The way in which clinicians practice the art and science of vascular access insertion and management is subject to change as more information and research are made available regarding the implications of practices. The goal is ever to minimize complications while administering the necessary treatment for the patient. In this chapter, we explore standards of practice, uncovering the causes of complications to reinforce best practice. The underlying principle of vessel health and preservation, the act of placing the Right device at the Right time for the Right patient™ (Teleflex, Raleigh, North Carolina, USA), is the aim. However, without the right insertion practice, the “Rights” included in the VHP model become unattainable.
KeywordsPeripheral intravenous cannula Central venous catheter Seldinger technique Guidewire Number of attempts Local anesthetic Jugular Axillary Femoral veins Insertion Complications Malposition Securement
6.1 Introduction to Insertion
Selection of the right device, right inserter, and insertion technique encompasses the second stage in quadrant 2 of the VHP process. Appropriate device selection and number of necessary lumens are determinations made according to lowest risk for patient insertion and potential for infection in conjunction with the needs of the therapy. Selection of the inserter and application of infection prevention principles are contributing factors for patient safety. The technique chosen for insertion is dependent on the device selected, whether peripheral or central, and the indications dictated by patient and treatment factors. The use of technology for visualization during insertion and tip positioning of central catheters aids in reducing insertional and post-insertional complications.
6.2 Appropriateness in Device Selection
According to the Society for Healthcare Epidemiology of America (SHEA), intravenous devices, specifically CVADs, should be inserted only when clinically indicated (Marschall et al. 2014). Evidence for indications specific to VADs was not available until 2016. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) was developed by an international panel of experts to establish indications and contraindications for VAD usage (Chopra et al. 2015). MAGIC guidelines suggest that shorter PIVC, 1–6 cm, be inserted for treatment up to 5 days, with longer length catheters (4–6 cm) used with ultrasound guidance and treatment from 6 to 14 days. Local policy should advocate removal when clinically indicated; routine scheduled replacement of a peripheral catheter is no longer needed (Rickard et al. 2012).
The designation of patients with difficult venous access (DIVA), as a patient who has experienced one or more failed attempts or has unidentifiable veins, necessitates higher-level insertion and the use of ultrasound or other visualization technology as a recommended next step to gaining successful access (Gorski et al. 2016). Some patients receive the designation DIVA through chronic illness resulting in recurrent admissions and repeated VAD. It is important that healthcare organizations have strategies in place to initiate optimal practice when a patient is readmitted with DIVA to avoid subjecting the patient to multiple insertion attempts. Highlighting the patient as DIVA means the patient ideally is escalated to a VAD specialists, anesthetics, or other higher skill level clinician to receive the optimal VAD selection, visualization technologies, and insertion consistent with their current presentation and treatment.
6.3 Optimal Peripheral Cannula Insertion
PIVCs are the most commonly placed vascular access device, with over a billion sold worldwide each year, but their failure rate lies between 35 and 50% (Bertoglio et al. 2017). PIVCs are still the default vascular access device in many institutions, even when other alternatives may be more suitable for the indicated therapy. This may be because of limited resources in terms of the availability of skilled staff to perform a more advance insertion, staff availability to provide ultrasound-guided cannula insertion, or the lack of availability of ultrasound or vein viewing technology.
In the absence of skilled vascular access teams/specialists, an environment may be created where a PIVC seems the easy, fast, and predominant solution, regardless of other options. Nursing staff and junior doctors are often the frontline providers and clinicians initiating IV treatment and inserting PIVC. Failed attempts at this stage may result in escalation to a more experienced colleague and then, perhaps another before eventually, an expert such as an anesthetist provides the final successful access after many attempts. Such journeys for patients are sadly not uncommon, reflected in the VADER study by Carr et al. (2016) who identified the overwhelming device of choice of emergency department colleagues was for a PIVC and identified documentary evidence that many devices were failing to the last 3 days (Carr et al. 2015). Identified in that study, PIVC first-time success ranged from 18 to 86% among clinical staff in pediatric and adult populations, but specialist vascular access insertion teams can achieve 98–99% first-time insertion success.
