360 likes | 581 Views
Venous Access Devices in Clinical Practice. An overview of guidelines and services for maximizing outcomes for patients receiving intravenous therapies. Useful to Know. Venous Access is essential . Establishing and maintaining reliable access is a priority.
E N D
Venous Access Devices in Clinical Practice An overview of guidelines and services for maximizing outcomes for patients receiving intravenous therapies
Useful to Know • Venous Access is essential . • Establishing and maintaining reliable access is a priority. • EARLY access planning prevents IV related complications and negative outcomes for patients and the hospital. • The choice of which VAD to use is a collaborative process.
Access is essential • Infusion therapies play a major role in the treatment plan for almost every disease process. • Need for IV therapy is one of the criteria for provider approval of hospital admission.
2 types of devices • PIV’s short catheters (less than 3 inches) placed in the veins of the upper extremities. • CVAD’s long catheters whose terminal tip position is in the central veins.
Peripheral Most appropriate device for short term therapies (less than 5 days) that are nonirritating. Central When ordered meds have pH greater than 9.0 or less than 5.0, osmolality greater than 500 mOsm. Ordered meds/fluids are known irritants PN with dextrose con-centration greater than 10%. IV inotropes Vesicants Venous Access Devices
Peripheral IV’s Placed by the nursing staff on the units 24/7 with the assistance of the IV Team for those patient’s that are difficult sticks. IV Team is in house 7 days a week from 8AM-7:30PM. Pager #3471988
CVAD’s Are placed by multiple physician and non-physician providers throughout the hospital based on the type of device that is required.
3 Types of CVAD’s • Non-tunneled • Tunneled • Implanted
Nontunneled • Inserted by percutaneous stick into the internal jugular, subclavian, femoral or upper arm veins.
Tunneled • The catheter is tunneled under the skin to a vein in the neck or chest. A cuff near the exit site anchors the catheter in place.
Implanted Surgically inserted under the skin in the upper chest or the arm and appears as a bump under the skin.
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 Selection • Minimizes patient discomfort, morbidity and mortality • Decreases health care costs associated with delays of therapy and increased LOS. • Enhances therapeutic benefits for patients with minimal impact on ADL’s.
"A good beginning makes a good end." Louis L’amour
Planning is essential Starts with the first IV order Discuss on rounds…..with the patient.
What type of access device is the most appropriate for the patient? • Duration of therapy • Characteristics of the infusates • Available insertion sites • Existing co-morbidities • Impact on ADL’s
Duration of Therapy • < 5-7 days – peripheral IV • >7 days<2 weeks (in house patients) temporary CVAD • 1-6 weeks – PICC • >6 weeks – Tunneled or Implanted
Type of infusates • pH < 5 • pH > 9 • Osmolality > 600 • Caustic or vesicant medications
Available insertion sites Consider CVAD placement when: • Peripheral IV access cannot be initiated or maintained in the upper extremities. IV’s ‘blow’ or last only a few hours. No lower extremity IV’s. • The patient has a history of being a “difficult stick” and has required central access in the past.
Co-morbidities and Device Selection • Certain types of CVAD’s may be contraindicated based on pre-existing conditions. • Chronic Kidney Disease, Hypercoaguable syndromes, preexisting venous stenosis, thrombosis, etc.
Impact on ADL’s • Availability of care giver assistance. • Dressing requirements and catheter stability. • Use of mobility aids. • Work and home activity limitations.
When, how and by whom will the device be placed? PIV’s Unit staff and IV Team CVAD’s Nontunneled – resident staff, PICC nurses, interventional radiology, anesthesia Tunneled – Interventional radiology, peds surgery Implanted – Interventional radiology
When to Order? • Based on patient need and ordered therapies • Early decision making and placement of an appropriate device is correlated with positive clinical outcomes and decreased length of stay. • Remember: PICC, tunneled and implanted device placement requires lead time of 1-3 days. Do not wait until day of discharge to order lines for home infusion.
Which device to order? Temporary Nontunneled: Best for short term facility based access (less than 14 days) Long term Nontunneled: Typically used for 1-6 weeks of therapy. (PICC’s) May be used in the home setting.
Which device to order? • Tunneled catheters: More permanent device best used for dwell times > than 4-6 weeks or when a PICC is contraindicated. • Ports: Most beneficial when long term intermittent therapies are needed.
How to order CVAD’s • For PICC’s: Search ‘PICC’ in CPOE Select “PICC Procedure (Adult and Ped) from the order menu.
How to order • Tunneled or Implanted devices: • Search ‘CVAD’: ‘CVAD-insert tunneled w/o port >5 years’ ‘CVAD-insert tunneled with port >5 years.
VAD Placement Decisions An integral part of the treatment plan Collaborative in nature Coordinated effort of multiple providers
Resources • Patient • Consult services (nephrology, infectious disease) • PICC RN: 2168219 • VIR: consult pager 2168477 • Home Infusion Nurse: 3471934 • CCM and Social Workers
Useful to Know • Venous Access is essential . • Establishing and maintaining reliable access is a priority. • EARLY access planning prevents IV related complications and negative outcomes for patients and the hospital. • The choice of which VAD to use is a collaborative process.