X

IVOPINION

IVOPINION
PICC to vein ratio
October 24, 2015 at 8:13 am 0
First of all I fully support the idea of small catheters and large veins. However, I must mention that vein diameter may not be a static measurement. Do we need to consider issues such blood pressure and the hydration status of the patient? Do we need to consider the clinical impact of reliable vascular access? When examining PICC to vein ratio we should judge how the impact of PICC placement may allow drug and fluid delivery that will hydrate and improve the contractibility of the heart. The PICC itself as a reliable means of delivering clinical treatments may improve the overall clinical picture and the PICC to vein ration? Finally, remember... this is opinion not science!  
CONTINUE READING ...
IVOPINION
Blood culture contamination prevention
August 27, 2015 at 12:09 am 0
Blood culture contamination reduction is the goal of many healthcare organisations. Hospitals have recently been encouraged to reduce blood culture contamination rates in this article. The Rotherham NHS Foundation Trust have an interest in this challenge and have recently produced two videos aimed at helping clinicians update on blood culture contamination reduction. Thank you to the clinical skills and graphic design departments at The Rotherham NHS Foundation Trust. https://youtu.be/LHOuvh8w5bc https://youtu.be/LGCG9sUQYPE
CONTINUE READING ...
IVOPINION
The language of vascular access
May 19, 2015 at 10:08 pm 0
I believe that the language of vascular access is an import gauge of how well quality infusion and vascular access standards are embedded within an organisation. Ask yourself how well any recent conversations or educational sessions were accepted at your place of work. Did the conversation flow easily? Or did you have to explain the everyday language of IV practitioners. Did words such as ‘bundle’, ‘lock’, ‘vipscore’, 'extravasation', 'clabsi' etc need explaining? I feel very fortunate that I work within an organisation that freely uses the terminology of vascular access and infusion therapy across all professional groups. How does your organisation fair?
CONTINUE READING ...
IVOPINION
Time to question central venous catheter tip location
March 9, 2015 at 9:17 pm 0
Take a short stroll through the IVTEAM pages and you will discover a number of articles that describe ideal tip location with respect to patient safety. York (2012) reminds us that the lower third of the superior vena cava is the ideal location for a central venous catheter tip. It is also suggested by York (2012) that upper extremity DVT is linked to tip location. I would suggest that this phenomena is accepted by the majority of the global vascular access community. Being part of that community I have to say that I believe tip location is important. However, I would like to briefly discuss the variation in tip location that our patients experience on a daily basis.
It is important that we do not view a central venous catheter tip as a fixed object! 2.5L/min of the patients blood flooding the superior vena cava provides somewhat of a turbulent environment for a central venous catheter tip to reside. Also, the position of the patient (sitting, lying or standing) and arm position will also add a variance to tip location. Confirmation of tip location is really 'tip location at a single point in time'. Also, central venous catheters with staggered lumen exits do not appear to fulfil our desire for a fixed tip location! The variance between proximal and distal exit points could be 4cm or more with multi-lumen catheters. Finally, should we be concerned about catheter migration at dressing change? Of course the answer is yes! However, I feel that tip location is not the only important consideration when placing central venous catheters. An equal question for consideration is one of acceptable tip (or more accurately - lumen exit) variance that can be tolerated before we will worry about an increased risk of upper extremity DVT.
Following this brief discussion can we view tip location in a different way? My advice would be to view the risk of upper extremity DVT as problem that extends beyond tip location. Other considerations include 'multiple central venous catheters' (Altassan et al 2014), 'obesity' (Maneval and Clemence 2014) and 'catheter gauge and diagnosis of cancer' (Chopra et al 2014) - not an exhaustive list. Closing remarks... when you next place a central venous catheter consider the variance in 'lumen exit' and start a) counting the incidence of upper extremity DVT, b) list the confounding factors that may have contributed towards the formation of the upper extremity DVT and c) describe the anatomical location of the DVT and suggest its anatomical/catheter position origin if possible! Reference: Altassan, R., Al Alem, H. and Al Harbi, T. (2014) Temporary central line related thrombosis in a pediatric intensive care unit in central Saudi Arabia. Two-year incidence and risk factors. Saudi Medical Journal. 35(4), p.371-6. Chopra, V., Ratz, D., Kuhn, L., Lopus, T., Lee, A. and Krein, S. (2014) Peripherally Inserted Central Catheter-Related Deep Vein Thrombosis: Contemporary Patterns and Predictors. Journal of Thrombosis and Haemostasis. March 10th. [epub ahead of print]. Maneval, R.E. and Clemence, B.J. (2014) Risk Factors Associated With Catheter-Related Upper Extremity Deep Vein Thrombosis in Patients With Peripherally Inserted Central Venous Catheters: A Prospective Observational Cohort Study: Part 2. Journal of Infusion Nursing. 37(4), p.260-268. York, N. (2012) The importance of ideal central venous access device tip position. British Journal of Nursing. 21(21), p.19-24.
CONTINUE READING ...
IVOPINION
IVTEAM upgrade
November 16, 2014 at 9:59 pm 0
Recently we have updated the IVTEAM website. Not that you may have noticed. We have tried very hard to stay within the format that our visitors have found so appealing over previous years. The changes will not detract from our philosophy of providing visitors with a premier service that has no financial or subscriber based restrictions. In addition, our editorial stance that ensures no editorial restrictions exist remains. The two main changes that you may notice are:
Mobile device responsive.  When you visit IVTEAM on a tablet or smartphone that site will present itself in a way that suits the dimensions of your device. This will make it easier to navigate IVTEAM on your smartphone or tablet. Rate content. All new content on IVTEAM can now be rated by the visitor. Once you have read an item on IVTEAM you can now help other visitors and choose a star rating for what you have read.
