Right Assessment and Vein Selection
Right assessment and selection of the best vein and location is the first stage of the vascular access cycle within quadrant 1 of VHP. This stage begins at the time of admission and continues as diagnosis is established and treatment initiated. Most patients receive their first intravenous device during the assessment in the emergency department, typically a PIVC is inserted in a hurried fashion, and location and method of insertion are often not optimal. Once the patient has stabilized, consideration can be given to the most appropriate vascular access device, one that will provide the administration of the prescribed therapy. Assessments of patient history, comorbidities, contraindications, available veins, diagnosis, and duration of therapy are factors that determine level of risk, the appropriate device, and most qualified inserter. Individuals with ultrasound training can apply their skills for assessment and selection of the right location and vein for device insertion.
KeywordsAssessment Patient assessment Vein assessment Ultrasound assessment Vein characteristics RAPEVA RACEVA
Within the first 48 h of admission to an acute care facility, a patient receives a diagnosis, PIVC placement, and initiation of treatment (Santolucito 2001). Since most PIVCs fail within the first 48 h, the optimal window for patient vein assessment and device selection is within this time frame (Hallam et al. 2016; Jackson et al. 2013). A patient-centered approach is focused on the vascular assessment of the patient, recent and past history with access, critical or chronic nature of their illness, comorbidities that may affect the risk of infection or other complications, types of medications to be administered, duration of treatment, future needs, specific access needs, and risk assessment of all factors, followed by vein and device choice (Hallam et al. 2016; Jackson et al. 2013; Moureau 2017).
2.2 Patient and Vein Assessment
Gaining a patient history and clinical assessment assists in determining device selection. Clinical histories such as past surgery, comorbid conditions, hematological or oncological history, as well as past vascular access-related complications that include difficult venous access or thrombosis are important factors that influence device choice (Sou et al. 2017; Woller et al. 2016). Physical assessment of the patient should include neurological, cardiovascular, respiratory, and gastrointestinal assessment. The assessment of coagulation profile, electrolyte, and full blood count review informs the inserter of areas of potential risk (Lonsway 2010).
Assessment for either peripheral or central access is enhanced with the use of ultrasound (Moureau 2014; Sharp et al. 2015a, b). Determination of the need for central venous access device (CVAD) requires a risk benefit assessment to avoid unnecessary placement of these higher risk devices (Chopra et al. 2015). Risk ratios with CVADs are higher than with peripheral devices both with insertion and post insertion-related complications (Maki et al. 2006; Mcgee and Gould 2003; Sou et al. 2017). The goal with assessment and selection is to choose the lowest risk VAD, which will complete the prescribed treatment plan while minimizing both insertion and post insertion-related complications (Chopra et al. 2013, 2015). The vessel health and preservation model incorporates a planned vascular access assessment that evaluates the patient factors correlated with the treatment plan to select the most suitable device and inserter (Hallam et al. 2016; Hanchett and Poole 2001; Moureau et al. 2012; Rotter et al. 2010).
2.3 Vessel Assessment
Clinical evaluation of the blood vessels and the pathway determines anatomical placement and ultimately the most appropriate device. Evaluation through observation and palpation of vessels or visualization with ultrasound can facilitate successful insertion and longer dwell times (De La Torre-Montero et al. 2014). Vessels that are tortuous in nature, have bifurcations, or thrombosis make placement of the device difficult and should be avoided (Moureau 2014). Approaches developed by the Italian Group for Venous Access Devices (GAVeCeLT) that include the Rapid Assessment of the Central Veins (RaCeVA) and the Rapid Assessment of the Peripheral Veins (RaPeVA) are protocols that can be used to thoroughly evaluate vessels and surrounding structures (Pittiruti 2012).
