the art and science of infusion nursing - gli accessi...

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VOLUME 34 | NUMBER 1S | JANUARY/FEBRUARY 2011 S31

clean devices prior to access are unresolved. Theaccess port should be accessed only with steriledevices.6,7 (V)

F . The nurse should change the add-on device withthe catheter, with each administration set replace-ment, or as defined by the organization, andwhenever the integrity of the product is compro-mised or suspected of being compromised.1 (V)

G . The use of stopcocks is not recommended due tothe increased risk of infection. When a stopcock isattached as an add-on device, the nurse shouldattach sterile caps to the ports of the stopcock toprovide a closed system when not in use andaccess sites that will allow cleaning prior toaccessing.1 (V)

REFERENCES

1. H adaway L . Infusion therapy equipment. In: A lexander M ,Corrigan A , Gorski L , H ankins J, Perucca R . eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, M O :Saunders/Elsevier; 2010:391-436.

2. The Joint Commission. Tubing misconnections: a persistent andpotentially deadly occurrence. Joint Commission Sentinel EventAlert. http://www . jointcommission .org/SentinelEvents/SentinelEventA lert/sea_36.htm. Accessed December 5, 2009.

3. US Food and Drug Administration. 2009 medical device safetycalendar on luer misconnections. http://www .fda.gov/medicalde-vices/Safety/Alertsand N otices/ucm134863.htm. Accessed July 8,2009.

4. Institute for Safe M edication Practices (ISMP). Problems persistwith life-threatening tubing misconnections. Medication SafAlert! June 17, 2004.

5. American Nurses Association [position paper]. Safety Issues Relatedto Tubing & Catheter Misconnections. http://www.nursingworld.org/position/practice/tube.aspx. Accessed February 13, 2010.

6. Kaler W , Chinn R . Successful disinfection of needleless mechani-cal valve access ports: a matter of time and friction. J AssocVascular Access. 2007;12(3):140-142.

7. Marschall J, M ermel L, Classen D , et al. Compendium of strategiesto prevent central line-associated bloodstream infections in acute carehospitals. Infect Control Hosp Epidemiol. 2008;29(S1):S22-S30.

26. ADD-ON DEVICES

Standard

26.1 The use of add-on devices shall be established inorganizational policies, procedures, and/or practiceguidelines and according to manufacturers’ directions foruse.26.2 The nurse shall be competent in the use of theadd-on device and shall be knowledgeable about therisk of misconnection and potential disconnections.26.3 All add-on devices shall be of luer-lock design toensure a secure junction.

Practice Criteria

A . Add-on devices may include, but are not limited to,stopcocks, single- and multilumen extension sets,manifold sets, extension loops, solid cannula caps,needleless systems, in-line filters, and manual flow-control devices.1 (V)

B. All add-on devices should be compatible with theadministration system to prevent the risk of leaks,disconnections, or misconnections.2,3 (V)

C . The nurse should be aware that the potential forcontamination exists with all add-on devices. Inan effort to decrease the risk of contamination,the number of manipulation episodes, accidentaldisconnections or misconnections, and costs,there should be limited use of these devices.1 (V)

D . To determine the appropriate placement of theselected add-on device, the nurse should trace theadministration set from the patient to the point oforigin before attaching the device.2,4,5 (IV)

E . The nurse should disinfect the ports of the add-ondevice using friction, with an appropriate disin-fectant such as 70% alcohol before accessing.Specific guidelines directing the appropriate tech-nique, disinfectant, or amount of time required to

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27. NEEDLELESS CONNECTORS

Standard

27.1 The use of needleless connectors shall be established inorganizational policies, procedures, and/or practice guide-lines and according to manufacturers’ directions for use.27.2 N eedleless connectors attached to a catheter hubor access site shall be of luer-lock design to ensure asecure junction.27.3 The nurse shall be competent in the use of needle-less connector devices.27.4 The nurse shall disinfect the needleless connectorprior to each access.27.5 N eedles shall not be used to access catheters, admin-istration sets, access sites, or needleless connectors.

Practice Criteria

A . The nurse should be aware that needleless con-nectors are identified by design (simple and com-plex) and function. The simple needleless connec-tor group includes the split-septum design with nointernal mechanisms, a straight fluid pathway,and can be blunt cannula or luer-lock design. Thecomplex needleless connector group includes avariety of luer-lock mechanical valve needlelessconnector with various internal mechanismdesigns and fluid pathways.1-5 (IV)

B. The nurse should be knowledgeable about thefunction of the needleless connector and the man-ufacturer’s directions for use for each needlelessconnector to reduce the risk of blood reflux intothe catheter tip upon disconnection. Currently,there are 3 categories of needleless connectorfunction: negative fluid displacement, positivefluid displacement, and neutral design.2-11 (II)

C . The nurse should be aware that the catheter hubis a known source for the deve lopment ofcatheter-related bloodstream infection (C R-BSI)and that needleless connectors are recognized sitesfor microbial contamination.5,10,12-26 (II)

D . The nurse should be aware of and implement manufacturers’ directions for use, implementappropriate infection prevention practices, andreview the research and published literature relat-ed to this issue to promote and provide qualitypatient outcomes.2,4-8,10,14-18,20,21,27-36 (II)

E . The needleless connector should be consistentlyand thoroughly disinfected using alcohol, tinctureof iodine, or chlorhexidine gluconate/alcoholcombination prior to each access. The optimaltechnique or disinfection time frame has not beenidentified.3,5,9,12,13,15-17,19,22-25,27,29,31,32,37-41 (III)

F . The nurse should change the needleless connectorin the following circumstances: if the needleless

connector is removed for any reason; if there isblood or debris within the needleless connector;prior to drawing a blood culture sample from thecatheter; upon contamination; per organizationalpolicies, procedures, and/or practice guidelines; orper the manufacturer’s directions for use. Thenurse should be knowledgeable about the manu-facturer’s directions for use and other device per-formance criteria to assist in the development ofpolicies and procedures for needleless connectorchange frequency. The optimal time frame forchanging the needleless connector has not beendetermined (see Standard 49, Infection).7,8,22,37,42-46

(IV)

REFERENCES

1. Gorski L , Perucca R , H unter M . Central venous access devices:care, maintenance, and potential complications. In: A lexander M ,Corrigan A , Gorski L , Hankins J, Perucca R , eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, M O : Saunders/Elsevier; 2010:495-515.

2. H adaway L , Richardson D . N eedleless connectors: a primer onterminology. J Infus Nurs. 2010;33(1):1-11.

3. Yebenes J, Delgado M , Sauca G , et al. Efficacy of three differentvalve systems of needle-free closed connectors in avoiding accessof microorganisms to endovascular catheters after incorrect han-dling. Crit Care Med. 2008;36(9):2558-2561.

4. Rupp M , Sholtz L , Jourdan D , et al. O utbreak of bloodstreaminfection temporally associated with the use of an intravascularneedleless valve. Clin Infect Dis. 2007;44:1408-1414.

5. Safdar N , M aki D . Lost in translation [editorial]. Infect ControlHosp Epidemiol. 2006;27(1):3-7.

6. Jasinsky L , Wurster J. O cclusion reduction and heparin elimina-tion trial using an antireflux device on peripheral and centralvenous catheters. J Infus Nurs. 2009;32(1):33-39.

7. Khalidi N , Kovacevich D , Papke-O ’Donnell L , Btaiche I. Impactof the positive pressure valve on vascular access device occlusionsand bloodstream infections. J Assoc Vascular Access. 2009;14(2):84-91.

8. Assoc iation for Professionals in Infect ion C ontrol andEpidemiology (APIC). Guide to the Elimination of Catheter-relatedBloodstream Infections. Washington, D C: APIC; 2009.

9. E C RI Institute. N eedleless connectors. Health Devices. 2008;37(9):261-283.

10. Blake M . Update: catheter-related bloodstream infection rates inrelation to clinical practice and needleless device type. Can JInfect Control. 2008;23(3):156-160, 162.

11. Jacobs BR , Schilling S, Doellman D , et al. Central venous catheterocclusion: a prospective, controlled trial examining the impact ofa positive pressure valve device. J Parenter Enteral Nutr. 2004;28:113-118.

12. Ivy D , Calderbank M , Wagner B, et al. C losed-hub systems withprotected connections and the reduction of risk of catheter-relat-ed bloodstream infection in pediatric patients receiving intra-venous prostanoid therapy for pulmonary hypertension. InfectControl Hosp Epidemiol. 2009;30(9):823-829.

13. Buchman A L , Spapperi J, Leopold P. A new central venouscatheter cap: decreased microbial growth and risk for catheter-related bloodstream infection. J Vascular Access. 2009; 10(1):11-21.


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14. Jarvis W , M urphy C , H all K , et al. H ealth-care associated blood-stream infections with negative- or positive-pressure or displace-ment mechanical valve needleless connectors. Clin Infect Dis.2009;49:1821-1827.

15. Soothill J, Braver K , H o A , et al. A fall in bloodstream infectionsfollowed a change to 2% chlorhexidine in 70% isopropanol forcatheter connection antisepsis: a pediatric single center before/afterstudy on a hematopoietic stem cell transplant ward. Am J InfectControl. 2009;37(8):626-630.

16. Field K , M cFarlane C , Cheng A , et al. Incidence of catheter-relatedbloodstream infection among patients with a needleless, mechanicalvalve-based intravenous connector in an Australian/hematology-oncology unit. Infect Control Hosp Epidemiol. 2007;28(5):610-613.

17. M enyhay S, M aki D . D isinfection of needleless catheter connec-tions and access ports with alcohol may not prevent microbialentry: the promise of a novel antiseptic-barrier cap. Infect ControlHosp Epidemiol. 2006;27(1):23-27.

18. Adams D , Karpanen T , Worthington T , et al. Infection risk asso-ciated with a closed leur access device J Hosp Infect. 2006;62(3):353-357.

19. Leon C , Alvarez-Lerma F, Ruiz-Santana S, et al. Antiseptic chamber-containing hub reduces central venous catheter-related infection:a prospective, randomized study. Crit Care Med. 2003;31(5):1318-1324.

20. Seymour V M , Dhallu TS, M oss H A , et al. A prospective clinicalstudy to investigate the microbial contamination of a needlelessconnector. J Hosp Infect. 2000;45(2):165-168.

21. Donlan R M , M urga R , Bell M , et al. Protocol for detection ofbiofilms on needleless connectors attached to central venouscatheters. J Clin Microbiol. 2001;39(2):750-753.

22. Do A , Ray B, Banerjee S, et al. Bloodstream infection associated withneedleless device use and the importance of infection-control prac-tices in the home health care setting. J Infect Dis. 1999;179:442-448.

23. Arduino M , Bland L , Danzig L , et al. M icrobiologic evaluation ofneedleless and needle-access devices. Am J Infect Control. 1997;25(5):377-380.

24. Segura M , A lvarez-Lerma F , Tellado J, et al. A clinical trial on theprevention of catheter-related sepsis using a new hub model. AnnSurg. 1996;223(4):363-369.

25. Randolph A , Cook , D . Antiseptic hub connectors reduce centralvenous catheter-related sepsis. Crit Care Med. 1999;27(1)(suppl):141A .

26. M urga R , M iller J M , Donlan R M . Biofilm formation by gramnegative bacteria on central venous catheter connectors: effect ofconditioning films in a laboratory model. J Clin Microbiol. 2001;39(6):2294-2297.

27. M ermel L , A llon M , Bouza E , et al. C linical practice guidelinesfor the diagnosis and management of intravascular catheter-relat-ed infection: 2009 update. Clin Infect Dis. 2009;49:1-45.

28. Hadaway L. Infusion therapy equipment. In: Alexander M , CorriganA , Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: AnEvidence-Based Approach. 3rd ed. St Louis, M O: Saunders/Elsevier;2010:391-436.

29. M arschall J, M ermel L , C lassen D , et al. Compendium of strate-gies to prevent central line-associated bloodstream infections inacute care hospitals: SH E A/IDSA practice recommendations. Infect Control Hosp Epidemiol. 2008;29(1):522-530.

30. Cherneck C , M acklin D , Casella L , Jarvis E . Caring for patientswith cancer through nursing knowledge of IV connectors. Clin JOncol Nurs. 2009;13(6):630-633.

31. C asey A L , W orthington T , Lambert PA , et al . A randomized ,prospective clinical trial to assess the potential risk associated

with the PosiF low needleless connector. J Hosp Infect. 2003;54(4):288-293.

32. Casey A L , Burnell S, Whinn H , et al. A prospective clinical trialto evaluate the microbial barrier of a needleless connector. J Hosp Infect. 2007;65(3):212-218.

33. Salgado C , Chinnes L , Paczesny T , Cantey, R . Increased rate ofcatheter-related bloodstream infection associated with use of aneedleless mechanical valve device at a long-term acute care hos-pital. Infect Control Hosp Epidemiol. 2007;8(6):684-688.

34. Jarvis W R . Choosing the best design for intravenous needlelessconnectors to prevent bloodstream infections. Infect ControlToday. http://www .infectioncontroltoday.com. Published July2010. Accessed August 5, 2010.

35. US Food and Drug Administration. Letter to infection control prac-titioners regarding positive displacement needleless connectors.http://w w w . fda .gov/ M edical D evices/Safety/ A lertsand N otices/ucm220459.htm. Accessed August 5, 2010.

36. Guerin K , Wagner J, Rains K , Bessesen M . Reduction in centralline-associated bloodstream infections by implementation of apostinsertion care bundle. Am J Infect Control. 2010;28(6):430-433.

37. M athew A , Gaslin T , Dunning K , Y ing, J. Central catheter bloodsampling: the impact of changing the needleless caps prior to col-lection. J Infus Nurs. 2009;32(4):212-218.

38. Kaler W , Chinn R . Successful disinfection of needleless accessports: a matter of time and friction. J Assoc Vascular Access. 2007;12(3):140-142.

39. H orvath B, N orville R , Lee D , et al. Reducing central venouscatheter-related bloodstream infections in children with cancer.Oncol Nurs Forum. 2009;36(2):232-238.

