Talk:Intravenous therapy/GA1

GA Review
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Reviewer: Tom (LT) (talk · contribs) 07:04, 13 October 2020 (UTC)

Pleasure to interact with you again,. My initial review is below. --Tom (LT) (talk) 07:04, 13 October 2020 (UTC)

Comments
Overall, this is a very clearly written article for a very important topic - thanks for your work here. I don't think it meets GA standards at the moment but am happy to put the article on hold if you would like some time to address my concerns below. In general, there are some common things:
 * Use of "IV" to mean "intravenous" or "intravenous therapy" or "intravenous cannula". I suggest stick with the meaning of "intravenous" and update the rest of the uses in this regard ✅ - "IV" is now used in the article solely as an abbreviation for "intravenous(ly)" - any reference to a line, cannula, or other is specified after the abbreviation.
 * citations that need ot be improved - either out of date, with insufficient information such as page numbers
 * specific citations that are used to cite general information
 * some important things missing from the article ✅
 * the history section is too short ✅

I am yet to:
 * Do a copyright check
 * Do a sources check - important for the reasons mentioned in this article - I will do this when the citations have been updated

Specific feedback below:
 * Lead - "abbreviated as IV" to "abbreviated as IV therapy" (consistent with use below)
 * Uses


 * I suggest that you divide for ease of use into "Medical uses" (fluid, medications, blood products) and "Other uses" (sport, drugs etc.) ✅
 * First line "Intravenous access" should I think either be "Intravenous (IV) access" or "IV access" given you use the acronym in the following sentences✅
 * "The World Anti-Doping Agency (WADA) prohibits" - no need for (WADA) as that acronym isn't used.✅
 * "Medications may be mixed into the fluids mentioned above, commonly normal saline, or dextrose solutions. " requires a citation✅
 * "Certain types of medications can only be given intravenously, such as when there is insufficient uptake by other routes of administration." requires a citation✅
 * "Parenteral nutrition is the act of providing" - the referenced part of the citation is "35" - needs to be clarified✅ (dang CS1 templates don't include "chapter" by default)
 * "Illicit drug use" - suggest add ventanyl, and provide a wikilink. I am not sure about the preferred term for Illicit or illegal here. ❌ - it already has fentanyl in it.
 * Whoops - I'm sure I had a brilliant idea here that wasn't to do with fentanyl, but it's gone now, so I apologise for this weird comment. --Tom (LT) (talk) 22:34, 14 October 2020 (UTC)
 * Use for intravenous contrast and medical imaging is not described ✅ - short section but it has (well, should have) a main article so I hope it's okay.
 * Thanks. --Tom (LT) (talk) 22:34, 14 October 2020 (UTC)
 * Medication and treatment - for other uses of IV medications see here:, including due to concentration, side effects related to high oral doses, problems with absorption, nausea or vomiting, and for rapid administration in EG sepsis. Fluids and medications are I think the primary use of IV therapy throughout the world and this section should be expanded.
 * I tried to limit it intentionally given this is an "overview" article per WP:SS - leaving the specifics of the exact medicines and things to their own articles. If you still think it needs expanding I'll see what I can do
 * I do, per WP:DUE - this gets pride placement in your article and is probably the main reason IV lines are used worldwide, so I think an extra paragraph where you list some more medical reasons is relevant and important to include. --Tom (LT) (talk) 22:34, 14 October 2020 (UTC)
 * I agree - I've expanded it with some examples of drugs and with more information about why IV may be preferred over oral, as well as a small amount of information about prodrugs and IV->PO conversion. -bɜ:ʳkənhɪmez (User/say hi!) 13:41, 15 October 2020 (UTC)
 * Thanks, looks better now --Tom (LT) (talk) 04:08, 16 October 2020 (UTC)


