VASCULAR ACCESS DEVICES

Andrea Lemmo RN, BSN VA-BC Assistant Nurse Manager Vascular Access Team Sutter Medical Center Sacramento Vascular Access Practice Criteria

 Preserving venous access is essential  Establishing and maintaining appropriate reliable access is vital  Appropriate device selection and vascular access planning prevents intravenous related problems and complications for the patient  Collaborative process among the inter-professional team Vascular Access Practice Standards Device Selection  Collaborative process among the inter-professional team  Accommodates the vascular access needs  Prescribed therapy/treatment  Duration of therapy  Vascular characteristics  Patient comorbidities  Smallest diameter device, fewest lumens, least invasive 2 Types of Vascular Access Devices PERIPHERAL IV CENTRAL VENOUS ACCESS DEVICE

 Short catheters (less than 3 inches)  Placed in IJ, subclavian, femoral

 Placed in the veins of the upper  Long catheter whose tip extremities terminates in a great vessel  Used for therapy less than 6 days in duration  3 Types of CVAD’s Contraindicated for use with Non-tunneled Continuous vesicants Tunneled Parenteral nutrition Implanted Infusates >900 mOsmL

 Midline Peripheral IV (PIV)

 Short catheters generally placed in forearm, hand, scalp vein and lower extremity  Short term therapy (less than 6 days) when infusate is non-irritating Peripheral Sites

Veins of the Forearm 1. Cephalic vein 2. Median Cubital vein 3. Accessory Cephalic vein 4. Basilic vein 5. Cephalic vein 6. Median antebrachial vein Peripheral Sites

Veins of the Hand

1. Digital Dorsal veins

2. Dorsal Metacarpal vein

3. Dorsal venous network

4. Cephalic vein

5. Basilic vein Midline

Complications of Peripheral IV’s Complications of Peripheral IV’s Local Complications Systemic

 Infiltration  Thrombophlebitis  Phlebitis  Blood Stream Infection  Extravasation  Air Embolus  Hematoma Infiltration Phlebitis Extravasation Cellulitis Hematoma Central Venous Access Devices (CVAD) What Is A Central Venous Access Device

An intravascular access device that terminates in one of the great vessels Radiographic Anatomy of Tip Position

According to INS Standards- position of the tip of a CVAD in the lower segment of the superior vena cava at or near the caval- atrial junction in adults and children

Carina

Carina is often used as a landmark to determine proper position of catheter tip Central Venous Access Devices

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

Non-Tunneled

Percutaneous-subclavian, IJ, femoral Peripherally Inserted (PICC) Non-Tunneled Percutaneous

 Direct venipuncture through the skin into the internal jugular, subclavian or femoral  To minimize CLABSI/risk of thrombotic occlusion subclavian vein is favored  Hx chronic kidney disease (CKD) the internal jugular is vein of choice  Infants/children-no preferred vein selection to reduce CLABSI  Use ultrasound for vein identification/cannulation failure Non Tunneled Percutaneous Central Venous Access Ultrasound guided Central Venous Access Ultrasound guided Percutaneous Subclavian

Insertion Site Percutaneous Insertion Site Internal Jugular Percutaneous Insertion Site Femoral Non-Tunneled CVAD Peripherally Inserted Central Catheter PICC PICC

• Long catheter inserted into the cephalic, brachial or basilic vein of the upper arm • Inserted by specialty trained nurses and physicians • Can be inserted at the bedside • 1-3 lumen configuration • Most are power injectable • Optimal dwell time is unknown • Lower rate of CLABSI Non-tunneled CVAD’s

Pros Cons

 Rapid insertion/removal  Easily dislodged  Inexpensive  May be uncomfortable or  Dwell time unsightly   Can be comfortable Maintenance required depending on site  Some activity limitations  Available in 1-4 lumen  Higher risk of infection configurations depending on type, site Types of CVAD’s Tunneled

 Hickman  Broviac  Permacath TUNNELED CATHETERS

▪ Surgically inserted ▪ Tunnel made through subcutaneous tissue (usually b/t clavicle and nipple) ▪ Tip inserted through cephalic, internal or external jugular and threaded into superior vena cava ▪ Held in place with Dacron cuff under skin ▪ Placement verified through x-ray ▪ Can be single, double or triple lumen TUNNELED CATHETERS Hickman Tunneled versus Non-tunneled