40. Z ack J. Z eroing in on zero tolerance for central line-associatedbacteremia. Am J Infect Control. 2008;36(10):s176.e1-s176.e2.

41. Doellman D , Pettit J, Catudal P, Buckner J, Burns D , Frey A M .Association for Vascular Access. Best Practice Guidelines in theCare and Maintenance of Pediatric Central Venous Catheters.PE DIV A N ; 2010.

42. M c Goldrick M . Infection prevention and control. In: A lexanderM , Corrigan A , Gorski L , H ankins J, Perucca R , eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, M O :Saunders/Elsevier; 2010:204-228.

43. Toscano C , Bell M , Z ukerman C , et al. Gram-negative blood-stream infections in hematopoietic stem cell transplant patients:the roles of needleless device use, bathing practices, and cathetercare. Am J Infect Control. 2009;37(4):327-334.

44. Yebenes JC , Serra-Prat M . C linical use of disinfectable needle-freeconnectors. Am J Infect Control. 2008;36(10):S175e1-S175e4.

45. Sharp M K , M ohammed SF . H emolysis in needleless connectorsfor phlebotomy. J Am Soc Artif Intern Organs (ASAIO). 2003;49(1):128-130.

46. Sheretz R , Karchmer T , O hl C , Palavecino E , Bischoff W . Bloodcultures (BC) drawn through valved catheter hubs have a 10-20%positivity rate with the majority being false positives. Paper pre-sented at: Fifth Decennial International Conference on H ealthcare-Associated Infections; March 18-22, 2010; Atlanta, G A .

28. FILTERS

Standard

28.1 The use of bacteria- and particulate-retentive, air-eliminating, and blood and blood component filters



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shall be established in organizational policies, proce-dures, and/or practice guidelines.28.2 For nonlipid-containing solutions that require fil-tration, a 0.2-micron filter containing a membrane thatis particulate-retentive and air-eliminating shall be used.28.3 For lipid infusions or total nutrient admixtures thatrequire filtration, a 1.2-micron filter containing a membranethat is particulate-retentive and air-eliminating shall be used.28.4 Blood and blood component filters appropriate tothe therapy shall be used to reduce particulate matter,microaggregates, or leukocytes in infusions of blood orblood components.28.5 For intraspinal infusions, a 0.2-micron filter thatis surfactant-free, particulate-retentive, and air-elimi-nating shall be used.28.6 A blunted filter needle or filter straw shall be usedwhen drawing medications from glass ampoules.

Practice Criteria

A . Use of all filters should adhere to manufacturers’directions for use and filtration requirements ofthe therapy.1 (V)

B. Bacteria- and particulate-retentive and air-elimi-nating membrane filter changes should coincidewith administration set changes.2 (V)

C . Blood and blood component filters should bechanged every 4 hours or coincide with bloodadministration set changes.3 (V)

D . Add-on bacteria- and particulate-retentive and air-eliminating membrane filters should be locatedas close to the catheter insertion site as possible.2 (V)

E . When an electronic infusion device is used, con-sideration should be given to the pounds persquare inch (psi) rating of the filter.1,2,4 (V)

REFERENCES

1. H adaway L . Infusion therapy equipment. In: A lexander M ,Corrigan A , Gorski L , H ankins J, Perucca R , eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, M O :Saunders/Elsevier; 2010:418-421.

2. Principles and use of intravenous equipment for infusion therapy.In: Weinstein S, ed. Plumer’s Principles & Practice of IntravenousTherapy. 8th ed. Philadelphia, PA: Lippincott Williams &Wilkins; 2007;45:193-230, 563.

3. A ABB. Technical Manual. 16th ed. Bethesda, M D: A ABB; 2008:618-621.

4. Phillips L D . Manual of I.V. Therapeutics. 5th ed. Philadelphia,PA: F A Davis; 2010:253.

29. FLOW-CONTROL DEVICES

Standard

29 .1 T he type of f low-control device se lected shallbe based on patient age , condition , prescribed infu-

sion therapy , type of vascular access device , and caresett ing.29 .2 O nly electronic infusion devices with administra-tion-set–based anti–free-flow mechanisms shall beused.29.3 Dose-error reduction systems shall be consideredin the selection and use of electronic infusion devices.29.4 The use of flow-control devices shall be estab-lished in organizational policies, procedures, and/or practiceguidelines.29.5 The nurse shall be competent in the use of flow-control devices, including manual devices, mechanicaldevices, and electronic infusion devices.

Practice Criteria

A . Flow-control devices should be monitored duringthe administration of infusion therapy to ensureaccurate delivery of the prescribed infusion rate.1-6

(III)B. The nurse should not rely on the electronic infu-

sion device alarms to detect IV infiltration orextravasation as these alarms are not intended todetect disruption of the fluid flow pathway.6-8 (V)

C . Safety features and dose-error reduction systemsshould be considered in the selection of all electronicflow-control devices. The nurse should be involvedin the evaluation and selection of flow-controldevices.9-15 (V)

D . Systematic methods, such as failure mode andeffects analysis (F M E A) or Six Sigma, should beincorporated into the evaluation of flow-controldevice selection and used to reduce errors andenhance safety. In addition, adverse event reports(such as those from the US Food and DrugAdministration’s M anufacturer and User FacilityDevice Experience site) should be consulted whenconsidering mechanical and electronic flow-con-trol devices for purchase.12-14,16 (V)

E . The frequency of inspection, cleaning, testing, andmaintenance of electronic flow-control devicesshould adhere to manufacturers’ direction(s) for useand directions and guidelines established by regulato-ry agencies.10,11,17,18 (V)

F . The choice of a flow-control device (manual flowregulators, pressure bags, mechanical pumps, elas-tomeric balloon pumps, spring-based pumps, negative-pressure pumps, electronic infusion pumps) for agiven clinical application should take into accountsuch factors as age and mobility of the patient,severity of illness, type of therapy, and health caresetting. Features should be consistent with recom-mendations for safe and effective use. Additionalfeatures are recommended for patient-controlledanalgesia (PC A) pumps (eg, patient ease of use,accuracy) and systems that require a higher pump-ing pressure (eg, arterial and epidural lines).11,17(V)



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G . Patient education for those using electronic flow-control devices in the home care setting shouldinclude written instructions, troubleshooting guides,whom/how to contact for assistance, signs of under-or over-infusion, and pump malfunction. Educationshould include demonstration and explanation ofinfusion pump functions followed by observation ofthe patient/caregiver performance.19,20 (V)

REFERENCES

1. Rosenthal K . Smart pumps help crack the safety code. NursManag. 2004;35(5):49-51.

2. H ertzel C , Sousa V D . Use of smart pumps for preventing medica-tion errors. J Infus Nurs. 2009;32(5):257-267.

3. M urdoch LJ, Cameron V L . Smart infusion technology: a mini-mum safety standard for intensive care? Br J Surg.2008;17(10):630-636.

4. Rothschild J M , Keohane C A , Cook EF , et al. A controlled trial ofsmart infusion pumps to improve medication safety in critically illpatients. Crit Care Med. 2005;33(3):679-680.

5. Institute for H ealthcare Improvement. Reduce adverse drugevents (A D Es) involving intravenous medications: implementsmart infusion pumps. www .I H I.org. Accessed M arch 26, 2010.

6. Ilan R , Fowler F A , Ferguson N D , et al. Prolonged time to alarmin infusion devices operated at low flow rates. Crit Care Med.2008;36(10):2763-2765.

7. Pennsylvania Patient Safety Reporting System. IV infiltration: bealarmed even when your infusion pump isn’t. Patient SafAdvisory. 2007;4(3):1-4.

8. H uber C . IV infusion alarms: don’t wait for the beep. Am J Nurs.2009;109(4):32-33.

9. Bowcutt M , Rosenkoetter M M , Chernecky C C , Wall J, Wynn D ,Serrano C . Implementation of an intravenous medication infusionpump system: implications for nursing. J Nurs Manage. 2008;16:188-197.

10. E C RI Institute. Large volume infusion pumps. Health Devices.http//www .ecri.org. Published December 2009. Accessed M arch15, 2010.

11. E C RI Institute. E C RI Institute’s infusion pump criteria. HealthDevices. http//www .ecri.org. Published February 2008. AccessedM arch 15, 2010.

12. N emeth C , N unnally M , Bitan Y , N unnally S, Cook RI. Betweenchoice and chance: the role of human factors in acute care equip-ment decisions. Patient Saf. 2009;5(2):114-121.

13. Adachi W , Lodolce A E . Use of failure mode and effects analysisin improving the safety of I. V . drug administration. Am J Health-Syst Pharm. 2005;62(9):917-920.

14. Christopher D A , Campbell A , Dateshidze J. Working smarter withintelligent pumps. Pharm Solutions. http//www.nursingmanagement.com. Published N ovember 2008. Accessed February 22, 2010.

15. Rothschild J M , Keohane C A , Cook EF , et al. A controlled trial ofsmart infusion pumps to improve medication safety in critically illpatients. Crit Care Med. 2005;33(3):533-540.

16. US Food and Drug Administration. Manufacturer and user facilitydevice experience (M AUDE). http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfM AUDE/search.CF M . Accessed December 30, 2009.

17. Perucca R . Infusion therapy equipment: types of infusion therapyequipment. In: A lexander M , Corrigan A , Gorski L , H ankins J,Perucca R , eds. Infusion Nursing: An Evidence-Based Approach.3rd ed. St Louis, M O : Saunders/Elsevier, 2010:411-418.

18. Rutala W , Weber D . H ealthcare Infection Control PracticeAdvisory Committee (H ICPA C). Guideline for Disinfection andSterilization in Healthcare Facilities, 2008. http://w w w .cdc .gov/nc idod/dhqp/pdf/guidelines/Disinfection_ N ov_2008.pdf.Accessed December 5, 2009.

19. US Food and Drug Administration. Infusion pump risk reductionstrategies for home health nurses. http://www .fda.gov/ M edicalD evices/Productsand M edicalProcedures/G eneral H ospitalD evicesandSupplies/InfusionPumps/ucm205411.htm. Published April 22,2010. Accessed June 1, 2010.

20. Gorski L A . Pocket Guide to Home Infusion Therapy. Boston,M A: Jones & Bartlett, 2005.

30. BLOOD AND FLUID WARMERS

Standard

30.1 The use of blood and fluid warmers shall be estab-lished in organizational policies, procedures, and/or prac-tice guidelines and in accordance with A ABB standardsfor administration of blood.30.2 Blood and fluid warming shall be performed onlywith devices specifically designed for that purpose.30.3 Blood shall be warmed in a manner to avoidhemolysis.

Practice Criteria

A . Blood and fluid warmers should be used whenwarranted by patient history, clinical condition,and prescribed therapy, including, but not limited to,avoiding or treating hypothermia, during car-diopulmonary bypass, when the patient is knownto have cold agglutinins, or during replacement oflarge blood volumes.1-5 (III)

B. The frequency of cleaning and preventive mainte-nance of blood and fluid warming devices shouldadhere to the manufacturer’s directions for use andguidelines established by regulatory agencies.1,4,5

(V)C . N urses should use blood and fluid warmers

equipped with warning systems, including an audi-ble alarm and visual temperature gauges.6-8 (V)

D . O ther warming methods, including, but not lim-ited to, microwave ovens, hot water baths, anddevices not expressly designed for blood andfluid warming, should not be used because tem-peratures and infection risks cannot be con-trolled.9-11 (V)

REFERENCES

1. A ABB. Standards for Blood Banks and Transfusion Services. 26thedition. Bethesda, M D: A ABB; 2009.

2. E C RI Institute. Suggested guidelines for blood warmer use.http://w w w .mdsr .ecr i .org/summary/de ta i l .aspx?doc_id/8269 .Accessed January 11, 2010.



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3. H asankhani H , M ohammadi E , M oazzami F , M okhtari M ,N aghgizadh M M . The effects of intravenous fluids temperatureon perioperative hemodynamic situation, post-operative shiver-ing, and recovery in orthopaedic surgery. Can Oper Room NursJ. 2007;25(1):20-27.

4. Stainsby D , M acLennan S, H amilton PJ. M anagement of massiveblood loss: a template guideline. Br J Anaesth. 2000;85:487-491.

5. US Food and Drug Administration. C FR T itle 21. H ematologyand Pathology Devices. Blood and plasma warming devices(864.9205). http://www .accessdata.fda.gov/scripts/cdrh/cfdocs/cf C F R/C F RSearch .cfm?F R=864 .9205 . A ccessed January 11 ,2010.

6. Stammers A H , M urdock JD , K layman M H , et al. Utilization ofrapid-infuser devices for massive blood loss. Perfusion. 2005;2:65-69.

7. AST M Standard F217-02 (2009), “Standard Specification forBlood/Intravenous F luid/Irrigation F luid W armers, ” AST MInternational, West Conshohocken, PA , 2009. www .astm.org.Accessed January 22, 2010.

8. Avula RR , K ramer R , Smith C E . A ir detection performance of theLevel 1 H-1200 fluid and blood warmer. Anesth Analog. 2005;101:1413-1416.

9. M cEwen MP, Roxby D . Can latent heat safely warm blood? In vitrotesting of a portable prototype blood warmer. BMC Emerg Med.2007;7(8). http://www.ncbi.nlm.nih.gov/pmc/articles/PM C1988795/.Accessed April 5, 2010.

10. Riley W . BelmontT M hyperthermia pump in the conduct of intra-operative heated chemotherapy. Perfusion. 2009;24:115-118.

11. Trick N . Blood component therapy. In: A lexander M , CorriganA , Gorski L , H ankins J, Perucca R , eds. Infusion Nursing: AnEvidence-Based Approach. 3rd ed. St Louis, M O : Saunders/Elsevier; 2010:249-253.

31. TOURNIQUETS

Standard

31.1 A tourniquet shall be properly applied to promotevascular distension in preparation for peripheralvenipuncture.31.2 The use of tourniquets shall be established in orga-nizational policies, procedures, and/or practice guidelines.

