Kathy Kokotis RN BS MBA Becton Dickinson Director Global Clinical Development BASTSHW03180058 Disclosure The speakers presentation today is on behalf of Becton Dickinson Any discussion regarding ID: 776210
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Slide1
Vascular Access Change in Practice
Kathy Kokotis RN BS MBABecton DickinsonDirector Global Clinical Development
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Slide2Disclosure
The speaker’s presentation today is on behalf of Becton Dickinson. Any discussion regarding Becton Dickinson products during the presentation today is limited to information that is consistent with Becton Dickinson labeling. Please consult Becton Dickinson product labels and inserts for any indications, contraindications, hazards, warnings, cautions and instructions for use.Results presented may not be predictive for all institutions or patients.Kathy Kokotis is an employee of Becton Dickinson and holds Becton Dickinson Stock as well as Johnson and Johnson Medical Stock.
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Slide3My Grandmother (84)Why I started my quest for early assessment in vascular access needs
Taken November 1995: Brain metastasis no chemotherapy
Day 6 of a two week hospital stayAcute care CICC Jugular for TPN/antibiotics in the ICU (day 7)CICC was pulled for a CR-BSI on day 14 prior to her death(CLA-BSI definition did not exist in 1995)
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Slide4Decision Change: Infusates2011 versus 2017 Infusion Nursing Standards of Practice
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Slide5Decision Making: INS 2011
Therapies not appropriate for short peripheral catheters include continuous vesicant therapy, parenteral nutrition, infusates with pH less than 5 or greater than 9, and infusates with an osmolality greater than 600 mOsm/L. The nurse should collaborate with the pharmacist and the licensed independent practitioner (LIP) to assist in selection of the most appropriate vascular access device based on a projected treatment planTherapies not appropriate for midline catheters include continuous vesicant therapy, parenteral nutrition, infusates with pH less than 5 or greater than 9, and infusates with an osmolality greater than 600 mOsm/L.
Infusion Nurses Society: (2011) Infusion Nursing Standards of Practice, JIN 34 (1S)S p. 37
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Slide6Decision Making: INS 2016
A. Choose a short peripheral catheter as follows:1. Consider the infusate characteristics (eg, irritant, vesicant, osmolarity) in conjunction with anticipated duration of infusion therapy (eg, less than 6 days) and availability of peripheral vascular access sites.2. Use vascular visualization technology (eg, near infrared, ultrasound) to increase success for patients with difficult venous access (refer to Standard 22, Vascular Visualization ).3. Do not use peripheral catheters for continuous vesicant therapy, parenteral nutrition, or infusates with an osmolarity greater than 900.
Infusion Nurses Society: (2016): Infusion Therapy Standards of Practice JIN (Jan/Feb) 39(1S)
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Slide7MAGIC: 2015 Appropriateness Guide
For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days. Midline catheters and ultrasonography-guided peripheralMidline catheters and ultrasonography-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days.
Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1-39S
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Slide8Definitions
Vesicant
An agent capable of causing blistering, tissue sloughing, or necrosis when it escapes from the intended vascular pathway into the surrounding tissues
Extravasation
The inadvertent infiltration of vesicant solution or medication into the surrounding tissue
Gorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence-based list of noncytotoxic vesicant medicationsAnd solutions JIN 40(1) Jan/Feb 26-40
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Slide9List of Non Cytotoxic Vesicants
Red List
Calcium ChlorideCalcium GluconateContrast Media – nonionicDextrose containing ≥ 12.5%DobutamineEpinephrineNorepinephrineParenteral nutrition solutions exceeding 900 mOsm/LPhenylephrinePhenytoinPromethazineSodium bicarbonateSodium chloride ≥ 3%Vasopressin
Yellow List
AcyclovirAmiodaroneArginineDextrose concentrations ≥ 10% to 12.5%Mannitol ≥ 20%NafcillinPentamidinePhenobarbital sodiumPotassium ≥ mEq/LVancomycin hyrdrochloride
Infusion Nurses Society: (2016) Noncytoxic Vesicant Medications and Solutions www.INS1.org on the ONS Learning Center Tab
This list of “Noncytotoxic Vesicant Medications & Solutions” was developed by a task force of the Infusion Nurses Society for the use and education of its members. The list is provided for informational purposes only. The provision of the list is not meant to replace clinical judgment and does not constitute endorsement by Bard Access Systems. Bard Access Systems has not independently confirmed the information in this list.