 * Types


 * "Some medications are able to be administered as a bolus dose, which is called an "IV push". A syringe containing the medication is connected to an access port in the primary tubing and the medication is administered through the port. A bolus may be administered rapidly (with a fast depression of the syringe plunger) or may be administered slowly, over the course of a few minutes" is uncited ✅ - whole paragraph there can be cited to that journal article which discusses the difference between a bolus/infusion/etc.
 * "Continuous infusions are used where the variation in concentration that arises from gaps in administration would be undesirable, such as antibiotic therapy" citation is for beta lactam antibiotics and I thin kthis needs further clarification. I assume the meaning is gaps in administration that are undesirable that might lead to subtherapeutic concentrations. ✅ - tried to clarify
 * "Any additional medication to be administered IV at the same time as an infusion may be connected to the primary tubing; this is termed a secondary IV, or IV piggyback" needs a citation ✅
 * "If a bolus or secondary infusion is intended for administration in the same line as a primary infusion, the molecular compatibility of the solutions must be considered" uncited ✅ - most of the information was simply multiple sentences without citations after each one when they were all cited to the same journal article/textbook, so I've gone ahead and "overcited" to make it clearer.
 * Oh, got it - thanks. --Tom (LT) (talk) 22:34, 14 October 2020 (UTC)
 * "A continuous infusion may be used to correct fluid and electrolyte imbalances, or when it is desirable to have a constant blood concentration of a medication over time." uncited ✅ - added a cite (was after the next sentence instead)
 * Thanks, but I do have a concern about the citation. This is cited to ""Prolonged Versus Intermittent Infusion of β-Lactam Antibiotics: A Systematic Review and Meta-Regression of Bacterial Killing in Preclinical Infection Models". I don't think this is a reliable citation for the information that's included, because it seems to be talking about beta lactam antibiotics rather than indending to comment on the use of continuous infusions in general. --Tom (LT) (talk) 22:34, 14 October 2020 (UTC)
 * I've simply removed the part about the fluid/electrolyte imbalances from the sentence and made clear that it's referring to B-Lactams as an example. -bɜ:ʳkənhɪmez (User/say hi!) 13:41, 15 October 2020 (UTC)
 * Thanks for that. --Tom (LT) (talk) 04:08, 16 October 2020 (UTC)


 * Methods


 * "A peripheral cannula is the most common intravenous access method utilized in both hospitals and pre-hospital services" - outpatient services need mentioning too ✅
 * It would be great if what the guage is could be described (eg why is 14 gauge 14 and 16 gauge 16?) ❌ - I think this is better described in the articles linked about birmingham/french gauge.
 * Good point; happy to leave this one.
 * "A peripheral intravenous (PIV) line" unnecessary acronym ✅
 * "There are several types of central IV access, categorized based on the route the catheter takes from the outside of the body to the central vein output.[22]" - no page number in citation ✅ - I have it electronically so YMMV but I added the page number I can find.
 * "usually the superior vena cava, inferior vena cava" - no need for the SVC nor IVC to be italicised in this section ✅
 * "To make the procedure more tolerable for children," - and some adults! Maybe just "A topical anaesthetic can be used to make the procedure less painful, particularly for children" ✅ - what do you mean adults feel pain?
 * Hahaha maybe it's just me! --Tom (LT) (talk) 22:34, 14 October 2020 (UTC)
 * "If the cannula is not inserted correctly" - paragraph seems better placed in adverse effects ❌ I personally think this is best explained here because it is directly related to the technique itself.


 * "A peripherally inserted central catheter (also called a PICC line) is a type of central IV access which consists of a cannula is inserted through a sheath into a peripheral vein and then carefully fed towards the heart, terminating at the superior vena cava or the right atrium" the citation needs to be improved. (1) needs to be more general and (2) 1975?!! not reflecting current medical practice
 * PICC section - suggest add some example veins - generall femoral, jugular, subclavian, or brachial
 * "A tunnelled line is an option for long term venous access necessary for hemodialysis in people with poor kidney function" the citation to support this is inappropriate - the journal article specifically discusses the use of tunnelled lines for HD treatment, so I am confused here.
 * The source is "Permanent Arteriovenous Fistula or Catheter Dialysis for Heart Failure Patients", I am doubtful this is a reliable source relating to all patients with poor kidney function; it seems to cover the subset with heart failure. --Tom (LT) (talk) 22:34, 14 October 2020 (UTC)
 * Well, the sentence as worded now states it's an "option" - I personally think that source is likely okay to confirm it's an option for treatment. If you prefer, I guess I can reword it. -bɜ:ʳkənhɪmez (User/say hi!) 14:16, 15 October 2020 (UTC)