Practice Criteria

A . The tourniquet should be single-patient use.1-8 (IV)B. The nurse should assess the patient for latex aller-

gy when considering tourniquet material (seeStandard 25, Latex Sensitivity or Allergy).9,10 (V)

C . The tourniquet should be applied at an appropriatelocation above the selected venipuncture site.8,11,12 (V)

D . An arterial pulse should be easily palpable distalto the tourniquet location.8,11,12 (I A/P)

E . The tourniquet should be applied in such a man-ner as to prevent circulatory impairment. 8,11,12

(I A/P)F . The nurse should assess for factors indicating that

a tourniquet should be loosely applied or its useavoided in patients who bruise easily, are at riskfor bleeding, have compromised c irculation ,and/or have fragile skin or veins.11-13 (V)

REFERENCES

1. Franklin G F , Bal A M , M c Kenzie H . Phlebotomy tourniquets andM RSA . J Hosp Infect. 2007;65:173-184.

2. Fellowes C , Kerstein R , Azadian B. Breaking the cycle. J HospInfect. 2007;65:279-280.

3. Leitch A , M cCormick I, Gunn I, G illespie T . Reducing the poten-tial for phlebotomy tourniquets to act as a reservoir for methicillin-resistant Staphylococcus aureus. J Hosp Infection. 2006;63(4):428-431.

4. Sacar S, Turgut H , Kaleli I, et al. Poor hospital infection controlpractice in hand hygiene, glove utilization, and usage of tourni-quets. Am J Infect Control. 2006;34(9):606-609.

5. Fellowes C , Kerstein R , C lark J, Azadian BS. M RSA on tourni-quets and keyboards. J Hosp Infect. 2006;64(1):86-88.

6. Rourke C , Bates C , Read R C . Poor infection control practice invenipuncture and use of tourniquets. J Hosp Infect. 2001;49(1):59-61.

7. Golder M , Chan C L H , O ’Shea S, Corbett K , Chrystie IL .Potential risk of cross-infection during peripheral-venous accessby contamination of tourniquets. Lancet. 2000;355:44.

8. H adaway L C , M illam D A . O n the road to successful IV starts.Nursing. 2005;35(suppl 1):1-14.

9. Society of Gastroenterology N urses and Associates. Guideline forpreventing sensitivity and allergic reactions to natural rubberlatex in the workplace. Gastroenterol Nurs. 2008;31(3):239-246.

10. Gavin M , Patti PJ. Issues in latex allergy in children and adultsreceiving home healthcare. Home Healthc Nurse. 2009;27(4):231-239.

11. Perucca R . Peripheral venous access devices. In: A lexander M ,Corrigan A , Gorski L , H ankins J, Perucca R , eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, M O:Saunders/Elsevier; 2010:456-479.

12. Elkin, M K , Perry, A G , Potter, PA . Nursing Interventions and Clinical Skills. 4th ed. St Louis, M O : M osby/Elsevier, 2007:598.

13. M oureau N . T ips for inserting an IV in an older patient. Nursing.2004;34(7):18.



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D. The use of steel winged devices should be limited toshort-term or single-dose administration.13,14 (V)

E. Therapies not appropriate for short peripheralcatheters include continuous vesicant therapy,parenteral nutrition, infusates with pH less than 5or greater than 9, and infusates with an osmolal-ity greater than 600 mOsm/L. The nurse shouldcollaborate with the pharmacist and the licensedindependent practitioner (LIP) to assist in selec-tion of the most appropriate vascular access devicebased on a projected treatment plan.5,6,13,14,18-24

(IV)F. Peripheral administration of parenteral nutrition

via a short peripheral catheter should be usedwith caution in adults.21,22 (IV)

G. The nurse should be aware that a short peripher-al catheter of 14-24 gauge for adults and 22-24gauge for pediatric or neonates can generally be usedfor administration of blood or blood products.11,12,16

(V)

Practice Criteria

II. Midline Catheters

A. The nurse should consider selection of midlinecatheters for therapies anticipated to last 1-4 weeks.Reported dwell time for midline catheters inneonates is 6-10 days.9,10,16,25,26 (V)

B. A midline catheter should be used for hydration,intravenous solutions, pain medications, and someantibiotics. Therapies not appropriate for midlinecatheters include continuous vesicant therapy, par-enteral nutrition, infusates with pH less than 5 orgreater than 9, and infusates with an osmolalitygreater than 600 mOsm/L.9,13,14 (V)

C. Midline catheters are peripheral infusion deviceswith the tips terminating in either the basilic,cephalic, or brachial vein, distal to the shoulder.The basilic vein is preferred due to vein diameter.The tip does not enter the central vasculature.

32. VASCULAR ACCESS DEVICESELECTION

Standard

32.1 Indications and protocols for vascular access devices(VADs) shall be established in organizational policies,procedures, and/or practice guidelines and according tomanufacturers’ directions for use.32.2 The nurse shall select the appropriate type of catheter(peripheral or central) to accommodate the patient’s vas-cular access needs based on the prescribed therapy or treat-ment regimen, length of treatment, duration of dwell, vas-cular integrity, patient preference, and ability andresources available to care for the device.32.3 The catheter selected shall be of the smallest gaugeand length with the fewest number of lumens and shallbe the least invasive device needed to accommodate andmanage the prescribed therapy.32.4 The nurse shall not alter the vascular access deviceoutside the manufacturer’s directions for use.

Practice Criteria

I. Short Peripheral Catheters

A. The nurse should select a short peripheralcatheter based on prescribed therapies, durationof treatment (usually for treatments of less than 1week), availability of peripheral vascular accesssites, diagnosis, known complications of thedevice, and the inserter’s experience.1-9 (V)

B. A short peripheral catheter comes in a variety ofgauge sizes (ie, 14-27); winged or nonwinged; sin-gle or double lumen; or over-the-needle catheters.The tip of a short peripheral catheter terminates ina peripheral vein.2,3,5,6,10-16 (V)

C. The nurse should use short peripheral cathetersequipped with a passive or active safety mechanismto provide sharps injury protection.12,16,17 (V)

Vascular Access Device Selection and Placement


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Midline catheters inserted via a scalp vein inneonates and pediatric patients should have thetip terminating in the external jugular vein(EJV).5,16,20,27 (V)

D. Midline catheters are available as single- or double-lumen (1.9 Fr-5 Fr) polyurethane or silicone devices.Midline catheters for pediatric patients are availablein gauge sizes of 22-24.3,9,10,12-14,16,25,28 (V)

Practice Criteria

III. Central Vascular Access Devices(CVADs) (Nontunneled, PICC, Tunneled,Implanted Port)

A. The nurse should use CVADs to administer short- orlong-term continuous or intermittent infusion solu-tions such as antineoplastic medications, vesicants orknown irritants, parenteral nutrition, a variety ofantibiotics, and any medications with a pH of lessthan 5 or greater than 9 and osmolarity of greaterthan 600mOsm/L.5,6,13,29 (V)

B. The nurse should be aware that in order to minimizethrombotic complications, the tip of a CVAD shouldterminate in the central vasculature, such as the supe-rior vena cava (SVC) or inferior vena cava (IVC).Dialysis catheter tips may terminate in the right atrium.6,20,30 (V)

C. CVADs can be manufactured as single or multilumen,silicone, or polyurethane, along with various gaugesizes and lengths; open- or closed-ended; power-injectable; and/or as anti-infective devices.6,10,13,16,31-34

(V) D. The nurse should collaborate with the multidiscipli-

nary team to consider anti-infective CVADs in thefollowing circumstances: expected dwell of morethan 5 days; catheter-related bloodstream infection(CR-BSI) rate remains high even after employingother preventive strategies; neutropenic, transplant,burn, hemodialysis, or critically ill patients; catheterinsertion or exchange in patients with infection orbacteremia; or for emergency insertions. Anti-infec-tive CVADs have shown a decrease in colonizationand/or CR-BSIs. These types of CVADs includedevices coated or impregnated with chlorhexidineand silver sulfadiazine, minocycline and rifampin,and silver ion. The nurse should be aware that anti-infective CVADs should not be used in patients withallergies to silver, chlorhexidine, silver sulfadiazine,rifampin, or tetracyclines.1,29,32,35-51 (I)

E. CVADs designed to withstand high-pressure injec-tions (up to 300 pounds per square inch [psi]) havebeen found to be feasible and effective and withpublished reports of safe use.6,10,52-57 (II)

F. The nurse should be knowledgeable about whetherthe CVAD may be trimmed (considering factors

such as open- versus closed-ended; staggered lumenexits) and should follow the manufacturer’s direc-tions for use for altering the device length, shouldthe device require trimming. The use of scissorsshould be avoided in trimming catheter length. Useof scissors to adjust the length of peripherally insert-ed central catheters (PICCs) was found to result inrough, irregular surfaces as observed with scanningelectron microscopy. If the catheter length is modi-fied, the nurse should document the length in thepatient’s permanent medical record.34,58-60 (IV)

G. The nurse should be aware that there are specificcatheter selection and placement recommendations forpatients with chronic kidney disease (CKD). Catheterswith high flow rates should be used (see Standard 40,Hemodialysis Vascular Access Devices).30 (V)

H. CVAD tip location and dwell time for CKDpatients vary based on type of catheter selected andthe specific patient condition. Short-term CVADtips should be located in the SVC; long-term (tun-neled) CVAD tips should be located in the rightatrium; femoral CVAD tip locations should be inthe IVC. Uncuffed hemodialysis CVADs should beused in hospitalized CKD patients only and dwellup to 1 week. If an uncuffed hemodialysis CVADis selected for femoral placement, it should be usedin bed-bound CKD patients and dwell for only 5days (see Standard 40, Hemodialysis VascularAccess Devices).30 (V)

Practice Criteria

IV. Arterial Catheters

A. Peripheral or pulmonary arterial catheters shouldbe considered for short-term use for hemodynamicmonitoring, obtaining blood samples, and analyz-ing blood gas in critically ill patients.28 (V)

B. The nurse should be aware that the radial artery isthe most common insertion site because of easieraccess and a lower complication rate. Other possi-ble sites are the femoral, axillary, brachial, and tib-ial posterior arteries.61-64 (I)

C. If the radial artery site is selected, a 20-gauge arte-rial catheter is preferred to decrease the risk ofthrombosis.62 (I)

D. The nurse should be aware of the potential complica-tions associated with arterial catheters and that ratesof complications, such as thrombosis and infection,appear to increase with extended dwell time.61-65 (I)

REFERENCES

1. Joanna Briggs Institute, North Terrace Australia. Management ofperipheral intravascular devices: best practice information sheet.Aust Nurs J. 2008;16(3):25-28.



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2. Peripheral infusion therapy techniques. In: Weinstein S, ed.Plumer’s Principles & Practice of Intravenous Therapy. 8th ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2007:242-259.

3. Short peripheral access. In: Weinstein S, ed. Plumer’s Principles& Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007:260-276.

4. Antineoplastic therapy. In: Weinstein S, ed. Plumer’s Principles &Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007:474-548.

5. McGoldrick M. Infection prevention and control. In: AlexanderM, Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:204-228.

6. Bullock-Corkhill M. Central vascular access device access andinsertion. In: Alexander M, Corrigan A, Gorski L, Hankins J,Perucca R, eds. Infusion Nursing: An Evidence-Based Approach.3rd ed. St Louis, MO: Saunders/Elsevier; 2010:480-494.

7. Earhart A, Jorgensen C, Kaminski D. Accessing pediatric patientsfor vascular access and sedation. J Infus Nurs. 2007;30(4);226-231.

8. Seales K. Vascular access: a guide to peripheral venous cannula-tion. Nurs Standard. 2005;19(49):48-52.

9. Cheung E, Baerlocher M, Asch M, Myers A. Venous access: apractical review for 2009. Can Fam Physician. 2009;55:494-496.

10. Cook L. Choosing the right intravenous catheter. HomeHealthcare Nurse. 2007;25(8):523-531.

11. Transfusion therapy. In: Weinstein S, ed. Plumer’s Principles &Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007:413-464.

12. Pediatric intravenous therapy. In: Weinstein S, ed. Plumer’sPrinciples & Practice of Intravenous Therapy. 8th ed. Philadelphia,PA: Lippincott Williams & Wilkins; 2007:583-651.

13. Hadaway L. Infusion therapy equipment. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:391-436.

14. Perucca R. Peripheral vascular access devices. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:456-479.

15. Fabian B. Infusion therapy in older adults. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:571-582.

16. Scales K. Intravenous therapy: a guide to good practices. Br JNurs. 2008;17(19)(suppl):S4-S12.

17. Tosini W, Ciotti C, Goyer F, Lolom I et al. Needlestick injuryrates according to different types of safety-engineered devices:results of a French multicenter study. Infect Control HospEpidemiol. 2010;31(4):402-407.

18. American Society for Parenteral and Enteral Nutrition. Safe prac-tices for parenteral nutrition: practice guidelines for safe practicefor parenteral nutrition. J Parenter Enteral Nutr. 2004;28(6):S39-S70.

19. Isaacs JW, Milikan WJ, Stackhouse J, Hersh T, Rudman D.Parenteral nutrition of adults with 900-milliosmolar solutions viaa peripheral vein. Am J Clin Nutr.1977;30:552-559.

20. Pettit J, Wyckoff M. Peripherally Inserted Central Catheters:Guidelines for Practice. 2nd ed. Glenview, IL: NationalAssociation of Neonatal Nurses: 2007.

21. Gura KM. Is there still a role for peripheral parenteral nutrition?Nutr Clin Pract. 2009;24:709-717.

22. Krzywda EA, Meyer D. Parenteral nutrition. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:316-350.

23. Hayden BK, Goodman M. Chemotherapy: principles of adminis-tration. In: Yarbro CH, Frogge MH, Goodman M. CancerNursing: Principles and Practice. 6th ed. Boston, MA: Jones &Bartlett; 2005:352-412.

24. Oncology Nursing Society. Chemotherapy and Biotherapy:Guidelines and Recommendations for Practice. 2nd ed. Pittsburgh,PA: ONS; 2005.

25. Frey AM, Pettit J. Infusion therapy in children. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:550-570.

26. Dougherty L. Obtaining peripheral venous access. In: DoughertyL, Lamb J, eds. Intravenous Therapy in Nursing Practice. 2nd ed.London, England: Blackwell Publishing; 2008:223-270.