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Slide10List of Non Cytotoxic VesicantsYellow List pH
VesicantpHAcyclovir10.5-11.6 (p17)Amiodarone4.08 (p83)Arginine vasopressin antagonistConivaptan hydrochloride3-3.8 (p344)Pentamidine4.09-5.4 (1021)Phenobarbital sodium8.5-10.5 (p1033)Vancomycin hydrochloride2.4-5.0 (p1264)
VesicantpHDextrose concentration ≥ 10%-12.5%3.5-6.5 (p413)Mannitol ≥ 20%4.5-7 (p814)Potassium ≥ 60nmEq/LPotassium acetatePotassium chloride4.0 – 8.0 (p1065)Nafcilln6-8.5 (p894)
Gahart B, Nazareno AR, Ortega MQ: (2017) Gaharts 2017 Intravenous Medications A Handbook for Nurses and Health Professionals
33 rd Elsevier St Louis Missouri
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Slide11List of Non Cytotoxic VesicantsRed List pH
VesicantpHDextrose concentration ≥ 12.5%3.5-6.5 (p413)1Dobutamine2.5-5.5 (p446)1Dopamine2.5-5.0 (p461)1Epinenphrine2.5-5.0 (p504)1Norepinephrine3.0-4.5 (p933)1Phenylephrine3.0-6.5 (p1036)1Phenytoin12 (p1038)1Promethazine4-5.5 (p1081)1Vasopressin2.5-4.5 (p1268)1
VesicantpHCalcium chloride5.5-7.5 (p225)1Calcium gluconate6-8.2 (p228)1Contrast media non ionicLoversal 6.0-7.42Sodium bicarbonate7-8.5 (p1162)1Sodium chloride ≥ 3%4.5-7.0 (p1164)1Parenteral nutrition solutions exceeding 900 mOsm/LNA
1Gahart B, Nazareno AR, Ortega MQ: (2017) Gaharts 2017 Intravenous Medications A Handbook for Nurses and Health Professionals33 rd Elsevier St Louis Missouri2Optiray injection (loversolinjection): Side Effects, Interactions, Warning, Dosage & Usage www.rxlist.com/optiray-injection-drug.htm 1-26
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Slide12“While some vesicant infusates possess extreme pH levels (eg, acyclovir, pentobarbital, phenytoin) or are clearly hyperosmolar (eg, calcium chloride, high dextrose concentrations), many of the vesicants have neither property”
Gorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence-based list of noncytotoxic vesicant medicationsAnd solutions JIN 40(1) Jan/Feb 26-40
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Slide13Vancomycin Extravasation: Single Case
Nanjappa S, Snyder et al: (2017) Vancomycin Infiltrate-Induced Dermatitis Mimicking Bullous Cellulits, Journal of drugs in Dermatology, 16(11) 1160-1163Gorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence-based list of noncytotoxic vesicant medications And solutions JIN 40(1) Jan/Feb 26-40
67 year old male
1Pneumonia & pancytopeniaVancomycin (V) and Pipercillin tazobacram1“Patient’s dermatitis and resultant cellulitis likely originated due to extravasation of the drug (vancomycin) when he ripped out his peripheral line”1This abstract is not cited in the INS paper “Development of an evidence- based list of noncytotoxic vesicant medications and solutions2
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Slide14Vancomycin Extravasation: Single Case
84 year old Female developed hospital acquired pneumoniaVancomycin (1,000 mg daily) & cefepime (1,000 mg BID)220 pounds, anemia, asthma, afib., CAD, hypertension, Diabetes Type 2, previous CABG20 g right wristDay 2 extravasation with blistering to right wristNecrotic tissue developed (over week)Black eschar overlapping an ulcer developedRight thrombophelbitis mid forearm near the cephalic veinWound healing 5 weeks with no surgical consultAuthor recommends central administration
Peyko V, Saasson E: (2016) Vancomycin extravasation: evaluation, treatment, and avoidance of This adverse drug event, Case Reports in Internal Medicine 3(3) p. 40-43
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Slide15Decision Making: INS 2016
Use caution with intermittent vesicant administration due to risk of undetected extravasation.The administration of vancomycin for less than 6 days through a midline catheter was found to be safe in 1 study (Level IV evidence)
Infusion Nurses Society: (2016): Infusion Therapy Standards of Practice JIN (Jan/Feb) 39(1S)
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Slide16Definitions
