2/20/2017 TRENDS IN VASCULAR ACCESS: MIDLINES AND USGPIV FINANCIAL DISCLOSURES OBJECTIVES. Define DIVAs and discuss challenges

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1 TRENDS IN VASCULAR ACCESS: MIDLINES AND USGPIV Thank you 3M for education sponsorship NANCY L. MOUREAU PICC EXCELLENCE, INC. FINANCIAL DISCLOSURES Speaker Disclosure of Relevant Financial Relationships I have the following financial relationships to disclose: Owner and CEO: PICC Excellence, Inc. educator and consultant Speaker s Bureau for: Access Scientific, BD Carefusion,Teleflex, 3M Grant/Research/Consulting from: Nexus, Chiesi, Cook, 3M, Teleflex Employee of: Greenville Memorial University and Medical Center, Greenville, SC IV/PICC Team OBJECTIVES Define DIVAs and discuss challenges Determine advantages, benefits and risk of infection with USGPIV and Midlines Describe indications and usage of midlines versus piccs/cvads 1

2 WHAT IS A DIVA? Difficult intravenous access (DIVA) is defined as multiple attempts and/or anticipation of special interventions being required to establish and maintain peripheral access (Kuensting 2009, ENA Crowley 2011, Gregg 2010) When DIVA is present clinicians are scrambling to find solutions like Midlines Once a DIVA, always a DIVA? Why not insert something that will last? MIDLINES & CDC GUIDELINES Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed six days. (CDC Category II) Midline catheters are associated with lower rates of phlebitis than short peripheral catheters [CDC] Midlines have lower rates of infection than CVCs. [CDC] Replace midline catheters only when there is a specific indication. (Category II) Sterile gloves should be worn for the insertion of arterial, central, and midline catheters. [37, 73, 74, 76] (CDC Category IA) There is no mention of ph as a limiting factor for peripheral or midline infusion in the CDC guidelines O'Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., et al. (2011). Guidelines for the Prevention of Intravascular Catheter Related Infections. Centers for Disease Control Retrieved August 2013, from guidelines 2011.pdf DEFINING MIDLINES A midline catheter is: A vascular access device - Length From 6-20cm in length (CDC 2011) Position Terminal tip distal to shoulder/axillary vein - not extending into the chest or past the shoulder. Distal tip dwelling in the basilic, cephalic or brachial vein Insertion commonly inserted into veins of the mid to upper arm. No x-ray necessary for catheters that remain in periphery Dwell time Clinically indicated dwell applies (CDC/INS 2016) 2

3 CURRENT PRACTICE While USGPIV insertions are popular, success is variable. Success improves with supervised insertions of10 or more Results show longer peripheral catheters with US have more consistent results (6-15cm which are really midlines) Midline catheters have much greater success Courtesy of PICC Excellence, Inc. White 2010, Dargin 2010, Meyer 2014, Elia 2012, Gregg 2009, Chinnock 2006, Au 2012, Shokoohi 2013, Bauman 2009, Moore 2013, Schoenfeld 2011, Stein 2009, Witting 2010, Keyes 1999 ISSUES How often are Central Venous Catheters placed just because of difficult peripheral access? How often do clinicians really look at indications for placement of a CVC? usually based on crisis management and the need to just get a catheter inserted BENEFITS OF MIDLINES Midline infection rate /1000 catheter days (Maki, Mermel, Moureau) PICC infection /1000 catheter days (Safdar, Maki) Infection rate /1000 catheter days for PIV. The average peripheral catheter lasts 44 hours due to phlebitis and infiltration Since the year 2000, thrombosis, phlebitis and infiltration rates with midlines <2.0% 1. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infections in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clinic Proc 2006;81(9): Mermel LA, Parenteau S, Tow SM. The risk of midline catheterization in hospitalized patients. A prospective study. Ann Intern Med 1995; 123: Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore) 2002; 81: Dawson R, Moureau N. Midlines: An Essential Tool in CLABSI Reduction. Infect Contr Today Moureau N, Poole S, Murdock M, et al. Central Venous Catheters in home infusion care: outcomes analysis in 50,470 patients. J Vasc Interv Radiol 2002;13(10): Frey AM, Shears D. Why are we stuck on Tape and Suture? J Infus Nurs 2006;29(1): Maki DG, Ringer M. Risk Factors for Infusion related Phlebitis with Small Peripheral Venous Catheters. Ann Int Med 1991;114: do Reqo Furtado. Maintenance of Peripheral Venous Access and its Impact on the Development of Phlebitis. J Infus Nurs 2011;34(6):

4 INFECTION RATE COMPARISON Devices 0.2 Non-Tunneled Arterial Tunneled CVC PICC PIV Midline Port 0.1 Maki 2004, Safdar 2002, Maki 2006 ADVANTAGES OF MIDLINES Suitable for all IV fluids and medications Longer dwell time than PIV, maximum 296 days (Griffiths 2006). Average dwell two to six weeks (Gorski and Czaplewski 2004) No x-ray required Provides alternative for IV therapy when CVAD is not needed Ease of insertion Improved patient comfort with lower phlebitis and infection rates than other VADs Well suited for older patients with limited access Midline is comfortable, reliable and well tolerated Blood return similar in reliability to a PIV 1. Griffiths, Vivien. "Midline catheters: indications, complications and maintenance." Nursing standard (2007): Anderson, N. Richard. "Midline catheters: the middle ground of intravenous therapy administration." Journal of Infusion Nursing 27.5 (2004): Anderson, N. Richard. "When to use a midline catheter." Nursing (2005): Gorski, Lisa A., and Lynn M. Czaplewski. "Peripherally inserted central catheters and midline catheters for the homecare nurse." Journal of Infusion Nursing 27.6 (2004): Pathak, Rahul, et al. "The Incidence of Central Line Associated Bacteremia After the Introduction of Midline Catheters in a Ventilator Unit Population." Infectious diseases in clinical practice (Baltimore, Md.) 23.3 (2015): Alexandrou, Evan, et al. "The use of midline catheters in the adult acute care setting clinical implications and recommendations for practice." Journal of the Association for Vascular Access 16.1 (2011): INDICATIONS FOR DIFFICULT ACCESS MIDLINES, NOT PICCS No visible veins and need for therapy >6 days Two or more failed attempts at traditional PIV Need for continued infusions Non central fluid medication/fluid formulations Patients with chronic illness Dehydration Obesity IV Drug use Renal failure Sickle cell Edema Diabetes Multiple prior hospitalizations Chopra 2015 MAGIC, Wilson 2013, Lapostolle 2007, Schoenfeld 2011, Stein 2009, Witting 2010, Keyes 1999, White 2010, Alexandrou 2011, Giuliani 2013, Moureau

5 MAGIC MICHIGAN APPROPRIATENESS GUIDE Evidence and expert consensus through systematic RAND Appropriateness Method CVAD Indications 1. Clinical instability of the patient 2. Chemotherapy for more than 3 months 3. Continuous infusion therapy or long term intermittent therapy 4. Delivery of non-peripherally compatible infusates (irritating or vesicant medications) 5. Frequent phlebotomy every 8 hours or more 6. Intermittent infusion, infrequent phlebotomy or difficult intravenous access (DIVA) with duration of 6 days or more; nursing homes or home care 15 days or more Reference: INS Standards 2016, Chopra MAGIC 2015 EVIDENCE-BASED PRACTICE WITH DEVICES Open access article and poster Select the smallest outer diameter catheter with the fewest number of lumen and least invasive device which will effectively deliver the treatment (INS 2016) Consider risk benefit ratio, individual patient condition factors, diagnosis, treatment and length with