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Vascular Assessment: Are you doing your due diligence?
Sandy Sucy M.S., R.N., VA-BCClinical Specialist ManagerBard Access Systems
BAS/EDUC/0816/0048No discussion of off label use will be
included in this presentation
- the care that a reasonable person exercises to avoid harm to other persons or their property
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Vascular Access Assessment
• What are we assessing for…?▫ Treatment plan?▫ Vessel health?▫ Appropriate device?▫ Risk factors?▫ Other?
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INS 2016 standard 26.1
“The appropriate type of vascular access device (VAD), peripheral or central, is selected to accommodate the patient’s vascular access needs based on the prescribed therapy or treatment regimen; anticipated duration of therapy; vascular characteristics; and the patient’s age, comorbidities, hx of infusion therapy, preference for VAD location, and ability and resources available to care for the device.”
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INS 2016 standard 26.3
“The VAD selected is the smallest outer diameter with the fewest number of lumens and is the least invasive device needed for the prescribed therapy.”
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Short Peripheral IV
• Placed in many patient care settings, both inpatient and outpatient
• No special equipment required, but may use imaging technology such as ultrasound or infrared light
• Most commonly used VAD in the US at an estimated 300M units annually
• Is it easy to place?• Is it cost effective?
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Midline
Definition: A catheter inserted in the upper arm via the basilic, cephalic, or brachial vein, with the internal tip located level at or near the axillaand distal to the shoulder
• Types▫ No touch▫ AST▫ MST
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Central lines
Definition: Catheter inserted into a peripheral or centrally located vein with the tip in the superior or inferior vena cava
• Types▫ Acute CVC, PICC, Port, Tunneled
• Insertion site• Risk/benefit ratio
▫ Complications Insertion Dependent on type/location of insertion
Post insertion
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Preventable complications
• Infiltration?
• Phlebitis?
• Infection?
• Catheter related thrombosis?
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Infiltration
• Inadvertent administration of a nonvesicantsolution or medication into the surrounding tissue; rated by a standard tool
• INS 2016 standard 46.1“The clinician assesses the peripheral and central vascular access device site for signs and symptoms of infiltration and extravasationbefore each infusion and on a regular basis…..”
BAS/EDUC/0816/0048 12Are you doing your due diligence?
Phlebitis
• Inflammation of a vein; may be accompanied by pain, erythema, edema, streak formation, and/or palpable cord; rated by a standard scale
• INS 2016 standard 45.1 A.“Assess regularly, based on patient population, type of therapy, and risk factors, the vascular access sites of short peripheral catheters, midline catheters, and PICCs for signs and symptoms of phlebitis using a standard tool.”
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INS 2016 standard 45.1.B
Recognize risk factors that can be addressed1. Chemical Phlebitis – related to infusate properties, lack of
hemodilution, and/or skin antiseptic not fully dried prior to insertion
2. Mechanical phlebitis – related to vein wall irritation, may be caused by to catheter size, movement, insertion trauma, or catheter material
3. Bacterial phlebitis – may be related to emergent catheter insertion and poor aseptic techinque
4. Patient related factors – current infection, immunodeficiency, diabetes, lower extremity insertion (except in infants) and age > 60
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CLABSI vs. CR-BSI
• CLABSI▫ A laboratory confirmed, primary bloodstream
infection (BSI) in a patient with a central line in place for more than 2 calendar days before the development of the BSI and the BSI is not related to an infection at another site
• CR-BSI▫ A clinical definition used when a catheter is
identified through specific laboratory testing to be the source of the BSI
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Rates of Intravascular Device-Related BSI By Type of Devices *
*An analysis of 200 published studies. Data collected from 1966 - 2005
18BAS/EDUC/0816/0048 18
Maki DG, Kluger DM, & Crnich CJ. (2006). The risk of bloodstream infection in adults with differentintravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 81:1159–71
Device # of studies
# of catheters
# of IV days
# of BSIs
per 100 devices
Per 1,000 IVD-days
Pooled Mean Pooled Mean
Peripheral IV catheters 110 10,910 28,720 13 0.1 0.5
PICCs (Inpatient & OP) 15 3566 105,839 112 3.1 1.1
Short term non-tunneled catheters with CHG/silver
18 3367 54,054 89 2.6 1.6
Tunneled CVC 29 4512 622,535 1013 22.5 1.6
Implanted port 14 3007 983,480 81 3.6 0.1
Dialysis cathetersTemporary 16 3066 51,840 246 8 4.8
Long-term 16 2806 373,563 596 21.2 1.6
HAI Progress Report
19BAS/EDUC/0816/0048 19
Centers for Disease Control and Prevention. 2014 National and State Healthcare-Associated Infections Progress Report. Published January 2016. Available at http://www.cdc.gov/hai/progress-report/index.html
• Standardization of clinical processes where practice variation may lead to increased risk of CLABSIs
Tilley, T., Hoffman, J. et al. (2015). Journal of Trauma Nursing, 22(2), pp 78-86.