Irritant
An agent capable of producing discomfort (burning, stinging) or pain as a result of irritation in the internal lumen of the vein with or without immediate external signs of vein inflammation
Gorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence-based list of noncytotoxic vesicant medicationsAnd solutions JIN 40(1) Jan/Feb 26-40
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Slide17Vesicant and Irritant
Vesicants cause severe damage when the agent escapes the veinIrritants cause damage within the vein
Gorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence-based list of noncytotoxic vesicant medicationsAnd solutions JIN 40(1) Jan/Feb 26-40
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Slide18Decision: Vesicant
VAD selection is a complex decision not based on a single factor Peripheral administration of short term vesicant in an ER or small number of doses may or may not be appropriate given a patient’s vascular assessment
Gorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence-based list of noncytotoxic vesicant medicationsAnd solutions JIN 40(1) Jan/Feb 26-40
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Slide19Vesicants in Yellow are still a VesicantPatient Assessment is important
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Slide20Decision Making Changes: ICU Patients
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Slide21Decision Making ICU: INS 2016
Use a PICC with caution in patients who have cancer or are critically ill due to venous thrombosis and infection risk.
Infusion Nurses Society: (2016): Infusion Therapy Standards of Practice JIN (Jan/Feb) 39(1S)
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Slide22Audience participation
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Slide23The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta-Analysis
The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta-Analysis Author(s): Vineet Chopra, MD, MSc; John C. O’Horo, MD; Mary A. M. Rogers, PhD; Dennis G. Maki, MD, MS; Nasia Safdar, MD, PhD Source: Infection Control and Hospital Epidemiology, Vol. 34, No. 9 (September 2013), pp. 908- 918 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/671737 Accessed: 07/08/2013 13:40
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Slide24The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta-Analysis Author(s): Vineet Chopra, MD, MSc; John C. O’Horo, MD; Mary A. M. Rogers, PhD; Dennis G. Maki, MD, MS; Nasia Safdar, MD, PhD Source: Infection Control and Hospital Epidemiology, Vol. 34, No. 9 (September 2013), pp. 908- 918 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/671737 Accessed: 07/08/2013 13:40
The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta-Analysis
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Slide25The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta-Analysis
“risk of CLABSI associated with CVCs and PICCs appears to be similar in hospitalized patients, expansion of practices and campaigns such as hub decontamination and “scrub the hub” should specifically be targeted toward PICCs.”“hospitalized patients who underwent PICC placement experienced CLABSI rates that statistically paralleled that associated with CVCs”
The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta-Analysis Author(s): Vineet Chopra, MD, MSc; John C. O’Horo, MD; Mary A. M. Rogers, PhD; Dennis G. Maki, MD, MS; Nasia Safdar, MD, PhD Source: Infection Control and Hospital Epidemiology, Vol. 34, No. 9 (September 2013), pp. 908- 918 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/671737 Accessed: 07/08/2013 13:40
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Slide26Chopra V, Anand SA, Buist, Rogers M, Saint S, Flanders : July 27, 2013) Risk of venous thromboembolism associated with peripherally Inserted central catheters: A systematic review and meta=analysis Lancet 382 p311-325
