I am working on updating our hospital policy on Infiltration and Extravasation. In reviewing frequency of assessing the line for patency I have come upon the INS Position Paper on Peripheral Iv Assessments.
It looks very achievable/doable until I read the part about assessing the peripheral line with an intermittent infusion of a vesicant every 5-10 minutes. So.....if we have a Vanco , K+, Phenergan etc....piggyback going this is what they recommend , am I reading that right?? below is the statement I am referring to;
d. More frequently: every 5 to 10 minutes
- Patients receiving intermittent infusions of vesicants
• The nurse should advocate for central vascular access administration of vesicant medications whenever possible. The peripheral infusion of vesicant agents should be limited to less than 30 to 60 minutes.
• In addition to visual assessment of the site, a blood return should be verified every 5 to 10 minutes during the infusion
2. Patients receiving infusions of vasoconstrictor agents
• The nurse should advocate for central vascular access administration of vasoconstrictor agents whenever possible as these agents can cause severe tissue necrosis with extravasation.
I realize this is a position statement and standards are recommndations and not mandatory but....I am also aware that these standards are used in the court of law and our choices and actions are compared to these when being reviewed.
Am I reading this wrong?? Because I feel pretty sure that we are not assesing these sites that frequently during infusion of intermittent piggybacks that are vesicant. We do certainly assess the line/site for patentcy prior to starting the medication, if any complaints, alarms etc. and then upon completion.
I am anxiously awaiting your feedback!
thanks, Gina Ward R.N, VA-BC
You are reading and interpreting this correctly. It is derived from the same standards as administration of cytotoxic oncology medications that are vesicants. Noncytotoxic vesicants can cause just as much damage as cytotoxic ones and need the same level of attention. Having been an expert on hundreds of cases, I have used these guidelines and patency assessment is one of the main things I look for when evaluating a set of medical records. Most records now come to me in electronic form and I can search the whole document. So I enter "blood return" and see what comes up. Most of the time there is nothing! Red flag for sure.
With that being said, the risks do vary with different drugs. Vancomycin is a weak vesicant, although there are a couple of articles reporting blisters or bullae from vancomycin in the SC tissue. It must be infused slowly due to the nature of the drug and its other adverse events like red man syndrome and kidney damage. I would always require a blood return prior to starting this infusion, I would NEVER infuse through a site in the hand, wrist or ACF, and I would educate the patient to let someone know immediately if there is any discomfort during the infusion. Remember that pump is going to keep on pumping regardless of where that drug is going.
Promethazine, calcium chloride, calcium gluconate, and high concentrations of potassium plus the others on the red list of noncytoxic vesicants are very different. These are very high risk drugs with huge probablity of severe tissue damage if they extravasate. Most do not need to be mixed as an infusion - promethazine, calciums can and IMHO should be given by the slow IV push method so the nurse is requred to remain with the patient and check for this blood return every 5-10 minutes. All pumps add great risk because it will not stop infusing if fluid is going into the tissue. The nurse simply cannot hang these drugs and walk away.
I have reviewed hundreds of cases with promethazine and calcium extravasations, most causing lifelong limitations on function with that extremity and even amputations. They demand the highest level of attention. When I do not find any documentation of blood return assessment during the administration of these drugs, it is a huge red flag to me and it is always discussed in deposition and at trial if the case goes that far. I know some of the red listed noncytoxic vesicants are given by continuous infusion (vasopressors, K riders) and aspirating for a blood return can be a challenge, but if it does not alter patient stability, patency assessment during infusion should be done. Again, absolutely NO sites in areas of joint flexion, adequate use of engineered stabilization devices, smallest gauge catheter in largest vein possible, careful site assessement before, during, and after administration are critical elements of safe administration of these drugs.
I have seen far too many horrow stories and serious, life altering outcomes for patients in these legal cases. Please pay careful attention to these details.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you very much for your prompt and thorough response.
I will meet with the powers at be and see what we can do to better comply with this.
Phenergan is currently IVPB maybe we can look into changing that.
The Calcium drugs, and K+ we may need to do alot of staff education on and also see if our computerized charting system is user friendly for frequent documentation of line assessments when these drugs are being infused. I know if they are being given frequently in a pt an advanced line such as a midline or PICC line might be better suited depending on frequency . On the other hand our facility is really pushing on reducing the amount of central lines but I am diligently defending the use of the right line for the patient.
I dont even like giving these high risk drugs in a midline because it is even more difficult to identify an infiltration in the insertion site. I educate pts strongly to speak up if any pain, tightnes, or anything occurs.
You make mention of "red list" , the only time I have seen or heard of that is when I was doing research on this subject and came upon the awesome tool developed by the Cincinnati Childrens hospital regarding extravasations, prevention and treatment. Is there a standardized list out there? RED, YELLOW, GREEN LIST??
I look at each drugs ph and or osmolality and planned lenght of administration to help guide me in the selection of the best suited access device for the pt.
