Peripheral Vascular Access Devices: Placement, Care, and Maintenance

Transcription

1 Peripheral Vascular Access Devices: Placement, Care, and Maintenance By Lisa Gorski, MS, RN, HHCNS-BC, CRNI, FAAN Upon successful completion of this course, continuing education hours will be awarded as follows: Nurses: 5 Contact Hours* *Western Schools is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation.

2 P.O. Box 1930 Brockton, MA ABOUT THE AUTHOR Lisa Gorski, MS, RN, HHCNS-BC, CRNI, FAAN, has worked as a clinical nurse specialist in home health since She currently works for Wheaton Franciscan Home Health and Hospice in Milwaukee, WI. She is the author of more than 40 published journal articles and books and frequently presents on infusion therapy-related topics across the country and internationally. Her primary areas of expertise include infusion therapy, home care, and care of chronically ill adult patients. She served as the president of the Infusion Nurses Society (INS), is an editor for the INS textbook Infusion Nursing in Clinical Practice: An Evidence-based Approach, and served as the chairperson of the 2011 and 2016 INS Infusion Therapy Standards of Practice Committee. She is currently the chairperson for the Infusion Nurses Certification Corporation Board of Directors and also serves on the editorial board for Home Healthcare Now. Ms. Gorski was inducted as a fellow in the American Academy of Nursing in 2006 and was awarded the CNS of the Year award in 2011 by the National Association of Clinical Nurse Specialists. Lisa Gorski has disclosed that she is on the speakers bureau for Genentech and has served on advisory boards for Baxter, Teleflex, ivwatch, and Hospira. She also serves as a speaker for 3M and BD Medical. Western Schools ensures that this content is free from bias and commercial influence through its peer review process. ABOUT THE PEER REVIEWER Lynn M. Czaplewski, MS, ACNS-BC, CRNI, AOCNS, has been a part-time faculty member in the School of Health at Waukesha County Technical College in Pewaukee, WI, since During this same time period, she served as a clinical nurse specialist (CNS) and director of nursing services at Oncology Alliance and as an oncology CNS at Columbia St. Mary s Hospital and Froedtert Hospital, all in Milwaukee, WI. She received her bachelor of science degree in nursing from Regents College in Albany, NY, and her master s degree as a CNS from University of Wisconsin Milwaukee. She is certified as an infusion therapy nurse, a clinical specialist in adult health, and advanced oncology CNS. Ms. Czaplewski has served as president of the Infusion Nurses Society (INS), as a reviewer for the INS s 2016 Infusion Nursing Standards of Practice, and as an editorial board member of the Oncology Nursing Certification Corporation. She has published articles and book chapters and has presented on topics of infusion nursing. Lynn M. Czaplewski has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book. Nurse Planner: Deborah A. Bauer, MSN, RN The planner who worked on this continuing education activity has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book. Copy Editor: Graphic World, Inc. Western Schools courses are designed to provide healthcare professionals with the educational information they need to enhance their career development as well as to work collaboratively on improving patient care. The information provided within these course materials is the result of research and consultation with prominent healthcare authorities and is, to the best of our knowledge, current and accurate at the time of printing. However, course materials are provided with the understanding that Western Schools is not engaged in offering legal, medical, or other professional advice. Western Schools courses and course materials are not meant to act as a substitute for seeking professional advice or conducting individual research. When the information provided in course materials is applied to individual cases, all recommendations must be considered in light of each case s unique circumstances. Western Schools course materials are intended solely for your use and not for the purpose of providing advice or recommendations to third parties. Western Schools absolves itself of any responsibility for adverse consequences resulting from the failure to seek medical, or other professional advice. Western Schools further absolves itself of any responsibility for updating or revising any programs or publications presented, published, distributed, or sponsored by Western Schools unless otherwise agreed to as part of an individual purchase contract. Products (including brand names) mentioned or pictured in Western Schools courses are not endorsed by Western Schools, any of its accrediting organizations, or any state licensing board. ISBN: COPYRIGHT 2018 S.C. Publishing. All Rights Reserved. No part(s) of this material may be reprinted, reproduced, transmitted, stored in a retrieval system, or otherwise utilized, in any form or by any means electronic or mechanical, including photocopying or recording, now existing or hereinafter invented, nor may any part of this course be used for teaching without written permission from the publisher. FP1217WS ii

3 COURSE INSTRUCTIONS IMPORTANT: Read these instructions BEFORE proceeding! HOW TO EARN CONTINUING EDUCATION CREDIT To successfully complete this course you must: 1) Read the entire course 2) Pass the final exam with a score of 75% or higher* 3) Complete the course evaluation *You have three attempts to pass the exam. If you take the exam online, and fail to receive a passing grade, select Retake Exam. If you submit the exam by mail or fax and you fail to receive a passing grade, you will be notified by mail and receive an additional answer sheet. Final exams must be received at Western Schools before the Complete By date located at the top of the FasTrax answer sheet enclosed with your course. Note: The Complete By date is either 1 year from the date of purchase, or the expiration date assigned to the course, whichever date comes first. HOW TO SUBMIT THE FINAL EXAM AND COURSE EVALUATION ONLINE: BEST OPTION! For instant grading, regardless of course format purchased, submit your exam online at Benefits of submitting exam answers online: Save time and postage Access grade results instantly and retake the exam immediately, if needed Identify and review questions answered incorrectly Access certificate of completion instantly Note: If you have not yet registered on Western Schools website, you will need to register and then call customer service at to request your courses be made available to you online. Mail or Fax: To submit your exam and evaluation answers by mail or fax, fill out the FasTrax answer sheet, which is preprinted with your name, address, and course title. If you are completing more than one course, be sure to record your answers on the correct corresponding answer sheet. Complete the FasTrax Answer Sheet using blue or black ink only. If you make an error use correction fluid. If the exam has fewer than 100 questions, leave any remaining answer circles blank. Respond to the evaluation questions under the heading Evaluation, found on the right-hand side of the FasTrax answer sheet. See the FasTrax Exam Grading & Certificate Issue Options enclosed with your course order for further instructions. CHANGE OF ADDRESS? Contact our customer service department at , or customerservice@westernschools.com, if your postal or address changes prior to completing this course. WESTERN SCHOOLS GUARANTEES YOUR SATISFACTION If any continuing education course fails to meet your expectations, or if you are not satisfied for any reason, you may return the course materials for an exchange or a refund (excluding shipping and handling) within 30 days, provided that you have not already received continuing education credit for the course. Software, video, and audio courses must be returned unopened. Textbooks must not be written in or marked up in any other way. Thank you for using Western Schools to fulfill your continuing education needs! WESTERN SCHOOLS P.O. Box 1930, Brockton, MA iii

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5 WESTERN SCHOOLS COURSE EVALUATION PERIPHERAL VASCULAR ACCESS DEVICES: PLACEMENT, CARE, AND MAINTENANCE INSTRUCTIONS: Using the scale below, please respond to the following evaluation statements. All responses should be recorded in the right-hand column of the FasTrax answer sheet, in the section marked Evaluation. Be sure to fill in each corresponding answer circle completely using blue or black ink. Leave any remaining answer circles blank. A B C D Agree Agree Disagree Disagree Strongly Somewhat Somewhat Strongly OUTCOMES: After completing this course, I am able to: 1. Discuss issues related to the selection and placement of peripheral, subcutaneous, and intraosseous access devices. 2. Discuss the ongoing care and maintenance required to safely manage short peripheral and midline catheters and reduce the risk for complications. COURSE CONTENT 3. The course content was presented in a well-organized and clearly written manner. 4. The course content was presented in a fair, unbiased, and balanced manner. 5. The course content presented current developments in the field. 6. The course was relevant to my professional practice or interests. 7. The final examination was at an appropriate level for the content of the course. 8. The course expanded my knowledge and enhanced my skills related to the subject matter. 9. I intend to apply the knowledge and skills I ve learned to my practice. A. Yes B. Unsure C. No D. Not Applicable CUSTOMER SERVICE The following section addresses your experience in interacting with Western Schools. Use the scale below to respond to the statements in this section. A. Yes B. No C. Not Applicable 10. Western Schools staff was responsive to my request for disability accommodations. 11. The Western Schools website was informative and easy to navigate. 12. The process of ordering was easy and efficient. 13. Western Schools staff was knowledgeable and helpful in addressing my questions or problems. ATTESTATION 14. I certify that I have read the course materials and personally completed the final examination based on the material presented. Mark A for Agree and B for Disagree. v continued on next page

6 vi Course Evaluation Peripheral Vascular Access Devices: Placement, Care, and Maintenance COURSE RATING 15. My overall rating for this course is A. Poor B. Below Average C. Average D. Good E. Excellent You may be contacted within 3 to 6 months of completing this course to participate in a brief survey to evaluate the impact of this course on your clinical practice and patient/client outcomes. Note: To provide additional feedback regarding this course and Western Schools services, or to suggest new course topics, use the space provided on the Important Information form found on the back of the FasTrax instruction sheet included with your course.

7 CONTENTS Course Evaluation...v Figures and Tables...ix Pretest...xi Introduction...xiii Learning Outcomes...xiii Chapter 1: Peripheral Vascular Access Devices and Alternative Infusion Access: Device Selection and Placement...1 Learning Outcome...1 Chapter Objectives...1 Introduction...1 Definitions and Descriptions: Peripheral Access Devices...2 Venous Anatomy and Physiology...4 Factors Affecting VAD Selection...4 Peripheral IV Catheter Placement...7 Preparation for Venipuncture...7 Catheter Selection...8 Vein Identification...8 Vein Selection...9 Pain Management...11 Site Preparation: Skin Antisepsis...12 Catheter Placement...12 Alternative Infusion Access: The Subcutaneous Route...13 Alternative Infusion Access: Intraosseous Access...15 Documentation...17 Case Study Case Study Summary...19 Exam Questions...21 References...23 Chapter 2: Peripheral Vascular Access Devices: Care and Maintenance...25 Learning Outcome...25 Chapter Objectives...25 Introduction...25 Assessment...25 vii

8 viii Contents Peripheral Vascular Access Devices: Placement, Care, and Maintenance Peripheral IV Site Rotation...27 Site Care and Dressing Changes...28 Catheter Stabilization...29 Site Protection and Joint Stabilization...30 Maintaining Patency: Catheter Flushing and Locking...30 Needleless Connectors and Other Add-On Devices...31 Blood Sampling Via a Peripheral Catheter...34 Patient Education...35 Documentation...35 Case Study Summary...36 Exam Questions...37 References...39 Summary...41 Resources...43 Glossary...45

9 FIGURES AND TABLES Chapter 1 Table 1-1: Peripheral Catheter Indications, Advantages, and Disadvantages...3 Table 1-2: Noncytotoxic Vesicant List...6 Figure 1-1: View of Veins Using Near-Infrared Technology...9 Figure 1-2: Veins of the Arm and Hand...10 Figure 1-3: Bone Anatomy...16 Chapter 2 Table 2-1: Signs and Symptoms of Peripheral IV Complications...27 Table 2-2: Needleless Connector Function and Implications...33 Figure 2-1: Passive Disinfection Caps Placed on Ends of the Catheter Lumens...34 ix

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11 PRETEST 1. Begin this course by taking the pretest. Circle the answers to the questions on this page, or write the answers on a separate sheet of paper. Do not log answers to the pretest questions on the FasTrax test sheet included with the course. 2. Compare your answers to the answers in the PRETEST KEY located at the end of the pretest. The pretest key indicates the page where the content of that question is discussed. Make note of the questions you missed, so that you can focus on those areas as you complete the course. 3. Read the entire course and complete the exam questions at the end of each chapter. Answers to the exam questions should be logged on the FasTrax test sheet included with the course. Note: Choose the one option that BEST answers each question. 1. The most appropriate veins for insertion of a peripheral intravenous catheter are located in the a. antecubital space. b. dominant extremity. c. hand. d. wrist area. 2. The subcutaneous route is an alternative infusion route that is appropriate for administration of a. antibiotics. b. hydration fluids. c. parenteral nutrition. d. meperidine infusions. 3. Dwell time for intraosseous access is limited to a. 24 hours. b. 12 hours. c. 8 hours. d. 2 hours. PRETEST KEY 1. C Page 9 2. B Page A Page A Page C Page A Page 32 xi 4. Lack of a blood return from a peripheral catheter when planning to administer a vesicant medication should result in a. catheter removal and replacement. b. slow medication administration. c. obtaining a physician order for administration. d. an automatic peripherally inserted central catheter placement. 5. Catheter locking refers to the solution left instilled in the catheter to prevent a. flushing. b. movement. c. occlusion. d. infection. 6. The simplest type of needleless connector a. consists of a split septum. b. is considered a mechanical valve. c. allows only infusion. d. must be changed each day.

