‘Pinholes in my arms’: The vicious cycle of vascular access

Vascular access devices (VADs) are essential for delivery of intravenous therapies. There are notable gaps in the literature regarding a focus on patient experience and meaning-making related to living with a VAD, specifically a central venous access device (CVAD). To explore how patients make sense of living with a CVAD. This study followed an interpretive phenomenological analysis (IPA) approach. Purposive sampling was used to identify 11 cancer patients who had a CVAD in situ. One-to-one semi-structured interviews were performed. Interviews were digitally recorded, transcribed and analysed by the lead author. Four superordinate themes were identified: the self under attack; being rescued/being robbed; protection of others/protection of self; bewilderment and dismay at lack of staff competence. Having a CVAD affects the psychological, social, and personal self and impacts on self-esteem and self-image. Despite this, CVADs are accepted by patients and are eventually 'embodied' by them.

ABSTRACTBackgroundVascular access devices (VADs) are essential for delivery of intravenous therapies. There are notable gaps in the literature regarding a focus on patient experience and meaning-making related to living with a VAD, specifically a central venous access device (CVAD).AimsTo explore how patients make sense of living with a CVAD.MethodsThis study followed an interpretive phenomenological analysis (IPA) approach. Purposive sampling was used to identify 11 cancer patients who had a CVAD in situ. One-to-one semi-structured interviews were performed. Interviews were digitally recorded, transcribed and analysed by the lead author.FindingsFour superordinate themes were identified: the self under attack; being rescued/being robbed; protection of others/protection of self; bewilderment and dismay at lack of staff competence.ConclusionHaving a CVAD affects the psychological, social, and personal self and impacts on self-esteem and self-image. Despite this, CVADs are accepted by patients and are eventually ‘embodied’ by them.

Paediatric vascular access

Background: Central-line–associated bloodstream infections (CLABSIs) result in increased patient morbidity. Guidelines recommend against peripheral venous catheters when access is required for longer than 6 days, often leading to central venous catheter (CVC) placement. To improve vascular access device choice and reduce the potential risk of CLABSI, we implemented a quality improvement initiative comprised of a vascular access algorithm and introduction of a midline vascular access device (MVAD). We report complications associated with MVAD use including deep vein thrombosis (DVT), thrombophlebitis, and BSI. Methods: A prospective quality improvement assessment from October 2017 through March 2018. All MVADs were monitored for DVT, thrombophlebitis, and BSI. Insertion time and removal of MVAD were tracked, as well as presence of other vascular access devices. Results: From October 2017 through March 2018, 858 MVADs were inserted in 726 different patients, yielding 3,588 MVD days. In total, 6 primary BSIs occurred in patients with MVADs. In patients with only a MVAD, the rate was 0.72 BSI per 1,000 MVAD days, whereas patients with an MVAD as well as a CVC had a rate of 1.98 per 1,000 MVAD days. The overall CLABSI rate at the institution during this period of time was 1.24 per 1,000 CVC days. Also, 29 cases of thrombophlebitis occurred, for a rate of 3.84 per 1,000 catheter days in patients with only an MVAD compared to 4.63 per 1,000 catheter days in patients with an MVAD and a CVC. Also, 25 DVTs occurred during this time, resulting in a rate of 2.88 per 1,000 catheter days in patients with only an MVAD and 4.63 per 1,000 catheter days in patients with multiple vascular-access devices. A significant correlation was noted between MVAD indwell time and BSI (P = .0021) and thrombophlebitis (P = .0041). The median indwell time for patients experiencing BSI was 16.17 days ± 8.04 days, whereas the median indwell time for patients experiencing thrombophlebitis was 9.24 days ± 7.99 days. Conclusions: The implementation of a vascular-access algorithm including MVAD may effectively reduce CVC insertions and BSIs. The rate of BSI in MVAD was below that of CLABSI during the assessment period. Known complications associated with MVAD include DVTs and thrombophlebitis, which correlates with the duration of catheterization, and these risks appear to be further compounded in patients requiring multiple devices for vascular access. Further research into comparing the risk of vascular access of MVAD with CVC is warranted.Funding: NoneDisclosures: None

