Peripheral Catheters

45Reliable vascular access is a major factor allowing for the success of home infusion therapy. Selecting the most appropriate vascular access device (VAD) as well as the site of placement is a critical decision that impacts the clinical outcome as well as the patient experience and satisfaction with care and this decision requires critical thinking and analysis of multiple factors (Gorski et al., 2016). Home infusion therapy via a peripheral catheter is less common than infusion via a central VAD (CVAD) due to the fact that many home infusion therapies involve irritating drugs or fluids and the duration of therapy is often weeks versus days.

Peripheral catheters include the traditional “short peripheral catheter,” or SPC as referred to by the Infusion Nurses Society (INS), and midline catheters. Although use of the SPC is limited to shorter courses, the use of midline catheters for patients requiring a few weeks of infusion therapy is growing. This chapter provides an overview addressing appropriate use of peripheral catheters, care and maintenance guidelines, and potential complications.

After reading this chapter, the reader will be able to:

■ Discuss indications for peripheral catheter placement

■ Differentiate between short peripheral and midline catheters

■ Describe catheter placement issues

■ Identify potential complications of peripheral catheters

46PATIENT SELECTION CONSIDERATIONS: PERIPHERAL VENOUS ACCESS

The patient is often referred to the home care agency with a VAD already in place. However, in some situations, the home care nurse is involved in the decision-making process. General guidance in selecting the most appropriate type of VAD is found in the INS standards under the VAD Planning Standard (Gorski et al., 2016, p. S51):

■ Consider the prescribed therapy or treatment regimen; anticipated duration of therapy; vascular characteristics; and patient’s age, comorbidities, history of infusion therapy, preference for VAD location, and ability and resources available to care for the device.

■ VAD selection should be a collaborative process among the interprofessional team, the patient, and the patient’s caregivers. With home care, patient preference should always be a consideration. For home infusion patients, consider safety and the impact on activities of daily living as well as ability to care for the VAD.

■ The VAD selected should have the fewest number of lumens, have the smallest outer diameter, and be the least invasive device to meet the patient’s needs. A peripheral catheter would be considered less invasive than a CVAD.

When considering a peripheral catheter, consider the anticipated duration of infusion therapy in conjunction with the prescribed infusate characteristics (irritant, vesicant, and high osmolarity) and the availability of peripheral sites.

■ Duration of infusion therapy:

Consider the SPC when infusion therapy is anticipated for less than 1 week if the prescribed medication or solution is well tolerated by peripheral veins. An SPC is also an appropriate choice for patients who require infusions on a less frequent basis, such as the patient who requires an occasional dose of furosemide or infliximab infusions every 6 weeks.

Consider a midline catheter when infusion therapy is anticipated for more than 1 week and less than 3 to 4 weeks if the prescribed medication or solution is well tolerated by peripheral veins. Typical medications and solutions administered via a midline include antimicrobials, fluid replacement, 47and analgesics. Caution is recommended with intermittent vesicant infusions due to the risk of undetected extravasation in the deep veins of the upper arm. Research on appropriate infusates via midline catheters continues to evolve.

■ Avoid administration via peripheral catheters with continuous vesicant infusions, parenteral nutrition, or infusates with an osmolarity greater than 900 mOsm/L.

Fast Facts in a Nutshell

There are three layers of veins. The innermost layer of the vein is called the “tunica intima.” It consists of a single, smooth layer of endothelial cells. These cells are easily damaged through a variety of insertion and/or care-related factors such as rapid catheter advancement, use of large catheters, catheter motion during dwell time due to lack of catheter stabilization, or poor insertion technique, allowing entry of microorganisms. Results of cellular damage include vein inflammation, infiltration, and infection. The “tunica media” is the middle layer of the vein, which is composed of muscular and elastic tissue and nerve fibers for vasoconstriction and vasodilation. The outermost vein layer is the “tunica adventitia,” which consists of connective tissue that supports the vein. As part of the aging process, changes in venous structure can make placement of peripheral IV catheters challenging. The tunica intima, as well as the tunica media, become thicker making vein entry more difficult. Valves located within the veins also become more rigid and sclerotic (Coulter, 2016).

IDENTIFYING NONCYTOXIC VESICANTS

Cytotoxic vesicants used in cancer treatment are addressed in Chapter 11. The INS identified a “red” and “yellow” list of vesicants (Gorski et al., 2017). Red list vesicants, defined as well-recognized vesicants with multiple citations and reports of tissue damage upon extravasation, include dobutamine, dextrose solutions with greater than or equal to 12.5% dextrose concentration, parenteral nutrition solutions with an osmolarity greater than 900 mOsm/L. Yellow list vesicants are associated with fewer published reports of extravasation, but published drug information and infusate characteristics indicate caution and potential for tissue damage. Yellow list vesicants 48administered in home care include acyclovir, dextrose solutions with greater than or equal to 10.5% to 12.5% dextrose concentration, nafcillin, pentamidine, phenobarbital sodium, potassium greater than or equal to 60 mEq/L, and vancomycin.

