GUEST COLUMN
Usage is key in IV catheter selection, tip termination
A guide to making the proper choice
By Nancy Moureau, CRNI
President, PICC Excellence
Orange Park, FL
Early selection of the most appropriate IV catheter can lead to a safer, more efficient administration of IV therapy with the best possible outcome.
Catheter selection made early in the course of a patient’s IV therapy can lead to greater patient satisfaction, reduced overall nursing time for IV maintenance, fewer supplies, reduced risk of complications and a greater chance that the therapy will complete the prescribed length of treatment.
The positive aspects of early selection are overwhelming, in addition to the cost savings with enhanced efficiency. When the initial order for intravenous therapy is given while the patient is in the hospital, doctor’s office, or in the home care setting, the first thought is often to start a peripheral device. A peripheral catheter, while being the most common device, is not always the best choice for the therapy.
Information for the determination of IV c atheter use is available through the Intravenous Nurses Society (INS) Standards of Practice, the National Association of Vascular Access Network’s (NAVAN) "Tip Termination Position Paper," and to a lesser degree, the CDC’s Guideline for the Prevention of Intravascular Device-related Infections. These documents aid the practitioner in deciding the best IV catheter to use for each patient situation. Each case is different and catheter selection is not easy. Factors that need to be considered for IV catheter selection include:
• type of medication to be used;
• osmolarity and pH of the solution to be infused;
• duration of therapy;
• diagnosis of the patient;
• secondary risk factors, chronic diseases, or problems that may affect the incidence of complications;
• patient preference, activities, job and lifestyle;
• financial resources to cover required therapies;
• future intravenous needs and long-term prognosis;
• current availability and status of peripheral veins;
• history of neurologic impairments, surgeries affecting the veins or lymphatic system, blood dyscrasias, thrombosis, or previous threading problems. (See chart, p. 45. The catheter choices are listed in the table with emphasis given on concerns, confirmation, deciding factors, and dwell-time for each device.)
Short peripheral catheters are chosen when therapy is not expected to exceed five days. When therapy will extend beyond five days, but not more than four weeks, a midline catheter is considered.
Short peripheral or midline catheters should not be considered if the osmolarity of a solution is greater than 500 mOsm, or has a pH less than five or greater than nine. Solutions with high osmolarity or a pH beyond 5-9 are considered irritants or vesicants based on the response of the tissue to the solution.
Irritants, vesicants, and lines
Other medications not governed by osmolarity or pH variations can also be considered irritants, such as nafcillin. Check with your pharmacist for the current list of irritants and vesicants.
Midclavicular lines are another option. Inserted through the antecubital fossa, terminating in the subclavian region, midclavicular lines are beginning to receive careful scrutiny following the connection between subclavian (suboptimal) placement and thrombosis occurrence.
Literature has indicated an incidence of thrombosis between 58% and 68% with suboptimal tip placement, defined as anything other than superior vena cava (SVC) placement. INS considers midclavicular line peripheral placement as carrying the same osmolarity, pH limitations as peripheral and midline catheters.
Midclavicular lines have been widely used in home care to avoid the costs and time of confirming by X-ray. NAVAN published "A Position Paper on Tip Location" in the summer 1988 issue of the JVAD (NAVAN can be reached by calling [888] 57-NAVAN).
In that issue, the NAVAN board recommended all catheters advanced into the chest should terminate in the lower one-third of the superior vena cava, close to the junction of the SVC and the right atrium. According to NAVAN, terminal tips should not advance into the right atrium. NAVAN is recommending the use of peripherally inserted central catheters (PICCs) with tip termination in the SVC, over midclavicular placement, as the safest option for IV therapy.
Timing is everything
PICC lines can be used for patients receiving IV therapy over periods greater than five days, but less than one year. PICC lines have been shown in numerous studies to be safe and cost effective. PICC lines can be used to administer any type of IV therapy and have much less risk with peripheral insertion. X-ray placement check is always required after insertion and prior to use.
The final choice for catheter placement are non-tunneled and tunneled catheters, with subclavians, Groshong chest lines, Hohn, Hickman, Broviac, and other dialysis catheters and subcutaneous ports.
All of these catheters, with the exception of the subclavian non-tunneled type, can be used for long-term therapy. Cost is frequently an issue with these lines. Patients requiring therapies exceeding three months, with estimated duration of years, benefit from tunneled or implanted catheters/ports.
Decision trees, algorithms, and other types of flow charts can be instituted to aid in the decision process for IV catheter selection. A pair of articles, one appearing in Nursing Clinics of North America and the other in Surgical Oncology Clinics of North America, list peripheral and central algorithms to enhance proper catheter selection.1,2
The most important factor in determining the best catheter for the patient is to consider the usage early in the therapy. If outcomes are the key, then usage-based catheter selection can help to identify the best means of administering IV therapy resulting in a win-win situation for the patient, the facility, and the medical team.
Nancy Moureau, CRNI, is the president of PICC Excellence, a PICC and IV education company. Call (888) 714-1951.for information about classes across the United States. PICC insertion videos are available for purchase, along with a PICC PACK quick reference guide, tourniquet, and educational manuals.
References
1. Ryder MA. Peripherally Inserted Central Venous Catheters. Nursing Clinics of North America 1993; 28:937-971.
2. Ryder MA. Peripheral Access Options. Surgical Oncology Clinics of North America 1995; 4:395-427.
Suggested reading
1. NAVAN Position Statement. JVAD Summer 1998; pp. 8-10. Call (888) 714-1951 for more information.
2. Intravenous Nurses Society. INS Revised Standards 1998; 21(suppl):No. 15.
3. Kearns PJ, Coleman S, Wehner JH. Complications of long arm catheters: A randomized trial of central vs. peripheral tip location. JPEN 1996; 20:20-24.
4. Prian GW, Way CWV. The long arm silastic catheter: A critical look at complications. JPEN 1978; 2:124-128.
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