• Specialized teams for consistent high quality clinical outcomes (ex. Vascular Access Team)
The Joint Commission. Available from: www.jointcommission.org/topics/hai_clabsi.aspx.
• A process in place to identify/assess patients with indwelling central line
Chopra, V., Ratz, D. et. al. (2014). The American Journal of Medicine , 127 (4). pp 319-328.
• Bundling practices How-to Guide: Prevent Central Line-Associated Bloodstream Infections (CLABSI). Cambridge, MA: Institute for Healthcare Improvement; 2012. (Available at www.ihi.org)
Key Strategies for Minimizing CLABSIs
20BAS/EDUC/0816/0048 20
Patient
ProductClinician
Developing a Bundle• A central line insertion-and-
maintenance bundle is a group of evidence-based preventive practices and technologies that produce better outcomes when implemented collectively than when implemented individually.
• A bundle will only be effective to the degree that it addresses the actual origins of CLABSI. It must include efforts to combat the formation of biofilm, because it is now well established that CLABSI develop as a result of bacteria colonizing on catheter walls.21BAS/EDUC/0816/0048 21
When Can Central Line Bundles Succeed?
• Dedicated, specially trained teams to conduct and/or oversee all line insertions & maintenance*
Silow-Carroll, S. & Edwards, J. N. (2011). Eliminating Central Line Infections and Spreading Success at High-Performing Hospitals, The Commonwealth Fund, December.
• Standardized, Evidence Based Protocols (Bundle) including:▫ Insertion Checklist▫ Central Line Cart Inventory▫ Hand Hygiene▫ Maximal Barrier▫ Daily Necessity Checks (early line removal)▫ Site preparation with Chlorhexidine▫ Site Selection (avoiding femoral lines)
How-to Guide: Prevent Central Line-Associated Bloodstream Infections (CLABSI). Cambridge, MA: Institute for Healthcare Improvement; 2012. (Available at www.ihi.org)
22BAS/EDUC/0816/0048 22
* Single center study – may not be representative of all institutions
What is missing?Could there be additional emphasis on care-and-maintenance?
•CVCs may be in place for a week or longer, and will be accessed by nurses numerous times.•Lines left in place more than 1-2 weeks have a longer care-and-maintenance phase which may present numerous opportunities for infection. •It was recently reported that over 70% of all CLABSIs reported to the NHSN by Pennsylvania acute care hospitals in 2010 occurred more than five days after insertion, suggesting that infection prevention lapses likely occurred in the post-insertion care and maintenance of the CVCs Pennsylvania Safety Authority. Central-Line-Associated Bloodstream Infection: Comprehensive, Data-Driven Prevention. Pennsylvania Patient Safety Advisory. Sep 2011. Accessed Mar 19, 2012. http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/sep8(3)/Pages/100.aspx.
23BAS/EDUC/0816/0048 23
A comprehensive bundle should addresscare and maintenance as thoroughly as it does
catheter insertion.
What is missing?
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Central Line Bundle Initiative
Presence of a Policy
Adherence to Policy
Insertion Checklist 92% 52%
Hand Hygiene Monitoring 94% 62%
Maximal Barrier for Insertion 96% 62%
Chlorhexidine 97% 71%
Selecting optimal site 91% 46%
Daily necessity checks 87% 37%
Compliance to guidelines can be challenging…
25BAS/EDUC/0816/0048 25
Stone, P. W., et al. (2014). State of infection prevention in US hospitals enrolled in the National Health and Safety Network. American journal of infection control 42(2). 94-99.