 * Adverse effects


 * Infection - should mention importance factors including duration of the line (and recommendations to remove at certain intervals) and site of insertion (particularly high risk for femoral is my understanding) ✅ - I added the duration of the line, I can't find a good source for the specific sites and their risks right now but I'll try to revisit this later/tomorrow.
 * Phlebitis - "A peripheral IV" the alternating use of "IV" for "Intravenous" and "Intravenous X" is confusing ✅ clarified
 * Phlebitis - I will review the citations but am doubtful the text "Inflammation of the vein may also occur, called phlebitis. This may be caused by infection, the catheter itself, or the specific fluids or medication being given. Repeated instances of phlebitis can cause scar tissue to build up along a vein. This is particularly common in intravenous drug users, and of cancer patients undergoing chemotherapy, whose veins become sclerotic and difficult to access over time, sometimes forming a hard, painful “venous cord”. " is completely referenced by the metaanlysis
 * Cited specifics (IV and chemo causes) with different citations. -bɜ:ʳkənhɪmez (User/say hi!) 14:16, 15 October 2020 (UTC)
 * Phlebitis - the sentences about infection probably belong better in the infection area ✅ - I've combined the infection/inflammation into one section as they're quite related - can undo if you prefer.
 * Should mention the difference between superficial thrombophlebitis and deep venous thrombosis, as well as some common treatment options such as topical nonsteroidals and use of blood thinning agents.
 * DVT is completely different and I'm unaware of any relationship between DVT and intravenous therapy (aside from the obvious that sometimes IV drugs are used to treat a DVT) - thrombophlebitis is different. -bɜ:ʳkənhɪmez (User/say hi!) 14:16, 15 October 2020 (UTC)
 * the 'cord' thing should be mentioned as a separate paragraph phlebitis as these are separate concepts - chronic scarring vs. acute inflammation ✅
 * "Infiltration is characterized by coolness and pallor to the skin as well as localized swelling or edema. It is treated by removing the intravenous line and elevating the affected limb so the collected fluids drain away. Injections of hyaluronidase around the area can be used to speed the dispersal of the fluid/drug" again, I'm doubtful this is contained wihtin the relevant reference, but will check ✅ - added another cite just to be sure.
 * "If the solutions administered are colder than the temperature of the body, induced hypothermia can occur. If the temperature change to the heart is rapid, ventricular fibrillation may be caused. Furthermore, if a solution which is not balanced in concentration is administered, a person's electrolyte balance may become imbalanced. In hospitals, regular blood tests may be used to proactively monitor electrolyte levels. Failure to account for and correct electrolyte imbalance may lead to acidosis or alkalosis." is uncited ✅ - cited both
 * "In some Asian countries, intravenous glucose is used to improve a person's energy, but is not a part of routine medical care in the United States where glucose solutions are prescription drugs. However, intravenous glucose (called "ringer") may be administered clandestinely in store-front clinics catering to Asian immigrants, posing increased risks due to improper technique and oversight.[35]" Um, what. Firstly this is US centric, secondly it comes across quite racist and thirdly, this is completely different in tone (and location) to the rest of the article. I suggest that this is moved to the 'non medical uses' section and written in more general form that in many countries people use IV for nonmedical uses such as fluids, vitamin (eg C) infusions, and glucose infusions as part of alternate medicine. ✅ - this was a holdover from before my work on the article and I didn't know what in heck to do with it so I just kept moving it around and not touching it. I've now touched it and moved it as you suggest.
 * Ok, the phrasing has improved somewhat and, although it still is quite US centric I don't think it needs to hold up this nomination.--Tom (LT) (talk) 02:54, 20 October 2020 (UTC)


 * History section - too short. I would mention bloodletting if it required intravenous access, development of fluids, and changes in cannulas (eg development of smaller, plastic cannulas), recognition of overuse and move to PO treatments instead of IV, as well as some relevant information about the invention of different types of fluids, and something about the history of cannula infections ✅ - didn't mention bloodletting as it is unrelated imo, couldn't find too much information on the cannula development that seemed useful, and I included the types of fluids. Please let me know if you think further expansion is still warranted and I can keep looking.
 * Addit: you use this relevant source earlier: "The history of peripheral intravenous catheters: how little plastic tubes revolutionized medicine"
 * I'm unsure if it's my access method being finicky again, or whether it was a carryover from the prior article, or what, but I do not have access to that article now to use it for expansion. -bɜ:ʳkənhɪmez (User/say hi!) 14:25, 15 October 2020 (UTC)
 * Some additional thoughts
 * I think the article needs to mention more about medical uses that are acute (as mentioned above), requirements for some important medications when a person is in ICU or surgery (for example, vasopressors, inotropes), and use in some longer term situations (such as for chemotherapy, haemodialysis via a cannula, and ECMO) ✅ - added amiodarone as a specific example, I'm leery to go deeper and risk just becoming a "proseified list" of specific medications - I've mentioned multiple emergency uses and a couple chronic ones (at various parts of the article) and beyond that specific medications seem too detailed to me. Happy to disagree and work with you further on this, obviously :) -bɜ:ʳkənhɪmez (User/say hi!) 14:16, 15 October 2020 (UTC)
 * Thanks for that, agree with you - most of the other things are mentioned throughout the article
 * I think the commonly experienced side effect of a flushing sensation as fluids go through a cannula should be mentioned - I haven't personally heard of this myself occurring (nor do I remember feeling a flushing sensation when I've had IVs previously) - and of course "flushing" and "IV" together are going to come up with tons of sources on flushing a line - any chance you have more information about this?
 * Ok no need for this in setting of above
 * there's no mention of:
 * peripheral vasoconstriction, which is one common reason that cannulas need to be placed in certain sites
 * ✅, although the citation is fairly old, this is imo "settled science" for which a newer source is unnecessary. -bɜ:ʳkənhɪmez (User/say hi!) 14:16, 15 October 2020 (UTC)
 * that certain medical imaging need cannulas in certain sites to put contrast in at faster rates to acquire adequate images
 * ❌ - I feel this is too in depth for this article per WP:SS and should be covered more in the specific articles for contrast agents. -bɜ:ʳkənhɪmez (User/say hi!) 14:16, 15 October 2020 (UTC)
 * Ok, that's fine. --Tom (LT) (talk) 02:54, 20 October 2020 (UTC)
 * perhaps a very general subsection in 'adverse effects' should be included stating the (obvious) fact that side effects are also related to what is infused, with infusion pain very common with some substances such as potassium
 * Two comments about sources not mentioned above:
 * "Intermittent infusion may be used when there are concerns about the stability of medicine in solution for long periods of time (as is common with continuous infusions), or to enable the administration of medicines which would be incompatible if administered at the same time in the same IV line" is sourced to "Vancomycin Dosing and Monitoring: Critical Evaluation of the Current Practice" - again I don't think this is a reliable source to comment about the use of infusions in general
 * I clarified that the citation is specifically for vancomycin. -bɜ:ʳkənhɪmez (User/say hi!) 14:16, 15 October 2020 (UTC)
 * "Know The Difference: Infiltration vs. Extravasation" is one of two citations and seems just to be a news article, this is not a reliable medical citation
 * Carry-over from the pre-me article - removed as it's unnecessary given the other citation.
 * Many thanks
 * Many thanks

