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Newborns in intensive unit receives a number of invasive procedures that would causeschanges in sensitizationof pain and possible long-term effects on child’s subsequentdevelopmental period. This encourages the need for pain measurement that could reflectthe actual pain responses especially in blood sampling.The purpose of this review is tooverview pain responses in newborns receiving procedures invasive of blood samplingusing advance pain measurement. Literature search was conducted through threeonline database, namely EBSCO (CINAHL and MEDLINE), Scopus, and Wiley, withinrelated keyword applied are invasive procedure, neonate, newborn, pain assessment andpain intensity. Twelve articles were identified for critical review. This literature studyprovides an overview of responses to blood collection procedures through measurementsof behavioral and skin conductance activities in neonates. Pain response with behavioralmeasurement shows the range of mild-moderate pain in the procedure of blood samplingthrough peripheral veins, the range of moderate-severe pain in heel pricking, and therange of severe pain in arterial blood sampling. Skin conductance measurement reflectsympathetic activity to pain stimulus through sweat gland activity in the superficiallayer of the skin, and is expected to be an objective method of pain measurement forneonates in clinical practice.

Peripheral vein catheterization is the most common invasive hospital procedure, which, however, may be accompanied by the development of various complications.The aim of the study was to assess the frequency of complications associated with peripheral vein catheterization, and to compare two types of peripheral catheters in surgical patients.Materials, methods and results. The study was conducted at the Department of Anesthesiology and Intensive Care at the National Cancer Institute. The study included 122 patients of both sexes who were scheduled for surgery. In the operating room with compliance of the aseptic rules the peripheral veins of the patients upper extremities were catheterized. Intravenous catheters of two types were used for catheterization of the peripheral vein: made of fluoroethylenepropylene (FEP) (FEP IV CannulaVogt Medical with wings and port, size 16-18 G) and of polyurethane (PU) (PU IV CannulaVogt Medical with wings, size 16-18 G) according to the diameter of the punctured vein. The frequency of complications was investigated and the causes of problems with catheterization of peripheral veins were considered. The clinical manifestations of phlebitis were evaluated on the Infusion Nurses Society Phlebitis Scale (INS) scale. The total complication rate in our study was significantly different between the two groups and amounted to 32.6% in gr. 1 and only 7% in gr. 2.Conclusion. The study shows that one of the risk factors may be the design of the instrument and the material from which the peripheral catheter is made. Despite the positive characteristics of both catheters, the impact of which we investigated in our work, the use of PU catheters contributes to reducing the number of complications and increases the duration of their use compared to FEP catheters.

Background: This study was conducted to measure the hemoglobin (Hb) levels, erythrocytes, and related measurements (particularly mean corpuscular volume [MCV], mean corpuscular hemoglobin [MCH], mean corpuscular hemoglobin concentration [MCHC], and hematocrit) in healthy individuals donating blood at the National Blood Transfusion Center (NBTS) in Asmara city, Eritrea. Methods: Venous blood samples were taken from the candidates' peripheral veins into the EDTA tube and examined for red blood cell(RBC) count, Hb, hematocrit (%),MCV, MCH, MCHC, and red cell distribution width (RDW), analyzed and measured by automated blood analyzer. Results: The mean Hb level was 14.428 ± 1.485g/dl, RBCs count was 4.744 ± 0.482 × 10 12 /L, HCT was 41.929 ± 3.75%, RDW mean was 13.571 ± 0.744%, MCV was 88.582 ± 4.0558 Femtoliter, MCH was 30.470 ± 2.188picogram, and MCHC was a mean of 34.393 ± 1.347g/dl. The difference between males and females in MCV and MCHC was significant in favor of female donors. A correlation of a weak positive naturewas found between the ages and genders of donors and the Hb level. All measured values were found to be within the global referenced ranges. Conclusion: Hb, RBCs count, and RBCs indices of apparently healthy Eritrean blood donors were measured for reference, and all values were found to be within the normal reference ranges.

Emergency access to the venous system is vitally important to all veterinary practitioners. This access most commonly requires catheterization of peripheral veins to facilitate treatment of patients in shock or cardiopulmonary arrest. Oftentimes, venous access is challenging and difficult because of poor perfusion, the size of the patient, exotic veterinary species, edematous patients, obesity, or the lack of technical skills of the veterinarian or technician. Peripheral veins continue to be the primary sites for emergency placement of catheters. These sites include the jugular, cephalic, medial saphenous, and lateral saphenous veins. When these veins are unavailable, the most logical site depends on the need for emergency access. Intravenous use of catheters involves the selection of a catheter, proper vein selection, preparation of the venipuncture site, insertion, bandaging, maintenance of the catheter, and an awareness of potential complications. The need for an intravenously placed catheter should be assessed daily. At present, intravenously placed catheters are usually changed every 72 hours.

Hospitalization rate in India is increasing over years and treatment is given mostly via intravenous route.Moist heat therapy for identifying vein before cannulation will reduce number of attempts for cannulation,supply costs and will improve patient satisfaction. AIM: To assess the efficacy of moist heat therapy onvisibility and palpability of peripheral veins prior to intravenous cannulation. SETTINGS: Day care unit(chemotherapy ward), Medicine and Orthopaedic wards of GGS hospital, Faridkot. MATERIAL ANDMETHODS: Using Quasi experimental research design and convenient sampling 60 patients undergoingI.V.cannulation whose veins were not visible and palpable were randomly assigned to experimental (n=30)and conventional group (n=30). In experimental group moist heat therapy with conventional tourniquettechnique and in conventional group only tourniquet was used then post assessment was checked by VeinAssessment Scale in both the groups. RESULTS: In experimental group, the post intervention vein assessmentscore improved from pre intervention score 1-2 to 3-5 and in conventional group from score 1-2 to 1-4. Afterintervention, in experimental group majority of subjects had vein score 4(vein visible and palpable), whereasin conventional group majority scored vein score 3(vein barely visible and palpable). 7(23.3%) subjects ofexperimental group scored vein score 5(vein clearly visible and palpable) whereas in conventional group nosubject scored 5 vein score. Also, 2(6.7%) subjects of this group had vein score 1 that remained unchangeddespite of routine technique. Difference between post intervention scores of experimental and conventionalgroup was found to be significant (?2= 20.06 and p-value 0.00) at p-value

