Use of vein‐viewing device to assist intravenous cannulation decreases the time and number of attempts for successful cannulation in pediatric patients

Abstract Every child who contacts a healthcare setting has a potential for intravenous cannulation (IV) procedure and related pain, fear, and distress. Many of the healthcare professionals recognize that there is a lack of intervention to prevent multiple cannulation attempts and to reduce pain and distress inflicted to children during IV cannulation. A quasi‐experimental study was undertaken in pediatric patients to study the effect of a vein‐viewing device (VTorch) on IV cannulation procedure. The number of cannulation attempts and time taken for successful cannulation were assessed with the use of this device (experimental group, n = 159) and compared it with the standard procedure (control group, n = 159). The effect of this device in cannulation associated pain, fear, and behavioral distress were also evaluated among these children. Using Vein‐viewing device as an aid for IV cannulation significantly reduced the time taken for cannulation (P = .003) and the number of cannulation attempts (P = .03). In addition, there was a significant increase in the first‐attempt cannulation success rate with the use of this device (P = .04). The use of vein‐viewing device did not have any direct effect on cannulation associated pain, fear, or behavioral distress among the study participants. The results of this study may aid in improving the quality of intravenous access procedure in pediatric patients.

small veins, it often requires multiple cannulation attempts to obtain a patent intravenous access. Multiple attempts for cannulation can further increase the experience of pain and discomfort in children.
Children may be subjected to physical restraint or the use of force to achieve this. 6 In addition, multiple cannulation attempts can lead to arterial puncture, thrombophlebitis, skin, and soft tissue injury. 7 Nurses spend a considerable amount of their time in IV cannulation procedure in children, and it often requires the involvement of phlebotomists or experienced nurses or doctors to perform this procedure. Therefore, a delay in carrying out the treatment can occur. The average time requirement for peripheral IV cannulation is reported as 2.5-16 minutes, with difficult IV access requiring approximately 30 minutes. 8 Various interventions to improve peripheral venous insertion success rates use traditional methods to improve visibility & palpability of peripheral veins. This includes tapping the skin, use of betadine solution, warming catheter insertion site, and application of tourniquet. 9 Currently, new devices with the advanced visualization technologies like ultrasound, transillumination, light-emitting diode (LED) light waves, and near-infrared lighting are employed to enhance the visibility of veins and minimize cannulation attempts during an IV cannulation. [10][11][12] Use of these devices has shown to significantly reduce the IV procedure time and the parents of children rated nurses as having significantly more skill as compared to the group that did not use vein viewer. [13][14][15][16] VTorch is a commercially available vein-viewing device which works based on LED technology. 17 This handheld vein-viewing device produces a ring of bright light which is focused down and to the center of the ring. When the device is placed on the skin, the light uniformly illuminates the superficial tissues inside the ring. De-oxygenated blood in veins absorbs the light and appears as dark lines which help in easier visualization of veins. At present, there is no published evidence for the effectiveness of this device in assisting IV cannulation in a pediatric population. We hypothesized that the use of this device would increase the cannulation success rate in pediatric patients. The primary outcome of the study was to investigate the use of VTorch in improving the number of cannulation attempts and time taken for cannulation. We also looked for the effect of this device on pain, fear, and behavioral distress experienced among children undergoing IV cannulation.

| ME THODS
This was a prospective, unblinded, quasi-experimental study. The study was conducted over a period of 6 weeks in the pediatric medical and surgical outpatient departments and pediatric general wards at a tertiary hospital. Sample size was calculated to show a significant difference, with 80% power and 5% level of significance, for three different outcomes-mean number of cannulation attempts, time taken for cannulation, and pain score. 10,18,19 The calculated sample sizes were found to be 63, 36, and 159, respectively. Among the three, the highest number of 159 for each group was chosen as the sample size for the study. Pediatric patients who were aged between 6-12 years, who required IV cannulation and fulfilled the inclusion criteria were enrolled in to the study. Patients who required emergency medical management, known case of bleeding disorders, mentally challenged and those on mechanical ventilation and sedation were excluded from the study. The study was approved by the hospital's Institutional Review Board (IRB No: 10796 dated 23.8.2017).
The IV cannulation procedure was performed by staff nurses who had a minimum of 5 years of experience in pediatric wards.
Before the commencement of the study, the investigator educated the staff nurses with the use of vein-viewing device and provided hands-on training. Study subjects were selected using convenient sampling technique. Children who required IV cannulation were identified by the nurses. The Investigator obtained assent from the children and informed consent from the parents as required. In order to avoid selection bias, the first 159 subjects enrolled for the study were allocated to control group and the next 159 to the experimen- We also assessed the pain, fear, and behavioral distress experienced by the children during the cannulation procedure. Pain was assessed using Wong Baker's faces pain assessment scale. 20 This scale has pictures of "faces" indicating the levels of pain, with scores from 0 to 10 where 0 indicates "no hurt" and 10 indicates "hurts worst." Fear was assessed using Children's fear scale, which contains pictures of "faces" indicating increasing degrees of fear, which ranged from 0 to 4. 21 Once the cannula was placed successfully, children were asked to point to the face that exactly describes the pain and fear they experienced during the procedure. This was done within 2 minutes after completion of the procedure. The behavioral distress was assessed by the investigator using the revised Procedure Behavior Rating Scale (PBRS-R) during the three stages of the procedure. 22 Stage 1 includes the time when the child entered the room. Stage 2 is the period when the cannula punctures through the skin till securing the cannula with adhesives, while stage 3 begins 2 minutes after fixing the cannula. The instrument consists of 11 distress behaviors: cry, cling, pain, scream, stall, flail, refusal position, restrain, muscular rigidity, emotional support, and request for termination. These are scored as present or absent over three periods of the procedure. The total PBRS-R scores can vary from 0 to 33, with higher scores representing greater distress.
Statistical analysis was carried out using Statistical Package for Social Scientists (SPSS), version 16.0. The Mann-Whitney U test was used to compare between groups. Categorical data between the groups were compared using Chi-squared test. Correlational analysis was done by Spearman's correlation test. A P value < .05 was considered significant in all cases.

