4/12/2018. Kathy Kokotis RN BS MBA Becton Dickinson Director Global Clinical Development BAS/TSHW/0318/0058 BAS/TSHW/0318/0058

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1 Kathy Kokotis RN BS MBA Becton Dickinson Director Global Clinical Development The speaker s presentation today is on behalf of Becton Dickinson. Any discussion regarding Becton Dickinson products during the presentation today is limited to information that is consistent with Becton Dickinson labeling. Please consult Becton Dickinson product labels and inserts for any indications, contraindications, hazards, warnings, cautions and instructions for use. Results presented may not be predictive for all institutions or patients. Kathy Kokotis is an employee of Becton Dickinson and holds Becton Dickinson Stock as well as Johnson and Johnson Medical Stock. Taken November 1995: Brain metastasis no chemotherapy Day 6 of a two week hospital stay Acute care CICC Jugular for TPN/antibiotics in the ICU (day 7) CICC was pulled for a CR BSI on day 14 prior to her death (CLA BSI definition did not exist in 1995) 1

2 Therapies not appropriate for short peripheral catheters include continuous vesicant therapy, parenteral nutrition, infusates with ph less than 5 or greater than 9, and infusates with an osmolality greater than 600 mosm/l. The nurse should collaborate with the pharmacist and the licensed independent practitioner (LIP) to assist in selection of the most appropriate vascular access device based on a projected treatment plan Therapies not appropriate for midline catheters include continuous vesicant therapy, parenteral nutrition, infusates with ph less than 5 or greater than 9, and infusates with an osmolality greater than 600 mosm/l. Infusion Nurses Society: (2011) Infusion Nursing Standards of Practice, JIN 34 (1S)S p. 37 A. Choose a short peripheral catheter as follows: 1. Consider the infusate characteristics (eg, irritant, vesicant, osmolarity) in conjunction with anticipated duration of infusion therapy (eg, less than 6 days) and availability of peripheral vascular access sites. 2. Use vascular visualization technology (eg, near infrared, ultrasound) to increase success for patients with difficult venous access (refer to Standard 22, Vascular Visualization ). 3. Do not use peripheral catheters for continuous vesicant therapy, parenteral nutrition, or infusates with an osmolarity greater than 900. Infusion Nurses Society: (2016): Infusion Therapy Standards of Practice JIN (Jan/Feb) 39(1S) 2

3 For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days. Midline catheters and ultrasonography guided peripheral Midline catheters and ultrasonography guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days. Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1 39S VESICANT An agent capable of causing blistering, tissue sloughing, or necrosis when it escapes from the intended vascular pathway into the surrounding tissues EXTRAVASATION The inadvertent infiltration of vesicant solution or medication into the surrounding tissue Gorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence based list of noncytotoxic vesicant medications And solutions JIN 40(1) Jan/Feb Red List Calcium Chloride Calcium Gluconate Contrast Media nonionic Dextrose containing 12.5% Dobutamine Epinephrine Norepinephrine Parenteral nutrition solutions exceeding 900 mosm/l Phenylephrine Phenytoin Promethazine Sodium bicarbonate Sodium chloride 3% Vasopressin Yellow List Acyclovir Amiodarone Arginine Dextrose concentrations 10% to 12.5% Mannitol 20% Nafcillin Pentamidine Phenobarbital sodium Potassium meq/l Vancomycin hyrdrochloride This list of Noncytotoxic Vesicant Medications & Solutions was developed by a task force of the Infusion Nurses Society for the use and education of its members. The list is provided for informational purposes only. The provision of the list is not meant to replace clinical judgment and does not constitute endorsement by Bard Access Systems. Bard Access Systems has not independently confirmed the information in this list. Infusion Nurses Society: (2016) NoncytoxicVesicant Medications and Solutions on the ONS Learning Center Tab 3