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Slide27Chopra V, Anand SA, Buist, Rogers M, Saint S, Flanders : July 27, 2013) Risk of venous thromboembolism associated with peripherally Inserted central catheters: A systematic review and meta=analysis Lancet 382 p311-325
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Slide28Risk Factors Associated with Peripheral Inserted Central Venous Catheter-Related Large Vein Thrombosis in Neurological ICU Patients (Single Center retrospective review)
Wilson TJ, Brown DL, Meurer WJ et al: (2012) Risk factors associated with peripheral inserted central venous catheter-related large vein Thrombosis in neurological intensive care patients*Statistically significant
Entire cohort(n=431)No PRLVT(n=395)PRLVT(n=36)P valueAge, years, (mean, SD)55 (16)55 (16)56 (19)0.792Female sex216 (50%)205 (52%)12 (33%)0.035Ethnicity0.241 Caucasian365 (85%)336 (85%)29 (81%) African American35 (7%)33 (8%)2 (6%) Other31 (7%)26 (7%)5 (14%)Tobacco abuse119 (28%)110 (28%)9 (25%)0.714*Obese (BMI > 30 kg/m2)133 (31%)118 (30%)15 (42%)0.143Prothrombotic state20 (5%)18 (5%)2 (6%)0.679Coagulopathy29 (9%)37 (9%)2 (6%)0.759Cancer73 (17%)67 (17%)6 (17%)0.964*Congestive heart failure34 (8%)28 (7%)6 (17%)0.041*History of VTE33 (8%)25 (6%)8 (22%)0.001History of VTE in same arm7 (2%)5 (1%)2 (6%)0.109*Surgery longer than 1 h during dwell time of PICC99 (23%)83 (21%)16 (44%)0.001Length of stay, days (median IQR)16 (14)17 (13)34 (16)<0.001Estrogen3 (1%)3 (1%)0 (0%)1.000Aspirin79 (18%)74 (19%)5 (14%)0.653Clopidogrel14 (3%)13 (3%)1 (3%)1.000Hypertonic saline104 (24%)95 (24%) 9 (25%)0.899*Mannitol44 (10%)35 (9%)9 (25%)0.002Vancomycin188 (44%)170 (43%)18 (50%)0.420Statin103 (24%)90 (23%013 (36%)0.073DVT prophylaxis413 (96%)378 (96%)35 (97%)0.938
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Slide29Risk Factors Associated with Peripheral Inserted Central Venous Catheter-Related Large Vein Thrombosis in Neurological ICU Patients (Single center retrospective review
Wilson TJ, Brown DL, Meurer WJ et al: (2012) Risk factors associated with peripheral inserted central venous catheter-related large veinThrombosis in neurological intensive care patients*Statistically significant
Procedure-related variablesEntire cohort (n=431)No PRLVT (n=395)PRLVT (n=36)P valueCatheter insertion Right279 (65%)256 (65%)23(64%)0.912 Left152 (35%)139 (35%)13 (36%)Catheter insertion Basilic316 (73%)289 (73%)27 (75%)0.483 Brachial94 (22%)88 (22%)6 (17%) Cephalic21 (5%)18 (5%)3 (8%)Catheter diameter 5 French171 (40%)160 (41%11 (31%)0.243 * 6 French260 (60%)235 (59%)25 (69%)Catheter tip outside SVC6 (1%)6 (2%)0 (0%)1.000*placed in a paretic arm76 (18%)56 (14%)20 (56%)<0.001Attempts at placement (median, IQR)1 (1)1(1)1(1)0.832Manipulations (median, IQR)0 (1)0 (1)0 (1)0.828Lumens clotted82 (19%)75 (19%)7 (19%)0.947Duration of use, days (median, IQR)12 (16)12 (15)13 (15)0.443
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Slide30Hypercoagulability
(Blood clots are
likely to form)
Stasis
(Decreased
blood flow)
DVT
Risk
DVT Risk
Vessel Injury
DVT
Risk
Highest
DVT Risk
Virchow’s Triad
Minimizing Endothelial Injury
Understanding DVT Risk in PICC Patients
Proper Patient Selection
Minimizing Blood Flow Reduction
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Slide31Risk Factors Associated with Peripheral Inserted Central Venous Catheter-Related Large Vein Thrombosis in Neurological ICU Patients
Risk of development of PICC related large vein thrombosis (PRLVT)Surgery over one hour during the dwell time of a PICCPlacement PICC paretic armMannitol therapyHistory of previous VTE
Wilson TJ, Brown DL, Meurer WJ et al: (2012) Risk factors associated with peripheral inserted central venous catheter-related large veinThrombosis in neurological intensive care patients
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Slide32Nolan
ME, et al. Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. J Crit Care 2015;31:238-242