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13 INTRODUCTION LEARNING OUTCOMES After completing this course, the learner will be able to: 1. Discuss issues related to the selection and placement of peripheral, subcutaneous, and intraosseous access devices. 2. Discuss the ongoing care and maintenance required to safely manage short peripheral and midline catheters and reduce the risk for complications. Infusion therapy is administered across all healthcare settings, including hospitals, long-term care facilities, outpatient settings, physician offices, and the home. For nurses working in hospitals, placement of a vascular access device (VAD) for infusion therapy is the most common invasive procedure. Because it is such common practice, nurses may consider infusion therapy routine and may underestimate potential risks and complications that may be serious and even life-threatening. Education and orientation to infusion therapy practices and assessment of competency within any organization vary. Competency may focus on psychomotor skills but not address rationale, decision making, and critical thinking. In a survey conducted by the Infusion Nurses Society (Vizcarra et al., 2014), in relation to peripheral intravenous (IV) catheters, 71% reported having received on-the-job training often using a see one, do one approach. Although the skill level in placement of devices is important, knowledge related to the rationale for selection of the most appropriate vascular access device and evidence-based care for the patient often is lacking. When appropriate care is not provided, it potentially affects clinical outcomes. This course is intended for nurses who administer infusion therapy in all healthcare settings. The course describes different peripheral VADs, the factors that affect VAD selection, and the effects of VAD placement. Selection of a suitable vein site is discussed as well as interventions to decrease pain associated with their insertion. Safety concerns are explained, including issues related to peripheral catheter site rotation, routine site care and protection, flushing and locking, and the risks and benefits of peripheral catheter blood sampling. The course is designed for both newer and experienced nurses. The newer or less-experienced nurse who takes this course will gain information needed to become knowledgeable and confident in providing infusion therapy-related care, whereas the experienced nurse will find opportunities to review the basics and grow in understanding the professional implications of practicing infusion therapy. Reference Vizcarra, C., Cassutt, C., Corbitt, N., Richardson, D., Runde, D., & Stafford, K. (2014). Recommendations for improving safety practices with short peripheral catheters. Journal of Infusion Nursing, 37(2), xiii

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15 CHAPTER 1 PERIPHERAL VASCULAR ACCESS DEVICES AND ALTERNATIVE INFUSION ACCESS: DEVICE SELECTION AND PLACEMENT LEARNING OUTCOME After completing this chapter, the learner will be able to discuss issues related to the selection and placement of peripheral, subcutaneous, and intraosseous access devices. CHAPTER OBJECTIVES After completing this chapter, the learner will be able to: 1. Describe the different peripheral vascular access devices (VAD) and safety measures. 2. Discuss the anatomy of a vein and the effects of VAD placement. 3. Discuss factors that affect VAD selection, including type of treatment, duration, patient s age, comorbidities, and available resources. 4. Describe preparation and catheter selection before placement of a VAD device. 5. Explain methods used to identify a vein and the selection of a suitable vein site for infusion. 6. Discuss interventions to decrease pain associated with peripheral intravenous (IV) catheter insertion. 7. Explain the process for peripheral IV catheter placement and safety concerns. 8. Describe indications for the use of the subcutaneous route or an intraosseous access device. INTRODUCTION The first step in provision of infusion therapy is the selection and placement of an appropriate vascular access device (VAD). Most patients in hospitals will receive at least one peripheral intravenous (IV) catheter, making it the most commonly used invasive device. Because it is so common, nurses often underestimate the risks associated with peripheral access. Based on a review of the literature, peripheral IV catheters fail 35% to 50% of the time (Helm, Klausner, Klemperer, Flint, & Huang, 2015) with complications that lead to pain, patient dissatisfaction, depletion of venous access, and increased costs in treating minor and major complications. There is great focus and emphasis on appropriate selection and placement of VADs to reduce such complications. The Infusion Therapy Standards of Practice (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016) provides recommendations for VAD 1

16 Chapter 1 2 Peripheral Vascular Access Devices: Placement, Care, and Maintenance selection. It is important to recognize that a positive patient outcome is maximized when the right VAD is selected, properly placed, and maintained. One key strategy for this is to select the least invasive VAD that has the greatest likelihood of reaching the end of the planned infusion therapy with the fewest number of replacements and the lowest rate of complications (Gorski, Hadaway, Hagle, McGoldrick, Meyer, et al., 2016). Although a peripheral IV catheter would be considered a less invasive device and quite often is a good choice, the anticipated type and duration of infusion therapy may make a central VAD or an alternative route more appropriate. For example, there is growing use of the subcutaneous (SC) route because it is a relatively simple procedure, can be used in most healthcare settings, and a number of medications as well as hydration fluids may be safely administered subcutaneously (Arthur, 2015; Caccialanza, Constans, Cotogni, Zaloga, & Pontes-Arruda, 2016). Another alternative, primarily used in emergent settings, is the intraosseous (IO) route, which provides a rapid means of infusion access. In a clinical practice guideline by the Emergency Nurses Association (2015), both the SC and IO routes are recommended as alternatives for patients with difficult peripheral venous access. It is important that the nurse evaluate the order for infusion therapy and the most appropriate VAD for administration. With a sound knowledge base, the nurse is prepared to be a patient advocate, making the decision for the most appropriate device, be it a peripheral catheter, an alternative route, or a central VAD. The purpose of the present chapter is to familiarize the nurse with the peripheral and alternative access routes for infusion therapy. DEFINITIONS AND DESCRIPTIONS: PERIPHERAL ACCESS DEVICES A peripheral IV access device, more commonly called a catheter, has a tip that terminates in the peripheral vasculature, most often the veins located in the upper extremities. There are traditional short peripheral catheters (SPCs), the term used by the Infusion Nurses Society (INS), and midline peripheral catheters. There are two basic categories of SPC: 1. The over-the-needle catheter leaves a plastictype catheter in place after needle removal. This is the most common type of peripheral IV. It can remain in place for several days. 2. The stainless steel needle, sometimes called a butterfly, is indicated only for single-dose administration and is not used frequently. It most often is used in obtaining blood samples for laboratory studies. The butterfly also is used for therapeutic phlebotomies. In terms of infusion administration, appropriate indications include patients who require a one-time or infrequent infusion; for example, the patient with hemophilia who requires an intermittent IV infusion of factor replacement. Stainless steel needles are immediately removed after each use because they are associated with a high risk for infiltration. (Gorski, Hadaway, Hagle, McGoldrick, Meyer, et al., 2016) The midline catheter is a longer peripheral catheter placed in a peripheral vein. The placement and use of midlines are becoming quite prevalent across the country. The midline can be thought of as a bridge between an SPC and a central VAD. It is usually inserted in the upper arm, above the antecubital fossa, with the catheter tip located at or below the level of

17 Chapter 1 Peripheral Vascular Access Devices and Alternative Infusion Access: Device Selection and Placement 3 the axilla. Typical medications and solutions administered via a midline include antimicrobials, fluid replacement, and analgesics. Midline catheters are placed by nurses who have been specially trained in the technique for their insertion. Indications, advantages, and disadvantages of SPC and midline catheters are summarized in Table 1-1. Personal safety is paramount when placing peripheral IV catheters. Needlestick injuries from hollow-bore needles filled with blood, such as peripheral IV catheters, pose the risk for transmission of diseases such as hepatitis and HIV. Only catheters with built-in safety features that reduce the risk for accidental needlestick should be used. There are two types of safety catheters: active and passive. Active safety catheters require the nurse to manually activate the safety mechanism, for example, by pushing a button. If distracted or busy, the nurse could forget to activate the safety mechanism, thus enabling exposure to a needle and increasing the risk for injury. Passive safety catheters do not require the nurse to activate any mechanism because it is automatically activated during product use. The evidence supports passive safety device use, and the healthcare market is moving toward their use. The INS recommends that organizations consider the use of passive devices (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). Based on a multicenter study in France, passive devices were associated with the lowest rate of needlestick injury (Tosini et al., 2010). Nurses should understand the type of VADs used in their individual work settings, including each device s safety mechanisms; be active participants in their organizations plans to reduce needlestick injuries; and TABLE 1-1: PERIPHERAL CATHETER INDICATIONS, ADVANTAGES, AND DISADVANTAGES Type of VAD Indications Advantages Disadvantages Short peripheral catheter Peripheral midline catheter Short duration (<7 days) or intermittent infusion (e.g., monthly infusion for a home care patient) Nonirritating infusate, osmolarity <900 mosm/l, dextrose <10% concentration Expected duration of IV therapy up to 4 weeks Nonirritating infusate with osmolarity <900 mosm/l, dextrose <10% concentration Low risk for infection Low cost Placed by nurses Low risk for infection Single, double lumen Does not require x-ray confirmation of catheter tip Less frequent catheter replacement than short, peripheral catheter Less costly than CVAD Short term Limitations in types of medications and solutions that may be infused Site may need to be replaced Must be placed by specially trained nurse Limited indications, same as short, peripheral IV catheter; primarily hydration fluids or nonirritating antimicrobial drugs VAD = vascular access device; IV = intravenous; CVAD = central vascular access device. Note. Adapted from Phillips, L., & Gorski, L. A. (2014). Manual of I.V. therapeutics: Evidence based practice for infusion therapy. Philadelphia, PA: FA Davis. Gorski, L. A., Hadaway, L., Hagle, M., McGoldrick, M., Orr, M., & Doellman, D. (2016). Infusion therapy standards of practice. Journal of Infusion Nursing, 39(1 Suppl.), S1-S159.

