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Indications for peripheral, midline and central catheters: Summary of the MAGIC recommendations

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Patients admitted to acute care frequently require intravenous access to effectively deliver medications and prescribed treatment. For patients with difficult intravenous access, those requiring multiple attempts, those who are obese, or have diabetes or other chronic conditions, determining the vascular access device (VAD) with the lowest risk that best meets the needs of the treatment plan can be confusing. Selection of a VAD should be based on specific indications for that device. In the clinical setting, requests for central venous access devices are frequently precipitated simply by failure to establish peripheral access. Selection of the most appropriate VAD is necessary to avoid the potentially serious complications of infection and/or thrombosis. An international panel of experts convened to establish a guide for indications and appropriate usage for VADs. This publication summarises the work and recommendations of the panel for the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC).
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I
ntravenous access is a necessary component of the
delivery of medical treatment in hospitals. More than
60% of patients in acute care worldwide, and higher
percentages in the USA, require a vascular access device
(VAD) (Alexandrou, 2015). Central venous access devices
(CVADs) exceed 7million units per year in the USA and
10 million worldwide (iData Research, 2014), and while
necessary in most cases, each CVAD carries signicant risk to
the patient (Napalkov et al, 2013; Chopra et al, 2012a; 2012b).
Recent concerns over serious complications of infection
and thrombosis require closer scrutiny of CVAD use with
particular emphasis on applying evidence-based indications
and avoiding potential overuse of peripherally inserted central
catheters (PICCs) (Maki et al, 2006; Chopra et al, 2012b; 2013a;
2013b; 2014; Hammes et al, 2015; Carr and Rippey, 2015).
Due to increasing popularity, ease of insertion, low insertion
related complications, reduced cost and placement primarily
by vascular access teams, PICCs now comprise nearly half of
all CVADs currently used in the USA (iData Research, 2014).
Despite the advantages and safety in terms of insertion, PICCs
are prone to occlusion and venous thrombosis, by a factor
of more than 2 in comparison with other CVADs (Moureau
et al, 2002; Spencer et al, 2007; Evans et al, 2010; Saber et al,
2011; Marnejon et al, 2012; Chopra et al, 2013a; Evans et al,
2013). PICC venous thrombosis is known to also impact the
risk of lower-extremity thrombosis and potentially contribute
to incidence of pulmonary emboli (Greene et al, 2015; Kaplan
et al, 2015). Selecting the intravenous device with the lowest
risk that most eectively supports the patient’s treatment
plan should be performed based on available evidence and
specied indications.
Indications for peripheral, midline and
central catheters: summary of the
MAGIC recommendations
Nancy Moureau and Vineet Chopra
Nancy Moureau, Registered Nurse, Adjunct Associate Professor,
Grifth University, Brisbane, Australia; Chief Executive Ofcer,
PICC Excellence, Inc and Vascular Access Specialist, Greenville
Memorial Hospital, Greenville, South Carolina
Vineet Chopra, Doctor of Medicine, Assistant Professor of
Medicine and Research Scientist, School of Medicine, University
of Michigan, and Ann Arbor VA Medical Center, Ann Arbor,
Michigan
Accepted for publication: March 2016
Method
Recognising the need to establish evidence-based indications
for intravascular devices and specically PICCs, an international
group of expert physicians, clinicians and one patient was
selected to work together as part of a University of Michigan/
Society of Hospital Medicine-funded initiative. In this initiative,
the RAND/UCLA Appropriateness Method (Fitch et al, 2001)
was applied to develop criteria for the selection of the best VAD
for each patient. A systematic literature review was performed
and disseminated to the 15-member panel for evaluation with
the 665 patient scenarios. To determine the eect on clinical
decision-making, devices including peripheral intravenous
catheters, ultrasound-guided peripheral intravenous catheters,
midline catheters, non-tunnelled central venous catheters
(CVCs), tunnelled CVCs, and ports, were compared with
PICCs. Additionally, scenarios evaluating the appropriateness
of individual devices were also created. Each scenario was
rated based on appropriateness of PICC or other VAD usage.
The RAND/UCLA Appropriateness Method incorporated
information synthesis, panelist selection, patient scenarios, a
rating process and analysis of results all specic to VADs.
ABSTRACT
Patients admitted to acute care frequently require intravenous access to
effectively deliver medications and prescribed treatment. For patients with
difcult intravenous access, those requiring multiple attempts, those who
are obese, or have diabetes or other chronic conditions, determining the
vascular access device (VAD) with the lowest risk that best meets the needs
of the treatment plan can be confusing. Selection of a VAD should be based
on specic indications for that device. In the clinical setting, requests for
central venous access devices are frequently precipitated simply by failure
to establish peripheral access. Selection of the most appropriate VAD is
necessary to avoid the potentially serious complications of infection and/or
thrombosis. An international panel of experts convened to establish a guide
for indications and appropriate usage for VADs. This publication summarises
the work and recommendations of the panel for the Michigan Appropriateness
Guide for Intravenous Catheters (MAGIC).
Key words: Central venous catheters Peripheral catheters Midline
catheters Peripherally inserted central catheters Central line associated
bloodstream infections Thrombosis
British Journal of Nursing, 2016, (IV Therapy Supplement) Vol 25, No 8 S15
VASCULAR ACCESS
© 2016 MA Healthcare Ltd
Results
The results of the review by the Michigan Appropriateness
Guide for Intravenous Catheters (MAGIC) panel included
ratings from 391 unique indications of appropriateness or
inappropriateness for PICCs and other VADs with two
rounds of in-person rating scenarios by the panel (Chopra et
al, 2015a). The nal results established 38% of these indications as
appropriate, 43% as inappropriate and 19% neutral or uncertain
for the 665 scenarios. Details for each device are summarised
in the following sections.