Complication rates for PICCs & CICCs followed from MICU insertion until MICU Discharge
PICC (N=200)CICC (N=200)P valueIndwelling Days750535Median Indwelling Days2.32.0.266Symptomatic CRDVTn(%)4 (2%)2 (1%).685Per 1000 cath days5.33.7Median days to DVT6.13.3CLABSIn(%)0 (0%)0 (0%)
No significant difference in DVT rate or CLABSI rate
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Slide33Risk of Symptomatic DVT Associated With PICCs (single center observational study)
Catheter SizeNumberPercentageSL 4 F33816.8%DL 5F1,51675.3%TL 6F160 7.9%
Evans RS, Sharp JH, Linford LH et al: ( Oct 11, 2010) Risk of symptomatic DVT associated with peripherally inserted central Catheters Chest 138 (4) p 803-810
Average PICC duration, d (range) 7.5(<1-78)
Average length of hospitalization, d (range) 14.5(<1-161)
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Slide34Risk of Symptomatic DVT Associated With PICCs (single center observational study)
CharacteristicNo.Total PICC insertions with DVT (%)60 (3.0)Total distinct patients with DVT57Patients with two DVTs during same hospitalization2Patients with two DVTs during different hospitalizations1Mean duration from PICC insertion to DVT Diagnosis, d (range)9.5 (1-64)Veins affected by DVTs Axillary49 Subclavian26 Basilic10 Brachial3 Cephalic3
Risk of PICC associated DVTPICC sizePrevious DVTSurgery
Evans RS, Sharp JH, Linford LH et al: ( Oct 11, 2010) Risk of symptomatic DVT associated with peripherally inserted central Catheters Chest 138 (4) p 803-810
Characteristics of Patients with PICC-Associated DVT at Intermountain Medical Center During 2008
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Slide35Who got a PICC
Risk of Symptomatic DVT Associated With PICCs (single center observational study)
Reason for PICCNumber PatientsPercentage (%)Venous access48223.9 %Antibiotics58829.2 %TPN1477.3 %Chemotherapy120.6 %Medications78939.2 %Blood products170.8 %Hydration90.4%Replacement422.1%Other733.6%Not documented80.4%
Patient
Evans RS, Sharp JH, Linford LH et al: ( Oct 11, 2010) Risk of symptomatic DVT associated with peripherally inserted central Catheters Chest 138 (4) p 803-810
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Slide36Risk of Symptomatic DVT Associated With PICCs (single center observational study)
Medical ConditionNumber PatientsPercentage %Cardiology32115.9%Neurology1145.7%Infectious diseases66232.9%Gastroenterology25312.6%Trauma874.3%Pulmonary1989.8%Oncology1246.2%Vascular512.5%Orthopedics532.6%Renal673.3%Other844.2%
Patient
Evans RS, Sharp JH, Linford LH et al: ( Oct 11, 2010) Risk of symptomatic DVT associated with peripherally inserted central Catheters Chest 138 (4) p 803-810
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Slide37The ICU PatientRisk Evaluation
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Slide38MAGIC: 2015 Appropriateness Guide
For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer daysIn critically ill patients, nontunneled central venous catheters were preferred over PICCs when 14 or fewer days of use were likely
Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1-39S
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Slide39PICCCICCCLABSI12CLABSI12Brachial Arterial InjuryPneumothorax12HematomaAir Embolism12HemothoraxCarotid/Subclavian/Femoral2 Arterial InjuryHematoma
Prevalent Risks of Placing and Removing PICCs & CICCs7
12Hospital-Acquired Conditions and Present on Admission Indicator Reporting Provision. Centers for Medicare & Medicaid Services. ICN 901046 September 2014
7Dariushnia et al. Quality Improvement Guidelines for Central Venous Access. 2010. J Vasc Inter Radiol. 21. 976-981
Notes: Complications marked as “0%” are not included in lists.7 Arterial injury expanded to include femoral artery based on Bowdle (2014) observations.23
2Bowdle. Vascular Complications of Central Venous Catheter Placement: Evidence-Based Methods for Prevention and Treatment. 2014. J Cardiothoracic and Vascular Anesthesia. 21. 358-368.