Thorough ultrasound assessment for vein selection reduces insertion-related complications (Flood and Bodenham 2013; Pirotte 2008). When urgency of placement is not necessary, time taken with selection of a location for cannula insertion in a stable area, away from joints and movement, results in lower rates of failure (Marsh et al. 2017). Vein selection for PIVC placement must be balanced with consideration for speed versus longer dwell time and reduced complications. Placement of a device in the hand or antecubital fossa is initially easier in most respects due to identification of veins visually and through palpation; however, these devices become dislodged, are uncomfortable for patients, and often fail in less than 72 h (Alexandrou et al. 2018). Vein selection with CVAD is dictated by insertion risk related to site, vein size, depth, and surrounding structures that may impact risk of complications (i.e., nerves, lymphatic tissue, artery) (Moureau 2017).
2.4 Ultrasound Assessment of the Patient
Ultrasound for vascular access site selection is used to identify and map structures within the arm, chest, neck, and leg that may be most suitable for device insertion and treatment. Ultrasound is used widely for central venous access, PICCs, midlines, and in more recent times for PIVCs too. The patient safety benefits of using ultrasound are undisputed (Bodenham et al. 2016; Gorski et al. 2016; Lamperti et al. 2012; Loveday et al. 2014). Gorski et al., in INS Standards (2016), recommend using visualization technologies like infrared or ultrasound to increase insertion success for patients with difficult access.
With ultrasound imaging and the use of a conductive medium, such as gel, the probe or transducer transmits sound waves that are interpreted on a viewing screen. Scanning for peripheral veins and structures within the arms begins at the level of the forearm working toward the body. Optimal peripheral cannula site selection is one that allows ultrasound-guided needle access in a vein 2–4 mm in diameter or larger and 0.3–1.5 cm in depth (Witting et al. 2010).
It is essential to assess the veins with ultrasound prior to the procedure to select the vein with optimal characteristics including the size, depth, and pathway with minimal risk to arterial/nerve injury, check the vein for patency, ensure thrombosis is not present, and identify any anatomical variations. Ultrasound assessment is undertaken without using a tourniquet to assess the vein in its normal state. Assess the depth, patency, and respiratory collapse; for instance, a critically ill patient may present in a cardiovascular hyperdynamic state with the artery pounding and encroaching the vein, which may itself be collapsing with each respiratory cycle. Application of assessment methods, such as RACEVA and RAPEVA, covered later in this chapter, guides the inserter to select the best vein and identifies any venous abnormalities prior to insertion (Pittiruti and Scoppettuolo 2017).
Anatomy is not exact, and variations exist. For example, the basilic veins are only present in the text book or traditional form of anatomy in 66%, as discovered in a study by Anaya-Ayala et al. (2011), who mapped veins of 290 patients including 426 arms (221 right, 205 left arm). From the mapped veins, the authors identified that the basilic vein joins the axillary vein around the same area that the brachial veins do. In the remaining 34% of patients, either the basilic joins the paired brachial veins in the mid to lower arm or the basilic joins an unpaired brachial in the mid to lower section of the arm (Anaya-Ayala et al. 2011).
Shape: Observe for irregularities in lumen size and vessel wall thickness. These types of abnormalities are usually best visualized in the sagittal plane.
Size: Measure basilic, brachial, and cephalic vein diameter in their native state without a tourniquet. Vein size determines suitability of desired catheter size and number of lumens (i.e., caliber of peripheral vein must at least equal diameter of midline or PICC in French size). Diameter may be measured in the transverse or sagittal plane. The occupation of more than one third of the diameter of a blood vessel with a catheter reduces blood flow within the region and increase thrombosis risk. Generally, the scale in Fig. 2.1 provides a guide for determining the most appropriate catheter for vein size (Sharp et al. 2015a, b, 2016).
Path: Note any aberrancy along the course of the vessel (tortuosity), areas of dilation, or stenosis. Also observe for symmetry of the vessel wall looking for irregularities rather than the normal round vessel shape. Uniformity of the path and vein wall is viewed specifically in sagittal, longitudinal view providing a more detailed view of vein path or vein wall abnormalities.
Patency: Compress veins. Look for echogenic material within non-compressible veins that may indicate thrombosis or other structures such as nerves or arteries (use pulse wave Doppler if indicated). Look for collaterals around areas of non-compressible or retracted veins.