6.4 Selection of an Insertion Site for PIVC Cannulation
6.4.1 Vein Characteristics
When performing an ultrasound assessment of veins for cannulation, look for veins that are palpable and bouncy and refill quickly following compression (Weinstein 2007). The vein selected should be straight, long enough to house the catheter, and more than double the diameter of the catheter (Dougherty and Lister 2011). Avoid veins with bifurcations, tortuosity, and thrombosis. The lower arm area of the forearm is associated with decreased pain, greater stability to reduce accidental removal, and increased dwell time (Gorski INS 2016). The veins can be selected by visualization/palpation or ultrasound assessment (Larue 2000; Mcdiarmid et al. 2017). Some of the steps detailed in the Marsden Manual (Dougherty and Lister 2015) include placing the tourniquet 6–8 in. above the site, tapping on the vein lightly to release histamines which cause dilatation, positioning the limb below the heart, and consideration for using a warm compress if necessary. PIVC can also be placed in the external jugular vein or veins in the foot for emergent use or when used for less than 4 days.
6.4.2 Skin Considerations
The skin and tissue integrity changes from patient to patient and can be a factor affecting VAD insertion success. These differences in skin integrity are perceptible to the clinician through tactile feedback and subtle pressure variations as the needle passes through the skin, tissues, and venous wall. The amount of pressure required to pass through the skin and tissues and enter the vein is influenced by the patient’s skin integrity and the quality and sharpness of the access needle. Many factors determine skin and tissue integrity, but age is a universal common denominator. As we age, the structural stability of the skin and tissues inevitably deteriorates. The amount and speed of deterioration vary and are subject to intrinsic and extrinsic factors such as a buildup of damaging waste products, cellular metabolism, and extrinsic environmental factors (Farage et al. 2013).
6.5 Safe Practices for Insertion
Attention to good practices with peripheral insertion focuses on vein selection, catheter choice, skin disinfection, and ANTT with insertion, stabilization of the catheter, and consideration for add-on extension tubing and flushing to confirm patency. Vein and catheter selections are discussed in previous sections. Skin disinfection is best performed with a 70% alcohol and greater than 0.5% chlorhexidine solution (O’Grady et al. 2011). Disinfection of the access point is also necessary with each flush and infusion. ANTT applies to all aspects of insertion, access for infusions, and care of the cannula and surrounding areas.
Hand hygiene is performed immediately prior to any patient contact and just before an insertion procedure. Following handwashing apply clean or sterile gloves for insertion of any intravenous device, sterile gloves for arterial and central access. Consider the use of strategies for improving visualization of veins (e.g., warm towels, warm blankets, palpation, augmentation, transillumination, ultrasound, infrared). Specific recommendations that follow for peripheral cannula insertion can be applied that lead to improved outcomes for the patient (Bertoglio et al. 2017).
6.6 Recommendations for PIVC Insertion
A PIVC is clinically indicated for administration of medical intravenous treatment.
Use a PIVC of appropriate size/gauge and length for the patient, the vein size, and treatment indications.
- Select a vein in the forearm as the preferred location; avoid areas of insertion near joints (i.e., wrist, fingers, antecubital fossa); insert two or more centimeters away from a joint or mobile area.
Clean skin with alcoholic chlorhexidine or other approved disinfecting agents.
Consider extended dwell cannula, catheter length of 2–6 cm as the preferred length for ultrasound-guided insertion when duration of treatment exceeds 3 days.
Consider the use of PIVC with added extension or integrated extension.
Stabilize the cannula with securement device prior to transparent dressing application.
6.7 Patient Assessment and Insertion
Hand hygiene performed immediately prior to PIVC insertion.
Clean or sterile glove use during insertion procedure for operator and patient protection.
Apply strategies for improving venous access vein visualization (e.g., warm towels/blankets, palpation, augmentation).
Single use of single patient tourniquet applied to the upper arm to dilate veins.
