Peripheral venous access is a fundamental component of perioperative management in orthopedic patients. Reliable vascular access is required for administering intravenous fluids, perioperative antibiotics, analgesics, thromboprophylactic drugs, and anesthetic induction agents [1]. Orthopedic patients particularly those undergoing major joint replacement, spine surgery, trauma fixation, or revision procedures often present with unique vascular-access challenges [2]. These include advanced age, chronic comorbidities such as diabetes or peripheral vascular disease, limb oedema related to immobility or injury, and repeated venous cannulations from prior medical encounters. These anatomic and physiological factors frequently contribute to difficult venous access, increasing preoperative delays, procedural discomfort, and the likelihood of complications [3]. Traditional venipuncture relies on the landmark technique, where the clinician identifies a suitable vein by inspection, palpation, and the application of a tourniquet. Although widely practised, the success of this technique depends heavily on the operator’s experience and the visibility/palpability of superficial veins [4]. In orthopedic patients, especially the elderly or those with significant limb edema, the veins may be poorly visualised or impalpable, leading to multiple puncture attempts. Repeated failures not only increase patient anxiety and pain but also elevate the risk of local complications such as hematoma, phlebitis, extravasation, and infiltration. Moreover, unsuccessful attempts may delay surgery and disrupt operating room workflow, straining perioperative efficiency [5]. Near-infrared (NIR) vein-finder devices have emerged as a potential solution to these challenges. NIR technology functions by projecting infrared light onto the skin, allowing visualization of subcutaneous veins by exploiting differential light absorption [6]. The real-time projection of the venous network creates a map on the patient’s skin, guiding clinicians toward optimal cannulation sites [7]. These devices have shown benefit in pediatric and difficult-access populations, although studies in adults, particularly in preoperative surgical groups, remain limited [7]. Early evidence suggests that NIR devices may improve the first-attempt cannulation rate, reduce procedure time, and enhance operator confidence, especially in settings where anatomical difficulty impairs vein visibility [8]. In orthopedic practice, where preoperative efficiency and patient comfort are critical, the potential for NIR devices to streamline vascular access merits rigorous evaluation. Orthopedic patients often represent a high-value clinical subgroup due to their advanced age, comorbid burden, and perioperative physiological vulnerabilities [9]. Improving vascular access success in this population may reduce procedure-related stress, minimize complication rates, and optimize preoperative readiness for anesthesia and surgery. Furthermore, technology-assisted venous cannulation aligns with contemporary surgical and anesthetic protocols emphasizing patient safety, minimally invasive interventions, and workflow optimization [10]. Existing literature offers valuable insights from critical-care and emergency settings, but the translational applicability of such data to the orthopedic preoperative environment is uncertain. Differences in patient physiology, clinical priorities, staff workflow, and time constraints necessitate dedicated investigation. Thus, a structured comparative evaluation of NIR vein-finder technology versus traditional venipuncture may provide clinically meaningful guidance for perioperative practice in orthopedic departments. Therefore, it is of interest to systematically compare the effects of NIR vein-finder technology and traditional venipuncture on safe vascular access in orthopedic patients in the preoperative period. Aim To compare the effectiveness and safety of near-infrared (NIR) vein-finder technology versus the traditional landmark-based venipuncture technique for establishing peripheral vascular access in adult orthopedic patients during the preoperative period. Objectives Primary Objective • To compare the first-attempt success rate of peripheral venous catheter (PVC) placement between NIR-guided venipuncture and the conventional landmark method. Secondary Objectives 1. To determine the total number of attempts required for successful venous cannulation in each study group. 2. To assess the time required for peripheral venous access from tourniquet application to successful catheter placement. 3. To evaluate local complications (e.g., venitis, thrombophlebitis, hematoma, extravasation) within the short perioperative observation period. 4. To compare patient-reported pain scores associated with venipuncture in conscious individuals undergoing each technique. 5. To assess the success rate among patients with difficult venous access, defined by predictors such as obesity, edema, scarring, advanced age, or poor vein visibility. 6. To analyse operator-related factors, including nurse experience and perceived ease of cannulation, in both intervention arms. 7. To evaluate overall procedural safety and efficiency, integrating multiple metrics such as device utility, workflow impact, and readiness for anesthesia.

