Traditional methods to assess peripheral veins have relied exclusively on palpation of the vein lying under the skin. In many patients, t1he experienced inserter can easily locate veins that are not seen and determine their health by certain characteristics such as a hard, cordlike feeling. Palpation provides little information about the actual size of the vein and it is an educated guess about what size catheter the vein will accommodate. Until recently, there have been very few studies on the actual diameter of peripheral veins.
 
An increasing awareness of the unacceptable outcomes associated with peripheral catheters1 is driving change. We now have several studies assessing the diameter of peripheral veins. An ultrasound study of peripheral vein anatomy reported that the average diameter of veins in the adult hand is 2 mm and the adult forearm is an average of 2.9 mm.2 Mapping superficial veins of the upper extremity is necessary for creation of arteriovenus fistulas and has provided useful information for the cephalic and basilic vein the entire length of the arm. 3 4
 
We also know from these and other studies that the cephalic vein does not always get larger in diameter as it moves up the arm and that the basilic vein is the largest diameter in only 55% of patients according to one study.5
 
Additionally, studies now point to contact between the catheter and vein wall as the source of endothelial damage leading to inflammation and thrombophlebitis. Pressure against the endothelial call layer causes release of von Willebrand Factor and Interleukin-8, both pro-inflammatory and pro-coagulant substances.6
 
Vascular visualization technology now allows a clear view of the vein and its pathway, venous valves and bifurcations. We can now improve these unacceptable outcomes by using visualization technology, plus incorporating all 3 types of peripheral catheters into our practice. Time to think about the lowly peripheral veins in a new way.
 
 
 
 References
1.              Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but Unacceptable: Peripheral IV Catheter Failure. Journal of Infusion Nursing. 2015;38(3):189-203.
2.              Gagne P, Sharma K. Relationship of Common Vascular Anatomy to Cannulated Catheters. International Journal of Vascular Medicine. 2017;2017.
3.              Spivack DE, Kelly P, Gaughan JP, van Bemmelen PS. Mapping of Superficial Extremity Veins: Normal Diameters and Trends in a Vascular Patient-Population. Ultrasound in medicine & biology. 2012;38(2):190-194.
4.              Ayez N, Van Houten V, De Smet A, et al. The basilic vein and the cephalic vein perform equally in upper arm arteriovenous fistulae. European Journal of Vascular and Endovascular Surgery. 2012;44(2):227-231.
5.              Sharp R, Cummings M, Fielder A, Mikocka-Walus A, Grech C, Esterman A. The catheter to vein ratio and rates of symptomatic venous thromboembolism in patients with a peripherally inserted central catheter (PICC): a prospective cohort study. Int J Nurs Stud. 2015;52(3):677-685.
6.              Weiss D, Avraham S, Guttlieb R, et al. Mechanical Compression Effects on the Secretion of vWF and IL-8 by Cultured Human Vein Endothelium. PloS one. 2017;12(1):e0169752.

Nurses from many different practice areas frequently ask this question. The patient has many visible veins on their chest or breast area, so why can’t we use those for insertion of a short peripheral I.V. catheter when there are no veins in the upper extremity? Take a close look at the picture, especially how these veins appear.

There are many reasons why using these veins is not good practice. First, the nurse must be concerned about WHY those superficial veins of the chest are so visible. The answer here is simple – changes in venous return due to injury, surgery, or some type of disease process. There can easily be vein thrombosis or stenosis that is restricting the blood flow and causing these veins to be so prominent. Engorged veins of the chest are a classic sign of vein thrombosis. Infusion into these veins will add to the problem of venous return.

The second thing to be concerned about is the tortuous nature of those veins. Notice in the picture below how these visible veins are not lying in a relatively straight path. It would be most difficult to get a catheter to advance into those veins. There is no method to distend these veins for venipuncture.

The risk of infiltration/extravasation is a third factor. There are numerous cases of severe extravasation injury due to leakage from a CVAD insertion site and from a needle used for accessing an implanted port. I have seen lawsuits where a total mastectomy was required due to these events. Many times these questions come from nurses in the emergency department. And many times these nurses will need to give vesicant medications such as calcium chloride or calcium gluconate, 50% dextrose, or high concentrations of potassium – all are vesicants that can produce severe tissue damage if they leak from the vein into the subcutaneous tissue. Even if the prescribe I.V. therapy is only for fluids, the alteration in normal venous return will cause fluid to overflow the puncture site and into the subcutaneous tissue.

