Venous Access Devices in Clinical Practice An overview

Venous Access Devices in Clinical Practice An overview of guidelines and services for maximizing outcomes for patients receiving intravenous therapies

Useful to Know • • Venous Access is essential. Establishing and maintaining reliable access is a priority. • EARLY access planning prevents IV related complications and negative outcomes for patients and the hospital. • The choice of which VAD to use is a collaborative process.

Access is essential • Infusion therapies play a major role in the treatment plan for almost every disease process. • Need for IV therapy is one of the criteria for provider approval of hospital admission.

2 types of devices • PIV’s short catheters (less than 3 inches) placed in the veins of the upper extremities. • CVAD’s long catheters whose terminal tip position is in the central veins.

Venous Access Devices • Peripheral Most appropriate device for short term therapies (less than 5 days) that are nonirritating. • Central • When ordered meds have p. H greater than 9. 0 or less than 5. 0, osmolality greater than 500 m. Osm. • Ordered meds/fluids are known irritants • PN with dextrose concentration greater than 10%. • IV inotropes • Vesicants

Peripheral IV’s Placed by the nursing staff on the units 24/7 with the assistance of the IV Team for those patient’s that are difficult sticks. IV Team is in house 7 days a week from 8 AM-7: 30 PM. Pager #3471988

CVAD’s Are placed by multiple physician and non-physician providers throughout the hospital based on the type of device that is required.

3 Types of CVAD’s • Non-tunneled • Tunneled • Implanted

Nontunneled • Inserted by percutaneous stick into the internal jugular, subclavian, femoral or upper arm veins.

Tunneled • The catheter is tunneled under the skin to a vein in the neck or chest. A cuff near the exit site anchors the catheter in place.

Implanted Surgically inserted under the skin in the upper chest or the arm and appears as a bump under the skin.

CVAD’s Non-tunneled Temporary triple lumen, PICC’s Tunneled Powerline, Hickman, Broviac Implanted Mediport, Portacath

Which VAD? The goal is to choose a device with the lowest risk of complications (infectious and noninfectious) which will last the duration of therapy or be managed with minimal replacements.

Appropriate VAD Selection • Minimizes patient discomfort, morbidity and mortality • Decreases health care costs associated with delays of therapy and increased LOS. • Enhances therapeutic benefits for patients with minimal impact on ADL’s.

Patient Experience

"A good beginning makes a good end. " Louis L’amour

Planning is essential Starts with the first IV order Discuss on rounds…. . with the patient.

What type of access device is the most appropriate for the patient? • • • Duration of therapy Characteristics of the infusates Available insertion sites Existing co-morbidities Impact on ADL’s

Duration of Therapy • < 5 -7 days – peripheral IV • >7 days<2 weeks (in house patients) temporary CVAD • 1 -6 weeks – PICC • >6 weeks – Tunneled or Implanted

Type of infusates • p. H < 5 • p. H > 9 • Osmolality > 600 • Caustic or vesicant medications

Available insertion sites Consider CVAD placement when: • Peripheral IV access cannot be initiated or maintained in the upper extremities. IV’s ‘blow’ or last only a few hours. No lower extremity IV’s. • The patient has a history of being a “difficult stick” and has required central access in the past.

Chemical Phlebitis

Infiltration

Extravasation

PICC Thrombosis

Co-morbidities and Device Selection • Certain types of CVAD’s may be contraindicated based on preexisting conditions. • Chronic Kidney Disease, Hypercoaguable syndromes, preexisting venous stenosis, thrombosis, etc.

Impact on ADL’s • Availability of care giver assistance. • Dressing requirements and catheter stability. • Use of mobility aids. • Work and home activity limitations.

When, how and by whom will the device be placed? PIV’s Unit staff and IV Team CVAD’s Nontunneled – resident staff, PICC nurses, interventional radiology, anesthesia Tunneled – Interventional radiology, peds surgery Implanted – Interventional radiology

When to Order? • Based on patient need and ordered therapies • Early decision making and placement of an appropriate device is correlated with positive clinical outcomes and decreased length of stay. • Remember: PICC, tunneled and implanted device placement requires lead time of 1 -3 days. Do not wait until day of discharge to order lines for home infusion.

Which device to order? Temporary Nontunneled: Best for short term facility based access (less than 14 days) Long term Nontunneled: Typically used for 1 -6 weeks of therapy. (PICC’s) May be used in the home setting.

Which device to order? • Tunneled catheters: More permanent device best used for dwell times > than 4 -6 weeks or when a PICC is contraindicated. • Ports: Most beneficial when long term intermittent therapies are needed.

How to order CVAD’s • For PICC’s: Search ‘PICC’ in CPOE Select “PICC Procedure (Adult and Ped) from the order menu.

How to order • Tunneled or Implanted devices: • Search ‘CVAD’: ‘CVAD-insert tunneled w/o port >5 years’ ‘CVAD-insert tunneled with port >5 years.

VAD Placement Decisions An integral part of the treatment plan Collaborative in nature Coordinated effort of multiple providers

Resources • Patient • Consult services (nephrology, infectious disease) • PICC RN: 2168219 • VIR: consult pager 2168477 • Home Infusion Nurse: 3471934 • CCM and Social Workers

Useful to Know • • Venous Access is essential. Establishing and maintaining reliable access is a priority. • EARLY access planning prevents IV related complications and negative outcomes for patients and the hospital. • The choice of which VAD to use is a collaborative process.