In 2016, a 263-bed public district hospital in California trialed a peripheral intravenous catheter (PIVC) inserted using ultrasound, with the potential to increase first attempt success in difficult intravenous access (DIVA) patients. This led to the implementation of a hospital-wide initiative to improve nursing vascular access skills and expedite vascular access device (VAD) placement. To trial a PIVC and ultrasound-guided (USG) insertion, a training program was developed and led to a doctoral Capstone project piloting an evidence-based nurse-driven protocol for the identification of DIVA patients. A Vascular Access Committee was established to achieve vascular access excellence throughout the hospital by increasing the number of nurses with advanced skills in VAD placement and by developing a central venous access device (CVAD) insertion and maintenance bundle to decrease the incidence of central line-associated bloodstream infections (CLABSI). With ongoing support of nursing leadership and achievement of ANCC Magnet Recognition® in 2021, the hospital developed a comprehensive initiative to provide patients with a consistent level of nursing expertise for VAD placement across all shifts. Requests for USGPIVCs increased throughout the hospital, DIVA patients themselves requested ultrasound guidance be used for PIVC insertions, and there were fewer requests for Emergency Department (ED) physicians to insert CVADs. From the related Doctor of Nursing Practice (DNP) Capstone project, there were higher first-attempt cannulation successes, longer PIVC dwell times, and a reduction in devices and supplies utilized. The CVAD bundles resulted in the number of central line-associated bloodstream infections decreasing from four in 2019 to one in 2020. Since the initiative's inception, a total of 92 nurses completed the USGPIVC insertion training, and patient access to advanced-skilled clinicians is now available around the clock. This manuscript discusses the initiative implemented to standardize patient care through a collaborative multidisciplinary approach and has potential generalizability to other acute care hospitals to reduce associated healthcare costs and to prevent poor patient outcomes by expediting the arrival of a vascular access nurse for DIVA patients. The vascular access excellence initiative implemented provided an effective strategy to enhance the skills and confidence of nurses in VAD placement and improved efficiency in processes to expedite the arrival of an advanced skilled nurse to place VADs on DIVA. Targeted educational initiatives improved patient outcomes by reducing catheter-related bloodstream infections.

To develop consensus recommendations for the selection and management of vascular access devices (VADs) in oncology patients in India by addressing unique challenges in the Indian healthcare ecosystem. An expert panel of 11 specialists in oncology and interventional radiology convened to review literature and develop consensus statements on 10 key questions related to the selection of VAD in cancer patients. The panel used a nominal group technique during a face-to-face meeting, achieving 100% consensus on all statements through structured discussions. The panel deliberated and agreed upon 10 consensus statements, addressing the indications for central venous access devices (CVADs), available CVAD options, clinical decision-making processes for identifying appropriate CVADs for different groups of patient, decision-makers for device selection and insertion, factors influencing port selection, the logistical requirements and CVAD maintenance protocols in cancer patients in India. Key recommendations emphasize the use of CVADs for administering vesicant drugs, considering both external catheters and implantable ports based on the duration and frequency of treatment. The recommendations also highlight the importance of involving multidisciplinary teams in device selection and implementing standardized training and protocols for insertion and maintenance. These consensus recommendations provide guidance on VAD selection and management tailored to the Indian oncology setting. The statements emphasize the importance of patient-centred decision-making, proper training for healthcare providers, and the need for increased awareness and education to enhance the appropriate adoption of implantable ports in India. Implementation of these recommendations may improve vascular access care and outcomes for cancer patients across diverse healthcare environments in India.

