PARENTERAL NUTRITION: VASCUAR ACCESS DEVICE SELECTION Winifred Magambo-Gasana Vascular Access Nurse Practitioner Oxford University Hospitals NHS Foundation Trust
Aim An overview of the range of Vascular Access Devices (VADs) that can be used to administer Parenteral Nutrition Classification of VADs (short, intermediate, long term) Advances in technology Types of VADs Considerations when selecting VAD Presentation Title/Date Can Go Here
Background VADs have been inserted into the venous system for almost 100yrs Initially VADs used for short-term to administer antibiotics via peripherally accessed vein Introduction of silastic led to the introduction & use of long term VADs Advances in technology has seen a continued growth and evolvement of VADs
CLASSIFICATION OF VADS
Classification of VADs Short-term VADs Peripheral Cannula Non-irritant short-term treatments Short term IV medication Short-term administration of antibiotics Temporary central lines CVC (non-tunnelled) - CVP monitoring -Administration of fluid and/ toxic drugs -Short term access 7-10days
Classification of VADs Intermediate-term VADs Midline Catheters (*PIC) - Usually 7.5-20cm in length - Tip location in the axilla/upper arm - 2-6weeks dwell time -Administration of non-vesicants/non-irritant drugs Peripherally Inserted Central Catheter (PICC) - Usually 50-60cm in length -Tip location in lower third SVC /Cavo atrial junction -Used for treatments of 6weeks 1 year -Administration of vesicants/irritants -Conditions requiring regular blood sampling
Classification of VADs Long-term VADs Totally Implantable Ports (Port-a Cath) Used mainly in Oncology & CF patients Lower risk of infection Prolonged intravenous therapy Tunnelled Central Venous Access Devices Hickman, Broviac Dacron cuff Prolonged intravenous therapy
ADVANCES IN TECHNOLOGY
Power Injectables: Advances in Technology Vascular Access Devices that can have infusions through them at high pressures without causing damage to the device or the vessel. 5ml/sec 300psi. Polyurethane Open-ended Available in all ranges
ECG & Tip Location Systems (TLS) for Adult Patients Mechanism Magnetic field generated between console & stylet Real time display on interface as VAD is advanced Baseline ECG extravascular Confirmatory intravascular ECG changes in P waves Benefits Tip position confirmed at placement No need for X-ray Better accuracy Reduced time delay in starting treatment Reduced costs of having to resite PICC if mispositioned Miniature Printer
ECG & TLS Contra-indicated Patients in AF Patients with fast tachycardia Patients with Pacemaker
TYPES OF VADS
Venflons for Peripheral Parenteral Nutrition o Size 20G-18G o Dwell time 7-10 days unless clinically indicated o Complications - phlebitis, dislodgement, extravasations, infiltration (Epic 3 2014 )
MIDLINE: Power wand for Peripheral Parenteral Nutrition POWER WAND (Extended dwell catheter) o Size 4Fr-5Fr o 7cm-10cm o Dwell time 29 days o Power injectable 325psi 130-180ml/min o Kink resistant o Can withdraw blood o Low thrombosis & phlebitis rates Presentation Title/Date Can Go Here
MIDLINE: Power glide for Peripheral Parenteral Nutrition POWER GLIDE o Size 22G-18G o 8cm-10cm o Dwell time 29 days o Power injectable 300psi 2ml- 7ml/sec o Minimize vessel trauma o Can withdraw blood Presentation Title/Date Can Go Here
MIDLINE: Power Midline for Peripheral POWER MIDLINE o Size SL 3Fr & 4Fr o Size DL 4Fr & 5Fr o 8cm-10cm o Dwell time 29 days o Power injectable 300psi o Rates SL 3Fr 3ml/sec 4Fr 7ml/sec o Rates DL 4Fr 4ml/sec* 5Fr 7ml/sec o Minimize vessel trauma o Kink resistance o Can withdraw blood Parenteral Nutrition Presentation Title/Date Can Go Here
MIDLINES for Peripheral Parenteral Nutrition LIFECATH LEADERFLEX o Size 3Fr, 4Fr, 5Fr, 22G o Dwell time 2-4weeks o Complications lack of blood withdrawal Occlusion phlebitis Presentation Title/Date Can Go Here
PICCs for Parenteral Nutrition o Size 4Fr, 5Fr o Single or multi-lumen o Dwell time up to 18 months manufacturers guidance o Complications o thrombosis, o occlusions, o Dislodgement o CRBSI o Fracture Presentation Title/Date Can Go Here
Tunnelled VADs for Parenteral Nutrition 6.6fr, 7fr, 9fr Dwell time 3yrs-5yrs Complications CRBSI Thrombosis Fractures Occlusion PWO Displacement
CONSIDERATIONS WHEN SELECTING VAD
UK Vessel Health & Preservation Based on 4 Clinical Decision Aides Peripheral vein assessment tool Suitability of IV fluids/medications for peripheral vein administration Right line decision tool Re-evaluation of vascular access device Hallam C et al J Infect Prev. 2016 Mar; 17(2): 65 72.
Selecting a VADs Considerations Expected duration of therapy Regular or intermittent use Flow rate of prescribed therapy Any existing devices present Need for concurrent IV access/therapy Condition of patient s veins Considerations Need for CT Method of insertion o Palpation o USS o ECG TLS o Fluoroscopy Aftercare and maintenance
Overview of VADs Summary Classification Types of VADs Power injectables ECG TLS Considerations for selecting VAD
BAPEN CONFERENCE 2018