4 Vesicant Acyclovir Amiodarone Arginine vasopressin antagonist Conivaptan hydrochloride ph (p17) 4.08 (p83) (p344) Pentamidine (1021) Phenobarbital (p1033) sodium Vancomycin (p1264) hydrochloride Vesicant Dextrose concentration 10% 12.5% ph (p413) Mannitol 20% (p814) Potassium (p1065) 60nmEq/L Potassium acetate Potassium chloride Nafcilln (p894) Gahart B, Nazareno AR, Ortega MQ: (2017) Gaharts 2017 Intravenous Medications A Handbook for Nurses and Health Professionals 33 rd Elsevier St Louis Missouri Vesicant ph Dextrose (p413) 1 concentration 12.5% Dobutamine (p446) 1 Dopamine (p461) 1 Epinenphrine (p504) 1 Norepinephrine (p933) 1 Phenylephrine (p1036) 1 Phenytoin 12 (p1038) 1 Promethazine (p1081) 1 Vasopressin (p1268) 1 Vesicant ph Calcium chloride (p225) 1 Calcium gluconate (p228) 1 Contrast media non ionic Loversal Sodium bicarbonate (p1162) 1 Sodium chloride 3% (p1164) 1 Parenteral nutrition solutions exceeding 900 mosm/l 1 Gahart B, Nazareno AR, Ortega MQ: (2017) Gaharts 2017 Intravenous Medications A Handbook for Nurses and Health Professionals 33 rd Elsevier St Louis Missouri 2 Optiray injection (loversolinjection): Side Effects, Interactions, Warning, Dosage & Usage injection drug.htm 1 26 NA Gorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence based list of noncytotoxic vesicant medications And solutions JIN 40(1) Jan/Feb

5 67 year old male 1 Pneumonia & pancytopenia Vancomycin (V) and Pipercillin tazobacram 1 Patient s dermatitis and resultant cellulitis likely originated due to extravasation of the drug (vancomycin) when he ripped out his peripheral line 1 This abstract is not cited in the INS paper Development of an evidencebased list of noncytotoxic vesicant medications and solutions 2 1. Nanjappa S, Snyder et al: (2017) Vancomycin Infiltrate Induced Dermatitis Mimicking Bullous Cellulits, Journal of drugs in Dermatology, 16(11) Gorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence based list of noncytotoxic vesicant medications And solutions JIN 40(1) Jan/Feb year old Female developed hospital acquired pneumonia Vancomycin (1,000 mg daily) & cefepime (1,000 mg BID) 220 pounds, anemia, asthma, afib., CAD, hypertension, Diabetes Type 2, previous CABG 20 g right wrist Day 2 extravasation with blistering to right wrist Necrotic tissue developed (over week) Black eschar overlapping an ulcer developed Right thrombophelbitis mid forearm near the cephalic vein Wound healing 5 weeks with no surgical consult Author recommends central administration Peyko V, Saasson E: (2016) Vancomycin extravasation: evaluation, treatment, and avoidance of This adverse drug event, Case Reports in Internal Medicine 3(3) p Use caution with intermittent vesicant administration due to risk of undetected extravasation. The administration of vancomycin for less than 6 days through a midline catheter was found to be safe in 1 study (Level IV evidence) Infusion Nurses Society: (2016): Infusion Therapy Standards of Practice JIN (Jan/Feb) 39(1S) 5

6 IRRITANT An agent capable of producing discomfort (burning, stinging) or pain as a result of irritation in the internal lumen of the vein with or without immediate external signs of vein inflammation Gorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence based list of noncytotoxic vesicant medications And solutions JIN 40(1) Jan/Feb Vesicants cause severe damage when the agent escapes the vein Irritants cause damage within the vein Gorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence based list of noncytotoxic vesicant medications And solutions JIN 40(1) Jan/Feb VAD selection is a complex decision not based on a single factor Peripheral administration of short term vesicant in an ER or small number of doses may or may not be appropriate given a patient s vascular assessment Gorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence based list of noncytotoxic vesicant medications And solutions JIN 40(1) Jan/Feb

7 Use a PICC with caution in patients who have cancer or are critically ill due to venous thrombosis and infection risk. Infusion Nurses Society: (2016): Infusion Therapy Standards of Practice JIN (Jan/Feb) 39(1S) 7

8 The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta Analysis The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta Analysis Author(s): Vineet Chopra, MD, MSc; John C. O Horo, MD; Mary A. M. Rogers, PhD; Dennis G. Maki, MD, MS; Nasia Safdar, MD, PhD Source: Infection Control and Hospital Epidemiology, Vol. 34, No. 9 (September 2013), pp Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: Accessed: 07/08/ :40 The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta Analysis The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta Analysis Author(s): Vineet Chopra, MD, MSc; John C. O Horo, MD; Mary A. M. Rogers, PhD; Dennis G. Maki, MD, MS; Nasia Safdar, MD, PhD Source: Infection Control and Hospital Epidemiology, Vol. 34, No. 9 (September 2013), pp Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: Accessed: 07/08/ :40 8