Tunneled Non-tunneled TUNNELED CATHETERS

Pros Cons

 Long lasting  Special training  Comfortable required to insert, remove  Useful for most therapies  Imaging needed for insertion  Available in 1,2,3 lumen  Maintenance required  Some activity limit Tunneled Line Placement Hickman Tunneled Line IMPLANTED PORT IMPLANTED PORT Power vs. Non-Power Implanted Ports

Pros Cons

 Long lasting  Most invasive to insert/remove  Minimal maintenance  Needle stick required to access  Cosmetically desirable  Not appropriate for all Rx  1, 2 lumen configurations Port Placement Procedure Port Placement Guide wire introduced under fluoroscopy Port Placement

Skin anesthesia Incision Made Port Placement Create the tunnel Port Placement Insert device into pocket Implanted Port Ports aren’t just placed in the chest Complications Related to CVAD’s

▪ Phlebitis ▪ Infiltration/Extravasation ▪ Catheter Occlusion ▪ Venous Thrombosis ▪ Infection ▪ Air Embolism ▪ Malposition ▪ Fracture Phlebitis

• An inflammation of the vein • Endothelial cells of vein wall irritated • Cell walls roughen-platelets adhere • Inflamation induced phlebitis Infiltration/Extravasation

Infiltration Leakage of non vesicants into surrounding tissue Extravasation Leakage of vesicants into surrounding tissue Catheter Occlusion

Accumulation of fibrin within, surrounding or at the tip of a CVAD that interferes with patency Venous Thrombosis

Blood clot formation in 1 or more deep veins Infection

Central Line Associated Bloodstream Infection is a laboratory confirmed bloodstream infection in a patient who has had a central line in place within the 48 hour period before the development of the Blood Stream Infection (BSI) and that is not related to an infection at another site Malposition

A central line inserted into the right subclavian vein has migrated “UP” into the right internal jugular vein

Pinch-off Syndrome Implanted port

Compression between the clavicle and rib Let’s test your skills Questions?? References

Berenholtz SM, et al. Eliminating catheter-related bloodstream infection Journal of Infusion Nursing. January/February 2016. Vol. 39. Number 1S Centers for Disease Control and Prevention. (2002) Guideline for hand hygiene in health-care setting: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports, 51(RR-16), 1-45. March 2016 Hamblin, Richelle. CLABSI Maintenance Bundles: How Nurses Can Lead Practice Change in Any Health Care Setting. Newsline. Vol 38, No 6. Nov-Dec 2016 Humphrey, Joy S. Improving the Registered Nurses’ Knowledge of Evidence Based Practice Guidelines to Decrease the Incidence of Central Line- Related Bloodstream Infections: An Educational Intervention. Association for Vascular Access. 2015 Infusion Therapy Standards of Practice. Journal of Infusion Nursing. January/February 2016. Vol. 39. Number1S Kuter, David. Thrombotic Complications of Central Venous Catheters in Cancer Patients. November 24, 2003. Marshall et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hosptal Epidemiology. July 2014. Vol. 35, No. S2 O’Grady NP, et al.; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular catheter- related infections. Clin Infect Dis.2011 May; 52(9):e162–193. Epub 2011 Apr 1. R.S. Boersma; K.-S. G. Kie; A. Verbon; E.C.M. van Pampus; H.C. Schouten. Thrombotic and infections Oncology (2008) Vol. 19. (pg.433-442). 2007 Ryder, Marcia. Catheter-Related Infections: It’s All About Biofilm. Topics in Advanced Practice Nursing eJournal. 2005; 5(3) Ryder, Marcia. The Role of Biofilm in Vasculature Catheter-Related Infections. Physicians and Scientists Publishing Co. 2001. US Centers for Disease Control and Prevention. Reduction in central line–associated bloodstream infections among patients in intensive care units— Pennsylvania, April 2001–March2005. MMWR Morb Mortal Wkly Rep. 2005 Oct 14; 54(40):1013–1016. www.edc.gov/hicpac/bsi-guidelines-2011.html Guidelines for the Prevention of Intravascular Catheter-Related Infections