Vascular Access Devices & Insertion PDF

# Section I: Vascular Access Devices and Insertion ## A. Device Selection - General - Early consultation between the vascular access specialist and the patient and/or family is critical in achieving optimal outcomes of placing the right device in the right location at the right time, while promoti...

# Section I: Vascular Access Devices and Insertion ## A. Device Selection - General - Early consultation between the vascular access specialist and the patient and/or family is critical in achieving optimal outcomes of placing the right device in the right location at the right time, while promoting vessel preservation and health - Review of patient variables (preferably at admission) and projected therapies to be delivered across the continuum of care, promotes timely and appropriate vascular access insertion, reduces vascular access associated complications, and promotes safe delivery of infusates - Consider the patient specific vascular assessment and personal preferences as the VAD may impact their daily activities, lifestyle, and employment - Assess the patient and/or caregiver's understanding of the diagnosis and prescribed therapy, including duration, risks, benefits, care, and maintenance ### Pediatric Considerations - Device selection may be limited in the pediatric population due to smaller vessel size which may make it difficult to visualize and palpate the vein. Other considerations include multiple attempts, previous complications, and child's developmental stage. - Clinicians providing vascular access in the pediatric population must have specific training in the competent management for these patients. Vascular access devices (VAD) have the potential to preserve vessels by minimizing the need for additional venipuncture attempts and thereby avoiding unnecessary pain and anxiety with repeated attempts. - Assess the child for the following: - age - size - vascular access sites - reason for therapy - duration of therapy - activity and mobility - cognitive ability - gross and fine motor skills - body image ## B. Indications for Vascular Access - Hydration - Medication administration - Total or partial parenteral nutrition (TPN or PPN) - Chemotherapeutic agents - Blood and blood components - Clinical or diagnostic indication requiring vascular access - Hemodynamic and arterial blood pressure monitoring - Plasmapheresis/Aquapheresis/Hemodialysis - Frequent blood sampling in the difficult access patient - Therapeutic Phlebotomy ## C. Device Facts - **French Scale** (abbreviated as Fr): Measurement of the external diameter of the catheter. - Fr size = external diameter in mm x 3 (i.e. 2 mm ext. dia. (x 3) = 6 Fr catheter) - The larger the French size, the larger the catheter diameter - Central venous catheter sizes range from 1.2 Fr (neonatal PICCs) to 15 Fr (dialysis catheters) - **Gauge Scale** (abbreviated as g or ga): Measurement of the internal diameter of the catheter - Inversely related to Fr size as the larger the gauge, the smaller the internal diameter of the catheter - Higher infusion rates are facilitated by larger gauge catheters - Intravenous catheter sizes range from 27g to 12g - **Needle characteristics** - Needles are single use and intended to pierce tissue once - Repeated attempts with same needle may cause micro tissue damage, site contamination, and dull the needle tip - Needles come in various lengths and bevels - **Catheter Material** - All IV devices manufactured in the USA are required to be radiopaque to facilitate visualization of catheter, tip location, and catheter emboli in the event of shearing or fracture - **Silicone:** Soft, biocompatible polymer material - Extremely flexible; Lower tensile strength (compared to polyurethane) results in higher inner/outer diameter ratio - Not affected by chemicals such as alcohol - **Polyurethane:** Biocompatible urethane-based polymer material - Various formulations are used to manufacture peripheral and central venous catheters - Higher tensile strength (over silicone) minimizes outer/inner diameter ratio - Alcohol can act as a solvent on some types of polyurethane catheters, possibly causing degradation. Consideration of catheter material is necessary when considering use of ethanol lock, consult the manufacturer's instructions for use (IFU) prior to application ## D. Peripheral Catheters - Both short and long peripheral IV catheters exist in current clinical practice - These range in length from 0.56" to 2.5" and 14mm to 10cm - Inserted as a catheter-over-needle, accelerated, or modified Seldinger technique - **Indications/Contraindications** - **Indications** - Infusions projected for 6 days or less - Non-irritant medications and solutions - Non-vesicant medications and solutions - Single dose (non-continuous) vesicant administration when clinician monitored - **Contraindications** - Therapies expected to last more than 6 days - Infusates with osmolarity > 900 mOsm/L - Administration of vesicants, Irritants, or infusates with high phlebitis risks - Placement in an arm with venous thrombosis, fracture, trauma, infection, or compromised circulation (such as might be found on an extremity affected by impaired mobility) - Veins in an arm on the same side of a mastectomy with axillary lymph node dissection - Veins in an arm with an A/V fistula or graft - **Site and vessel selection** - Cephalic, Basilic, Median, and accessory veins of the arms - Metacarpals are **not recommended** for general use. Primarily used for chronic kidney disease (CKD) patients (2019 NKF KDOQI Clinical Practice Guidelines). - In the adult patient avoid vessels in the lower extremities. - **Avoid areas of flexion** (hand, wrist, and antecubital fossa) - When using ultrasound, consider the depth of the vessel being used and ensure greater than 50% of the catheter length dwells in the vein. - **Insertion procedures and supplies** - **General considerations** - Follow all manufacturer's instructions for use (IFU) - Adhere to aseptic non-touch technique - Perform skin antisepsis - Only two attempts per healthcare provider - Limit of two individuals, two attempts each to a maximum of 4 attempts before escalating to a vascular access specialist - When successful access appears unlikely based on clinician assessment, refer to a more experienced clinician or vascular access specialist - Select the smallest gauge size possible to successfully deliver the prescribed therapy - Consider the use of visualization technology (see AVA Position Paper at AWAinfo.org) - **Supplies** - Peripheral IV catheter - Skin antiseptic agent - Clean gloves (consider sterile gloves) - Extension set - Needleless connector - Normal saline (NS) flush solution - Transparent semi-permeable (TSM) and or antimicrobial dressing - Consider skin adhesive - Tissue adhesive - Skin protectant - Engineered stabilization device