9 risk of CLABSI associated with CVCs and PICCs appears to be similar in hospitalized patients, expansion of practices and campaigns such as hub decontamination and scrub the hub should specifically be targeted toward PICCs. hospitalized patients who underwent PICC placement experienced CLABSI rates that statistically paralleled that associated with CVCs The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta Analysis Author(s): Vineet Chopra, MD, MSc; John C. O Horo, MD; Mary A. M. Rogers, PhD; Dennis G. Maki, MD, MS; Nasia Safdar, MD, PhD Source: Infection Control and Hospital Epidemiology, Vol. 34, No. 9 (September 2013), pp Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: Accessed: 07/08/ :40 Chopra V, Anand SA, Buist, Rogers M, Saint S, Flanders : July 27, 2013) Risk of venous thromboembolism associated with peripherally Inserted central catheters: A systematic review and meta=analysis Lancet 382 p Chopra V, Anand SA, Buist, Rogers M, Saint S, Flanders : July 27, 2013) Risk of venous thromboembolism associated with peripherally Inserted central catheters: A systematic review and meta=analysis Lancet 382 p

10 Entire cohort (n=431) No PRLVT (n=395) PRLVT (n=36) P value Age, years, (mean, SD) 55 (16) 55 (16) 56 (19) Female sex 216 (50%) 205 (52%) 12 (33%) Ethnicity Caucasian 365 (85%) 336 (85%) 29 (81%) African American 35 (7%) 33 (8%) 2 (6%) Other 31 (7%) 26 (7%) 5 (14%) Tobacco abuse 119 (28%) 110 (28%) 9 (25%) *Obese (BMI > 30 kg/m 2 ) 133 (31%) 118 (30%) 15 (42%) Prothrombotic state 20 (5%) 18 (5%) 2 (6%) Coagulopathy 29 (9%) 37 (9%) 2 (6%) Cancer 73 (17%) 67 (17%) 6 (17%) *Congestive heart failure 34 (8%) 28 (7%) 6 (17%) *History of VTE 33 (8%) 25 (6%) 8 (22%) History of VTE in same arm 7 (2%) 5 (1%) 2 (6%) *Surgery longer than 1 h during dwell time of PICC 99 (23%) 83 (21%) 16 (44%) Length of stay, days (median IQR) 16 (14) 17 (13) 34 (16) <0.001 Estrogen 3 (1%) 3 (1%) 0 (0%) Aspirin 79 (18%) 74 (19%) 5 (14%) Clopidogrel 14 (3%) 13 (3%) 1 (3%) Hypertonic saline 104 (24%) 95 (24%) 9 (25%) *Mannitol 44 (10%) 35 (9%) 9 (25%) Vancomycin 188 (44%) 170 (43%) 18 (50%) Statin 103 (24%) 90 (23%0 13 (36%) DVT prophylaxis 413 (96%) 378 (96%) 35 (97%) Wilson TJ, Brown DL, Meurer WJ et al: (2012) Risk factors associated with peripheral inserted central venous catheter related large vein Thrombosis in neurological intensive care patients *Statistically significant Procedure related variables Catheter insertion Entire cohort (n=431) No PRLVT (n=395) PRLVT (n=36) P value Right 279 (65%) 256 (65%) 23(64%) Left 152 (35%) 139 (35%) 13 (36%) Catheter insertion Basilic 316 (73%) 289 (73%) 27 (75%) Brachial 94 (22%) 88 (22%) 6 (17%) Cephalic 21 (5%) 18 (5%) 3 (8%) Catheter diameter 5 French 171 (40%) 160 (41% 11 (31%) * 6 French 260 (60%) 235 (59%) 25 (69%) Catheter tip outside SVC 6 (1%) 6 (2%) 0 (0%) *placed in a paretic arm 76 (18%) 56 (14%) 20 (56%) <0.001 Attempts at placement (median, IQR) 1 (1) 1(1) 1(1) Manipulations (median, IQR) 0 (1) 0 (1) 0 (1) Lumens clotted 82 (19%) 75 (19%) 7 (19%) Duration of use, days (median, IQR) 12 (16) 12 (15) 13 (15) Wilson TJ, Brown DL, Meurer WJ et al: (2012) Risk factors associated with peripheral inserted central venous catheter related large vein Thrombosis in neurological intensive care patients *Statistically significant Understanding DVT Risk in PICC Patients Hypercoagulability (Blood clots are likely to form) Proper Patient Selection DVT Risk Highest DVT Risk Stasis (Decreased blood flow) DVT Risk DVT Risk Vessel Injury Minimizing Blood Flow Reduction Minimizing Endothelial Injury Virchow s Triad 10