Are you doing your due diligence?
Catheter related thrombosis
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Catheter Associated Venous Thrombus
A secondary vein thrombosis related to the presence of a CVAD; includes the presence of an extraluminal fibrin sheath encompassing all or part of the CVAD’s length, with a mural or veno-occlusive thrombosis overlying the fibrin sheath; may be located in deep veins or superficial veins when placed for CVAD use
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Infusion Therapy Standards of Practice (2016). Journal of Infusion Nursing, S147
Catheter-Related Thrombosis
Intraluminal Occlusion• Occurs when blood refluxes
into catheter• Adherent to the inner lumen
of the catheter but not to the vessel wall
• Can result from inadequate flushing
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Catheter-Related Thrombosis
Fibrin tail or flap• Extends from the catheter tip
and blocks the catheter lumen during aspiration
• Infusion may be possible, but aspiration is not
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Catheter-Related Thrombosis
Fibrin sheath or sleeve• Forms when fibrin adheres to
the external catheter surface• May completely cover the
opening of the catheter tip
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Catheter-Related Thrombosis
Mural Thrombus• Forms when the catheter rubs
against a vessel wall• Catheter may adhere to the
vessel wall• May form at the entry site,
along the catheter path, or at the catheter tip
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Catheter-Related Deep Vein Thrombosis
• A blood clot that forms on a vein where a vascular catheter has been positioned. Deep veins in the upper extremity include the brachial and axillaryveins.
• Mean of 8-9 days from PICC insertion to DVT diagnosis.
32
Symptomatic vs. Asymptomatic DVT
• Symptomatic DVT:▫ A minority of catheter-related
DVTs present with symptoms▫ For PICCs this may include
swelling (“edema”), redness, and/or pain in the catheterized arm
• Asymptomatic DVT:▫ A majority of catheter-related
DVTs are “clinically silent” and NOT associated with symptoms
▫ These DVTs pose similar clinical risk
BAS/EDUC/0816/0048 33
Acute CVCs and DVTs
Kujir, R. et. al. (2012) Indian Journal of Critical Care Medicine, 16(1), pp 17-21.
prospective observationa
l study
thrombus found in 33% (33 of 100) of patients withright IJ CVC
Frizzelli, R. et. al.(2008). Intern Emergency Medicine, 3. pp 325-330
prospective study
48% (386 of 815) of patients with IJ CVCs had ultrasound proven DVT
Wu, X. et. a. (1999). Journal of Clinical Anesthesia, 11. pp 482-485
prospective study
56% (45 of 81) of patients with IJ CVCs had ultrasound proven thrombi. 56% of those were sleeve-shaped, 44% were compact thrombi.
Timsit, JF, et. al. (1998). Chest, 114. pp 207-213
prospective, multicenter
study
33% (69 of 208) of patients with either IJ or subclavian acute CVCs had ultrasound proven DVT. The rate was higher with the IJ approach at 41%. Authors also found a 2.62 fold higher rate of CRBSI when thrombus was present.
Karnik, R. et. al. (1993). Clinical Cardiology, 16. pp. 26-29
prospective study
63.5% (40 of 63) of patients with IJ CVCs had ultrasound proven DVT
How does a DVT form?
• The inner-most layer of the vein is endothelium (tunica intima)▫ Single layer of smooth, flat
endothelial cells• Any trauma that roughens
endothelial lining encourages thrombin formation▫ Insertion Needle▫ Guidewire▫ Microintroducer▫ Catheter during insertion▫ Indwelling
catheter/catheter movement
▫ Infusates
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RBC trapped in platelet and fibrin mesh
Activated Platelets
RestingPlatelets
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Risk factors for DVT Formation• “Virchow’s Triad”: Three well established risk
factors that increase thrombus risk:
Endothelial Injury: damage to the endothelium causes activation of the body’s clotting mechanisms Circulatory Stasis: Slowing of blood flow and flow disturbance can activate clotting and thrombus formation Hypercoagulability: Some disease states and genetic disorders place some patients at higher risk for thrombus formation
BAS/EDUC/0816/0048 37
Examples of Specific Risk Factors
• Endothelial injury:▫ Trauma▫ Surgery▫ Mechanical injury (including
both skilled and non-skilled placement of a vascular access device and dwell)
▫ Chemical injury (ex: meds with pH extreme)
▫ Malpositioned central line tip
BAS/EDUC/0816/0048 38
Examples of Specific Risk Factors
• Circulatory Stasis:▫ Immobility (bedrest,
stroke, fatigue, etc.)▫ Many illnesses and
medical conditions (dehydration, sedation, etc.)