Most appropriate insertion site selected and marked (mid-forearm preferred, avoiding other contraindicated areas as with mastectomy or dialysis fistula sites).
Insertion vein assessed by palpation and when necessary infrared visualization or ultrasound evaluation.
Disinfect skin with 70% alcoholic chlorhexidine for 30 s and allow to dry completely.
Perform cannula access/insertion using Surgical-ANTT or Standard-ANTT.
No more than two attempts per clinician and new cannula with each attempt.
Flush PIVC with sterile 0.9% sodium chloride to verify correct vein placement and patency. Consider the use of 0.9% sodium chloride prefilled syringes.
Use positive pressure flushing technique of push pause, and follow correct clamping sequence for needle-free connectors.
6.7.1 Needle Design and Quality
The extra pressure that is then needed to puncture the vessel wall can lead to “overshooting” of the needle or passing the needle through the anterior and posterior wall in one movement, causing an unnecessary puncture in the back wall of the vein. This situation is avoidable and is not in keeping with the goals of vessel health and preservation. The clinician would then have to retract the needle until blood drips from the needle or until blood is aspirated into the syringe, establishing a good blood flow prior to guidewire advancement.
Patient factors may also influence needle selection (e.g., a patient with graft-versus-host disease). In some circumstances, the vessel walls and skin can become harder (scleroderma), and the quality and sharpness of the needle play an even more significant role in successful access. Similarly, the rigidity of the puncture needle is important when accessing deeper vessels. During insertion, micro movements are made as the needle tip passes from the surface of the skin toward the vein. As the clinician guides the needle in the direction of the vein, if slight changes in direction of the needle are needed, needle responsiveness becomes a factor. How responsive is the distal tip of the needle to clinician direction change/movement? Too much flexibility in the needle reduces the responsiveness at the needle tip and may cause bending, potentially impacting the successful puncture of the vessel. The quality and design of vascular access equipment can be determining factors in the success of the insertion procedure (Pearson and Rawlins 2005).
6.8 Additional Products
Following insertion of peripheral cannula, specific add-on devices may contribute to the reduction of catheter failure. Cannulas with adequate securement have fewer complications and longer dwell (Marsh et al. 2015). Manufactured securement devices including securement dressings have outperformed traditional tape and gauze and reduce the need to re-site the cannula. Another device included at the time of insertion is the short extension tubing that functions to reduce movement of the cannula at the insertion site and provide additional stress relief locations where the extension is taped to the arm (Bertoglio et al. 2017). Stabilizing the catheter and reducing movement in and around the insertion site promote longer dwell with reduced complications.
The introduction of new intravascular devices or components should be monitored for an increase in the occurrence of device-associated infection. If an increase in infection rates is suspected, this should be reported to the Medicines and Healthcare Products Regulatory Agency in the UK.
6.9 CVAD Insertion Preparation
Before the procedure: Perform a timeout to identify the patient and procedure establishing informed consent, check for allergy, have a pertinent history, and select the VAD with the lowest risk for the treatment ordered.
During the procedure: Perform skin disinfection with alcoholic chlorhexidine or other approved agents, maintain Surgical-ANTT, confirm venous placement (ultrasound guidewire), aspirate each lumen and flush with physiologic solution (saline), and secure catheter.
After the procedure: Verify terminal tip position, provide patient education, and ensure dressing is secure and date documented.
Identification numbers, i.e., NHS number with or without hospital number
Date of birth
Site and side of procedure if relevant
Location of patient, e.g., ward or admissions lounge
Further information that can be provided when relevant may include:
NCEPOD classification of intervention
Allergies, e.g., to latex or iodine
Any nonstandard equipment requirements or nonstock prostheses
Body mass index
Planned post-procedural admission to high dependency or intensive care facility
NatSSips follow the World Health Organization (WHO) safety checklist introduced in 2009 shown to improve patient safety and reduce complications and following the 2015 update now offer a more comprehensive safety approach (Pugel et al. 2015).