11 Risk of development of PICC related large vein thrombosis (PRLVT) Surgery over one hour during the dwell time of a PICC Placement PICC paretic arm Mannitol therapy History of previous VTE Wilson TJ, Brown DL, Meurer WJ et al: (2012) Risk factors associated with peripheral inserted central venous catheter related large vein Thrombosis in neurological intensive care patients PICC (N=200) CICC (N=200) P value Indwelling Days Median Indwelling Days Symptomatic n(%) 4 (2%) 2 (1%).685 CRDVT Per 1000 cath days Median days to DVT CLABSI n(%) 0 (0%) 0 (0%) No significant difference in DVT rate or CLABSI rate Nolan ME, et al. Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. J Crit Care 2015;31: Average PICC duration, d (range) 7.5(<1 78) Average length of hospitalization, d (range) 14.5(<1 161) DVT Rates 10.00% 8.80% 5.00% 0.00% 0.60% 4 Fr Single Lumen 2.90% 5 Fr Double Lumen 6 Fr Triple Lumen Catheter Size Number Percentage SL 4 F % DL 5F 1, % TL 6F % Evans RS, Sharp JH, Linford LH et al: ( Oct 11, 2010) Risk of symptomatic DVT associated with peripherally inserted central Catheters Chest 138 (4) p

12 Characteristics of Patients with PICC Associated DVT at Intermountain Medical Center During 2008 Characteristic No. Total PICC insertions with DVT (%) 60 (3.0) Total distinct patients with DVT 57 Patients with two DVTs during same hospitalization 2 Patients with two DVTs during different hospitalizations 1 Mean duration from PICC insertion to DVT Diagnosis, d (range) 9.5 (1 64) Veins affected by DVTs Axillary 49 Subclavian 26 Basilic 10 Brachial 3 Cephalic 3 Risk of PICC associated DVT PICC size Previous DVT Surgery Evans RS, Sharp JH, Linford LH et al: ( Oct 11, 2010) Risk of symptomatic DVT associated with peripherally inserted central Catheters Chest 138 (4) p Patient Reason for PICC Number Patients Percentage (%) Venous access % Antibiotics % TPN % Chemotherapy % Medications % Blood products % Hydration 9 0.4% Replacement % Who Other got a PICC % Not documented 8 0.4% Evans RS, Sharp JH, Linford LH et al: ( Oct 11, 2010) Risk of symptomatic DVT associated with peripherally inserted central Catheters Chest 138 (4) p Patient Medical Condition Number Patients Percentage % Cardiology % Neurology % Infectious diseases % Gastroenterology % Trauma % Pulmonary % Oncology % Vascular % Orthopedics % Renal % Other % Evans RS, Sharp JH, Linford LH et al: ( Oct 11, 2010) Risk of symptomatic DVT associated with peripherally inserted central Catheters Chest 138 (4) p

13 For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days In critically ill patients, nontunneled central venous catheters were preferred over PICCs when 14 or fewer days of use were likely Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1 39S PICC CICC CLABSI 12 CLABSI 12 Brachial Arterial Injury Pneumothorax 12 Hematoma Air Embolism 12 Hemothorax Carotid/Subclavian/Femoral 2 Arterial Injury Hematoma Notes: Complications marked as 0% are not included in lists. 7 Arterial injury expanded to include femoral artery based on Bowdle (2014) observations Dariushnia et al. Quality Improvement Guidelines for Central Venous Access J Vasc Inter Radiol Hospital Acquired Conditions and Present on Admission Indicator Reporting Provision. Centers for Medicare & Medicaid Services. ICN September Bowdle. Vascular Complications of Central Venous Catheter Placement: Evidence Based Methods for Prevention and Treatment J Cardiothoracic and Vascular Anesthesia

