Vascular Access Device Selection

 Vascular Access Guidelines1-3

screen-shot-2017-02-15-at-4-15-40-pm

Select a Device Based on Length of Desired Therapy

Device slection image

Peripheral IV

  • IVs may be left in place as long as they are functioning. Routine replacement of IVs does not prevent complications. Signs of IV failure include
    • Pain with flushing
    • Swelling around the catheter
    • Inability to flush the IV
  • IVs with a minimum 20 gauge size are preferred for arterial phases contrast bolus (e.g. CTA) and rapid blood transfusions
  • Placement of an IV in the leg is used only for emergencies until other access can be placed, and should be avoided in patients at high risk for chronic lower extremity ulters (e.g CKD, diabetes, peripheral arterial disease)

Ultrasound Guided IVs and Midline Catheters

  • US guided IVs
    • Usually placed into deeper, and larger veins in the upper or lower arm
    • Because these  IVs are anchored in deeper veins, US guided IVs often last longer than traditional IVs
  • Midline catheters
    • Sometimes called “extra long” US guided IVs
    • They start in the upper arm, usual the basilic vein, and typically run 8 to 24 cm, versus the typical 45cm PICC.
    • The Arrow Arterial Line kit has a 12cm catheter that is ideal and has been proven to last 3 weeks3
    • In general a PICC is prefered to midline catheter as there is a similar complication rate, but you cannot draw labs from a midline
  • US IV is preferred over PICCs for use between 6 to 14 days. If no suitable vessels are available in the lower arm, a midline can be placed in the upper arm instead.1
  • Neither is appropriate for irritant/vesicant drugs (TPN, chemo, etc)

PICC

  • Highest rate of DVT and blood stream infection, so should be reserved for patients who need IV access greater than 14 days
  • Appropriate regardless of duration if
    • Infusing irritants or vesicants (chemo, TPN, ect.)
    • Frequent blood draws (every 8 hours), especially if the duration is greater than 6 days.

Central Venous Catheters (CVC)

  • Appropriate for all hemodynamically unstable stable patients
  • Also appropriate for hemodynamically stable patients that are hospitalized if the duration is duration is expected to be about 6-14 days, especially if they are hypercoagulable or severely ill1

Tunneled CVC or Port

  • Generally appropriate if PICC is indicated, but the patient has Stage 3b CKD (GFR < 45) and there is a desire to preserve arm veins for HD access
  • Otherwise generally appropriate if used for > 30 days

IV use table

Next Page

References

  1. Chopra V, Flanders SA, Saint S, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Annals of internal medicine 2015;163:S1-S40.
  2. Stone P, Meyer B, Aucoin J, et al. Ultrasound-guided peripheral IV access: Guidelines for practice.
  3. Simonov M, Pittiruti M, Rickard CM, Chopra V. Navigating venous access: A guide for hospitalists. Journal of hospital medicine 2015.
  4. Elia F, Ferrari G, Molino P, et al. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. The American journal of emergency medicine 2012;30:712-6.