Vascular access device selection & placement

Alisa Seangleulur, MDAnesthesiology 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 non-irritant 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 chlorhexidinegluconate 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

IV bag change IV line change

No additives in infusion

Every 72 h Every 72 h

Additives in infusion

Every 24 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