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Patient Assessment for Appropriate Vascular

Device PlacementDevice Placement

Theresa Murphy RN, BS, CRN, CRNI, VA-BCTmurphy@matherhospital.org

Financial Disclosure

• Reference to products are examples and does not imply endorsement.

• The content being presented at today’s educational activity is without bias or compensation from any pharmaceutical or commercial product.

Objective

• List 3 patient characteristic that will influence vascular access selection

• Describe 3 risk factors that affects vascular health

• Discuss early vascular assessment and line necessity

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Expertise in Infusion Therapy

Know own limitation

Early Assessment

Knowledge of Staff

Pa

Patients support system

Patient Preference

Patient Centered

Care

Daily necessity

Basics of Vascular Access

Duration

Short term……hours to days

Medium term…days to up to 6 months

Long term…….months to years

PH Blood = 7.35 - 7.45

Above 7 = Base

Below 7 = Acid

7 = Neutral5-9

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TherapeuticConsiderations

Isotonic- 250 - 350 mEq/Liter mOsmo/l-same as

human plasma

Hypotonic-< 250 mEq/Liter shifts fluids fromHypotonic < 250 mEq/Liter shifts fluids from

extracellular to intracellular (cells swell)

Hypertonic-> 350 mEq/Liter shifts fluids from

intracellular to extracellular (cells shrink)

In simple terms, it is the total concentration of solutes in a solution.

Vascular access selection

Plumer’s Principle & practice of Intravenous Therapy 8th ed. P. 286

Early AssessmentThink Alternative: Sooner than Later

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Basics of Vascular Access

Non-tunneled, Noncuffed Central Catheters

Description -These catheters are usually inserted at bedside using the jugular, subclavin, femoral or large veins in the arm and are in place for less than 14 days with the exception of PICC or Midlines, (Forauer and Theoharis 2003)

Intended Use: Temporary or Short Term

Non-tunneled, NoncuffedCentral Catheters

Peripherally Inserted Central Catheter (PICC) is a central venous catheter that is inserted peripherally in the basilic, brachial or cephalic vein at or above the antecubital fossa with the tip terminating in the Superior Vena Cava (SVC). The intended dwell time is up to one year.

Subclavian, Internal jugular or Femoral catheter may be single, double or multiple lumen catheter inserted percutaneously by a licensed prescriber. The intended dwell time is 14 days.y

Swan-Ganz catheters may be double or triple lumen catheters inserted percutaneously or by cutdown. The catheter enters the pulmonary artery and measures arterial pressures. It allows for assessment of both right and left heart pressures.

Peripheral catheter

Midline Catheter is a peripherally inserted catheter is placed in same vessels as PICC with tip at or below the axilary level distal to the shoulder. The intended dwell time is 10 days to 4 weeks. NOTE: This is not a central line catheter.

Arterial Catheters are introduced into the arterial circulation for two purposes: monitoring or administration of organ specific infusions (i.e., hepatic artery).

This is NOT a central line catheter.

Tunneled, cuffed Central catheters

Description - These catheters, such as Broviac®, Hickman®, and Hohn catheters, are considered permanent

th t Aft 10 14 d dh icatheters. After 10–14 days, adhesions form on the Dacron cuff that stabilizes and seals the catheter, which creates a barrier for infection

Intended Use: Long Term

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Tunneled, cuffed Central catheters

Hickman and Broviac catheters are inserted intra-operatively in the cephalic vien or subclavin vien through an incision made below the clavicle; this is the entrance site. From the clavical the catheter is tunneled subcutaneously to the midway point between the nipple and the sternum. There the catheter exits the skin; this is the exit site.

NOTE: They only differ in diameter. Both are 90 cm long.

The diameter of the Hickman is one and one-half times that of the Broviac.

Groshong is inserted intra-operatively and is an alternative to a Hickman or Broviac. A rounded blunt catheter tip with a three way valve that remains closed at normal venous pressure distinguishes it.

NOTE: For the valve to function properly the tip must be in the mid-superior

part of the vena cava.

Implanted Vascular DevicesDescription- Like tunneled catheters; implanted ports are used for

long term therapies. They require no care when the patient does not need access other than flushing with heparin & saline.

