be used. Another nurse performed skin ntisepsis nd the ctheter insertion, nlyzing the imge on the screen. In the EG venipunctures, the ctheter ws inserted nd visulized by rel-time imging during its dvnce into the vein (Figure 1). Insertions mong the children in the CG group were ccomplished using the stndrd lndmrk method. Venous ccess nd the insertion of the ctheter were cliniclly evluted with inspection nd plption. 18 Two nurses crried out the procedure; 1 performed the insertion nd the other provided the required support. In both groups, routine ssessments of the ctheter insertion site were performed 4 times dy nd when there ws complint of pin. 18 The ssessment of complictions in the EG, including visuliztion of the intrvessel ctheter position to obtin imges tht might suggest infiltrtion or phlebitis in the insertion nd surrounding res, ws performed by positioning the trnsducer on the trnsprent ctheter dressing. Clinicl evlutions were performed in the CG, including inspection, plption, nd ttention to ny complints. Outcome Mesures The min outcomes of interest were the success of the insertion nd the incidence of infiltrtion nd phlebitis. The success of the insertion ws defined s blood reflux through the ctheter followed by the dministrtion of 2 ml 0.9% NCl solution with no complints of pin nd without ny signs of complictions in the insertion re. 6,19,20 Figure 1 Longitudinl ultrsound imge of peripherl IV ctheter in the vein. Abbrevition: IV, intrvenous. VOLUME 38 NUMBER 5 SEpTEMBER/OCTOBER 2015 Copyright 2015 Infusion Nurses Society 321

3 TABLE 1 Bseline Chrcteristics of the Smple Chrcteristics EG (n = 188) CG (n = 194) P Age, medin (Q1-Q3), y 8.2 ( ) 7.2 ( ).028 Mle gender 105 (55.9) 107 (55.2).891 b Nutritionl condition Eutrophic 156 (83.0) 160 (82.5) Mlnutrition 22 (11.7) 20 (10.3) Overweight 10 (5.3) 14 (7.2) 1 or more clinicl predispositions to venipuncture filure or complictions 1 or more therpeutic risk fctors for venipuncture filure nd complictions occurrence.698 b 70 (37.2) 79 (40.7).485 b 47 (25.0) 44 (22.7).595 b Previous infusion therpy 145 (77.1) 150 (77.3).964 b History of complictions 33 (17.6) 30 (15.5).582 b Using the Mnn-Whitney test. b 2 Using the χ test. Abbrevitions: EG, experimentl group; CG, control group; Q1, first qurtile; Q3, third qurtile. Infiltrtion ws defined s the escpe of solutions into the extrvsculr re, the presence of cold skin round the insertion site, dependent edem, or n bsent or slow continuous infusion rte. 21, 22 Phlebitis ws defined s vein inflmmtion t the ctheter insertion site resulting in rigid or tortuous veins, heightened sensitivity, pin, nd occsionlly, purulent dringe. 21, 22 Identifiction of such dverse events ws performed by following the Infusion Nurses Society s (INS ) Infusion Nursing Stndrds of Prctice. 21 Dt Anlysis Dt were nlyzed by using IBM SPSS 16 softwre for Windows. The ssocitions between ctegoricl vribles were evluted using the χ2 test nd the Fisher exct nd the Fisher exct test. Numericl vribles were evluted by the Mnn-Whitney test. All ssocitions considered P vlue <.05 to denote sttisticl significnce. RESULTS Tble 1 shows tht subjects were for the most prt school ged, mle, nd eutrophic; hd undergone previous infusion therpy without complictions; nd did not exhibit clinicl conditions cpble of compromising venipuncture success (ie, chronic illness, premturity, infection, vsculr disese, extended infusion therpy) or therpeutic risk fctors (ie, ph < 5 or > 9, osmolr- ity higher thn 350 mosm/l, risk of developing complictions described by the mnufcturers of the solutions or drugs), which would predispose the ptient to insertion filure nd complictions. Tble 1 lso shows there were no significnt differences between the groups, lthough the medin ge in the EG ws higher thn in the CG ( P =.028). Successful ctheter plcement ws more frequent in the CG thn in the EG, with no significnt differences between the groups ( Figure 2 ). The procedure filed in 43 of the 382 insertion ttempts, with 161 (85.6%) successful insertions in the