PURPOSE To provide direction on how to safely insert an extended dwell peripheral catheter into the peripheral venous system, conserving veins and morbidity. INDICATIONS 1. Hospital Intravenous (IV) therapy exceeding 3 days in duration and up to 29 days maximum 2. Appropriate for infusion of peripheral medications: osmolality less than 900 mosm, infusates with a ph greater than 5 or less than 9 consider. Not intended for medications which must be administered via central line: vesicants or irritants (See CV.01.15A Appendix A: List Of Vesicant And/Or Irritant Drugs Or Solutions) 3. Lack of vascular access POLICY STATEMENTS Early identification of patients requiring therapy as indicated below will minimize discomfort related to multiple venous access attempts, preserve veins for future use and to reduce delays in and provide uninterrupted therapy. EPIV are inserted by Physicians and Registered Nurses on IV Team using Ultrasound and Modified Seldinger Technique. Maximum number of attempts (skin and venous punctures), insertion limited to two (2) times per inserter to a maximum of 4 attempts per event. SITE APPLICABILITY BC Children s Hospital PRACTICE LEVEL/COMPETENCIES Registered Nurses on IV team and PICU Physicians trained to insert EPIV DEFINITIONS Sterile barrier precautions: wearing sterile gloves, and mask and using a small fenestrated drape and ultrasound probe cover during the placement of EPIV. PRECAUTIONS Maintain ASEPTIC technique throughout the procedure A NEW administration setup and bag of fluid must be hung with each newly placed line to prevent contamination and decrease risk of sepsis Refer to online version Print copy may not be current Discard after use Page 1 of 7
EQUIPMENT Small drape Additional 22g catheter (if required) Dressing tray Sterile injection cap (neutron) Sterile 0.9% NaCl (normal saline) pre-filled syringe IV Advanced dressing Prep swab 2% chlorhexidine with 70% alcohol 4x4 sterile gauze as needed 2x2 sterile gauze as needed Sterile ultrasound probe cover and gel Securement device Grip-lok (in insertion tray) Mask Sterile gloves Sterile probe cover EPIV Vygon Leaderflex Basic Insertion Tray (4 cm, 6cm or 8 cm) Ultrasound machine PROCEDURE Prior to Insertion 1. CONFIRM physicians order for EPIV insertion 2. COMPLETE consultation for EPIV insertion. Assessment will include patient age, history of previous vascular access; level of anxiety, vein selection assessment by ultrasound. 3. Identify patient using two patient-identifiers, procedure verification process and explain procedure to patient and/or family 4. Provide pharmacological and/or nonpharmacological interventions for painful or anxiety provoking procedures as ordered by the prescriber. These may include: Positive verbal encouragement and feedback Position patient for comfort Distraction and relaxation techniques Encourage parental participation Child life involvement Application of topical anesthetic as appropriate Nitrous oxide where approved Oral sedation as ordered (Midazolam etc) Follow Procedural Sedation Guidelines (CC.08.01) 5. Identify need for assistance for the procedure. If so, contact Child Life prior to the procedure and arrange for someone to be present. Bedside nurse to assist in preparing the patient and assist in monitoring and holding the patient during the procedure if required. Rationale Explaining the procedure to the patient/family will help to gain trust, cooperation and reduce anxiety. Use appropriate pain assessment tools as necessary. Individual age appropriate comfort measures may contribute to minimizing pain and anxiety and optimizing cooperation. Topical anesthetic: see Comparison table of Ametop gel, Emla cream The nursing assistant is responsible to: Assist with the insertion procedure Support and answer questions for parents IV Team personnel and/or Bedside RN Refer to online version Print copy may not be current Discard after use Page 2 of 7
Prior to insertion POSITION patient in appropriate position for procedure, pad under arm as necessary for visualization. ASSESS vasculature: use ultrasound to assess patient s veins to determine patency, shape, pathway and size CONFIRM selected insertion site is avoiding areas of flexion (antecubital fossa and axilla). Choose forearms, upper arm or saphenous (if possible). Apply Emla/Ametop. (if applicable) APPLY warm compresses to desired limb, ensure patient is warm Rationale Avoid areas of joint flexion including the hands, all areas of the wrist to avoid radial nerve damage and the antecubital fossa and axilla. Choose insertion sites in the forearm to increase dwell time and decrease complications, Consider the saphenous vein in patients up to one year, who are not walking. Choose the length of the device to ensure catheter tip does not extend beyond the axilla/groin. Warm compress will dilate the vessel allowing for increased blood flow, which can aid in insertion. Insertion Procedure 1. CLEAN working surface with surface cleaner & disinfectant. Apply non sterile gloves, personal protective equipment including: mask, protective eyewear (as necessary) and assemble equipment. 