Study Design This was a prospective, randomised, parallel-group, controlled superiority trial designed to compare the effectiveness of near-infrared (NIR) vein-finder technology versus the traditional landmark-based venipuncture technique for securing peripheral venous access in adult orthopedic patients during the preoperative period. The methodological framework was adapted from established clinical trial protocols in vascular-access research, ensuring adherence to Good Clinical Practice (GCP) and international ethical standards. Study Setting The study was conducted in the preoperative holding area of a tertiary-care orthopedic surgery department. All venous access procedures were performed by preoperative nursing staff trained and certified in both NIR-guided and landmark-based cannulation techniques. A uniform, department-wide standard operating procedure (SOP) governed all cannulation attempts. Study Population Inclusion Criteria Patients fulfilling the following criteria were included: Age ≥18 years. Scheduled for elective or semi-elective orthopedic surgery (e.g., joint arthroplasty, arthroscopy, fracture fixation, spine surgery). Required preoperative peripheral venous access for anesthetic and perioperative drug administration. Able to provide written informed consent. Exclusion Criteria Absolute contraindication to upper-limb venipuncture (e.g., active infection, severe lymphedema, AV fistula, limb amputation). Extensive tattoo coverage obscuring vein visualization. Known hypersensitivity to cannulation materials or antiseptics. Hemodynamic instability requiring central venous access. Pregnancy or lactation. Prior or concurrent enrolment in another venous-access study. Refusal to provide informed consent. Randomisation and Allocation Eligible participants were randomised in a 1:1 ratio to either: NIR vein-finder–guided venipuncture, or Traditional landmark-based venipuncture. Randomisation used computer-generated, concealed block sequences with stratification based on: Anticipated difficulty of venous access, and Type of orthopedic procedure (minor vs major). Anticipated difficult access was defined by the presence of ≥1 criterion: Upper-limb edema, Non-palpable veins despite tourniquet, BMI >30 kg/m², Age >65 years, Scarring or multiple previous venipuncture sites. Due to the nature of the intervention, operator blinding was not feasible; however, postoperative complication assessment was performed by a nurse not involved in the cannulation. Intervention Procedures 1. NIR Vein-Finder–Guided Cannulation Peripheral venous access in this group was established using a portable NIR device capable of projecting a real-time venous map on the skin surface. Procedure steps: Application of tourniquet. Projection of NIR light to identify accessible superficial veins. Standard skin preparation with antiseptic solution. Cannulation performed with NIR visualization active. Confirmation of catheter placement using venous flashback and 10 mL normal saline flush. Documentation of vein characteristics and perceived ease of access. 2. Traditional Landmark-Based Cannulation Standard venipuncture was performed through clinical evaluation of veins by: Visual inspection, Palpation, Tourniquet application, Optional supportive techniques (vein tapping, warm compress). Skin asepsis and cannulation followed standard nursing protocol. Successful placement was confirmed with venous flashback and saline flush. Procedure Standardization A maximum of five attempts per patient was allowed. A single nurse could perform up to three attempts, after which a second trained nurse could continue. All attempts (successful or unsuccessful) were recorded in detail. If no successful cannulation occurred after five attempts, ultrasound-guided access was permitted but excluded from study outcomes. Outcome Measures Primary Outcome First-attempt success rate, defined as: Successful venous puncture with visible flashback, Full advancement of the catheter into the vein, A smooth 10 mL saline flush without extravasation. Secondary Outcomes Total number of attempts needed for successful