Peripheral access (PIV, USGPIV)
Peripheral catheters establish access into the veins and arteries
of the arms and, less frequently, legs or other paediatric or
neonatal applications of the scalp (Rickard et al, 2012; McCay,
2014). They are inserted using a direct visual approach or with
visualisation devices such as infra-red or ultrasound technology.
Peripheral access is considered less invasive than central
access and has a lower risk of infection (0.5/1000 catheter
days) (Maki et al, 2006; Hadaway, 2012). Peripheral catheters
are considered appropriate for treatment of peripherally
compatible medications and solutions (less than 900mOsm/
litre, not vesicant or irritant) when the duration of treatment
is 6 days or less (Table 1) with transition to midline or PICC
when duration is extended (Periard et al, 2008; Gorski et
al,2016).
When multiple peripheral catheter attempts fail, the
designation of dicult intravenous access (DIVA) may lead
to assessment and access with ultrasound or other forms of
visualisation technology (Figure1). Success is enhanced with
deeper ultrasound-guided access and the use of longer peripheral
catheters (Chinnock et al, 2007; Elia et al, 2012; Liu et al, 2014;
Stolz et al, 2015). For all patients considered DIVAs, those with
one or more failed attempts, inability to identify veins visually
or with a history of dicult access, use of ultrasound or other
visual technologies is recommended to help obtain the preferred
peripheral intravenous access (Gorski et al, 2016). Ultrasound-
guided peripheral access (USGPIV), commonly inserted in the
veins of the forearm, antecubital fossa or upper arm, is indicated
for treatment duration less than 6 days or up to 15days with a
transition to midline catheter or PICC if treatment continues.
USGPIV is also recommended for contrast-based radiographic
studies requiring upper-extremity veins with larger catheters,
20-16 gauge, where visible veins to accommodate the size
are not available (Table2). Evidence supports greater success
with ultrasound-guided peripheral catheter access after training
(Schoenfeld et al, 2011). Greater success with these procedures
results in reduced need and avoidance of CVADs (Gregg et al,
2010; Au et al, 2012; Shokoohi et al, 2013).
Current research and guidelines support maintaining
peripheral catheters until no longer clinically indicated or
until a complication develops (Rickard et al, 2012; Gorski et al,
2012; Loveday et al, 2014; Tuaha et al, 2014; Wallis et al, 2014;
Bolton, 2015). Insertion of peripheral catheters into external
jugular or leg veins is considered appropriate in emergent
situations with veried inserter training prior to the insertion
and treatment is 4 days or less (Chopra et al, 2015a). Peripheral
catheters in the hand or distal portion of the upper extremity
are the preferred choice when chronic kidney disease (CKD)
is present and glomerular ltration rate (GFR) is less than
44ml/minute, stage 3b or greater, with a focus on preserving
peripheral and central veins for haemodialysis, stula or grafts
(Chopra et al, 2015a).
Peripheral catheters are the preferred access for all patients
where no indication is present for central venous access (Chopra
et al, 2015a). Increasing clinical skill with vein selection and
access through the use of ultrasound and other visual aids
facilitates the goal of avoiding CVADs when no indication
Table 1. Peripheral catheter indications
Peripheral intravenous catheter treatment involves the infusion of peripherally
compatible solutions for 5 days or less
Patient has adequate veins to accommodate catheter size and length
Emergent use with placement in the external jugular or foot veins (emergent or less
than 4 days)
Cyclic or episodic chemotherapy (non-vesicant) treatment for less than 3 months
Table 2. Ultrasound-guided peripheral catheter indications
Use visualisation technology to establish peripheral access using longer catheters
for the purpose of intravenous treatment less than 5 days or more than 15 days
(with transition to midline or PICC)
For patients with one or more failed attempts, inability to identify veins visually or
those identied as difcult intravenous access (DIVA) commonly inserted in the
forearm, antecubital fossa or upper arm
For contrast based radiological studies requiring upper extremity access in larger
veins with 20-, 18- or 16-gauge catheter (where visible veins to accommodate
catheter size are not present)
Table 3. Midline catheter indications
Treatment involves peripherally appropriate solutions that will likely exceed 6 days
Preferred for patients requiring infusions of up to 14 days
Patients with difcult intravenous access (DIVA) despite ultrasound-guided peripheral
catheter attempts
Single-lumen midline is placed unless specic indication for dual lumen with
compatible infusions
Figure 1. Ultrasound-guided peripheral catheter in the
forearm (used with permission from PICC Excellence, Inc.)
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exists for these devices. Many hospitals have incorporated
vascular access teams to insert and maintain both peripheral
and central catheters with positive outcomes (Hawes, 2007).
The added expertise and skill of these team members supports
the longer use of peripheral catheters.
Midline catheters
Midline catheters are experiencing a resurgence of attention
with great usage owing to improvements in catheter materials
and products. The two most recent midline catheters are
8–10cm in length utilising the insertion technique referred
to as accelerated Seldinger (AST) (Access Scientic, Bard
Access Systems, Teleex). These all-in-one devices with the
modied Seldinger technique (MST) have the needle, wire
and introducer in a combined unit for ease and speed in
access. The evidence supporting midlines is growing with
a variety of publications demonstrating positive outcomes
(Anderson et al, 2004; Griths, 2007;Alexandrou et al, 2011;
Cummings et al, 2011; Warrington et al, 2012; Dawson and
Moureau, 2013; Caparas and Hu, 2014; Moureau et al, 2015).
Midline catheters have lower phlebitis rates than peripheral
catheters and lower rates of infection than other central
catheters. Midlines are considered appropriate for patients
with peripherally compatible solutions or medications where
treatment will likely exceed 6days. Midlines are preferred for
patients requiring infusions up to 14 days, but may be used in
a manner consistent with the clinically indicated removal of
peripheral catheters (O’Grady et al, 2011; Caparas and Hu,
2014) (Table 3). When patients are considered DIVAs and
ultrasound-guided peripheral access has failed, midlines are
preferred (Figure2). As with all vascular access devices, single
lumen midline catheters are placed unless a specic indication
for dual lumen is needed (only single and dual-lumen midlines
are currently available).