Fast Facts in a Nutshell

A vesicant is defined as an agent capable of causing tissue damage when it escapes outside of the blood vessel into the surrounding tissue—this complication is called “extravasation.” A nonvesicant does not produce tissue damage upon escape into the surrounding tissue—this complication is called “infiltration.” Two caveats: (a) Even nonvesicant solutions and medications may cause tissue damage in neonates and infants, and (b) severe infiltrations can result in a compartment syndrome with resulting nerve and arterial damage. An “irritant” is defined as an agent capable of producing discomfort (e.g., burning and stinging) or pain as a result of irritation in the internal lumen of the vein with or without external signs of vein inflammation (Gorski et al., 2016).

TYPES OF PERIPHERAL IV CATHETERS

Short Peripheral IV Catheters

Description

■ The SPC is approximately 2 inches or less in length. Choices of SPCs include stainless steel needles and the over-the-needle that leaves a plastic-type catheter in place. Stainless steel needles are indicated only for single-dose administration and are not left in place due to the increased risk of infiltration. Peripheral catheters with engineered safety devices are used.

Advantages

■ Low risk of infection and catheter-related complications

■ Low cost

Key Points Regarding Placement

■ Catheter Size: Use smallest gauge catheter needed to deliver the infusion therapy; this allows for good blood flow around catheter 49decreasing the risk for phlebitis. A 22-gauge catheter is a common choice; a 24 gauge is also appropriate, especially for those with small, fragile veins including pediatric and older adult patients.

■ Site Selection:

Select nondominant extremity whenever possible.

The forearm is recommended as it will likely last longer due to larger veins, have less movement (i.e., away from an area of flexion), be easier to stabilize, and have less interference with activities of daily living.

Consider activity level and patient needs before placing an SPC in the hand.

Avoid areas of flexion (e.g., antecubital fossa and wrist) and areas of previous venipuncture; subsequent peripheral intravenous (IV) insertions are always proximal or above previous sites.

Do not use lower extremities due to risk of tissue damage, thrombophlebitis, and ulceration.

Be aware of and avoid areas associated with increased risk for nerve damage: Cephalic vein at the wrist due to proximity to superficial radial nerve, palm side of the wrist due to proximity to median nerve, and antecubital fossa due to proximity to median/anterior interosseous/antebrachial nerves.

Pediatric: Veins of the scalp, and if not walking, the foot may be used. If the SPC is placed in the hand, avoid the hand where a child is thumb-sucking.

■ Vein Identification:

A tourniquet is typically used. Loosely apply or avoid tourniquet use in patients who bruise easily, who are at risk for bleeding, have compromised circulation, and/or who have fragile veins (Gorski et al., 2016, p. S64).

Use of warmth, including dry heat, can be very successful in dilating veins.

Use of visualization technology: Ultrasound is increasingly used in acute care settings. There are also light devices that provide transillumination to identify veins. Another option is near infrared (nIR) light technology. Portable nIR units are available and are being used by some home care agencies. Deeper veins (e.g., 10 mm in depth) not visible to the naked eye may be identified by nIR. Specifically, bifurcations and valves may be identified and the venous pathway can be seen. For placement of SPCs in the forearm, nIR can be a valuable tool. As with any technology, the use of nIR requires specific education and training and competency assessment.

■ 50Aseptic Technique:

Skin antisepsis is a critical step. Prior to skin antisepsis, if the skin is visibly dirty, cleanse with soap and water. If hair removal is indicated, use scissors and do not shave. The preferred antiseptic agent is >0.5% chlorhexidine in alcohol solution; if contraindicated, an iodophor, tincture of iodine, or 70% alcohol may be used. Apply for recommended time frame (e.g., 30 seconds) and allow to completely dry.

Use a new pair of disposable nonsterile gloves in conjunction with a no-touch technique—do not touch the insertion site after skin antisepsis.

■ Peripheral Attempts and Placement Issues:

Use a 10 to 15 degree angle from the skin when inserting the SPC. For the older adult, use a lower angle of 5 to 15 degrees due to the loss of subcutaneous fat and more superficial veins. This will reduce the risk of going through the underside of the vein wall. Too often, the older adult patient endures multiple attempts at venous access (Coulter, 2016). Nurse knowledge and competency are essential for this prevalent home care population.

Make no more than two attempts at short peripheral catheter placement per clinician and limit total attempts to no more than four. It is important to recognize the consequences of multiple attempts at placement, which include pain, delayed treatment, limiting future vascular access, cost, and increased risk for complications. Patients with difficult vascular access require a careful assessment of VAD needs and collaboration with the health care team to discuss appropriate options (Gorski et al., 2016, p. S64). Although this is challenging to home care agencies, identifying and ensuring nurse competence in SPC placement is important to positive patient outcomes and patient satisfaction.

If nerve damage is suspected during the placement procedure based upon patient reporting of numbness, tingling, or other paresthesias, immediately remove the SPC and notify the physician (Gorski et al., 2016, p. S64). Early identification and intervention may reduce the risk of permanent nerve damage. Avoid probing for the vein as this increases the risk for nerve damage.

If an artery is inadvertently accessed, immediately remove and apply pressure to the site.

■ 51Catheter Stabilization:

Purpose: To minimize the catheter movement at the hub, reducing the risk for dislodgement and other complications; the risk for mechanical phlebitis and infiltration is reduced when catheter movement is minimized.