2. Remove topical anesthetic 3. Inserter to do personal scrub (hands and arms up to elbows for one minute) using chlorhexidine hand solution or scrub brush. Rationale Surface cleaners and disinfectants may include: Hydrogen peroxide, Alcohol 70% solution Standard precautions; reduces the transmission of microorganisms. Bedside RN assistance will be necessary to preserve sterility of the field and limit the movement of the child during the procedure Open dressing tray and organize equipment 4. Inserter to put on sterile gloves and prepare equipment, flush EPIV catheter with NS. 5. With the patient s palm facing up, use 2% Chlorhexidine & 70% Alcohol swab stick and clean the planned insertion site and area to be covered by the dressing with a back and forth motion with friction for 15 seconds, flip the swab moving in the opposite direction for 15 seconds, allow to dry one minute 6. Place sterile drape and apply sterile tourniquet under the prepared arm, have assistant secure in place and positioned for comfort, apply fenestrated drape. Provides immediate and long term suppression of nearly all nosocomial organisms. Scrubbing will create enough friction on the skin so that all dirt and loose skin cells are removed. As per Health Canada Guidelines Maintain sterile barrier precautions To distend vein during insertion. 7. Apply gel and probe cover to Ultrasound probe Refer to online version Print copy may not be current Discard after use Page 3 of 7
8. Apply sterile gel or saline to skin at prepared insertion site. 9. Insert the introducer needle (or 22 g catheter) bevel up into the skin at angle needle appropriate to vein depth. Observe the ultrasound screen to visualize the needle entering the vein, advance needle tip to the center of the vein. Blood return is seen from the needle hub, indicates the needle in the vessel lumen 10. Remove the ultrasound probe, stabilize the needle (if using 22 g catheter remove stylet), pick up the wire in the middle and thread the wire into the introducer the wire should be advanced into the vein 1 3 cm so that a few centimeters of wire is between your finger and the hub of the introducer. Do not use force. Note: Guidewire must not be inserted in the absence of blood return and must be removed when resistance is encountered with the introducer to prevent the needle from damaging the guide wire 11. Holding pressure over the insertion site, remove the introducer needle (or 22g catheter) over and off the wire 12. Always holding the wire thread the catheter over the wire and into the skin and vein slowly by 1 cm increments, withdraw the wire. 13. Release the tourniquet through the sterile drape, maintaining sterility. 14. Confirm venous blood flow, attach 10 ml NS syringe and flush. Attach injection cap and 10 ml NS syringe, flush and check for blood return Flush catheter with additional NS as needed. 15. Secure with provided securement device. 16. Apply transparent dressings over the insertion site securing catheter. NOTE: Do not encircle transparent dressing around limb Secure with a limb board PRN Mark patient s skin with marking, measure and document limb circumference at estimated catheter tip placement, The vein should compress easily. The arteries will not compress as easily and may continue to demonstrate a pulse motion. A thrombosed vein may appear more opaque and will neither compress nor pulsate. A new introducer should be used for each vein cannulation attempted. It is important to observe the pattern of blood flow from the vessel to ascertain that a vein, and not an artery, has been cannulated. A pulsating flow of blood is the true indicator of arterial access, even in patients with low blood pressure. To ensure that the introducer is inside the tunica intima, ultrasound may be used to check the position of the wire in the vein. The wire should easily pass into the vein. Insertion of the wire 1 to 3 cm into the vein will ensure that the wire is secure and not easily dislodged with subsequent equipment changes. Never forcefully advance the wire as this may cause intima vein damage or tangling of the wire. Maintain a firm grip on the wire at all times making sure the wire is always in sight Rapid entry may cause vasospasm. If difficulty threading, check for blood return, pull back a little, flush, and advance again. Check for venous blood withdrawn from catheter, watch for pulsatile blood flow or bright red blood to differentiate arterial blood. Refer to online version Print copy may not be current Discard after use Page 4 of 7