each catheter t selection Perform the placement procedure with the least risk for the patient (CDC 2011) Apply Vessel Health and Preservation principles INS 2016, Chopra 2015, CDC 2011, RNAO 2008, Moureau 2012, 2010, 2007 MAGIC MICHIGAN APPROPRIATENESS GUIDE Evidence and expert consensus Ultrasound Guided Peripheral Catheter Indications 1. Use visualization technology to establish peripheral access using longer catheters for the purpose of intravenous treatment less than 5 days or greater than 15 days (with transition to midline or PICC) Midline Catheter Indications 2. For patients with one or more failed attempts, inability to identify veins visually 1. Treatment involves peripherally appropriate solutions that will or those identified as difficult intravenous likely exceed 6 days access (DIVA) 2. Preferred for patients requiring infusions of up to 14 days 3. For contrast based radiological studies 3. Patients with difficult access (DIVA) despite ultrasound requiring upper extremity access in larger guided peripheral catheter attempts veins with 20, 18 or 16 gauge catheter 4. Single lumen midline is placed unless specific indication for (where visible veins to accommodate dual lumen with compatible infusions catheter size are not present) 5. The administration of Vancomycin 6 days was considered safe in one study References: INS 2016, Chopra MAGIC

6 DEVICE SELECTION WITH CHRONIC RENAL FAILURE PATIENTS When not to place a PICC or Midline Inappropriate for PICC or Midline 1. Patients with an estimated glomerular filtration rate (egfr) less than 44 ml/min/1.73 m2, or if no egfr then serum creatinine level greater than 2.0 mg/dl 2. Nephrology clearance prior to placing catheters in the upper arm. Consider dorsal veins of the dominant hand as preferred sites 3. Understand peripheral vein preservation for chronic renal patients can be a matter of life and death. Fistulas have lower risk References: Hoggard ASDIN GUIDELINES 2008, Grove 2000, Allen 2004, Saad 2004, McLennan 2007, Sasadeusz 1999, Maki 2006, CDC 2011 DEVICE INDICATIONS AND SELECTION PIV USG Peripheral Midline PICC 5 days or less 2-3cm Variable dwell Infection rate.07-.5/1000 Aseptic Non Touch Technique Optimal 1-5 up to 15 days Transition to midline or PICC if continued need Ultrasound allows assessment and greater success Reliable dwell, Blood draws, Lower forearm or upper arm veins Sterile insertion preferred 6 days or more 1-29 days 8-20cm Upper arm veins Safe, fast Infection rate /1000 Sterile insertion More information and references in Midline course 14 days or more 30-55cm to SVC Reliable dwell For frequent blood draws Requires tip placement check Infection rate /1000 Sterile insertion VEIN SELECTION FOR MIDLINES Midline Termination Cephalic Basilic Antecubital Cephalic Basilic Accessory Cost-effective alternative to traditional peripheral catheters Low infection rate compared to central catheters Increased patient comfort fewer venipunctures Preservation of peripheral veins Decreased clinician time, and improved workflow Reliable venous access INS Standards 2016, Monreal 1999, Hawes 2007, Mahler 2010, Dargin 2010, Elia 2012, Meyer 2014, Idemoto 2014, Mills 2007, Drawing Grays Anatomy 1918 open access 6

7 TREATMENTS INDICATING USE OF MIDLINE INS 2016, Anderson 2006, MAGIC 2015 Continuous infusions, hydrating solutions Isotonic, lower osmolarity infusions (<900mOsm/L) Antibiotics appropriate for peripheral infusion Heparin infusions, steroids, antacids, pain medications Treatments requiring extended dwell without need of central venous access Therapies that extend longer than 6 days or require an established reliable access AVOID MIDLINES FOR IRRITANTS Do not use midline catheters for continuous vesicant therapy, parenteral nutrition or infusates with osmolarity greater than 900 mosm/l, nothing about ph INS Standards 2016, Gorski 2015 Reviewing the Evidence for ph. INS Taskforce Position Statement Noncytotoxic Vesicant Medications and Solutions