Intended Use: Long Termg

Port-A-Cath (mediport/passport) is a surgically implanted infusion device that consists of a self-sealing silicone septum encased in a port made of metal or plastic and attached to a silicone or polyurethane catheter. The catheter is inserted in a blood vessel. Then the catheter is passed through a subcutaneous pocket created over bony prominence. The port may be placed in the arm or the chest.

Dialysis cathetersShort Term Double Lumen Dialysis Catheters (i.e., Quinton) - is a non-

tunneled double lumen catheter inserted percutaneously via the subclavian, femoral or internal jugular vein by physician for the purpose hemodialysis.

Short term Special Triple Lumen Dialysis/Aphresis Catheter (i.e. Makurkar) – is a non-tunneled triple lumen catheter insertedpercutaneously via the subclavian, femoral or internal jugular vein by physician for the purpose hemodialysis. The third infusion port is independent and can be treated like a standard central line.

Temporary Double Lumen Dialysis Catheters (i.e., permacath) - is a surgically placed tunneled double lumen catheter inserted in the subclavian, femerol or internal jugular vein for the purpose of dialysis until the patient can have a permanent (Fistula) access or maturation.

• The catheter has a Dacron cuff, which provides an infection barrier in the tunnel track and anchors the catheter subcutaneously to minimize the risk of catheter dislodgment ensuring patient safety.

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Apheresis catheters

Description - These catheters such as Perm Cath, Tesio, Quinton or Mahurkar are placed percutaneously for temporary use or tunneled for long tern use. i.e.,. They are commonly placed in the internal jugular or subclavian vein with the catheterinternal jugular or subclavian vein with the catheter tip ideally placed in the superior vena cava.

Intended Use: The catheters are used for both aspiration of blood from the body and its reinfusion after selected cellular components are removed by an apheresis machine. The blood is aspirated and returned to the patient at a rate of 200-300mL/min.

Keep your sight onthe mission

Patient Centered Care (PCC)

PCC is a model of care delivery in which the nurse and the interdisciplinary team partner with the patient and significant th id th t i tf l f dother provide care that is respectful of and

responsive to individual’s preferences, needs and values. Patient Centered Care incorporates patient advocacy with compassion, honesty and trust to guide all clinical decisions.

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Basic Assessment Matching Patient with Device• Circulatory status

• Vascular status

• Mobility/acitivity

• Medical Dx/Hx

• Medication profile

• Allergiesy y

• Mental status

• Integrity of skin

• Obesity

• Hydration status

• Age

g

• Coagulation status

• Past medical condition

• History of IV therapy

• Life style

• Language/culture

• Prognosis

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Infusion therapyin pediatrics

Stages

Infant Birth to 1 yr.

Toddler 1-3 yr

Google images

Toddler 1 3 yr

Preschool 4-6 yr

School age 6-12 yr

Adolescence 13-19 yr

Wongs’ nursing care of infants and children (pp1158-1177)

St. Louis, 2007, Mosby

Vascular Considerations in Pediatrics

• Predisposed to hypothermia due to large body surface areay

• Blood vessels are smaller

• Increase in subcutaneous fat in toddler and prepubescents

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Factors to consider in Pediatrics

Developmental

• Age

• Pre-maturity

Activity

• Mobility

• Physical activity

• Ability to tolerate procedure

• Size and condition

• Ability to tolerate procedure

• Body image

• Cognitive ability

Catheter SelectionCatheter Site Preference

Non tunneled percutaneous Femoral, internal jugular, subclavian

PICC Arms in all agesFoot, scalp/neck in infants

Tunneled Chest into superior vena cava (SVC) orInferior vena cava (IVC) tunneled to abdomen, thigh or back

Implanted ports Chest wall with the tip in the SVC or IVCArm ports with tip in SVC

Umbilical Vein (UVC) (1)Umbilical Artery (UAC) (2)

Several days to 2 weeks (tip in IVC at 8th to 9th rib)Remove in 2 weeks (tip at T7-9 or L3-4)

Intraosseous Small children- Tibia, femur, iliac crestAdult- Sternum, prox. Tibia, distal femur, radius, ulna, pelvis, clavical clacaneous

