Venous Access Venous Access Devices in Devices in

Clinical Clinical PracticePracticeAn overview of

guidelines and services for maximizing

outcomes for patients receiving intravenous

therapies

Useful to KnowUseful to Know

• Venous Access is essentialVenous Access is essential . .• Establishing and maintaining Establishing and maintaining

reliable access is a priority.reliable access is a priority.• EARLYEARLY access planning prevents access planning prevents

IV related complications and IV related complications and negative outcomes for patients negative outcomes for patients and the hospital.and the hospital.

• The choice of which VAD to use The choice of which VAD to use is a collaborative process.is a collaborative process.

Access is essentialAccess is essential

• Infusion Infusion therapies play a therapies play a major role in the major role in the treatment plan treatment plan for almost every for almost every disease process.disease process.

• Need for IV Need for IV therapy is one of therapy is one of the criteria for the criteria for provider approval provider approval of hospital of hospital admission.admission.

2 types of devices2 types of devices• PIV’sPIV’s

short catheters short catheters (less than 3 inches) (less than 3 inches) placed in the veins placed in the veins of the upper of the upper extremities.extremities.

• CVAD’sCVAD’s

long catheters long catheters whose terminal tip whose terminal tip position is in the position is in the central veins.central veins.

Venous Access Venous Access DevicesDevices

• Peripheral Peripheral

Most appropriate Most appropriate device for short device for short term therapies term therapies

(less than 5 (less than 5 days) that are days) that are nonirritating.nonirritating.

• CentralCentral • When ordered meds When ordered meds

have pH greater than have pH greater than 9.0 or less than 5.0, 9.0 or less than 5.0, osmolality greater than osmolality greater than 500 mOsm. 500 mOsm.

• Ordered meds/fluids are Ordered meds/fluids are known irritants known irritants

• PN with dextrose con-PN with dextrose con-centration greater than centration greater than 10%.10%.

• IV inotropesIV inotropes

• VesicantsVesicants

Peripheral IV’sPeripheral IV’s Placed by the nursing staff on Placed by the nursing staff on

the units 24/7 with the the units 24/7 with the assistance of the IV Team for assistance of the IV Team for

those patient’s that are those patient’s that are difficult sticks.difficult sticks.

IV Team is in house 7 days a IV Team is in house 7 days a week from 8AM-7:30PM. week from 8AM-7:30PM.

Pager #3471988Pager #3471988

CVAD’sCVAD’sAre placed by multiple Are placed by multiple

physician and non-physician and non-physician providers physician providers

throughout the hospital throughout the hospital based on the type of based on the type of

device that is required.device that is required.

3 Types of CVAD’s3 Types of CVAD’s

•Non-tunneledNon-tunneled•TunneledTunneled•ImplantedImplanted

NontunneledNontunneled•Inserted by Inserted by

percutaneous percutaneous stick into the stick into the internal internal jugular, jugular, subclavian, subclavian, femoral or femoral or upper arm upper arm veins.veins.

TunneledTunneled• The catheter is The catheter is

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

ImplantedImplanted

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

CVAD’s

Non-tunneledTemporary triple lumen,

PICC’s

TunneledPowerline, Hickman,

Broviac

ImplantedMediport, Portacath

Which VAD?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 Appropriate VAD SelectionSelection

• Minimizes patient discomfort, Minimizes patient discomfort, morbidity and mortalitymorbidity and mortality

• Decreases health care costs Decreases health care costs associated with delays of associated with delays of therapy and increased LOS.therapy and increased LOS.

• Enhances therapeutic benefits Enhances therapeutic benefits for patients with minimal for patients with minimal impact on ADL’s.impact on ADL’s.

Patient ExperiencePatient Experience

""A good A good beginning makes beginning makes

a good end."a good end."

Louis L’amourLouis L’amour

Planning is Planning is essentialessential

Starts with the first Starts with the first IV orderIV order

Discuss on Discuss on rounds…..with the rounds…..with the

patient.patient.

What type of access What type of access device is the most device is the most appropriate for the appropriate for the

patient?patient?• Duration of therapyDuration of therapy• Characteristics of the Characteristics of the

infusatesinfusates• Available insertion sitesAvailable insertion sites• Existing co-morbiditiesExisting co-morbidities• Impact on ADL’sImpact on ADL’s

Duration of TherapyDuration of Therapy

•< 5-7 days – peripheral IV < 5-7 days – peripheral IV •>7 days<2 weeks (in house >7 days<2 weeks (in house

patients) temporary CVADpatients) temporary CVAD•1-6 weeks – PICC1-6 weeks – PICC•>6 weeks – Tunneled or >6 weeks – Tunneled or

ImplantedImplanted

Type of infusatesType of infusates• pH < 5pH < 5

• pH > 9pH > 9

•Osmolality > 600Osmolality > 600

•Caustic or vesicant Caustic or vesicant medicationsmedications

Available insertion sitesAvailable insertion sites

Consider CVAD placement when:Consider CVAD placement when:• Peripheral IV access cannot be Peripheral IV access cannot be

initiated or maintained in the upper initiated or maintained in the upper extremities.extremities.