8 GORSKI 2015/2017 VANCOMYCIN EVIDENCE Vancomycin reached 87.5% completion of therapy in Midlines without phlebitis in 396 catheter days reported (Baliad 2013) Thrombophlebitis can be minimized by using dilute solutions of Vancomycin 2.5mg 5mg/ml (Trissels 2013) Dilution of commonly administered intravenous medications significantly reduces phlebitis (Harrigan 1984) Patients receiving Vancomycin peripherally had 7.3 times lower phlebitis than all patients receiving other medications. Patients receiving only amiodarone had an average phlebitis rate of 10.6%; patients receiving only vancomycin had an average phlebitis rate of 0.3%. (Mowry 2010) Trissels 2013 p1115, Simamora 1995, Vesley 2002, Stranz 2002 IJPC p219, Mowry 2010, Baliad

9 EVIDENCE IN FAVOR OF VANCOMYCIN Caparas 2014 study NY Prospective randomized prospective study Vancomycin through either PICC or Midline Percentage complications similar both groups Phlebitis and thrombosis 0% Infiltrations for midlines -3 One suspected CLABSI in PICC group and final result of 2 CLABSIs PICC group. Zero midline infections with 8,426 catheter days Reduction of PICCs to Midlines :1, :1 Nurses were able to draw blood from 901 midlines out of total 906 Caparas JV, Hu JP. Safe administration of vancomycin through a novel midline catheter: a randomized, prospective clinical trial. J Vasc Access. Apr ; access.info/article/safe administration of vancomycin through a novel midlinecatheter a randomized prospective clinical trial VANCOMYCIN CONCLUSIONS It s all about dilution! Dilution of the infusate and dilution of infusate within the blood Vancomycin can safely be given through a peripheral device in concentrations of 2.5-5mg/ml Administer Vancomycin solution 1 gram/200ml over minutes Size matters! Both vein size and catheter length are important. Vein size at least three times diameter of catheter Larger veins and longer catheters result in lower phlebitis rates. Upper arm highest flow rates Vancomycin is not definitively an indication for central venous access Review the characteristics of each medication. Don t rely on ph alone; normal osmolarity, lower concentrations plus adequate venous blood flow have a greater impact on reducing vein irritation Monreal 1999, Hawes 2007, Caparas 2014, Baliad 2013, Robibaro 1998, Harrigan 1984, Stranz 2002, Vesely 2002, Trissel 2013, Lanbeck 2002, Roszell 2010, Mowry 2010 ISSUES WITH MIDLINES Dual lumen catheters noncompatible solutions - NO Blood draws and administration Drawing blood from a midline is determined by the facility and functionality of the device Administration of blood is best through a 4 French catheter or larger (18 gauge or larger lumen size) Power injection per device Based on the indications of the specific catheter and manufacturer (must be noted on the catheter) Based on facility policy for midline usage or usage of non-central intravenous device for CT 9

10 XXXX XXXX 2/20/2017 CLINICAL ECONOMICS - COST PIV USGPIV MIDLINE PICC Supplies, time and staff costs $69 ea insertion. Usage cost $237/wk Dychter JIN 2012 Estimated with extended time and supplies $99.31, dwell?? Estimated at $345 or less, avg dwell 2-4 weeks Facility cost $690, Unlimited dwell, greater risk Dychter 2012 SUMMARY OF BENEFITS/ECONOMIC FACTORS OF MIDLINES Peripheral devices with lowest infection rates Midlines are an excellent way to preserve veins rather than multiple PIVs or non-indicated PICCs/CVCs Useful for blood draws and no need for site rotation; can last the length of therapy Verified reimbursement codes -same as PICCs with lower insertion cost. HCPCS C1751- Catheter, infusion, inserted peripherally, centrally or midline GOALS FOR BEST PRACTICE Avoid CVCs when not specifically indicated Use lowest risk device to avoid infection and thrombosis Gain reliable access for difficult IV access patients (DIVA) with midlines Studies demonstrate CVC reduction of up to 80% with well organized USGPIV/Midline program For every 8 USGPIV/midline insertions one CVC complication is avoided (Au 2012) Mills 2007, Moureau 2012, Dawson 2012, Shohoohi 2013, Au 2012, Meyer