Peripherally inserted central catheters (PICC)
PICCs have provided a reliable bridge between shorter peripheral
catheters and chest-inserted central venous catheters (CICC)
for more than 20 years (Figure3). There is reduced risk of
pneumothorax, haemothorax, nerve damage, stenosis and other
Table 4. PICC indications
Patient requires intravenous access for longer than 14 days. For proposed treatment
of 6or more days ultrasound-guided or midline catheter preferred over PICC
Clinically stable patient requiring intravenous therapy with peripherally incompatible
solutions. Haemodynamically unstable patients where cardiac monitoring or use
of vasopressors is necessary in cases less than 14 days and more than 15 days
(CVCs favoured over PICCs)
PICC is preferred to CVAD for critically ill patients with bleeding disorders for 14 days
or less and those requiring 15or more days of treatment
For use with continuous infusions of vesicant, parenteral nutrition, chemically
irritating or non-peripherally compatible solutions for any duration. For cyclic
chemotherapy with active cancer where treatment is more than 3 months.
Consideration given to discontinuation of PICC when each cycle complete (peripheral
catheter preferred when less than 3months)
Use with patients receiving frequent phlebotomy of every 8hours or more often with
duration of 6 days or more
For burn patients where early implementation of PICC decreases risk of bacteraemia
For use with chronic or lifelong access populations (sickle cell, cystic brosis,
short gut) or those hospitalised more frequently than 6 times per year (tunnelled
catheterpreferred)
For use in patients in palliative treatment, actively dying or in hospice requiring
intravenous solutions
For skilled nursing facilities when duration of treatment is more than 14 days
Prior nephrology approval if glomerular ltration rate (GFR) less than 30 or creatinine
more than 2.0
Single-lumen PICCs preferred unless specic indication for additional lumen. Use
smaller gauge PICC with fewer lumen to reduce risk of deep vein thrombosis
(DVT) (Grove and Pevec, 2000; Evans et al, 2013). Measure vein size to establish
appropriate catheter size of less than 45% of vein diameter (Sharp et al, 2015).
Position of terminal tip of PICC in lower third of the superior vena cava, cavoatrial
junction or right atrium
Figure 2.Midline for patient with difficult intraven ous
acc es s (used with pe rmi ssion from Matthew O str off)
Figure 3 Peripherally inser ted centra l cathe ter (PICC)
(Us ed with permissi on from PICC E xcelle nce, In c.)
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more serious CVAD-related complications with PICC placement.
Indications for PICCs (Table4) include any patient requiring
peripherally incompatible infusions or for intravenous treatment
more than 14days (Chopra et al, 2015a). Expanded nursing roles
support safe placement of PICCs by specially trained teams of
nurses (Robinson et al, 2005; Falkowski, 2006; Simcock, 2008).
Increased awareness of PICCs has reduced the number of other
CVAD placements. Bedside nurses are more likely to request a
PICC order after having diculty establishing peripheral access
rather than considering all options and appropriateness of central
access (Chopra et al, 2015b; Helm et al, 2015; Woller et al, 2015).
With rising concerns over the incidence of thrombosis
with PICCs and the relationship of thrombosis to infection,
closer evaluation of each PICC request is necessary to evaluate
the need for central versus peripheral access for each patient
(Marschall et al, 2014; Chopra et al, 2015a). Measuring the vein
diameter and choosing a catheter–to–vein ratio of 45% or less
may reduce thrombosis risk in PICCs and midlines (Nifong
and McDevitt, 2011; Sharp et al, 2015; Gorski et al, 2016). Use
of antimicrobial PICCs may reduce risk and was statistically
signicant in reducing the level of infection by a factor of 4 in
one hospital study (Rutko, 2014). In Tables 4 and 5 a list of
appropriate and inappropriate indications for PICCs is provided
based on MAGIC (Chopra et al, 2015a).
Non-tunnelled central venous catheters
Non-tunnelled CVCs are commonly used for internal jugular
access with acute care patients who are unstable and who
require haemodynamic monitoring or large uid infusions.
These percutaneously inserted catheters have a rate of infection
similar to PICCs (Maki et al, 2006) and are used for short-term
critical access. Non-tunnelled CVCs are preferred over PICCs
when treatment is required for 14 days or less. Antimicrobial
non-tunnelled catheters are often used for these critical patients
when the catheter is expected to stay in place for more than
5days to reduce risk of infection (Hockenhull et al, 2008;
Pittiruti et al, 2009; Lai et al, 2013; Chopra et al, 2015a; Lorente
et al, 2016) (Table6).
Tunnelled central venous catheters
Tunnelled CVCs are inserted into internal jugular or subclavian
veins with a subcutaneous tunnel commonly to the mid-
chest region, but also other areas customised to the patient.
Tunnelled catheters are indicated for use with intravenous
treatment of 31 days or longer, or more episodic treatment
over several months. Typically, these CVADs are reserved for
patients not considered candidates for a PICC due to vein
size or thrombosis risk. Tunnelled internal jugular catheters
and small bore catheters are preferred for patients with any
level of CKD requiring intravenous treatment for more than
15days. PICC and tunnelled catheters are appropriate at all
time intervals for infusion of irritating or chemotherapeutic
medications. Tunnelled catheters are recommended over multi-
lumen PICCs when multiple or frequent infusions are required
due to their lower incidence of complications (Tran et al, 2010;
Chopra et al, 2015a) (Table7).
Subcutaneously implanted ports
With subcutaneously implanted ports, a catheter is inserted into
either the internal jugular or subclavian vein and attached to
a port reservoir. The port is implanted into a pocket created
in a subcutaneous area on the chest (or arm as in arm ports),
connected to the catheter, tested for ow and secured with
sutures or glue (Simonova et al, 2012; Chopra et al, 2015a).