18 Chapter 1 4 Peripheral Vascular Access Devices: Placement, Care, and Maintenance be advocates for passive safety-engineered devices. VENOUS ANATOMY AND PHYSIOLOGY A brief review of venous anatomy and physiology is presented to provide the reader with information that supports proper decision making, problem solving, and insertion techniques related to VAD placement. It is important to understand that all vein walls consist of three distinct layers: 1. The tunica adventitia is the outer layer. It consists of connective tissue that supports and surrounds the vein. 2. The tunica media is the middle layer that contains smooth muscle, fibrous tissue, and nerve fibers for vasoconstriction and vasodilation. Stimulation by changes in temperature or by mechanical or chemical irritation may cause spasms within the vein. For example, administration of a cold solution may cause vasoconstriction, impede blood flow, and cause pain. 3. The tunica intima, the innermost layer, consists of a single layer of smooth, flat endothelial cells that line the length of each vein. Trauma to the endothelial cells can result in thrombotic clot formation. The endothelial cells of the tunica intima can be damaged easily by various IV insertion- and care-related factors, such as advancing the catheter too rapidly, inserting a catheter too large for the vein, catheter motion caused by inadequate catheter stabilization, microorganisms entering the vein during cannulation because of inadequate skin antisepsis, and the infusion of irritating solutions. Valves originate from the tunica intima into the lumen of the vein. The purpose of the valves is to keep blood moving toward the heart. Valves are found in most veins, except for those veins that are very small or very large. Valves are usually found at bifurcations, where two veins meet. Their presence may be seen with a noticeable bulge in the veins. There are no diagrams listing specific locations for valves within the superficial veins used for venipuncture because there is great variation among individual patients. The significance of the valves may be recognized when blood withdrawal is attempted. The valves may compress and close the vein lumen when suction is applied, not allowing a blood return. A catheter tip lying against a valve can impede the flow of the infusion as well. When caring for the older patient, the nurse must recognize that the tunica intima and the tunica media become thicker, which make vein entry more difficult. Additionally, the valves become more rigid and sclerotic (Coulter, 2016). FACTORS AFFECTING VAD SELECTION Factors to consider when assessing and determining the most appropriate device for the patient include an analysis of the prescribed infusate or treatment regimen; anticipated duration of infusion therapy; vascular characteristics; and patient age, comorbidities, history of infusion therapy, preference for VAD location, and ability and resources available to care for the device (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). This assessment may occur at various times in any healthcare setting, for example, at admission to a hospital, in an outpatient setting, during the course of home care when a patient presents with a need for IV antibiotics, or in a long-term care facility when a patient becomes dehydrated. The assess-

19 Chapter 1 Peripheral Vascular Access Devices and Alternative Infusion Access: Device Selection and Placement 5 ment process may be ongoing as infusion needs change over time. For SPCs, the anticipated duration of infusion therapy in conjunction with the prescribed infusate characteristics (irritant, vesicant, and/ or high osmolarity) and the availability of peripheral sites are important decision-making points. Using an expert consensus method, appropriateness criteria for use and care of VADs were developed for hospitalized patients (Chopra et al., 2015). This study, referred to as MAGIC (Michigan Appropriateness Guide for Intravenous Catheters), is widely cited and increasingly applied in practice because it provides some specific recommendations in terms of proposed duration of infusion therapy as follows: For peripherally compatible (i.e., nonirritating) infusates, choose an SPC for no more than 5 days of infusion and a midline catheter for infusions anticipated to up to 14 days. For infusions anticipated to last beyond 14 days, a central line such as a peripherally inserted central catheter (PICC) should be considered. Peripheral and midline catheters are not recommended for any duration of peripherally noncompatible (e.g., osmolarity >900 mosm/l, dextrose concentration >10%) infusates. (Chopra et al., 2015) The INS specifically states that SPCs or midline catheters should not be placed for administration of continuous vesicant therapy, parenteral nutrition, or infusates with an osmolarity greater than 900 mosm/l (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). A vesicant is defined as an agent capable of causing tissue damage when it escapes outside of the blood vessel into the surrounding tissue this complication is called extravasation. A number of chemotherapy drugs are vesicants and are administered by oncology nurses who are well educated in risks and interventions. Nurses who work in general medical-surgical settings are frequently unaware of noncytotoxic vesicant drugs and the risks associated with administration. Recognizing that the first step in reducing extravasation risk begins with the identification and recognition of vesicant drugs and solutions, the INS identified a red and yellow list of vesicants (Gorski et al., 2017) as shown in Table 1-2. Large infiltrations of nonvesicant medications or solutions may also be associated with severe tissue damage. Red list vesicants, defined as well-recognized vesicants with multiple citations and reports of tissue damage upon extravasation, include dobutamine, dextrose solutions with greater than or equal to 12.5% dextrose concentration, and parenteral nutrition solutions with an osmolarity greater than 900 mosm/l. Yellow list vesicants are associated with fewer published reports of extravasation, but published drug information and infusate characteristics indicate caution and potential for tissue damage. Peripheral administration of a shortterm vesicant infusion or a small number of intermittent doses may be appropriate given a patient s vascular access. For example, in the situation of a severe hypoglycemic episode, administration of 50% dextrose is required. The nurse must be aware of the risk and carefully assess the patency of the SPC before administration, or permanent damage may result. When the patient requires continued infusions or frequent vesicant administration, the nurse must advocate for a central vascular access device (CVAD; Gorski et al., 2017). Osmolarity refers to the concentration of particles in the solution. Circulating plasma is isotonic at approximately 290 mosm/l. Hypertonic solutions contain more particles and thus have a higher osmolarity. Hypertonic solutions draw water out of the blood vessel cells,

20 Chapter 1 6 Peripheral Vascular Access Devices: Placement, Care, and Maintenance TABLE 1-2: NONCYTOTOXIC VESICANT LIST RED LIST Well-recognized vesicants with multiple citations and reports of tissue damage upon extravasation YELLOW LIST Vesicants associated with fewer published reports of extravasation; published drug information and infusate characteristics indicate caution and potential for tissue damage Acyclovir Amiodarone Arginine Calcium chloride Calcium gluconate Contrast media nonionic Dextrose concentration 12.5% Dextrose concentration 10% to 12.5% Dobutamine Mannitol 20% Dopamine Nafcillin Epinephrine Pentamidine Norepinephrine Pentobarbital sodium Parenteral nutrition solutions >900 mosm/l Phenobarbital sodium Phenylephrine Potassium 60 meq/l Phenytoin Vancomycin hydrochloride Promethazine Sodium bicarbonate Sodium chloride 3% Vasopressin Note. From Infusion Nurses Society. (2016). Noncytotoxic vesicant medications and solutions. Norwood, MA: Author. Retrieved from center.ins1.org/products/noncytotoxic-vesicant-medications-and-solutions. Used with permission. causing shrinkage and exposing the endothelial cells to damage, potentially causing phlebitis. Solutions such as total parenteral nutrition are always given via a CVAD due to high osmolarity as well as high dextrose content. Other examples of hypertonic solutions include 10% calcium chloride, 20% mannitol, and 3% sodium chloride solution. Information about infusate characteristics can be obtained from the pharmacist or reference textbooks. Caution is recommended with intermittent vesicant infusions via midline catheters due to the risk for undetected extravasation in the deep veins of the upper arm. The greatest controversy has been in relation to administration of vancomycin via a midline catheter. Current research has demonstrated that it may be safely administered via midlines (Caparas & Hu, 2014; Caparas & Hung, 2017). Research related to the safe medication infusion via midline catheters continues to evolve. Support systems and resources must be considered, especially when planning for infusion therapy beyond the hospital. Many patients and their caregivers will become involved in VAD care and maintenance, so patient preferences should be considered. Patients should be given the opportunity to evaluate the various types of VADs in light of their lifestyles, their abilities, and their willingness to perform needed catheter maintenance care. Patients living at home are typically very engaged in their self-care, and their needs should always be assessed. Patients should be presented with information related to VAD options, advantages, and disadvantages. It is helpful to provide patients with sample devices

21 Chapter 1 Peripheral Vascular Access Devices and Alternative Infusion Access: Device Selection and Placement 7 Practice Pointers: Infusate Considerations for Peripheral Administration Choose a peripheral IV for short courses of infusion therapy when the prescribed infusate(s) is nonirritating: The osmolarity is less than 900 mosm/l, and the dextrose concentration is less than 10%. Choose a CVAD when the prescribed infusate is hyperosmolar (>900 mosm/l) or has a dextrose concentration exceeding 10%. Collaborate with the pharmacist for questions regarding infusate characteristics. Collaborate with the physician for placement of a CVAD for the infusion of irritating infusates. to help them to understand what they look like and how the devices will affect their lives. Device availability also is a consideration. In smaller communities, resources and supplies may not be readily available. For example, a midline catheter may be an appropriate option for some patients, but nurses who possess the skills to place a midline may not be available. PERIPHERAL IV CATHETER PLACEMENT Preparation for Venipuncture Patient education is imperative before peripheral IV placement and should address the purpose for placement and what to expect in terms of the procedure. Following placement, patient education should also address signs and Practice Pointers: General Considerations in VAD Selection Characteristics of the infusate osmolarity, known irritant, vesicant Anticipated duration of infusion therapy Vascular characteristics appropriate veins available for IV access Patient age, comorbidities older patients, patients with diabetes mellitus, and those on long-term steroids may have fragile veins History of infusion therapy what does the patient say about the ease or difficulty of previous blood draws or IV access Preference for location often the patient s dominant arm has the most accessible veins, but patient activity must be considered Ability and resources to care for the device (e.g., home care patients) depending on the device and care required, a home care nurse or competent caregiver must be available to the patient Device availability (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016) symptoms indicative of complications and the importance of immediate reporting to the nurse. For example, the patient should be instructed to immediately report any swelling or pain at the insertion site. It is important to make sure that the patient is in a comfortable position, that privacy is ensured, and that the environment is conducive for the

22 Chapter 1 8 Peripheral Vascular Access Devices: Placement, Care, and Maintenance nurse to maintain aseptic technique and place the peripheral IV. Good lighting for venous assessment and peripheral IV placement are essential. In alternative care settings, such as the home, creating a good environment can be challenging. Often, the kitchen table works well because there is usually good light and seating. The table can be cleaned, a fresh barrier placed, and all supplies can be organized and accessible. Practice Pointers: Creating a Good Environment for Peripheral IV Placement Ensure there is patient privacy. Make sure the patient is in a comfortable position. Ensure there is good lighting. Obtain and organize all supplies needed for peripheral IV placement. Catheter Selection Peripheral IV catheters are available in a variety of gauge sizes and lengths. Recommendations include using the smallest gauge and length appropriate for the prescribed therapy (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). Small gauge catheters take up less space in the vein, allowing for blood flow around the catheter, and also cause less trauma when inserted. If a larger gauge catheter is required, such as with emergent care or blood transfusions, a larger vein should be chosen. For most applications, a 22- to 24-gauge catheter is most appropriate, and blood transfusions can be given through these catheters. An 18- to 20-gauge catheter often is appropriate in emergent situations. Vein Identification Venous Distention Most often, a tourniquet is used to promote venous distention as part of the venous assessment process and then in actual preparation for venipuncture. It is important that the tourniquet is applied to impede venous flow but not arterial flow; an arterial pulse should be easily palpable distal to the tourniquet. Tourniquets should be applied loosely or not used at all in patients with fragile veins or in those who bruise easily, such as older adult patients. The tourniquet is released immediately upon cannulating the vein. Alternative methods for promoting venous distention include the use of a blood pressure cuff inflated to just below diastolic pressure, lowering the extremity below the heart and instructing the patient to open and close his or her fist, lightly stroking the vein downward, and the use of warm compresses. The use of dry heat is often helpful in venous distention. Visualization Technology The use of visualization technology to identify appropriate veins for cannulation, especially for patients with difficult venous access, is increasing. The INS (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016) categorizes such technology as follows: Transillumination: This term simply refers to shining of a light through a body area or organ. There are a number of specific devices available that provide transillumination of peripheral veins. These devices are easy to use. The room should be darkened to remove ambient light when using these devices. Near-infrared: This is used to identify superficial veins for SPC placement. Veins can be visualized to about 10 mm below the skin surface. Bifurcations and venous valves may be identified and the venous pathway can be seen (Gorski, Hadaway, Hagle, McGoldrick,