| RE SULTS
A total of 318 IV cannulation procedures were assessed within a time period of 6 weeks. Mean age of children and distribution of male and female participants were similar in control (n = 159) and experimental groups (n = 159) ( Table 1). Numbers of previous IV cannulation exposure in children were comparable between the two groups (Table 1). Collectively, these results suggest that the demographic variables were similar in the control and experimental group, and thus, the study participants were homogenously distributed among the two groups. The working experience of nurses who performed the cannulation and the number of cannulations performed by them in a month were also similar in two groups ( Table 1).
Majority of cannulations were done using 22G sized cannula in both the experimental and control group. The number of cannula used for intravenous cannulation was significantly lower in experimental group, when compared to control group. Frequently used sites of cannulation were brachial, dorsal metacarpal, cephalic, radial, basilic, and medial veins. Distal veins are usually selected for cannulation so as to preserve the proximal veins for future cannulations. If a proper cannulation is not possible in distal site, other proximal veins will be used. In the present study, it was found that 60% of IV cannulations were successful in dorsal metacarpal veins when vein-viewing device was used to assist cannulation. The successful IV cannulation in dorsal metacarpal veins was only 36% in the control group.

| Effect of vein-viewing device on the number of cannulation attempts and time taken for IV cannulation
Utilization of the vein-viewing device to assist IV cannulation significantly reduced the number of cannulation attempts in the experimental group, when compared to the control group ( Figure 1A). The first-attempt success rate of intravenous cannulation was significantly higher with the use of vein-viewing device (77.4%, n = 123), when compared to control group (67.3%, n = 107) (x 2 = 4.0, P = .04). Success in two attempts was 25.8% in control group and 20.8% in experimental group. The number of cases which required more than two attempts for successful cannulation was 11 (6.9%) in control group and 3 (1.8%) in the experimental group. In patients on whom vein-viewing device was used, IV placement was 1.6 times more likely to be successful in the first attempt (Odds ratio 1.66; 95% confidence interval [CI]:

| Effect of vein-viewing device on pain, fear, and behavioral distress associated with IV cannulation
Cannulation procedures are often associated with pain, fear, and distress among children. We assessed whether the use of vein-viewing device to assist IV cannulation improved these parameters. Distribution of pain and fear score among study subjects are shown in Tables S1 and S2. The scores of pain during IV cannulation were similar in control and experimental groups ( Table 2). The mean value for fear score tended to be lower in experimental group than the control group, but these decreases were not statistically significant (P = .08). The score for total behavioral distress experienced during cannulation procedure in control and experimental groups were comparable (P = .21) ( Table 2). Correlational analysis showed that in the control group, pain and fear scores were positively correlated with the number of IV cannulation attempts (Table 3). A significant positive correlation was also seen between the pain score and time taken for the IV cannulation. Such correlations were not seen in the experimental group (Table 3). There are a few limitations to the present study. The study included only children aged between 6-12 years, while new-born, infants, and toddlers were not included in the study. Hence the generalizability of this study in these populations is limited. In the present study, participants were recruited in the control and experimental groups in two time frames, first in the control arm and then in the experimental arm. It may have been a better strategy to use randomized sampling to decrease the possibility of selection bias.

| D ISCUSS I ON
Although factors such as age and gender were similar between the two groups, we did not examine the causes of multiple cannulation attempts, such as the diameter of veins, level of dehydration, cannulation difficulty, and body mass index of study participants, and whether these factors were significantly different in the two arms of the study. The other limitation was the fact that it was impossible to blind the person who performed the procedure.
To summarize, the present study indicates that the use of veinviewing device to assist IV cannulation significantly reduced the number of cannulation attempts and time taken for cannulation. The first-attempt success rate for IV cannulation was significantly higher with the use of this device. Use of vein-viewing device has minimal effect on pain, fear and distress experienced during cannulation.
The findings of this study support the use of the vein-viewing device to improve IV cannulation procedure among pediatric patients and thereby provide better clinical care, avoid complications and reduce procedural delays in starting treatment.