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Navigating Venous Access: a Guide for Hospitalists

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Navigating Venous Access: a Guide for Hospitalists REVIEW Navigating Venous Access: A Guide for Hospitalists Michael Simonov, BS1, Mauro Pittiruti, MD2, Claire M. Rickard, RN, PhD3, Vineet Chopra, MD, MSc4* 1University of Michigan Medical School, Ann Arbor, Michigan; 2Department of Surgery, Catholic University, Rome, Italy; 3Alliance for Vascular Access Teaching and Research, National Health and Medical Research Council Centre of Research Excellence in Nursing Interventions, and Centre for Health Practice Innovation, Griffith University, Brisbane, Australia; 4Patient Safety Enhancement Program and Center for Clinical Management Research of the Ann Arbor VA Medical Center and the Department of General Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan. Venous access is the foundation for safe and effective cal characteristics, advantages, and disadvantages of hospital-based care. Inpatient providers must have a deep VADs commonly used in the hospital setting. In doing so, knowledge of the different types of venous access devices we seek to improve the safety and share the science of vas- (VADs), their relative indications, contraindications, and cular access with frontline clinicians. To aid decision- appropriateness. However, such knowledge is difficult to making, we conclude by operationalizing the available data come by and usually only gleaned through years of clinical through algorithms that outline appropriate vascular access experience. To bridge this gap, we provide an in-depth for the hospitalized patient. Journal of Hospital Medicine summary of the relevant anatomical considerations, physi- 2015;10:471–478. VC 2015 Society of Hospital Medicine Reliable venous access is fundamental for the safe and inserted central catheter, central venous catheters, and effective care of hospitalized patients. Venous access vascular access device complications. We concentrated devices (VADs) are conduits for this purpose, providing on full-length articles in English only; no date restric- delivery of intravenous medications, accurate measure- tions were placed on the search. We reviewed guide- ment of central venous pressure, or administration of lines and consensus statements (eg, from the Center life-saving blood products. Despite this important role, for Disease Control [CDC] or Choosing Wisely crite- VADs are also often the source of hospital-acquired ria) as appropriate. Additional studies of interest were complications. Although inpatient providers must bal- identified through content experts (M.P., C.M.R.) and ance the relative risks of VADs against their benefits, bibliographies of included studies. the evidence supporting such decisions is often limited. Advances in technology, scattered research, and growing SCIENTIFIC PRINCIPLES UNDERPINNING availability of novel devices has only further fragmented VENOUS ACCESS provider knowledge in the field of vascular access.1 It is useful to begin by reviewing VAD-related nomen- It is not surprising, then, that survey-based studies clature and physiology. In the simplest sense, a VAD of hospitalists reveal important knowledge gaps with consists of a hub (providing access to various connec- regard to practices associated with VADs.2 In this nar- tors), a hollow tube divided into 1 or many sections rative review, we seek to bridge this gap by providing (lumens), and a tip that may terminate within a cen- a concise and pragmatic overview of the fundamentals tral or peripheral blood vessel. VADs are classified as of venous access. We focus specifically on parameters central venous catheters (eg, centrally inserted central that influence decisions regarding VAD placement in catheters [CICCs] or peripherally inserted central hospitalized patients, providing key takeaways for catheters [PICCs]) or peripheral intravenous catheters practicing hospitalists. (eg, midlines or peripheral intravenous catheters) based on site of entry and location of the catheter tip. METHODS Therefore, VADs entering via proximal or distal veins To compile this review, we systematically searched of the arm are often referred to as “peripheral lines,” Medline (via Ovid) for several keywords, including: as their site of entry and tip both reside within periph- peripheral intravenous catheters, ultrasound-guided eral veins. Conversely, the term “central line” is often peripheral catheter, intraosseous, midline, peripherally used when VADs enter or terminate in a central vein (eg, subclavian vein insertion with the catheter tip in the lower superior vena cava). *Address for correspondence and reprint requests: Vineet Chopra, Attention to a host of clinical and theoretical MD, 2800 Plymouth Road, Building 16, Room 432W, Ann Arbor, MI 48105; Telephone: 