***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background and Aim : Pain on intravenous ( IV ) cannulation  continues to cause considerable anxiety among the patients visiting the hospital for elective surgery . Often , it is the only unpleasant experience , especially in ambulatory surgical setting s. Although , anecdotal evidence suggests that antecubital fossa ( ACF ) might be less painful site for venous cannulation , no scientific study exists to vali date the same . Methods : In this prospect i ve r and omised study , effect of site selection on pain of venous cannulation was studied . Fifty-five consecutive adults , scheduled to undergo elective surgery , were r and omly allocated to get IV cannulation first on ACF ( 28 patients ) or on dorsum of h and ( DOH ) ( 27 patients ) followed by cannulation on the contralateral arm on the alternative site ( DOH or ACF ) .  Five patients were excluded due to multiple cannulation attempts . Pain scores on cannulation related to both sites were recorded and compared . Results : Non-parametric data and frequency data analysis , using the Wilcoxon signed rank test or the Chi-square test as appropriate , showed that ACF approach was significantly less painful in comparison to the DOH when using a 20-gauge cannula for venous cannulation ( P < 0.05 ) . Conclusion : We recommend that in the absence of any contraindications , ACF should be the cannulation site of choice . However , considerations like increased chance of kinking and obstruction might preclude such practice Background We sought to identify the reasons for  peripheral intravenous cannulae insertion in the emergency department ( ED ) , and the first-time insertion success rate , along with patient and clinician factors influencing this phenomenon . Methods A prospect i ve cohort study of patients requiring peripheral cannulae insertion in a tertiary ED . Clinical and clinician data were obtained . Results A total 734 peripheral intravenous cannula ( PIVC ) insertions were included in the study where 460 insertions were analysed . The first-time insertion success incidence was 86 % . The antecubital fossa ( ACF ) site accounted for over 50 % of insertions . Multivariate logistic regression modelling to predict first-time insertion success for patient factors found : age < 40 versus 80 + years , emaciated versus normal patient size , having a visible or palpable vein/s , and ACF versus forearm insertion site to be statistically significant . Statistically significant clinician factors predicting success were : higher number of prior cannulation procedures performed , and increased clinician perception of the likelihood of a successful insertion . When patient and clinician factors were combined in a logistic regression model , emaciated versus normal , visible vein/s , ACF versus forearm site , higher number of prior PIVC procedures performed and increased clinician perceived likelihood of success were statistically associated with first-time insertion success . Conclusions Peripheral intravenous cannulation insertion success could be improved if performed by clinicians with greater procedural experience and increased perception of the likelihood of success . Some patient factors predict cannulation success : ‘ normal ’ body weight , visible vein/s and cubital fossa placement ; venepuncture may be a cheaper alternative for others if intravenous therapy is not imperative OBJECTIVES To report our success and complication rates with emergency department ( ED ) technician-performed  ultrasound (US)-guided peripheral intravenous ( IV ) catheter placement and to compare our results to similar studies in the literature . METHODS We conducted a retrospective review of a prospect i ve data base of patients who underwent US-guided peripheral IV catheter placement attempts for clinical care in the ED . All patients meeting difficult IV access criteria who had a US-guided peripheral IV catheter placement attempted by a trained ED technician were included .  