A Modified Landmark-Guided Technique for Cannulation of the Internal Jugular Vein in Pediatric Patients: A Preliminary Report

Theoretical proposals for two new vascular access devices (a central venous catheter (CVC) and a peripheral vascular access system, PVAS) are presented in this article. The new CVC concept is based on a mechanical obturator used for CVC locking. Compared to conventional locks, it should, theoretically, allow the reduction of bacterial contamination, biofilm and thrombotic formation. A new tunneling technique, based on a "rigid tunnel sheath" providing a more stable connection, as compared to a traditional CVC cuff, and an increasingly protected exit site, allows CVC changing changeover to take place through the sheath; therefore, avoiding surgical intervention. PVAS, based on the same mechanical lock concept, is structured from four components: obturator, soft graft, rigid tunnel sheath and foldable sheath. The total graft length is about 80 mm, its inner extremity being uncovered to allow a gentle curve reaching the native vessel. The outer extremity and bifurcation are reinforced by a titanium rigid sheath together with a Dacron cuff. The obturator is protected, and several technical solutions have been considered to guarantee sterility: the "accordion sheath", the "foldable sheath", and the "balloon obturator system". The major advantage of PVAS on CVC is the implant on the peripheral vessel which allows the saving of central veins and possibly avoiding life-threatening complications. As compared with an arterial-venous fistula or an arterial-venous graft, PVAS's main advantage should be the possibility of implanting even in "desperate" cases, so avoiding fistula needle positioning. It could be indicated for pediatric or psychiatric patients, for home-based or frequent dialysis schedules. Lower hemodynamic stress should therefore reduce vessel damage, such as aneurism, pseudo-aneurism, intimal hyperplasia and cardiac overload. The development of prototypes is in progress to verify both device usefulness and safety in clinical practice.

Central venous catheter tip placement and catheter occlusion

British Journal of NursingVol. 20, No. Sup11 ClinicalPreventing infections related to catheter occlusionSherri Ogston-TuckSherri Ogston-TuckSearch for more papers by this authorSherri Ogston-TuckPublished Online:16 Aug 2013https://doi.org/10.12968/bjon.2011.20.Sup11.S4AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Cook N (1999) Central venous catheters: preventing infection and occlusion. Br JNurs 8(15): 980–9 Link, Google ScholarDepartment of Health (2007) Saving Lives: Reducing Injection, Delivering Clean and Safe Care. The Stationery Office, London Google ScholarDrewett S (2000) Complicaitons of central venous catheters: nurisng care. Br J Nurs 9(8): 466–78 Link, Google ScholarDougherty L (2006) Central Venous Access Devices: Care and Management. Wiley Blackwell, Oxford Google ScholarDougherty L (2008) Obtaining peripheral access. In: Dougherty LLamb J (2008) Intravenous Therapy for Nursing Practice. Blackwell, Oxford Google ScholarGabriel J, Bravery K, Dougherty L, Kayley J, Malster M, Scales K (2005) Vascular access: indications and implications for patient care. Nurs Stand 19(26): 45–54 Crossref, Medline, Google ScholarDi Giacomo M (2009) Comparison of three peripherally inserted central catheters: pilot study. Br J Nurs 18(1): 8–16 Link, Google ScholarInfusion Nursing Society (2011) Infusion nurisng standards of practice. J Intravenous Nurs 34(Suppl): S1–92 Google ScholarKelly L (2011) A guide to the use and care of vascular access devices in the palliative care setting. Journal of Palliative Care Nursing 17(9): 425–9 Link, Google ScholarLenhart C (2000) Prevention vs treatment of vascualr access device occlusions. J Vascular Access Devices 5(4): 34–5 Crossref, Google ScholarMayo DJ (2001) Catheter-Related thrombosis. Journal of Intravenous Nursing 24(3S): S13–S22 Google ScholarNicol M, Bavon C, Cronin P et al. (2008) Essential Nursing Skills. Elsevier, London Google ScholarPratt RJ, Pellowe CM, Wilson JA et al. (2007) Epic 2: national evidence-based guidelines for preventing healthcare – associated infections in the NHS hospitals in England. J Hosp Inj65(Suppl 1): S1–64 Crossref, Medline, Google ScholarPearson MJ (1996) Guidelines for the prevention of intravascular-related infections. J Inj Control 24(4): 262–93 Crossref, Medline, Google ScholarSantilli J (2002) Fibrin sheath and central venous catheter occlusions: diagnosiss and management. Tech Vasc Interv Radiol 5(2): 89–;94 Crossref, Medline, Google ScholarRoyal College of Nurses (2010) Standards for Infusion Therapy. RCN, London Google Scholar FiguresReferencesRelatedDetailsCited byPatient safety and pain in IV therapy20 February 2014 | British Journal of Nursing, Vol. 23, No. Sup1Intravenous therapy: guidance on devices, management and care16 August 2013 | British Journal of Community Nursing, Vol. 17, No. 10 26 October 2011Volume 20Issue Sup11ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 16 August 2013 Published in print 26 October 2011 Information© MA Healthcare LimitedPDF download