Pediatric Complications

Contributing factors Outcomes

Small veins, small IV’s =slow rate Catheter occlusions

Fragile vessels Infiltration

High activity levels Infiltration, migration

Infant & small children Fluid overload

>10 yrs of age Risk of phlebitis same as adults (Nelson & Garland 1987)

Pumps, <visibilty, TPN, Intraosseous<subcutaneous Tissue (dorsum of foot)

Extravasation

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PediatricComplications

Contributing factors Outcomes

Umbilical Catheterization Vascular compromise, hemorrhage, air embolism, infection , vascular perforation & occlusion

UVC Pericardial effusion & tamponade(heart and lung sounds)

UAC Thromboemboli or venous spasms.(assessment hourly of distal pulses,, perfusion cyanosis, blanching of buttocks or lower extremities)

Vascular Considerations in Older Adult

The United Nations World Population Prospects: The 2006 Revision estimates that from 2005 to 2050 theestimates that from 2005 to 2050 the growth of the population aged 60 or older will account for half of the total world wide population.

Infusion Nursing An evidence-Based Approach, 3rd edition, P571.

World d Health Organization defined older adult as > 60

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Special Consideration

Advanced directives, living will, power of attorney

Entire family is involved. Health care team advocated for patient

Consent Confusion does not eliminate right to refuse.Needs sense of independence & control of environment

Diversity/Aging Everyone ages differently, life experiences & skill level

ADL Affected by hormone changes, insomnia, sundown syndrome

Aging Process

Systems Outcomes

Cardiovascular Deposits of lipids, calcium, decrease elastic & collagen, ↓ elasticity & effectiveness of alveolivenous elasticity and lack of mobility impairs venous return

Respiratory ↓ elasticity & effectiveness of alveoli

Endocrine Immune system hyporesponsive to antigen and hyperresponsive to self

Gastrointestinal HTN or CVA-more prone to aspiration

Sensory ↓ skin nerve endings, ↓ hearing & understanding

Musculoskeletal ↓ muscle mass, ↑fibrous connective tissue, ↑ incidenceof arthritis

Aging Process

Integumentary - All levels of the skin are affected.

Epidermis outermost layer4 cellular layers

Protective barrier &

↓ healing rates & barrier protection↓ thermal regulation

Skin color

Dermis middle layerProtein structure

Blood vessels, nerve endings, hair follicles,

sweet glands

↓ sensation↑ skin tears****phlebitis undetected****

Subcutaneous layer

Layer of fatInsulation & shock

absorber

↑ risk of hypothermia↑ skin tears****mechanical phlebitis & infiltration

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Site Selectionin Older Adult

• Similar to young adult (distal to upward)

• Side lighting

• Tourniquet: snug not tightTourniquet: snug not tight

Consider no tourniquet: vein distention may cause vein damage (hematoma)

• Ribbed vein-thick walls causing narrow lumen or occlusion

• Sluggish returns

Special Precautions

Caution Prevention of poor outcome.

Small gauge PIV Allows for hemidilution around cathteer

Hydration Increase vein visibility

Pumps/controllers Large infiltrates. Loose skin does not allow for i h l ti i tperipheral tissue resistance

Traction Maintain vein stabilization and skin tension

Catheter material ↑ dwell time (silicon, polyurethene, teflon)

Skin prep No shaving, gentle prep, polymer solution

Vein wall damage Remove tourniquet ASAP with blood return

Immobilization Observe edema due to venous stasis

Site observation Frequent-small infiltrate may lead to severe complication

Matching Patient with Device

The American Society of Diagnostic and Interventional Nephrology/Association for Vascular

Access (ASDIN/AVA)position statement is..

P ti t ith ti t d l l filt tiPatients with an estimated glomerular filtration rate(eGFR) < 60mL/min/1.73 m² or if an eGFR is not available than a serum creatinine level > 2.0mg/dl, should undergo an expert vascular assessment prior to placement of any vascular access device.