14 Patient Coagulation Considerations and damaging the vein or artery Procedures with Low Risk of Bleeding, Easily Detected and Controllable (Category 1) 20 Applicable Vascular Procedures Dialysis access intervention Central line removal PICC line placement Procedures with Moderate Risk of Bleeding (Category 2) 20 Applicable Vascular Procedures Tunneled central venous catheter Subcutaneous port procedure Management related to line placement 20 Platelet count: < 50 x 10 9 /L International normalized ratio (INR):> 2.0 CICC large vein, large catheter PICC small vein, small catheter Platelet count: < 50 x 10 9 /L International normalized ratio (INR):< Patel et al. Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image guided Interventions. JVIR : Patient Position & Condition Considerations Example 1 Insertion Position CICC: Trendelenberg (required 16 PICC: No requirement Example 2 Neurology or Pulmonary Issues CICC: Reverse Trendelenberg (required) 16 PICC: No requirement Other Considerations PICC may be suboptimal if: ESKD (III or IV) 6 Past breast surgery 11 History of VTE 6 Arm burn, infection, paralysis 24 CICC may be suboptimal if: Neck/chest abnormalities 6 High infection risk/tracheotomy 6 Longer dwell time foreseen Interdisciplinary Clinic Practice Manual. Vascular Access Device Policy, Adult (IFC035). The John Hopkins Hospital Cotogni et al. Focus on peripherally inserted central catheters in critically ill patients. World Journal of Critical Care Medicine (4) Insertion Site Choice CICC neck clavicular triangle groin PICC either upper arm 14

15 CICC neck: proximity to ear, nose & throat clavicular triangle: upper chest groin 1 PICC either upper arm 1 Avoid using the femoral vein for central venous access in adult patients. (Category 1A). Guidelines for the Prevention of Intravascular Catheter Related Infections, CICC Jugular Incidence Rate (per SIR Central Venous Access CPG) 3 NEVER Subclavian & Event (IPPS HAC PPC Estimated PICC Lines Jugular Lines Complication Code 2 HAC Cost 2 reportable) 1 CLABSI* X 54 $12,455 1% 1% 3% Air Embolism X 48 $9,350 Not Listed 1% Pneumothorax X 49 $4,136 0% 1% 3% Thrombosis 16 $8,607 3% 4% Hemothorax 8 $5,165 0% 1% Perforation 42 $3,215 Not Listed 0.5% 1% Hematoma 64 $712 1% 1% 3% Wound Dehiscence 64 $712 1% 1% Phlebitis 64 $712 4% Not Listed Arterial Injury 64 $ % Not Listed *Procedure induced sepsis 1. Centers for Medicare & Medicaid Services. (2012). Hospital acquired conditions (HAC) in acute inpatient prospective payment system (IPPS) hospitals; May Fuller, R. L., McCullough, E. C., & Averill, R. F. (2011). A new approach to reducing payments made to hospitals with high complication rates. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 48(1), Dariushnia, S. R., Wallace, M. J., Siddiqi, N. H., Towbin, R. B., Wojak, J. C., Kundu, S., & Cardella, J. F. (2010). Quality improvement guidelines for central venous access. Journal of Vascular and Interventional Radiology, 21(7), MC MM

16 Status of bleeding Status of ability to cooperate Status of position for insertion and removal Status of neck and chest Status of breathing Status of hemodynamics Risk of infection with placement site Pulmonary Status o CHF, COPD o Emphysema o Lung surgeries o Asthma o Pneumonia o Pneumothorax Coagulopathy Status o PLT 50 x 10 9 /L o INR 1.5 o aptt 20 s o Anticoagulants o Clotting disorder o Past history thrombosis Mechanical Status Placement concerns o Cervical Collars o Halo o Pacemaker Wires o Positive pressure ventilation o Vena cava filters Patient Status Device Type Considerations o Trendelenburg position contraindicated o Confusion/Dementia o Hypovolemia o Local infection site o Lymph node dissection / lymphedema o Obesity / Cachexia o Contralateral pneumothorax o Hemothorax o Oral Candida / Nasal MRSA o Need for arterio venous fistula o Persistent left Superior Vena Cava o Previous catheterizations o Radiotherapy in anatomic region of interest o Operative history (Thoracic) o Clavicular fracture o Sternotomy o Severe hypoxemia Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1 39S 16