Venous thromboembolism (VTE) is an important complication of coronavirus disease 2019 (COVID-19). To date, few studies have described vascular access device use and VTE risk in this cohort. To examine the use of vascular access devices and incidence of VTE in patients hospitalized with COVID-19. We performed a retrospective, multi-center cohort study of patients hospitalized with COVID-19 who received a midline catheter, peripherally inserted central catheter (PICCs), tunneled or non-tunneled central venous catheter (CVC), hemodialysis (HD) catheter or a port during hospitalization. Mixed-effects multivariable logit models adjusting for VTE risk factors in the Caprini risk score were fit to understand the incremental risk of VTE in patients with vascular access devices vs. those that did not receive devices. Management of VTE was determined by examining anticoagulant use pre- vs. post-thrombosis. Results were expressed using odds ratios (ORs) and associated 95% confidence intervals (CI). A total of 1228 hospitalized COVID-19 patients in 40 hospitals, of which 261 (21.3%) received at least one vascular access device of interest, were included. The prevalence of acute, non-tunneled CVCs was 42.2%, acute HD catheters 18.4%, midline catheters 15.6%, PICCs 15.6%, tunneled CVCs 6.8%, and implanted ports 1.4%. The prevalence of VTE was 6.0% in the study cohort, and 10.0% among patients with vascular access devices. After adjusting for known VTE risk factors, patients that had a vascular access device placed were observed to have a four-fold greater odds of VTE than those that did not (OR 4.17, 95% CI 2.33–7.46). Patients who received multiple different catheters experienced more VTE events compared with patients that received only one type (21.5% vs. 6.1%, p < .001). Among the 26 patients with VTE, only 8 (30.8%) survived to discharge and among these, only 5 were discharged on therapeutic doses of anticoagulation. Hospitalized patients with COVID-19 that receive vascular access devices experienced higher rates of VTE than those that do not. Future studies to evaluate the nexus between COVID-19, vascular device use, and thrombosis appear are warranted.

An efficient vascular access is mandatory for the proper conduction of therapeutic plasma exchanges (TPE). Peripheral and central venous catheters may be used, with respective advantages and limitations. In this study, vascular access devices (IV catheter, dialysis cannula, central venous catheter) and anatomic vein characteristics were evaluated. From January to June 2016, 162 TPE in 29 patients were reviewed. Only TPE using centrifugation method (Spectra Optia apheresis system) were evaluated. Volume exchanged, procedure duration, mean flow rate, number of inlet, and return pressure pauses were recorded. Site, width, and depth of punctured veins were studied. Median exchange volume planned was 3500 mL, and 152 (94%) procedures could be completed. Peripheral venous catheter was inserted in 103 (64%) cases (IV catheter: 61, dialysis cannulae: 42). Ultrasound guidance was used in 12 (11%) cases. Median procedure duration was shorter with central venous catheter (94 minutes), rather than dialysis cannula (133 minutes) or IV catheter (133 minutes). Median numbers of inlet pressure pauses were lower with central venous catheter (0) and dialysis cannulae (6), rather than IV catheter (10). There were no complications with peripheral venous access. There were no anatomic differences between catheterized veins with IV catheter or dialysis cannula. The use of peripheral venous access is possible in most of TPE, for emergency and during maintenance therapy. Dialysis cannulae are good compromise between classic IV catheters and central venous catheters, as it allows high flow rates, are easy to insert and associated with few complications.