▫ Presence of a catheter in the vein (stasis and flow disturbance)
BAS/EDUC/0816/0048 39
Examples of Specific Risk Factors
• Hypercoagulability:▫ Many disease states such
as cancer and its treatment, sepsis, diabetes, ESRD, tissue damage such as trauma
▫ Genetically inherited conditions
▫ Variable platelet function between individuals
BAS/EDUC/0816/0048 40
It is not uncommon for patients in the acute care setting to have one or more of these risk factors
putting them at risk for DVT formation.
Careful assessment of these risk factors is essential prior to adding a CVC or PICC
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INS 2016 standard 52.1.AAssess risk factors for thrombosis PRIOR to CVAD
insertion. Risk factors include• Hx of DVT• Presence of chronic diseases associate with
hypercoagulable state• Surgery or trauma• Critically ill• Known genetic coagulation abnormalities• Pregnancy• Extremes of age• Hx of multiple CVADs, especially traumatic or difficult
insertions and presence of other intravascular devices
BAS/EDUC/0816/0048 42Are you doing your due diligence?
Which Risks Can Be Managed?
Patients’ underlying risk factors▫ Need for central venous access
and indwelling vascular device▫ Hypercoagulability, inherited
or acquired▫ Pre-existing disease states and
co-morbidities▫ Blood stasis associated with
immobility, dehydration, surgery, etc.
BAS/EDUC/0816/0048 43
Which Risks Can Be Managed?
Endothelial injury at insertion:Use of ultrasound guidance provides Real-time visualization of
venipuncture Can help reduce risk of back wall
puncture Access veins of upper arm can help
to reduce mechanical phlebitis associated with antecubitalinsertion
Skilled Clinicians
BAS/EDUC/0816/0048 44Are you doing your due diligence?
Which Risks Can Be Managed?
Stasis and flow disturbance:▫ Catheter gauge vs. lumen size▫ Use of ultrasound for
measurement of vein to catheter ratio
▫ Tip placement
BAS/EDUC/0816/0048 45Are you doing your due diligence?
Catheter size matters
BAS/EDUC/0816/0048 46
Evans, R. S. et. Al. (2010). Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest. 138(4). pp 803-810.
Catheter size matters
BAS/EDUC/0816/0048 47
Evans, R. S. et.al. (2013). Reduction of peripherally inserted central catheter-associated DVT. Chest, Vol. 123(3). pp 627-633.
INS 2016 standard 52.1
• For PICCs, measure the vein diameter, using ultrasound before insertion. Choose a catheter with a catheter vein ratio of <45%• Italian Group for the Study of Long-term Central Venous
Access Devices (GaVeCelt) suggests at ratio of no greater than 33% with tourniquet off (Emoli et. al. 2014)
• Ensure CVAD tips are located in the lower third of the SVC or cavoatrial junction as tips located in the mid-to-upper portion of the SVC are associated with greater rates of DVT
• Measure the upper arm circumference before insertion of a PICC and when clinically indicated to assess presence of edema and possible DVT
BAS/EDUC/0816/0048 48Are you doing your due diligence?
To Pull or Not to Pull• Recently published study shows that patients who get a DVT from
one PICC have an 86% chance of developing another DVT when that PICC is removed and one is immediately placed in a new vein
Jones, M. A. et. al. (2010). Characterizing resolution of catheter-associated upper extremity deep venous thrombosis. Journal of Vascular Surgery, 51 (1). pp 108-113
• Published CHEST (2012) guidelines recommend NOT pulling a PICC with diagnosed UE-DVT if central access is still clinically necessary
BAS/EDUC/0816/0048 49
9.3.1 For most patients with UEDVT in association with an indwelling central venous catheter, we suggest that the catheter not be removed if it is functional and there is an ongoing need for the catheter (Grade 2C)
Guyatt, G. H. et. al. (2012). Antithrombotic therapy and prevention of thrombosis, 9th ed:American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141 (2).