EG nd 178 (91.8%) in the CG. Complementry nlysis of the use of ultrsound with the peripherl ctheter insertions ws conducted. Tble 2 shows tht higher plcement success rte occurred when good visuliztion of the vessel by ultrsound ws possible, with sttisticlly significnt correltion. A good visuliztion of the ctheter progression in rel time ws not relted to significnt improvement in peripherl vsculr ccess. The chrcteristics of the infusion therpy the ctheter insertion site, limb immobiliztion, method of fluid dministrtion, nd the infusion of solutions or drugs with therpeutic risk fctor hd similr distributions between the studied groups. However, ctheter redjustment, or bck nd forwrd movement, ws more frequent in the EG nd differed significntly compred with the CG ( Tble 3 ). Ctheter lengths used were 24 g 0.75 in ( mm) nd 22 g 0.75 in ( mm), with predominnce of 24-guge ctheters used in both study groups (EG = 155, 82.4%; CG = 162, 83.5%). The 322 Copyright 2015 Infusion Nurses Society Journl of Infusion Nursing

4 Figure 2 Success of peripherl IV puncture ccording to studied groups. Abbrevitions: EG, experimentl group; CG, control group; IV, intrvenous. 22-guge ctheters were used in 33 (17.6%) children from the EG nd in 32 (16.5%) children from the CG. There ws no significnt difference between the groups ( P =.783). The ge of the children differed significntly between the groups, s shown in Tble 1. Tble 4 presents the nlysis of the influence of ge nd the success of the ctheter insertion, demonstrting better results relted to ultrsound use in dolescents but without significnt correltion. Of the 339 ctheters successfully inserted, 228 (67.3%) were removed becuse infusion therpy ws discontinued, nd 111 (32.7%) were removed s the result of dverse events, with sttisticlly similr distributions between the studied groups ( P =.948/χ 2 ). Infiltrtion ws identified in 57 (16.8%) ptients nd phlebitis in 9 (2.6%). With regrd to the complictions observed, the incidence of infiltrtion differed significntly between the groups ( P =.025), occurring more frequently in the EG. Phlebitis occurred nerly 4 times more frequently in the CG, but no significnt difference ws observed ( Tble 5 ). DISCUSSION No significnt influence of ultrsound ws found in the successful ctheter insertions performed in the smple TABLE 2 Evlution of the Ultrsonogrphic Imges by Nurses nd Successful Peripherl Venous Insertion Successful Unsuccessful Ultrsonogrphic Evlution f (%) f (%) Vessel visuliztion Yes 150 (93.2) 21 (77.8) No 11 (6.8) 6 (22.2) Ctheter insertion visuliztion Yes 48 (29.8) 3 (11.1) No 113 (70.2) 24 (88.9) P b Using the χ 2 test. b Using the Fisher exct test. VOLUME 38 NUMBER 5 SEPTEMBER/OCTOBER 2015 Copyright 2015 Infusion Nurses Society 323

5 TABLE 3 Chrcteristics of Infusion Therpy Chrcteristics EG (n = 161) CG (n = 178) P Ctheter insertion site Upper limbs 159 (98.7) 177 (99.4).669 Limb immobiliztion 97 (60.2) 118 (66.3).249 Ctheter redjustment 60 (37.3) 46 (25.8).023 b Method of infusion dministrtion Continuous 94 (58.4) 91 (51.1) Intermittent 31 (19.2) 47 (26.4) Continuous nd intermittent 36 (22.4) 40 (22.5) Solutions or drugs with therpeutic risk fctor Using the Fisher exct test. b 2 Using the χ test. Abbrevitions: EG, experimentl group; CG, control group (82.6) 142 (79.8).506 b of children studied. The rte of phlebitis ws sttisticlly similr between groups; infiltrtion ws significntly higher in the ultrsound group. These results re consistent with those obtined in rndomized study showing tht ultrsound did not improve insertion success rte in children. 12 In nother rndomized study, the uthors concluded tht ultrsonogrphy-guided peripherl ctheter insertions in children improved overll success rtes. However, they did not find significnt difference in success rtes ( P =.208). 