Ports are appropriate for patients with expected treatment longer
than 6 months. The MAGIC panelists rated ports as having
neutral appropriateness for duration of treatment equal to 3-6
months. Ports may also be considered appropriate for dicult
venous access if use for 31 days or more is expected (Chopra
et al, 2015a)(Table 8).
Table 5. Inappropriate PICC
Placement of PICC for any non-central indication
Insertion of a PICC primarily for the purpose of establishing intravenous access when
the duration of treatment is unknown
Use with any infusion other than non-peripherally compatible infusates
Placement of a PICC with conrmed PICC-related bloodstream infection without
documented clearance of infection (line-free interval of 48–72 hours with negative
blood cultures)
Avoid PICC use for inappropriate indications, or for patients with history of thrombosis,
hypercoagulability or decreased venous ow to extremities; consider alternative
devices and remove PICC when no longer needed
For renal failure stage 3b or greater chronic kidney disease with GFR of less than
44ml/minute or for patients currently receiving any renal replacement therapy
Insertion for infrequent phlebotomy, less than 3 times daily
Medical, nursing or patient/family request without central indication, actively dying/
hospice or other appropriate criteria for PICC
Urgent or ‘STAT’ request for PICC for a haemodynamically unstable or critical patient
Placement of PICC on the basis of arm dominance
Removal or replacement of PICC that is clinically necessary without evidence of
bloodstream infection or other complication
Advancement of PICC or other dislodged vascular access device in the case of
migration of the catheter
Table 6. Non-tunnelled catheter indications
Unstable patients requiring haemodynamic monitoring, multiple medications, large uid
infusions, blood or blood products or continuous parenteral nutrition
Short-term critical access. Non-tunnelled CVCs are preferred over PICCs for access up
to 14days
Chemotherapy treatment anticipated for more than 3 months
Antimicrobial non-tunnelled catheters are often used for these critical patients to
reduce the risk of infection by approximately 40%
Table 7. Tunnelled catheter indications
Patients receiving treatment exceeding 31 days
Infusion of vesicant, irritant, parenteral nutrition or chemotherapeutic agents
regardless of duration
Patients likely to receive cyclic or intermittent ongoing therapy exceeding 31 days
Patients with more than than 6 hospitalisations annually with expected duration of
therapy longer than 15 days per hospitalisation
Table 8. Totally implanted subcutaneous port indications
Patients with expected treatment longer than 6 months (neutral rating for 3–6 month
duration of treatment)
Patients requiring intermittent or cyclic infusion treatment, rather than continuous, for
more than 6 months
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Discussion
For the rst time, the MAGIC document provides appropriateness
ratings for specic VADs based on infusate, patient, duration
and treatment characteristics. Factors such as proposed duration
of medication infusions, eects of the medication on vessels,
patient condition (renal, critical, chronic) or complications of
infection were all evaluated (Figure4), helping create clinically
practical recommendations. However, recommendations for
clinical appropriateness are often based on criteria that are
dicult to estimate, such as duration of treatment. As emphasised
by the patient panelist in the MAGIC initiative, an individualised
approach is necessary in manysituations.
Application of the appropriateness criteria may also require
adaptation to the particular care setting (hospital, skilled nursing,
home environment). Factors such as reliability of the VAD are
more important in the skilled nursing and home environment
where clinical support and expertise may be limited. Peripheral
catheters and midlines have variable reliability outside the
hospital setting.
The concept of vessel health and preservation is focused not
just on gaining better outcomes during a single hospitalisation,
but on preserving veins for future patient needs (Moureau
et al, 2012; Hallam et al, 2016). Understanding and applying
clinical research indicating the treatment, practice or process
leading to the best results for the patient is challenging for
clinicians. Selection of recommendations and guidelines is often
convenience and economically oriented rather than patient
focused, leading to a greater risk of complications for the patient.
It is important to remember that limitations exist for the
MAGIC guidance. First, not all recommendations translate to
all patient populations. For instance, placement of CVCs in
critically ill patients requires the availability of experienced
and skilled sta to insert devices in manners that are safe
from insertion complications such as pneumothorax. This is
implicitly assumed in MAGIC, but may not be so in the real
world. Second, MAGIC does not address certain technological
advances including antimicrobial-coated catheters or advanced
devices such as infra-red vein nders that may impact on choice
and selection of device. These limitations must be borne in
mind when considering MAGIC. Technology ever advances
and MAGIC should thus not be viewed as an all-encompassing
document, but a living and breathing statement that changes
with available evidence and practice. Third, it is unclear how best
to implement recommendations from MAGIC. Should these
be incorporated into checklists, software-based applications
or electronic-medical record systems? Who is responsible for
adherence? Are there potential barriers in implementation that
have not been considered? These types of challenges require
careful thought and the use of implementation science to
better understand what works and what does not in the real-
worldsetting.
MAGIC has succeeded in creating a practical list of
indications, both appropriate and inappropriate, for VAD use.
This document guides physicians, bedside clinicians, and those
on vascular access teams to the most appropriate selection of
the safest device and practices for the patient. To quote Thomas
Vesely, a fellow clinician and designated Doctor of Medicine,
who spoke to the authors:
‘More than 20 nationally-recognised guidelines,
recommendations, and standards documents
concerning vascular access were created by
10dierent organisations. Insular creation of
such documents is the wrong approach. It’s time
that all involved agree on ‘the rules’ even if that
requires compromise and MAGIC is a good step
in the right direction.