27. Infusion therapy in alternate clinical settings. In: Weinstein S, ed.Plumer’s Principles & Practice of Intravenous Therapy. 8th ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2007:662-687.

28. Mermel L, Allon M, Bourza E, et al. Clinical practice guidelines for thediagnosis and management of intravascular catheter related infection:2009 update by the Infectious Diseases Society of America. Clin InfectDis. 2009;49:1-45.

29. Bishop L, Dougherty L, Bodenham A, et al. Guidelines on the inser-tion and management of central venous access devices in adults. IntJ Lab Hematol. 2007;29(4):261-278.

30. National Kidney Foundation Vascular Access Work Group.Kidney Disease Outcomes Quality Initiative (KDOQI). Clinicalpractice guidelines and recommendations for vascular access. AmJ Kidney Dis. 2006; 48(1)(suppl 1): S248-S273.

31. Catheter selection. In: Weinstein S, ed. Plumer’s Principles &Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007:277.

32. Richardson D. Vascular access nursing: standards of care andstrategies in the prevention of infection: a primer on central venouscatheters (Part 2). J Assoc Vascular Access. 2007;12(1):19-27.

33. Doellman D, Nichols I. Modified Seldinger Technique with ultra-sound for peripherally inserted central catheter (PICC) placement inthe pediatric patient: a precise advantage. J Assoc Vascular Access.2009;14(2):93-99.

34. Pettit J. Trimming of peripherally inserted central catheters: theend result. J Assoc Vascular Access. 2006;11(4):209-214.

35. Raad I, Hanna H. Intravascular catheter related infections: new hori-zons and recent advances. Arch Intern Med. 2002;162(8):871-878.

36. McGee D, Gould M. Preventing complications of central venouscatheterization. N Engl J Med. 2003;348(12):1123-1133.

37. Maki D, Stolz S, Wheeler S, Mermel L. Prevention of centralvenous catheter-related bloodstream infection by use of an anti-septic impregnated catheter: a randomized, controlled trial. AnnIntern Med. 1997;127(4):257-266.

38. Raad I, Darouiche R, Dupuis J, et al. Central venous catheters coat-ed with minocycline and rifampin for the prevention of catheterrelated colonization and bloodstream infections: a randomized dou-ble-blind trial. Ann Intern Med. 1997;127(4):267-274.

39. Hanna H, Benjamin R, Chatzinikolaou I, et al. Long-term siliconecentral venous catheters impregnated with minocycline andrifampin decrease rates of catheter-related bloodstream infectionin cancer patients: a prospective, randomized clinical trial. J ClinOncol. 2004;22:3163-3171.



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40. Bassetti S, Hu J, D’Agostin R, et al. Prolonged antimicrobial activ-ity of a catheter containing chlorhexidine and silver sulfadiazineextends protection against catheter infection in vivo. AntimicrobAgents Chemother. 2001;45:1535-1538.

41. Logghe C, Vanossel C, Dhoore W, et al. Evaluation of chlorhex-idine and silver sulfadiazine-impregnated central venous cathetersfor the prevention of bloodstream infection in leukaemic patients:a randomized controlled trial. J Hosp Infect.1997;37:145-156.

42. Bach A, Eberhardt H, Frick A, et al. Efficacy of silver-coating cen-tral venous catheters in decreasing bacterial colonization. CritCare Med. 1999;27:515-521.

43. Bong JJ, Kite P, Wilco M, et al. Prevention of catheter related blood-stream infections by silver iontophoretic central venous catheters: arandomized controlled trial. J Clin Pathol. 2003;56:731-735.

44. Fraenkel D, Rickard C, Thomas P, et al. A prospective randomized trialof rifampin-minocycline coated and silver-platinum-carbon impregnat-ed central venous catheters. Crit Care Med. 2006;34:668-675.

45. Ranucci M, Guiseppi I, Gromarelli P, et al. Impact of oligon cen-tral venous catheters on catheter colonization and catheter-relat-ed bloodstream infections. Crit Care Med. 2003;31:52-59.

46. Crnick JC, Maki DG. Are antimicrobial-impregnated catheterseffective? When does repetition reach the point of exhaustion?Clin Infect Dis. 2005;41:681-685.

47. Kusminsky RE. Complications of central venous catheterization.J Am Coll Surg. 2007;204(4):681-696.

48. Hockenhull J, Dwan K, Smith G, et al. The clinical effectivenessof central venous catheters treated with anti-infective agents inpreventing catheter-related bloodstream infections: a systematicreview. Crit Care Med. 2009;37(2):702-712.

49. Rupp M, Lesco S, Lipsett P, et al. Effect of second generationvenous catheters impregnated with chlorhexidine and silver sulfa-diazine (CHSS) on central catheter-related infections: a random-ized controlled trial. Ann Intern Med. 2005;143:570-580.

50. Darouiche R, Raad I, Heard S, et al. A comparison of two antimicrobial-impregnated central venous catheters. N Engl J Med. 1999;340:1-8.

51. Marschall J, Mermel L, Classen D, et al. Strategies to prevent cen-tral line associated bloodstream infections in acute care hospitals:SHEA/IDSA practice recommendations. Infect Control HospEpidemiol. 2008;29:522-530.

52. Sanelli P, Deshmukh M, Dugorets I, et al. Safety and feasibility ofusing a central venous catheter for rapid contrast injection rates.Am J Roentgenology. 2004;183(6):1829-1834.

53. Coyle D, Bloomgarden D, Beres R, et al. Power injection of contrastmedia via peripherally inserted central venous catheters for computer-ized tomography. J Vascular Intervent Radiol. 2004;15(8):809-814.

54. Herts B, O’Malley C, Wirth S, Lieber M, Pohlman B. Power injec-tion of contrast media using central venous catheters: feasibility,safety and efficacy. Am J Roentgenology. 2001;176(2):447-453.

55. Ruess L, Bulas D, Rivera O, Markle B. In-line pressures generated insmall-bore central venous catheters during power injection of comput-erized tomography contrast media. Radiology. 1997;203:625-629.

56. Zamos D, Ernich T, Patton H, D’Amico F, Bansal S. Injectionrate threshold of 3-lumen central venous catheters: an in vitrostudy. Acad Radiol. 2007;14(5):574-578.

57. Rigsby C, Gasber E, Seshadri R, et al. Safety and efficacy of pressurelimited power injection of iodinated contrast medium through cen-tral lines in children. Am J Roentgenology. 2007;188(3):726-732.

58. Trottel C. Why are we trimming peripherally inserted centralvenous catheters? Neonatal Network. 2004;23(3):82-83.

59. Parvez B, Parmar N, Chan A. Trimming of peripherally inserted cen-tral venous catheters may increase the risk of thrombosis. ThrombRes. 2004;113(2):175-177.

60. Rutledge DN, Viele C. Insertion and care of peripherally insertedcentral catheters (PICCs) for intravenous infusions. Online J ClinInnovations. 2006;9(2):1-73.

61. Scheer BV, Perel A, Pfeiffer U. Clinical review: complications andrisk factors of peripheral arterial catheters used for haemodynam-ic monitoring in anaesthesia and intensive care medicine. CritCare. 2002;6(3):198-204.

62. Lorente L, Santacreu R, Martin M, Jimenez A, Mora, M. Arterialcatheter-related infection of 2,949 catheters. Crit Care. 2006;10. http://ccforum.com/content/10/3/R83. Accessed January 23, 2010.

63. Koh DB, Gowardman JR, Rickard CM, Robertson IK, Brown A.Prospective study with peripheral arterial catheter infection and com-parison with concurrently sited central venous catheters. Crit CareMed. 2008;36(2):397-402.

64. Blot F, Estphan G, Boughaba A, Soltani D, et al. Is routine chang-ing of peripheral arterial catheters justified? Clin Microbiol Infect.2008;14(9):813-815.

65. Khalifa R, Dahyot-Fizelier C, Laksiri L, et al. Indwelling time andrisk of colonization of peripheral arterial catheters in critically illpatients. Intensive Care Med. 2008;34(10):1820-1826.

33. SITE SELECTION

Standard

33.1 Site selection for all vascular access devices (VADs)shall be established in organizational policies, proce-dures, and/or practice guidelines.33.2 The vasculature shall accommodate the gauge andlength of the catheter required for the prescribed therapy.33.3 Site selection for vascular access shall include assess-ment of the patient’s condition; age; diagnosis; comorbidi-ties; condition of the vasculature at the insertion site andproximal to the intended insertion site; condition of skin atintended insertion site; history of previous venipuncturesand access devices; type and duration of infusion therapy;and patient preference.33.4 Prior to insertion of a peripherally inserted centralcatheter (PICC), anatomical measurements shall be takento determine the length of the catheter required to ensurefull advancement of the catheter to the lower third of thesuperior vena cava and the junction of the superior venacava and right atrium.33.5 Placement of central vascular access devices(CVADs) by nurses shall be established in organizationalpolicies, procedures, and/or practice guidelines and inaccordance with rules and regulations promulgated by thestate’s Board of Nursing.

Practice Criteria

I. Peripheral Venous Access via ShortPeripheral Catheters

A. For adult patients, veins that should be consid-ered for peripheral cannulation are those found onthe dorsal and ventral surfaces of the upper extremi-ties, including the metacarpal, cephalic, basilic, and



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median veins. Avoid the lateral surface of the wristfor approximately 4-5 inches because of the poten-tial risk for nerve damage. For pediatric patients,similar veins to consider are in the hand, forearm,antecubital area, and upper arm below the axilla, aswell as the veins of the scalp, foot, and fingers ininfants and toddlers. For adult and pediatricpatients: avoid the ventral surface of the wrist due tothe pain on insertion and possible damage to theradial nerve.1-5 (V)

B. Site selection should be initiated routinely in the dis-tal areas of the upper extremities; subsequent cannu-lation should be made proximal to the previouslycannulated site.3 (V)

C. Site selection should be initiated routinely in thenondominant arm. VAD sites should avoid areas offlexion; areas of pain on palpation; veins that arecompromised (eg, bruised, infiltrated, phlebitic, scle-rosed, or corded); location of valves; and areas ofplanned procedures. In infants and children, avoidthe hand or fingers, or the thumb/finger used forsucking.2,3,6,7 (V)

D. Veins of the lower extremities should not be usedroutinely in the adult population due to risk oftissue damage, thrombophlebitis, and ulceration.2(I A/P)

E. Veins in an upper extremity should be avoided onthe side of breast surgery with axillary node dissec-tion, after radiation therapy to that side, or with lym-phedema, or the affected extremity from a cere-brovascular accident. For patients with chronic kid-ney disease stage 4 or 5, avoid forearm and upper-arm veins “suitable for placement of vascularaccess.” A collaborative discussion with the patientand the licensed independent practitioner (LIP)should take place related to the benefits and risks ofusing a vein in an affected extremity.3,6,8-12 (V)

F. Veins in the right arm of infants and childrenshould be avoided after procedures treating congen-ital cardiac defects that may have decreased bloodflow to the subclavian artery.13 (V)

G. Cannulation of hemodialysis fistulas and graftsfor infusion therapy requires the order of anephrologist or LIP.3 (V)

H. The nurse should consider using visualizationtechnologies that aid in vein identification andselection.3,14(V)

Practice Criteria

II. Peripheral Venous Access via MidlineCatheters

A. Site selection should be routinely initiated in theregion of the antecubital fossa. Veins that should beconsidered for midline catheter cannulation are thebasilic, cephalic, and brachial veins. For neonate and

pediatric patients, additional site selections includeveins in the leg with the tip below the groin and in thescalp with the tip in the neck, above the thorax.1,3 (V)

B. Site selection should avoid areas of pain on palpa-tion, veins that are compromised (eg, bruised, infil-trated, phlebitic, sclerosed, or corded), and forpatients with chronic kidney disease stage 4 or 5,avoid forearm and upper-arm veins “suitable forplacement of vascular access.”2,3,8,12 (V)

C. Veins in an upper extremity should be avoided on theside of breast surgery with axillary node dissection,after radiation therapy to that side, or with lymphedema,or the affected extremity from a cerebrovascular acci-dent. For patients with chronic kidney disease stage 4or 5, avoid upper-arm veins “suitable for placement ofvascular access.” A collaborative discussion with thepatient and the licensed independent practitioner (LIP)should take place related to the benefits and risks ofusing a vein in an affected extremity.3,8,9,11 (V)

D. Veins in the right arm of infants and childrenshould be avoided after procedures treating specif-ic congenital cardiac defects that may havedecreased blood flow to the subclavian artery.13 (V)

E. The nurse should consider using visualizationtechnologies that aid in vein identification andselection.14 (V)

Practice Criteria

III. Central Venous Access via PeripherallyInserted Central Catheters (PICCs)

A. Veins that should be considered for PICC cannula-tion are the basilic, median cubital, cephalic, andbrachial veins. For neonate and pediatric patients,additional site selections include the temporal veinand posterior auricular vein in the head and thesaphenous vein in the lower extremities.13,15 (V)

B. Site selection should avoid areas of pain on palpa-tion; veins that are compromised (eg, bruised, infil-trated, phlebitic, sclerosed, or corded); and forpatients with chronic kidney disease stage 4 or 5,avoid forearm and upper-arm veins “suitable forplacement of vascular access.”2,8,12 (V)

C. Veins in an upper extremity should be avoided on theside of breast surgery with axillary node dissection,after radiation therapy to that side, or with lymphedema,or the affected extremity from a cerebrovascular acci-dent. For patients with chronic kidney disease stage 4or 5, avoid upper-arm veins “suitable for placement ofvascular access.” A collaborative discussion with thepatient and the licensed independent practitioner (LIP)should take place related to the benefits and risks ofusing a vein in an affected extremity.8,9,11 (V)

D. The nurse should consider using visualizationtechnologies that aid in vein identification andselection.14-16 (V)



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Practice Criteria

IV. Central Venous Access via NontunneledCentral Vascular Access Devices (CVADs)

A. To minimize the risk of catheter-related infectionwith a nontunneled CVAD, the subclavian vein isrecommended in adult patients, rather than the jugu-lar or femoral veins, although benefits and risksaccompany each access site. For patients with chron-ic kidney disease, the subclavian vein is not recom-mended in order to preserve the vein.8,12,17,18 (I)