4 Observtionl studies crried out with dults hve reported s much s 97.0% increse in the success of insertion with ultrsound guidnce Such findings indicte notble differences between peripherl vsculr ccess nd ultrsound use in children nd dults. Technicl, biologicl, nd behviorl spects could be studied to ddress the evidence to support these findings nd promote dvnces. The results of this study my hve been ffected by severl fctors, including (1) the introduction of new technology into dily prctice nd (2) the inclusion of children with different levels of venous ccess difficulty nd different ges nd behvior tht my hve influenced their coopertion with the procedure. These vribles lso could hve influenced the ssessment of the ultrsound imges nd ctheter insertions in rel time. The use of ultrsonogrphy to peripherl vsculr ccess by nurses ws not usul before the study beginning. We believe tht the erly development of technicl skills nd interprettion of the imges my hve contributed to the identified results. TABLE 4 Success of Peripherl Venous Insertion by Age Age EG (n = 161) CG (n = 178) P < 2 yers 13 (36.1) 23 (63.9) yers 50 (46.7) 57 (53.3) yers 51 (45.1) 62 (54.9) yers 47 (56.6) 36 (43.4).055 Using the χ 2 test. Abbrevitions: EG, experimentl group; CG, control group. It should be noted tht most of the studies with higher success rte of peripherl ctheter insertions with ultrsound were conducted in dults with difficult venous ccess nd tht none of tht studies were rndomized controlled trils. 19, 20, A prospective, nonrndomized study of the frequency of successful insertions in infnts nd dolescents without the use of ultrsound demonstrted tht of 249 procedures, 91.0% of insertions were successful. 7 These results re similr to those obtined in this study (91.8%), suggesting tht the peditric nurses in this study were qulified nd prepred to perform the procedure successfully. Apprisl of the ultrsonogrphic imge by professionls showed sttisticlly significnt reltionship ( P =.009) between successful insertions nd vessel visuliztion (93.2%). The reltionship observed between the ultrsonogrphic imge visuliztion of the ctheter insertion nd the success of insertion (29.8%) my hve been reduced becuse of the size of the infnts vessels, TABLE 5 Incidence of Infusion Therpy Complictions: Infiltrtion nd Phlebitis Complictions EG (n = 161) CG (n = 178) P Infiltrtion 34 (73.9) 23 (51.1).025 Phlebitis 2 (4.3) 7 (15.6).090 b Using the χ 2 test. b Using the Fisher exct test. Abbrevitions: EG, experimentl group; CG, control group. 324 Copyright 2015 Infusion Nurses Society Journl of Infusion Nursing

6 the ctheter guge, the sensitivity nd size of the equipment trnsducer, nd the children s coopertion. The child s coopertion is necessry to identify the ultrsonogrphic imge. Any movement cuses loss of the imge. In generl, the older the child, the greter the rte of insertion success (P =.055) (Tble 4). In situtions in which the child did not cooperte, the vessel imge ws nlyzed, nd the professionl hd to memorize the intended site of insertion becuse of the impossibility of completing the puncture in rel time. Vessel visuliztion nd ctheter insertion is esier in older children nd dolescents who cooperte during the procedure becuse venous ccess procedures re significnt source of distress for young children. 12,29 Another fctor tht my hve influenced these findings is the size of the limb tht enbles dequte trnsducer positioning, vrible identified by other reserchers. A rndomized, clinicl tril performed in children younger thn 7 yers demonstrted tht the limited physicl spce in the extremities of smll children does not llow for the ccommodtion of the trnsducer during venipuncture becuse of the trnsducer s size. Insted, sttic ultrsound technique ws used in which the vessel ws identified nd the overlying skin ws mrked with pen tip. 12 Becuse child s coopertion during the procedure is essentil for ultrsound use in rel time, n evlution of the nxiety level, ctivity, nd potentil need for sedtion must guide nursing decisions before the procedure, which should be supported by multidisciplinry prctice. 