11 Midline online education at just register and enjoy! Home of the ONLY PICC Certification! CPUI THANK YOU FOR YOUR ATTENTION! Nancy Moureau Thank you 3M for education sponsorship REFERENCES Adhikari S, Blaivas M, Morrison D, Lander L. Comparison of infection rates among ultrasound-guided versus traditionally placed peripheral intravenous lines. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine. May 2010;29(5): Au AK, Rotte MJ, Grzybowski RJ, Ku BS, Fields JM. Decrease in central venous catheter placement due to use of ultrasound guidance for peripheral intravenous catheters. The American journal of emergency medicine. Nov 2012;30(9): Baliad P. Midline Catheter Reduces Infiltration for Coronary Artery Bypass Graft Patients. Poster presented at 41st INS Annual Convention and Industrial Exhibition, May 2013, Charlotte, NC. Ball RD, Scouras NE, Orebaugh S, Wilde J, Sakai T. Randomized, prospective, observational simulation study comparing residents' needle-guided vs free-hand ultrasound techniques for central venous catheter access. British Journal of Anaesthesia. January 1, ;108(1): Bauman M, Braude D, Crandall C. Ultrasound-guidance vs. standard technique in difficult vascular access patients by ED technicians. The American journal of emergency medicine. Feb 2009;27(2): Blaivas M, Brannam L, Fernandez E. Short-axis versus long-axis approaches for teaching ultrasound-guided vascular access on a new inanimate model. Acad Emerg Med. Dec 2003;10(12): Blaivas M, Lyon M. The effect of ultrasound guidance on the perceived difficulty of emergency nurse-obtained peripheral IV access. The Journal of emergency medicine. Nov 2006;31(4): Brannam L, Blaivas M, Lyon M, Flake M. Emergency nurses' utilization of ultrasound guidance for placement of peripheral intravenous lines in difficult-access patients. Acad Emerg Med. Dec 2004;11(12): Calvert N, Hind D, McWilliams R, Davidson A, Beverley CA, Thomas SM. Ultrasound for central venous cannulation: economic evaluation of cost-effectiveness. Anaesthesia. Nov 2004;59(11): Caparas JV, Hu JP. Safe administration of vancomycin through a novel midline catheter: a randomized, prospective clinical trial. J Vasc Access. Apr ;0(0):0. Chinnock B, Thornton S, Hendey GW. Predictors of success in nurse-performed ultrasound-guided cannulation. The Journal of emergency medicine. Nov 2007;33(4): Costantino TG, Kirtz JF, Satz WA. Ultrasound-guided peripheral venous access vs. the external jugular vein as the initial approach to the patient with difficult vascular access. The Journal of emergency medicine. Oct 2010;39(4): Costantino TG, Parikh AK, Satz WA, Fojtik JP. Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med. Nov 2005;46(5): Crowley M, Brim C, Proehl J, Barnason, S, Leviner S, Lindauer C, Naccarato M, Storer A, Williams J, Papa A. Emergency Nursing Resource: Difficult Venous Access: Emergency Nurses Association (ENA). Journ Emerg Nurs 2012;38(4): Dargin JM, Rebholz CM, Lowenstein RA, Mitchell PM, Feldman JA. Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access. The American journal of emergency medicine. Jan 2010;28(1):1-7. Dawson, R. B. (2014). Navigating the Depths: Ultrasound Guided Short PIV Insertions - Implications and Limitations for Practice [Presentation], INS 2014, Phoenix, AZ. Dawson R, Moureau N. Midlines: An Essential Tool in CLABSI Reduction. Infect Contr Today 2013 Deutsch GB, Sathyanarayana SA, Singh N, Nicastro J. Ultrasound-guided placement of midline catheters in the surgical intensive care unit: a cost-effective proposal for timely central line removal. Journal of Surgical Research. 