Note date of insertion on dressing 17. Dispose sharps and other used equipment into appropriate containers. DOCUMENTATION 1. Document procedure on PIV insertion record: Date and time, size and length of catheter, site, number of attempts arm circumference at catheter tip complications (if applicable), person performing procedure Medications administered (if applicable). Unexpected outcomes and related treatment and patient tolerance 2. Fill out EPIV bedside record and keep with bedside documents (Appendix A of this document) Document the procedure in the nursing notes if more detail is required. 3. CV.01.15A Appendix A: List Of Vesicant And/Or Irritant Drugs Or Solutions Refer to online version Print copy may not be current Discard after use Page 5 of 7
REFERENCES Agnot-Johnston, T., Chuchmuch, M., Friesen, N., Pinkerton, C., Swinton, M., (2014 revised). Annual Competency Learning Package for Nurse Inserters of Peripherally Inserted Central Catheters (PICC). Winnipeg Regional Health Authority: Manitoba. American Institute of Ultrasound in Medicine. (2012) AIUM Practice Parameter for the Use of Ultrasound to Guide Vascular Access Procedures. Retrieved from http://www.aium.org/resources/guidelines/usgva.pdf Anderson, J., Greenwell, A., Louderback, J., Polivka, B., & Behr, J. (2016). Comparison of Outcomes of Extended Dwell/Midline Peripheral Intravenous Catheters and Peripherally Inserted Central Catheters in Children. Journal of the Association for Vascular Access, 21(4), 249. doi:10.1016/j.java.2016.10.025 Association for Vascular Access. (2015). Best Practice Guidelines in the Care and Maintenance of Pediatric Central Venous Catheters (2nd Ed.). Utah:USA Baudin, G., Occelli, A., Boyer, C., Geoffray, A., & Chevallier, P. (2013). Évaluation des cathéters centraux à insertion périphérique en population pédiatrique. Archives de Pédiatrie, 20(10), 1089-1095. doi:10.1016/j.arcped.2013.07.006 Chopra, V., Flanders, S. A., Saint, S., Woller, S. C., Ogrady, 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_Supplement). doi:10.7326/m15-0744 Cincinnati Children's Hospital. (2017, August 2). Venous Infusion Extravasation Risk. Retrieved January 08, 2018, from https://www.cincinnatichildrens.org/service/v/vascular-access/hcp Curry, S., Honeycutt, M., Goins, G., & Gilliam, C. (2009). Catheter-associated bloodstream infections in the NICU: Getting to zero. Neonatal Network, 28(3), 151-155. Gibson, C., Connolly, B., Moineddin, R., Mahant, S. Filipescu, D. & Amaral, J. (2013). Perhipherally inserted central catheters: Use at a tertiary pediatric care center. Journal of Vascular Interventional Radiology, 24. 1323-1331. Infusion Nurses Society, Mary, M., A., Gorski, L., Hankins, J., Cone, M. H., & Perucca, R. (2010). Infusion Nursing: An Evidence-based Approach (3rd ed.) (M. Alexander, Ed.). St. Louis, MO: Saunders/Elsevier. IWK Health Centre. (2013). Policy #1522 - Percutaneous Insertion of Peripherally Inserted Central Catheter (PICC) by Registered Nurses (RNs). Nova Scotia. Received August 14, 2015. O Grady, N.P., Alexander, M., Burns, L.A., Dellinger, E.P., Garland, J.,...Heard, S.O., (2011) Healthcare Infection Control Practices Advisory Committee. Guidelines for the Prevention of Intravascular Catheter-Related Infections. American Journal of Infection Control, 39(4), S1-34. Scoppettuolo, G., Pittiruti, M., Pitoni, S., Dolcetti, L., Emoli, A., Mitidieri, A.,... Annetta, M. G. (2016). Ultrasound-guided short midline catheters for difficult venous access in the emergency department: a retrospective analysis. International Journal of Emergency Medicine, 9(1). doi:10.1186/s12245-016-0100-0 Refer to online version Print copy may not be current Discard after use Page 6 of 7
APPENDIX A Extended Dwell Peripheral IV (EPIV) Bedside Record Working Draft Patient Label Date of insertion: Length of 22g Catheter inserted: 4cm 6cm 8cm Insertion Site: Limb circumference at catheter tip as marked: Up to 29 dwell days in the absence of signs and symptoms of infection, infiltration or extravasation - hourly checks. Measure limb circumference q shift, document on daily flowsheet in the other measurements area Flush as per PIV policies Dressing change by IV team every 7 days or as needed. Keep dry and intact, if dressing becomes loose, soiled or wet it must be changed. Bedside RN may remove the EPIV as necessary Do not use for regular blood sampling may be attempted under special consideration Do not take blood pressure on arm with EPIV Do not insert a PIV below the EPIV Do not use for vesicant or irritant infusions, use for infusions that are appropriate for peripheral infusions Call IV team for any questions or concerns. Refer to online version Print copy may not be current Discard after use Page 7 of 7