More expert discussion, evaluation and research is needed on
issues where panelists failed to reach a decision, were neutral or
disagreed for VAD indications. Consistent with the variation in
panelist responses, published literature often has contradictions
in results from one study to another. There was a paucity of
randomised controlled trials for specic VADs necessary to
establish denitive conclusions. Furthermore, what works in
Table 9. Selection, care and maintenance appropriate practices
Evaluate a PICC or CVC order prior to insertion to determine optimal device choice
Exchange PICC to change device features (number of lumen) or to correctly position
catheter
Verify tip position via chest radiography, uoroscopy or electrocardiography guidance
(after training and technical prociency is conrmed)
Provide more than 3 months of uninterrupted systemic anticoagulation for treatment
of PICC-related deep vein thrombosis (DVT) in the absence of contraindications. Do not
remove a functional catheter unless no longer needed or worsening symptoms persist
after more than 72 hours of anticoagulation.
PICCs of the smallest-sized catheter and appropriate vein size on the contralateral arm
may be inserted with patients after DVT with more than 3 months of anticoagulation
Provide line-free interval (48–72 hours) to ensure clearance of bacteraemia prior to
insertion of central catheter
Removal of a central venous catheter (PICC, CVC, tunnelled catheter) after notication
of physician and when catheter has not been used for any clinical purpose for
48hours or longer
Removal of catheter when patient no longer has a clinical indication for use or the
original use has been met
Removal of catheter when used only for blood samples in stable patient when
peripheral veins available
Removal of catheter only by clinician trained for removal of specic device
Figure 4. Selection criteri a for vascular acces s d evices (PI CC Excellence,
Inc . ©2016)
Care setting/population > qualication of inserters/providers >
appropriate device selection
Patient
treatment plan
Patient condition
(acute chronic
renal)
Vein
characteristics
Patient risk
factors
Medication/infusate
characteristics
Estimated
duration
Indications
for VAD
Device and
treatment risk
factors
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one setting may not work in another. Understanding how
best to implement MAGIC to improve decision-making in
vascular access remains a key goal—one that must be actively
targeted by those in this eld.
Conclusion
Guidelines, recommendations and standards point to the need
for evidence-based indications when selecting a VAD. Relying
on available literature, the combined clinical experience of
the panelists, patient input, and an established methodology
embodied in the RAND/UCLA Method, a consensus was
reached through MAGIC to establish a working guide for
intravenous device indications and contraindications. Careful
evaluation and application of MAGIC conclusions into the
programme of each facility administering intravenous treatments
provides guidance toward the most appropriate and safe patient
applications. In this age of electronic medical records, criteria
such as MAGIC may serve as a clinical decision process
embedded in the electronic medical records framework to
guide clinical decisions in keeping with the theory of vessel
health and preservation for patients from birth to death. bjn
Declaration of interest: none
This article is jointly published with The Journal of the Association
for Vascular Access
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KEY POINTS
The ability to preserve vessel health for future medical needs requires
clinical education and training in three areas: device selection, placement
and daily device care
Selection of the most appropriate vascular access device (VAD) is
necessary to avoid the potentially serious complications of infection and/
or thrombosis.
Selection of a central VAD (CVAD) should be based on indications for that
specic device rather than the inability to gain peripheral access
All VADs have a risk of infection and other complications for the patient and
should be removed as soon as no longer medically necessary
British Journal of Nursing, 2016, (IV Therapy Supplement) Vol 25, No 8 S23
VASCULAR ACCESS
© 2016 MA Healthcare Ltd
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S24 British Journal of Nursing, 2016, (IV Therapy Supplement) Vol 25, No 8
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... Vascular access is the placement of a plastic cannula into a vein for infusion of fluids, medication, blood product, or nutrition and it is one of the most used techniques at all levels of care [1], peripheral intravenous cannulation (PIVC) being the most frequent one [2]. The goals of infusion therapy are to preserve vascular health [3] and to administer needed treatment [4] safely. The selection of the most appropriate vascular access device (VAD) is necessary to avoid potentially severe complications of infection and/or thrombosis, so indications and recommendations must be considered [4]. ...
... The goals of infusion therapy are to preserve vascular health [3] and to administer needed treatment [4] safely. The selection of the most appropriate vascular access device (VAD) is necessary to avoid potentially severe complications of infection and/or thrombosis, so indications and recommendations must be considered [4]. The insertion and care of catheters are nurses' responsibilities. ...
... In different short-term monitoring studies, midline use was associated with a lower risk of infection and bloodstream occlusion versus PICC use. The use of different long-term systems [16,19] may have advantages in the quality of life in specific cases, such as children [20,21], people with difficulties to access peripheral vasculature [9,22], or chronic situations [23] by reducing the need for punctures and their associated complications as well [4]. The impact on quality of life due to vascular access complications has been measured in different studies [23][24][25][26]. ...
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Canalization of vascular accesses is one of the most used techniques in hospitalization units. When talking about peripherally inserted catheters, we can differentiate between peripheral intravenous catheters (PIVC), midline catheters, and long peripheral catheters (LPC). Midline catheters are rarely used despite being recommended for intravenous therapies lasting more than six days. This research is a pilot study of a longitudinal clinical trial. It aims to compare the complications associated with intravenous therapy between the control group (CG) with a PIVC and the experimental group (EG) with a midline in an Internal Medicine Unit of a Spanish hospital for three months. In this study, 44 subjects participated, 25 in the CG and 19 in the EG. The duration of cannulation was longer in the experimental group (8.13 days vs. 3.22, p < 0.001), and the appearance of phlebitis was more significant in the control group (19 patients in CG and 25 patients in EG). Midlines have presented a longer duration of cannulation and fewer complications than the PIVC. This protocol was registered with ClinicalTrials.gov (NCT05512117).
... PICC is a commonly used method for nutrient intravenous delivery, tumor chemotherapy, and drug delivery and has been widely used for tumor patients in clinical treatment [1][2][3]. PICC can be implemented bedside operation, contributing to the infusion of liquid medicine through the blood vessels of the arm directly to the heart vessels, delivering necessary nutrient solution and reducing the pain of patients repeatedly puncture [4][5][6]. In practical application, PICC causes multiple types of complications such as catheter blockage, leakage, catheter ectopic, catheter-related infection, and venous thrombosis [7][8][9][10][11][12]. ...
