Peripheral Venous Access Devices (VADs)

1. Peripheral Venous Access Devices (VADs)

2. Objectives The learner will be able to: • Identify those patients and solutions appropriate for peripheral IV use. • Identify key care principles and complications associated with peripheral IVs.

3. General Principles of Care: VADs • Maintain strict aseptic technique for all procedures. • Wear appropriate PPE for all procedures. • Secure all tubing connections with Luer locks. • Procedures should be performed by personnel who know how to assess for complications. • Avoid using tape to secure connections (may cause bacterial transmission). • Change dressing, IV tubing, or protective cap if wet, soiled, contaminated, or damaged.

4. General Principles of Care: VADs:Dressing Changes • Change transparent dressing when catheter is changed. • Change gauze and tape dressing every two days or if wet, soiled, or nonocclusive. • Use aseptic no-touch technique.

5. General Principles of Care: VADs:Flushing Procedures • Essential to ensure patency and prevent accumulation of blood/drug precipitates in the catheter lumen • Can prevent fibrin buildup, but all VADs will accumulate fibrin coating to some extent • Locking solutions used to prevent occlusions when the device is not in use • Never use excessive force when flushing. • 0.9% normal saline 13 ml every 8, 12, or 24 hours when not in use to maintain patency

6. Peripheral IV Access Devices • Best for simple one-time use therapies, such as IV push of vesicant or nonvesicant chemotherapy • Patients with short life expectancy • Not indicated for continuous vesicant therapy or solutions with a pH < 5 or > 9, or osmolarity > 600 mOsm/L • Requires daily care and maintenance

7. General Principles of Care: Peripheral IV:Site Selection Preferred site locations: • Adults: Upper extremity • Hand veins have lower risk of phlebitis than wrist and upper arm veins. • Use most distal site possible, but proximal to previous venipuncture. • Choose gauge based on indicated use (large bore for surgery; smaller for most IV applications/blood). • Replace catheter every 7296 hours or earlier if signs of phlebitis or infiltration.

8. General Principles of Care: Peripheral IV:Site Selection (cont.) • Existing IV site • Avoid using if more than 24 hours old. • Assess for signs and symptoms of inflammation/ infiltration. • Assess for blood return and patency. • New IV site • Avoid steel needles. • Identify appropriate IV site. • Establish blood return and patency. • Secure IV site. • If unsuccessful, use the opposite arm.

9. Complications: Peripheral IV • Phlebitis is the most common complication. • Prevention is key. • Have sufficient vessel size to accommodate the catheter. • Nontraumatic insertions minimize risk. • Infusion of nonirritating solutions • Signs/symptoms: • Pain, erythema, and edema

10. Complications: Peripheral IV (cont.) • Infiltration: Also a common complication • Signs/symptoms: • Leaking fluid at insertion site • Cool, pale skin • Decreased infusion rate • Skin tightness • Assess for by applying digital pressure at tip of catheter. If infusion continues, it is probably infiltrated. • Use appropriately sized syringes to prevent vein rupture or infiltration with push administrations or aspirations.

11. Complications: Peripheral IV (cont.) • Extravasation • Peripheral vein wall puncture during administration of a vesicant in a vein below a recent venipuncture • Inadequately secured catheter • Prevention • Frequent blood return check during vesicant administration • Symptoms • Redness, edema, pain, burning, lack of blood return • Treatment: Stop infusion, aspirate residual drug, assess, give antidote if indicated/apply cold or heat as appropriate.

12. Complications: Peripheral IV (cont.) • Infection • Can occur at insertion, contaminated connectors, repalpation of puncture site prior to insertion, or contaminated infusate • Are rarely associated with bloodstream infections • Use strict aseptic technique for insertion and maintenance care.

13. Midline Catheter Devices • Considered peripheral device because tip is not located in the central circulation • Patients with therapy needs of 14 weeks with limited peripheral venous access • Limited life expectancy • Same contraindicated infusates as with peripheral IVs • Similar dressing/flushing as peripheral IVs • Complications similar to peripheral IVs

14. Routes of Administration: Subcutaneous (SC) or Intramuscular (IM) Injection • SC: Can be by infusion (discussed later) or injection depending on agent administered • IM: Injection • Advantages • Ease of administration, low maintenance/low cost • Decreased side effects • Disadvantages • Inconsistency of absorption, limited volume for rapid fluid replacement • Requires adequate muscle mass and tissue absorption

15. General Principles of Care:SC or IM Injection • Wear appropriate PPE. • Use smallest appropriate gauge needle. • Ensure site antisepsis and good technique. • Ensure documentation of where site is located. • Assess previous injection sites for signs and symptoms of infection or bleeding.

16. Routes of Administration: SC Infusion Devices • Used for continuous long- or short-term administration of parenteral drugs or fluids into the loose connective tissue underlying the dermis • Short-length catheter or needle is used for several days • Used when an oral or transdermal route is ineffective/inappropriate1, or if peripheral veins are poor • Usually used for pain management, nausea and vomiting, hypercalcemia treatment, chelation therapy, or fluid replacement therapy

17. Complications: SC Infusions • Usually local, and associated with the type of fluid, rate, or volume infused • May have local erythemic reactions caused by either prolonged duration of the catheter, rapid infusion, or irritating fluid, at which pain may occur • Leakage (Stop infusion, insert new catheter.) • Edema (If large amount, change site.) • Obstruction (Change site.) • Sloughing, infection, and bruising are rare but can occur. • Fluid overload can occur. Patients must be assessed frequently.

18. References Camp-Sorrell, D. (Ed.). (2011). Access device guidelines: Recommendations for nursing practice and education (3rd ed.). Pittsburgh, PA: Oncology Nursing Society. Polovich, M., Whitford, J.M., & Olsen, M. (Eds.). (2009). Chemotherapy and biotherapy guidelines and recommendations for practice (3rd ed.). Pittsburgh, PA: Oncology Nursing Society.