Conclusion

Patients were enrolled into the trial from 18 June 2013 to 16 August 2013 and the last intravenous catheter was removed from participants on 18 August 2013. We recorded three eligible women who declined participation. We stopped enrolment when all 320 numbered randomisation envelopes were used. We mistakenly enrolled one patient scheduled for Caesarean delivery– we discarded that envelope. There were 12 numbered envelopes or case report forms that could not be found; we did not replace these as we had accounted for the eventuality by preparing 320 numbered envelopes. Disregarding these 13, 154 women randomised to dorsum of the hand and 153 to forearm (total 307) were available for data analysis. Two participants randomised to forearm were not assessed after discharge from the delivery suite whilst on the postnatal ward, so their late outcome data were missing. The nine crossovers and the reasons for crossover are shown in Fig. 1. All crossovers had successful first insertions at the alternate site. All others had a per protocol first attempt at the allocated site. Following crossovers and reattempts after initial insertion failures, a first functional intravenous catheter was present in the dorsum of the hand in 165 and in the forearm in 142 participants.

The characteristics of participants (n = 307) stratified according to intention to treat are shown in Table 1. There was no significant difference in any characteristic between the trial arms. The indications for intravenous catheter placement, participants’ site preference and the inserting inserter’s job grade were also similar.

Primary outcomes based on intention to treat analysis are shown in Table 2. Successful first insertion rates were 144/154 (93. 5%) vs. 133/153 (86. 7%) RR 1. 1 (95% CI 1. 0–1. 2) P = 0. 052, insertion pain median [interquartile range] VNRS scores were 5 [3–6] vs. 4 [3–5] P = 0. 248 and replacement catheter rates were 12/154 (7. 8%) vs. 11/153 (7. 2%) RR 1. 1 (95% CI 0. 5–2. 4) P = 0. 841 for dorsum of the hand and forearm respectively. As the intention to treat analysis on successful insertion showed a borderline statistical result (P = 0. 052) and the insertion success rate difference across trial arms is narrower than the pilot data, we decided to explore success rate based on per protocol as well as site specific successful insertion rate to evaluate the pure impact of insertion site; for both these sub-analyses the P values were 0. 045 (NNTb 15 95% CI 7–595) and 0. 040 (NNTb 15 95% CI 7–316) respectively raising the possibility of Type 2 statistical error with the intention to treat analysis. There was no difference in insertion pain score or the need for catheter replacement in the sub-analyses. Sub-analyses based on first successful catheter dwell site which offered the clearest observational data of dwelling site impact on catheter malfunction was also done; this showed no difference across trial arms.

There was no difference across trial arms in the reasons underlying catheter malfunctions necessitating replacements, provider perception on technical difficulty of insertion, patient satisfaction regarding catheter site (VNRS score), catheter usages, need and indications for additional catheters, future catheterisation site fidelity rates, presence of swelling, bruising, tenderness, vein thrombosis or pain (VNRS scores) at original catheter site and time interval between insertion and last catheter removal.

Our finding indicate that the success rate for inserting an intravenous catheter in a dorsum of the hand vein compared to lower forearm vein might be higher; all other findings including insertion pain, catheter malfunction and replacement, additional catheter, patient satisfaction, post-removal catheter site complications or pain and future fidelity to the allocated site were similar. Our pilot data indicates that in routine practice, junior providers on our delivery suite would preferentially insert the intravenous catheter by a ratio of 81 to 19 into the dorsum of the hand compared to forearm. On the converse, at enrolment 63. 8% of participants in our trial had no preference on insertion site but where a preference was stated 25. 9% preferred the dorsum of the hand (vs. 10. 4% for forearm). The totality of our findings would indicate that less experienced providers on the delivery suite should be allowed to insert a catheter at the dorsum of the hand as that site was also slightly preferred by women.

In obstetrics patients on the delivery suite who needed a peripheral intravenous catheter, both the dorsum of the hand and lower forearm are viable insertion sites; if a dorsum of the hand vein is available and less experienced providers prefer to insert there, they may do so based on our finding.

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