Background Autologous and allogeneic hematopoietic stem cell transplantation of cytokine-mobilized peripheral blood stem cells (PBSCs) is increasingly used to treat patients with hematologic disorders. Different types of vascular access have been exploited for the apheresis procedure, including peripheral veins (PV) and central venous catheter (CVC). In some cases, PV access is unavailable. There are few published data on the efficiency and quality of harvesting with different types of vascular access. This study brings out complications and morbidity of this procedure linked to these different access. Methods We performed a comparative, retrospective, single-center study of hematopoietic stem cell collection using these two types of vascular access. We compared the efficiency and complication rate for 617 adults apheresis sessions in 401 patients and healthy donors, for PBSC collection via PV or CVC between 2010 and 2016. The quality of the HSC product was evaluated in terms of the total CD34 + count and neutrophil contamination. Results The PV and CVC groups did not differ significantly in terms of the quality of the apheresis product, mean ± SD CD34 + cells collected in PV group was 383.1 ± 402.7 × 10e6 and 298.8 ± 372.7 × 10e6 and the level of neutrophil contamination was 21.0 ± 17.8% in the PV group and 20.6 ± 18.4% in the CVC group. The complication rate did not differ between the two groups. Conclusion The type of vascular access for apheresis hematopoietic stem cell harvesting must be determined by trained staff. Successful harvesting can be performed via PV then CVC is not needed or not available.

Peripheral veins often contain tortuosities and valves that hinder the effective passage of intravenous catheters to the full extent of catheter length. This report describes a methodology termed flick-spin that has proven efficacious for venous catheter passage in tortuous and valve-rich peripheral veins. The method relies on (1) applying longitudinal tension to the vessel in an attempt to straighten it, (2) rotating or spinning the catheter along its longitudinal axis, and (3) flicking the skin or visible vein just beyond the catheter tip, all during catheter advancement. Additionally, lateral pressure may also be applied to the vessel—ie, proximal to the catheter tip and during catheter advancement—to fine-tune catheter tip direction. The report contains multiple illustrations to communicate the anatomic, physiologic, and technical underpinnings of the technique, as well as instructions for troubleshooting common problems.

The abundance of, and reliance upon, human electro-muscular incapacitation (HEMI) devices, especially in law enforcement, has generated scrutiny and examination of these technologies. The purpose of this study was to examine cardiovascular effects resulting from typical (5 sec) and longer activation (20 sec) HEMI applications studying myocardial function and peripheral vascular system using a combination of invasive cardiovascular catheters and transesophageal echocardiography (TEE). Six healthy swine (Sus scrofa)3–5 months in age and weighing between 60 and 86 kg were anesthetized and exposed to the TASER Model X26 waveform while transesophageal echocardiography was performed. Stroke volume was shown to statistically decrease during HEMI application indicating an increase in systemic vascular resistance, but HEMI application did not result in myocardial dysfunction ( “cardiac stunning”).

The aim of this study was to compare flucloxacillin concentrations between two specimens collected simultaneously during continuous infusion. One specimen was collected from a peripherally inserted central catheter (PICC) and the other collected simultaneously by peripheral venepuncture. We conducted a prospective study in seven patients who were enrolled in our outpatient parenteral antibiotic therapy (OPAT) service at John Hunter Hospital, Australia, and who were receiving continuous flucloxacillin infusions from an elastomeric device. Blood samples were drawn simultaneously from a PICC and a peripheral vein in each patient. Plasma drug concentrations were measured and compared by paired t test. Flucloxacillin concentrations from the patient’s PICC sample were disproportionately higher than the peripheral sample with a mean difference of 28.4 mg/L (95%CI 2.48 to 54.4; p = 0.037). Plasma flucloxacillin concentrations taken from central catheters are falsely elevated as compared with those from peripheral veins.

Imaging infections with radiolabeled WBC requires precise strategies in order to differentiate them from sterile inflammatory conditions. Indeed, radiolabeled neutrophil, when injected into peripheral veins, has a peculiar biodistribution characterized by a short transit through the lungs (usually 30–60 min), followed by rapid accumulation into liver, spleen, and bone marrow with slow migration into infection sites. This migration process is slower in chronic, low-degree infections and faster in acute, high-degree infections, and it is believed that it is driven by the local production of chemotactic factors.

Calcinosis cutis is a term used to describe a group of disorders in which calcium salt deposits form in the skin and subcutaneous tissue. We report a 6-year-old boy with hypoparathyroidism after thyroidectomy who was admitted to the hospital for severe hypocalcemia being treated with calcium gluconate intravenous infusion through peripheral veins. Within a few days we made a diagnosis of iatrogenic calcinosis cutis and treatment with 10% topical sodium thiosulfate was prescribed; complete resolution of lesions was achieved after 6 months, with no local or systemic adverse effects. Because of the lack of noninvasive alternatives and the good tolerance of the treatment, especially in childhood, we suggest the topical use of this drug as an option for this condition.