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Slide40Management related to line placement20Platelet count: < 50 x 109 /LInternational normalized ratio (INR): > 2.0Platelet count: < 50 x 109 /LInternational normalized ratio (INR): < 1.5
Patient Coagulation Considerations
…and damaging the vein or artery
Procedures with Low Risk of Bleeding, Easily Detected and Controllable (Category 1)
20Applicable Vascular Procedures Dialysis access intervention Central line removal PICC line placementProcedures with Moderate Risk of Bleeding (Category 2)20Applicable Vascular Procedures Tunneled central venous catheter Subcutaneous port procedure
PICC- small vein, small catheter
CICC- large vein, large catheter
20Patel et al. Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions. JVIR 2012. 23:727-736
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Slide41Example 1
Insertion Position
CICC: Trendelenberg (required16PICC: No requirement
Patient
Position & Condition Considerations
Example 2
Neurology or Pulmonary IssuesCICC: Reverse Trendelenberg (required) 16PICC: No requirement
16Interdisciplinary Clinic Practice Manual. Vascular Access Device Policy, Adult (IFC035). The John Hopkins Hospital. 2008
Other Considerations
PICC may be suboptimal if: ESKD (III or IV)6 Past breast surgery11 History of VTE6 Arm burn, infection, paralysis24CICC may be suboptimal if: Neck/chest abnormalities6 High infection risk/tracheotomy6 Longer dwell time foreseen11
6Cotogni et al. Focus on peripherally inserted central catheters in critically ill patients. World Journal of Critical Care Medicine. 2014. 3(4). 80-94
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Slide42Required Life Supporting Devices: Competing for Real Estate
Insertion Site Choice
CICC neck clavicular triangle groinPICC either upper arm
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Slide43CICC neck: proximity to ear, nose & throat clavicular triangle: upper chest groin 1PICC either upper arm
Insertion Site Choices
1
Avoid using the femoral vein for central venous access in adult patients. (Category 1A). Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011.
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Slide44Insertion Site Choices
CICC Jugular
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Slide45Central Line Complication Summary
ComplicationNEVER Event (IPPS HAC reportable) 1PPC Code2Estimated HAC Cost2CLABSI*X54$12,4551%1% - 3%Air EmbolismX48$9,350Not Listed1%PneumothoraxX49$4,1360%1% - 3%Thrombosis16$8,6073%4%Hemothorax8$5,1650%1%Perforation42$3,215Not Listed0.5% - 1%Hematoma64$7121%1% - 3%Wound Dehiscence64$7121%1%Phlebitis64$7124%Not ListedArterial Injury64$7120.5%Not Listed
Centers for Medicare & Medicaid Services. (2012). Hospital-acquired conditions (HAC) in acute inpatient prospective payment system (IPPS) hospitals; May 2012.
Fuller, R. L., McCullough, E. C., & Averill, R. F. (2011). A new approach to reducing payments made to hospitals with high complication rates. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 48(1), 68-83.Dariushnia, S. R., Wallace, M. J., Siddiqi, N. H., Towbin, R. B., Wojak, J. C., Kundu, S., & Cardella, J. F. (2010). Quality improvement guidelines for central venous access. Journal of Vascular and Interventional Radiology, 21(7), 976-981.
