Advances in the management of haemophilia: emerging treatments and their mechanisms

Mainstay haemophilia treatment, namely intravenous factor replacement, poses several clinical challenges including frequent injections due to the short half-life of recombinant factors, intravenous administration (which is particularly challenging in those with difficult venous access), and the risk of inhibitor development. These impact negatively upon quality of life and treatment compliance, highlighting the need for improved therapies. Several novel pharmacological therapies developed for haemophilia aim to rebalance the clotting cascade and potentially circumvent the aforementioned challenges. These therapies utilise a range of different mechanisms, namely: the extension of the circulating half-life of standard recombinant factors; the mimicking of factor VIII cofactor activity; rebalancing of coagulation through targeting of natural anticoagulants such as antithrombin and tissue factor pathway inhibitor; and inducing the production of endogenous factors with gene therapy. These therapies carry the potential of revolutionising haemophilia treatment by alleviating the current challenges presented by mainstay factor replacement. This review will provide an overview of the key trial findings related to novel therapies based on the mechanisms described above.

Evaluation of the AirgloveTM, An Air-Regulated Thermal-Venodilatory Device Facilitating the Cannulation of Patients With Difficult Venous Access

Background Difficult venous access (DVA) can prevent delivery of life-saving intravenous (IV) fluids and medication. The Airglove™ was developed to facilitate IV access, circumventing DVA in chemotherapy patients, as current warm-water immersion (WWI) methods are sub-optimal. Methods This study had two parts; EAGLE-1, an observational, proof-of-concept study and EAGLE-2, a prospective, cross-sectional comparative study. EAGLE-1 recruited 80 adult participants undergoing chemotherapy for cancer with DVA where venous cannula insertion success rate was evaluated using Airglove™. EAGLE-2 was carried out on 34 adult healthy participants where the degree of venodilation by WWI and AirGlove™ in three veins; cubital-fossa cephalic vein, cubital-fossa median vein and the third dorsal carpal vein on both arms were measured using the GE Logic S8 multi-frequency linear-array transducer (L6-15MHz), two-dimension B-mode ultrasound. Baseline measurements were taken at 23oC, forearms were warmed to 38oC using the two modalities prior to ultrasound assessment. Results An IV cannulation success-rate of 87.5% was achieved with the Airglove™ in EAGLE-1. The EAGLE-2 study demonstrated significant venodilation enhancement in all veins examined (p < 0.001, 95% C.I) using the Airglove™. BMI, percentage body-fat, age, gender, or blood-pressure did not significantly influence the degree of venodilation. Conclusions Airglove™ enabled a significant percentage of successful cannulations in participants with DVA in EAGLE-1. EAGLE-2 demonstrated that Airglove™ significantly enhanced venodilation compared to WWI. There may be potential for Airglove™ to be considered in specific clinical settings where DVA is encountered.

Long peripheral catheters and midline catheters: Insights from a survey of vascular access specialists

Background: Peripheral intravenous access is no longer limited to the standard intravenous catheter (cannula). Devices varying in length, material and insertion technique, are increasingly accessible. There is substantial variability surrounding the nomenclature and use of these devices in the literature. We wished to understand the attitude of vascular access specialists towards the nomenclature and use of peripheral intravenous catheters (PIVCs), long peripheral catheters (LPCs) and midline catheters (MCs). Methods: A 15-question electronic survey was sent to members of the Association of Vascular Access (AVA) regarding the nomenclature and use of PIVCs, LPCs and MCs. Results: A total of 228 participants completed the survey. Approximately two-thirds of respondents use LPCs (65.8%) and MCs (71.9%) in their clinical practice. The most common indication for LPCs was difficult venous access (56.5%), while the most common indication for MCs was medium-term (1–4 weeks) intravenous therapy (62.7%). The majority of participants (57.9%) agreed with the following classification of peripheral intravenous devices: PIVCs: 2 to 6 cm in length, terminating distal to the axilla; LPCs: 6 to 15 cm in length, terminating distal to the axilla; MCs: 15–25 cm in length, terminating in the axilla. Participants suggested that the length of the catheter should be considered a general recommendation, as LPCs and MCs should be primarily differentiated by tip location. Conclusions: The majority of vascular access specialists from AVA have incorporated LPCs and MCs into their repertoire of peripheral venous access tools. We envisage that their use will increase as the clinical community becomes more familiar with these devices.

Ultrasound-Guided Peripheral Intravenous Catheter Insertion: The Nurse’s Manual

Peripheral intravenous catheter placement is a skill that is used daily in the hospital. However, many nurses face the challenge of cannulating increasingly complex and difficult-to-access vasculature. Although emergency department clinicians have been using ultrasound to facilitate this procedure for the last 18 years, ultrasound-guided peripheral intravenous catheter placement has not been as rapidly adopted in the critical and acute care nursing realms. Given the benefits of this procedure, including increased patient satisfaction and reduced use of central catheters, its use should be encouraged among all acute care clinicians. The aim of this article is to provide the bedside nurse with a basic understanding of the techniques involved in placing ultrasound-guided peripheral intravenous catheters in patients with difficult venous access.

Prevalence of and factors associated with difficult peripheral venipuncture in adult surgical patients

Objective: To determine the prevalence of difficult venous access in adult patients admitted to a surgical unit. Method: This observational prospective cohort study included 235 patients from a Brazilian hospital. Clinical data were collected by direct observation and analyzed by descriptive, inferential statistics, and multiple binomial logistic regressions. Odds ratios were also calculated. Results: Most of the patients (66.4%) were men and self-reported as white (59.2%). The prevalence of difficult intravenous access was 32.8%. Predictors of peripheral intravenous cannula insertion failure were history of difficult intravenous access and nonvisibility of the vein. Conclusion: History of difficult intravenous access and a nonvisible venous network were significant predictors of peripheral cannula insertion failure in adults undergoing clinical surgery. The prevalence of difficult intravenous access was 32.8%.