Objective: To evaluate the prognostic potential of expression levels of miR-200 family members (miR-200a, miR-200b, miR-200c, miR-429, miR-141) in plasma and exosomes from the tumor-draining vein (mesenteric vein [MV]) and peripheral vein (PV) of colon cancer (CC) patients. Methods: We analyzed the expression of miR-200 family members in matched samples of MV and PV plasma from 50 resected patients with CC and correlated our findings with overall survival (OS). We also examined the content of these microRNAs in MV and PV exosomes. Results: Expression levels were higher in MV than in PV (miR-200a, p < 0.001; miR-200b, p < 0.001; miR-429, p = 0.01; miR-200c, p = 0.05; miR-141, p = 0.05). Low levels of both miR-200c and miR-141 in MV plasma were associated with longer OS (p = 0.02). This association was maintained for the MV exosome cargo of miR-200c and miR-141 (p = 0.02). Conclusion: Our findings provide the first indication that expression levels of miR-200c and miR-141 in MV plasma can identify CC patients with poor prognosis. In addition, our results lend further support to the premise that tumor-draining veins constitute a better source of biomarkers than do PVs.

Urgent hemodialysis (HD) in patients with uremia is usually performed using a central vein catheter unless an arteriovenous fistula (AVF) was created in the predialysis period. We present a unique approach, in a patient in whom the first two HD sessions were conducted without implantation of a catheter or AVF. The perfectly developed peripheral veins of a professional bodybuilder served as vascular access allowing catheter insertion to be avoided. The aim of this short case report is to recall a forgotten method for performing urgent HD in patients without a fistula, but with suitably enlarged superficial veins.

Background The scarcity of data on the anatomy of Sapajus libidinosus has impeded the execution for appropriate veterinary treatment. The objective of this study was to describe the main peripheral veins of the capuchin monkey, used in venipuncture and indicate the best access route for venipuncture procedures. Methods Ten S. libidinosus corpses were used. The face, neck, chest, and pelvic limb were dissected using surgical instruments to identify and locate surface vessels. Results The main superficial veins identified could be used for venipuncture in capuchin monkey where the external jugular, brachial, cephalic, saphenous, and femoral veins. The veins in the pelvic limb were the most suitable for this purpose, with an un anesthetized subject. Conclusions The femoral vein was shown to be the most suitable for blood sampling and drug administration and the saphenous vein for serum therapy protocols.

The peripheral veins of the forearm are widely used for medical conditions such as requiring blood draw, drug and fluid administration. Biological tissues of the forearm have different electro-physical properties. The electrical resistivity of venous blood is lower than the surrounding tissues, which makes it possible to detect veins using electrical impedance method. However, the influence of the inhomogeneity of electro-physical properties of the surrounding soft tissues to the measured impedance values is comparable with the change due to blood vessel depth location, which decreases the accuracy of electrical impedance method of peripheral veins detection. In this study, we proposed the use of venous occlusion simultaneously with electrical impedance measurement to achieve better accuracy of vein projection on skin surface.

Alkylated polycyclic aromatic hydrocarbons (alkyl-PAHs) are the predominant form of PAHs in oil, comprising 85-95% of total PAHs. However, little attention has been paid to these chemicals in ecological risk assessment of marine oil spill. A comparative study of the toxic effects of phenanthrene and retene (7-isopropyl-1-methylphenanthrene, an alkyl-phenanthrene) on the early life stage of marine medaka (Oryzias melastigma) was conducted. Results showed that retene was significantly more toxic than phenanthrene, and marine medaka could be more sensitive to retene than some freshwater fishes. Retene had a higher excretion rate than phenanthrene during the larvae stage. Both of compounds resulted in developmental malformation of marine medaka embryos, with phenanthrene affecting on peripheral vascular system and yolk sac, while retene affecting on cardiac tissues. The toxicity of phenanthrene might be mainly related to its anesthetic effects, and that of retene might be related to the CYP1A-mediated toxicity of its metabolites.

The investigation was carried out on 16 human foetal cadavers at the age of 17-23 weeks from the time of conception. The foetal vascular system was injected with the synthetic resin MERCOX CL-2R and analysed in scanning electron microscope.The vascular system of the foetal spinal cord was studied. The foetal vascular system was characterised by high variability concerning the number, course and localisation of blood vessels. It contained numerous anastomoses with the internal spinal venous plexuses, which included anterior and posterior radicular veins. Large arteries running on the surface of the spinal cord are accompanied by the homoname veins. The venous system of the investigated foetuses was divided into 2 categories of veins: internal veins responsible for the drainage of blood from the central area, that is central and peripheral veins coming radially to the surface of the spinal cord and external veins, which form the venous system of the surface of the spinal cord. The venous system of the foetal spinal cord was also examined as to the presence of the valves.

Collection of peripheral blood hematopoietic stem cells (PBSC) is the practice of choice for graft procurement in both autologous and allogeneic setting. The success of this procedure depends on the use of adequate vascular accesses. Well-sized peripheral veins are the first option in autologous and allogeneic donations. In autologous setting, in case of lack of adequate veins, central venous catheters (CVC) may be used for collection. In the allogeneic setting, although available data have shown the safety of the use of CVC, there are still some controversies about the possible insertion of a CVC in donors. A specific policy from competent registries is usually applied in the different countries to regulate the use of CVC in unrelated donors. In siblings, the question is still undefined due both to the lack of shared guidelines and to the specific characteristics of this donation. In fact, in not so rare cases, larger stem cell doses for specific cell manipulations (e.g., T/B cell depletion in the haploidentical setting) are needed. The lack of international rules or standard that forbid the use of a CVC in siblings and published data that document the safety of this procedure, allowed the Società Italiana di Emaferesi e Manipolazione Cellulare (SIdEM) national Board to identify a possible, shared, operational approach to address this issue by a case-specific risk-benefit assessment.