Due Diligence
Compliance
Knowledge
Skill
Assessment
BAS/EDUC/0816/0048 50
References• Centers for Disease Control and Prevention. 2014 National and State Healthcare-Associated Infections Progress
Report. Published January 2016. Available at http://www.cdc.gov/hai/progress-report/index.html
• Chopra, V., Ratz, D., Kuhn, L., Lopus, T., & Chenoweth, C. (2014). PICC-associated blood stream infections: Prevalence, patterns, and predictors. The American Journal of Medicine , 127 (4). pp 319-328.
• Evans, R. S. et. Al. (2010). Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest. 138(4). pp 803-810.
• Evans, R. S. et.al. (2013). Reduction of peripherally inserted central catheter-associated DVT. Chest, Vol. 123(3). pp 627-633.
• Frizzelli, R. et. al.(2008). Deep venous thrombosis of the neck and pulmonary embolism in patients with a central venous catheter admitted to cardiac rehabilitation after cardiac surgery: A prospective study of 815 patients. Intern Emergency Medicine, 3. pp 325-330
• Guyatt, G. H. et. al. (2012). Antithrombotic therapy and prevention of thrombosis, 9th ed:American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141 (2).
• How-to Guide: Prevent Central Line-Associated Bloodstream Infections (CLABSI). Cambridge, MA: Institute for Healthcare Improvement; 2012. (Available at www.ihi.org)
• Infusion Therapy Standards of Practice (2016). Journal of Infusion Nursing, 38(1S)
• Jones, M. A. et. al. (2010). Characterizing resolution of catheter-associated upper extremity deep venous thrombosis. Journal of Vascular Surgery, 51 (1). pp 108-113
• Karnik, R. et. al. (1993). Duplex sonographic detection of internal jugular venous thrombosis after removal of central venous catheters. Clinical Cardiology, 16. pp. 26-29
• Kujir, R. et. al. (2012). Thrombosis associated with right internal jugular central venous catheters: A prospective observational study. Indian Journal of Critical Care Medicine, 16(1), pp 17-21.
• Loftus,K., Tilley, T., Hoffman, J. et al. (2015). Use of Six Sigma strategies to pull the line on central line-associated blood stream infections in a Neurotrauma intensive care unit. Journal of Trauma Nursing, 22(2), pp 78-86.
• Maki DG, Kluger DM, & Crnich CJ. (2006). The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc ; 81:1159–71
• Pennsylvania Safety Authority. Central-Line-Associated Bloodstream Infection: Comprehensive, Data-Driven Prevention. Pennsylvania Patient Safety Advisory. Sep 2011. Accessed Mar 19, 2012. http://www.patientsafetyauthority.org/ADVISORIES /AdvisoryLibrary/2011/sep8(3)/Pages/100.aspx.
• Silow-Carroll, S. & Edwards, J. N. (2011). Eliminating Central Line Infections and Spreading Success at High-Performing Hospitals, The Commonwealth Fund, December.
• Stone, P. W., et al. (2014). State of infection prevention in US hospitals enrolled in the National Health and Safety Network. American journal of infection control 42(2). 94-99.
• Timsit, JF, et. al. (1998). Central vein catheter-related thrombosis in intensive care patients: Incidence, risk factors, and relationship with catheter-related sepsis. Chest, 114. pp 207-213
• The Joint Commissison. Preventing central line-associated bloodstream infections a global challenge, a global perspective. 2012 [cited 2013 January 9, ]; Available from: www.jointcommission.org/topics/hai_clabsi.aspx.
• Wu, X. et. a. (1999). High incidence of intravenous thrombi after short-term central venous catheterization of the internal jugular vein. Journal of Clinical Anesthesia, 11. pp 482-485
• Yacapetti, N. (2008). Central venous catheter-related thrombosis. Journal of Infusion Nursing, 31(4). Pp 241-248
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