PICC Lines
Subclavian & Jugular Lines
Incidence Rate(per SIR Central Venous Access CPG) 3
*Procedure induced sepsis
MC-MM-1072
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Slide46Key CVAD Patient Considerations
Status of bleedingStatus of ability to cooperateStatus of position for insertion and removalStatus of neck and chestStatus of breathingStatus of hemodynamicsRisk of infection with placement site
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Slide47Key Patient Considerations
Pulmonary StatusCHF, COPDEmphysemaLung surgeriesAsthmaPneumoniaPneumothorax
Coagulopathy StatusPLT ≤ 50 x 109 /LINR ≥ 1.5aPTT ≥ 20 sAnticoagulantsClotting disorderPast history thrombosis
Mechanical StatusPlacement concernsCervical CollarsHaloPacemaker WiresPositive pressure ventilationVena cava filters
Patient StatusDevice Type ConsiderationsTrendelenburg position contraindicatedConfusion/DementiaHypovolemiaLocal infection siteLymph node dissection / lymphedemaObesity / CachexiaContralateral pneumothoraxHemothoraxOral Candida / Nasal MRSANeed for arterio-venous fistulaPersistent left Superior Vena CavaPrevious catheterizationsRadiotherapy in anatomic region of interestOperative history (Thoracic)Clavicular fractureSternotomySevere hypoxemia
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Slide48Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1-39S
Annals of Internal Medicine (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): From a Multidisciplinary Panel Using the RAND/UCLA Appropriateness Method
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Slide49Decision-making: INS 2016
Consider the infusate characteristics (eg, irritant, vesicant, osmolarity) in conjunction with anticipated duration of infusion therapy (eg, less than 6 days) and availability of peripheral vascular access sites.
Infusion Nurses Society: (2016): Infusion Therapy Standards of Practice JIN (Jan/Feb) 39(1S)
Duration
Peripheral access
Irritant
Vesicant
osmolarity
Andrew Kokotis
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Slide50The following slides are based on personal real-world experience
Slide51My Dad: (September 2016)Age 84Day 14 IV TherapyAbscess admittingDiabetic type 2Stroke x 2VasculitisGiant Cell ArteritisPrednisone 10 mg (8 years)
Blood – 3 unitsVancomycinZosynKefzolZofranLab draws BID or TID
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Slide53P
hlebotic IV
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Slide54My Mom
Single lumen PICC for Sepsis
Did she get the right device?
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Slide55My Mom (March 2016)Age 80Sepsis admittingSingle Lumen PICCRheumatoid Arthritis Ulcerative ColitisIleostomyHeart MurmurWound InfectionSepsis x 3 in one yearPrednisone 10 mg (20 years)
Vasopressors (not day one)Hydration (day one)Blood draws (day one)Antibiotics (Vancomycin) &Primaxin (day one)
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Slide58Venous Access Device Recommendations for Infusion of Peripherally Compatible Infusate
Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1-39S
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Slide59Venous Access Device Recommendations for Patients with Difficult Venous Access
Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6)
p1-3
9S
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Both my mom and dadwere difficult access
Slide60Venous Access Device Recommendations for Infusion of Peripherally Non-Compatible Infusate
Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1-39S
My Dad received
Vancomycin a Vesicant Drug
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Slide61Venous Access Device Recommendations for Patients Who Require Frequent Phlebotomy
Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1-39S
My dad and mom both
Had frequent blood draws
My mom was not in the ICU on admit
My mom and dad
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Slide62Potential Alternatives
Mom – DIFFICULT ACCESS
Vancomycin - VesicantSepsis – potential for ICURepeated blood drawsSingle lumen PICC was inappropriate?Dual or Triple Lumen PICC should have been placed?My mom ended in ICU on vasoconstrictors
Dad – DIFFICULT ACCESS
Vancomycin – VesicantRepeated blood drawsOriginal length of treatment was supposed to be < 6 daysSingle lumen PICC Line should have been placed?