Introduction: The pre-test probability of pulmonary embolism (PE) is conventionally estimated by the clinical Wells score (WS). Several studies have considered the role of lung, heart and peripheral veins ultrasound in the diagnosis of PE. Aims and Objectives: The purpose of this multicenter study was to evaluate whether the combination of the WS with multiorgan ultrasound (MUS) performs better than the conventional criteria based on the sole WS. Methods: In consecutive patients with suspected PE we calculated the WS and performed MUS. We subsequently integrated the WS with the MUS diagnosis of deep venous thrombosis and the probability of an alternative diagnosis based on the lung examination. The final diagnosis was confirmed on computerized tomography and/or clinical follow-up at 30 days. Accuracy of WS alone and WS/MUS in the prediction of PE, were statistically compared. Results: We enrolled 249 patients, including 60 (24.1%) with a confirmed diagnosis of PE. The WS was >4 in 106 patients of which 35 (33%) had PE. In 143 patients with Wells score ≤4, 25 patients (17.5%) had EP. The MUS was performed in 7 ± 3 minutes. The WS-MUS was >4 in 62 patients of which 42 (67.7%) with PE, while in 187 patients with WS-MUS ≤4, only 18 cases (9.6%) had PE. A WS-MUS >4 showed sensitivity 70% and specificity 89.4%, significantly higher than the traditional WS (sensitivity 58.3% and specificity 62.4%). The area under the curve of WS-US (88.4%) was significantly superior to WS (62.1%, p Conclusions: The integration of the WS with a bedside MUS examination improves the accuracy of the conventional WS for the pre-test stratification of PE likelihood.

WOS: 000307957500014, PubMed ID: 22454038, Nitric oxide synthesized from L-arginine via the nitric oxide synthase enzyme family is the main regulatory molecule in many physiological systems. The level of nitric oxide can now be measured in tissues by a direct real-time amperometric method. The effect of electrical stimulation of the upper cervical spine on the arteries that supply the brain and upper extremities has been established by experimental studies, and thus it has begun to be used in clinical practice to increase blood flow in the brain and the peripheral vascular system. The mechanism of this effect is still a subject of research. This is the first report of real-time nitric oxide measurement in living brain and dermal tissue during electrical stimulation of the upper cervical spine. Using the amperometric method, nitric oxide levels in frontal subcortical and front foot skin were measured before, during and after electrical stimulation of the upper cervical spine in three groups of rabbits that received infusions of saline solution, 7-aminoguanidine or atropine. By electrical stimulation, tissue nitric oxide levels increased significantly and remained increased during stimulation in the brain and skin. The nitric oxide levels dropped back to normal value 1 min after stimulation was turned off. The results we obtained have showed that real-time nitric oxide could also be measured by an amperometric method in living tissues like brain. The effect of stimulation on nitric oxide levels of living tissues disappears immediately when the stimulation is turned off., Scientific Research Project Fund of Cumhuriyet University [T275], This work is supported by the Scientific Research Project Fund of Cumhuriyet University under the project number T275. We thank Mrs. Ziynet Cinar for her assistance in the statistical analysis.

The primary objective of this study was to measure the width and depth of peripheral veins using bedside ultrasound in children younger than 3 years. Secondary objectives included the evaluation of other vein and patient characteristics that may affect intravenous (IV) site selection. Assessment of nursing preferences for peripheral IV site selection was performed.Sixty children aged 0 to 3 years who presented to an urban pediatric emergency department were enrolled. Ultrasound measurements of the transverse diameter (width) and distance from the top of the vein to the skin (depth) were recorded. Upon examination, veins were categorized as visible, palpable, detectable only by ultrasound, or not detectable. Sixteen staff nurses rated the likelihood of successful IV placement among different peripheral veins.The mean width of saphenous veins was significantly larger than that of hand veins (2.8 vs 1.8 mm, P0.0001). When comparing saphenous veins to antecubital veins, no significant difference was measured between the mean width (2.8 vs 2.8 mm). The mean depth of saphenous veins was significantly greater than those of hand veins (1.9 vs 1.4 mm, P0.0001) and antecubital veins (1.9 vs 1.6 mm, P = 0.019). Differences in visibility and palpability were observed between different vein types. Hand veins and antecubital veins were rated by the nursing staff as the most likely sites for successful IV placement, whereas saphenous veins were among the least likely (P0.0001).In children younger than 3 years, the saphenous vein is larger than hand veins and is similar in size to antecubital veins, although marginal differences in depth exist. The sonographic findings of the saphenous vein and antecubital vein suggest that either should be considered a superior first choice for IV cannulation in this age group. Knowledge of these differences is important when choosing a site for peripheral IV placement. Future studies should evaluate peripheral IV success rates by vein type with or without ultrasound guidance.

Introduction: The pre-test probability of pulmonary embolism (PE) is conventionally estimated by the clinical Wells score (WS). Several studies have considered the role of lung, heart and peripheral veins ultrasound in the diagnosis of PE. Aims and Objectives: The purpose of this multicenter study was to evaluate whether the combination of the WS with multiorgan ultrasound (MUS) performs better than the conventional criteria based on the sole WS. Methods: In consecutive patients with suspected PE we calculated the WS and performed MUS. We subsequently integrated the WS with the MUS diagnosis of deep venous thrombosis and the probability of an alternative diagnosis based on the lung examination. The final diagnosis was confirmed on computerized tomography and/or clinical follow-up at 30 days. Accuracy of WS alone and WS/MUS in the prediction of PE, were statistically compared. Results: We enrolled 249 patients, including 60 (24.1%) with a confirmed diagnosis of PE. The WS was >4 in 106 patients of which 35 (33%) had PE. In 143 patients with Wells score ≤4, 25 patients (17.5%) had EP. The MUS was performed in 7 ± 3 minutes. The WS-MUS was >4 in 62 patients of which 42 (67.7%) with PE, while in 187 patients with WS-MUS ≤4, only 18 cases (9.6%) had PE. A WS-MUS >4 showed sensitivity 70% and specificity 89.4%, significantly higher than the traditional WS (sensitivity 58.3% and specificity 62.4%). The area under the curve of WS-US (88.4%) was significantly superior to WS (62.1%, p Conclusions: The integration of the WS with a bedside MUS examination improves the accuracy of the conventional WS for the pre-test stratification of PE likelihood.