cannulation. Time (minutes) from tourniquet application to successful cannulation. Pain scores in conscious patients using a Visual Analogue Scale (VAS). Local complications observed up to anesthesia induction: Venitis, Thrombophlebitis, Hematoma, Extravasation, Local inflammatory signs. Cannulation success among patients with anticipated difficult venous access. Nurse-related factors: Experience level (<1 year, 1–5 years, >5 years), Subjective ease-of-procedure rating. Overall procedural safety and readiness for anesthesia. Follow-Up Given the preoperative setting, all patients were monitored until: Initiation of anesthesia, or Two hours post successful cannulation, whichever occurred first. Any early complications were documented during this interval. Sample Size Calculation The sample size was computed using the standard formula for comparing two independent proportions: n=〖[Z_(α/2) √(2P(1-P))+Z_β √(P_1 (1-P_1)+P_2 (1-P_2))]〗^2/((P_1-P_2 )^2 ) Where: P_1= expected success rate in the NIR group P_2= expected success rate in the landmark group P=(P_1+P_2)/2 Z_(α/2)=1.96(α = 0.05) Z_β=0.84(power 80%) Assumptions: Expected NIR success rate: P_1=0.75 Expected landmark success rate: P_2=0.55 Substitution: P=0.65 n=((1.321+0.553)^2)/((0.20)^2 ) n=3.51/0.04=87.75≈88" per group" Thus: "Total Sample Size"=176" patients" Accounting for a 5–10% attrition rate: "Final Target Sample Size"=190"–" 200" patients" • Based on these assumptions, the minimum required sample size was 176 patients (88 per group).” • Allowing for an anticipated 5–10% attrition, the planned sample size was 190–200 patients, and 190 were finally enrolled and analysed. Statistical Analysis The primary outcome was analysed using logistic regression, adjusting for stratification variables (difficulty level and surgery type). Continuous variables (time, VAS pain, etc.) were compared using Mann–Whitney U or independent t-tests, based on distribution normality. Categorical variables were compared using Chi-square or Fisher’s exact test. Subgroup analysis was prespecified for difficult vs non-difficult access and for nurse-experience strata. The modified intention-to-treat (mITT) population included all participants with at least one cannulation attempt recorded.

A total of 190 orthopedic patients were enrolled and analysed, with 95 patients in the NIR group and 95 in the landmark group. Baseline demographic characteristics, including age, sex distribution, BMI categories, and major comorbidities, were comparable between the two arms. The prevalence of predictors of difficult venous access such as obesity, limb edema, non-palpable veins, and advanced age was also similar across both groups. The first-attempt cannulation success rate was higher in the NIR group compared with the landmark group. When multiple attempts were considered, patients in the NIR arm required fewer total attempts to achieve successful cannulation. The mean cannulation time from tourniquet application to successful placement was shorter in the NIR group, suggesting greater procedural efficiency. Among conscious patients, pain scores on the visual analogue scale were lower in the NIR group than in the landmark group. Local complications, including venitis, hematoma, extravasation, and local inflammation, occurred less frequently following NIR-guided venipuncture. Subgroup analysis demonstrated that the benefit of NIR technology was particularly pronounced in patients with difficult venous access. Overall, NIR-guided venipuncture improved cannulation success, reduced procedure-related discomfort, and enhanced readiness for anesthesia in the preoperative orthopedic setting. Table 1. Baseline demographic characteristics of the study population (N = 190) This table describes the demographic distribution including age, sex, BMI, and comorbidities. Variable Category NIR (n=95) Landmark (n=95) Age group (years) 18–39 13 (13.7%) 15 (15.8%) 40–59 41 (43.2%) 38 (40.0%) ≥60 41 (43.2%) 42 (44.2%) Sex Male 57 (60.0%) 58 (61.1%) Female 38 (40.0%) 37 (38.9%) BMI category Normal 24 (25.3%) 25 (26.3%) Overweight 38 (40.0%) 37 (38.9%) Obese (BMI >30 kg/m²) 