Good Vein, Bad Vein NIR & Choosing the Best IV Access Site Greg Schears, MD Mayo Clinic, Rochester, MN Objectives Identify what is known regarding optimal PIV sites in guidelines and the literature Discuss the use of NIR to enhance optimal site choice for PIVs and Phlebotomy Hypothesize how NIR may help prolong PIV dwell time through reduction in complications How Do We Choose Optimal PIV Sites? INS Site Choice Advice Key Points Smallest gauge that will accommodate prescribed therapy Avoid areas of joint flexion, including the hand, all surfaces of the wrist, and the antecubital fossa. Choose insertion sites in the forearm to increase dwell time, decrease complications, promote self care, and prevent accidental removal. INS Policies and Procedures, Section 3 VAD Placement p 52, 2016 1
Extremely Limited Information On Optimal PIV Site Choice! Reality With unaided eye and fingers, we are very limited on vein based critical information We are 20/20 Vein Blind! Because we have almost no idea what s going on inside the vein 2
PIV Failure Rates 1990 2014 Helm, RE, et al, 2015, JIN 38 (3) 189 203 If we are going to advance PIV catheter insertion and reduce complications, we must embrace technology and better understand the dynamic relationship of the catheter within the vein particularly its tip position relative to other intravenous structures! PIV Catheter Outcome Factors Site Choice Vein Integrity Catheter Materials Insertion Technique Tip Location Catheter/ Vein Size Catheter Movement Stabilization Infusate / Fluid Jet Other Common Theme in Medicine Selection Determines Outcome 3
Ideal Vein for PIV Access Ideal Vein Characteristics Not across joint Adequate size No valves within the area of catheter Adequate supportive No thrombus subcutaneous tissue Good venous flow Healthy vein wall Tip not near Straight pathway tortuosities or bifurcations Method For Identification Veins and Valves 4
bum Have You Ever? Blown a vein due to hitting a valve? Caused more pain to a patient from hitting a valve? Second stick? Had the IV pump beep incessantly because the IV catheter tip bumps up against a valve? Have reduced IV flow because the IV catheter tip was up against a valve? 5
K Video, Valve 6
Easy to Find Valves and Avoid Them Wrist Valve ology Valves are well know to interfere with optimal PIV insertion functionality Difficult to predict where valves will be Rarely can see with the naked eye Very difficult to identify with U/S NIR easily identifies valves by milking vein. Thus NIR necessary for optimal PIV positioning regardless of vein difficulty 7
Finding the Straight and Wide 8
Picking an Optimal Access Site Must Find Must Avoid Must Avoid Risk of Thrombosis Sharp R, et al. International J Nurs Studies 2015;52:677-685 Impact of Catheter Size to Venous Flow TF Nifong, TJ McDevitt, CHEST 2011; 140(1):48 53 9
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Optimal Catheter/Vein Difficult to estimate real vein size for most PIV access using unaided eye. Palpation even more difficult. U/S good but harder to know straightaways and can t easily see valves or tortuosities NIR easily identifies straightaways and projects exact vein width with some products. Thus NIR is necessary for optimal PIV catheter/ vein strategies to preserve flow & integrity. Ideal VA Encounter Provides Pre Access Assessment Pt Hx, Understand Therapy Goals Examine Pt, Consider Options Educate & Partner with the Patient Perform VA Best Practice! Uncomplicated Course Success!!! Everyone s Satisfied 11
J Nursing Care Quality, 13 (2), 77 85, 1998 J Nursing Care Quality, 13 (2), 77 85, 1998 PICC Excellence, Nancy Moureau, BSN, CRNI, CPUI, VA BC What must we do to solve this? Need to better define the problem Provide a practical screening tool Work with smart ware developers Help patients to be educated consumers Show how this will improve outcomes Monitor and report patient satisfaction Define financial benefits and compliance with the Affordable Care Act 12
INSERTION ATTEMPT Assessment Tool for PIV Access GUIDELINES Grade I Mild Difficulty (Score 6 8) Allow 1 attempt by a nurse/patient care technician with limited IV access experience (supervised by a nurse with IV access experience) or 2 attempts by a nurse/patient care technician with IV access experience, not to exceed 2 attempts total Then contact the Vascular Access Team (VAT) for a maximum of 4 total attempts Grade II Moderate Difficulty (Score 9 12) Contact experienced nurse for a total of 2 attempts Then contact VAT for a maximum of 4 total attempts Grade III Severe Difficulty (Score >12) Contact VAT for a total of 4 attempts (no more than 2 attempts per individual) Purpose: Minimize IV attempts and ensure patient safety and comfort. Available Access Sites 0-1 sites = 3 points 2-3 sites = 2 points > 3 sites = 1 point Patient Age in Years Neonate <1500 grams = 4 points 0-1 = 3 points 1-2 = 2 points > 2 = 1 point Anticipated Duration of IV Access (PICC recommended for treatment > 5 days) > 7 days = 3 points 3-7 days = 2 points < 3 days = 1 point Patient Cooperation Uncooperative/hard to immobilize = 3 points Uncooperative/easy to immobilize = 2 points Cooperative = 1 point Neonate or Poor tolerance to care tasks or extreme agitation with handling = 5 points On narcotic drip for pain or oxygen requirement 30% above patient s previous assessment/baseline = 3 points Desaturations or bradycardia with handling or oxygen 10% above patients previous assessment/baseline = 2 points Parent Cooperation Extreme anxiety (example: request only 1 attempt) = 5 points Expressing concern = 2 points Able to effectively assist or not available = 1 point Patient History Difficult access: previous PICC/CVC = 5 points Poor access (obesity, contracture, congenital anomalies interfering with vascular access) = 4 points Dehydration (dry mucous membranes, decreased UOP, sunken fontanel) = 3 points Prior history of difficult IV access = 2 points No history of IV access problems = 1 point Defining the Problem Defining the Problem No standardized method of screening No standard means of quantifying difficulty of access or limited veins Need to take advantage of modern technology and practices Need scoring system that promotes communication and research Ideal Tool for PVA Easy to apply Makes clinical sense Uses technology available Provides meaningful categorization Allows refined algorithm for line choice Can be validated and is relevant Promotes research and CQI 13
Visual Screening Palpation Screening U/S Screening Screening Tool 5 categories for PVA Difficulty 1. V Easily locate accessible veins by sight 2. T Easily locate accessible veins by palpation 3. N Easily locate accessible veins with nearinfrared vein visualization 4. U Accessible veins only identified with ultrasound 5. 0 Lacks adequate veins for peripheral venous access 14
Screening Tool cont. Quantification A. > 10 Optimal Choices B. 5 10 Optimal Choices C. 1 5 Optimal Choices Qualifiers A. RF Renal Failure B. CS Chronic Steroids C. SL Site Limitations D. LD Limited Dwell E. P Pediatrics F. G Geriatrics G. Site:B Bilateral, L Left, R Right Pre Assessment Visible, Bilateral, 1 5 veins: V, B, C Palpable, Bilat, 1 5 veins: T, B, C Near Infrared, Bilat, > 10: N, B, A Summary Minimal data on optimal access sites Vision and palpation unable to identify valves & other problems NIR identifies venous obstacles NIR allows for better PIV planning NIR best for finding optimal PIV site Thank You Questions? schears.gregory@mayo.edu 15