6.9.1 Insertion Environment
The environment and circumstances in which a vascular access device is placed can impact the outcomes of the procedure. For instance, devices placed in emergent settings are at higher risk for infections and complications than those placed electively (Tsotsolis et al. 2015). In the author’s experience, the occasions in which complications have occurred have resulted from the clinician feeling pressured either by the procedure, circumstances of the day or both, and working in an unfamiliar environment. In the elective setting, there is a greater opportunity to create a more relaxed environment for the patient and for the clinician. Additionally, familiarity with equipment is essential. Using a compressive, inclusive procedure prep pack which may include the catheter allows the clinician to have a recognizable set up of equipment and creates an element of routine and adheres to normal practice, even in unfamiliar environments (Marschall et al. 2014; INS 2016).
It is important to ensure that the patient is placed in a position of comfort, and necessary analgesia is optimized if needed prior to the procedure. Clinician comfort is important, too, allowing for better focus and ability to maintain sterile procedure. Placing the ultrasound, ECG/navigation equipment in the line of site so the clinician can glance effortlessly from ultrasound to insertion site without twisting, turning, or having to alter the screen allows for optimal function and view.
6.9.2 Local Anesthetic
The effective use of anesthetic is a fundamental component of a successful procedure. It facilitates patient comfort at key stages, such as vein cannulation and passing the dilator into the skin. Firstly, the anesthetic should be infiltrated superficially under the surface of the skin with the bevel of the needle pointing upward. Blanching of the skin may be observed. Depending upon the depth of the vein, anesthetic may need to be infiltrated slightly deeper to ensure an adequately anesthetized pathway from the surface of the skin to the selected vein, making sure the dermatome nerve supply is adequately anesthetized while taking care to keep a safe distance from vascular and nerve branches.
Injecting the anesthetic may cause the tissues to swell, increasing the distance from the skin to vein. Applying mild pressure over the site allows the anesthetic to infiltrate the tissues close to the vein and help restore normal anatomy. Infiltration of the anesthetic should be cautiously administered using an advance, aspirate and inject method, ensuring that no blood is aspirated into the syringe. Higher gauge or smaller diameter needles increase the difficulty of aspirating blood, and deflection is also higher in smaller diameter needles (Reed et al. 2012). The infiltrated anesthetic works on nerve endings; the larger the nerve branch, the more difficult it is to anesthetize. Nerve structures within the arm should be identified prior to commencing the insertion and local anesthetic. Injecting anesthetic too close to the nerve bundle may cause paresthesia. Paresthesia caused by lidocaine should subside within 2 h of administration as the serum half-life of lidocaine is approximately 90 min (Becker and Reed 2006). The local anesthetic with the least toxic and/or the least risk for allergic reaction should be considered (RCN 2016). INS (2016) recommends removal of any peripheral catheter when there are reports of paresthesia-type pain, as the dwell of the catheter and fluid accumulation may lead to compression injuries (Gorski et al. 2016).
6.10 Seldinger Technique
We owe much of our vascular access practice to clinicians like Dr. Sven Ivar Seldinger, who originally described an over-wire technique of catheter insertion, using needle, a guidewire, and catheter. The technique includes access with a needle, advancement of a wire, needle removal, and catheter advancement over the wire. Initially, this technique was used in arterial cannulation; subsequent modifications saw it used in venous catheterization, and it is now seen in emergency medicine, CVC cannulation and percutaneous tracheal ventilation (Bishay et al. 2018). PICCs and Midlines are mainly inserted using a modified Seldinger technique, a standard 21-gauge needle and 0.018 guidewire followed by peel-away sheath and dilator. This approach allows the insertion of a catheter that is larger than the puncture site created by the access needle in the vessel. The initial puncture site is dilated and stretched as the peel-away introducer is inserted. This modification with the two-part dilator and peelable sheath is preferable to traditional approaches when PICCs were initially inserted by passing the PICC through a 14G cannula sheath, usually accessing antecubital veins and without ultrasound (Gabriel 2001). One of the advantages of the modification is avoidance of skin contact and reduction of catheter contamination during insertion. For patients with difficult venous access, ultrasound should be used to provide for better assessment, to enhance vein selection, to reduce access attempts, and to facilitate successful insertion (Gorski et al. 2016). Evidence underscores the increase in successful placement and improved outcome for those clinicians receiving education and precepted insertions when employing the use of ultrasound (Moore 2013).