Tom, I'm happy to work on this and try to improve it to meet the standards and resolve the issues - but it may take me a couple days or so. If you're fine to leave it on hold, I will do my best to get to this no later than Friday - I am limited in my time to do the in-depth work this will require during this, one of my "on weeks" at work, but I will be able to get to it in the evenings most likely. I will likely be editing other "easier" things and maybe making some easier changes here during the week, but I am committed to this article and will do the "depth work" as soon as I possibly can. Thank you for the thorough review and I will re-ping you when I am able to resolve the issues you bring up. -bɜ:ʳkənhɪmez (User/say hi!) 13:39, 13 October 2020 (UTC)
 * No problem, take your time and no need to rush. --Tom (LT) (talk) 03:34, 14 October 2020 (UTC)
 * I've made many of the changes, still working on a couple of the other suggestions, but I am here and willing to keep working on it as able. I do apologize for my very piecemeal treatment of your suggestions - I've been trying to pick a few of the quicker ones when I can here, and leaving a couple of longer ones for the evening. I am not sure if it is normal for us to keep going back and forth on this GA nomination or how that works, but I would greatly appreciate another review when you get a chance and a renewed set of suggestions for improvement. I'll ping you again when I feel I'm at a stuck point on the first list but I figured I'd go ahead and comment here. -bɜ:ʳkənhɪmez (User/say hi!) 19:13, 14 October 2020 (UTC)
 * Not to worry at all. In my experience there is often a bit of too and fro for complex or medical articles. I follow WP:GAN/I which I generally take to mean that while we're both responsive there is no harm in keeping the review open for a reasonable timeframe (eg 2-3 weeks if it's clear things are improving). You and I both have real life responsibilities which mean sometimes people can only response once or twice a week which is ok too. Happy for you to take your time to do a good job with some comments above rather than rush it. Or, if you do feel too overwhelmed I'm happy to mark the review as closed and pick up the second review when you're ready. I'll await your ping.--Tom (LT) (talk) 22:07, 14 October 2020 (UTC)
 * I've run through sources and added two I have concerns with. I don't expect to be adding anything new after this - will have a look at the article once you're run through your edits. As you go through concerns I'll box up the ones I'm happy with. Stopping at 'methods' today.--Tom (LT) (talk) 22:34, 14 October 2020 (UTC)
 * Tom, it seems whenever I actually tell people I'm going to be busy for a while it causes a change in the moons of Mercury and the sun is in retrograde (or whatever the proper way to say that is) and I have time to work on things. I am about to redo the lead to flow based on the current new sectioning and things, but after that I think I'm ready for another full look through. I'm going to preface this request by saying that if there are still any large issues, it may take me another day or few to get to them - workload is extremely low this morning but unpredictable for the next few days - but I am still committed to this article. More minor issues like if you find any citations that you feel still need rp page numbers or similar added, or if you'd like to discuss the use of some older sources in some places, I can likely address throughout the day when I have a minute. Thank you again for your thoughtful work on this review. -bɜ:ʳkənhɪmez (User/say hi!) 14:25, 15 October 2020 (UTC)

Thanks for your many edits with regard to my comments. I'm satisfied the article meets the good article criteria. I think this article has some room for improvement prior to FA nomination if you're heading in that direction, but think you've done a stellar job at updating this important article about a very common medical treatment / procedure. Well done! --Tom (LT) (talk) 02:54, 20 October 2020 (UTC)