The Valsalva manoeuvre versus tourniquet for venipuncture

Villa, Gianluca; Chelazzi, Cosimo; Giua, R; Lavacchini, Laura; Tofani, Lorenzo; Zagli, Giovanni; Barbani, Francesco; Gaudio, Angelo Raffaele De; Romagnoli, Stefano; Pinelli, Fulvio

doi:10.1177/1129729818757977

Cited by 9 publications

(5 citation statements)

References 22 publications

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“…Given these published controversial results, we administered uids only at induction of general anesthesia and mostly in a "mild" form of less than 2 ml/kg body weight. Positive pressure ventilation can also act like a Valsalva maneuver and thus affect vein width [27]. In our study, the respiratory settings were within ranges considered normal, without particularly increased respiratory pressures, and were not altered during measurements for individual patients.…”

Section: Discussionsupporting

confidence: 55%

Impact of arm position compared to tourniquet and general anesthesia on peripheral vein width in supine adult patients: A prospective, monocentric, cross-sectional study

Berger,

Brandhorst,

Asen

et al. 2024

Preprint

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Background IV access is a commonly performed procedure that is often taught based on tradition rather than evidence. The effect of arm retroflexion on vein width, either alone or in combination with a tourniquet or general anaesthesia (GA), remains unclear. In this case, the sonographically measured vein width is a surrogate parameter for the success of the puncture. Methods Prospective, cross-sectional study involving 57 patients scheduled for surgery in general anesthesia. We analyzed the impact of arm retroflexion, tourniquet, general anesthesia, and their combinations on the antebrachial veins in supine patients by ultrasound. Measurements were taken awake and during general anesthesia, each with and without the application of a tourniquet, and in three different arm positions (0°, 30°, and max° retroflexion) each. Data are presented as median and interquartile range [IQR]. Results Tourniquet application (AT) had the greatest single effect on Cubital vein outer diameter (CuV-OD) compared to the baseline value of all measures (3.9 mm [3.4–5.1]; 4.8 mm [4.1–5.7], P = 0.001, r = 0.515). This effect was surpassed by the combination of AT and GA (5.1 mm [4.6–6.6], P = 0.001, r = 0.889). In contrast, retroflexion alone did not result in an increase in the CuV–OD at either 30° (4.2 mm [3.7–5.1], p = 1.0, r = 0.12) or max° (4.2 mm [3.6–4.9], p = 0.72, r = 0.23). With GA and AT, no further enlargement was measurable by 30° (5.4 mm [4.6–6.6], p = 1.0, r = 0.15) or max° (5.4 mm [4.6–6.6], p = 1.0, r = 0.07) retroflexion compared to GA-AT-0° (5.1 mm [4.6–6.6], p = 1.0, r = 0.15). Conclusions This study provides evidence that retroflexion of the arm in supine patients, whether alone or in addition to a tourniquet or GA, does not have any additional effect on vein width as a surrogate parameter for successful IV success. It shows for the first time that general anesthesia effectively increase vein diameter. Trial registration DRKS00029603

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Section: Discussionsupporting

confidence: 55%

Impact of arm position compared to tourniquet and general anesthesia on peripheral vein width in supine adult patients: A prospective, monocentric, cross-sectional study

Berger,

Brandhorst,

Asen

et al. 2024

Preprint

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“…With the development of imaging technologies including ultrasound, the optimized Seldinger PICC placement technique has been derived gradually under ultrasound guidance [ 25 ]. In a large number of clinical studies, the success rate of traditional PICC placement is only 78%, that rises to 84% as modified Seldinger technique was used, and reaches 98% using optimized ultrasound-guided Seldinger PICC placement [ 26 , 27 ]. The ultrasound-guided optimized Seldinger technique has a wide range of great clinical applications for PICC placement.…”

Section: Discussionmentioning

confidence: 99%

Therapeutic Effect of Ultrasound-Guided Peripherally Inserted Central Catheter Combined with Predictive Nursing in Patients with Large-Area Severe Burns

Zhang

2022

Computational and Mathematical Methods in Medicine

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This study was aimed to explore the application value of ultrasound-guided peripherally inserted central catheter (PICC) combined with predictive nursing in the treatment of large-area severe burns. 88 patients with large-area severe burns who visited hospital were chosen as the research objects. They were randomly divided into the observation group and the control group, with 44 cases in each. The patients in the observation group were treated with ultrasound-guided PICC combined with predictive nursing, while those in the control group were treated with traditional PICC and nursing methods. Then, the anxiety of patients was compared between groups by the Self-rating Anxiety Scale (SAS), while the depression was compared by the Self-rating Depression Scale (SDS). The pain of the patients was analyzed by the McGill Pain Questionnaire (MPQ), and a self-made nursing satisfaction questionnaire was adopted to evaluate the nursing satisfaction. The surgery-related indicators of the patients were detected and recorded (the success rate of one-time puncture, the success rate of one-time catheter placement, incidence of complications, heart rate, blood pressure, etc.). The success rates of one-time puncture (93% vs. 86%) and of catheter placement (95% vs. 81%) in the observation group were significantly higher than those in the control group, P < 0.05 . The pain scores of the observation group were much lower than those of the control group at each time period, P < 0.05 . The number of patients with negative emotions such as anxiety and depression in the observation group was markedly less than that in the control group. The incidence of complications in the observation group was notably lower than that in the control group (4.5% vs 18%), P < 0.05 . The nursing satisfaction of the observation group was significantly higher than that of the control group (93% vs 79.5%), P < 0.05 . In conclusion, ultrasound-guided PICC and predictive nursing had high clinical application values in the treatment of patients with large-area severe burns.