Resistance during the guidewire advancement following cannulation may occur with Midline and PICC insertions. Guidewire resistance may be experienced at the needle bevel or further down the venous pathway and may be caused by several factors:
6.10.1 Guidewire Advancement Difficulties
Needle is not in the vein—While a blood flashback was initially observed, it is possible that while the clinician is moving and reaching for the guidewire, the tip of the needle may move out of the vein. Secondly, it may be that the flash of blood was from the needle passing through the vein, but the needle was then inadvertently advanced through the back wall of the vessel (e.g., in a dehydrated patient), in which case a syringe (if not already being used) should be added to the needle and, while gently aspirating, slowly withdrawn until the needle tip enters the vein and blood is aspirated.
Bevel of the needle has not fully entered the vein—This occurs when the needle tip has entered the vessel, allowing for a blood return, but the whole portion of the bevel has not entered the vein; therefore, a clear pathway for the guidewire has not been established. Slight advancement of the needle is needed.
Angle or position of the needle in the vein—A steeper-angled needle approach is often needed in patients with increased body mass leading to a more difficult passage of the guidewire as it meets the posterior wall of the vessel and moves up the vein. Lowering the needle angle slightly may alleviate the resistance. Similarly, the proximity of the needle to the posterior vein wall may cause resistance as the wire attempts to negotiate passage through the acute angle and restricts space between needle tip and vein. Optimizing needle tip position within the vein will help to eliminate this problem.
Obstruction against a valve—A valve can cause resistance of the guidewire advancement within the venous pathway. Other guidewire advancement difficulties are found with distorted vein system seen in patients with a history of IV drug abuse where veins can be tortuous, sclerosed, or thrombosed. Good ultrasound assessment is the key to ensure the optimal device and outcomes, along with acquiring patient history for which veins were not previously used during drug abuse.
6.10.2 Guidewire Check
The visualization of the guidewire once it has been inserted into the vein is an important safety check, but it is not infallible. The wire can be passed through the vein and then into the adjacent or underlying artery, and this is not always appreciated on ultrasound (Bowdle 2014). A singular static ultrasound view of the wire in the vein is insufficient; thorough visualization of the wire as it passes from the skin, through the tissues into the vein and then advances through the vein, is needed to exclude posterior wall puncture and to ensure arterial or extravenous placement has not occurred.
For all vascular access insertions, the ultimate aim is a single wall puncture on the first pass of the cannulating needle. However, this is not the reality in some situations and may be related to clinician skill, situational stress, working out of comfort zone, procedural fatigue, and anatomical presentation of the patient. If the view of the guidewire is unclear, movement of the outside portion of the wire may aid the view of the wire within the vein, but this should be reserved for when the wire cannot readily be seen, as the wire movement may increase friction on the intima. If there is doubt over the wire position, X-ray imaging should be obtained to ensure correct placement prior to advancing the dilator or advancing the catheter.
The National Safety Standards for Invasive Procedures view guidewire retention as a never event and set out requirements for organizations to establish policy, protocols, good education, and safe practices for practitioners (England 2015). Some manufacturers have placed a slight bend at the proximal end of the guidewire to help prevent guidewire advancement.