23 Chapter 1 Peripheral Vascular Access Devices and Alternative Infusion Access: Device Selection and Placement 9 Orr, et al., 2016). Near-infrared may be a valuable tool especially for placement of SPCs in the forearm (see Figure 1-1). Ultrasound (US): US is used by nurses and other clinicians specifically trained in its use. When used for SPC insertion, US is associated with fewer venipuncture attempts in both adults and children (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). The use of US allows for placement in deeper veins; however, longer catheters must be used to ensure that the catheter adequately resides in the vein or the risk for infiltration/extravasation is increased. US is routinely used with midline catheter placement. In patients with difficult venous access, a randomized controlled trial compared US-guided SPC insertion to usual placement using palpation. Emergency room nurses who were trained in the use of US were 2.52 times more likely to be successful in SPC insertion using US (76% success rate) compared with usual placement using palpation (56% success rate). (Bahl, Pandurangadu, Tucker, & Bagan, 2016) Vein Selection The veins most commonly used for insertion of peripheral IV catheters are the superficial veins in the hand and dorsal side of the forearm (see Figure 1-2). The metacarpal veins located on the dorsum of the hand are easily visualized, palpated, and accessed. Their use may be limited because of excessive fat in infants and loss of SC tissue and skin turgor in older adults. The cephalic vein follows along the radius side of the forearm; it is a larger vein and relatively easy to access. The accessory cephalic vein branches off of the cephalic vein along the radius. The basilic vein follows along the ulnar side of the forearm to the upper arm; it is easily palpated but moves more easily, so it is important to stabilize the vein with traction during access. The antecubital veins including the median cephalic (radius side), median basilic (ulnar side), and median cubital (in front of elbow) are located in the bend of the elbow. These are large veins that should be reserved for FIGURE 1-1: VIEW OF VEINS USING NEAR-INFRARED TECHNOLOGY Note. From Christie Medical Holdings, Memphis, TN. Retrieved from Used with permission.

24 Chapter 1 10 Peripheral Vascular Access Devices: Placement, Care, and Maintenance FIGURE 1-2: VEINS OF THE ARM AND HAND Posterior (dorsal) Anterior (palmar) Cephalic vein Basilic vein Accessory cephalic vein Accessory cephalic vein Median cephalic vein Cephalic vein Intermediate (median) antebrachial vein Median basilic vein Perforating veins Cephalic vein Basilic vein Dorsal metacarpal veins Dorsal venous arch Intercapitular veins Note. From Western Schools, blood sampling and emergency, rather than routine placement of a peripheral IV. Traditional practice has been to begin placement of the SPC in the hand and then move up the arm for subsequent SPC placement and to rotate sites based on an established time frame, for example, every 96 hours. Current research supports site rotation based on clinical indications and changes in the site selection process. Current INS recommendations are to use the venous site most likely to last the full length of the prescribed therapy using the forearm to increase dwell time, decrease pain during dwell time, promote self-care, and prevent accidental removal and occlusions (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). The fore-

25 Chapter 1 Peripheral Vascular Access Devices and Alternative Infusion Access: Device Selection and Placement 11 arm is recommended, as it is likely to last longer due to larger veins where there is better hemodilution of the infusion solution and thus less irritation to the vein wall, less movement (i.e., away from an area of flexion), is easier to stabilize, and there is less interference with activities of daily living. Some additional recommendations include the following: Select a nondominant extremity whenever possible. Consider the patient s activity level and needs if an SPC must be placed in the hand. Use only 22- or 24-gauge catheters in the hand due to small vessel diameter. Avoid infusion of irritating infusates into the small veins of the hand. Subsequent peripheral IV insertions always should be above previous sites. Do not use lower extremities due to risk for tissue damage, thrombophlebitis, and ulceration. The exception is with infants who are not yet walking. Veins or areas to avoid include the following: Places where there is pain upon palpation Compromised veins such as those that are hard and sclerosed Areas of flexion such as veins in the fingers, thumb, and antecubital fossa. Placement in such areas limits range of motion and increases the risk for infiltration and phlebitis due to catheter movement within the vein. In the case of the antecubital fossa, peripheral IV placement interferes with blood sampling and may prevent the use of those veins for a PICC if needed in the future. Areas associated with increased risk for nerve damage such as the cephalic vein at the wrist due to proximity to superficial radial nerve, palm side of the wrist due to proximity to median nerve, and antecubital fossa due to proximity to median/anterior interosseous/antebrachial nerves. Nerve injury can result in permanent damage. The affected extremity when there is evidence of cellulitis, presence of an arteriovenous fistula, history of axillary lymph node dissection, skin grafts, fractures, stroke damage (due to impaired sensation), and planned limb surgery Veins used for insertion of midline catheters include the cephalic, basilic, or median veins above the antecubital fossa. The basilic vein is preferred because it is usually the largest and has fewer obstructions. In infants, a midline may be placed in a scalp vein, with the tip terminating in the external jugular vein above the clavicle or in the leg with the catheter tip below the inguinal crease (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). Pain Management Pain management during peripheral IV catheter insertion should be considered. Although most nurses would agree that peripheral IV insertion can be painful, interventions to minimize pain are not always implemented, especially with adult patients. It is important to assess the patient s tolerance to pain, level of anxiety, and preferences related to pain management. Interventions to reduce anxiety, such as distraction, may be effective. Anesthetic options available to minimize pain include topical transdermal agents such as lidocaine/ prilocaine; intradermal injection of lidocaine hydrochloride solution; intradermal injection of bacteriostatic sodium chloride (the preservative benzyl alcohol acts as a local anesthetic);

26 Chapter 1 12 Peripheral Vascular Access Devices: Placement, Care, and Maintenance iontophoresis, the delivery of drugs, such as lidocaine, through the skin using an electric current; a needle-free cartridge that uses pressurized carbon dioxide to force lidocaine through the skin; sucrose for infants and neonates; and a reusable vibrating cold device that is applied over a cold pack; this type of device is based on the gate control theory. In simple terms, nonpainful input (e.g., cold treatment, rubbing, shaking off pain) closes the gate to painful input from the venipuncture, preventing pain from traveling up the spinal cord to the brain; stimulation by nonnoxious input, in this case cold vibration, suppresses pain. (Capriotti & Frizzell, 2016; Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016) Recent research with pediatric patients demonstrated reduced pain with peripheral IV catheter placement with the use of the needle-free pressurized carbon dioxide device as well as the vibrating cold device (Kearl, Yanger, Montero, Morelos-Hoeard, & Claudius, 2015; Kelly, Russell, Devgon, & Rosen, 2017; Potts, Davis, Elci, & Fein, 2017). For neonates and term infants, sucrose (e.g., provided on a pacifier) is commonly used for procedural-based pain including venipuncture. In a Cochrane review of 74 randomized controlled trials and including 7,049 neonates, high-quality evidence demonstrated effective pain management without evidence of serious side effects or harm with the use of 2 ml of 24% sucrose before venipuncture (Stevens, Yamada, Ohlsson, Haliburton, & Shorkey, 2016). Site Preparation: Skin Antisepsis One of the most critical steps in reducing the risk for infection is skin preparation using an antiseptic solution. Skin antisepsis is important because microbes on the skin at the insertion site are potentially tracked into the vein along the external surface of the catheter during catheter insertion, a potential source for bloodstream infection. Several steps are involved in site preparation. If the site is visibly dirty, the skin should be washed with soap and water. If there is excess hair at the site, it can be clipped using a scissors or disposable head surgical clippers. The skin should not be shaved as microabrasions from shaving may increase the risk for infection. The preferred antiseptic agent is greater than 0.5% chlorhexidine in alcohol solution; if contraindicated, an iodophor, tincture of iodine, or 70% alcohol may be used (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). Apply the agent for the recommended time frame using a backand-forth method (e.g., 30 seconds for chlorhexidine solutions) and allow it to completely dry. Although traditional practice has been to apply an antiseptic in concentric circles from the insertion, moving outward, this practice has never been studied. An area of skin at least the size of the sterile dressing that will cover the insertion site should be prepared with the antiseptic. It is important that the skin is allowed to fully dry before venipuncture, and the prepared area should not be touched after skin antisepsis. If not, antiseptic can be tracked into the vein during insertion, which can cause phlebitis or vein inflammation. Catheter Placement Catheter placement is a skill that is validated with a competency assessment. Critical issues during placement include maintaining aseptic technique and following the device manufacturer s instructions for use, including safety features of the catheter used. Although the following does not represent every step in peripheral IV insertion, some key procedural points about peripheral IV placement are summarized:

27 Chapter 1 Peripheral Vascular Access Devices and Alternative Infusion Access: Device Selection and Placement 13 Perform hand hygiene and put on gloves; clean gloves are considered acceptable for peripheral IV placement as long as the insertion site is not palpated after skin antisepsis. If it is necessary to repalpate the site, sterile gloves must be used. Inspect the peripheral IV for product integrity; ensure that the catheter is intact within its packaging to ensure catheter sterility. Make sure that all other needed supplies are present, including a tourniquet, skin antiseptic, dressing, saline-filled flush syringe, needleless connector, and/or primed IV tubing. Apply antiseptic to the skin for the required amount of time; for example, chlorhexidine/alcohol solution should be applied for at least 30 seconds. Povidone-iodine must remain on the skin for at least 2 minutes until completely dry. Allow the antiseptic to fully dry. This is important to ensure maximum effectiveness of skin antisepsis and to reduce the risk for tracking in the antiseptic during insertion, which could cause vein irritation and contribute to phlebitis. Do not touch the prepped skin after antisepsis. Apply traction to the skin with the nondominant hand; this helps stabilize the vein, which also contributes to less discomfort during insertion. Ensure that the peripheral IV catheter is bevel side up. Enter the skin/vein at a 10 to 15 angle. Once a blood return is obtained, the angle of the catheter should be lowered and then advanced completely into the vein to prevent the catheter tip from residing in the vessel wall. The tourniquet should then be released and the catheter safety mechanism activated to retract the needle/stylet from the plastic catheter, if required. Avoid probing of the vein during catheter insertion because this may increase the risk for nerve damage. If acute pain or paresthesia occurs upon catheter insertion, or numbness or tingling occur at the IV site, the catheter should be removed immediately because these symptoms could signal nerve damage. Although patients will experience some initial pain with insertion, the pain should resolve with peripheral IV placement. Secure the catheter with a sterile dressing and apply a stabilization device, if used. Label the dressing with the date and the nurse s initials, according to the organization s policies and procedures. It is recommended that a single nurse attempt peripheral IV placement no more than two times with total attempts limited to no more than four. The consequences of multiple attempts at placement include pain, delayed treatment, limiting future vascular access, cost, and increased risk for complications. Patients with difficult vascular access require a careful assessment of VAD needs and collaboration with the healthcare team to discuss appropriate options (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). If a nurse has made two unsuccessful attempts, the nurse with the best skills should evaluate the patient s veins and make further attempts at peripheral IV insertion only if venous access is felt to be adequate. ALTERNATIVE INFUSION ACCESS: THE SUBCUTANEOUS ROUTE An alternative option to IV access is SC tissue access. Lying beneath the dermal layer of the skin, the SC tissue contains blood vessels, nerves, and adipose tissue. Fluids or drugs are absorbed into the blood vessels in

