vascular access infection prevention
Critical Thinking : Insertional Assessment for IV Therapy and PICCs
While more than 90 % of patients entering acute care in the U . S . today require IV access , critical thinking is necessary to determine the best IV device for the prescribed therapy .
Performing intravenous ( IV ) access assessment for patients is a dynamic and ongoing process for clinicians in an acute-care setting . Critical thinking is required to initiate and maintain the best device for the patient , the diagnosis , the medications , and the duration of therapy . Ideally , one device without complications should allow completion of therapy for the IV patient . Peripherally inserted central catheters ( PICCs ) can provide the patient with reliable IV access for therapies exceeding five days and are most cost-effective when initiated at the beginning of the patient ’ s acute-care stay .
Determination of suitability with an indication for placement of a central catheter such as a PICC be established prior to placement with collaboration between the ordering physician and inserting clinician . Conditions such as sepsis , elevated INRs and renal failure require higher level consideration for device selection , estimated dwell time , potential complications , and impact on the need for future fistulas . Discussion of the best timing for placing a PICC with a febrile patient is centered around cultures , results , and initiation of antibiotics specific to sensitivity results . Considerable savings may be achieved by good timing of PICC placement rather than insertion and removal when culture results are ready . Ideally , the physician has initiated antibiotics that match with preliminary sensitivity results so the PICC can be placed with confidence and have a dwell time longer than 24 to 48 hours . When confidence is low and culture results unavailable , peripheral IV therapy should be considered for the short term , before the PICC can be safely placed .
Initiation of intravenous therapy always has the potential for problems in the presence of elevated platelets or in patients with bleeding problems as can be present with COVID-19 cases . The goal is to maintain needed intravenous access as long as possible with few skin penetrations , thus avoiding multiple bleeding sites . PICCs carry the lowest risk for access for the patient at risk of bleeding . No INR level will contraindicate the insertion of a PICC , although adequate experience for management of complications is essential by the inserter . High INR levels should identify the need for platelet transfusions and / or availability of bedside coagulating foam , glue or other coagulating agents to control insertion related bleeding . The potential for bleeding into the tissues
• remains a risk with every needle penetration . The patient with bleeding risk requires close monitoring following every access looking for the development of hematomas and subsequent compartment syndrome . Pressure dressings , coagulation foam , close observation and critical thinking all reduce the risk of serious complications for the patient with bleeding issues .
Renal , pre-renal and chronic renal patients require careful determination for the best type of access needed for administration of non-dialysate infusions . In all cases the nephrologists should be contacted regarding the IV access plan . All renal patients must have a plan for future fistula formation , ideally unimpeded by complications of peripheral intravenous therapy . PICC are only used with renal patients in situations where no other access is available and current needs outweigh future needs . Thankfully , many new dialysis catheters have intravenous access ports incorporated into the design thus eliminating the IV access decision process .
While more than 90 percent of patients entering acute care in the U . S . today require IV access , critical thinking is necessary to determine the best IV device for the prescribed therapy . Nurses and physicians now must have a good understanding of the vascular access options and be able to apply that knowledge to each patient diagnosis and therapy need . Prior to the insertion of any central catheter indications and need for central access should be confirmed , integrating the guidance present in the Michigan Appropriateness Guide to Intravenous Catheters ( MAGIC ) into every patient and catheter choice . Effective application of these concepts reduces risk for patients resulting in better outcomes now and in the future .
Nancy Moureau , RN , PhD , CRNI , CPUI , VA-BC , is the chief executive officer at PICC Excellence , Inc ., a research member of the Alliance for Vascular Access Teaching and Research ( AVATAR ) Group , and an adjunct associate professor at Griffith University in Brisbane , Australia .
nancy @ piccexcellence . com
References :
Chopra V , Flanders S , Saint S , et al . The Michigan appropriateness guide for intravenous catheters ( MAGIC ): Results from a multispecialty panel using the RAND / UCLA appropriateness method . Ann Intern Med . 2015 ; 163 ( 6 Suppl ): S1-40 .
Gorski LA , Hadaway L , Hagle ME , et al . Infusion Therapy Standards of Practice , 8th Edition . J Infusion Nurs . 2021 ; 44 ( 1S ): S1-S224 . doi : 10.1097 / nan . 0000000000000396