6.11 Number of Access Attempts
Eisen et al. (2006) analyzed 385 consecutive non-tunneled CVC insertions undertaken on adult critically ill patients (Eisen et al. 2006). The authors identified that, with increasing attempts, the relative risk of complications increased accordingly and reported a rate of mechanical complications of 54% when two or more punctures were needed. Tsotsolis et al. (2015) identify the risk of one attempt at 4.3% and two or more attempts at 24% (Tsotsolis et al. 2015). The incidence of gaining first-time access to the vessel is considerably increased when using ultrasound. A randomized controlled trial (RCT) of 100 patients conducted by Karimi-Sari et al. (2014) compared landmark technique versus ultrasound-guided central venous catheter placements (Karimi-Sari et al. 2014). In this study, the mean access time, number of attempts, rate of first attempt success, and procedure success rates were all superior in the ultrasound group. Mehta et al. (2012) undertook a systematic review of US versus landmark approach of emergency physicians and identified IJ placements had a success rate of 93.9% versus 78.5% with landmark, and complications were 4.6% with US versus 16.9% with landmark technique (Mehta et al. 2013). Kornbau et al. (2015) confirmed that overall, the number of unsuccessful insertion attempts is the biggest predictor of complications and confirms that US has significantly reduced the incidence of immediate complications (Kornbau et al. 2015).
Our aim is to minimize trauma to the vessel, thereby reducing harmful effects and preserving the vessel for the future life of the patient. Thrombosis, infection, and mechanical-related complications can all be affected by the way we access veins. This is exemplified in the RCT performed by Li and colleagues (Li et al. 2014). The study involved 100 patients and included 50 blind insertions using a traditional 14G cannula passing the catheter through the cannula sheath and 50 insertions using MST with ultrasound guidance. The MST/ultrasound group showed higher migration rates but had lower unplanned removal, mechanical phlebitis, and incidence of thrombosis.
The rate of misplacement of catheters varies between VAD types and sites of insertion. Internal jugular, for instance, has lower instances of misplacement than axillary placements or PICCs. PICCs are reported to have three times greater risk of primary malposition than other CVADs (Gorski et al. 2016). PICCs must negotiate a longer distance from the insertion site to the lower SVC and CAJ and may be inadvertently placed into a number of wrong veins on their journey. The most frequent malpositioning is the internal jugular vein. Inadvertent tip position into the jugular vein can be assessed using ultrasound during placement. Additionally, the catheter may be laid on the wall of the vein, which is not always readily visible with ultrasound. Close attention is needed to identify the hyperechogenic catheter. Using a sterile saline flush causes a saline swirl (microbubbles at catheter terminal end viewed with ultrasound). This “swirl” can be seen within the vein, also indicating that the tip has migrated into the internal jugular vein. Tip navigation and confirmation systems aid visualization of tip positioning into alternative veins so that corrective action can be undertaken immediately.
Insertion of a PIVC or CVAD is an invasive process that includes associated complications. Education and training on specific complications and methods to avoid those complications with insertion techniques will contribute to patient safety. VHP embraces consistent education for inserters in keeping with the Society for Healthcare Epidemiology of America recommendations (Marschall et al. 2014). Institutions are responsible to their patients to establish credentialing processes to ensure inserter safe practice. Initial training with supervision, precepting for ultrasound skill acquisition, insertion techniques for different devices, applications for each technique and device, competency assessment, and data collection on outcomes as measurement criteria are all necessary components of a high-quality program.
Mrs. Jones, recently diagnosed with stage 4 lung cancer, required a CVAD for the administration of her vesicant chemotherapy treatment for 6 months. Following discussion with Mrs. Jones, a decision was made to insert a tunneled CVAD, and appointment was arranged with interventional radiology for placement. A specially trained nurse within the radiology department, with more than 10 years of experience and many hundreds of insertions, performed the insertion without complications. Mrs. Jones was satisfied with the procedure and thanked the inserter.
Summary of Key Points
The goal of vascular access is to minimize trauma to the vessel and preserve the vessel for the future life of the patient.
The number of unsuccessful insertion attempts is the biggest predictor of complications.
The number of insertions a clinician has performed directly affects the likelihood of first time access success. The more experience (e.g., >50), the more likely to gain access on first attempt.
Supervised or precepted insertions with ultrasound promote a higher percentage of success with subsequent insertions.
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