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Not intended to prohibit access intended to foster critical thinking

• Avoid forearm, upper arm & subclavian veins

• Long-term access solutions ASAPg

• Preferred IJ (subcutaneous tunnel) exit chest

• Ipsilateral subclavian is extremity not suitable

for a graft or fistula

• Avoid PICC

DiabetesCDC National Diabetic Fact Sheet 2011

How many Americans have diabetes

• 26 million

1 9 illi di d i 2010• 1.9 million diagnosed in 2010

(26.9% of population)

• 215, 000 Americans younger than 20

• 79 million Adults are pre-diabetic

• Projection 1 in 3 US adults will have diabetes by 2050

CDC 2011

Diabetic Complication

• Cardiovascular

Macrocirculation: Early Atherosclerosis

Microcirculation: Decrease in tissue perfusionMicrocirculation: Decrease in tissue perfusion

• Neuropathies

• Increase susceptible to infection

• Diabetic retinopathy

• Peripheral vascular

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Obesity

• No state < 20% of population

• 30% of population: Alabama, Arkansas, Kentucky Louisiana Michigan TexasKentucky, Louisiana, Michigan, Texas, Mississppi, Missouri, Oklahoma, South Carolina, Tennessee, West Virginia (CDC 2010)

• 1.9 million diagnosed in 2010

Obesity Challenges

Characteristic

• Short neck

• Pendulous abdomen

Recommendation• Avoid using femoral veins

(CDC catagory 1A)

• Subclavian vein is • Extremities Skin folds

• Decrease mobility

• Large body mass

• Increase glycemia

• Altered neutrophils

recommended except in CKD (INS 2011 S42, CDC 2010 category 1B)

• Basilic 1st choice for PICC (Plumers Principle & Practice of

Infusion Therapy 8th ed.))

What ??????? puts blood vessels at risk• Autoimmune diseases increase the risk of clotting and

vasculitis, CLABSI and mechanical phlebitis

• Pancreatic and Ovarian cancers

• HTN

• Pregnancy

• Smoking

• Immobility

• Oral contraceptives

• Trauma

• Elevated Lipids• American Autoimmune Related Diseases (AARDS)

• American Society of Hematology

• American Heart Association

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Vein illuminatorVeinlite

Shed some light on the challenge: Please!!!!!

Vein viewer Ultrasound

CDC MMWR March-2011 (Vol. 60)

• HAI affect 5% of hospitalized patients

• CLABSI-Mortality rate of 12%-25%

• 58% Reduction of CLABSI in ICU from• 58% Reduction of CLABSI in ICU from 2001 to 2009

6000 lives saved

$414 million in potentate excess costs

• 1.8 billions in cumulative cost since 2001

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John T. MatherMemorial Hospital

3 43 5

4

ICU/CCU CLABSI Rates 2007-2011

Reflects a76%

reduction in CLABSI Rates

2007 2008 2009 2010 2011

CLABSI Rate 3.4 2.3 1.92 1.88 0.83

NHSN Benchmark 2.8 2.8 2.8 2 1.3

Utilization Rate 2.24 2.22 2.53 2.83

3.4

2.31.92 1.88

0.83

0

0.5

1

1.5

2

2.5

3

3.5

Rate/BenchmarkUtilization Rate

John T. MatherMemorial Hospital

30

35

Med-Surg CLABSI2009 -2011

Reflects a 28% reduction

in rates 2009-10

2009 2010 2011# of CLABSI 25 31 8Rate of CLABSI 3.26 3.56 2.352009 NHSN Benchmark 1 1 1

0

5

10

15

20

25

Number/RateNHSN

Benchmark

John T. MatherMemorial Hospital

10

12

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3 Year Hospital Wide CLABSI Trend2009-2010-2011

Reflects a 72% decrease in # of CLABSI Cost savings$702, 000

2010-11

1st qtr

2nd qtr

3rd qtr

4th qtr

1st qtr

2nd qtr

3rd qtr

4th qtr

1st qtr

2nd qtr

3rd qtr

4th qtr

2009 2010 2011

# of CLABSI 2 6 13 10 11 12 4 9 2 5 2 1

Rate of CLABSI 0.6 1.9 3.5 3.3 5.5 3.8 1.5 3 0.68 1.7 0.88 0.37

2008-09 HNSH Benchmark average critical care & med-surg 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.2 1.2 1.2 1.2

0

2

4

6

8

Number/RateNHSN

Benchmark

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Bottom Line Triad

Prevent CLABSI

Vein Salvation

Decrease Complications

References