The fourth factor is there is no research to support this practice and it is not recognized by any professional organization.

Fortunately, there are much better alternatives. All nurses with responsibility for performing peripheral catheter insertion MUST have the skill of vein palpation. This skill can easily be learned. Practice palpating the upper extremity for veins before choosing a site on all patients. Always use the same finger of the same hand for this technique. Press downward and feel for an elastic rebound of a healthy vein beneath your fingertip. Do not simply rub your finger over the skin surface, as this will not provide useful information about the vein condition. If the vein feels hard or cord-like, it is sclerosed and should not be used. Palpation may not work for every patient due to vein changes from many courses of infusion therapy, or disease processes such as diabetes. Nevertheless, you may be surprised at the unseen, palpable veins you will be able to find when you have mastered this skill.

If the situation requires rapid access, choose an intraosseous device. Again, insertion is a skill to be learned. The intraosseous route provides rapid assess and is now recommended when time is critical. Do not waste time searching for a peripheral vein and making many unsuccessful attempts. This delay only adds to the risk for the patient.

Finally, if time is not a critical factor, use an infrared light device or ultrasound to locate veins in the upper extremity that you cannot palpate. Again, these are more skills that must be learned and your facility must make the investment into providing these devices. However, these devices are well documented to increase the success of peripheral venipuncture in patients with difficult venous access

The bottom line is that superficial veins of the chest or breast area should never be used for insertion of a peripheral catheter because the risks are much greater than the benefits. Moreover, there are many other alternatives.

These definitions indicate a major difference of where the damage is taking place. For a vesicant, the damage is occurring in the subcutaneous tissue OUTSIDE of the vein. For irritants, the damage is occurring to the vein wall INSIDE the lumen.

Vesicants cause tissue damage that may OR may not require surgical intervention. Notice in the definition the use of the word “or” – blistering, tissue sloughing OR necrosis. Blistering and tissue sloughing are tissue damage but necrosis may not be present. Time is required to heal the area, hopefully without any permanent tissue destruction. Necrosis requires surgical debridement and maybe even skin grafting to allow for complete healing. Vesicants produce this entire range of tissue injury with the damage occurring to the subcutaneous tissue at or near the point of where the fluid is escaping from the vein. This can be at the point of vein puncture or the catheter’s tip location or both.

Irritants cause phlebitis (vein inflammation) and thrombophlebitis (thrombus plus inflammation), so the damage is occurring inside the vein lumen. This inflammatory process can produce severe edema but there is no infusing fluid leaking from the vein into the subcutaneous tissue. When peripheral catheters are used for infusion, this is occurring in superficial veins, thus the diagnosis of superficial thrombophlebitis. When it occurs with a PICC or other CVAD, it is most often a deep vein thrombophlebitis.

The term, “extravasation” is referring to the leakage of vesicant fluid/medications into the subcutaneous tissue. But this term is not used when the event is from an irritant inside the vein lumen.

Signs and symptoms often overlap between these 2 complications. It may be difficult for staff nurses to distinguish the difference and this is where the knowledge and skill of an infusion nurse is required.

Have you checked out our new EBP Reports?
 
These concise reports

• Ask the clinical question
• Provides a short synopsis of the background
• Defines key words and phrases
• Analyzes the applicable studies
• Provides practice recommendations
• And the list of references used.

We are constantly scanning the published literature for many projects. Our company database has over 113,000 published studies and other articles and we are constantly adding more. Let us put them to work for you.
 
These concise reports

• Ask the clinical question
• Provides a short synopsis of the background
• Defines key words and phrases
• Analyzes the applicable studies
• Provides practice recommendations
• And the list of references used.

 After purchase, you will receive an email with a link to download the paper.

We just launched our latest Evidence-based Practice Report.

Central Vascular Access Device Insertion and the Risk of Coagulopathy

The Clinical Question:

What is the reported risk of bleeding during insertion of any type of central vascular access device (CVAD)?