28 Chapter 1 14 Peripheral Vascular Access Devices: Placement, Care, and Maintenance Practice Pointers: Peripheral IV Placement Choose a vein on the hand or arm. Avoid areas of flexion, such as the wrist or elbow. Always start subsequent peripheral IVs above previous sites. Consider local anesthesia or other pain management strategies. Never attempt peripheral IV placement more than twice by one nurse. Use the smallest gauge and length catheter needed to deliver the infusion therapy. the SC space. Although there is a slower rate of achieving the maximum concentration of a medication, there is similar bioavailability by both the SC and the IV administration routes (Arthur, 2015). The advantages of an SC infusion include decreased cost and ease of access compared with IV access. The difficulty of finding a good vein for infusion is eliminated, and most patients have adequate SC tissue to support an infusion. Minimal skill is required, allowing some patients and caregivers to learn SC access (Arthur, 2015). There are two categories of continuous SC infusion therapy: medication infusion and fluid infusion. Continuous SC infusions of opioid drugs (morphine, hydromorphone, and fentanyl for pain and symptom management) for chronic pain are commonly implemented in palliative care and hospice settings. In fact, the dosing for SC opioids is considered equivalent to an IV dose. For example, a patient receiving a continuous morphine infusion via a peripheral IV catheter at 10 mg per hour can be converted to the same dose and rate subcutaneously. Some other medications that may be infused subcutaneously include insulin, deferoxamine mesylate (iron chelation), immunoglobulin, antiemetics, and steroids. Isotonic fluids, such as 5% dextrose in water, 0.9% sodium chloride, and lactated Ringer s solution, also may be given via the SC route for the treatment of mild to moderate dehydration. The term used to describe this procedure is hypodermoclysis. Hypodermoclysis has been used since the 1950s and is currently seeing a resurgence as it is recognized as a relatively easy, lowrisk, and cost-effective method for delivery of hydration fluids. Most often, hypodermoclysis is used with patients experiencing short-term dehydration, such as that associated with the flu or an infection, or in alternate care settings, such as the long-term care facility. Fluids may be infused at a rate of up to 1,500 ml over 24 hours (~60 ml/ hour). More than one infusion site may be used to accomplish a larger infusion volume (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). The infusion is set up the same as an IV administration. A standard administration set is used for hypodermoclysis. Fluids can be infused using gravity with an add-on flow regulator (most common) or a pump; however, the rate of infusion should remain within the limits of fluid absorption from SC tissues (Caccialanza et al., 2016). With IV administration, medications or fluids are injected directly into the bloodstream and there is no need for the tissue absorption required with SC injection. Human recombinant hyaluronidase is a medication that can be used to facilitate and hasten the absorption of SC fluids or medications. It is injected just before or with the SC agent. The current INS stan-

29 Chapter 1 Peripheral Vascular Access Devices and Alternative Infusion Access: Device Selection and Placement 15 dards recommend consideration of hyaluronidase to facilitate the dispersion and absorption of hydration fluids and other SC-administered drugs (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). Although most patients tolerate SC infusion quite well, limitations and potential contraindications to the SC route may include poor circulation, limited SC tissue, and bleeding or coagulation disorders. Sites for SC access include the upper arm, subclavicular chest wall, abdomen, upper back, and thighs (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). There are different choices related to the type of SC access device. A 24-gauge over-the-needle catheter, such as used for SPC placement, can be used. It is placed into the SC tissue at about a 30 to 45 angle based on the thickness of the SC tissue. There also are specially designed SC access devices that are manufactured at specific lengths (e.g., 6 or 9 mm) to optimize access to the SC tissue, depending on the thickness of the SC layer. These may leave a metal needle in place or a small plastic-type catheter. There also are sets that allow for more than one SC site to be accessed at the same time; these are used most often for hypodermoclysis and for SC immunoglobulin therapy. Before placement of an SC access device, skin antisepsis is performed as with peripheral IV catheter placement. SC sites used for medication administration are rotated every 7 days and as clinically indicated, based on the integrity of the access site (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). Indications for more frequent site rotation include erythema, swelling, leaking, bruising, burning, and pain. With hypodermoclysis, some nonpainful swelling is expected as the fluid is absorbed and the site is changed after 1,500 ml have been infused. Individual patient assessment is important. For the patients receiving an SC infusion under home care, the patient and family must be taught to check the site every day and report any local signs of irritation that would require site rotation. Patients or family members can be taught to replace the SC access device. ALTERNATIVE INFUSION ACCESS: INTRAOSSEOUS ACCESS Intraosseous (IO) access is defined as placement of a VAD into the matrix of the bone. The long bones of the body have two ends: the diaphysis and the epiphysis. The epiphysis is spongelike bone, whereas the diaphysis contains hard bone with a hollow interior space called the medullary cavity (see Figure 1-3). Bone marrow, consisting of blood, blood-producing cells, and connective tissue, fills the space that is directly connected to the central circulation. Within the IO space, blood flow is steady, even during states of shock. Any medication that can be given as an IV can be given via the IO route because they are both vascular access routes. The primary indication for the IO route is emergent use in patients with limited or no vascular access. In fact, the IO route is recommended by the American Heart Association (2015) as a standard for alternative vascular access and is cited in the algorithms for the American Heart Association s Advanced Cardiac Life Support and Pediatric Advanced Life Support treatment protocols. The IO route also may be used in nonemergent situations when the patient is at risk for increased morbidity or mortality if access is not obtained; use of IO infusion is reported in pediatric anesthesia. As with all VAD placements, nurses who place IO devices must complete an education and competency program that includes demonstration of appropriate IO placement and main-

30 Chapter 1 16 Peripheral Vascular Access Devices: Placement, Care, and Maintenance FIGURE 1-3: BONE ANATOMY Note. From Teleflex. (2013). The science & fundamentals of intraosseous vascular access (2nd ed.). Shavano Park, TX: Vidacare Corporation. Retrieved from Used with permission. Image courtesy of Teleflex Incorporated Teleflex Incorporated. All rights reserved. tenance and knowledge of signs and symptoms of potential complications (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). The most commonly reported sites used for IO access in both adults and children are the proximal and distal tibia and the proximal humerus, the distal femur for children, and the sternum for adults (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). Manufacturers directions for IO devices should be reviewed as each IO device has approval for particular sites. There are a variety of IO devices that are easy to use and very fast, providing access within seconds. Pain management during insertion and infusion should always be considered, especially in the conscious patient. IO catheter insertion pain is variable and generally moderate, but pain associated with pressured IO infusion may be severe (Garside, Prescott, & Shaw, 2015). The use of SC lidocaine is widely recommended at the intended site and also administered into the IO space before starting an infusion (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). It is important to recognize that the IO route is a temporary route and that dwell time is limited to 24 hours. Assessment for the most appropriate VAD for ongoing infusion needs is necessary. Complications are rare with IO access but include extravasation from dislodgement, iatrogenic fracture, growth plate injury, infection, fat emboli, compartment syndrome, and osteomyelitis. The most commonly reported complication is infiltration/extravasation from IO device dislodgement with the risk for a compartment syndrome, which occurs when the fluid or medication collects in tight spaces bound by the fascia, bone, muscle, and skin. The increased pressure of the fluid decreases perfusion in the area, which can lead to irreversible nerve damage and loss of function. Infants and young children are at greater risk due to small bone size and too long needle length. The risk for infectious complications is increased with prolonged infusion or if bacteremia is pres-

31 Chapter 1 Peripheral Vascular Access Devices and Alternative Infusion Access: Device Selection and Placement 17 ent during the time of insertion (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016). DOCUMENTATION As every nurse knows, it is important to document assessments, interventions, and ongoing evaluation in all aspects of patient care. In relation to decision making and placement of the VAD, documentation should include assessment (physical assessment, vital signs); patient education, including specific content and response/understanding; site preparation, including the specific antiseptic used and other safety precautions; local anesthetic, if used; date of insertion; type, length, and gauge/size of the VAD inserted and number of lumens; presence of blood return; identification of the anatomical site or vein by descriptors, landmarks, or drawings; and condition of the site, dressing, type of stabilization device (if used), and patient report of discomfort or pain on insertion. (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016) CASE STUDY 1-1 Mrs. Aster has been on the medical-surgical unit undergoing antimicrobial treatment for an infected diabetic ulcer on her ankle for 3 days. She will require a daily infusion of IV ceftriaxone for at least 2 more weeks. The hospital case manager has met with Mrs. Aster and explored both the outpatient clinic and home care as possible settings for her continued infusion needs. Because her mobility is limited, it would be difficult for her to travel to the clinic on a daily basis; therefore, the plan is to send her home with a home care referral for continued IV administration. You are currently administering the ceftriaxone via a peripheral IV catheter. Questions 1. Because you are involved in Mrs. Aster s discharge planning, what VAD would you recommend for venous access for home care? 2. How would you prepare Mrs. Aster for home IV therapy? Responses 1. When infusion therapy is anticipated to last a week or longer, an alternative to a peripheral IV is recommended, such as a PICC or a midline catheter. In this case, a midline catheter would be a good choice. You have reviewed the drug characteristics for ceftriaxone, and it meets the criteria for a nonirritating infusate; therefore, it can be given peripherally. The midline catheter is a peripheral catheter that should not require replacement. The cost of placement is lower than a PICC because it can be placed by a nurse who is educated and competent in placement. Because the PICC is a central line, it is associated with greater risk. However, the support systems and resources within the organization also must be considered. If your organization lacks an IV team with specially trained nurses who place midline catheters, this may not be an option. A PICC also may be considered, and the patient could be referred to the physician or interventional radiologist for placement. 2. Because Mrs. Aster is going home with a VAD, she should be presented with options for vascular access; however, due to the relatively short need for home IV antibiotic therapy, the choices are limited. The midline becomes the best choice when you consider the INS recommendation to use the least

32 Chapter 1 18 Peripheral Vascular Access Devices: Placement, Care, and Maintenance invasive VAD with the greatest likelihood of reaching end of the planned infusion therapy with the fewest number of replacements and the lowest rate of complications. So you will need to explain to Mrs. Aster about the midline catheter, how it will be placed by a skilled nurse, that it should last for the duration of her course of IV antibiotics, and that she will have some responsibility related to care of the midline, such as how to dress with the catheter in her arm and how to protect the dressing during bathing. Because a home care nurse will be seeing her at home to assist with the care, the home care nurse will provide more detailed information. It is helpful to show Mrs. Aster a midline catheter or a photograph of it to help her understand what the midline looks like and how it may affect her life for the short term. CASE STUDY 1-2 Mr. Tamarack is a 90-year-old male who lives in a skilled nursing facility. He is recovering from a 24-hour flu and has experienced several bouts of diarrhea and some vomiting. Although his symptoms are resolved and he is feeling a little better, you suspect he is dehydrated. Despite the nurses and nursing assistants encouraging him to drink fluids, his intake remains inadequate, his urine output is low, and the urine is dark and concentrated. Laboratory studies ordered earlier today show an elevated blood urea nitrogen level and serum osmolality, indicative of dehydration. The nurse practitioner (NP) has ordered the administration of 1 L of 0.9% NaCl (normal saline) via a peripheral IV catheter over 8 hours daily for 2 days while continuing to encourage oral fluids and monitor his intake. Questions 1. What do you think about this order? 2. What are some considerations in SC fluid administration? 3. What should you teach the patient? Responses 1. There are two options to consider in this patient s case. Usually a peripheral catheter would be a first choice for short-term IV hydration fluids. However, Mr. Tamarack is thin and frail with fragile skin. Furthermore, his venous access is poor with veins that are sclerosed and cordlike. However, although Mr. Tamarack is thin, he has adequate SC tissue in his abdomen and upper thighs. So, another option to consider is SC hydration, or hypodermoclysis, because its primary indication is short-term hydration, particularly in older patients. A major advantage to using the SC route includes the ease of access compared with locating and cannulating a vein. Many of the studies supporting hypodermoclysis were done in long-term care facilities with patients just like Mr. Tamarack. You decide to call the NP, provide the rationale for use of the SC infusion method, and suggest hypodermoclysis instead of IV fluid administration, and the NP agrees. 2. Although the original IV order was to administer 1 L of fluid over 8 hours, the rate would be 125 ml per hour. This is too rapid for hypodermoclysis. You know that 1,500 ml can be administered subcutaneously over 24 hours, representing a rate of approximately 60 ml per hour. This means that instead of completing the liter in 8 hours, the infusion will have to run over about 17 hours, and this rate is clarified in the orders for the fluid administration. The infusion can be run via a standard IV administration set using gravity with a flow regulator (e.g., dial-a-flow ). During the infusion, the site