2013(0). do Rego Furtado LC. Maintenance of peripheral venous access and its impact on the development of phlebitis: a survey of 186 catheters in a general surgery department in Portugal. J Infus Nurs. Nov-Dec 2011;34(6): REFERENCES Doniger SJ, Ishimine P, Fox JC, Kanegaye JT. Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients. Pediatr Emerg Care. Mar 2009;25(3): Dychter SS, Gold DA, Carson D, Haller M. Intravenous therapy: a review of complications and economic considerations of peripheral access. J Infus Nurs. Mar-Apr 2012;35(2): Elia F, Ferrari G, Molino P, et al. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. The American journal of emergency medicine. Jun 2012;30(5): Evans LV, Dodge KL, Shah TD, et al. Simulation training in central venous catheter insertion: improved performance in clinical practice. Academic medicine : journal of the Association of American Medical Colleges. Sep 2010;85(9): Fields JM, Dean AJ, Todman RW, et al. The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity. The American journal of emergency medicine. Sep 2012;30(7): Gorski LA, Hagle ME, Bierman S. Intermittently delivered IV medication and ph: reevaluating the evidence. Journal of Infusion Nursing Jan 1;38(1): Gorski LA, Stranz M, Cook LS, Joseph JM, Kokotis K, Sabatino-Holmes P, Van Gosen L. Development of an Evidence-Based List of Noncytotoxic Vesicant Medications and Solutions. Journal of Infusion Nursing Jan 1;40(1): Gregg SC, Murthi SB, Sisley AC, Stein DM, Scalea TM. Ultrasound-guided peripheral intravenous access in the intensive care unit. J Crit Care. Sep 2009;25(3): Gregg S, Murthi S, Sisley AC, Stein DM, Scalea TM. Ultrasound guided peripheral intravenous access in the intensive care unit. J Crit Care 2010;25:514. Grevstad U, Gregersen P, Rasmussen LS. Intravenous access in the emergency patient. Current Anaesthesia & Critical Care. 2009;20(3): Heinrichs J, Fritze Z, Vandermeer B, Klassen T, Curtis S. Ultrasonographically guided peripheral intravenous cannulation of children and adults: a systematic review and meta-analysis. Ann Emerg Med. Apr 2013;61(4): e441. Idemoto BK, Rowbottom JR, Reynolds JD, Hickman Jr RL. The AccuCath Intravenous Catheter System With Retractable Coiled Tip Guidewire and Conventional Peripheral Intravenous Catheters: A Prospective, Randomized, Controlled Comparison. Journal of the Association for Vascular Access. 6// 2014;19(2): Katsogridakis YL, Seshadri R, Sullivan C, Waltzman ML. Veinlite transillumination in the pediatric emergency department: a therapeutic interventional trial. Pediatr Emerg Care. Feb 2008;24(2): Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. 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A prospective observational pilot study. Patient safety in surgery. 2009;3(1):24. Mahler SA, Massey G, Meskill L, Wang H, Arnold TC. Can we make the basilic vein larger? maneuvers to facilitate ultrasound guided peripheral intravenous access: a prospective cross-sectional study. International journal of emergency medicine. 2011;4:53. Mahler SA, Wang H, Lester C, Conrad SA. Ultrasound-guided peripheral intravenous access in the emergency department using a modified Seldinger technique. The Journal of emergency medicine. Sep 2010;39(3): Mahler SA, Wang H, Lester C, Skinner J, Arnold TC, Conrad SA. Short- vs long-axis approach to ultrasound-guided peripheral intravenous access: a prospective randomized study. The American journal of emergency medicine. Nov 2011;29(9): Maiocco G Coole C Use of ultrasound guidance for peripheral intravenous placement in difficult to access patients: advancing practice with evidence J Nurs Care 11