Flow: Observe arterial and venous flow. Flow in the arterial system pulsatile and rhythmical if the patient has normal heart function. Flow in the venous system is typically slower without pulsatility. It is important to note that the “red” and “blue” colors typically used do not demonstrate arterial or venous flow but rather movement toward and away from the probe.
Pre-insertion Ultrasound Assessment of the Central and Peripheral Veins (RACEVA & RAPEVA (Emoli et al. 2014; Pittiruti 2012; Pittiruti and Scoppettuolo 2017)): Pre-insertion scanning of the major blood vessels prior to catheter insertion and mapping pathway of the catheter improves success rates and minimize complications. The RACEVA protocol is a six-step assessment of the major central vessels and important associated structures.
2.5 Rapid Vein Assessment RAPEVA and RACEVA Protocols (Pittiruti and Scoppettuolo 2017)
Rapid assessment peripheral vein assessment (RAPEVA) and rapid assessment central vein assessment (RACEVA) are performed with ultrasound to determine the most appropriate location for catheter insertion. Scanning of the peripheral vasculature includes visualization by starting at the antecubital region of the arm, moving up medially, and toward the chest. More information on ultrasound scanning and the RAPEVA methods are found in the references (Pittiruti 2012).
2.5.1 RAPEVA Position 1
2.5.2 RAPEVA Position 2
2.5.3 RAPEVA Position 3
2.5.4 RAPEVA Position 4
2.5.5 RAPEVA Position 5
2.5.6 RAPEVA Position 6
2.5.7 RAPEVA Position 7
2.6 RACEVA Rapid Central Vein Assessment
The RACEVA protocol uses ultrasound for thorough assessment of vascular structures in terms of size, patency and overal vialbility for catheterization. It also provides information on overall anatomy of the area do reduce inadvertant puncture of surrounding anatomic structures (Spencer and Pittiruti 2018). More information on ultrasound scanning and the RACEVA and RAPEVA methods are found in the references (Pittiruti 2012).
2.6.1 RACEVA Position 1
2.6.2 RACEVA Position 3
2.6.3 RACEVA Position 4
2.6.4 RACEVA Position 5
2.6.5 RACEVA Position 6
Position 6—Again visualizing the axillary vein and artery in the deltopectoral or a subclavicular fossa area, view the vessels in a longitudinal perspective. Probe position should be perpendicular to the pectoral groove in long access, below the clavicle (lateral third of the clavicle).
2.6.6 RACEVA Position 7
2.6.7 RACEVA Position 8
A 45-year-old male entered the emergency room with elevated temperature, severe fatigue, weakness, shortness of breath, sleeping problems, some nausea, poor appetite, frequent small quantity urination, dry skin and poor turgor, and swelling to the legs and ankles with some muscle cramping. Laboratory blood work confirms a high creatinine level and a glomerular filtration rate (GFR) of 35 indicating moderate renal dysfunction. The issues noted with this patient include the need for dialysis, cautious fluid replacement for dehydration, and further testing to rule out sepsis. The emergency physician is trained in the RACEVA protocol and evaluates vein options, and configuration knowing the best choice for this patient is an internal jugular placement for the dialysis catheter. After numerous failed attempts at peripheral access, consideration was given to placement of a second axillary central catheter for fluids and antibiotic infusions. Prior to catheter placement, it was discovered that a tri-lumen dialysis catheter was available that included an extra lumen for the intravenous medications. The tri-lumen catheter was placed successfully in the right internal jugular vein under ultrasound guidance, the first infusion of antibiotics given, baseline central venous pressure and oxygen levels obtained, and the patient sent to dialysis for first treatment.
Summary of Key Points
The Vessel Health and Preservation process is designed to select the vein, location, and device that has lowest risk, preserves veins, and is most reliable for the treatment.
CVAD selection is optimal when individualized for the patient based on treatment plan, medication types, duration, and patient-specific factors.
Patients are the focus of VHP with individualized assessment, selection, and placement that reduces unnecessary trauma and VAD-related complications.