17 Consider the infusate characteristics (eg, irritant, vesicant, osmolarity) in conjunction with anticipated duration of infusion therapy (eg, less than 6 days) and availability of peripheral vascular access sites. Irritant Vesicant osmolarity Peripheral access Duration Andrew Kokotis Infusion Nurses Society: (2016): Infusion Therapy Standards of Practice JIN (Jan/Feb) 39(1S) Blood 3 units Vancomycin Zosyn Kefzol Zofran Lab draws BID or TID 17

18 Phlebotic IV My Mom Did she get the right device? Single lumen PICC for Sepsis 18

19 Vasopressors (not day one) Hydration (day one) Blood draws (day one) Antibiotics (Vancomycin) & Primaxin (day one) 19

20 Device Type Peripheral IVC US guided peripheral IVC Nontunneled/acute central venous catheter Midline catheter PICC Tunneled catheter Port Venous access device recommendations for infusion of peripherally compatiable infusate Proposed Duration of Infusion < 5 d 6 14 d d > 31 d No preference between peripheral IV and US guided peripheral IVC for use < 5 d US guided peripheral IVC preferred to peripheral IVC if proposed duration is 6 14 d Central venous catheter preferred in critically ill patients or if hemodynamic monitoring is needed for 6 14 d Midline catheter preferred to PICC if proposed duration is < 14 d PICC preferred to midline catheter if proposed duration of infusion is > 15 d PICC preferred to tunneled catheter and ports for infusions d Appropriate Neutral Inappropriate Disagreement Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1 39S Peripheral IVC US guided Peripheral IVC Nontunneled/acute central venous catheter Midline catheter PICC Tunneled catheter Port Device Type Venous access device recommendations for infusion of non peripherally compatible infusate Proposed Duration of Infusion < 5 d 6 14 d d > 31 d Central venous catheter preferred in critically ill patients of if hemodynamic monitoring is needed for 6 14 d My Dad received Vancomycin a Vesicant Drug PICCs rated as appropriate at all proposed durations of infusion Tunneled catheter neutral for No preference between tunneled catheter and PICC for use > 15 d proposed durations > 15 d No preference among port, tunneled catheter, or PICC for > 31 d Appropriate Neutral Inappropriate Disagreement Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1 39S Venous access device recommendations for patients with difficult venous access Device Type Proposed Duration of Infusion < 5 d 6 14 d d > 31 d No preference between Peripheral IVC peripheral IV and US guided peripheral IVC for use < 5 d US guided peripheral US guided peripheral IVC preferred to peripheral IVC if proposed IVC duration is 6 14 d Midline catheter Midline catheter preferred to PICC if proposed duration is < 14 d Nontunneled/acute Central venous catheter preferred to PICC for use < 14 d in critically ill central venous patients catheter PICC Tunneled catheter Port Disagreement on appropriateness of PICC for durations < 5 d Both my mom and dad were difficult access PICC use appropriate if proposed duration is > 6 d; PICCs preferred to tunneled catheters for durations of d Tunneled catehter neutral for difficult IV access for use > 15 d No preference between tunneled catheter or port for use > 31 d Appropriate Neutral Inappropriate Disagreement Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1 39S 20

21 Device Type Peripheral IVC US guided peripheral IVC Midline catheter Nontunneled/acute central venous catheter Venous access device recommendations for patients who require frequent phelbotomy Proposed Duration of Infusion < 5 d 6 14 d d > 31 d No preference between peripheral IV and US guided peripheral IVC for use < 5 d US guided peripheral IVC preferred if venous access difficult My dad and mom both Had frequent blood draws Midline catheter preferred to PICC if proposed duration is < 14 d Central venous catheter preferred to PICC for use < 14 d in critically ill patients Midline catheter neutral for frequent phelbotomy at this duration My mom was not in the ICU on admit PICC Tunneled catheter Port Disagreement on appropriateness of PICC for durations < 5 d My mom and dad PICC use appropriate if proposed duration is > 6 d; PICCs preferred to tunneled catheters for durations of d Tunneled catehter neutral for difficult IV access for use > 15 d Ports inappropriate for frequent phelbotomy, regardless of proposed duration of use Appropriate Neutral Inappropriate Disagreement Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1 39S MOM DIFFICULT ACCESS Vancomycin Vesicant Sepsis potential for ICU Repeated blood draws Single lumen PICC was inappropriate? Dual or Triple Lumen PICC should have been placed? My mom ended in ICU on vasoconstrictors DAD DIFFICULT ACCESS Vancomycin Vesicant Repeated blood draws Original length of treatment was supposed to be < 6 days Single lumen PICC Line should have been placed? Length of Therapy Location of Therapy Infusates Vascular Access Decision Patient 21