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Purpose: To explore the clinical value of coagulation index changes in early diagnosis and nursing intervention for PICC-related venous thrombosis in tumor patients. Patients and Methods. A total of 170 tumor patients hospitalized for the first time with catheterization were enrolled from February 2018 to June 2022. According to the diagnostic criteria of venous thromboembolism, high-risk patients with venous thrombosis within 13 days after catheterization were enrolled in the observation group, and those without thromboembolism were enrolled in the control group. Venous blood was taken from all patients on days 1, 5, 9, and 13 after catheterization to measure the change trend of coagulation indexes of patients and to compare the difference of coagulation indexes between the observation group and the control group. Results: PT values of all patients were within the normal reference range at days 1, 5, 9, and 13 after catheterization. Compared with the control group, the observation group was significantly reduced on days 5, 9, and 13 after catheterization (P < 0.05), and continued to decrease with the prolonging of time(P < 0.05). After catheterization, the values of all patients at each time point were lower than the normal reference range. Compared with the control group, the values of tumor patients in the observation group were significantly decreased on days 5, 9, and 13 (P < 0.05) and continued to decrease at each time point (P < 0.05). DD values in the observation group were all higher than the normal reference range on days 1, 5, 9, and 13 after catheterization. Compared with the control group, DD values in the observation group were significantly higher on days 1, 5, 9, and 13 after catheterization (P < 0.05). Conclusion: PT and APTT continued to decrease after catheterization, and DD kept fluctuating at a high level, highly suggesting the possibility of venous thrombosis. The nursing staff should keep high vigilance and give appropriate nursing intervention.
... Central venous catheters (CVCs) are used in perioperative management to monitor central venous pressure (CVP), administer cardiovascular agents and drugs irritating to veins, perform rapid fluid infusion and transfuse blood. However, because CVC insertion is associated with severe mechanical complications, the indications of CVCs are limited [1]. In contrast, the insertion of a peripherally inserted central catheter (PICC) is safer and easier than that of a CVC according to a retrospective study [2]. ...
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Background Although peripherally inserted central catheters (PICCs) have been widely used, they have not been frequently used in anesthesia practice. The central venous pressure measured via PICCs are reportedly as accurate as that measured via central venous catheters (CVCs), but the findings concerning rapid infusion are unclear. This study examined whether or not pressure-resistant PICCs could be used for rapid fluid infusion. Methods The in-line pressure was measured in similar-sized double-lumen catheters—4-Fr PICC (55, 45 and 35 cm) and 17-G CVC (20 and 13 cm)—at flow rates of saline decided using a roller pump system. We also examined the flow rate at an in-line pressure of 300 mmHg, which is the critical pressure at which hemolysis is considered to occur during blood transfusion. Results The pressure-resistant PICCs obtained a high flow rate similar to that of CVCs, but the in-line pressures increased in proportion to the flow rate and catheter length. Flow rates at an intra-circuit pressure of 300 mmHg were not significantly different between the 45-cm PICC and 20-cm CVC. Conclusion Pressure-resistant PICCs can be used for rapid fluid infusion.
... Central venous catheters (CVCs) are used in perioperative management to monitor central venous pressure (CVP), administer cardiovascular agents and drugs irritating to veins, perform rapid uid infusion and transfuse blood. However, because CVC insertion is associated with severe mechanical complications, the indications of CVCs are limited [1]. In contrast, the insertion of a peripherally inserted central catheter (PICC) carries a lower risk of mechanical complications [2] and is technically easier than CVC insertion. ...
Preprint
Full-text available
Background Peripherally inserted central catheters (PICCs) have been widely used because of their low risk of mechanical complications associated with insertion compared with central venous catheters (CVCs). However, PICCs are not widely used for anesthetic management due to concerns regarding the measurement of central venous pressure (CVP) and rapid fluid infusion. The CVP measured via PICCs are reportedly as accurate as that measured via CVC, but the findings concerning rapid infusion are unclear. We therefore investigated the usefulness of a PICC as a rapid infusion route compared with a CVC. Methods The in-line pressure was measured in similar-sized double-lumen catheters - 4-Fr PICC (55, 45 and 35 cm) and 17-G CVC (13 and 20 cm) - at flow rates of saline decided using a roller pump system. We also examined the flow rate at an in-line pressure of 300 mmHg, which is the critical pressure at which hemolysis is considered to occur during blood transfusion. Results In-line pressures increased in proportion to the flow rate and catheter length in both the PICC and CVC. On comparing the 45-cm PICC and 20-cm CVC, the in-line pressures were higher in the PICC than in the CVC at a flow rate of ≤30 mL/min, although the opposite was true at a flow rate of ≥90 mL/min. Flow rates at an intra-circuit pressure of 300 mmHg were not significantly different between the 45-cm PICC and 20-cm CVC. Conclusion A PICC can be used for rapid fluid infusion and blood transfusion, just like a CVC.
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O objetivo foi construir e validar o conteúdo de um formulário de coleta de dados para avaliar o conhecimento e as práticas de enfermeiros sobre as técnicas de inserção do cateter central de inserção periférica (PICC). Trata-se de um estudo metodológico que adotou procedimentos psicométricos para construção e validação de conteúdo. Foi realizada uma revisão da literatura pautada nas recomendações das diretrizes da Infusion Nurse Society (ISN), no Guia para cateter intravenoso (MAGIC) e no documento Saúde e preservação dos vasos: a abordagem certa para o acesso vascular (AVA). O formulário possui 68 itens que foram validados por 9 juízes seguindo a classificação dos sistemas de experts proposto por Jasper e com base nas respostas dos juízes, foi calculado o índice de validade de conteúdo (IVC). A primeira versão possuía 68 itens, após ter sido avaliada pelos Juízes, originou-se uma segunda versão com 78 itens. Todos os itens do formulário tiveram o IVC de 100%. Assim, o formulário pode contribuir para a avaliação utilizada nos cursos de habilitação de PICC e para a avalição dos enfermeiros das instituições de saúde.