B. To minimize the risk of catheter-related thromboticcomplications with a nontunneled CVAD, the sub-clavian vein is recommended in adult patients, ratherthan the femoral vein, although benefits and risksaccompany each access site.17 (I)

C. There is no preferred venous insertion site for anontunneled CVAD in infants and children tominimize the risk of infection.19 (V)

Practice Criteria

V. Central Venous Access via TunneledCentral Vascular Access Devices andImplanted Ports

A. The nurse should collaborate with the health care teamand patient in assessment and site selection for place-ment of tunneled catheters and implanted ports.11 (V)

Practice Criteria

VI. Peripheral Arterial Access

A. Criteria for selection should include the presence of apulse and assessment of distal circulation. An Allentest should be performed when selecting the appro-priate artery for cannulation, prior to device inser-tion, and for assessment of distal arterial perfusion.2(I A/P)

B. The radial artery should be considered the mostappropriate access for percutaneous cannulation inadults for its advantages and to prevent infection.Alternative arteries include ulnar, brachial, and dor-salis pedis in adults, with each having advantagesand disadvantages. These sites are preferred over thefemoral or axillary to reduce the risk of infection.For pediatric patients, site selections include radial,posterior tibial, and dorsalis pedis arteries and arepreferred over the femoral or axillary sites to reducethe risk of infection. The brachial artery should notbe used in pediatric patients due to the absence ofcollateral blood flow.2,20 (I A/P)

C. Infusion therapy is not administered in peripheralarteries via peripheral arterial catheters; these cathetersare used for hemodynamic monitoring, blood gasanalysis, and obtaining blood samples.2,14 (V)

D. The nurse should consider using visualizationtechnologies that aid in arterial identification andselection.14 (V)

Practice Criteria

VII. External Jugular Vein Access

A. Nurses who are competent in infusion therapy mayinsert short peripheral intravenous (IV) cathetersand PICCs, using the external jugular vein inpatients in acute care settings and in emergency sit-uations when other veins cannot be accessed.2,21 (V)

B. A short peripheral catheter in the external jugularvein should not be used for contrast media orwith power injectors.21 (V)

C. Central venous pressure monitoring may be performedthrough PICCs in the external jugular vein.21 (V)

D. When a short peripheral catheter is inserted intothe external jugular vein and infusion therapy isexpected to exceed 72 to 96 hours, the nurseshould collaborate with the LIP for an alternativevascular access site as soon as possible.3,21 (V)

REFERENCES

1. Frey AM, Pettit J. Infusion therapy in children. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:550-570.

2. Hadaway L. Anatomy and physiology related to infusion thera-py: In: Alexander M, Corrigan A, Gorski L, Hankins J, PeruccaR, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed.St Louis, MO: Saunders/Elsevier; 2010:139-177.

3. Perucca R. Peripheral venous access devices. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:456-479.

4. Laskowski-Jones L, Falkowski A. Infusion therapy. In: IgnatiaviciusDD, Workman ML. Medical-Surgical Nursing: Patient-CenteredCollaborative Care. 6th ed. St Louis, MO: Mosby/Elsevier; 2010:213-240.


6. Ostendorf W. Fluid, electrolyte, and acid-base balance. In: PotterP, Perry A. Fundamentals of Nursing. 7th ed. St Louis, MO:Mosby/Elsevier; 2009:966-1027.

7. Taylor E. Infant perioperative patients. AORN J. 2007;86:843-848.8. American Nephrology Nurses’ Association Board of Directors

[position statement]. Vascular access for hemodialysis. http://www.annanurse.org/cgibin/WebObjects/ANNANurse.woa/wa/viewSection?s_id/1073744052&ss_id/536873322&tName/vascAccess.Published 2010. Accessed March 17, 2010.

9. Felty CL, Rooke TW. Lymphedema. In: Fahey V.Vascular Nursing.4th ed. St Louis, MO: Saunders; 2004:33-46.

10. Hayden BK, Goodman M. Chemotherapy: principles of administra-tion. In: Yarbro CH, Frogge MH, Goodman M. Cancer Nursing:Principles and Practice. 6th ed. Boston, MA: Jones and Bartlett;2005;352-412.



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11. Institute of Medicine. Committee on Quality of Health Care inAmerica. Crossing the Quality Chasm: A New Health System for the21st Century. Washington, DC: National Academies Press; 2001.

12. Vascular Access Work Group. Clinical practice guidelines for vas-cular access. Am J Kidney Dis. 2006;48(suppl 1):S176-S247.

13. Beauman SS, Swanson A. Neonatal infusion therapy: preventingcomplications and improving outcomes. Newborn Infant Nurs Rev.2006;6(4):193-201.

14. Hadaway L. Infusion therapy equipment. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:391-436.

15. Bullock-Corkhill M. Central venous access devices: access andinsertion. In: Alexander M, Corrigan A, Gorski L, Hankins J,Perucca R, eds. Infusion Nursing: An Evidence-Based Approach.3rd ed. St Louis, MO: Saunders/Elsevier; 2010:480-494.

16. Association for Vascular Access Board of Directors [position state-ment]. The use of ultrasound guidance by registered nurses forcentral venous catheter insertion. http://www.avainfo.org/website/download.asp?id/272333. Published June 17, 2010. AccessedAugust 5, 2010.

17. Hamilton HC, Foxcroft D. Central venous access sites for the pre-vention of venous thrombosis, stenosis and infection in patientsrequiring long-term intravenous therapy. Cochrane Database SystRev. 2007;(3):CD004084.

18. Ruesch S, Walder B, Tramer MR. Complications of central venouscatheters: internal jugular versus subclavian access: a systematicreview. Crit Care Med. 2002;30:454-460.

19. Koletzko B, Goulet O, Hunt J, Krohn K, Shamir R. Venous access:guidelines on paediatric parenteral nutrition of the European Society ofPaediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)and the European Society for Clinical Nutrition and Metabolism(ESPEN), supported by the European Society of Paediatric Research(ESPR). J Pediatr Gastroenterol Nutr. 2005;41(suppl 2):S54-S62.

20. Alternate access. In: Weinstein S, ed. Plumer’s Principles & Practiceof Intravenous Therapy. 8th ed. Philadelphia, PA: LippincottWilliams & Wilkins; 2007:331-357.

21. Infusion Nurses Society [position paper]. The role of the registerednurse in the insertion of external jugular peripherally inserted cen-tral catheters (EJ PICC) and external jugular peripheral intra-venous catheters (EJ PIV). J Infus Nurs. 2008;31(4):226-227.

34. LOCAL ANESTHESIA FOR VASCULAR ACCESS DEVICEPLACEMENT AND ACCESS

Standard

34.1 Local anesthesia shall be considered based upon nursingassessment of patient condition, needs, risks, and benefits.34.2 When local anesthesia is ordered or necessary, theagent and method that is least invasive and carries the leastrisk for allergic reaction or infection shall be considered first.34.3 The nurse shall be competent to administer local anes-thesia for vascular access device (VAD) placement and access.34.4 Use of local anesthesia shall be established in orga-nizational policies, procedures, and/or practice guide-lines, and in accordance with the rules and regulationspromulgated by the state’s Board of Nursing.

Practice Criteria

A. Local anesthetic agents including, but not limitedto, topical transdermal agents, intradermal lido-caine, iontopheresis, and pressure-acceleratedlidocaine, should be considered and used accord-ing to manufacturers’ directions for use.1-10 (II)

B. The nurse should consider and encourage the use ofall available and effective local anesthetic methodsand agents prior to each painful dermal procedurein children and some adults. These include topicalanesthetics as well as adjunctive and less invasiveanxiolytic, cognitive, behavioral, and complemen-tary therapies to reduce pain and discomfort.11-16 (II)

C. The nurse should assess the patient for potentialallergic reactions, tissue damage, or inadvertentinjection of the drug into the vascular systemwhen administering a local anesthetic.9,17 (V)

REFERENCES

1. Fetzer SJ. Reducing venipuncture and intravenous insertion painwith eutectic mixture of local anesthetic: a meta-analysis. NursRes. 2002;51:119-124.


3. Fry C, Aholt D. Local anesthesia prior to the insertion of peripheral-ly inserted central catheters. J Intraven Nurs. 2001;24(6):404-408.

4. Gorski L. Guideline 90: intravenous insertion. In: Ackley BJ,Ladwig GB, Swan BA, Tucker SJ. Evidence-Based Nursing CareGuidelines: Medical-Surgical Interventions. St Louis, MO: Mosby/Elsevier; 2008:477-482.


6. Hudson TL, Dukes SF, Reilly K. Use of local anesthesia for arte-rial punctures. Am J Crit Care. 2006;15:595-599.

7. McGowan D, Wood S. Developing a venous assessment tool inIV chemotherapy administration. Br J Nurs. 2008;17:158-164.

8. Migdal M, Chudzynska-Pomianowska E, Vause E, Henry E, Lazar J.Rapid, needle-free delivery of lidocaine for reducing the pain of venipunc-ture among pediatric subjects. Pediatrics. 2005;115(4):e393-e398.

9. Peripheral infusion therapy techniques. In: Weinstein S, ed.Plumer’s Principles & Practice of Intravenous Therapy. 8th ed.Philadelphia, PA: Lippincott Williams & Wilkins. 2007;242-259.

10. Zempsky WT, Cravero JP; American Academy of Pediatrics Committeeon Pediatric Emergency Medicine and Section on Anesthesiology andPain Medicine. Relief of pain and anxiety in pediatric patients in emer-gency medical systems. Pediatrics. 2004;114(5):1348-1356.

11. Bisignano A, Bush JP. Distress in pediatric hematology: oncologypatients undergoing intravenous procedures: evaluation of a CD-ROM intervention. Child Health Care. 2006;35:61-74.

12. Breiner SM. Preparation of the pediatric patient for invasive pro-cedures. J Infus Nurs. 2009;32:252-256.

13. Fanurik D, Koh JL, Schmitz ML. Distraction techniques com-bined with EMLA: effects on IV insertion pain and distress inchildren. Child Health Care. 2000;29(2):87-101.



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14. Pediatric intravenous therapy. In: Weinstein S, ed. Plumer’sPrinciples & Practice of Intravenous Therapy. 8th ed. Philadelphia,PA: Lippincott Williams & Wilkins; 2007:613-685.

15. Gold J, Kim SH, Kant AJ, Joseph MH. Effectiveness of virtualreality for pediatric pain distraction during IV placement.Cyberpsychology Behav. 2006;9:207-212.

16. Skarbek-Borowska S, Becker BM, Lovgren K, Bates A, Minugh PA.Brief focal ultrasound with topical anesthetic decreases the pain ofintravenous placement in children. Pediatr Emerg Care. 2006;22:339-345.

17. Brown D. Local anesthesia for vein cannulation: a comparison oftwo solutions. J Infus Nurs. 2004;27(2):85-88.

35. VASCULAR ACCESS SITEPREPARATION AND DEVICEPLACEMENT

Standard

35.1 The nurse shall place a vascular access device (VAD)upon the order of a licensed independent practitioner(LIP) in accordance with the rules and regulations pro-mulgated by the state’s Board of Nursing and organiza-tional policies, procedures, and/or practice guidelines.35.2 VAD placement shall be established in organiza-tional policies, procedures, and/or practice guidelinesand according to manufacturers’ directions for use.35.3 The nurse shall be competent in insertion tech-nique, infection prevention measures, identifying poten-tial complications, implementing nursing interventions,and in assisting the LIP with VAD placement.35.4 The nurse shall prepare the intended VAD insertionsite with antiseptic solution using aseptic technique.35.5 Maximal sterile barrier (MSB) precautions, includ-ing mask, sterile gown, cap, sterile gloves, protectiveeyewear, and large full-body drapes, shall be used withthe insertion of central vascular access devices(CVADs).35.6 Antiseptic solutions in a single unit configurationshall be used.35.7 Only 1 vascular access device shall be used foreach catheterization attempt.35.8 Tip location of a CVAD shall be determined radi-ographically or by other approved technologies prior toinitiation of infusion therapy.

