Vascular Access (PDF)

# AVM Resource Guide for Vascular Access: Recommended Study Guide for Vascular Access Board Certification ## Condition History and Assessment Best Practice Rationale ### Skin Conditions, Trauma or Abnormalities - Cellulitis, burn, fracture, or wound at potential insertion site - Insert VAD with th...

# AVM Resource Guide for Vascular Access: Recommended Study Guide for Vascular Access Board Certification ## Condition History and Assessment Best Practice Rationale ### Skin Conditions, Trauma or Abnormalities - Cellulitis, burn, fracture, or wound at potential insertion site - Insert VAD with the least potential complications to complete the therapeutic goal. - Avoid the VAD insertion on the ipsilateral side of fracture or major skin trauma/wound. - Infection - Lack of skin integrity. - May interfere with safe insertion of catheter with appropriate care and maintenance. ### Patient Body Habitus - Morbid Obesity - Insert the VAD that will complete the therapeutic goal with least risk. - Requires US guidance and an experienced clinician. - Consider potential sites in terms of ability to maintain a dry and intact dressing, and the ability to stabilize the CVAD. - Due to the location, a PICC inserted in the basilic or brachial may lead to dressing disruption, a moist insertion site or catheter dislodgement. - Consider tunneling to the outer aspect of the arm. - Consider Cephalic vein placement. ### Cardiac Conditions and Implanted Devices - Congenital Heart Disease (CHD): Glenn or Fontan anastomosis - Smallest catheter with the least number of lumens to complete the therapeutic goal. - Increased risk of occluded vessels. - Pediatrics: For patients with congenital heart disease, the SVC or IVC tip placement is safer and has longer dwell times. ### Cardiac Conditions and Implanted Devices, cont - Permanent Pacemaker - Automatic Implanted Cardioverter Defibrillator (AICD) - Other Implanted Endovascular Devices (i.e., filters) - CWD on contralateral side of AICD. - If it is necessary to place on the ipsilateral side, consider consultation with a Cardiologist or Electrophysiologist prior to placement. - Preferred extremity is right side for PICC placement for patients with a Fontan repair. - Lower extremity PICC, left side preferred due to potential need for cardiac catheterization. - Recently placed devices have greater risk of lead dislodgement. - Consider having devices interrogated following placement/removal of CVWDS. - Risk of occlusion of the subclavian vein increases with placement of a pacer or AICD. - It is recommended to place a CVAD when at all possible, on the contralateral side of a cardiac device. ### Vascular Conditions - Reynaud's Syndrome - Peripheral Vascular Disease - Thrombosis - Smallest gauge to accomplish the therapeutic goal. - VAD on contralateral side of known thrombus. - VAD with appropriate catheter to vessel ratio. - Smallest gauge to accomplish the therapeutic goal. - Increased risk of catheter related thrombosis due to compromised circulation. - Avoid inserting VAD in extremity or location with known thrombus. ## Vascular Conditions, cont - Injury or previous surgery involving SVC, including: - Prior radiation therapy - Previous history of CVAD central occlusion such as SVC syndrome - Stenosis of major upper thoracic vessels - Any device that would safely reach SVC or IVC via an appropriate and safe pathway. - Location and degree of stenosis may impact ability to advance catheter to optimal tip location. - Stenosis may occur bilaterally or unilaterally. - Placing a VAD in a stenosed vessel puts the patient at increased risk for thrombosis and infection. ### Blood Stream Infection - Sepsis - Bacteremia - CVAD with antimicrobial/anti infective protection. - PIV if no protected CVAD is available and medication properties are appropriate for PIV. - Patient may require a short term CVAD for, volume resuscitation, inotropic and cardiotonic drugs/drips and antibiotics. - Implanted long term CVAD insertion should be avoided until acute bacteremia/sepsis is resolved. (Time to positivity blood cultures should be performed to determine if the CVAD is the source of bacteremia prior to removing the device. ### Pediatric Considerations - General Pediatric Considerations for Age and Developmental stage specific considerations (see table 8) - VAD insertion sites may be limited by congenital anomalies or small veins. - Avoid VAD insertion in lower extremities of crawling or ambulating patients - Lower extremity insertion presents a higher risk of dislodgement and subsequent infiltration/extravasation. ## D. ADDITIONAL FACTORS RELATED TO VASCULAR PATHOLOGY - Structural damage to veins begins with vein wall puncture for device insertion. - Endothelial layer damage initiates collagen layer reaction and platelet activation to create platelet plug - Activation of blood factors deposits fibrin over platelet plug at the site of vein wall injury - Collagen and platelet activation occur when catheter tip is infusing against the vein wall or catheter movement causes damage or trauma to vein endothelium - Primary damage to superficial veins of forearms and hands occurs with repeated venipuncture. - Cumulative damage is caused by repeated or ongoing exposure to caustic infusates. - Irritant or vesicant in chemical nature - Osmolality 900mOsm/liter and greater - Extremes in pH ## The pH Scale <br> More Acidic [[0]] [[1]] [[2]] [[3]] [[4]] [[5]] [[6]] [[7]] [[8]] [[9]] [[10]] [[11]] [[12]] [[13]] [[14]] <br> <br> Neutral [[0]] [[1]] [[2]] [[3]] [[4]] [[5]] [[6]] [[7]] [[8]] [[9]] [[10]] [[11]] [[12]] [[13]] [[14]] <br> <br> More Alkaline [[0]] [[1]] [[2]] [[3]] [[4]] [[5]] [[6]] [[7]] [[8]] [[9]] [[10]] [[11]] [[12]] [[13]] [[14]] - Primary damage occurs to deep veins of thorax and upper arm with CVADs. - Repeated and/or traumatic insertion. - Longer dwell times. - Greater vessel exposure to mechanical effects of catheter movement and catheter tip - The following cause increased risk of catheter related venous thrombosis - Inflammatory diseases - Solid tumor malignancies - Thrombosis may occur to some degree with all indwelling catheters, but thrombi can <br> # AVM Resource Guide for Vascular Access: Recommended Study Guide for Vascular Access Board Certification