Vein access can be challenging for a variety of patients. The development of robots-assisted central or peripheral veins puncture would facilitate life of health professionals and patients. New robots are under development for this purpose and probably they will become available for practical use in the near future. These techniques may decrease significantly the cost of medicine, which currently uses less informatics resources than other industries. O acesso venoso pode ser difícil em muitos pacientes. O desenvolvimento de robôs com capacidade de puncionar veias centrais ou periféricas pode facilitar a vida dos profissionais de saúde e dos pacientes. Novos robôs estão sendo desenvolvidos para essa finalidade e, provavelmente, entrarão em uso na prática clínica em um futuro próximo. Técnicas como estas poderão baixar progressivamente o custo em medicina, que, atualmente, tem usado menos recursos de informática que outras áreas.

Venous physiology and pathophysiology are described in relationship to two main functions of the peripheral veins – venous volume and venous return. These two interconnected functions are determined by basic physiological characteristics of venous vessels such as compliance, capacitance, and resistance. Special attention is paid to the role of the valves as modulators of venous function. Pathological changes in the vein wall in primary and postthrombotic disease and the resultant changes in venous function are described, but the details of the molecular mechanisms are left for further reading.

Veins in biological tissue produce electrical impedance to the alternating current passes through it. Bioimpedance method based on measuring this electrical impedance value using an array of surface electrodes has the capability of detecting peripheral veins. This paper presents the theoretical and experimental studies, reflecting the possibility of impedance method of peripheral veins localization. Mathematical model has been proposed to calculate the resistivity anomalies of vein in soft tissues and reflects the electrical impedance characteristic, depending on the location of the electrode system and the vein. A system electrode has been designed to be attached to the body in order to measure the electrical impedance value. The data obtained will determine the capabilities of the method. Experimental studies confirm the adequacy of the proposed mathematical model.

Red blood cell (RBC) exchange transfusion is a procedure in which a machine removes the patient's abnormal RBCs using a centrifuge to separate the blood into its various parts. These abnormal cells are replaced with RBC units from volunteer healthy blood donors. RBC exchange transfusion can be done either using needles placed in the peripheral veins of each arm or using a central venous catheter. Since this technique is often performed in pediatric patients, it is important to evaluate its indications, and it is also necessary to consider some particular aspects for the apheretic procedure. RBC exchange transfusion is used to treat serious complications of sickle-cell disease, including stroke and acute chest syndrome, and can also be used in certain infections such as malaria or babesiosis, in which red blood cells are damaged.

As the specialty art and practice of placing intravenous devices continues to evolve, ultrasound provides a means to identify, assess, and insert catheters resulting in greater success and patient safety. The identification of peripheral veins can be challenging due to skin color, vein size, depth, and distribution. With ultrasound assessment, the identification of veins is enhanced, not only allowing determination of location but also leading the clinician, with knowledge of vessel size and vein health, to the selection of better insertion sites. The insertion of peripheral venous access devices into the small veins of the arm is a skill requiring fine motor movement. The insertion of these devices is primarily done in the upper extremities. Veins of the lower extremities may be used in pediatric patients or critically ill adults requiring femoral access. This chapter is focused on ultrasound-guided insertion in the arm and offers a brief overview of the identification of veins with venous anatomy specific to upper arm, assessment of the vasculature and a step-by-step process of insertion of peripherally inserted central catheters (PICCs).

Investigations of the equine peripheral vascular system have been constrained by the lack of a non-invasive method of examining the arteries and veins of the limbs of the conscious horse. Precise correlations were established between the gross anatomical features of the peripheral vessels and their B-mode sonographic appearance in each thoracic limb of 35 horses. A sonographic imaging protocol was established. Additional Doppler sonographic recordings defined the arterial waveforms and demonstrated that blood flow to the foot could be evaluated in the lateral proper digital artery, distal to the level of the coronary band. Valves (with 2-4 cusps) were identified in the lumina of the medial and lateral palmar common digital veins and those of the medial and lateral palmar proper digital veins. Spontaneous echo contrast, a smoke-like haze of echoic blood, was seen in the lateral and medial palmar common digital veins, the distal deep palmar venous arch and communicating branches, and the palmar proper digital veins, and occasionally seen in the distal deep palmar arterial arch and distal proper palmar digital arteries. The value of duplex sonography (B-mode and Doppler) for anatomical and physiological studies of the peripheral vasculature of the horse was clearly established. Such data could be applied to the investigation of diseases affecting the peripheral circulation.