Practice Criteria

I. General

A. Prior to inserting a vascular access device, thenurse should provide patient education, address-ing the rationale for VAD placement; insertionprocess; expected dwell time; care and mainte-nance of the device; and signs and symptoms ofcomplications to report (see Standard 12,Informed Consent).1 (V)

B. If the intended insertion site is visibly soiled, cleanthe area with soap and water prior to applicationof antiseptic solution(s).2,3 (V)

C. Clipping should be performed to remove excesshair at the insertion site with single-patient-usescissors or disposable-head surgical clippers;microabrasions produced from shaving increasethe risk for infection.4 (V)

D. The nurse should inspect the VAD for productintegrity prior to insertion.5 (V)

E. If an artery is inadvertently accessed or if the patientcomplains of paresthesias, numbness, or tingling uponVAD insertion, the catheter should be immediatelyremoved and the LIP promptly notified, as rapidattention may prevent permanent injury; nerves andarteries are often located in very close proximity to thevenipuncture site.6-8 (V)

F. No more than 2 attempts at vascular access place-ment should be made by any 1 nurse, as multipleunsuccessful attempts limit future vascular accessand cause patients unnecessary pain. Patients withdifficult vascular access require a careful assess-ment of VAD needs and collaboration with thehealth care team to discuss appropriate options.4(V)

G. Chlorhexidine solution is preferred for skin antisep-sis. One percent to two percent tincture of iodine,iodophor (povidone-iodine), and 70% alcohol mayalso be used. Chlorhexidine is not recommendedfor infants under 2 months of age.4,9(I)

H. The nurse should consider using visualization tech-nologies that aid in vein identification and selec-tion.5,10,11(V)

Practice Criteria

II. Short Peripheral and Midline Catheters

A. The nurse should consider the use of methods topromote vascular distention in addition to theappropriate use of tourniquets, such as gravity(positioning the extremity lower than the heart forseveral minutes), having the patient open and closehis or her fist, and lightly stroking the vein down-ward (see Standard 31, Tourniquets).4,12 (I A/P)

B. The use of warmth should be considered anothermethod to promote vascular dilation. The use ofdry heat was found to increase the likelihood ofsuccessful peripheral catheter insertion.4,12-15 (II)

C. The nurse should use a new pair of disposable,nonsterile gloves in conjunction with a no-touchtechnique for peripheral IV insertion. With no-touch technique, the planned IV insertion site isnot palpated after skin cleansing unless sterilegloves are worn.16 (V)

D. Insertion techniques for midline catheter placementinclude threading the catheter through an introducer



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or using the Modified Seldinger Technique (MST),also known as the microintroducer technique.5,17-19

(V)E. The midline catheter tip location should be at or

below the axillary line.5,17-19 (V)

Practice Criteria

III. Central Vascular Access Devices (CVADs)

A. The nurse should use a standardized checklist toencourage adherence to recommended practices foraccess site preparation, infection prevention, andsafety precautions. The CVAD placement proce-dure should be stopped for any breaches in steriletechnique that occur during the procedure.9,20,21 (IV)

B. The nurse should use a standardized supply cartor kit that contains all necessary components forthe insertion of a CVAD.9,20,21 (V)

C. Ultrasound technology should be used when insert-ing PICC and percutaneous centrally insertedcatheters to increase success rates and decreaseinsertion-related complications.22-31 (III)

D. The nurse should use the Seldinger or ModifiedSeldinger Technique (MST) as the preferred methodfor CVAD (ie, peripherally inserted central catheter[PICC], subclavian) insertion due to advantages ofdecreased vein trauma, decreased insertion compli-cations, and decreased risk of arterial puncture ornerve injury.8,30-34 (V)

E. CVADs shall have the tip dwelling within the supe-rior vena cava (SVC) near its junction with the rightatrium or, if placed via the femoral vein, shall havethe tip dwell in the inferior vena cava (IVC) abovethe level of the diaphragm.8,35,36 (IV)

F. The nurse should be aware that the presence of a pace-maker requires a careful evaluation and thoroughassessment to select the appropriate catheter andinsertion site. Pacemakers are usually placed on theleft side of the chest or abdomen. The contralateralside is preferred for CVAD placement, but if ipsilater-al side is selected, a peripherally inserted centralvenous catheter may be the safest choice. It is impor-tant to have the pacemaker evaluated before and afterCVAD insertion to determine integrity of the pace-maker unit and leads. There are no published reportsof displaced leads noted during CVAD insertion, andthere are currently no practice guidelines developedrelated to pacemakers and CVADs.37,38 (V)

Practice Criteria

IV. Arterial Catheters

A. The nurse should use a cap, mask, sterile gloves,eyewear, and a large, sterile fenestrated drape whenplacing a peripheral arterial catheter.39 (II)

B. Maximal sterile barrier precautions should be usedwhen placing arterial catheters in the axillary orfemoral artery.39 (II)

REFERENCES

1. Czaplewski L. Clinician and patient education. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:71-108.

2. National Kidney Foundation/Dialysis Outcomes Quality Initiative.Clinical practice guidelines for vascular access: update 2000. Am JKidney Dis. 2001;37(suppl 1):S137-S181.

3. Parienti JJ. A paradigm shift to prevent nosocomial infection: “takea bath before I touch you.” Crit Care Med. 2009;37(6):2097-2098.

4. Perucca R. Peripheral venous access devices. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:456-479.


6. Boeson MB, Hranchook A, Stoller J. Peripheral nerve injury fromintravenous cannulation: a case report. AANA J. 2000;68(1):53-57.

7. Masoorli S. Nerve injuries related to vascular access insertion andassessment. J Infus Nurs. 2007;30(6):346-350.

8. Bullock-Corkhill M. Central venous access devices: access andinsertion. In: Alexander M, Corrigan A, Gorski L, Hankins J,Perucca R, eds. Infusion Nursing: An Evidence-Based Approach.3rd ed. St Louis, MO: Saunders/Elsevier; 2010:480-494.

9. Marschall J, Mermel LA, Classen D, et al. Strategies to preventcentral line-associated bloodstream infections in acute care hospi-tals. Infect Control Hosp Epidemiol. 2008;29(suppl 1):S22-S30.

10. Dargin JM, Rebholz CM, Lowenstein RA, Mitchell PM, FeldmanJA. Ultrasonography-guided peripheral intravenous catheter sur-vival in ED patients with difficult access. Am J Emerg Med.2010;28(1):1-7.

11. Katogridakis YL, Roopa S, Sullivan C, Waltzman M. Veinlite tran-sillumination in the pediatric emergency department: a therapeuticinterventional trial. Pediatr Emerg Care. 2008;28(2):83-88.

12. Techniques for initiation and maintenance of peripheral infusiontherapy. In: Phillips LD. Manual of IV Therapeutics: Evidence-BasedPractice for Infusion Therapy. 5th ed. Philadelphia, PA: FA Davis;2010:303-401.

13. Fink RM, Hjort E, Wenger B, et al. The impact of dry versus moistheat on peripheral IV catheter insertion in a hematology-oncologyoutpatient population. Oncol Nurs Fourm. 2009;36 (4):E198-E204.

14. Lenhardt R, Seybold T, Kimberger O, Stoiser B, Sessler DI. Localwarming and insertion of peripheral venous cannulas. BMJ.2002;325(7361):409-410.

15. Roberge RJ. Venodilatation techniques to enhance venipunctureand intravenous cannulation. J Emerg Med. 2004;27(1):69-73.

16. Betsy Lehman Center for Patient Safety and Medical ErrorReduction. JSI Research and Training Institute. Prevention ofbloodstream infections. In: Prevention and Control of Healthcare-associated Infections in Massachusetts. Part 1: Final Recomm-endations of the Expert Panel. Boston, MA: Massachusetts Departmentof Public Health; January 31, 2008:69-82.

17. Anderson NR. Midline catheters. J Infus Nurs. 2004;27(5):313-321.



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18. Infusion equipment. In: Phillips LD. Manual of IV Therapeutics:Evidence-Based Practice for Infusion Therapy. 5th ed. Philadelphia,PA: FA Davis; 2010: 230-302.

19. Rosenthal K. Bridging the IV access gap with midline catheters.Nursing. 2008;(suppl 2):4-5.

20. Institute for Healthcare Improvement. Implement the central linebundle. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheCentralLineBundle.htm. Accessed January5, 2010.

21. Pronovost P, Needham D, Berenholtz S, et al. An intervention todecrease catheter-related bloodstream infections in the ICU. N EnglJ Med. 2006;355(26):2725-2732.

22. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locatingdevices for central venous cannulation: meta-analysis. BMJ. 2003;327(2411):361.

23. Froehlich C, Rigby M, Rosenberg E, et al. Ultrasound-guided centralvenous catheter placement decreases complications and decreasesplacement attempts compared with the landmark technique in patientsin a pediatric intensive care unit. Crit Care Med. 2009;37(3):1090-1096.

24. Johnson M, McKenzie L, Tussey S, Jacobs H, Couch C. Portableultrasound: a cost-effective process improvement tool for PICCplacement. Nurs Manage. 2009;40(1):47-50.

25. Stokowski G, Steele D, Wilson D. The use of ultrasound toimprove practice and reduce complication rates in peripherallyinserted central catheter insertions. J Infus Nurs. 2009;32(3) 145-153.

26. Nichols I, Humphrey JP. The efficacy of upper arm placement ofperipherally inserted central catheters using bedside ultrasound andmicrointroducer technique. J Infus Nurs. 2008;31(3):165-175.

27. Stokowski G, Steele D, Wilson D. The use of ultrasound to improvepractice and reduce complication rates in peripherally inserted cen-tral catheter insertions. J Infus Nurs. 2009;32(3):145-153.

28. Dargin JM, Rebholz CM, Lowenstein RA, Mitchell PM, FeldmanJA. Ultrasonography-guided peripheral intravenouw catheter sur-vival in ED patients with difficult access. Am J Emerg Med. 2010;28(1):1-7.

29. Sandhu NPS, Sidhu DS. Case reports: mid-arm approach to basil-ic and cephalic vein cannulation using ultrasound guidance. Br JAnaesth. 2004;1-3.

30. Rutledge DN, Viele C. Insertion and care of peripherally insertedcentral catheters (PICCs) for intravenous infusions. Online J ClinInnovations. 2006;9(2):1-73.

31. Association for Vascular Access [position paper]. The use ofultrasound guidance by registered nurses for central venouscatheter insertion. http://www.avainfo.org/website/download.asp?id=272333. Published 2010. Accessed October 19, 2010.

32. Richardson D. Vascular access nursing: standards of care, andstrategies in the prevention of infection: a primer on central venouscatheters (Part 2). J Assoc Vascular Access. 2007;12(1):19-27.

33. Doellman D, Nichols I. Modified Seldinger technique with ultrasoundfor peripherally inserted central catheter (PICC) in the pediatric patient:a precise advantage. J Assoc Vascular Access. 2009;14(2):93-99.

34. Higgs ZC, Macafee DA, Braithwaite BD, Maxwell-Armstrong,CA. The Seldinger Technique: 50 years on. Lancet. 2005;366:1407-1409.

35. DeChicco R, Seidner DL, Brun C, et al. Tip position of long-termcentral venous access devices used for parenteral nutrition. JParenter Enteral Nutr. 2007;31(5):382-387.

36. Caers J, Fontaine C, Vinh-Hung V, et al. Catheter tip position as arisk factor for thrombosis associated with the use of subcutaneousinfusion supports. Support Care Cancer. 2005;13(5):325-331.

37. Pacana C, Durand JB. The risk of central venous placement ipsilat-eral to the permanent pacemaker. J Assoc Vascular Access. 2009;14(1):28-30.

38. McGee D, Gould M. Preventing complications of central venouscatheterization. New Engl J Med. 2003;348(12):1123-1133.

39. Koh DB, Gowardman JR, Rickard CM, Robertson IK, Brown A.Prospective study of peripheral arterial catheter infection andcomparison with concurrently sited central venous catheters. CritCare Med. 2008;36:397-402.

36. VASCULAR ACCESS DEVICESTABILIZATION

Standard

36.1 Vascular access device (VAD) stabilization shall beused to preserve the integrity of the access device, mini-mize catheter movement at the hub, and preventcatheter dislodgment and loss of access.36.2 VADs shall be stabilized using a method that doesnot interfere with assessment and monitoring of theaccess site or impede vascular circulation or delivery ofthe prescribed therapy.36.3 The use of stabilization methods shall be estab-lished in organizational policies, procedures, and/orpractice guidelines.36.4 The nurse shall be competent in proper use andapplication of VAD stabilization methods and devices.

Practice Criteria

A. The use of a catheter stabilization device should beconsidered the preferred alternative to tape orsutures when feasible. Several studies have demon-strated a reduction in overall complications andimproved dwell time with peripheral IV catheters.One study demonstrated reduced risk of infectionwith peripherally inserted central catheters (PICCs)when a catheter stabilization device was used.Sutures were associated with fewer complicationswhen compared to use of tape with PICCs in pedi-atric patients in a randomized, controlled trial thatexcluded use of stabilization devices.1-6 (III)

B. Transparent semipermeable membrane (TSM)dressings or other dressings are often cited ashelpful in stabilizing the catheter; however, thereis insufficient evidence supporting their benefits instabilization at the intravenous catheter hubalone. A randomized, controlled trial with periph-eral IV catheters demonstrated that use of aperipheral IV catheter with an integrated stabi-lization feature in combination with an IV secure-ment dressing performed as well as a standardperipheral IV with a catheter stabilization device.It is important to recognize that these results can-not be generalized to all types of short peripheralcatheters.5,7-11 (III)



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C. The use of alternative methods of VAD stabiliza-tion in lieu of sutures should be considered to miti-gate the risk of needlestick injury; the use of stapleshas been cited in the literature as an alternative tosutures, reducing exposure to contaminated sharps.Studies are limited, however; they have not demon-strated benefits and may not be appropriate in thenonsedated patient.5,6,12 (V)

D. Use of any stabilization method should be basedon evidence as well as analysis of risks versus ben-efits. While sutures may increase risk of needle-stick injury and/or risk of infection due to thepresence of suture wounds near the insertion siteand development of biofilm on the sutures,sutures may be considered appropriate in specialpopulations such as pediatric patients or thosewith skin integrity problems, precluding use oftape or an engineered stabilization device.5,10,13

(V)E. If sutures used to stabilize a VAD at placement

become loosened or no longer intact, they shouldbe removed and the VAD should be secured usinganother stabilization method or resutured asappropriate.5 (V)

F. Removal and replacement of the engineered stabi-lization device or tape should be done at estab-lished intervals according to the manufacturer’sdirections for use, and/or in conjunction withreplacement of the VAD, or with routine site careand dressing changes.5,14 (V)

G. A catheter that migrates externally should not bereadvanced into the vein prior to application of acatheter stabilization device; the VAD should bestabilized at the point of external migration andassessed for proper placement in the vasculaturebefore further use.14 (V)

REFERENCES

1. Frey AM, Schears GJ. Why are we stuck with tape and suture? Areview of catheter securement devices. J Infus Nurs. 2006;29(1):34-38.

2. Smith B. Peripheral intravenous catheter dwell times: a compari-son of 3 securement methods for implementation of a 96-hourscheduled change protocol. J Infus Nurs. 2006;29(1):14-17.

3. Yamamoto AJ, Soloman JA, Soulen MC, et al. Sutureless secure-ment device reduces complications of peripherally inserted centralvenous catheters. J Vascular Intervent Radiol. 2002;13(1):77-81.

4. Schears GJ. Summary of product trials for 10,164 patients: com-paring an intravenous stabilizing device to tape. J Infus Nurs.2006;29(4):225-231.

5. Registered Nurses Association of Ontario. Nursing best practiceguideline: Care and maintenance to reduce vascular access com-plications. http://www.rnao.org/Storage/39/3379_Assessment_and_Device_Selection_for_Vascular_Access._with_2008_Supplement.pdf. Accessed December 30, 2009.