33 Chapter 1 Peripheral Vascular Access Devices and Alternative Infusion Access: Device Selection and Placement 19 should be monitored for excessive swelling; some nonpainful swelling is expected. 3. Patient education is important, and the patient should be told the following: He is receiving fluid administration due to concern for dehydration. A small catheter will be placed in his belly area. He should not feel pain as the fluid is administered. A small amount of swelling at the site is expected. He should let you know if he has any pain or burning while the fluid infuses. You will be regularly checking on him as the fluid is infused. SUMMARY The nurse plays a critical role in selecting the most appropriate vascular access route. It is important that the nurse understand infusate characteristics, the expected duration of the infusion, and the patient s available venous access. Alternative routes, such as the SC or IO routes, may be appropriate and should be considered for some patients. For those who will require infusion therapy beyond the hospital setting, special attention must be paid to the patient s preferences and lifestyle in selecting the most appropriate access route and device. The nurse who thoroughly understands vascular access options will be able to effectively teach patients and their caregivers about the choices they have for infusion therapy. The confident and knowledgeable nurse will be able to effectively collaborate with physicians and advocate for patients.

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35 EXAM QUESTIONS CHAPTER 1 Questions 1 12 Note: Choose the one option that BEST answers each question. 1. Which of the following statements regarding peripheral intravenous (IV) catheter safety is true? a. There is minimal risk for needlestick injury associated with peripheral IV catheter insertion. b. Decisions on the type of safety devices to use should be made based primarily on cost. c. Catheters with active safety mechanisms are preferred. d. Catheters with passive safety mechanisms are preferred. 2. The layer of the vein that contains smooth muscle, fibrous tissue, and nerve fibers for vasoconstriction and vasodilation is the a. tunica media. b. tunica adventitia. c. tunica intima. d. intraosseous space. 3. Factors that would support placement of a short peripheral catheter include a. infusate osmolarity of 950 mosm/l. b. anticipated duration of infusion therapy of 14 days. c. small infiltrations of nonvesicant medication. d. physician preference. 4. Small-gauge peripheral IV catheters (e.g., 22- to 24-gauge) a. should be avoided because they only allow slow infusion rates. b. allow more blood flow around the catheter. c. dislodge more easily. d. are used only with pediatric patients. 5. Near-infrared technology may be helpful in identifying a. veins deeper than 10 mm. b. presence of venous valves. c. presence of a blood clot. d. presence of a nerve. 6. A good first choice for placement of a peripheral IV catheter is the vein a. in the wrist area. b. on the dorsal side of the forearm. c. in the antecubital fossa. d. above the antecubital fossa. 7. Lower extremity veins are not recommended for peripheral IV placement in adults because of the increased risk for a. infiltration. b. thrombophlebitis. c. nerve damage. d. infection. 21 continued on next page

36 Chapter 1 22 Peripheral Vascular Access Devices: Placement, Care, and Maintenance 8. Which of the following areas should be avoided with peripheral IV placement? a. Cephalic vein in the wrist area b. Metacarpal veins c. Cephalic vein in the midforearm d. Basilic vein in the midforearm 9. Pain management during peripheral IV placement 12. Use of the intraosseous space for the infusion of solutions and medications a. is an appropriate choice in emergent situations. b. is limited because irritating medications can cause bone damage. c. is recommended for adults only. d. is limited to a 48-hour duration. a. is not important because it only hurts for a minute. b. should be considered only with pediatric patients. c. should include administration of a dose of morphine. d. may include the use of a topical anesthetic. 10. When placing a peripheral IV, if a nurse is unable to access the vein after two attempts, the next step should be a. trying at least one more time. b. having another nurse try two more times. c. finding the nurse with the best skills to evaluate the patient s veins. d. calling the physician and requesting placement of a peripherally inserted central catheter. 11. Infusion therapies appropriate for subcutaneous administration include a. morphine and ceftriaxone. b. morphine and 10% dextrose in water. c. morphine and ceftazidime. d. morphine and dextrose 5% in water.

37 REFERENCES American Heart Association. (2015) American Heart Association guidelines for CPR & ECG. Retrieved from guidelines.heart.org/index.php/circulation/ cpr-ecc-guidelines-2/ Arthur, A. (2015). Innovations in subcutaneous infusions. Journal of Infusion Nursing, 38(3), Bahl, A., Pandurangadu, A. V., Tucker, J., & Bagan, M. (2016). A randomized controlled trial assessing the use of ultrasound for nurseperformed IV placement in difficult access ED patients. American Journal of Emergency Medicine, 34, Caccialanza, R., Constans, T., Cotogni, P., Zaloga, G. P., & Pontes-Arruda, A. (2016). Subcutaneous infusion of fluids for hydration or nutrition: A review. Journal of Parenteral and Enteral Nutrition. Advance online publication. doi: / Caparas, J. V., & Hu, J. (2014). Safe administration of vancomycin through a novel midline catheter: A randomized, prospective clinical trial. Journal of Vascular Access, 15(4), Caparas, J. V., & Hung, H. S. (2017). Vancomycin administration through a novel midline catheter: Summary of a 5-year, 108-patient experience in an urban community hospital. Journal of Vascular Access, 22(1), Capriotti, T., & Frizzell, J. P. (2016). Pathophysiology: Introductory concepts and clinical perspectives. Philadelphia, PA: F. A. Davis. Chopra, V., Flanders, S. A., Saint, S., Woller, S. C., O Grady, N. P., Safdar, N., Bernstein, S. J. (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), S1-S40. Coulter, K. (2016). Successful infusion therapy in older adults. Journal of Infusion Nursing, 39(6), Emergency Nurses Association. (2015). Clinical practice guideline: Difficult venous access. Retrieved from org/docs/default-source/resource-library/ practice-resources/cpg/difficultivaccesscpg. pdf?sfvrsn=9944da58_8 Garside, J., Prescott, S., & Shaw, S. (2015). Intraosseous vascular access in critically ill adults A review of the literature. Nursing in Critical Care, 21(3), Gorski, L. A., Hadaway, L., Hagle, M., McGoldrick, M., Meyer, B., & Orr, M. (2016). Policies and procedures for infusion therapy. Norwood, MA: Infusion Nurses Society. Gorski, L. A., Hadaway, L., Hagle, M., McGoldrick, M., Orr, M., & Doellman, D. (2016). Infusion therapy standards of practice. Journal of Infusion Nursing, 39(1 Suppl.), S1-S

38 Chapter 1 24 Peripheral Vascular Access Devices: Placement, Care, and Maintenance Gorski, L. A., Stranz, M., Cook, L., Joseph, J. M., Kokotis, K., Sabatino-Holmes, P., & VanGosen, L. (2017). Development of an evidence-based list of noncytotoxic vesicant medications and solutions. Journal of Infusion Nursing, 40(1), Helm, R. E., Klausner, J. D., Klemperer, J. D., Flint, L. M., & Huang, E. (2015). Accepted by unacceptable: Peripheral IV catheter failure. Journal of Infusion Nursing, 38(3), doi: /nan Infusion Nurses Society. (2016). Noncytotoxic vesicant medications and solutions. Norwood, MA: Author. Retrieved from learningcenter.ins1.org/products/noncytotoxicvesicant-medications-and-solutions Kearl, Y. L., Yanger, S., Montero, S., Morelos- Howard, E., & Claudius, I. (2015). Does combined use of the J-tip and Buzzy device decrease the pain of venipuncture in a pediatric population? Journal of Pediatric Nursing, 30, Kelly, S., Russell, J., Devgon, P., & Rosen, P. (2017). Transformation of the peripheral intravenous catheter experience in pediatrics. Journal of Vascular Access, 18(3), Advance online publication. doi: / jva Phillips, L., & Gorski, L. A. (2014). Manual of I.V. therapeutics: Evidence based practice for infusion therapy. Philadelphia, PA: FA Davis. Potts, D. A., Davis, K. F., Elci, O. U., & Fein, J. A. (2017). A vibrating cold device to reduce pain in the pediatric emergency department. Pediatric Emergency Care. Advance online publication. doi: / PEC Stevens, B., Yamada, J., Ohlsson, A., Haliburton, S., & Shorkey, A. (2016). Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database of Systematic Reviews, 2016, CD doi: / CD pub5 Teleflex. (2013). The science & fundamentals of intraosseous vascular access (2nd ed.). Shavano Park, TX: Vidacare Corporation. Retrieved from usa/ezioeducation/documents/ez-io_safio VA-M-607%20Rev%20B-PrintVersion.pdf Tosini, W., Ciotti, C., Goyer, F., Lolom, I., L Hériteau, F., Abiteboul, D., Bouvet, E. (2010). Needlestick injury rates according to different types of safety-engineered devices: Results of a French multicenter study. Infection Control and Hospital Epidemiology, 31,

39 CHAPTER 2 PERIPHERAL VASCULAR ACCESS DEVICES: CARE AND MAINTENANCE LEARNING OUTCOME After completing this chapter, the learner will be able to discuss the ongoing care and maintenance required to safely manage short peripheral and midline catheters and reduce the risk for complications. CHAPTER OBJECTIVES After completing this chapter, the learner will be able to: 1. Describe key aspects and frequency of assessment for peripheral intravenous catheters. 2. Explain issues relative to clinically indicated peripheral catheter site rotation. 3. Identify aspects of routine site care. 4. Describe the importance of, and rationale for, stabilization, site, and joint protection. 5. Define catheter flushing and locking. 6. Discuss issues associated with needleless connectors. 7. Summarize risks and benefits for peripheral catheter blood sampling for laboratory studies. INTRODUCTION Proper care and maintenance of the vascular access device (VAD) is critical in safe infusion administration and in reducing the risk for complications. Research and clinical practice 25 today is very much focused on postinsertion care of VADs, identifying those key critical interventions to reduce the risk for infection and other complications. Care and maintenance begin with ongoing assessment of the VAD site. Patients living at home with a device and their caregivers must receive instruction on what to look for and what to report. Early identification of potential problems or complications is essential, providing the opportunity for timely interventions. Care and maintenance of peripheral catheters include regular site care and dressing changes for midline catheters, site rotation and possibly site care and dressing changes for short peripheral catheters (SPCs), and attention to catheter stabilization. Catheters must be routinely flushed and locked to maintain patency. Needleless connectors and other add-on devices are changed at the time of peripheral IV site rotation and on a regular basis with midlines. In this chapter, the reader is provided with the latest evidence-based recommendations in peripheral catheter care and maintenance. ASSESSMENT Assessment of the peripheral intravenous (IV) site includes frequent observation of the insertion site and surrounding area, the integrity of the dressing, and the extremity in which the catheter is placed.

