Vascular Access Guidelines PDF

## Pediatric Considerations - **Vein selection:** Use assistive vein visualization devices (i.e., ultrasound, transillumination, or near-infrared technology) to thoroughly assess all available sites, prior to attempting placement. - **Scalp:** (Infants less than 18 months old) - superficial tem...

## Pediatric Considerations - **Vein selection:** Use assistive vein visualization devices (i.e., ultrasound, transillumination, or near-infrared technology) to thoroughly assess all available sites, prior to attempting placement. - **Scalp:** (Infants less than 18 months old) - superficial temporal - frontal - occipital - post auricular - external jugular - **Lower extremities:** (Infants before walking and crawling if possible) - **Foot:** metatarsal - **Leg:** saphenous - Implement a comfort plan appropriate to the child's age. - Secure peripheral IV catheter with appropriate dressing, engineered stabilization device, tissue adhesive, and other methods. ## E. Midline Catheter ### Indications/Contraindications #### Indications - Infusions projected for more than 6 days. - Non-irritating medications and solutions. - Non-vesicant medications and solutions. - Single dose (non-continuous) vesicant administration when clinician monitored. - Vancomycin may be administered by a midline for up to 6 days. #### Contraindications - Placement into an arm with fracture, trauma, infection, or compromised circulation. - Veins in the arm with an A/V fistula. - Chronic kidney disease patients. ### Site and Vessel Selection - Basilic, Brachial, or Cephalic veins of the upper arm preferred. ### Insertion Procedures and Supplies #### General Considerations - Select a product that is specifically designed and labeled as a peripheral midline catheter. ## Follow all manufacturer's instructions for use related to the device - Adhere to aseptic non-touch technique - Appropriate skin antisepsis. - Consider maximum sterile barrier precautions. - **Do not trim PICC for midline placement.** This practice will risk confusion related to the type of device a patient has and places the catheter tip outside the SVC. This is considered an off-label product use and contrary to the manufacturer's IFU and could cause patient harm as well as potential liability for the clinician. - Do not hub the catheter (unless specifically recommended by the manufacturer's IFU). Many catheters are numerically marked, have a zero, dot, or dash at the most proximal area of the catheter is the farthest the catheter should be advanced. The remaining area is intended for the proper application of an antimicrobial disc and securement. ### Supplies - Midline catheter device. - Sterile procedural insertion tray. - Ultrasound equipment for vein visualization and access. - Normal saline flush solution. - Sterile transducer cover. - Dressing supplies. - Engineered stabilization device. ### Optimal insertion site adults: - Smallest catheter to vessel ratio (CVR). - Middle 1/3 of the upper arm. A minimum of 2 inches above the antecubital fossa. ### Tip location: - at or proximal to the axillary line and distal to the shoulder. ## Pediatric Considerations - Alternative vein sites: - Scalp veins. - Popliteal veins. - Saphenous veins. ## Non-Acute Care Considerations - Educate patients and caregivers with midlines regarding their VAD type, and encourage/empower patients to inform clinicians that VAD is a midline NOT a central line. ## F. Non-Tunneled Catheter ### Indications/Contraindications #### Indications - Short to long term central venous access (device dependent). - Emergent central venous access (not preferred, consider Intraosseous 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 monitoring - Frequent blood sampling in the difficult access patient - Plasmapheresis/Aquapheresis - Hemodialysis/Apheresis - Patients who require an extended duration of venous access for infusion therapy. - Infusion of medications considered irritants or vesicants - Difficult intravenous access patients ## Contradictions - Neck or chest sites may be excluded for patients with tracheostomies, radical neck dissection, and cervical fracture instability, or unstable airway. - Inability to safely position patient, insert, or stabilize catheter. - **Less desirable:** The insertion of a second central line on the same side as a PICC that passes through the subclavian vein. Be cautious of catheter to vein ratio (CVR) in central veins where two catheters dwell. ### PICC Specific Contraindications: - Placement into an arm with fracture, trauma, infection, amputations, or compromised circulation. - Placement into an arm paralyzed as a result of a Cerebrovascular Accident (CVA). - Increased risk of catheter-related thrombosis due to compromised circulation. - Placement into an arm on the same side of axillary lymph node dissection. - Placement into an extremity where vasculature has had an endovascular filter or other such device implanted within the intended path of the catheter. - Chronic kidney disease patients. - Prior catheter related deep vein thrombosis (CRDVT). - **Relative contraindications:** Automatic Implantable Cardioverter Defibrillator (AICD) Pacer laterality, implanted neurostimulators. ### Site and vessel selection - Upper extremity (PICC) Basilic, Brachial, Cephalic veins. ## Internal and external jugular veins - Axillary/Subclavian Veins - Femoral veins and Mid-thigh ### Insertion procedures and supplies #### General considerations - Follow all manufacturer's instructions for use related to device. - Antimicrobial catheters may be used in patients at greater risk for catheter related bloodstream infections (CRBSI). - Adhere to aseptic technique. - Perform skin antisepsis. - Use maximum sterile barrier precautions. - Position patient in slight Trendelenburg position to avoid the risk of air emboli during the placement of CVAD. - No "blind-sticks" to access veins (see AVA Position Paper at AVAinfo.org). ### Supplies - Non-tunneled percutaneous venous catheter. - Sterile procedural insertion tray with maximum sterile barrier components. - Ultrasound and manufactured probe/cord cover for vein visualization and access. - Tip location technology preferred (ECG or ECG/Doppler). - Normal saline flush solution. - Heparin flush, if indicated. - Engineered Stabilization Device. - Transparent/Antimicrobial Dressing. ### Optimal tip location - **For Upper extremity, U, Subclavian, and Axillary insertion sites, the lower third of the SVC or the Cavo atrial junction (CAJ/Upper RA) is the optimal tip location.** - From a femoral approach the optimal tip location is the Inferior Vena Cava (IVC) above the level of the diaphragm.