12 REFERENCES Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infections in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clinic Proc 2006;81(9): Maki DG, Ringer M. Risk Factors for Infusion-related Phlebitis with Small Peripheral Venous Catheters. Ann Int Med 1991;114: Mermel LA, Parenteau S, Tow SM. The risk of midline catheterization in hospitalized patients. A prospective study. Ann Intern Med 1995; 123: Meyer P, Cronier P, Rousseau H, et al. Difficult peripheral venous access: Clinical evaluation of a catheter inserted with the Seldinger method under ultrasound guidance. J Crit Care. May Mills CN, Liebmann O, Stone MB, Frazee BW. Ultrasonographically guided insertion of a 15-cm catheter into the deep brachial or basilic vein in patients with difficult intravenous access. Ann Emerg Med. Jul 2007;50(1): Moore CL. Ultrasound first, second, and last for vascular access. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine. Jul 2014;33(7): Moureau N, Trick N, Nifong T, et al. Vessel Health and Preservation (Part 1): A New Evidence-Based Approach to Vascular Access Selection and Management. J Vasc Access (Medical). Nov ;13(3): Moureau N, Poole S, Murdock M, et al. Central Venous Catheters in home infusion care: outcomes analysis in 50,470 patients. J Vasc Interv Radiol 2002;13(10): Nafiu OO, Burke C, Cowan A, Tutuo N, Maclean S, Tremper KK. Comparing peripheral venous access between obese and normal weight children. Paediatr Anaesth. Feb 2010;20(2): Panebianco NL, Fredette JM, Szyld D, Sagalyn EB, Pines JM, Dean AJ. What you see (sonographically) is what you get: vein and patient characteristics associated with successful ultrasound-guided peripheral intravenous placement in patients with difficult access. Acad Emerg Med. Dec 2009;16(12): Periard D, Monney P, Waeber G, et al. Randomized controlled trial of peripherally inserted central catheters vs. peripheral catheters for middle duration in-hospital intravenous therapy. Journal of Thrombosis and Haemostasis. 2008;6(8): Ricard JD, Salomon L, Boyer A, Thiery G, Meybeck A, Roy C, Pasquet B, Le Miere E, Dreyfuss D. Central of Peripheral Catheters for Initial Venous Access of ICU Patients: A Randomized Controlled Trial. Critical Care Medicine 2013 ;41(9): Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore) 2002; 81: Sandhu NP, Sidhu DS. Mid-arm approach to basilic and cephalic vein cannulation using ultrasound guidance. Br J Anaesth. Aug 2004;93(2): Schoenfeld E, Boniface K, Shokoohi H. ED technicians can successfully place ultrasound-guided intravenous catheters in patients with poor vascular access. The American journal of emergency medicine. Jun 2011;29(5): Seldinger SL. Catheter replacement of the needle in percutaneous arteriography: a new technique. Acta Radiol 1953;39(5): Shokoohi H, Boniface K, McCarthy M, et al. Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients. Ann Emerg Med. Feb 2013;61(2): Stein J, George B, River G, Hebig A, McDermott D. Ultrasonographically guided peripheral intravenous cannulation in emergency department patients with difficult intravenous access: a randomized trial. Ann Emerg Med. Jul 2009;54(1): Troianos CA, Hartman GS, Glas KE, et al. Special articles: guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society Of Cardiovascular Anesthesiologists. Anesth Analg. Jan 2012;114(1): Weiner MM, Geldard P, Mittnacht AJ. Ultrasound-guided vascular access: a comprehensive review. Journal of cardiothoracic and vascular anesthesia. Apr 2013;27(2): Witting MD, Schenkel SM, Lawner BJ, Euerle BD. Effects of vein width and depth on ultrasound-guided peripheral intravenous success rates. The Journal of emergency medicine. Jul 2010;39(1): VESSEL HEALTH AND PRESERVATION IN ACTION Reference: Hallam 2016 Journal of Infection Prevention 12