I realize vessicants and irritants are not always titled or labeled as such because of the PH, or Osmolality but the effects it has on the vessel/tissue when infused. Years ago we got with pharmacy and identified our common vessicants and irritants that we utilize in the hospital and had them labeled on the computer generated Medication Administration Record as such and a red flag to consider the use of a Central Line for the infusion of such. But such a list, RED, YELLOW, GREEN, as a refernce for nurses would be great.
But I also read in the INS statement about if a vessicant is intermittent but to be infused over 60 minutes to look into getting a central line. Many times our patients are started on Vanco, and then in a matter of days switched to something else when the cultures come in. In these situations we tend to stick with a peripheral or iinsert a Midline if they are having difficulty gaining or keeping access. Or.....in the OP setting pts may be getting large doses of Vanco that are diluted making it about a 250ml or more infusion that they many times give over 2 hours. Then according to their , the INS , recommendations they should be giving in a central line and not as stated above , correct??
Wow, the more I look, the more things I am finding we need to work on.
thank you in advance!
Gina Ward, R.N., VA-BC
Gina Ward R.N., VA-BC
Promethazine must be diluted to slow down the injection rate, however 10 ml is sufficient and it requires accurate timing of this injection slowly.
pH and osmolarity alone are not the only factors that creates a vesicant. Vesicants do their damage in the SC tissue. Irritants do their damage inside the vein.
An extensive list of noncytoxic drugs is published in Gorski LA, Stranz M, Cook LS, et al. Development of an Evidence-Based List of Noncytotoxic Vesicant Medications and Solutions. Journal of Infusion Nursing. 2017;40(1):26-40.
You must also understand that evidence constantly evolves and changes. The articles you are using may appear to be in conflict due to their age and new subsequent evidence. A midline should not be used for an infusion of any vesicant, so in your situation of a few days of vancomycin I would rely only on a PIVC and not a midline. If a midline is chosen, the concentration of Vancomycin should be no more than 4 mg per mL.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
thanks again, I so value your input.
So, why would a peripheral be better choice than Midline?
Im thinking a bigger vessel with more hemodilution in a midline for the couple of day.
I thought i read somewhere that an intermittent infusion of vanco for approx 5 days has been studied to be ok in a midline?
We have been going with that info to allow us to not just jump right into a PICC line for all Vanco orders to see how it goes instead of just getting a PICC line, then 4 days later they are downgraded to a iv med that is fine in peripheral.
thanks very much for your responses and wisdome
Gina Ward R.N., VA-BC
Vancomycin is a weak vesicant. Infiltration and extravasation are reported to be low rates with midlines, but those complications do occur. The vein at tip location is much deeper in the tissue that a vein in the forearm. Most of the time you would be using basilic or brachial veins, which are categorized as deep veins, so there is muscle on top of the vein. This means you cannot detect signs and symptoms as easily and quickly as with a superficial vein in the subcutaneous tissue is used. A complication at the site in the forearm would be more readily noticed than from a deep vein. You can still apply the same principle of small catheter in a large peripheral vein, and stay away from joints. Site selection is the biggest problem with use of hands, wrists, and ACF sites. Now there are several studies reporting use of vancomycin in a midline. But I don't agree with your approach. You really cannot make a good VAD recommendation until you know the medical plan of care. Use peripheral catheters until those decisions have been made - after cultures results are known, etc. Then when you know if the vancomycin therapy will be 2 weeks or 8 weeks, you can decide on midline vs PICC. use of a midline from the beginning can cause vein damage that would prevent use of that site for a PICC insertion. I would only use a midline if there were enough compressible veins available to be able to insert a second midline if the first one fails. But even that is counter to the standard of practice which calls for using the most appropriate VAD to reach end of therapy with the minimum number of devices used. So 2 midlines is not meeting that standard when 1 PICC would have. Also what is your concentration for vancomycin. To infuse through a midline, it should be no more than 4 mg per mL. Have you collaborated with pharmacy on this? See the INS SOP on VAD Planning. Also my online class on midline catheters assesses all the published studies and provides this data in evidence tables. You need to know the evidence and the sources of that evidence to make good decisions,
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I should clarify. We only are putting Midlines in these particular Vanco pts when they are having problems securing a peripheral vein and we do not have all the results back to know if its long term, or changed to a much less caustic med. We give Vanco alot peripherally in those situations as you stated. sometimes we even start an ultrasound guided peripheral in the forearm to avoid a Midline until we know more.
Nursing would love for us to start a Midline on everyone getting Vanco but we do not . We try to keep peripheral until official decision made. We , our team of inserters, do certainly try to stick with the smallest device and least invasive and the least number of lines.
I understand what you are saying on identifying issues with those veins. Most of the time we use the cephalic vein for Midlines and ocassionally the Basilic. But , yes, I have seen many infilitrates with these lines that took way too long to notice.
I was not aware of the specific concentration issues you discussed. I actually just looked up a pts Mediction Record and it is being given with a final concentration of 5mg/ml and getting it twice a day and another pt is 4mg/ml once a day via midlines.
I will see about looking into your course to benefit from the studies you are referring too.
thanks so much for your time and your responses.
Gina
Gina Ward R.N., VA-BC