40 Chapter 2 26 Peripheral Vascular Access Devices: Placement, Care, and Maintenance Patient education should always address the importance of immediately reporting any pain or swelling associated with the catheter. The patient should be asked about the presence of any pain or discomfort or signs of nerve injury including paresthesia, numbness, or tingling at the site or in the extremity. The site at which the catheter enters the skin is visually assessed through the transparent dressing for signs of infection, phlebitis, erythema, drainage, swelling, or induration. The area should be gently palpated for any tenderness or swelling indicative of possible infiltration of fluid into the tissue or infection. Gauze dressings rarely are used over peripheral IV catheters; however, if used, the dressing should be inspected for any evidence of drainage and palpated for tenderness. If site tenderness or drainage is present, the gauze dressing should be removed to visually assess the insertion site. Preferably a transparent semipermeable membrane dressing is used to cover the insertion site to facilitate observation of potential complications. The Infusion Nurses Society (INS) published a position paper providing guidance for the frequency of assessing the SPC. These guidelines are incorporated in the INS standards (Gorski et al., 2012; Gorski et al., 2016). Assess the short peripheral IV site at least every 4 hours for alert and oriented adult patients who are receiving nonirritant/ nonvesicant infusions; every 1 to 2 hours for critically ill patients, for adult patients who have cognitive/sensory deficits or who are receiving sedative-type medications and are unable to notify the nurse of any symptoms, and for patients in whom peripheral IVs are placed in a high-risk location (e.g., external jugular, area of flexion); every hour for pediatric and neonatal patients; more often for patients receiving vesicant infusions (e.g., every 5 to 10 minutes); and before each use or minimally at least twice per day for home care patients. The importance of checking the patient s temperature also is addressed and should be based on the organization s policy and procedures, as well as nursing judgment. The presence of a fever in any patient with an invasive device should be a signal for further assessment and for consideration of the possibility of a catheterrelated bloodstream infection (CR-BSI). It is important to recognize that a bloodstream infection may be present even when the catheter site is without any signs of infection. Catheter patency is another component of peripheral IV assessment. A patent peripheral IV catheter should be easy to flush (i.e., without any resistance) without any patient complaints of pain and should yield a blood return upon aspiration. If unable to aspirate blood, there are several possible causes. The catheter tip may have punctured the wall of the vein and is lying in subcutaneous tissue; signs of fluid infiltration will be evident with flushing (such as tissue swelling), necessitating catheter removal. If the catheter tip is near a valve, the valve may be pulled onto the catheter tip, thus precluding a blood return. If able to flush the catheter, and in the absence of other signs or symptoms of dysfunction, one option may be to leave the catheter in place and closely monitor the site. However, the decision to leave a peripheral IV catheter in place without a blood return must be based on venous status, assessment, the patient s condition, and type of infusate. When a vesicant solution is infusing and there is no blood return, the catheter should be removed. If continued vesicant infusion therapy is anticipated, the nurse should collaborate with the licensed independent provider regarding the need for a central VAD.

41 Chapter 2 Peripheral Vascular Access Devices: Care and Maintenance 27 PERIPHERAL IV SITE ROTATION Peripheral IV catheters should be promptly removed and replaced as necessary in the event of suspected phlebitis, infection, infiltration, or extravasation. Table 2-1 lists signs and symptoms of peripheral IV complications. Note there are overlap and commonality of signs and symptoms among the complications. It is important that the IV catheter is removed in the presence of a suspected complication. More detailed information on complications, including causes, prevention, and interventions follows. Traditional practice has been to routinely rotate short peripheral IV sites on a scheduled basis (generally every 72 to 96 hours) with the exception of pediatric patients whose sites are only rotated when necessary (due to a complication or dislodgement). Based on current research, the recommendations from the INS (Gorski et al., 2016) are to replace the peripheral catheter when clinically indicated, based on an assessment of the patient s condition; access site; skin and vein integrity; length and type of prescribed therapy; and integrity and patency of the VAD, dressing, and stabilization device. What does this mean? It means that when the site is regularly assessed and there is no evidence of complications, it can remain in place rather than performing another peripheral IV catheter placement based solely on how long it has been in place. Although many nurses are happy to not replace a catheter that looks good TABLE 2-1: SIGNS AND SYMPTOMS OF PERIPHERAL IV COMPLICATIONS Complication Signs and Symptoms Local infection Redness Tenderness Purulent drainage at insertion site Edema Warm to touch Phlebitis Redness Swelling Induration Pain Red streak formation along vein tract Palpable venous cord Infiltration/extravasation Lack of blood return Skin color changes such as blanching or bruising or redness around site Swelling Coolness at site Pain or burning with infusion Fluid leakage at site Can progress to development of blisters, impaired range of motion, and paresthesias in affected extremity Nerve injury Acute pain, numbness, or paresthesias during insertion or during dwell time IV = intravenous. Note. From Western Schools, 2018.

42 Chapter 2 28 Peripheral Vascular Access Devices: Placement, Care, and Maintenance and is functioning well, this process demands careful assessment. The longer the catheter is in place, the more likely that a complication may occur. There is concern regarding increasing rates of CR-BSIs with clinically indicated removal. Peripheral IV catheters that are at higher risk for bloodstream infection include those placed in the antecubital fossa and those placed in emergent situations or outside of the hospital setting (Davis, 2014; Stuart et al., 2013; Trinh et al., 2011). The INS standards state that catheters inserted under suboptimal conditions, such as in an emergency situation or en route by emergency transport personnel, should be removed or replaced preferably within 24 to 48 hours (Gorski et al., 2016). This is because it is unknown whether the catheter has been placed under aseptic conditions. Furthermore, the catheter is removed in the presence of erythema, local drainage, swelling, or induration, or if the patient is experiencing pain. The nurse also should be aware of other risks such as infusate characteristics that may limit catheter dwell time (as discussed in Chapter 1). When organizations make the change from time-based to clinically indicated peripheral site rotation, there are critical issues to consider: Appropriate site selection for example, avoiding areas of flexion Appropriate device selection for example, using the smallest diameter catheter to allow good blood flow around the catheter Attention to conditions under which the catheter is placed for example, attention to skin antisepsis and aseptic technique during catheter insertion Catheter stabilization Maintenance of intact dressing With a carefully planned change to clinically indicated site rotation, one hospital system reported a significant reduction in both peripheral and central line-related bloodstream infections as well as cost savings (DeVries, Valentine, & Mancos, 2016). The researchers developed what they called a protected clinical indication bundle, which included chlorhexidine skin preparation, use of sterile gloves for insertion, an IV catheter with an integrated extension set (reduces use of add-on devices), a chlorhexidine-impregnated (e.g., foam, gel) dressing, a securement dressing, and disinfection caps over the needleless connectors (discussed in a subsequent section). Although research continues, the risk for peripheral catheter-related bloodstream infection is an increasingly recognized problem and nurses must pay attention to this widely used IV catheter. The INS recognizes that peripheral catheter insertion and care techniques are essential to positive patient outcomes, and the standards committee recommends that organizations pay increased attention to insertion technique, considering the use of sterile gloves with insertion (Gorski et al., 2016). SITE CARE AND DRESSING CHANGES Routine site care is required for the midline catheter due to the extended dwell time. Site care and dressing changes are performed at least every 5 to 7 days when using a transparent dressing, and if a gauze dressing is used, site care and dressing change is done every 48 hours. For the SPC, routine site care and dressing changes generally are not needed unless the dwell time is extended. In that case, the INS recommends changing dressings on SPCs at least every 5 to 7 days. Site care and dressing changes on either the midline or SPC should be done sooner if the dressing becomes damp, loosened, or soiled (Gorski et al., 2016).

43 Chapter 2 Peripheral Vascular Access Devices: Care and Maintenance 29 Site care is performed regularly in conjunction with dressing changes for midline catheters. Steps included in site care are removal of the old dressing and stabilization device, if used; cleansing the skin using an acceptable antiseptic; assessing the condition of the insertion site and surrounding skin; and replacing the stabilization device and the dressing. Aseptic technique is followed when providing site care. Aseptic technique refers to the application of methods to prevent transfer of organisms from one person to another or from one body site to another. Aseptic technique is sometimes referred to as sterile technique. Key principles include proper hand hygiene, skin antisepsis, and the use of appropriate sterile attire. In the case of providing site care, sterile gloves are worn. After the skin has been cleansed with an antiseptic, it should not be touched except with sterile gloves. Use of a dressing kit is recommended because it standardizes the dressing change procedure, promotes adherence to proper technique, and also improves time efficiency by eliminating the need to gather individual supplies. Patient education is important; the patient should be instructed as to why the dressing change must be done. For patients in the hospital who may be going home with a peripheral catheter, teaching should include the importance of hand hygiene and aseptic technique, regardless of who will be providing their care. They should be taught to advocate for good care for their device, ensuring that all healthcare providers are, for example, washing their hands before assessing their catheter. CATHETER STABILIZATION Stabilization of movement at the catheter hub is recognized as an important intervention in increasing the dwell time for peripheral IV catheters and reducing the risk for phlebitis, infection, catheter migration, and catheter dislodgment. Many nurses equate stabilization with application of a dressing and tape; however, the use of an engineered stabilization device is the preferred method. This is defined as a device or system placed subcutaneously or topically specifically designed to control movement at the catheter hub (Gorski et al., 2016). For short peripheral and midline peripheral catheters, options for stabilization include the following: Products that consist of an adhesive pad and a mechanism to hold the catheter to the pad, controlling movement at the insertion site; a stabilization device is attached at the time of catheter placement and removed when the catheter is discontinued Bordered transparent dressings that have an indication for catheter securement or stabilization Tissue adhesives at the insertion site, which currently are an area of clinical research; in essence, an adhesive or glue is used in conjunction with a standard transparent dressing (Marsh et al., 2015) An important concern when using medical adhesive types of stabilization devices or any tape is the risk for medical adhesive-related skin injury. The risk may be increased with very young and older patients due to fragility of skin, when there is joint movement, and in the presence of edema. Skin tears can easily occur. The use of approved skin barrier solutions is important in reducing the risk for skin damage. It is important to let the barrier solution fully dry before placement. For