28 During dt collection, sedtives for insertions were not used, which could hve ffected the results. In Brzilin clinicl prctice, the use of conscious sedtion for children who undergo insertions is not routine. In nother rndomized study conducted by the reserch tem, in which children were sedted during insertion of peripherlly inserted centrl ctheter guided by ultrsonogrphy, the success in the first ttempt ws higher (P =.003) in the ultrsound group (90.5%) thn in the control group (47.6%). 30 Children with difficult venous ccess could be considered cndidtes for the use of conscious sedtion to llow the use of ultrsound. Compliction rtes for ultrsonogrphy-guided peripherl ctheter insertions hve been studied only in dults t the moment of the venipuncture or immeditely following it, including rteril punctures, hemtoms, nd nerve pin. 31,32 In this investigtion, 66 children exhibited infiltrtion or phlebitis, which, ccording to severl studies, re the most common peripherl infusion complictions Prospective nd observtionl studies of complictions in ultrsonogrphy-guided insertion in 75 dult ptients identified infiltrtion (28%), indvertent dislodgment of the ctheter (11%), nd phlebitis (4%) s the most common cuses of peripherl vsculr ccess filure. The uthors described the bsence of control group s the study s mjor limittion. 32 In this study, infiltrtion ws more frequent thn phlebitis. The predominnce of infiltrtion nd its significntly higher rte in the EG compred with the CG could possibly be relted to ctheter redjustment. Although the ultrsound llowed the nurse to view the vessel nd ttempt to position the ctheter properly, redjustment cn contribute to vessel trnsfixing nd consequent infiltrtion. Therefore, while using ultrsound, it would be better to use n indirect method of vein ccess to prevent ctheter redjustment in regions too close to the blood vessel wll. Another fctor to consider is tht nurses were unble to visulize the ctheter insertion in some situtions, which mde the successful positioning of the ctheter in the vessel impossible. A previous study reported tht 58% of the children exhibited some infiltrtion, n incidence 3 times greter thn tht identified in this reserch. 37 In study with Brzilin children, 73.4% of 113 dverse events were infiltrtions. 35 The overll incidence of phlebitis ws lower (2.6%) thn tht suggested by INS, which reports 5% s the mximum rte ccepted for the incidence of phlebitis in ny popultion of ptients. 21 However, it is importnt to underscore tht when evluting the phlebitis frequency seprtely in the 2 study groups, the EG experienced lower rtes (15.6% of the CG ws bove INS recommendtions, compred with 4.3% of the EG ). To the best of the uthors knowledge, no studies hve simultneously evluted the influence of ultrsound on the success of peripherl venous ccess nd infusion therpy compliction rtes in children. The lck of such studies mkes it difficult to compre this study with others. Moreover, direct comprisons between dults nd children my be mde incresingly complex becuse of lck of scientific evidence regrding the differences nd the diverse chrcteristics inherent to the peditric group. Innovtion in clinicl prctice is n essentil component of the evolution of nursing science. This study my encourge other investigtions on this subject nd the enhncement of nursing cre provided to children undergoing infusion therpy. LIMITATIONS OF THE STUDY The limittions of the study include smple size, the ge differences mong the children, the introduction of new technology into nursing prctice, nd the recent professionl chievement of skills nd competencies. CONCLUSION The use of ultrsound guidnce in peripherl ctheter insertion in children promotes successful insertions nd VOLUME 38 NUMBER 5 SEpTEMBER/OCTOBER 2015 Copyright 2015 Infusion Nurses Society 325