6. Occupational Safety and Health Administration [fact sheet].Securing medical catheters. http://www.osha.gov/SLTC/blood-

bornepathogens/factsheet_catheters.pdf. Accessed February 20,2010.

7. Stephenson C. The advantages of a precision-engineered secure-ment device for fixation of arterial pressure monitoring catheters.J Assoc Vascular Access. 2005;10(3):130-132.

8. Bausone-Gazsa D, Lefaiver CA, Walters SA. A randomized con-trolled trial to compare the complications of 2 peripheral IVcatheter stabilization systems. J Infus Nurs. 2010;33(6):371-384.

9. Hadaway L. Infusion therapy equipment. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010: 391-436.

10. Ryder M. Catheter-related infections: it’s all about biofilm.Topics in Advanced Practice Nursing eJournal. 2005;5(3). http://www.medscape.com/viewarticle/508109;meddomainjsession=nBHmM5gPdD049THgwNsvQyjMCcNdM8CqRtjMTv2nh4Z8ns0sX4HZ!-228635945. Accessed February 8, 2010.

11. Frey AM, Pettit J. Infusion therapy in children. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:550-570.

12. Vinjirayer A, Jefferson P, Ball D. Securing central venous catheters:a comparison of sutures with staples. Emergy Med J. 2004;21(5):582-583.

13. Graf JM, Newman CD, McPherson ML. Sutured securement ofperipherally inserted central catheters yields fewer complications inpediatric patients. J Parenter Enteral Nutr. 2006;30(6): 532-535.

14. Gorski L, Perrucca R, Hunt M. Central venous access devices: care,maintenance, and potential complications. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:495-515.

37. JOINT STABILIZATION

Standard

37.1 Joint stabilization, using such devices as an armboard or limb or finger splint, shall be implemented tofacilitate infusion delivery when the catheter is placed inor adjacent to an area of flexion, and is not considereda restraint.37.2 A joint stabilization device shall be considered asingle-patient-use device.37.3 The use of joint stabilization devices shall be estab-lished in organizational policies, procedures, and/orpractice guidelines and according to manufacturers’directions for use.37.4 The nurse shall be competent in the proper use andapplication of joint stabilization devices.

Practice Criteria

A. A joint stabilization device, such as an arm boardor limb or finger splint, should be padded andsupport the area of flexion (ie, finger, hand, arm,foot) in order to maintain a functional position.1-3

(V)



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B. The joint stabilization device should be applied ina manner that will provide the ability to visuallyinspect and assess the vascular access site and veinpath, prevent circulatory constriction, prevent skinimpairment, and prevent nerve pressure in the areaof flexion.1-4 (V)

C. The nurse should assess the patient’s risk for devel-opment of pressure ulcers, perform skin inspectionand assessment, and implement appropriate inter-ventions to avoid the risk of skin breakdown. Thepotential risk for skin breakdown and develop-ment of pressure ulcers exists due to pressurecreated from the device restricting vascular circula-tion.5-8 (V)

D. Joint stabilization devices should be used to minimizecomplications and maintain device patency.9 (III)

E. Documentation in the patient’s permanent med-ical record should include the application of thejoint stabilization device and the periodic removalfor assessment of circulatory status, range ofmotion, and skin integrity.1-4,10 (V)

REFERENCES



3. Fabian B. Infusion therapy in the older adult. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:571-582.


5. Lyder CH, Ayello EA. Pressure ulcers: a patient safety issue. In:Hughes RG, ed. Patient Safety & Quality: An Evidence-BasedHandbook for Nurses. Rockville, MD: Agency for HealthResearch & Quality (AHRQ): 1-33. http://www.ahrq.gov/qual/nurseshdbk/docs/LyderC_PUPSI.pdf. Published 2008. AccessedJanuary 15, 2010.

6. Defloor T. The risk of pressure sores: a conceptual scheme. J ClinNurs. 1999;8(2):206-216.

7. Wound, Ostomy and Continence Nurses Society. Guidelines forPrevention and Management of Pressure Ulcers. Mt. Laurel, NJ:WOCN; 2003.

8. Mathison CJ. Skin and wound care challenges in the hospitalized mor-bidly obese patient. J Wound Ostomy Continence Nurs. 2003;30(2):78-83.

9. Tripathi S, Kaushik V, Singh V. Peripheral IVs: factors affectingcomplications and patency: randomized controlled trial. J InfusNurs. 2008;31(3):182-188.

10. Phillips LD. Manual of I.V. Therapeutics: Evidence-Based Practicefor Infusion Therapy. 5th ed. Philadelphia, PA: FA Davis; 2010:337.

38. SITE PROTECTION

Standard

38.1 The use of site protection and/or physical immobi-lization devices, proper application, and patient moni-toring shall be established in organizational policies,procedures, and/or practice guidelines.38.2 The nurse shall be competent in the application, use,and removal of a site protection or immobilization device.38.3 The use of physical immobilization devices (ie,restraints) to protect the vascular access device (VAD)site shall not be routinely implemented and shall beavoided whenever possible.

Practice Criteria

A. Site protection methods such as mittens are recom-mended for patient populations such as pediatric,elderly, those with cognitive limitations, or when-ever there is risk of accidental dislodgment. Clearplastic site protectors specifically designed for thispurpose are used to prevent accidental dislodg-ment or vein damage in children.1,2 (V)

B. The site protection method selected should be basedon a comprehensive assessment of the patient’sphysical, behavioral, and psychological status.3-9

(III) C. Immobilization devices or site protection methods

should be used in a manner that will preserve cir-culation and provide visualization of the vascularaccess site and in accordance with manufacturers’directions for use. The selected immobilizationdevice or site protection method should not inter-fere with the prescribed infusion rate, deliverymethod, ability to assess the vascular access site, orcatheter stabilization/securement.9,10 (V)

D. The physical immobilization device should beremoved at established intervals to allow assess-ment of the extremity’s circulatory status andprovide an opportunity for supervised range-of-motion activities.3-5,9 (V, Regulatory)

E. The immobilization device should be removedas soon as the patient’s condition allows.2-7,9-11

(V, Regulatory)F. The nurse should educate the patient, caregiver, or

legally authorized representative on the need forand appropriate use of patient-protective meth-ods, including physical immobilization devices.11

(IV)G. Documentation should include, but not be limited

to, the rationale for the immobilization device;type and location of the immobilization device;release and reapplication of the device; site andcirculatory assessment; any complications causedby the immobilization device; patient’s response to



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the immobilization device; reassessment of needfor the immobilization device; patient education;and removal of the device.3-7,10 (V, Regulatory)

REFERENCES

1. Frey AM, Pettit J. Infusion therapy in children. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionTherapy: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010;550-570.

2. Mion LC. Physical restraint in critical care settings: will they goaway? Geriatr Nurs. 2008;29(6):421-423.

3. Centers for Medicare & Medicaid Services. Conditions of partic-ipation (CoP) and conditions for coverage (CfCs): hospital COPsfor patients’ rights. http://www.cms.hhs.gov/CfCsAndCoPs/02_Spotlight.asp#TopofPage. Accessed August 25, 2009.

4. Centers for Medicare & Medicaid Services. Medicare andMedicaid Program. Hospital conditions of participation: patients’rights, final rule. Fed Regist. 2006;71(236):71378-71428.Codified at 42 CFR Part 482. http://www.cms.hhs.gov/CFCsAndCOPs/downloads/finalpatientrightsrule.pdf. Published December8, 2006. Accessed February 12, 2010.

5. Joint Commission on Accreditation of Healthcare Organizations.Restraints and seclusion in hospitals: acute medical/surgical care restraintstandards PC.03.02.01-PC.03.02.11. http://www.jointcommission.org/AccreditationPrograms/BehavioralHealthCare/Standards/09_FAQS/PC/Restraint!_Seclusion.htm. Published December 29, 2009.Accessed March 10, 2010.

6. Joint Commission on Accreditation of Healthcare Organizations.Standards for Behavioral Healthcare. Oak Brook, IL. Joint CommissionResources; 2009.

7. Sparks L, Setlick J, Luhman J. Parental holding and positioningto decrease IV distress in young children: a randomized controlledtrial. J Pediatr Nurs. 2007;22(6):440-447.

8. Antonelli MT. Restraint management: moving from outcome toprocess. J Nurs Care Quality. 2008;23(3):227-232.

9. Phillips LD. Manual of I.V. Therapeutics: Evidence-Based Practicefor Infusion Therapy. 5th ed. Philadelphia, PA: FA Davis; 2010:337.

10. Nadler-Moodie M. Clinical practice guideline: 1-hour face-to-faceassessment of a patient in a mechanical restraint. J Psychosoc Nurs.2009;47(6):37-43.

11. Martin A, Krieg H, Esposito F, Stubbe D, Cardona L. Reductionof restraint and seclusion through collaborative problem solving:a five-year prospective inpatient study. Psychiatr Serv. 2008;59(12):1406-1412.



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tion, palpation of the port should not be the onlyidentification method used.1,2 (V)

B. The nurse should be aware of the potential forcatheter rupture, which can lead to extravasation,catheter fragment emboli, and the need for portremoval and replacement. The most common riskfactors include pinch-off syndrome and powerinjection through ports not approved for this pur-pose (see Standard 51, Catheter Embolism).1-6 (V)

C. Aseptic technique, including the use of sterilegloves, should be used when accessing animplanted port. The use of a mask during accessis often recommended; however, it remains anunresolved issue due to lack of research.7-9(V)

D. The implanted vascular access port should beaccessed with the smallest-gauge noncoring nee-dle to accommodate the prescribed therapy. Toreduce risk of needle dislodgment during access,the noncoring needle should be of a length thatallows the needle to sit flush to the skin andsecurely within the port.8 (V)

E. Prior to use of the implanted vascular access portfor infusion, patency should be confirmed; thisshould include presence of a blood return andability to flush the port with preservative-free0.9% sodium chloride (USP) without evidence ofinfiltration (see Standard 48, Infiltration andExtravasation).8 (V)

F. When using an implanted vascular access port forcontinuous infusions, there is insufficient evidenceto support the optimal time for replacement of thenoncoring needle; the most common practice is toreplace the needle every 7 days.7,8 (V)

G. When an implanted vascular access port isaccessed, a transparent semipermeable membrane(TSM) dressing or gauze dressing should coverthe needle and access site. If gauze is used to sup-port the wings of an access needle and it does notobscure the needle insertion site under a TSMdressing, it can be considered a TSM dressing andchanged every 7 days (see Standard 46, VascularAccess Device Site Care and Dressing Changes).8(V)

39. IMPLANTED VASCULARACCESS PORTS

Standard

39.1 Placement and removal of an implanted vascularaccess port shall be considered surgical procedures andmust be performed by a licensed independent practi-tioner (LIP) with validated competency operating with-in the state’s rules and regulations for professional prac-tice and according to organizational policies, proce-dures, and/or practice guidelines.39.2 The nurse shall be competent in implanted vascu-lar access port use and maintenance, including portaccess, identification of potential complications, andappropriate nursing interventions, including patient andcaregiver education and according to organizationalpolicies, procedures, and/or practice guidelines.39.3 Noncoring safety needles shall be used to accessan implanted vascular access port.39.4 Only implanted vascular access ports and noncor-ing needles designed for power injection shall be usedwith power-injection equipment for radiologic imagingin accordance with manufacturers’ directions for use.39.5 A sterile transparent semipermeable membrane(TSM) dressing or gauze dressing shall be maintainedover the access site if the implanted vascular access portremains accessed.

Practice Criteria

A. When planning to use an implanted vascularaccess port for power injection, power-injectioncapability should be identified at the time ofaccess and immediately prior to power injection.At least 2 identification methods should be used,including presence of identification cards, wrist-bands, or key chains provided by the manufactur-er; review of operative procedure documentation;and palpation of the port. While some power-injection-capable implanted vascular access portshave unique characteristics identifiable by palpa-

Access Devices


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H. The use of positive pressure during noncoring needlewithdrawal should be used to reduce blood refluxand risk of thrombotic catheter occlusion.10,11 (V)

I. General patient and/or caregiver education shouldinclude placement procedure; type of port placed(eg, power injectable, number of lumens); impor-tance of carrying port identification card (eg, in wal-let); routine care, including frequency of flushing;expectations of aseptic technique during access; useof only noncoring needles (including appropriatetype for power injection); and identification ofpotential complications and interventions.1,12 (V)

J. For patients who are receiving infusions at home viaan accessed port, patient and/or caregiver educationshould include checking the dressing daily; how todress and undress to avoid pulling at the needle site;protecting the site during bathing; making surewomen’s bra straps do not rub over the accessedarea; immediately reporting any signs or symptomsof pain, burning, stinging, or soreness at the site;and recognizing the importance of stopping the infu-sion pump and immediately reporting any wetness,leaking, or swelling noted at the site.9,13 (V)

REFERENCES

1. Smith LH. Implanted ports, computed tomography, power injec-tors, and catheter rupture. Clin J Oncol Nurs. 2008;12(5):809-812.

2. US Food and Drug Administration. Caution on CT power injec-tion MRI and CT contrast media. http://www.accessdata.fda.gov/psn/printer.cfm?id=462. Accessed May 17, 2010.

3. Dillon PA, Foglia RP. Complications associated with an implantablevascular access device. J Pediatr Surg. 2006;41(9):1582-1587.

4. Vandoni RE, Guerra A, Sanna P, et al. Randomised comparisonof complications from three different permanent central venousaccess systems. Swiss Med Wkly. 2009;139:313-316.

5. Lin CH, Wu HS, Chan DC, et al. The mechanisms of failure oftotally implantable central venous access system: analysis of 73cases with fracture of catheter. Eur J Surg Oncol. 2010;36(1):100-103.

6. Ho CL, Chou CM, Chang TK, et al. Dislodgment of port-a-cathcatheters in children. Pediatr Neonatol. 2008;49(5):179-182.

7. Karamanoglu A, Yumuk PF, Gumus M, et al. Port needles: dothey need to be removed as frequently in infusional chemotherapy?J Infus Nurs. 2003;26(4):239-242.