44 Chapter 2 30 Peripheral Vascular Access Devices: Placement, Care, and Maintenance older adults, it is recommended to always use an adhesive remover or alcohol to loosen and remove tapes and adhesive devices (Coulter, 2016). The use of adhesive tape to secure the peripheral catheter under a transparent or gauze dressing should only be done with the use of sterile tape. Nonsterile tape is never used under a sterile dressing. It is also important not to use rolled bandages, with or without elastic properties, because they do not adequately secure, can obscure signs and symptoms of complications, and can impair circulation or the flow of infusion. The presence of skin disorders that contradict the use of medical adhesives (i.e., pediatric epidermolysis bullosa and toxic epidermal necrolysis) may necessitate the use of tubular gauze mesh rather than an adhesive engineered stabilization device (Gorski et al., 2016). This type of solution may be more likely used with a midline catheter. SITE PROTECTION AND JOINT STABILIZATION Site protection refers to the use of methods to prevent accidental catheter dislodgement. For example, with children, clear plastic site protectors are available for placement over the site. Although areas of joint flexion should be avoided with peripheral IV placement (as addressed in Chapter 1), there are times when this is not possible. An arm board should be used and applied in a manner that allows ongoing visual assessment of the catheter and vein path. Arm boards can be flat or contoured to fit the extremity, should be padded for comfort, and should support the area of flexion to assist in maintaining a functional position (Gorski et al., 2016). Any tape used should not obstruct the view of the catheter insertion site or impair circulation. When an arm board is used, additional assessment should address skin inspection for signs of breakdown. MAINTAINING PATENCY: CATHETER FLUSHING AND LOCKING The terms flushing and locking are commonly used, yet sometimes misunderstood. The catheter, peripheral or central, is flushed after each infusion to clear any medication from the catheter and to prevent contact between incompatible medications or IV solutions. If not properly flushed, a precipitate can form, essentially blocking the catheter. Catheter flushing is usually accomplished with preservative-free 0.9% sodium chloride solution (more simply referred to as normal saline solution throughout the rest of this chapter). However, there are some medications that are incompatible with normal saline solution. With these medications, 5% dextrose in water is used for flushing and is followed by normal saline and/ or a heparin solution. Dextrose should not be left in the catheter lumen because it provides nutrients for bacteria growth (Gorski et al., 2016). Catheter locking refers to the solution left instilled in the catheter to prevent occlusion when the catheter is not being actively used for an infusion. Examples include the hospitalized patient who receives an antibiotic infusion every 8 hours but otherwise is not receiving a running infusion. SPCs are locked with saline solution. There is no clear evidence as to the optimal locking solutions for midline catheters; either saline or low concentration heparin (e.g., 10 units/ml) may be used. The following list presents the general principles for catheter flushing and locking: Flush the catheter before, after, and between infusions using a volume of normal saline solution that is at least twice the internal

45 Chapter 2 Peripheral Vascular Access Devices: Care and Maintenance 31 volume of the VAD and needleless connectors. For peripheral and midline catheters, the internal volume is very small. Typical saline flushing amounts are 2 to 5 ml. Use a 10-mL barrel syringe for catheter flushing and locking. Many catheter manufacturers recommend this in their catheter care guidelines. Smaller-sized syringes exert more pressure and can cause catheter damage. In clinical practice today, there are still nurses and physicians who deal with sluggish catheter flow by using smaller syringes to push fluid aggressively through the catheter. This is an unsafe practice that may have an end result of catheter damage (e.g., catheter fracture) or pushing a blood clot into the circulatory system. Use single-use flushing systems, such as prefilled normal saline syringes, as an infection prevention measure: Prefilled syringes are available in a variety of flushing volumes, such as 3, 5, and 10 ml; they are all available in 10-mL barrel syringes. Multidose vials, if used, are dedicated to a single patient. Multidose vials of normal saline solution are not preservative free because they contain benzyl alcohol as a preservative. The purpose of the preservative is not to prevent infection but, rather, to allow repeated access into the vial. Preparing multiple flush syringes using a bag of normal saline should be avoided to prevent contamination. Do not use 0.9% sodium chloride solution with preservative with neonatal and pediatric patients; if used with adult patients, the volume used should not exceed 30 ml per day. (Gorski et al., 2016) NEEDLELESS CONNECTORS AND OTHER ADD-ON DEVICES Needleless connectors are connected to the hub of a VAD and are designed to accommodate the tip of a syringe or IV tubing for catheter flushing or administration of solutions into the vascular system. Needleless connector is the term commonly used in the literature and in the INS standards (Gorski et al., 2016); however, it is important to recognize that other terms for the device are commonly used, including injection caps, ports, or injection valves. Needleless connectors allow venous access without removing the connector, therefore maintaining a closed infusion system. In addition to needleless connectors, other addon devices may be attached to the catheter. Add-on devices include such items as single and multilumen extension sets, in-line filters, stopcocks, and extension loops. In general, the use of add-on devices should be minimized because there is less risk for accidental disconnections, less manipulation that may contribute to contamination and infection risk, and less cost. In all cases, needleless connectors and add-on devices must be of a Luer- Lock design to ensure that the junction between the devices is secure (Gorski et al., 2016). Appropriate use of add-on devices may include adding length to the catheter for easier access, providing clamping ability, and reducing movement at the site. For example, with peripheral IV catheters, an extension set such as a J loop is attached to the catheter. For the home care patient who self-administers infusion medications, an extension set added to a midline catheter may be necessary to enable easy access to the catheter. Needleless connectors are added to the extension set, or some extension sets may have an inherent needleless connector as part of the extension.

46 Chapter 2 32 Peripheral Vascular Access Devices: Placement, Care, and Maintenance Needleless connectors can function in a significantly different manner from one another, although they can look very similar. Many products are available with a variety of features and functions. Needleless connectors are categorized into two broad categories: 1. Simple: A simple device has no internal mechanisms, so fluid flows straight through the internal lumen. Simple devices include those with a split septum. The split in the septum opens when a blunt plastic cannula attached to the syringe or IV administration set is passed through the septum. Some designs allow the male luer end of a syringe tip or administration set to access the split septum without using a blunt plastic cannula. 2. Complex: Valves in the complex category include those that are mechanical. These valves include an internal mechanism that controls the flow of fluid through the device. The valve allows for both infusion and aspiration. Many types of sizes, shapes, colors, and internal fluid pathways are available. (Hadaway, 2012) Needleless connectors are further classified as to how they function, based on internal fluid displacement. Table 2-2 describes the functions of needleless connectors and their implications for nurses. Other important issues related to needleless connectors and add-on devices include the frequency of device change and maintaining aseptic technique when accessing the needleless connector for infusion, flushing, and locking. The needleless connector and any add-on devices are changed on a regular basis. They should be changed when the IV tubing is changed, if residual blood is present in the device, and whenever the integrity is compromised or suspected of being contaminated (Gorski et al., 2016). Specific to needleless connectors, they should be changed before drawing a blood sample for blood culture from the VAD; from the perspective of a time frame, they should be changed no more frequently than every 96 hours (Gorski et al., 2016). Manufacturers guidelines and organizational policies will provide further guidance on frequency of change, including whether the device should be changed after blood withdrawal for laboratory tests. For SPCs, the needleless connector is not routinely changed due to the shorter duration of catheter placement. In the home care setting, needleless connectors on midline catheters are usually changed every 7 days in conjunction with routine site care (Gorski, 2017). Needleless connectors are a known source for contamination via the intraluminal route, which is through the lumen of the catheter. Failure to disinfect a needleless connector for flushing or medication administration is a wellrecognized problem. In a systematic review of 140 published clinical studies and 34 abstracts presented at educational meetings, the researchers identified the needleless connector as the greatest risk for contamination after insertion of the VAD with 33% to 45% of needleless connectors identified as contaminated (Moureau & Flynn, 2015). Adherence to clinician (usually nurses) disinfection was reported as low as 10%. The Joint Commission (2017) included the following in the National Patient Safety Goals: use a standardized protocol to disinfect catheter hubs and injection ports before accessing the port (p. 10). The INS standards identify acceptable disinfecting agents of 70% alcohol (i.e., typical alcohol wipes), iodophors such as povidone iodine, or greater than 0.5% chlorhexidine in alcohol solution for needleless connector disinfection (Gorski et al., 2016). Many nurses are familiar with the scrub the hub mantra, emphasizing

47 Chapter 2 Peripheral Vascular Access Devices: Care and Maintenance 33 TABLE 2-2: NEEDLELESS CONNECTOR FUNCTION AND IMPLICATIONS Needleless Connector Function Description Implications Negative fluid displacement Positive fluid displacement Blood is pulled back into the catheter when the IV tubing or syringe is attached or disconnected and when an infusion is allowed to run dry. There is an internal reservoir that holds a small amount of fluid in the device. When IV tubing or a syringe is disconnected, fluid is pushed out to overcome the reflux of blood in the catheter. The positive fluid displacement only occurs when the IV tubing or syringe is disconnected. If an infusion container is allowed to run dry, the internal valve remains open and blood can reflux back into the catheter lumen. Blood that remains in the catheter can lead to thrombotic occlusion. Use a positive fluid displacement technique to overcome blood reflux by locking catheter and maintaining pressure on the syringe plunger while closing the clamp on the catheter or extension set. Clamp after syringe disconnection. If the catheter clamp is closed before disconnecting the syringe with the locking solution, the mechanism that pushes fluid out to the catheter tip is prevented from working. Blood that remains in the catheter can lead to thrombotic occlusion. Neutral displacement The device prevents blood reflux upon connection and disconnection of IV tubing or syringes. Function is not dependent on clamping technique, and catheter can be clamped either before or after disconnecting the syringe with the locking solution. IV = intravenous. Note. Adapted from Gorski, L. A., Hadaway, L., Hagle, M., McGoldrick, M., Orr, M., & Doellman, D. (2016). Infusion therapy standards of practice. Journal of Infusion Nursing, 39(1 Suppl.), S1-S159. Hadaway, L. (2012). Needleless connectors for IV catheters. American Journal of Nursing, 112(11), the importance of cleansing with friction, not just a quick wipe. The nurse should scrub the hub and the threads on the needleless connector. Unfortunately, research is conflicting, and more research is needed to establish an optimal time for scrubbing which may range from 5 to 60 seconds (Gorski et al., 2016; Moureau & Flynn, 2015). After scrubbing, the disinfectant must be allowed to dry before attaching a flush syringe or IV tubing to the needleless connector. An alternative to scrubbing the needleless connector is the passive disinfection cap. This is a plastic cap that contains a sponge saturated with 70% alcohol and that is placed on the end of the needleless connector between intermittent infusions, providing both a chemical (i.e., disinfectant) and physical barrier (Figure 2-1). The amount of time required for contact of the plastic cap on the needleless connector to achieve optimal disinfection varies with each device manufacturer. If left in place for a certain

48 Chapter 2 34 Peripheral Vascular Access Devices: Placement, Care, and Maintenance FIGURE 2-1: PASSIVE DISINFECTION CAPS PLACED ON ENDS OF THE CATHETER LUMENS Note. From Western Schools, Photo courtesy of author. Used with permission. length of time, based on manufacturer guidelines, the needleless connector does not require scrubbing before accessing the VAD for flushing and solution administration. After the first VAD access, the INS suggests consideration of a 5- to 15-second scrub with subsequent entries recognizing the risk for contamination as the VAD is repeatedly accessed (Gorski et al., 2016). Advantages of passive disinfection caps include reduced contamination, elimination of human factors issues (requiring nurses to have disinfection supplies at the bedside and to consistently use them), and provision of an easy-to-use solution for nurses (Moureau & Fynn, 2015). Although research on passive disinfections caps is primarily based on patients with central vascular access devices, one organization includes its use as part of a peripheral catheter bundle (Devries et al., 2016). BLOOD SAMPLING VIA A PERIPHERAL CATHETER Blood can be withdrawn from SPCs based on analysis of risks versus benefits. It may be useful in pediatrics, adults with difficult venous access, and in presence of bleeding disorders. Risks associated with routine venipuncture (i.e., not via a catheter) include anxiety, pain, skin and nerve damage, and hematoma and bleeding, especially in patients receiving anticoagulants, whereas those associated with blood sampling from a VAD include increased risk for infection due to catheter hub manipulation, loss of catheter patency, and erroneous laboratory values (Gorski et al., 2016). As related to peripheral IV catheters, blood sampling with catheter insertion is associated with a higher rate of hemolysis and inaccurate laboratory values; longer tourniquet times and difficult insertions may increase this risk. Nurses should follow organizational procedures in relation to this practice. Although in practice it is not uncommon to draw blood samples from a midline catheter, there is a lack of data for recommending blood sampling off of midline catheters. The INS does not make any recommendations for this practice as the effect on midline catheter patency and accuracy of laboratory values is unknown.