ObjectivesTo determine whether peripheral veins can be detected by ultrasound (US) and to determine vein characteristics, as measured by US, that are associated with successful peripheral venous (PV) catheterization in young children. MethodsThe authors conducted an observational study in the pediatric emergency department (ED), with a convenience sample of children younger than 7 years. They evaluated attempts at PV catheterization in two groups on the basis of the visibility and palpability of the patients' veins: 1) clinically apparent (visible or palpable) and 2) not clinically apparent (nonvisible and nonpalpable). The authors obtained sonographic measurements in a transverse view (vertical diameter, circumference, and area) and in a longitudinal view (maximal uninterrupted length). Practitioners blinded to the US images then attempted to catheterize veins in the usual manner. The proportion of clinically apparent veins and the proportion of veins that were successfully catheterized that were identified by US were assessed, and the association between ultrasonographic vein measurements and success at catheterization, controlling for possible confounders, was determined. ResultsThe authors assessed 120 attempts (90 clinically apparent and 30 not clinically apparent) at PV catheterization in 83 patients. US detected all 90 clinically apparent veins, and cannulation success rate was 62/90 (69%). In the not clinically apparent vein group, the rate of success was only 3/30 (10%), and US detected all successfully catheterized veins. In no instance was cannulation successful when the vein was not detected by US. Maximal vein length in longitudinal view was an independent predictor of cannulation success in multivariate analysis. ConclusionsUltrasound appears to be capable of detecting peripheral veins in children younger than 7 years of age, with lack of US vein visualization likely leading to unsuccessful PV placement. Greater vein length visualization may be a useful predictor of successful PV catheterization.

In this study, we investigated the phlebitic potentials of several infusion solutions for peripheral parenteral nutrition to clarify the effects of pH and osmolality on the development of infusion phlebitis. A 10% glucose solution with electrolytes (GE, pH 4.93, 727 mOsm/kg), a 10% amino acid solution (AA, pH 6.95, 929 mOsm/kg), or a 5:2 admixture of GE and AA (GEAA, pH 6.46, 779 mOsm/kg) was infused into the rabbit ear vein for 6 hr at 10 mL/kg/hr, and the infused veins were examined histopathologically. Both GE and AA caused phlebitic changes, such as loss of venous endothelial cells, inflammatory cell infiltration, and perivascular edema. However, their admixture, GEAA, caused scant phlebitic changes. These results were as follows: 1) rabbit peripheral veins could tolerate the pH (6.46) and the osmolality (779 mOsm/kg) of GEAA under the conditions of this study; 2) GE caused phlebitis due to its acidity (pH 4.93); 3) AA caused phlebitis due to its hyperosmolality (929 mOsm/kg); and 4) mixing GE and AA eliminated the factors causing phlebitis in each solution. The admixture of GE and another 10% amino acid solution (AB, pH 6.04) at the ratio of 5:2 (GEAB, pH 5.76, 758 mOsm/kg) caused phlebitic changes. Since its osmolality was lower than that of GEAA, it was considered that GEAB caused phlebitic changes due to its acidity (pH 5.76), which was attributed to the acidic amino acid solution used as a component.

A new system for external counter pulsation is presented. The leg muscles are stimulated periodically by textile electrodes which produce diastolic extra-flows into the peripheral vascular system. In an initial clinical experiment advanced peripheral perfusion and reduced systematic vascular resistance could be demonstrated. Therefore the use in chronic heart failure therapy is suggested.

Background Access to peripheral veins is necessary for sample collection, transfusion and infusion of fluids or medications. The peripheral intravenous catheterization (PIVC) procedure is the introduction of a short catheter into a peripheral vein and can be problematic, leading to multiple failed attempts. Purpose To analyze scientific literature regarding difficulties in establishing peripheral intravenous access and improvement strategies. Method A literature search was undertaken and secondary references were retrieved from the papers obtained from the initial search. A total of 128 papers published from 1975 to 2011 were reviewed. Results The first attempt of PIVC fails in 12-26% of adults and 24-54% of children. Factors associated with the currently utilized PIVC success include: (1) patient's characteristics such as age, gender, race, weight/BMI, co-existing medical conditions and skin/vein characteristics, (2) procedure related factors such as the insertion site and catheter caliber, and (3) the operator's expertise. Strategies to improve PIVC success include: (1) bedside techniques such as venodilation, vascular visualization and vein entry indication, (2) pain management and (3) engagement of expert health care providers. Conclusion Bedside techniques have shown more improvement in PIVC success rates as opposed to pain management. Expert health care providers have shown higher performance levels with regard to the difficult cases of PIVC.

Objective To assess the presence of pulmonary embolism and inflammation after polidocanol foam injection into the peripheral veins of rabbits. Method The animals were treated with polidocanol foam (1 or 3 mg/kg) or vehicle. Early (15 minutes) and late (30 days) animals were evaluated by perfusional lung scintigraphy and histopathological examination. Results In the control group no alterations were found. After polidocanol foam injection it was observed that an important reduction of pulmonary perfusion in the early periods, was mainly in the left lung ( P < 0.001), with consequent embolism in the histological evaluation. In late periods it was observed that the presence of thrombus was with fibrin in small veins, compatible with chronic thrombus and the presence of chronic pulmonary inflammation. Conclusions The injection of polidocanol foam in experimental animals can induce venous embolism and chronic inflammatory infiltration.

The pulmonary veins were identified from the silicone endocast heart models of 19 dogs. Although variation in the number of the more peripheral veins on each specimen existed, all of the casts had a consistency with regards to the most proximal coalescence of the pulmonary veins as they entered the body of the left atrium. That is, the confluence of the veins formed three ostia at the atrial entry point that consisted of 1) right cranial and right middle pulmonary lobe veins; 2) right caudal, accessory, and left caudal pulmonary lobe veins; and 3) both the left cranial and left caudal pulmonary lobe veins of the left cranial lung lobe. The location of these structures identified by the 3-dimensional endocasts were then used to assist in the identification of the pulmonary veins using computed tomography of 2 dogs. Slices were made that approximated those commonly performed during echocardiographic examination. Understanding which pulmonary veins are seen by echocardiography in the different imaging planes will permit prospective evaluations of pulmonary vein size and abnormal flow patterns.