7 compliction rtes of infusion therpy tht re sttisticlly similr to those chieved using the stndrd lndmrk method, with the exception of the incidence of infiltrtion, which ws sttisticlly higher in the ultrsound group. The findings of this study provide unique, preliminry dt on the use of ultrsound in lrge group of children who prticipted in rndomized controlled nlysis of peripherl ccess. Little or no innovtion hs been observed recently in the techniques used by nurses for peripherl insertion. The development of new methods tht could improve skills should be studied, nlyzed, nd djusted to improve clinicl outcomes. Future reserch should ddress issues such s the influence of the type of ultrsound on the success of peripherl insertion nd the incidence of complictions of infusion therpy in children, in ddition to how to improve nursing skills in the use of ultrsound with this popultion. REFERENCES 1. Morgn LM, Thoms DJ. 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Infusion nursing stndrds of prctice. J Infus Nurs. 2011;34(suppl 1):S65-S Phillips LD. Complictions of infusion therpy: peripherl nd centrl infusions. In: Phillips LD, ed. Mnul of I.V. Therpeutics: Evidence-Bsed Prctice for Infusion Therpy. 5th ed. Phildelphi, PA: FA Dvis; 2010: Constntino TG, Prikh AK, Stz WA, Fojtik JP. Ultrsonogrphyguided peripherl intrvenous ccess versus trditionl pproches in ptients with difficult intrvenous ccess. Ann Emerg Med. 2005;46(5): Keyes LE, Frzee BW, Snoey ER, Simon BC, Christy D. Ultrsound-guided brchil nd bsilic vein cnnultion in emergency deprtment ptients with difficult intrvenous ccess. Ann Emerg Med. 1999;34(6): Stein JC, Cole W, Krmer N, Quinn J. Ultrsound-guided peripherl intrvenous cnnultion in emergency deprtment ptients with difficult IV ccess. Acd Emerg Med. 2004;11(5): Blivs M, Lyon M. The effect of ultrsound guidnce on the perceived difficulty of emergency nurse-obtined peripherl IV ccess. J Emerg Med. 2006;31(4): Clvert N, Hind D, McWillims R, Thoms SM, Beverley CA, Dvidson A. The effectiveness nd cost-effectiveness of ultrsound locting devices for centrl venous ccess: systemtic review nd economic evlution. Helth Technol Assess. 2003;7(12): Nichols I, Doellmn D. Peditric peripherlly inserted centrl ctheter plcement: ppliction of ultrsound technology. J Infus Nurs. 2007;30(6): Copyright 2015 Infusion Nurses Society Journl of Infusion Nursing

8 29. Zempsky WT. Phrmcologic pproches for reducing venous ccess pin in children. Peditrics. 2008;122(suppl 3): S140-S Onofre PS, Pedreir M, Peterlini MA. Plcement of peripherlly inserted centrl ctheters in children guided by ultrsound: prospective rndomized nd controlled tril. Peditr Crit Cre Med. 2012;13(5):e282-e Bumn M, Brude D, Crndll C. Ultrsound-guidnce vs. stndrd technique in difficult vsculr ccess ptients by ED technicins. Am J Emerg Med. 2009;27(2): Drgin JM, Rebholz CM, Lowenstein RA, Mitchell PM, Feldmn JA. Ultrsonogrphy-guided peripherl intrvenous ctheter survivl in ED ptients with difficult ccess. Am J Emerg Med. 2010;28(1): Ferreir LR, Pedreir MLG, Diccini S. Phlebitis mong neurosurgicl ptients. Act Pul Enferm. 2007;20(1): Grlnd JS, Dunne WM, Hvens P, et l. Peripherl intrvenous ctheter complictions in criticlly ill children: prospective study. Peditrics. 1992;89(6 pt 2): Mchdo AF, Pedreir MLG, Chud MN. Adverse events relted to the use of peripherl intrvenous ctheters in children ccording to dressing regimens. Rev Lt Am Enfermgem. 2008;16(3): Pereir RC, Znetti ML, Ribeiro KP. Resons for discontinuing intrvenous therpy ssocited with the time of in-situ permnence of peripherl venous devices. Rev Guch Enferm. 2002;23(1): Phelps SJ, Helms RA. Risk fctors ffecting infiltrtion of peripherl venous lines in infnts. J Peditr. 1987;111(3): Notice: Online CE Testing Only Strting with this issue, the tests for CE issues will pper only in the online version of the issue, nd ll tests must be completed online t ( INS Members: Before you go to the test, go to for INS member benefit informtion. You cn go to the JIN CE test re from there. Simply select the CE test you re interested in. You will no longer hve the option to mil or fx in the test. If you hven t done so lredy, you will wnt to crete user ccount for yourself in Nursing Center s CEConnection. It s free to do so! Look for the Login link in the upper right hnd corner of the screen. VOLUME 38 NUMBER 5 SEpTEMBER/OCTOBER 2015 Copyright 2015 Infusion Nurses Society 327