The use of visualization technology aids in assessment, vein selection, and insertion.
- Alexandrou E, Ray-Barruel G, Carr PJ, Frost S, Inwood S, Higgins N, et al. Use of short peripheral intravenous catheters: characteristics, management, and outcomes worldwide. J Hosp Med. 2018;13 https://doi.org/10.12788/jhm.3039.
- Chopra V, Flanders SA, Saint S, Woller SC, O’Grady NP, Safdar N, Trerotola SO, Saran R, Moureau N, Wiseman S, Pittiruti M, Akl EA, Lee AY, Courey A, Swaminathan L, Ledonne J, Becker C, Krein SL, Bernstein SJ, Michigan Appropriateness Guide for Intravenous Catheters Panel. The Michigan appropriateness guide for intravenous catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;163:S1–40.CrossRefGoogle Scholar
- De La Torre-Montero J-C, Montealegre-Sanz M, Faraldo-Cabana A, Oliva-Pellicer B, Garcia-Real I, Fenwick M, Marcos CE, Rivas-Eguia B, Vila-Borrajo C, Valles-Andres J. Venous International Assessment, VIA scale, validated classification procedure for the peripheral venous system. J Vasc Access. 2014;15:45–50.CrossRefGoogle Scholar
- Emoli A, Cappuccio S, Marche B, Musaro A, Scoppettuolo G, Pittiruti M. [The ISP (Safe Insertion of PICCs) protocol: a bundle of 8 recommendations to minimize the complications related to the peripherally inserted central venous catheters (PICC)]. Assist Inferm Ric. 2014;33:82–9.Google Scholar
- Gorski L, Hadaway L, Hagle M, Mcgoldrick M, Orr M, Doellman D. Infusion therapy: standards of practice. J Infus Nurs. 2016;39(Suppl 1):S1–S159.Google Scholar
- Lonsway RA. Patient assessment as related to fluid and electrolyte balance. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, editors. Infusion nursing: an evidenced based approach. 3rd ed. St Louis: Saunders Elsevier; 2010.Google Scholar
- Marsh N, Webster J, Larson E, Cooke M, Mihala G, Rickard C. Observational study of peripheral intravenous catheter outcomes in adult hospitalized patients: a multivariable analysis of peripheral intravenous catheter failure. J Hosp Med. 2017;13(2), 83-89.Google Scholar
- Moureau NL. Ultrasound anatomy of peripheral veins and ultrasound-guided venipuncture. In: Peripherally inserted central venous catheters. Milan: Springer; 2014.Google Scholar
- Moureau NL. Vessel health and preservation: vascular access assessment, selection, insertion, management, evaluation and clinical education. Doctor of Philosophy by Publication (PhD) Thesis and Exegesis (PhD Doctorate), Griffith University; 2017.Google Scholar
- Moureau N, King K. Advanced ultrasound assessment for venous access clinical education program and DVD. 2007.Google Scholar
- Moureau N, Trick N, Nifong T, Perry C, Kelley C, Carrico R, Leavitt M, Gordon S, Wallace J, Harvill M, Biggar C, Doll M, Papke L, Benton L, Phelan D. Vessel health and preservation (Part 1): a new evidence-based approach to vascular access selection and management. J Vasc Access. 2012;13:351–6.CrossRefGoogle Scholar
- Pittiruti M. RaCeVA: a guide for a rational choice of the most appropriate vein for central venous catheterization. Association for Vascular Access 26th Annual Scientific Meeting. San Antonio; 2012.Google Scholar
- Pittiruti M, Scoppettuolo G. GAVeCeLT manual of PICC and midline—indications, insertion, management. Edra S.P.A.; 2017.Google Scholar
- Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, Snow P, Kugler J. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010;CD006632.Google Scholar
- Spencer TR, Pittiruti M. Rapid Central Vein Assessment (RaCeVA): a systematic, standardized approach for ultrasound assessment before central venous catheterization. J Vasc Access. 2018;1129729818804718.Google Scholar
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