22 Assess the patient s condition age diagnosis comorbidities condition of the vasculature at the insertion site and proximal to the intended insertion site; condition of skin at intended insertion site; history of previous venipunctures and access devices; type and duration of infusion therapy patient preference for VAD site selection. Infusion Nurses Society: (2016): Infusion Therapy Standards of Practice JIN (Jan/Feb) 39(1S 22

23 1. Avoid using the femoral vein for central venous access in adult patients. (Category 1A). Guidelines for the Prevention of Intravascular Catheter Related Infections, Bowdle. Vascular Complications of Central Venous Catheter Placement: Evidence Based Methods for Prevention and Treatment J Cardiothoracic and Vascular Anesthesia Centers for Medicare & Medicaid Services. (2012). Hospital acquired conditions (HAC) in acute inpatient prospective payment system (IPPS) hospitals; May Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1 39S 4. Chopra V, O Horo JC. Rogers M (Sept. 2013) The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta Analysis Author(s): Source: Infection Control and Hospital Epidemiology, Vol. 34, No. 9 (September 2013), pp Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: Accessed: 07/08/ :40 5. Chopra V, Anand SA, Buist, Rogers M, Saint S, Flanders : July 27, 2013) Risk of venous thromboembolism associated with peripherally Inserted central catheters: A systematic review and meta=analysis Lancet 382 p Cotogni et al. Focus on peripherally inserted central catheters in critically ill patients. World Journal of Critical Care Medicine (4) Dariushnia et al. Quality Improvement Guidelines for Central Venous Access J Vasc Inter Radiol Fuller, R. L., McCullough, E. C., & Averill, R. F. (2011). A new approach to reducing payments made to hospitals with high complication rates. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 48(1), Gahart B, Nazareno AR, Ortega MQ: (2017) Gaharts 2017 Intravenous Medications A Handbook for Nurses and Health Professionals 33 rd Elsevier St Louis Missouri 10. Gorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence based list of noncytotoxic vesicant medications And solutions JIN 40(1) Jan/Feb Helen Hamilton and Andrew R. Bodenham. Central Venous Catheters. (United Kingdom. John Wiley & Sons Ltd. 2009) Hospital Acquired Conditions and Present on Admission Indicator Reporting Provision. Centers for Medicare & Medicaid Services. ICN September Infusion Nurses Society: (2011) Infusion Nursing Standards of Practice, JIN 34 (1S)S p Infusion Nurses Society: (2016): Infusion Therapy Standards of Practice JIN (Jan/Feb) 39(1S 15. Infusion Nurses Society: (2016) Noncytoxic Vesicant Medications and Solutions on the ONS Learning Center Tab Clinic Practice Manual. Vascular Access Device 16. Interdisciplinary Clinic Practice Manual. Vascular Access Device Policy, Adult (IFC035). The John Hopkins Hospital Nanjappa S, Snyder et al: (2017) Vancomycin Infiltrate Induced Dermatitis Mimicking Bullous Cellulits, Journal of drugs in Dermatology, 16(11) Nolan ME, et al. Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. J Crit Care 2015;31: Optiray injection (loversolinjection): Side Effects, Interactions, Warning, Dosage & Usage injection drug.htm Patel et al. Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image guided Interventions. JVIR : Peyko V, Saasson E: (2016) Vancomycin extravasation: evaluation, treatment, and avoidance of This adverse drug event, Case Reports in Internal Medicine 3(3) p Wilson TJ, Brown DL, Meurer WJ et al: (2012) Risk factors associated with peripheral inserted central venous catheter related large vein Thrombosis in neurological intensive care patient 23

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