Vascular Access Decision Tree

50% of central lines are inappropriate. Approximately 20% cause morbidity and mortality from acute events, air emboli, and blood stream infections.

Perhaps it’s better to infuse dilute amiodarone through forearm cannulae with risk of thrombophlebitis, than endure the real but poorly documented risk of central/PICC line insertion. Read this review article on extravasation injuries in adults.

It’s difficult for us to make well informed decisions. Our ability to review venous access from decision to insert to removal and assessment of complications is poor. We need better means of auditing this vital information: see here. In the UK a large audit is currently underway (ICNAP-1): more info as we get it.

Please help.

One centralised decision tree should be used that staff are familiar with across many hospitals. It should be adaptable for use at particular institutions depending on the skills and facilities present.

We are driving a ‘Decision Support Tool’ for state wide use. This may be influenced by the MAGIC Guidelines.

A Cochrane review published in August 2015 concluded routine replacement of peripheral cannulae every 72 to 96 hours is unwarranted. Instead they should be inspected on every shift change and removed if signs of inflammation, infiltration or blockage are present.

Here are some more great resources we are working through to generate conservative intravenous access guidelines. Please forward any more that may be of use:

Trigger Tool nursing staff 2

Phlebogenic medications and other great resources from Pedagogy

Association of Anaesthetists of Great Britain and Ireland. Safe vascular access 2016. Anaesthesia.

Hallam VHP Journal of Infection Prevention 2016

Caparas JV.,Hu JPJVA-D-13-00154

How to Establish an Effective Midline Program 2015

Clark Doellman Reducing Risk of Harm From Extravasation 2014

Red Yellow Green Medication Chart

Critical Care Standard Infusion Concentrations: St Guys and Thomas’s

 

The ultrasound image of the patient’s right internal jugular indicates significant stenosis of the vessel so you proceed to successfully insert the Vas Cath on the patient’s left side. The patient complains of feeling unwell as you wheel them to recovery. Your suspicions of cardiac tamponade turn out to be true and despite appropriate resuscitative attempts the patient dies….

Interventional Radiologists performing left sided Vas Caths have expressed their concerns as they view the Vas Cath hitting the wall of the superior vena cava as it exits the innominate vein.

It would be prudent that left sided Vas Caths be inserted under fluoroscopic guidance. How do we introduce this nuance into a simple vascular access decision tree.

Several decision trees exist indicating which vascular access device should be requested for a particular situation. Many appear to underestimate the morbidity and mortality attributed to central lines, as a result patients may die from central line complications when a central line is not required. Existing decision trees overlook ‘stepping down’ with the invasiveness of requested line – e.g. if a PICC line cannot be inserted serial peripheral cannulation may be more appropriate than a central line.

One centralised decision tree should be used that staff are familiar with across many hospitals. It should be adaptable for use at particular institutions depending on the skills and facilities present.

The decision tree needs to be simple and readily accessible across all healthcare facilities.

 

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