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Objectives
Good Vein, Bad Vein
NIR & Choosing the Best IV Access Site
Greg Schears, MD
Mayo Clinic, Rochester, MN
• 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
INS Site Choice Advice
How Do We Choose Optimal PIV Sites?
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
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Extremely Limited Information On
Optimal PIV Site Choice!
We are 20/20 Vein Blind!
Reality
With unaided eye and
fingers, we are very
limited on vein based
critical information
Because we have almost no idea what’s going on inside the vein
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PIV Failure Rates 1990‐2014
Helm, RE, et al, 2015, JIN 38 (3) 189‐203 PIV Catheter Outcome Factors
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Site Choice
Vein Integrity
Catheter Materials
Insertion Technique
Tip Location
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Catheter/ Vein Size
Catheter Movement
Stabilization
Infusate / Fluid Jet
Other
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 !
Common Theme in Medicine
Selection Determines Outcome
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Ideal Vein for PIV Access
Ideal Vein
Characteristics
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• Not across joint
• Adequate size
• Adequate supportive •
subcutaneous tissue •
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• Healthy vein wall
• Straight pathway
No valves within the area of catheter
No thrombus
Good venous flow
Tip not near tortuosities or bifurcations
Method For Identification
Veins and Valves
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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?
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K‐Video, Valve
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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
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Finding the Straight and Wide
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Picking an Optimal Access Site
Must Find
Must Avoid
Risk of Thrombosis
Must Avoid
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
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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
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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
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J Nursing Care Quality, 13 (2), 77‐85, 1998
J Nursing Care Quality, 13 (2), 77‐85, 1998
What must we do to solve this?
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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
PICC Excellence, Nancy Moureau, BSN, CRNI, CPUI, VA‐BC
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Assessment Tool for PIV Access
INSERTION ATTEMPT
Grade I
Mild Difficulty
Grade II
Moderate Difficulty
Grade III Severe Difficulty
(Score 6‐8)
(Score 9‐12)
(Score >12)
GUIDELINES
•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
•Contact experienced nurse for a total of 2 attempts
•Then contact VAT for a maximum of 4 total attempts
Defining the Problem
•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
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Patient Age in Years
Neonate <1500 grams = 4 points
0-1 = 3 points
1-2 = 2 points
> 2 = 1 point
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Anticipated Duration of IV Access (PICC recommended for treatment > 5 days)
> 7 days = 3 points
3-7 days = 2 points
< 3 days = 1 point
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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
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Parent Cooperation
Extreme anxiety (example: request only 1 attempt) = 5 points
Expressing concern = 2 points
Able to effectively assist or not available = 1 point
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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
• 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
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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
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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 near‐
infrared vein visualization
4. U‐Accessible veins only identified with ultrasound
5. 0‐Lacks adequate veins for peripheral venous access
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Screening Tool‐cont. Quantification
A. > 10 Optimal Choices
B. 5‐10 Optimal Choices
C. 1‐5 Optimal Choices
Qualifiers
A.
B.
C.
D.
E.
F.
G.
RF‐Renal Failure
CS‐Chronic Steroids
SL‐Site Limitations
LD‐Limited Dwell
P‐Pediatrics
G‐Geriatrics
Site:B‐Bilateral, L‐Left, R‐Right
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 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
Thank You
Questions?
[email protected]
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