Background: Whether to remove or retain vascular access devices (VADs) when they are suspected of infection is an important clinical question with no certain answer. This review aims to explore current literature related to removal versus retention of central venous catheters (CVCs) and intra-arterial lines (IALs) suspected of infection in the adult intensive care population. Methods: A narrative review of studies describing management of VADs suspected of infection in the intensive care unit (ICU) was undertaken. After a systematic search, two clinical studies were included in the review. The methodological rigour of these studies was assessed per the Mixed Methods Appraisal Tool (MMAT). Results: The two eligible studies consisted of one randomised control trial and one prospective observational study, including a total of 448 patients. Both studies scored highly on the MMAT, but only pertained to CVCs. No studies relating to other VAD types were identified. No significant differences in outcome were identified between patients whose VADs were removed or retained in the adult ICU cohort, apart from a reduction in number of CVC replacements in patients whose VAD was retained after infection was suspected. Conclusions: There is minimal evidence pertaining to removal versus retention of VADs suspected of infection in the adult ICU patient cohort, and there are limited recommendations specific to suspected infection guiding clinical practice. As a result, VADs may be unnecessarily removed. Further research assessing these important patient outcomes are urgently needed to inform clinical practice.

When treating children with cancer, long-term venous access is critical. This is especially true in the context of children receiving daily radiation therapy (RT) under general anesthesia. We have previously reported <0.1% risk of complications in complications in over 4,040 pediatric treatments under general anesthesia in our outpatient facility. Here, we present our experience with venous catheter access techniques in children receiving daily proton RT. After Institutional Review Board approval, we reviewed our center's records between September 9, 2004 and October 23, 2012 with respect to complications and morbidity of indwelling catheters in our pediatric patients. Vascular access device (VAD) types included: 110 patients with indwelling port-a-cath (PAC), 34 PICC line devices, and 34 central venous catheter (CVC) devices in 170 patients. Median catheter life during RT was 43 days (range 1-86 days) with a total of 7,169 total catheter days while patients received RT. A 14% PAC complication rate included negative blood return (6.3%) and infection (3.6%). Complication rates for PICC and CVC access devices were 38% and 20.5%, respectively (χ(2) P = 0.007 when compared with PAC). Most frequent complications for PICC lines were no blood return (11.7%), and infection or occlusion (8.8% each). CVC complications were breakage (8.8%) and infection (8.8%). Access device replacement rates were 3.6% (PAC), 14.7% (PICC), and 8.8% (CVC). In the outpatient delivery of RT to children, indwelling ports provide greater convenience, less likelihood of infection or complication, and greater durability than PICC or CVC devices.

Patients with difficult intravenous (IV) access in emergency departments (EDs) often require invasive vascular access techniques, including ultrasound-guided peripheral intravenous catheters (USGIVs), mini-midline catheters (MMCs), and central venous catheters (CVCs). Although prior research has explored the safety and survival time of these vascular access devices (VADs), there is little available literature in comparing their procedural duration and clinical utility. A prospective observational study was conducted to evaluate the procedural duration, catheter utilization, and survival time of USGIV, MMC, and CVC insertion in the ED of a Level 1 Trauma Center. Procedural duration was measured using direct time-motion observations. Catheter utilization was assessed through prospective chart reviews. Statistical comparisons were performed using primarily the Wilcoxon Rank Sum Test and descriptive statistics. A total of 51 successful VAD insertions were observed: 13 USGIVs, 18 MMCs, and 20 CVCs. The mean total procedural duration (minutes) of CVCs was significantly longer than both USGIVs (p < 0.001, 95% Confidence Interval (CI) of the difference 15.45-26.94) and MMCs (p < 0.001, 95% CI of the difference 8.13-21.85), while no significant difference was found between MMCs and USGIVs (p = 0.085, 95% CI of the difference -0.38 to 12.90). Median catheter survival with early outliers removed was 2.5 days for USGIVs, 4.9 days for MMCs, and 5.2 days for CVCs. The mean number of IV medications infused within 24 h was 1.3 (Standard Deviation (SD) 1.5) for USGIVs, 5.3 (SD 3.7) for MMCs, and 7.3 (SD 3.2) for CVCs. The mean number of blood draws within 24 h was 3.8 (SD 2.3) for USGIVs, 5.8 (SD 3.2) for MMCs, and 7.2 (SD 2.3) for CVCs. These findings suggest that MMCs required less time to place than CVCs in the ED setting while also demonstrating expanded clinical functionality and longevity compared to USGIVs.