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“…One must recline the patient into a Trendelenburg position to distend the veins and minimize air embolism -which would unfortunately not be possible in severe dyspnoea or orthopnoea. Using the stethoscope as a tourniquet, [24] forced expiration manoeuvres [25] and occluding the EJV against the clavicle while anchoring the vein using one's thumb and index finger [26] can further augment venous distension. In cases where the patient's mandible is in the way (especially those with short necks or who cannot rotate their necks), one could bend the proximal-third of the angio-catheter slightly to maintain a shallow angle of approach.…”

Section: ) External Jugular Venous Cannulationmentioning

confidence: 99%

“…Villa et al [25] found significant increases in crosssectional basilic and brachial vein diameters following ten seconds of Valsalva manoeuvre compared to tourniquet application, suggesting that a properlyperformed Valsalva could augment venodilation in situations where tourniquet application is not possible (such as EJV cannulation, patients with fragile skin or patients who cannot tolerate tourniquet pain). Lewin et al [45] suggested having patients hum.…”

Section: Forced Expirationmentioning

confidence: 99%

Management of difficult intravenous access: a qualitative review

Ng¹,

Mark²,

Lateef³

2022

World Journal of Emergency Medicine

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Establishing peripheral intravenous access (PIV) is one of the most ubiquitous and crucial steps in managing critically ill patients. Yet only 74% of first attempts during emergency resuscitation in adults [1] are successful and this falls to an even-more-dismal 33% in difficult intravenous access (DIVA) patients. [2] A perennial challenge faced by clinicians, DIVA impacts patient outcomes adversely by causing downstream delays in both diagnoses (difficulty in obtaining blood specimens and administering intravenous contrast for advanced imaging) and therapy (provision of parenteral fluids, blood products or drug administration to facilitate procedures such as sedation or rapid-sequence intubation). [3] Failed cannulation attempts often cause patient and clinician alike considerable frustration and distress and may lead to complications like thrombophlebitis, infection and haematoma. [4] Moreover, time-to-cannulation averages 2.5-13.0 min for most patients but can take up to 30 min to hours in DIVA cases. [5] As DIVA patients tend to distract disproportionately more time and attention of the attending emergency physicians, this inevitably compromises the care of other patients.Although there is no consensus or universallyaccepted definition, DIVA is commonly defined as either two or more failed attempts by an experienced operator using traditional landmark-based methods BAcKGRound: A perennial challenge faced by clinicians and made even more relevant with the global obesity epidemic, difficult intravenous access (DIVA) adversely impacts patient outcomes by causing significant downstream delays with many aspects of diagnoses and therapy. As most published DIVA strategies are limited to various point-of-care ultrasound techniques while other "tricks-of-the-trade" and pearls for overcoming DIVA are mostly relegated to informal nonpublished material, this article seeks to provide a narrative qualitative review of the iterature on DIVA and consolidate these strategies into a practical algorithm. MEtHodS:We conducted a literature search on PubMed using the keywords "difficult intravenous access", "peripheral vascular access" and "peripheral venous access" and searched emergency medicine and anaesthesiology resources for relevant material. These strategies were then categorized and incorporated into a DIVA algorithm. RESuLtS:We propose a Vortex approach to DIVA that is modelled after the Difficult Airway Vortex concept: starting off with standard peripheral intravenous cannulation (PIVC) techniques, progressing sequentially on to ultrasound-guided cannulation and central venous cannulation and finally escalating to the most invasive intraosseous access should the patient be in extremis or should best efforts with the other lifelines fail. concLuSIon: DIVA is a perennial problem that healthcare providers across various disciplines will be increasingly challenged with. It is crucial to have a systematic stepwise approach such as the DIVA Vortex when managing such patients and have at hand a wide repertoire of techniques t...

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The Valsalva manoeuvre versus tourniquet for venipuncture

Abstract: This increase in cross-sectional basilic and brachial vein diameters was not different to that obtained with the elastic tube tourniquet.

Cited by 9 publications

References 22 publications

Impact of arm position compared to tourniquet and general anesthesia on peripheral vein width in supine adult patients: A prospective, monocentric, cross-sectional study

Impact of arm position compared to tourniquet and general anesthesia on peripheral vein width in supine adult patients: A prospective, monocentric, cross-sectional study

Therapeutic Effect of Ultrasound-Guided Peripherally Inserted Central Catheter Combined with Predictive Nursing in Patients with Large-Area Severe Burns

Management of difficult intravenous access: a qualitative review

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