8. Gorski L, Perrucca R, Hunt M. Central venous access devices:care, maintenance, and potential complications. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:495-515.

9. Schulmeister L, Camp-Sorrell D. Chemotherapy extravasationfrom implanted ports. Oncol Nurs Forum. 2000;27(3):531-538.

10. Lapalu J, Losser MR, Albert O, et al. Totally implantable portmanagement: impact of positive pressure during needle with-drawal on catheter tip occlusion (an experimental study). JVascular Access. 2010;11(1):46-51.

11. Camp-Sorrell D. Access Device Guidelines: Recommendationsfor Nursing Practice and Education. 2nd ed. Pittsburgh, PA:Oncology Nursing Society; 2004.

12. Arch P. Port navigation: let the journey begin. Clin J Oncol Nurs.2007;11(4):485-488.

13. Gorski LA. Pocket Guide to Home Infusion Therapy. Sudbury,MA: Jones & Bartlett, 2005.

40. HEMODIALYSIS VASCULAR ACCESS DEVICES

Standard

40.1 Placement and removal of a tunneled or implantedhemodialysis vascular access device (VAD), including anarteriovenous (AV) fistula, and insertion of an arteriove-nous graft shall be considered surgical procedures and shallbe performed by a licensed independent practitioner (LIP)with validated competency operating within the state’srules and regulations for professional practice and accord-ing to organizational policies, procedures, and/or practiceguidelines.40.2 The nurse shall be competent in hemodialysisVAD use and maintenance, including device access,identification of potential complications, and appropri-ate nursing interventions, including patient and caregiv-er education, and according to organizational policies,procedures, and/or practice guidelines.40.3 Administration of medications and solutionsthrough a hemodialysis VAD, including AV fistulas orgrafts, shall be upon the order of a licensed independentpractitioner (LIP).40.4 Removal of a temporary nontunneled or nonim-planted hemodialysis VAD shall be performed by thenurse with validated competency, in accordance withrules and regulations promulgated by the state’s Boardof Nursing and organizational policies, procedures,and/or practice guidelines.40.5 Hemodynamic monitoring and venipuncture shallnot be performed on the extremity containing an AVfistula or graft.

Practice Criteria

A. The decision to place a hemodialysis VAD or createa means of long-term vascular access for the pur-pose of hemodialysis is ideally made collaborative-ly between the nurse, physician responsible for care,and the patient/caregiver. General order for vascu-lar access preference is fistula, arteriovenous graft,and long-term VAD.1-4 (V)

B. The nurse should be knowledgeable about vein-preservation techniques for patients who are like-ly to need vascular access for hemodialysis.1,3,5 (V)

C. The nurse should wear sterile gloves and maskwhen performing dressing changes for hemodial-ysis VADs, including AV fistulas and grafts.3,6

(V)



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D. Povidone-iodine antiseptic ointment or bacitracin/neomycin/polymyxin B ointment can be used for theexit site of a hemodialysis VAD at the end of eachdialysis session only if this ointment does not interactwith the material of the hemodialysis catheter permanufacturer’s directions for use.7 (V)

E. To minimize the potential for catheter-relatedcomplications, consideration should be given tothe size and length of the hemodialysis VAD.3 (V)

F. Hemodialysis VADs should have their tips locat-ed in the superior vena cava or right atrium andconfirmed by chest radiograph or fluoroscopy.Right atrial thrombosis is a serious complicationwith VADs placed in the right atrium.3 (V)

REFERENCES

1. American Nephrology Nurses’ Association [position statement].Vascular access for hemodialysis. http://www.nncc-exam.org/cgi-bin/WebObjects/ANNANurse.woa/wa/viewSection?s_id!

1073744052&ss_id!536873322&tName!vascAccess. AdoptedFebruary 2003. Revised February 2009. Accessed March 2, 2010.

2. Sidawy A, Spergel L, Besarab A, et al. The Society for VascularSurgery: clinical practice guidelines for the surgical placement andmaintenance of arteriovenous hemodialysis access. J Vasc Surg. 2008;48:2S-25S.

3. National Kidney Foundation. KDOQI Clinical Practice Guidelines.Selection and placement of hemodialysis access.NKF;2006.

4. Chan M, Sanchez R, Young H, Yevzlin A. Vascular access out-comes in the elderly hemodialysis population: a USRDS study.Semin Dial. 2007;20(6):606-610.

5. McCann M, Einarsdottir H, Van Waeleghem JP, Murphy F,Sedgewick J. Vascular access management 1: an overview. J RenalCare. 2008;32(2):77-84.

6. Burrows-Hudson S, Prowant Barbara, eds. Standards of Practiceand Guidelines for Care. Pitman, NJ: American NephrologyNurses’ Association; 2005.

7. National Kidney Foundation. KDOQI Guidelines. 15: Cathetercare and accessing the patient’s circulation.NKF: 2000.

41. UMBILICAL CATHETERS

Standard

41.1 Placement and removal of an umbilical arterial orvenous catheter shall be considered a surgical procedureand must be performed by a licensed independent prac-titioner (LIP) with validated competency, operatingwithin the state’s rules and regulations for professionalpractice and according to organizational policies, proce-dures, and/or practice guidelines.41.2 The nurse shall be competent in umbilical catheteruse and maintenance, including catheter access, identifi-cation of potential complications, and appropriate nurs-ing interventions, including patient and caregiver educa-tion according to organizational policies, procedures,and/or practice guidelines.

41.3 Tincture of iodine shall not be used to cleanse theumbilical catheter site because of the potential deleteri-ous effect on the neonatal thyroid.41.4 Catheter tip location shall be radiologically con-firmed before catheter use and documented in thepatient’s permanent medical record.

Practice Criteria

A. Prior to insertion, the umbilical catheter siteshould be cleansed with an appropriate antisepticsolution such as povidone-iodine.1-3 (V)

B. Umbilical artery catheters should be placed sothat the tip is located in the descending aortaabove the level of the diaphragm and below theleft subclavian artery (high positioned catheter).1-

4 (V)C. Umbilical venous catheters should be placed so

that the tip is located in the inferior vena cava,above the level of the diaphragm.1-5 (V)

D. Removal of the catheter should be performedaseptically and slowly over several minutes, andfollowed by manual compression with sterilegauze applied to the umbilical stump until hemo-stasis occurs.1-5 (V)

E. The site should be monitored after catheterremoval for at least 12 hours, and then daily forsigns of complication development.1-5 (V)

F. Infusion of medications into the umbilical arterialcatheter should be avoided.1-6 (V)

G. The nurse should be knowledgeable of the signs,symptoms, and management of potential compli-cations related to the use of umbilical cathetersincluding, but not limited to, bleeding from theumbilical stump, hemorrhage, air embolism, infec-tion, thrombosis, vascular perforation, and periph-eral vascular constriction. The nurse should reportcomplications to the LIP and document them in thepatient’s permanent medical record.1-6 (V)

REFERENCES

1. Barrington KJ. Umbilical artery catheters in the newborn: effectsof position of the catheter tip (Cochrane Review). In: TheCochrane Library.(3);2004. Chichester, UK: John Wiley & Sons.


3. Smith L, Dills R. Survey of medication administration throughumbilical arterial and venous catheters. Am J Health-Syst Pharm.2003;60(15):1569-1572.

4. Jackson J, Biondo D, Jones J, et al. Can an alternative umbilicalarterial catheter solution and flush regimen decrease iatrogenichemolysis while enhancing nutrition? A double-blind, randomizedclinical trial comparing an isotonic amino acid with a hypotonicsalt infusion. Pediatrics. 2004;114;377-383.

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5. Shah P, Shah V. Continuous heparin infusion to prevent throm-bosis and catheter occlusion in neonates with peripherally placedpercutaneous central venous catheters Cochrane Database SystRev. 2005;(3):CD002772.

6. Shah PS, Ng E, Sinha AK. Heparin for prolonging peripheralintravenous catheter use in neonates (Cochrane Review) In: TheCochrane Library. (2);2004. Chichester, UK: John Wiley & Sons.

42. APHERESIS AND ULTRAFILTRATIONCATHETERS

Standard

42.1 Placement and removal of apheresis or ultrafiltra-tion catheters shall be performed by a nurse or licensedindependent practitioner (LIP) with validated compe-tency operating within the state’s rules and regulationsfor professional practice and according to organization-al policies, procedures, and/or practice guidelines.42.2 Indications and protocols for the insertion of orassisting with, use, and care of apheresis or ultrafiltra-tion catheters shall be established in organizational poli-cies, procedures, and/or practice guidelines.42.3 The nurse shall be competent in apheresis andultrafiltration catheter use and maintenance, includingidentification of potential complications, and appropriateinterventions, including patient and caregiver education.42.4 Apheresis or ultrafiltration catheters shall not beused for medication or solution administration.

Practice Criteria

A. A large-bore central catheter, percutaneously orsurgically placed, designed to maintain high flowrates and accommodate large blood volumesshould be selected and inserted in patients withinadequate peripheral vein access (adult or pedi-atric) for the purpose of apheresis.1-7 (IV)

B. If using a peripheral approach for apheresis, 2large-gauge intravenous catheters should beinserted for collection and reinfusion. A multilu-men apheresis central catheter should allow forrepeated apheresis procedures and provide a mul-tipurpose approach to accommodate long-terminfusion needs and supportive care.4,6,8 (IV)

C. The tip of the apheresis central catheter, if placedin the subclavian or internal jugular vein, shouldreside at the junction of the superior vena cavaand right atrium.8-15 (V)

D. Ultrafiltration is used to remove excess salt andwater in patients with fluid overload, particularlyin patients with congestive heart failure in whichconventional treatments have not been effective.This process typically uses a dual-lumen vascularaccess device.16-18 (V)

E. The nurse should be knowledgeable of potentialcomplications of apheresis/ultrafiltration cathetersand the apheresis/ultrafiltration process, alongwith appropriate nursing interventions. Potentialcomplications include, but are not limited to, cen-tral vascular access device (CVAD) mechanicaldysfunction; thrombosis; infection; hypotension;electrolyte imbalance; fluid overload; thrombocy-topenia; hypocalcemia; photosensitivity, and cit-rate toxicity.1-5,12,14,15 (IV)

F. The nurse should provide the patient and caregivereducation related to apheresis/ultrafiltration catheterinsertion procedure; reason for the CVAD; use,maintenance, and care; expected dwell time of thecatheter; potential insertion; mechanical or infectiouscomplications; and document teaching in thepatient’s permanent medical record.1-3 (V)

REFERENCES

1. Leighton S. The spin on apheresis. Nursing. 2008;38(4):29-31.2. Lopez J, Hausz M. Therapeutic apheresis. Am J Nurs. 1982;82(10):

1572-1578.3. Meehan K, Areman E, Ericson S, et al. Mobilization, collection

and processing of autologous peripheral blood stem cells: devel-opment of a clinical process with associated costs. J HematotherapyStem Cell Res. 2000;9:767-771.

4. Madero L, Diaz MA, Benito A, Villa M, Valdivielso A. Non-tunneledcatheters for the collection and transplantation of peripheral bloodstem cells in children. Bone Marrow Transplant. 1997;20(1):53-59.

5. Fontana S, Groebli R, Leibundgut K, et al. Progenitor cell recruit-ment during individualized high-flow, very large-volume aphere-sis for autologous transplantation improves cell efficiency.Transfusion. 2006;46(8):1408-1416.

6. Lazarus HM, Trehan S, Miller R, Fox RM, Creger RF, Raaf JH.Multi-purpose silastic dual-lumen central venous catheters forboth collection and transplantation of hematopoietic progenitorcells. Bone Marrow Transplant. 2000;25(7):779-785.

7. Hadaway L. Infusion therapy equipment. In: Alexander M, CorriganA, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: AnEvidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:391-436.

8. Restrepo A, Devore P, Encarnacion CE, et al. Performance of ahybrid central venous catheter utilized for both progenitor bloodstem cell harvest and transplant support of patients undergoingautologous peripheral blood stem cell transplantation. BoneMarrow Transplant. 2002;30(6):389-395.

9. Kapustay P. Blood cell transplantation: concepts and concerns.Semin Oncol Nurs. 1997;13(3):151-163.

10. Mareiras-Plaza M, Albo C, Ares C. Efficacy and safety of femoralvascular access for peripheral blood stem cell (PBSC) collection.Bone Marrow Transplant. 2004;33(3):347-350.

11. Canuad B. Long-term catheters for dialysis and apheresis: a dou-ble-edged weapon. Ther Apheresis Dial. 2003;7(2):147-149.

12. Stephens LC, Haire WD, Tarantolo S, et al. Normal saline versusheparin flush for maintaining central venous catheter patencyduring apheresis collection of peripheral blood stem cells (PBSC).Transfus Sci.1997;18(2):187-193.

13. Meisenberg B, Callaghan M, Sloan C, et al. Complications associat-ed with central venous catheters used for the collection of peripheral



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blood progenitor cells to support high-dose chemotherapy andautologous stem cell rescue. Support Care Cancer. 1997;5:223-227.

14. Young E, Contreras G, Robert N, Vogt N, Courtney T. Incidenceand influencing factors associated with exit site infections in tem-porary catheters for hemodialysis and apheresis. Nephrol Nurs J.2005;32(1):41-62.

15. Saif MW, Leitman SF, Cusack G, et al. Thromboembolism fol-lowing removal of femoral venous apheresis catheters in patientswith breast cancer. Ann Oncol. 2004;15:1366-1372.

16. Hunt SA, Abraham WT, Chin M, et al. 2009 focused update:ACCF/AHA guidelines for the diagnosis and management of heartfailure in adults. J Am Coll Cardiol. 2009;53(15):1343-1382.

17. Walsh CT, Wagemester D. Peripheral ultrafiltration for patientswith volume overload: a center’s 4-year experience. Crit Care NursQ. 2007;30:329-336.

18. Andrade JG, Stadnick E, Virani SA. The role of peripheral ultra-filtration in the management of acute decompensated heart fail-ure. Blood Purif. 2010;29:177-182.

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