IV’s ‘blow’ or last only a few hours.IV’s ‘blow’ or last only a few hours. No lower extremity IV’s.No lower extremity IV’s.• The patient has a history of being a The patient has a history of being a

“difficult stick” and has required “difficult stick” and has required central access in the past.central access in the past.

Chemical PhlebitisChemical Phlebitis

InfiltrationInfiltration

ExtravasationExtravasation

PICC ThrombosisPICC Thrombosis

Co-morbidities and Device Co-morbidities and Device SelectionSelection

•Certain types of CVAD’s may Certain types of CVAD’s may be contraindicated based on be contraindicated based on pre-existing conditions.pre-existing conditions.

•Chronic Kidney Disease, Chronic Kidney Disease, Hypercoaguable syndromes, Hypercoaguable syndromes, preexisting venous stenosis, preexisting venous stenosis, thrombosis, etc.thrombosis, etc.

Impact on ADL’sImpact on ADL’s

•Availability of care giver Availability of care giver assistance.assistance.

•Dressing requirements Dressing requirements and catheter stability.and catheter stability.

•Use of mobility aids.Use of mobility aids.•Work and home activity Work and home activity limitations.limitations.

When, how and by When, how and by whom will the device whom will the device

be placed?be placed?PIV’sPIV’s

Unit staff and IV TeamUnit staff and IV TeamCVAD’sCVAD’s

Nontunneled – resident staff, PICC Nontunneled – resident staff, PICC nurses, interventional radiology, nurses, interventional radiology,

anesthesiaanesthesiaTunneled – Interventional radiology, Tunneled – Interventional radiology,

peds surgerypeds surgeryImplanted – Interventional radiologyImplanted – Interventional radiology

When to Order?When to Order?

• Based on patient need and ordered Based on patient need and ordered therapiestherapies

• Early decision making and placement Early decision making and placement of an appropriate device is correlated of an appropriate device is correlated with positive clinical outcomes and with positive clinical outcomes and decreased length of stay.decreased length of stay.

• Remember: PICC, tunneled and Remember: PICC, tunneled and implanted device placement requires implanted device placement requires lead time of 1-3 days. Do not wait lead time of 1-3 days. Do not wait until day of discharge to order lines until day of discharge to order lines for home infusion.for home infusion.

Which device to order?Which device to order?

Temporary Nontunneled:Temporary Nontunneled: Best for short term facility Best for short term facility

based access (less than 14 based access (less than 14 days)days)

Long term Nontunneled:Long term Nontunneled: Typically used for 1-6 weeks of Typically used for 1-6 weeks of

therapy. (PICC’s) May be used therapy. (PICC’s) May be used in the home setting.in the home setting.

Which device to order?Which device to order?

•Tunneled catheters:Tunneled catheters: More permanent device best used More permanent device best used

for dwell times > than 4-6 weeks for dwell times > than 4-6 weeks or when a PICC is or when a PICC is contraindicated. contraindicated.

•Ports:Ports: Most beneficial when long term Most beneficial when long term

intermittent therapies are needed.intermittent therapies are needed.

How to order How to order CVAD’sCVAD’s

•For PICC’s:For PICC’s:

Search ‘PICC’ in CPOESearch ‘PICC’ in CPOE

Select “PICC Procedure Select “PICC Procedure (Adult and Ped) from the (Adult and Ped) from the order menu.order menu.

How to orderHow to order

•Tunneled or Implanted Tunneled or Implanted devices:devices:

•Search ‘CVAD’:Search ‘CVAD’: ‘ ‘CVAD-insert tunneled w/o CVAD-insert tunneled w/o port >5 years’port >5 years’‘‘CVAD-insert tunneled with CVAD-insert tunneled with port >5 years.port >5 years.

VAD Placement VAD Placement DecisionsDecisions

An integral part An integral part of the of the

treatment plantreatment planCollaborative in Collaborative in

naturenatureCoordinated Coordinated

effort of effort of multiple multiple providersproviders

ResourcesResources

•PatientPatient•Consult services (nephrology, Consult services (nephrology,

infectious disease)infectious disease)•PICC RN: 2168219PICC RN: 2168219•VIR: consult pager 2168477VIR: consult pager 2168477•Home Infusion Nurse: Home Infusion Nurse:

34719343471934•CCM and Social WorkersCCM and Social Workers

Useful to KnowUseful to Know

• Venous Access is essentialVenous Access is essential . .• Establishing and maintaining Establishing and maintaining

reliable access is a priority.reliable access is a priority.• EARLYEARLY access planning prevents access planning prevents

IV related complications and IV related complications and negative outcomes for patients negative outcomes for patients and the hospital.and the hospital.

• The choice of which VAD to use The choice of which VAD to use is a collaborative process.is a collaborative process.