Thread by @keithppereira

"What is the best Venous Access Device for my patient?"

An #InterventionalRadiology (#Irad) #Tweetorial to address a frequent clinical dilemmas for #Medtwitter and #NurseTwitter

#FOAMed

1a/

Type of VAD:

PIV: 3-6 cm, enter and terminate in peripheral veins.

US-PIV: US to reach deep veins when superficial veins difficult to palpate, ≥8 cm

Midline catheter: 7.5-25 cm, inserted basilic/cephalic vein), terminating short of subclavian. 🚫 vesicant infusions

1b/

CVC: duration 7-14 d, direct puncture of internal jugular, subclavian, or femoral veins.

TC : diff from CVC, seperate insertion site in upper chest and venipunture in neck
⬇️ risk of infection due to cuff
👍 location for catheter care

1c/

PICC: inserted in vein of arm with tip in RA
Similar to CVC: provide access to the central circulation
No risks associated with puncture of deep veins in the neck

Port:
reservoir for injection/aspiration
Provides central venous access 👍
cosmetically 👍
long term 👍

2a/

Choice of VAD depends on:

Duration of Infusion
Type of Infusate ( Vesicate/ Non vesicate)
Reason for use ( blood samples/ difficult access)
Patient specific (Cancer/CKD/Critical/Others)

2b/

Important to differentiate Vesicants (IV solutions and medications that cause ischemia and necrosis) vs non Vesicants.

🚫 vesicants in peripheral veins

PICC or central access 🙏

3a/

Hospitalized patients needing Non-vesicant infusion:

<5d: PIV, US-PIV
6-14d: US-PIV and Midline , CVC critically ill
>15d-4 w: Midline >PICC
>4 w: PICC > TC, Ports in c/o no suitable vein for PICC, recent thrombosis, episodic infusions over several months

3b/

Hospitalized patients needing Vesicant infusion: (parenteral nutrition or chemo)

PICC ideal 👍👍

If skilled operator:
<14 d :CVC
>15 d: TC
>31d: Port

🚫PIV, US-PIV and Midline

4/

Special situation : Difficult venous access

individualized between the patient and provider after discussing risks and benefits

<14 d: Midline and US-PIV > PICC > CVC (critically ill)
15-30d: PICC>TC
>31d: TC > Port

5a/

Special situation: Chronic Kidney disease CKD

Stg 1 to 3a (GFR>45 ml/min):
as general population, if ambiguity regarding severity of CKD, consult nephrologist

Stg 3b and greater:

🚫🚫 PICCs, midline catheters into arm veins

A personalized 🙎‍♂️🙎‍♂️ approach to access

5b/

Peripheral venous access:

<5d: PIV in dorsum of hand (not forearm) preferred

Important to note factors like HD access planned vs in place and dominant vs non dominant arm.

5c/

Central access:
4 Fr single lumen or 5 Fr Dual lumen, TC preferred for long duration or Vesicant solution

6/

Special situation: Cancer

Special concerns due to concern for infection (immunocompromised), thrombosis ( coagulable state), as well as infusion of vesicant (chemotherapy)

🚫 use of peripheral vein with vesicant chemo
PICC, TC, Port 👍👍

7/

Special Situation: Critically ill patients in ICU

If Hemodyn stable:
<5d: PIV
6-14d:Midline
>15 d: PICC

if Hemodyn unstable:
<14d: CVC
>15d: PICC

Therefore urgent request for PICC 👎
PICC > CVC in coagulopathy (DIC or sepsis)

8/

Special situations: lifelong iv access (sickle cell, short-gut syndrome, CF)

< 5 hospitalization per year:
<15 d: Midline
>15d: PICC

>5 hospitalization per year:
>15d: TC
>31d: Ports