Thank you for your continued interest in IVTEAM. If you find IVTEAM beneficial please remember to promote it amongst your colleagues. Best wishes Andrew.
CONTINUE READING ...
IVOPINION
My last comment on health & safety
August 18, 2014 at 2:13 pm 0
I promise I will stop now...
"The use of gardening tools at household waste recycling centres is not prohibited by health and safety law or by the HSE. Instead of forking out excuses, the site operators should either allow the individual to use their garden fork to transfer thorny green waste or dig up the real reasons behind their ban. Depending on the specific details of the site there may be concerns regarding other users’ safety but these could be easily managed without the need to ban the use of sensible and practical tools."
Click here for the full story from HSE.
CONTINUE READING ...
IVOPINION
Health and safety ‘beef’
August 18, 2014 at 11:10 am 0
On a daily basis I search sources for information that may be of use to IVTEAM visitors. One news feed that regularly updates in my NewsBar is the news feed from the HSE. If I'm lucky, an item of interest will appear. When an item does appear it is often related to sharps injury prevention and legislation. Today was different. Today, health and safety proved it had a sense of humour! The item relates to a burger van refusing (on the grounds of health and safety) to cut a burger in half! Which in itself has a degree on ironic humour attached. However, the humour is provided by the HSE themselves when they respond to the complaint:
"This is not a health and safety matter; there is no legislation which would prevent the stall from meeting the customer’s reasonable request to have their burger cut in half. Health and safety law does not prevent catering staff from using knives, in fact you expect them to know how use them safely. The panel have a real beef with this kind of unhelpful response to customers which completely misuses "health and safety"."
Click here for the original response from HSE.
CONTINUE READING ...
IVOPINION
Midline local site complications
July 27, 2014 at 11:16 am 0
Qian et al (2014) recently published an article on “the use of 8-cm 22G Seldinger catheters for intravenous access in children with cystic fibrosis” in the Journal of Vascular Access. The abstract in available here. In this small study the authors investigated the use of midline catheters for children. I read with interest in the abstract that “rates of local complications were high, but there were no serious adverse outcomes”. As an avid user of midlines I considered this remark in light of my own experience. I can think back to more than a decade ago when I first started using midlines and the local complications that we encountered. Of course, as a service that counts outcomes we can identify these issues easily. However, as a practitioner that believes we should be working towards zero for all IV related problems I wanted to minimise these issues of phlebitis, occlusion, infiltration etc that are sometimes linked with midlines. What have we done over the years to reduce local complications with midlines? This brief list is not an exhaustive list but it could be a place to start.
"We implemented and continue to use a positive pressure needlefree device. This virtually eliminated problems of occlusion. In addition, the use of the particular positive pressure needlefree device did not negatively impact on our midline infection rate. Our midline infection rate remains virtually nil." "Our securement approach includes the IV dressing and its combined securement strip. We do not use additional third party securement devices for our midlines. Our dislodgement rate is virtually nil." "Finally, the issue of phlebitis, upper extremity deep vein thrombosis (DVT) etc. It is vital that midline users specify which drugs are suitable for midline use. In our experience this approach has ensured our phlebitis and DVT rate is virtually nil."
Our midlines are patient specific and virtually all reach the end of treatment. Hope this helps. Read the Qian et al (2014) abstract on IVTEAM. Reference: Qian, S.Y., Horn, M.T., Barnes, R. and Armstrong, D. (2014) The use of 8-cm 22G Seldinger catheters for intravenous access in children with cystic fibrosis. The Journal of Vascular Access. July 4th. [epub ahead of print].
CONTINUE READING ...
IVOPINION
The three components of reliable vascular access and infusion therapy
July 22, 2014 at 12:20 am 0
I have spent a few years now talking about the concept of reliable vascular access. Also, I often recommend that we cannot initiate change in practice or invest in innovation unless we count. The aim of counting is to indicate how close we are to the goal of reliable vascular access. We should count what we feel is required... the list may include phlebitis, dislodgement, extravasation, occlusion... the list is virtually endless. However, before we decide what to count we need to clarify what is meant by 'reliable vascular access and infusion therapy'. I believe that to achieve reliable vascular access and infusion therapy we should consider outcomes at three particular stages of the patients journey. These are:
  1. Timely vascular access
  2. Insertion problem avoidance
  3. Reliable and expected outcome
If we first consider timely vascular access we may consider issues such as delays in treatment, access to community based services and first attempt insertions. Insertion problem avoidance includes the incidence of issues such as misplaced catheter tip and pneumothorax. Finally, counting outcomes related to reliability and expected outcomes on one end of the scale will provide data on issues such as morbidity, mortality, CLABSI etc. However, at the other end of the spectrum we can gather data on a vast array of significant topics such as... in-use interventions (e.g. resolving occlusions), length of stay and the number of devices that reached the anticipated dwell duration. These considerations are not meant as a definitive direction. However, I hope that they help to point practitioners in a direction that ensures we 'count' outcomes based on the whole patient journey.
CONTINUE READING ...
IVOPINION
Variable PICC tip location
July 20, 2014 at 1:51 pm 0
PICC tip location is a variable point during patient position, activity etc. I was recently reflecting on the clinical condition of the patient and its effect on PICC tip location. In particular I was thinking about abdominal distention that may alter the normal anatomical geography. One example I considered was ascites... will ascites alter the normal anatomical layout (possibly making the tip lower than expected)... equally, what effect would ascitic drainage have upon the tip location? I have posted a question on IV Answers if you would like to comment. Click the following link to see the question www.ivanswers.com/picc-tip-and-patients-with-ascites
CONTINUE READING ...