33 (34.7%) 33 (34.7%) Comorbidities* Diabetes mellitus 30 (31.6%) 32 (33.7%) Hypertension 46 (48.4%) 48 (50.5%) Peripheral vascular disease 9 (9.5%) 7 (7.4%) *Comorbidities are not mutually exclusive. Table 2. Surgical profile of orthopedic patients This table describes the distribution of surgical categories. Variable Category NIR (n=95) Landmark (n=95) Type of surgery Joint replacement 36 (37.9%) 37 (38.9%) Spine surgery 20 (21.1%) 19 (20.0%) Trauma/fixation 24 (25.3%) 23 (24.2%) Arthroscopy/minor procedures 15 (15.8%) 16 (16.8%) Table 3. Predictors of difficult venous access This table describes objective predictors such as edema, obesity, scarring, and poor vein palpability. Predictor (may be multiple per patient) NIR (n=95) Landmark (n=95) Upper-limb edema 22 (23.2%) 24 (25.3%) Non-palpable veins with tourniquet 29 (30.5%) 31 (32.6%) BMI >30 kg/m² 33 (34.7%) 33 (34.7%) Age >65 years 28 (29.5%) 26 (27.4%) Venous scarring / multiple prior punctures 11 (11.6%) 13 (13.7%) Table 4. First-attempt cannulation success rate (Primary outcome) This table describes the primary endpoint. Outcome on first attempt NIR (n=95) Landmark (n=95) Successful 67 (70.5%) 52 (54.7%) Unsuccessful 28 (29.5%) 43 (45.3%) Table 5. Total number of attempts required to achieve successful cannulation (up to 5 attempts) This table describes the distribution of attempts per patient. Final outcome category NIR (n=95) Landmark (n=95) Success on 1st attempt 67 (70.5%) 52 (54.7%) Success on 2nd attempt 18 (18.9%) 18 (18.9%) Success on 3rd attempt 6 (6.3%) 10 (10.5%) Success on 4th attempt 3 (3.2%) 6 (6.3%) Success on 5th attempt 0 (0.0%) 3 (3.2%) Failed after 5 attempts 1 (1.1%) 6 (6.3%) (Rows sum to 95 in each group; “Success” rows together represent overall cannulation success.) Table 6. Cannulation time (minutes) from tourniquet application to successful placement This table describes procedural time-efficiency. Time variable NIR (n=94*) Landmark (n=89*) Mean ± SD (minutes) 2.0 ± 0.9 3.5 ± 1.2 Median (IQR) (minutes) 2 (1–2) 3 (3–4) *Patients with failed cannulation after five attempts were excluded from time analysis. Table 7. Pain scores on Visual Analogue Scale (0–10) in conscious patients This table describes patient-reported pain intensity. Pain variable NIR Landmark Number of conscious patients assessed 80 78 Mean ± SD VAS score 2.4 ± 1.1 4.1 ± 1.5 Median (IQR) VAS score 2 (2–3) 4 (3–5) Table 8. Local complications in the perioperative period This table describes early local adverse events related to cannulation. Complication NIR (n=95) Landmark (n=95) Venitis 2 (2.1%) 7 (7.4%) Hematoma 3 (3.2%) 10 (10.5%) Extravasation 1 (1.1%) 6 (6.3%) Thrombophlebitis 0 (0.0%) 2 (2.1%) Local inflammation (redness/swelling) 3 (3.2%) 9 (9.5%) Table 9. Subgroup analysis: first-attempt success in patients with and without difficult venous access This table describes the effect of NIR in relation to access difficulty. Subgroup NIR success / total Landmark success / total Difficult venous access present 36 / 50 (72.0%) 25 / 52 (48.1%) No difficult venous access 31 / 45 (68.9%) 27 / 43 (62.8%) (“Difficult venous access” defined by ≥1 predictor from Table 3.) Table 10. Nurse-related factors and perceived ease of procedure This table describes operator characteristics and subjective ease. Variable NIR Landmark Cannulations by nurses with <1 year experience 21 cases 19 cases Cannulations by nurses with 1–5 years experience 44 cases 46 cases Cannulations by nurses with >5 years experience 30 cases 30 cases Ease-of-procedure score (1–10), Mean ± SD 8.1 ± 1.2 6.2 ± 1.4 Table 11. Per-protocol analysis of overall cannulation success (N = 190) This table describes the per-protocol distribution of successful and failed cannulations after excluding no major protocol deviations, reflecting true procedural outcomes in both groups. Outcome NIR Group (n = 95) Landmark Group (n = 95) Successful cannulation 94 (98.9%) 89 (93.7%) Failed cannulation 1 (1.1%) 6 (6.3%) Table 12. Time-to-anesthesia readiness (preoperative workflow metric) This table describes operational impact on preoperative timelines. Metric NIR (n=95) Landmark (n=95) Mean ± SD time to anesthesia readiness (minutes) 7.5 ± 2.4 11.2 ± 3.1 Median (IQR) (minutes) 7 (6–9) 11 (9–13) Table 1 summarises the baseline demographic characteristics of the study population and demonstrates that the NIR and landmark groups were comparable in terms of age distribution, sex ratio, BMI categories, and comorbidity profiles. The majority of patients in both groups were middle-aged to elderly, with obesity and hypertension constituting the most common comorbidities, indicating a clinically typical orthopedic surgical cohort. Table 2 presents the surgical profiles of the participants and shows a balanced distribution across major orthopedic procedure types, including joint replacement, spine surgery, trauma fixation, and arthroscopy. This similarity supports the internal validity of comparing cannulation outcomes across groups without procedural bias. Table 3 outlines the prevalence of predictors of difficult venous access and illustrates that both groups had nearly identical proportions of patients with edema, non-palpable veins, obesity, advanced age, and venous scarring. This reinforces that the two arms started with similar baseline difficulty levels in vascular access. Table 4 describes the primary outcome—first-attempt success rate—and demonstrates a clear advantage of NIR-guided cannulation over the landmark technique. The higher first-attempt success in the NIR group indicates improved initial visualization and reduced procedural uncertainty during venipuncture. Table 5 provides the distribution of the total number of attempts required to achieve successful cannulation. The NIR group shows a greater clustering at one and two attempts, whereas the landmark group required higher attempts more frequently, including multiple failures. This finding reflects a procedural efficiency benefit associated with NIR guidance. Table 6 reports cannulation time and shows that the NIR group had both a lower mean time and a narrower interquartile range compared with the landmark group. These findings are consistent with improved vein identification and faster decision-making during venipuncture when using NIR technology. Table 7 presents patient-reported pain scores using the Visual Analogue Scale. Patients cannulated under NIR guidance reported significantly lower pain intensity, suggesting that fewer attempts and smoother venous entry directly translate into improved patient comfort. Table 8 summarises local complications and shows a lower incidence of venitis, hematoma, extravasation, and inflammatory reactions in the NIR group. By reducing the number of repeated punctures and traumatic passes, NIR guidance appears to enhance safety and reduce tissue injury. Table 9 provides subgroup analysis based on difficult venous access status. Among patients with documented access difficulty, NIR guidance produced markedly higher success rates compared to the landmark method. This indicates that NIR benefits are most pronounced in anatomically challenging scenarios. Table 10 compares nurse-related variables and perceived procedural ease. Although nurse experience levels were comparable, the NIR group had a significantly higher ease-of-procedure score, suggesting improved operator confidence and reduced technical burden during cannulation. Table 11 summarises the per-protocol analysis of overall cannulation outcomes and demonstrates that, even after restricting the analysis to all patients without protocol deviations, the NIR-guided group maintained a higher successful cannulation rate and fewer failures compared with the landmark group. The per-protocol dataset preserved all 190 enrolled patients (95 per arm), and the failure rates remained consistent with the intention-to-treat findings, confirming the robustness of the observed benefit of NIR technology. Table 12 evaluates the time to anesthesia readiness, a critical workflow metric in the preoperative setting. NIR-guided cannulation resulted in faster readiness, indicating that efficient venous access contributes meaningfully to overall perioperative throughput and workflow optimization.