Are there recommendations for coagulation-related lab values when a CVAD is inserted?
What are the recommended values for coagulation-related lab test such as INR/PT, APPT, and platelets)?

The hospital’s policy about cleaning catheter hubs and needleless connectors recently changed due to the serious concern about central line associated bloodstream infection. There is now a great emphasis on cleaning the luer-locking threads of the female catheter hub before applying the new needleless connector. All nurses have been instructed to wrap an alcohol pad around the catheter hub and rotate it several times and then allow it to dry. Four days later it is now time for you to change the needleless connector, and it simply will not come off. Try as you might, it will not budge. Your only thought is to get a hemostat to hold the catheter hub and maybe a second hemostat to hold the needleless connector and twist. But even that does not work! Why did this happen and what do you do?

First, where is the evidence for this type of cleaning on the catheter hub? In the 1990’s there were several articles pointing out the catheter hub as the pathway for organisms to enter the bloodstream. But there were no studies then, or now, examining the methods for doing this type of cleaning. Remember 25 years ago, we were not focusing on the catheter hub like we are now. Many hospitals have adapted this practice of hub cleaning even without research to assess the outcomes of the practice. There could easily be dried blood, drug precipitate and skin oils contaminating the catheter hub and this debris could easily enter the catheter lumen. 

The needleless connector could be permanently fused to the catheter hub because of the type of plastics being used in those devices. Thermoplastic polyurethanes are a common type of material for these devices but there can be many different types within this group. Strength and durability are great characteristics, but some types can not tolerate exposure to alcohol. Both ethanol (the kind used for drinking and IV fluid) and isopropyl alcohol (the common disinfectant) can soften the plastic. Sometimes even allowing the alcohol to thoroughly dry is not enough but this could be the problem. The soften surface of the catheter hub could leave the used needleless connector permanently attached. There may not be any method for removing the needleless connector. 

One word of caution, use of hemostats can easily cause the catheter hub to crack and leak. This could provide any entry for organisms into the lumen. A needleless connector that can not be removed or the cracked catheter hub could require the insertion of a new catheter. 

Before instituting this cleaning policy, check the details in the instructions for use (the booklet inside the package of all central venous catheter packages) about use of alcohol on all parts of the catheter, including the hub. Some have a specific statement about cleaning the hub with alcohol. Others have warnings about use of alcohol for skin antisepsis, instillation of ethanol for clearing occlusion from the catheter lumen, but there may not be any statements about applying alcohol to the catheter hub. For more information about your issue, call the catheter manufacturer’s clinical information department. 

For anyone interested in the details of thermoplastic polyurethane, look at this YouTube video. But, be warned, this video is very technical about polymer science. 

Visit our website to learn more about online classes (limited time 15%OFF).

Every day, you make clinical decisions about many aspects of patient care, but you face challenges for many situations. Your first choice for a resource is the facility policy and procedure book, or to check other valued textbooks. Another option is to ask a trusted colleague. But what happens when your questions remain unanswered, or you wonder if  practice can be made safer through use of more recent evidence. The Institute of Medicine established a goal of having 90% of clinical decisions based on the latest evidence but we are far from that goal.
 
When do you have the time to go to a computer, sign on to a search engine, locate the needed papers and analyze them?
 
That is where we can help!
 
Our Evidence-Based Practice Reports asks a clinical question, then provides a concise report based on the latest published evidence. We include term definitions, analysis of studies, recommendations for practice and the complete list of references used.
 
We have just released a new EBP Report – Venipuncture and Lymphedema
The Clinical Questions are

• Is it acceptable to perform venipuncture or VAD insertion on the ipsilateral arm after any type of breast cancer surgery?
• What are the risk of venipuncture on the ipsilateral arm after breast cancer surgery?

 
Numerous guidelines have statements instructing patients to avoid all punctures on the ipsilateral arm after breast cancer surgery. This recommendation based on a theory dates back to 1921. Almost 100 years later we still do not have a complete scientific answer. We did find 4 systematic literature reviews on these questions, but the studies are not high-level evidence and are conflicting. What happens when all veins in the unaffected arm cannot be found or your patient has had bilateral breast cancer? Learn more about the evidence for these decisions by obtaining this paper here.
 
