Vascular access device selection & placement Alisa Seangleulur, MD Anesthesiology Department, Faculty of Medicine, Thammasat University
How to make the right choice of vascular access device..
Peripheral IV device management Definitions Selection of IV access type Hand hygiene IV insertion and dressing IV labelling IV management
Definitions Peripheral IV access Small peripheral vein Therapeutic purpose: administration of medicine, fluids and/or blood products Midlines A large peripheral vein (basilic > cephalic) but does not enter the central venous system Insert into a vein in the antecubital fossa and the tip extends into the vein of the upper arm up to 20 cm Single or double lumens, silicone and polyurethane, 20 cm. Use when patients do not have accessible peripheral veins or a CVC is contraindicated. Easy and less complication Radiological confirmation is not required.
Definitions Peripherally inserted central catheter (PICC) Basilic, cephalic, or brachial veins and ecter the SVC into a large vein Chest x-ray confirm the position PICC is used when there is a lack of peripheral access for infusion of vesicant and irritant drugs/fluids, TPN, and hyperosmolar solutions. Long-term access is required. Comparing with CVC, PICC are associated with lower rates of thrombosis and sepsis, pneumothorax, large vein perforation. Single and double lumen catheters Open ended or valved (valved PICCs: not blocking off)
Definitions Central venous access device (CVAD) Insert from jugular or subclavian vein and terminate in one of great vessels of the thorax and abdomen. Deliver medications, fluids, intravenous nutrition, and/or blood products. Diagnostic purposes: blood sampling, central venous pressure monitoring CVCs come in different sizes, with single or multiple lumens. Multiples lumens allow numerous drugs to be administered simultaneously without the risk of interaction. However, multiple lumens are documented as increase the risk of air embolism Every lumen must have an external clamp to minimize the risk of air embolism The use of needle free device such as a Bionector (Vygon) will reduce the risk of infection and prevent air embolism compared to three-way taps
Bionector
Selection of IV access type Skill of the operator Duration of IV access required Purpose of IV access Therapeutic and/or Diagnostic Lumens should be kept to a minimum to reduce the risk of infection
Selection of IV access type Number of days IV access is required Selection of catheter < 7 days Peripheral IV access Up to 14 days where continued venous access is considered necessary PICC/ Central catheter > 14 days PICC/ Central catheter or consider surgical line Long term (>30 days) Surgical line (HICKMAN/BROVIAC or Port/Port-A-cath)
Hand hygiene Hands should be decontaminated before and after Palpating catheter insertion sites Inserting or accessing cannula Repairing or dressing a peripheral IV
IV insertion and dressing Select the site Choose a site that does not cross a joint If possible, choose the non-dominant hand Ideally, choose the longest, straightest and widest vein Veins that are inflamed, fibrosed, thrombosed, bruised or have been venepunctured previously should be avoided.
IV insertion and dressing Select the site Preferred sites: Adults: metacarpal, cephalic and basilic. It is possible to use veins in the lower extremities, but this is best avoided owing to increased risk of thrombophlebitis. Children: back of hands/ forearm (start with distal sites) Cubital fossa (for blood taking and short-term IV therapy) Dorsal surfaces of feet (ideally this site is only used in infants or young children as it reduces mobility)
IV insertion and dressing Selection IV cannulae Standard wire gauge is the measurement used for needles and cannulae. This measures the internal diameter of the cannula, so the smaller the gauge size, the larger diameter of the cannulae The use of smallest, shortest gauge cannula is recommended because the incidence of complications increases as the ratio of the cannula s external diameter to vessel lumen increases.
IV insertion and dressing Selection IV cannulae The over-the-needle cannula is the type most widely used. A thin, smooth-walled cannula tapering to a scalloped end will cause less damage on insertion than one that is abruptly cut off. Using the thinnest walled cannula will reduce mechanical irritation to the vein wall, enable blood to flow around the line and increase the uptake of medication, fluids, bloods and blood products, thus decreasing the risk of chemical irritation. The largest internal diameter also aids maximum flow rates.
IV insertion and dressing Selection IV cannulae Cannula flow rates vary according to manufactuer, material and device length. Materials used to manufacture cannulae are nonirritant and should not predisposer to thrombus formation Teflon is quite rigid, Silicone elastomer and Polyurethane-based cannulae are preferable The cannula should be radio-opaque to aid detection should part of it shear off and cause an embolus.
IV insertion and dressing Pain management An injectable or topical LA drug should be used only upon the written order of a doctor or under a patient group direction Minimum 40-60 minutes priors to cannulation apply local anesthetic cream to several possible IV sites and cover with transparent occlusive dressing Injection local anesthetic at injection site should be monitored (allergic reaction, tissue damage, inadvertent injection of the drug into the vascular system
IV selection and dressing Cannula insertion Use a dressing pack Clean the site before insertion using chlorhexidine gluconate for between 30 sec (peripheral) and 2 min (central) Decontaminate hands and don disposable non sterile gloves (prevention of blood-borne pathogen exposure) A no-touch technique should be used for the insertion Once the cannula has been inserted, blood specimens can be taken if required, then 3-way tap with the extension tubing is attached Hands should be decontaminated after removal of gloves
IV selection and dressing Dressings The type of dressing remains controversial. Either traditional (tapes and Tubular-Fast) or the tegaderm/mefix dressing is acceptable Dressing can be transparent semipermeable memebrane (TSM), colloid, sterile guaze. TSM: promote evaporation, Sterile guaze: bleeding, oozing insertion sites Ensure that It is secure. The site is visible. Tapes are not too tight, to prevent tourniquet effect. For children, they can t injure themselves on the connections, and can t remove or dislodge IV Change dressing if it becomes insecure or if there is blood or fluid leakage
IV selection and dressing Locking Positive pressure locking technique: prevent blood reflux Maintaining positive pressure on the syringe plunger while closing the clamp and before removing the syringe from the cap of device Valve technology-positive pressure caps Redirecting a small amount of fluid into the internal catheter tip when the tubing is disconnected from the hub. Catheters using positive pressure valves should not be clamped until after disconnection of the flush syringe. Valve technology-vascular access devices Closed-ended valves: An internal three way valve at the tip of a catheter Open-ended valves: open ended tip, and a pressure valve in the hub When a syringe is disconnected, the valve is neutral position. Nurse needs to maintain positive pressure on the syringe plunger when disconnecting the syringe from the cap or hub
IV Labelling For all IVs Fluid bag/syringe AND Line (close to the 3-way tap near the patient) pump Labelling infusions Date Time Patient name Additive Signature of the two RNs who checked the fluid
IV management Checking procedures Each new bag/syringe or rate change two RNs double check: At the line/tubing Infusion rate on the pump When using a syringe pump, check and document Syringe level and Volume infused Bolus/loading doses Changing IV bags and lines
IV management Changing IV bags and lines No additives in infusion Additives in infusion IV bag change Every 72 h Every 24 h IV line change Every 72 h Every 72 h TPN/lipid Every 24 h Every 72 h other On change of order
IV mangement Changing cannulas: or up to 96 hours There is some research that supports longer dwell times in adults but the research primarily involves infusion nurse specialists inserting and maintaining the catheters with on going vigorous and cautious assessment. In children, there is no evidence to recommend regularly re-siting IV cannulas. It only need to be replaced when they fall out, show signs of phelbitis or become blocked.
IV management Removal of IVs Wearing non-sterile gloves, carefully remove the dressing and cannula If scissors are required to remove the dressing, only BLUNT-end scissors may be used. Apply gauze or cotton wool to prevent bleeding Cover site with cotton wool and tape