The present randomised controlled study compared the use of near-infrared (NIR) vein-finder technology with the traditional landmark-based venipuncture method for establishing peripheral venous access in adult orthopedic patients during the preoperative period. The findings demonstrate that NIR guidance offers clinically meaningful advantages in terms of success rates, efficiency, patient comfort, and complication reduction. These benefits were observed consistently across all levels of operator experience and were especially pronounced in patients with predictors of difficult venous access. Achieving reliable venous access is a fundamental requirement in the perioperative care of orthopedic patients, many of whom are elderly, obese, or affected by chronic vascular comorbidities. Such characteristics frequently make venous cannulation challenging, often requiring multiple attempts and increasing the risk of tissue trauma, hematoma formation, and procedural delay. In this context, the substantially higher first-attempt success rate observed with NIR guidance supports its role as a superior tool for vascular access. A first-attempt success rate exceeding 70% in the NIR group compared to approximately 55% in the landmark group suggests that NIR visualization effectively enhances initial needle placement precision. This aligns with existing literature in difficult-access populations, where NIR devices have similarly demonstrated improved first-pass success when superficial veins are poorly visible or impalpable [11,12]. The number of total attempts required also clearly favoured the NIR arm, with a larger proportion of patients achieving successful cannulation within one or two attempts. Repeated attempts during venipuncture are known to increase patient anxiety, raise pain scores, prolong preoperative preparation time, and elevate complication rates. The findings of this study indicate that NIR technology mitigates these concerns by providing a more predictable and controlled trajectory for venous entry. Correspondingly, cannulation time was shorter in the NIR group, supporting claims that improved visualization enables faster identification of suitable veins and reduces procedural hesitation [13]. Pain perception, as captured by the Visual Analogue Scale, was significantly lower in patients undergoing NIR-guided venipuncture. This reduction likely reflects fewer needle passes and smoother insertion, which together minimize nociceptive stimulation. Pain reduction during preoperative procedures is particularly important in orthopedic populations, where patients often experience baseline discomfort related to joint degeneration, spine disorders, or trauma. Minimizing additional pain contributes positively to overall patient experience and preoperative psychological readiness. The analysis of local complications further reinforces the procedural advantages of NIR guidance. Rates of venitis, hematoma, extravasation, and local inflammatory reactions were uniformly lower in the NIR group. These findings are consistent with the concept that fewer attempts and improved needle precision translate to reduced endothelial and soft-tissue injury. The clinical relevance of these benefits extends beyond the immediate perioperative window, as local complications can impact postoperative hand mobility, impede early rehabilitation efforts, and in some cases necessitate postoperative IV line repositioning [14]. Importantly, the subgroup analysis of patients with difficult venous access revealed that NIR guidance provides substantial benefit over the landmark technique in this vulnerable population. Among such patients, the first-attempt success rate was markedly higher with NIR. This aligns with prior data in critical-care and pediatric settings demonstrating that adjunctive visualization technologies have the greatest impact where veins are poorly perceptible by inspection or palpation [15,16]. Given the increasing prevalence of obesity and chronic vascular comorbidities among orthopedic patients, the availability of NIR devices may help standardize venous access success rates across heterogeneous clinical presentations. Operator-related findings showed that nurses using NIR guidance reported higher ease-of-procedure scores, regardless of experience level. This suggests that NIR technology not only benefits patients but also reduces the cognitive and technical burden on healthcare providers. Enhancing staff confidence and reducing the frustration associated with multiple failed attempts can improve workflow satisfaction and potentially reduce task-related fatigue. These findings also underscore the role of NIR devices as valuable educational tools for less experienced staff, facilitating real-time anatomical understanding. The per-protocol and overall workflow metrics provide additional context regarding