Cellular cardiomyoplasty describes the procedure of cell delivery to the injured heart with the goal to either reverse or at least halt the detrimental effects of myocardial injury. Several strategies for cell delivery to the injured myocardium are available. Direct intramyocardial injection may be performed using a transepicardial, surgical, transendocardial, or transvenous approach. Other strategies include the delivery of cells through coronary arteries, coronary veins, or peripheral veins. In this chapter, we review the successes and the shortcomings of the various procedures that have been tried in animal models of cardiac injury and clinically in patient trials.

Time-of-flight (TOF) MR angiography allows for noninvasive vessel imaging. To overcome the limited volumetric coverage of standard TOF techniques, the aim of this study was to investigate the combination of TOF and continuously moving table (CMT) acquisitions for peripheral vein imaging based on image subtraction. Two acquisition strategies are presented: a simple two-step method based on 2-fold CMT acquisition and an advanced one-step method requiring only one continuous scan. Image quality of both CMT TOF techniques was evaluated by semiquantitative image grading and by signal-to-noise ratio and contrast-to-noise ratio analysis for veins of the upper and lower leg in 10 healthy volunteers. Results were compared to a standard stationary two-dimensional (2D) TOF multistation acquisition. Image grading revealed good image quality for both CMT TOF methods, thereby confirming the feasibility of axial 2D CMT TOF to assess the veins of the lower extremities during a single scan. Quantitative evaluation showed no significant difference in signal-to-noise ratio and contrast-to-noise ratio compared to the stationary experiment. Additional measurements in three patients with postthrombotic changes and varicosities demonstrated the clinical applicability of the presented methods. CMT TOF provides promising results and permits the detection of various pathologic changes of the venous system.

Laparoscopic subtotal adrenalectomy (LSA) has emerged as a treatment option in the management of certain adrenal pathologies. After LSA, a satisfactory blood supply to the adrenal remnant is vital to preserve steroid function. The aim of this study was to review the adrenal blood supply with relevance to LSA.The adrenal blood supply was examined in three ways: 1) a review of six previous cadaver studies looking at adrenal blood supply; 2) a review of our 164 consecutive laparoscopic adrenalectomies (LAs) (January 1999-January 2009); the details of the main adrenal veins and variants had been prospectively recorded; and 3) dissection of 4 cadaver specimens (macroscopic and histologic examination was performed).The six cadaver studies showed duplication or triplication of the main adrenal vein with variable frequency. Four of six studies described smaller peripheral veins surrounding the adrenal gland. The arterial supply appeared constant, with each adrenal gland supplied by up to 60 small arteries. In our series of LA, the main adrenal vein was constant. In 6 cases, the main vein was duplicated. Our cadaver dissection showed the large number of small peripheral veins and arteries surrounding the adrenal gland. Histology confirmed that these peripheral veins drained the adrenal gland.After LSA, a nonfunctioning adrenal remnant is unlikely due to an inadequate arterial supply. Division of the main adrenal vein appears safe, but excessive mobilization of the adrenal remnant should be avoided to prevent destruction of the peripheral veins.

Treatment for children with severe haemophilia is based on prophylaxis and, if inhibitors occur, on immune tolerance induction (ITI). Both regimens require frequent infusions at early ages and therefore an adequate venous access is essential. Peripheral veins represent the best option; however, central venous catheters (CVCs) have been used to facilitate regular treatment. Unfortunately, survival of CVCs is affected by infectious and/or thrombotic complications that often lead to premature removal and consequent treatment discontinuation. This aspect may have an impact on treatment outcome, especially in the case of ITI. In light of this, internal arteriovenous fistula (AVF) has been proposed as an alternative option because of a lower rate of infectious complications. Moreover, AVF is easy to use in the home setting and is well accepted by children and parents. The possible complications are postoperative haematoma and transient symptoms of distal ischaemia; one case of symptomatic thrombosis has been reported to date. Other complications include loss of patency, aneurysmatic dilatation and limb dysmetria. A regular follow-up is mandatory to allow early remedial interventions. Surgical AVF dismantlement is recommended as soon as transition to peripheral vein access is possible.

Peripheral vein Peripheral venous cannulation is quick, safe and easy to learn and does not interfere with CPR. This should be the standard route of choice for delivering drugs. Access to peripheral veins can usually be achieved rapidly by medical personnel. Hypovolaemic, obese, hypothermic or dehydrated patients may present problems. If intravenous access is not in place at the time of cardiac arrest cannulation of an antecubital vein should be the site of choice. More distal veins on the hands and feet should normally be avoided because the longer time needed for drugs to reach the heart and great vessels. If experienced personnel are present the external jugular vein is the preferred site for venous access. For adults we recommend cannulas with relatively large diameter 1.2 or 1.4 mm. Once the cannula is in place it should be connected to an i.v. infusion of a Ringers solution. When a drug is given, infusion should run rapidly in order to facilitate rapid entry of the drugs to central circulation.

Placement of a peripherally inserted central catheter (PICC) is often complicated by the infant's small size and previous use of the peripheral veins, making the traditional means of insertion inadequate. New techniques and technologies, previously reserved for pediatric and adult patients, are now available for use in neonates and can enhance the practice of neonatal PICC teams. The modified Seldinger technique allows insertion of the PICC via smaller peripheral veins while decreasing venous trauma and enhancing the rate of successful placement. A second useful technique, the catheter exchange procedure, allows insertion of a new catheter within the same vein when complications such as occlusion, breakage, or inappropriate position occur and require removal of the currently dwelling PICC. Clinicians caring for neonates and infants must continually update their knowledge and skill by incorporating new techniques into their practice.