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Slide63Decision Making Basics
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Slide64Conclusion: Decision Making INS (2016)
Assess the patient’scondition agediagnosiscomorbidities condition of the vasculature at the insertionsite and proximal to the intended insertion site;condition of skin at intended insertion site; history ofprevious venipunctures and access devices; type andduration of infusion therapy patient preference for VAD site selection.
Infusion Nurses Society: (2016): Infusion Therapy Standards of Practice JIN (Jan/Feb) 39(1S
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Slide66References
Avoid using the femoral vein for central venous access in adult patients. (Category 1A). Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. Bowdle. Vascular Complications of Central Venous Catheter Placement: Evidence-Based Methods for Prevention and Treatment. 2014. J Cardiothoracic and Vascular Anesthesia. 21. 358-368 Centers for Medicare & Medicaid Services. (2012). Hospital-acquired conditions (HAC) in acute inpatient prospective payment system (IPPS) hospitals; May 2012.Chopra V. Flanders S. Saint S. (Sept. 2015)The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method, Annals of Internal Medicine 163(6) p1-39SChopra V, O’Horo JC. Rogers M (Sept. 2013) The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta-Analysis Author(s): Source: Infection Control and Hospital Epidemiology, Vol. 34, No. 9 (September 2013), pp. 908- 918 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/671737 Accessed: 07/08/2013 13:40Chopra V, Anand SA, Buist, Rogers M, Saint S, Flanders : July 27, 2013) Risk of venous thromboembolism associated with peripherally Inserted central catheters: A systematic review and meta=analysis Lancet 382 p311-325
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Slide67References
Cotogni et al. Focus on peripherally inserted central catheters in critically ill patients. World Journal of Critical Care Medicine. 2014. 3(4). 80-94Dariushnia et al. Quality Improvement Guidelines for Central Venous Access. 2010. J Vasc Inter Radiol. 21. 976-981Fuller, R. L., McCullough, E. C., & Averill, R. F. (2011). A new approach to reducing payments made to hospitals with high complication rates. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 48(1), 68-83.Gahart B, Nazareno AR, Ortega MQ: (2017) Gaharts 2017 Intravenous Medications A Handbook for Nurses and Health Professionals 33 rd Elsevier St Louis MissouriGorski LA, Stranz M, Cook LS, et al.: (2017) Development of an evidence-based list of noncytotoxic vesicant medications And solutions JIN 40(1) Jan/Feb 26-40Helen Hamilton and Andrew R. Bodenham. Central Venous Catheters. (United Kingdom. John Wiley & Sons Ltd. 2009) 38-84Hospital-Acquired Conditions and Present on Admission Indicator Reporting Provision. Centers for Medicare & Medicaid Services. ICN 901046 September 2014Infusion Nurses Society: (2011) Infusion Nursing Standards of Practice, JIN 34 (1S)S p. 37Infusion Nurses Society: (2016): Infusion Therapy Standards of Practice JIN (Jan/Feb) 39(1SInfusion Nurses Society: (2016) Noncytoxic Vesicant Medications and Solutions www.INS1.org on the ONS Learning Center Tab Clinic Practice Manual. Vascular Access Device Interdisciplinary Clinic Practice Manual. Vascular Access Device Policy, Adult (IFC035). The John Hopkins Hospital. 2008
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Slide68References
Nanjappa S, Snyder et al: (2017) Vancomycin Infiltrate-Induced Dermatitis Mimicking Bullous Cellulits, Journal of drugs in Dermatology, 16(11) 1160-1163Nolan ME, et al. Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. J Crit Care 2015;31:238-242Optiray injection (loversolinjection): Side Effects, Interactions, Warning, Dosage & Usage www.rxlist.com/optiray-injection-drug.htm 1-26Patel et al. Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions. JVIR 2012. 23:727-736Peyko V, Saasson E: (2016) Vancomycin extravasation: evaluation, treatment, and avoidance of This adverse drug event, Case Reports in Internal Medicine 3(3) p. 40-43Wilson TJ, Brown DL, Meurer WJ et al: (2012) Risk factors associated with peripheral inserted central venous catheter-related large vein Thrombosis in neurological intensive care patient
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Slide69Questions
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