Average attempts per success and overall success rates were compared to similar published studies . RESULTS There were 830 participants , with an overall success rate of ED technician- performed US-guided peripheral IV catheter placement of 97.5 % . Clinicians categorized 82.6 % of participants as having difficult IV access and reported that in 46.5 % , a central venous catheter would have been necessary if the US-guided peripheral IV catheter failed . Of successful catheter attempts , 86.8 % were placed on the first attempt ; 11.6 % were placed on the second attempt ; and 1.6 % were placed on the third attempt . For this study , the average number of attempts per success was 1.15 ( 95 % confidence interval , 1.12 - 1.18 ) , which was lower than in 6 other published studies , ranging from 1.27 to 1.70 . The overall success rate of our ED technician-performed attempts was 0.970 ( 95 % confidence interval , 0.956 - 0.983 ) , which was higher than that reported in previous ED technician studies ( 0.79 - 0.80 ) , and closer to that reported for physicians or nurses ( 0.87 - 0.97 ) . The arterial puncture complication rate was 0.8 % , which was also lower than in other published studies ( 1.25%-9.80 % ) . CONCLUSIONS With brief but comprehensive training , ED technicians can successfully obtain US-guided peripheral IV catheter access in patients with difficult IV access Patients with difficult intravenous access ( DIVA ) often experience discomfort because of failed attempts to place peripheral venous catheters ( PVCs ) ; however , ultrasound guidance may improve this problem with catheter placement . The aim of this study was to evaluate the use of ultrasound when operated by nurse anesthetists for these patients . This prospect i ve observational study with a pre/post design focused on in patients with DIVA referred for PVC placement , a service provided by nurse anesthetists in most Sc and inavian hospitals . The rate of success , procedure time , number of skin punctures , discomfort , catheter size , location , and incidence of central venous catheter placement are reported before and after implementation of a training program and a mobile service using ultrasound to place difficult-to-place PVCs . The success rate increased from 0 % ( 0 of 33 patients ) to 83 % ( 58 of 70 patients ) with ultrasound .  Procedure time was reduced from 20 to 10 minutes , discomfort was unchanged , and the median number of skin punctures decreased from 3 to 2 . The incidence of central venous catheter placement dropped from 34 % to 7 % . Implementation of a training program and a mobile service in which nurse anesthetists performed ultrasound-guided PVC placement improved the success rate and quality of care in patients with DIVA “ The generation of r and om numbers is too important to be left to chance.”—Robert R Coveyou The r and omized controlled trial ( RCT ) has become the st and ard by which studies of therapy are judged . The key to the RCT lies in the r and om allocation process . When done correctly in a large enough sample , r and om allocation is an effective measure in reducing bias . In this article we describe the r and om allocation process Background Millions of peripheral intravenous catheters are used worldwide . The current guidelines recommend routine catheter replacement every 72–96 h. This practice requires increasing healthcare re source use . The clinical ly indicated catheter replacement strategy is proposed as an alternative . Objectives To assess the cost effectiveness of clinical ly indicated versus routine replacement of peripheral intravenous catheters . Methods A cost-effectiveness analysis from the perspective of Queensl and Health , Australia , was conducted alongside a r and omized controlled trial . Adult patients with an intravenous catheter of expected use for longer than 4 days were r and omly assigned to receive either clinical ly indicated replacement or third-day routine replacement . The primary outcome was phlebitis during catheterization or within 48 h after catheter removal . Re source use data were prospect ively collected and valued ( 2010 prices ) . The incremental net monetary benefit was calculated with uncertainty characterized using bootstrap simulations . Additionally , value of information ( VOI ) and value of implementation analyses were performed . Results The clinical ly indicated replacement strategy was associated with a cost saving per patient of AU$7.60 ( 95 % confidence interval [ CI ] 4.96–10.62 ) and a non-significant difference in the phlebitis rate of 0.41 % ( 95 % CI −1.33 to 2.15 ) . The incremental net monetary benefit was AU$7.60 ( 95 % CI 4.96–10.62 ) . The expected VOI was zero , whereas the expected value of perfect implementation of the clinical ly indicated replacement strategy was approximately AU$5 million over 5 years . Conclusion The clinical ly indicated catheter replacement strategy is cost saving compared with routine replacement . It is recommended that healthcare organizations consider changing to a policy whereby catheters are changed only if clinical ly indicated Abstract Placement of a peripheral intravenous catheter is a routine procedure in clinical practice , but failure of intravenous cannulation regularly occurs . An accurate and reliable predictive scale for difficult venous access creates the possibility to use other techniques in an earlier time frame . We aim ed to develop a predictive scale to identify adult patients with a difficult intravenous access prospect ively : the A-DIVA scale . This prospect i ve , observational , cross-sectional cohort study was conducted between January 2014 and January 2015 , and performed at the department of anesthesiology of the Catharina Hospital ( Eindhoven , The Netherl and s ) . Patients 18 years or older were eligible if scheduled for any surgical procedure , regardless ASA classification , demographics , and medical history . Experienced and certified anesthesiologists and nurse anesthetists routinely obtained peripheral intravenous access . Cannulation was performed regarding st and ards for care . A failed peripheral intravenous cannulation on the first attempt was the outcome of interest . A population -based sample of 1063 patients was included .  Failure of intravenous cannulation was observed in 182/1063 patients ( 17 % ) . Five variables were associated with a failed first attempt of peripheral intravenous cannulation : palpability of the target vein ( OR = 4.94 , 95 % CI [ 2.85–8.56 ] ; P < 0.001 ) , visibility of the target vein ( OR = 3.63 , 95 % CI [ 2.09–6.32 ] ; P < 0.001 ) , a history of difficult peripheral intravenous cannulation ( OR = 3.86 , 95 % CI [ 2.39–6.25 ] ; P < 0.001 ) , an unplanned indication for surgery ( OR = 4.86 , 95 % CI [ 2.92–8.07 ] ; P < 0.001 ) , and the vein diameter of at most 2 millimeters ( OR = 3.37 , 95 % CI [ 2.12–5.36 ] ; P < 0.001 ) . The scoring system was applied in 3 risk groups : 36/788 patients ( 5 % ) suffered from a failed first attempt in the low-risk group ( A-DIVA score 0 or 1 ) , whereas the medium ( A-DIVA score 2 or 3 ) and high-risk group ( A-DIVA score 4 plus ) , included 72/195 ( 37 % ) and 74/80 ( 93 % ) patients with a failed first attempt of inserting a peripheral intravenous catheter , respectively . The additive 5-variable A-DIVA scale is a reliable predictive rule that implies the probability to identify patients with a difficult intravenous access prospect ively . Dutch Trial Register ( ref : 4595 ) Introduction Our primary objective was to describe the time to vessel penetration and difficulty of long-axis and short-axis approaches for ultrasound-guided small vessel penetration in novice sonographers experienced with l and mark-based small vessel penetration . Methods This was a prospect i ve , observational study of experienced certified emergency nurses attempting ultrasound-guided small vessel cannulation on a vascular access phantom . We conducted a st and ardized training , practice , and experiment session for each participant . Five long-axis and five short-axis approaches were attempted in alternating sequence . The primary outcome was time to vessel penetration . Secondary outcomes were number of skin penetrations and number of catheter redirections . We compared long-axis and short-axis approaches using multivariable regression adjusting for repeated measures , vessel depth , and vessel caliber . Results Each of 10 novice sonographers made 10 attempts for a total of 100 attempts . Median time to vessel penetration in the long-axis and short-axis was 11 ( 95 % confidence interval [ CI ] 7–12 ) and 10 ( 95 % CI 6–13 ) seconds , respectively . Skin penetrations and catheter redirections were equivalent and near optimal between approaches . The median caliber of cannulated vessels in the long-axis and short-axis was 4.6 ( 95 % CI 4.1–5.5 ) and 5.6 ( 95 % CI 5.1–6.2 ) millimeters , respectively . Both axes had equal success rates of 100 % for all 50 attempts . In multivariable regression analysis , long-axis attempts were 32 % ( 95 % CI 11%–48 % ; p=0.009 ) faster than short-axis attempts . Conclusion Novice sonographers , highly proficient with peripheral IV cannulation , can perform after instruction ultrasound-guided small vessel penetration successfully with similar time to vessel penetration in either the long-axis or short-axis approach on phantom models Ultrasound has been used to aid cannulation of veins of the neck , chest , antecubital fossa , and femoral vein . This investigation compared the 
    Output:
    
The primary outcome was successful peripheral i.v .
R and om‐effect meta‐ analysis was performed to determine the pooled odds ratio for success in peripheral i.v .
Furthermore , the ultrasound‐guided technique reduced the number of punctures and time needed to achieve i.v .
access , and increased the level of patient satisfaction , although it did not result in a decreased number of complications .
Conclusions Ultrasound guidance  increases the success rate of peripheral i.v .
cannulation , especially in patients with known or predicted difficult i.v .
access