734-936-400; FAX: 734-689-5488; E-mail: vineetc@ parameters is important when choosing a device for umich.edu venous access. Some such parameters are summarized Additional Supporting Information may be found in the online version of in Table 1. this article. Received: November 21, 2014; Revised: January 28, 2015; Accepted: VENOUS ACCESS DEVICES February 4, 2015 2015 Society of Hospital Medicine DOI 10.1002/jhm.2335 We will organize our discussion of VADs based on Published online in Wiley Online Library (Wileyonlinelibrary.com). whether they terminate in peripheral or central An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 10 | No 7 | July 2015 471 Simonov et al | Navigating Venous Access TABLE 1. Important Considerations When Selecting TABLE 2. Pathogenesis and Prevention of Common Vascular Access Devices VAD-Associated Complications Parameter Major Considerations Complications Major Considerations Desired flow rate Smaller diameter veins susceptible to damage with high flow Infection VADs breach the integrity of skin and permit skin pathogens to enter the rates. blood stream (extraluminal infection). Short, large-bore catheters facilitate rapid infusion. Inadequate antisepsis of the VAD hub, including poor hand hygiene, fail- Nature of infusion pH, viscosity, and temperature may damage vessels. ure to "scrub the hub," and multiple manipulations may also Vesicants and irritants should always be administered into increase the risk of VAD-related infection (endoluminal infection). larger, central veins. Infections may be local (eg, exit-site infections) or may spread hematog- Desired duration of vascular Vessel thrombosis or phlebitis increase over time with cathe- enously (eg, CLABSI). access, or “dwell time” ter in place. Type of VAD, duration of therapy, and host characteristics interact to Intermittent infusions increase complications in central cathe- influence infection risk. ters; often tunneled catheters are recommended. VADs with antiseptic coatings (eg, chlorhexidine) or antibiotic coatings Urgency of placement Access to large caliber vessels is often needed in (eg, minocycline) may reduce risk of infection in high-risk patients. emergencies. Antiseptic-impregnated dressings may reduce risk of extraluminal Critically ill or hemodynamically unstable patients may infection. require urgent access for invasive monitoring or rapid Venous thrombosis VADs predispose to venous stasis and thrombosis. infusions. Duration of VAD use, type and care of the VAD, and patient characteris- Patients with trauma often require large volumes of blood tics affect risk of thromboembolism. products and reliable access to central veins. VAD tip position is a key determinant of venous thrombosis; central Number of device lumens VADs may have single or multiple lumens. VADs that do not terminate at the cavo-atrial junction should be Multilumen allows for multiple functions (eg, infusion of mul- repositioned to reduce the risk of thrombosis. tiple agents, measurement of central venous pressures, Antithrombotic coated or eluting devices may reduce risk of thrombosis, blood draws). though definitive data are lacking. Device gauge In general, use of a smaller-gauge catheter is preferred to Phlebitis Inflammation caused by damage to tunica media.18 prevent complications. 3 types of phlebitis: However, larger catheter diameter may be needed for spe- Chemical: due to irritation of media from the infusate. cific clinical needs (eg, blood transfusion). Mechanical: VAD physically damages the vessel. Device coating VADs may have antithrombotic or anti-infective coatings. Infective: bacteria invade vein and inflame vessel wall. These devices may be of value in patients at high risk of Phlebitis may be limited by close attention to infusate compatibility with complications. peripheral veins, appropriate dilution, and prompt removal of cathe- Such devices, however, may be more costly than their ters that show signs of inflammation. counterparts. Phlebitis may be prevented in PICCs by ensuring at least a 2:1 vein:cath- Self-care compatibility VADs that can be cared for by patients are ideal for outpatient eter ratio. care. Extravasation Extravasation (also called infiltration) is defined as leakage of infusate Conversely, VADs such as peripheral catheters, are highly from intravascular to extravascular space. prone to dislodgement and should be reserved for super- Extravasation of vesicants/irritants is particularly worrisome. vised settings only. May result in severe tissue injury, blistering, and tissue necrosis.11 VADs should be checked frequently for adequate flushing and position prior to each infusion to minimize risk. NOTE: Abbreviations: VAD, vascular access device. Any VAD with redness, swelling, and tenderness at the entry site or problems with flushing should not be used without further
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