the integration of NIR devices into preoperative practice. Faster time-to-anesthesia readiness reflects a meaningful operational advantage. In high-volume orthopedic centers, reducing delays associated with cannulation can improve operating room turnover, decrease anesthesia wait times, and enhance perioperative efficiency. Even marginal reductions in preparation time can accumulate into significant annual improvements in resource utilization. While the study demonstrates several strengths, including its randomized design, standardized protocols, and balanced baseline characteristics, certain limitations merit acknowledgment. Blinding of operators was not feasible due to the nature of the intervention, although outcome assessment for complications was performed by independent nursing staff. The short perioperative follow-up window limited the evaluation of late complications, such as catheter-associated infection or delayed inflammatory responses. Additionally, findings may not generalize to settings with substantially different patient profiles or operator training levels. Overall, the results of this study support the integration of NIR vein-finder technology into preoperative vascular access protocols for orthopedic patients. The combination of improved first-attempt success, reduced cannulation time, lower pain scores, and fewer local complications represents a compelling case for clinical adoption. Given the evolving trends toward technological augmentation of basic procedures, NIR guidance appears to offer both patient-centered and system-level benefits.

Near-infrared (NIR) vein-finder technology demonstrates clear clinical advantages over the traditional landmark technique for establishing peripheral venous access in preoperative orthopedic patients. The use of NIR guidance is associated with higher first-attempt success, fewer total attempts, reduced cannulation time, lower patient-reported pain scores, and a lower incidence of local complications. These benefits are particularly significant in patients with difficult venous access, where anatomical and physiological challenges commonly impair the success of traditional cannulation techniques. In addition to improving patient comfort and procedural safety, NIR technology enhances nursing efficiency and accelerates anesthesia readiness, contributing to smoother perioperative workflow. Collectively, these findings support the integration of NIR vein-finder devices into routine preoperative practice for orthopedic surgical patients. Limitations 1. Lack of operator blinding: Owing to the visible nature of the devices used, blinding of nurses was not possible and may have introduced performance bias. 2. Short follow-up duration: The study assessed only immediate and short-term perioperative complications. Longer-term outcomes, such as delayed thrombophlebitis or catheter-related infection, were not measured. 3. Single-department setting: The study was conducted in a single orthopedic surgical unit, which may limit generalizability to other surgical populations or healthcare environments with different staffing patterns. 4. Experience-dependent variation: Although nurse experience was captured and analysed, subtle variations in individual technique, confidence, or familiarity with NIR devices may have influenced outcomes. 5. Exclusion of hemodynamically unstable patients: The findings apply only to elective and semi-elective preoperative patients; results may differ in emergent or high-acuity scenarios. 6. Device-specific performance: Results were based on one specific NIR device model; other brands or designs may produce different outcomes. Recommendations 1. Adopt NIR devices for routine preoperative cannulation in orthopedic patients, especially in those with predictors of difficult venous access such as obesity, edema, or non-palpable veins. 2. Implement structured training programs to ensure all nursing staff are proficient in NIR-guided venipuncture and comfortable transitioning from landmark-based techniques. 3. Use NIR technology as a first-line method in elderly patients and those with multiple comorbidities, given their higher likelihood of cannulation difficulty. 4. Integrate NIR guidance into institutional preoperative protocols to reduce cannulation failures, streamline anesthesia preparation, and improve patient experience. 5. Conduct larger multicenter studies to validate these findings across diverse clinical settings and evaluate the cost-effectiveness of widespread NIR adoption. 6. Evaluate long-term complications in future research by extending follow-up beyond the immediate perioperative window. 7. Explore integration with ultrasound-guided techniques for extremely difficult venous access cases, developing stepwise algorithms combining both technologies.

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