The first EBP Report is Continuous and Intermittent IV Sets
The Clinical Questions are:

• What is the difference between IV administration sets used for continuous infusion and those used for intermittent infusion?
• Is it safe to disconnect and reconnect a continuous administration set to allow for patient activities?

 
We welcome your ideas for new EBP Reports. Please email your suggestions.

Finally, as a free service, we have compiled a paper on infusion therapy references. This list includes textbooks, journals, and standards and guidelines. Find a copy of Your Infusion Library here .
 
And we are not finished with free services! All customers purchasing an online course, EBP report, recorded presentation, or other consulting services are invited to join a closed discussion group on Facebook – STIC or Stop the Infusion Confusion, an online, private community. The group discussions are facilitated by Lynn with her unique point of view as an experienced infusion therapy educator.  Post questions and obtain continued support through interactive discussions. Watch for your invitation by email after your purchase.

We can help with a different approach...

We combine online delivery with a skills lab, reducing classroom time while providing a valuable learning experience. The online course material is based on the familiar nursing process – one chapter each on patient assessment, planning, intervention, and evaluation. The nurse chooses the time and place to access the course material online and has access to the material for a year. The goal is knowledge acquisition and critical thinking. After successful completion determined by passing an online exam, the skills lab offers a full day of practice in a structured simulation lab. Practice is guided by case studies and repetition is encouraged until the learner is comfortable. This is followed by a de-briefing session to discuss the specific skill and follow up on additional questions.
 
The next Peripheral IV Therapy Skills day is March 28th. This offers a great way for developing IV therapy skills in your nursing staff. Register your nurses now to immediately begin the online class as its completion is required to attend the Skills Lab.
 
Also atch for our next announcement about next blended learning offering - Central Venous Access Devices COMING SOON.

Definitely Yes!

The 2016 Infusion Therapy Standards of Practice call for use of a large, sterile transparent membrane dressing over the probe for peripheral catheter insertion or a sterile probe cover along with sterile gel (page S45). Also, these standards support increased attention to strict aseptic technique by using sterile gloves when placing a peripheral IV catheter. (page S65).

There are several objections to these standards with some citing the cost of sterile probe covers. Others cite the possible conflict with the Use of Ultrasound to Guide Vascular Access Procedures, from the American Institute of Ultrasound in Medicine (AIUM). This document can be found at http://www.aium.org/resources/guidelines/usgva.pdf

This document states that maximum sterile barrier precautions are not needed for peripheral IV access, but goes on to state that a sterile probe cover or a transparent film dressing may be placed over the probe and that sterile gel is preferred.

The INS Standards consider one aspect of care not addressed by the AIUM guidelines. The standard for removal of a PIVC is now based on clinical indications and not removal by a certain number of days or hours of dwell time. Many clinicians automatically assume that this means these catheters can be allowed to dwell for extended periods of time. Research shows that the actual dwell time for PIVC is far less than 72 to 96 hours, with most failing less than 48 hours of dwell. Longer dwell times are possible but we must use every tool for strict aseptic technique to reduce the risk of PIV catheter associated infections. A sterile probe cover, or sterile transparent membrane dressing and sterile gel must be included in those tools.  

Midline catheters are 3- to 8-inch-long catheters; are inserted into peripheral veins; and require the use of sterile probe covers for insertion. USGPIVCs are 2 or even 3 inches long. Why should there be a lower level of aseptic technique for one and not the other?

The studies referenced in the INS Standards are descriptive studies using sterile technique for insertion of USGPIVC, which makes this Level V evidence. To my knowledge there are no higher-level studies comparing sterile vs non-sterile technique with USGPIV insertions. The literature search for these standards was completed in early 2015, and there may be newer studies published since then.

Although the level of evidence is low at present, we know that PIVC associated infections do occur, yet they are not tracked and documented like CLABSI. Patients are often discharged before clinical signs and symptoms of infection are seen. PIVC associated infections are being seen in lawsuits now. I firmly believe that sterile technique is required for USGPIVC insertion. And all clinicians must focus on better aseptic techniques for insertion of all PIVCs!