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Vascular access specialists are responsible for assessing the patient in their unique situation and determining the correct vascular access device to complete the therapeutic goal without complication or failure. This retrospective cohort study compared the failure rates of a variety of polyurethane (PU) midline catheters and a midline catheter constructed of an emerging hydrophilic biomaterial (HBM). A total of 205 patients received a midline catheter and were situationally randomized by the facility where they received it. Patients who had received a midline catheter between March 2021 and May 2021 were assessed for catheter-related failures leading to increased staff time, delays in treatment, or replacement with a new vascular access device to complete the therapy. There were 101 patients in the PU cohort and 104 patients in the HBM cohort. Comparing overall failure rates between the groups revealed a 23.8% failure rate in the PU control group and only a 3.8% failure rate in the HBM group. This suggests that a midline catheter constructed of HBM biomaterial is associated with significantly lower rates of failure, thereby improving patient experience and health care economics.
Article
Objective: Our objective was to evaluate the cost-effectiveness of the use of peripherally inserted central venous catheters (PICCs) by a vascular access team (VAT) versus central venous catheters (CVCs) for in-hospital total parenteral nutrition (TPN). Methods: The study used a cost-effectiveness analysis based on observational data retrospectively obtained from electronic medical records from 2018 to 2019 in a teaching hospital. We included all interventional procedures requiring PICCs or CVCs with the indication of TPN. We recorded the costs of insertion, maintenance, removal, and complications. The main outcome measure was the incidence rate of catheter-associated bacteremia per 1000 catheter days. Cost-effectiveness analysis was performed from the hospital perspective within the context of the publicly funded Spanish health system. Confidence intervals for costs and effectiveness differences were calculated using bootstrap methods. Results: We analyzed 233 CVCs and 292 PICCs from patients receiving TPN. Average duration was longer for PICC (13 versus 9.4 days, P < 0.001). The main reason for complications in both groups was suspected infection (9.77% CVC versus 5.18% PICC). Complication rates due to bacteremia were 2.44% for CVC and 1.15% for PICC. The difference in the incidence of bacteremia per 1000 catheter days was 1.29 (95% confidence interval, -0.89 to 3.90). Overall, costs were lower for PICCs than for CVCs: the difference in mean overall costs was -€559.9 (95% confidence interval, -€919.9 to -€225.4). Uncertainty analysis showed 86.37% of results with lower costs and higher effectiveness for PICC versus CVC. Conclusions: Placement of PICC by VAT compared with CVC for TPN reduces costs and may decrease the rate of bacteremia.
Chapter
Multiple factors determine the site of vascular access. Choosing the appropriate vascular access plays an important part in the patient management. As a treating physician, one needs to be knowledgeable about the types of vascular access catheters and the options to use in different scenarios. In this chapter, we discuss different types of vascular catheters, indications, insertion techniques and potential complications.
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Background Intravenous vesicants are commonly infused via peripheral intravenous catheters (PIVC) despite guidelines recommending administration via central route. The impact of these medications on PIVC failure is unclear. We aimed to assess dose-related impact of these caustic medications on ultrasound-guided (US) PIVC survivorship. Methods We performed a secondary analysis of a randomized control trial that compared survival of two catheters: a standard long (SL) and an ultra-long (UL) US PIVC. This study involved reviewing and recording all vesicants infusions through the PIVCs. Type and number of vesicants doses were extracted and characterized as one, two or multiple. The most commonly used vesicants were individually categorized for further analysis. The primary outcome was PIVC failure accounting for use and timing of vesicant infusates. Results Between October 2018 and March 2019, 257 subjects were randomized with 131 in the UL group and 126 in the SL group. Vesicants were infused in 96 (37.4%) out of 257 study participants. In multivariable time-dependent extended Cox regression analysis, there was no significant increased risk of failure due to vesicant use [adjusted hazard ratio, aHR 1.71 (95% CI 0.76–1.81) p = 0.477]. The number of vesicant doses was not significantly associated with the increased risk of PIVC failure [(1 vs 0) aHR 1.20 (95% CI 0.71–2.02) p = 0.500], [(2vs 0) aHR 1.51 (95% CI 0.67–3.43) p = 0.320] and [(� 3 vs 0) aHR 0.98 (95% CI 0.50–1.92) p = 0.952]. Conclusion Vesicant usage did not significantly increase the risk of PIVC failure even when multiple doses were needed in this investigation. Ultrasound-guided PIVCs represent a pragmatic option when vesicant therapy is anticipated. Nevertheless, it is notable that overall PIVC failure rates remain high and other safety events related to vesicant use should be considered when clinicians make vascular access decisions for patients.
Article
Full-text available
Peripherally inserted central catheters (PICCs) are being selected for venous access more frequently today than ever before. Often the choice of a PICC, when compared with other vascular access devices (VADs), is attractive because of perceived safety, availability, and ease of insertion. However, complications associated with PICCs exist, and there is a paucity of evidence to guide clinician choice for PICC selection and valid use. An international panel with expertise in the arena of venous access and populations associated with these devices was convened to clarify approaches for the optimal use of PICCs and VADs. Here we present for the busy hospital-based practitioner the methodology, key outcomes, and recommendations of the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) panelists for the appropriate use of VADs. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine.
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A review on current aspects of treatment, complications and prevention of intravascular catheter-related infections is out lineal. Practical aspects an how to treat these kind of infections are discussed. Results obtained in the multicenter study carried out by the Group of Infections from the 'Sociedad Espanola de Medicina Intensiva y Unidades Coronarias' are presented.
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Approximately every 5 years, the Infusion Nurses Society publishes evidence-based practice standards. This article provides an overview of the process used in standards development, describes the format of the standards, and provides a short summary of selected standards as applied to home care. The Standards are an important document that should be available to every home care organization that provides home infusion therapy.