Sir, We wish to raise certain issues regarding the article ‘Coiling of guide wire in the internal jugular vein during central venous catheter (CVC) insertion: A rare complication’.[1] Several anatomic features make the left side less attractive than the right.[2] The tortuous course of the vein on the left side partly contributes to the higher rate of coiling through this route. Although the authors ‘experienced mild resistance’ during threading of the guide wire, they stopped only after introduction of about half the length of guide wire. They certainly ignored the initial resistance leading on to guide wire getting fully coiled inside the vein. It is prudent to stop at the earliest moment at the feeling of ‘some resistance’ and check, re-check and further check the position of the guide wire with fluoroscope or with the help of bed-side ultrasound. How much resistance constitutes ‘significant resistance’ is poorly defined in the literature and remains one of clinical wisdom.[3] Unfortunately, two additional attempts were done by other operators even after the initial extraction effort. Instead of repeated attempts, the authors should have evaluated the position of guidewire by ultrasound or fluoroscopy, whichever is readily available. Real-time ultrasound-guidance can facilitate CVC placement and is of interest nowadays.[4] In contrast with authors' view, morbid obesity and coagulopathy cannot be held directly responsible for kinking or looping of the guide wire. In fact, unavailability of peripheral veins in morbid obesity may lead to a compulsion for CVC placement. Morbid obesity may impose difficulty in identification of landmarks. Patients with low or high body mass index, local scarring and history of prior surgery involving the site - are challenges to CVC placement.[2] Any 1st-time occurrence of rare complication may be missed owing to lack of awareness. Hence, there is need of such reporting which will increase our awareness. Gibson and Bodenham[5] proposed a useful aide memoire with regard to misplaced CVCs; in the short term, ‘if in doubt, don't take it out’. Evaluation followed by removal under vision after adequate exposure is the approach of prudence. This is in contrast with endotracheal intubation where it is said that ‘if in doubt, take it out’.

Background In this study, we aimed at determining the incidence of bacteremia during septoplasty and open septorhinoplasty. Methods The study included 60 patients (30 septoplasties and 30 open septorhinoplasties). Preoperative nasal cultures from the nasal cavity and vestibule were taken by using swabs, and blood cultures were obtained from peripheral veins preoperatively, intraoperatively, and postoperatively. Blood cultures were evaluated by using the BACTEC method. Results Neither the blood cultures taken preoperatively nor those obtained postoperatively was positive for any organisms. On the other hand, although the bacterial growth was observed in only one of the blood cultures (3.3%) taken intraoperatively during septoplasty, it was observed in four blood cultures (13.3%) obtained intraoperatively during open septorhinoplasty. Conclusion Our data indicate that a transient bacteremia occurs during open septorhinoplasty. Although this bacteremia is transient and it has not led to any clinical manifestations in our patients, the possibility of bacteremia during this surgery should be kept in mind and necessary precautions should be taken preoperatively in patients with a high risk of cardiovascular infection.

There are several strategies for cell delivery in cardiac stem cell therapy. The cells can be delivered through coronary arteries, coronary veins, or peripheral veins. Alternatively, direct intramyocardial injection can be performed, using a surgical, transendocardial, or transvenous approach. In this article, we describe the most important conceptual aspects and the evidence for the use of these techniques, with emphasis on intramyocardial injections.

A proof-of-principle prototype Vein Contrast Enhancer (VCE) has been designed and constructed. The VCE is an instrument that makes vein access easier by capturing an infrared image of peripheral veins, enhancing the vein-contrast using software image processing, and projecting the enhanced vein-image back onto the skin using a modified commercial projector. The prototype uses software alignment to achieve alignment accuracy between the captured infrared image and the projected visible image of better than 0.06 mm. Figure 1 shows the prototype demonstrated in our laboratory.

The purpose of the present study was to compare the plasma insulin levels in portal and peripheral veins in rats submitted to a prolonged exercise to exhaustion (mean +/- SE: 67 +/- 7 min). Plasma insulin levels were reduced significantly (p less than 0.01) during exercise in both the portal and peripheral venous circulation. The reduction was, however, more pronounced in the portal than in the peripheral vein (mean: -113 vs -64 and -162 vs -88 pmol.l-1 after 30 and 45 min of exercise, respectively), indicating that exercise reduced not only insulin secretion but also its removal. Accordingly, no significant differences were found for the portal/peripheral ratio of insulin at rest and during the first 45 min of exercise (1.86 +/- 0.2, 1.76 +/- 0.1, and 1.57 +/- 0.2 at rest, and after 30 and 45 min of exercise, respectively). This suggests that insulin removal during exercise is regulated in proportion to portal insulin concentrations.

Historically, total parenteral nutrition (TPN) has been administered by the central venous route because of the rapid development of thrombophlebitis when TPN solutions are administered into peripheral veins. The insertion and placement of central venous catheters is, however, associated with morbidity and mortality and is the main cause of TPN-related complications. By avoiding central venous catheterization, TPN can be made safer. Current awareness about the pathophysiology of peripheral vein thrombophlebitis and the use of a number of techniques that prevent or delay onset of peripheral vein thrombophlebitis mean it is now possible to administer TPN via the peripheral route. These techniques and changes in the practice of TPN in recent years (eg, reduction of caloric loads and use of lipid emulsions) mean peripheral parenteral nutrition is a technique that is now applicable to the majority of hospitalized, nutritionally compromised patients for whom intravenous feeding is anticipated for less than 10 to 14 days.

We report a case of intravenous talcosis in a 36 year old woman. Although she initially denied drug abuse clinical suspicion was aroused by the finding of obliterated peripheral veins, a pleural rub and a peripheral nodular lesion on chest x-ray. Diagnosis of intravenous talcosis was confirmed by finding birefringent particles on transbronchial biopsy. Confronted with this evidence the patient admitted long-standing drug abuse, including intravenous injection of crushed methadone tablets which contain talc filler.