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Vascular access is an important part of many patient care management plans but has some unwanted risks. Previous work published by Moureau et al. (2012) inspired a working group led by the UK Infection Prevention Society (IPS) to produce a vessel health and preservation (VHP) framework. This was with the intention of producing a resource for frontline staff to be able to assess and select the best vascular access device to meet the individual patient’s needs and to preserve veins for future use. The working group produced a framework that used available evidence, expert opinion and some small scale testing of the components of the framework. The work so far has received positive feedback but further work is required to formally evaluate the VHP framework in clinical practice to measure both staff knowledge and patient outcomes.
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Background: Peripherally inserted central catheters (PICCs) are increasingly used in hospitalized patients. Yet, little is known about the vascular access nurses who often place them. Methods: We conducted a Web-based survey to assess vascular access nursing experience, practice, knowledge, and beliefs related to PICC insertion and care in 47 Michigan hospitals. Results: The response rate was 81% (172 received invitations, 140 completed the survey). More than half of all respondents (58%) reported placing PICCs for ≥5 years, and 23% had obtained dedicated vascular access certification. The most common reported indications for PICC insertion included intravenous antibiotics, difficult venous access, and chemotherapy. Many respondents (46%) reported placing a PICC in a patient receiving dialysis; however, 91% of these respondents reported receiving approval from nephrology prior to insertion. Almost all respondents (91%) used ultrasound to find a suitable vein for PICC insertion, and 76% used electrocardiography guidance to place PICCs. PICC occlusion was reported as the most frequently encountered complication, followed by device migration and deep vein thrombosis. Although 94% of respondents noted that their hospitals tracked the number of PICCs placed, only 40% reported tracking duration of PICC use. Relatedly, 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness. Conclusion: This survey of vascular nursing experiences highlights opportunities to improve practices such as avoiding PICC use in dialysis, better tracking of PICC dwell times, and necessity. Hospitalists may use these data to inform clinical practice, appropriateness, and safety of PICCs in hospitalized patients. Journal of Hospital Medicine 2015. 2015 Society of Hospital Medicine.
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Insertion of peripheral venous cannulas is one of the most frequently performed procedures in hospitals. In the UK, one in three patients will have at least one cannula inserted while in hospital. Cannula insertion is uncomfortable and causes anxiety and distress to patients. The risks associated with this include infection, phlebitis and infiltration. In the UK, it is widely accepted that cannulas should be routinely changed every 72-96 hours in line with national guidelines ( Department of Health (DH) 2007 ). The updated epic3 guidelines recommend to change cannulas when clinically indicated, rather than routinely. The objective in a local NHS trust, was to look at the evidence for this, with an aim to change local policy and practice to reflect the new recommendation. The primary outcomes of the first 6 months from implementation suggest that patients have not been adversely affected. The change to practice has provided a significant reduction in financial costs to the trust, enabling a stock reduction of 25%. It is estimated that a total of 11 750 clinical hours have been saved for busy clinical staff. The most important outcome has been for patients, who have been spared the unnecessary pain and potential risks associated with repeated insertion of cannulas when there has been no clinical indication to do this.
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Introduction: Establishing an effective midline program involves more than simply learning an insertion technique for a new product. Midline catheters provide a reliable vascular access option for those patients with difficult venous access who would otherwise require multiple venipunctures or the use of higher-risk central lines to maintain access. An effective midline program establishes a protocol for device selection and includes standing orders to facilitate speed to placement. Methods: Our retrospective descriptive review evaluated the successful integration of midline programs into existing vascular access bedside insertion programs in 2 acute care hospitals. The investigator reviewed a convenience sample of hospital patients. Participants in the study included vascular access team managers and team members from the sample sites. Results: The results of this 2-hospital study demonstrate successful integration of a midline program into a bedside insertion program with 0 midline-related infections since initiation. Documentation of overall central line-associated bloodstream infection rates for hospital 1 changed from 1.7/1000 catheter-days to 0.2/1000 catheter-days, reflecting a 78% reduction in infections and a projected cost avoidance of $531,570 annually. Both hospitals demonstrated reduced rates of infection following implementation of a midline program. Conclusions: Midlines have a history of lower risk for both infection and thrombosis compared with central venous devices. Although more research is needed on the more recently developed midline catheters, available evidence suggests that midlines provide a safe and reliable form of vascular access, reducing costs and the risk of infection associated with central venous catheters, especially those placed solely for patients with difficult venous access.
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Background: The objective of this study was to compare the incidence of catheter-related bloodstream infection (CRBSI) with the use of second-generation chlorhexidine-silver sulfadiazine (CHSS)-impregnated catheters, rifampicin-miconazole (RM)-impregnated catheters, and standard catheters. Methods: Retrospective study of patients admitted to an intensive care unit who received CHSS, RM, or standard catheters in femoral venous access. Results: We diagnosed 18 CRBSIs in 245 patients with standard catheters in 2,061 days, zero CRBSI in 169 patients with CHSS-impregnated catheters in 1,489 days, and zero CRBSI in 227 patients with RM-impregnated catheters in 2,009 days. Patients with standard catheters compared with CHSS- and RM-impregnated catheters showed a higher rate of CRBSI (7.3%, 0%, and 0%, respectively; P < .001) and higher incidence density of CRBSI (8.7, 0, and 0 per 1,000 catheter days, respectively; P < .001). We found in the exact Poisson regression that standard catheters were associated with a higher CRBSI incidence than CHSS-impregnated catheters (P < .001) and RM-impregnated catheters (P < .001), controlling for catheter duration. We found in survival analysis that standard catheters were associated with a lower CRBSI-free time than CHSS-impregnated catheters (P < .001) and RM-impregnated catheters (P < .001). Conclusion: We found that CHSS- and RM-impregnated catheters decreased similarly the risk of CRBSI.