Device selection for patients with cancer

Common language facilitates communication between professional and organisations, the translation of evidence into clinical practice, data sharing, and research. CNSA, eviQ and eviQ Education are leading vascular access management and education in cancer care in Australia utilizing common, contemporary terminology (Table 1).

Table 1: CVAD terminology

Successful vascular access outcomes begin with appropriate device selection and maximising first insertion success to reduce VAD related complication, premature removal and reinsertion rates. This also minimises patient distress and pain and facilitates patient safety (3-5). This process includes -

• Consultation: with appropriate healthcare teams e.g. vascular access, renal, infectious diseases, pharmacy (2, 3, 6-10)
• Device: insertion of the smallest size catheter required for the therapy in the largest vein including peripheral intravenous cannulas (10), fewest number of lumens and least invasive VAD for the required therapy (11-13)
• Vein: insertion into the largest vein in the healthiest tissues avoiding injured areas (3, 14), avoiding areas of flexion (15)
• Timeframe: at earliest opportunity e.g. 24-48 hours after determining need for intravenous therapy
• Evaluation: with daily assessment for continued needs of the VAD (7, 12, 16)

The device selection process is standardised via algorithms documented in clinical procedures or electronic medical record order sets (5, 17-19), or with criteria for appropriateness considering multiple clinical scenarios (2, 8). The process commonly commences with identifying the urgency of the selection (emergent or elective), then proceeds to assessment of the type of therapy (peripherally or centrally compatible) and duration (days, weeks, months, years) of therapy. If the therapy is peripherally compatible, a peripheral venous assessment is performed (1, 18).

Device selection describes core time-related, patient-related, device-related, therapy-related, and workplace-related factors (1, 2, 4, 7, 17, 20, 21) which focuses the process on the patients’ needs and minimises clinician preferences and biases (20). These factors will be detailed in the following sections.

SUMMARY OF RECOMMENDATIONS

1. Education

CNSA recommends patient, family and healthcare team education includes VAD selection considering all relevant factors that may influence the decision for adult and paediatric patients with cancer to make an informed decision (8, 9, 13, 17, 19, 22-35) including:

• Patient-related factors: diagnosis and comorbidities, venous assessment, age, current pathology, and cognition and collaboration capacity.
• Time related factors: emergent or elective
• Therapy-related factors: type (peripheral or central compatibility), number and compatibility of therapies, timing (administration speed, duration - days, weeks, months, years, frequency - intermittent, continuous), intensity, setting (acute, ambulatory, community, home), and potential adverse effects.
• Workplace-related factors: availability of a range of VADs, access to technology (ultrasound, near infrared imaging), education of the healthcare team, patient and family, inclusion of the device selection process in clinical practice and procedures, VAD selection outcomes recorded in patient health records. Potential VADs include PIVCs, midlines, PICCs, CICCs, tc-CICCs, TIVAD and high flow CVADs e.g. apheresis CICCs/TIVADs or haemodialysis CICCs.
• Evaluation: including daily assessment for continued need of the VAD

GRADE Ib

2. Time related factors

CNSA recommends selection of the most appropriate vascular access device for elective insertion is accomplished within 24-48 hours from determining the need for intravenous therapy. Emergent VAD selection is determined by the medical needs of the patient (1-3, 5, 17, 18, 21, 23, 36).

GRADE Ib

3. Patient related factors

CNSA recommends patient-related factors are considered during the device selection process including:

• 3.1 Patient choice including values, experiences and preferences, capacity for collaboration for VAD maintenance, social relationships and support, and health literacy (7, 25, 30, 32, 33, 35, 37-81).

GRADE III

• 3.2 Diagnoses, comorbidities and the associated pathophysiology including:
  • Acute or chronic renal failure (2, 3, 6-9) GRADE V
  • Oncology or malignant haematology disease (19, 20, 56, 58, 82-85). GRADE III
  • Non-malignant haematological disorders e.g. haemophilia (20, 86). GRADE V
  • Disorders of the gastrointestinal tract, conditions or surgery that may require short or long-term parenteral nutrition (2, 8, 11, 87-92). GRADE Ib
  • History of thrombosis (2, 24, 93, 94). GRADE Ib
  • Diabetes (7, 95). GRADE IV
  • Increased or decreased body mass index or body habitus (7, 42, 85, 96, 97). GRADE IV

3.3 Venous assessment including:

• Peripheral and central veins (2, 7, 17, 22, 98). GRADE Ib
• Number, visibility, palpability, and condition of veins (19, 99-110). GRADE IV
• Vein size: vein diameter to calculate catheter to vein ratio occupying <45% for adult patients diagnosed with cancer and <40% for paediatric patients (10, 13, 111). GRADE Ib
• Using palpation or visual inspection (19). GRADE V
• Using assistive visual technology, for example ultrasound, near infrared (1, 2, 63, 95, 112-119). GRADE IV

3.4 Age including paediatric patients with congenital or age related diagnoses (21). GRADE V

3.5 Pathology results including full blood examination, coagulation profile and renal function (2, 3, 6-9). GRADE Ib

4. Therapy related factors

CNSA recommends therapy-related factors are considered during the device selection process including:

4.1 Type of therapy including:

• Infusate/s characteristics (peripheral or centrally compatibility) including osmolarity, pH, viscosity, vesicant, irritant, or vasoactivity of the infusate (1, 2, 7, 18, 31). GRADE Ib
• Number and compatibility of infusates (21). GRADE V
• Consult pharmacist in the healthcare team as required (120). GRADE IV

4.2 Time related factors including:

• Intensity e.g. (for autologous or allogeneic bone marrow transplant) (1, 2, 6, 7, 121). GRADE Ib
• Frequency GRADE CC
• Speed GRADE CC
• Duration GRADE CC

4.3 Setting including potential transition between inpatient, outpatient, community or home, e.g. home parenteral nutrition, infusional chemotherapy or antibiotics (7, 16, 20). GRADE V

4.4 Potential side effects including bleeding, clotting, inflammation and infection (7). GRADE V

Refer to eviQ protocols for information about central or peripheral compatibility of SACTs for haematological cancers and solid tumour cancers.

5. Device related factors

CNSA recommends all types of VADs available within a workplace are considered during the device selection process potentially including:

5.1 Peripheral VADs

• 5.1.1 Standard (short) PIVCs are appropriate for:
  • administration of peripherally compatible infusates (2, 7)
  • for short duration (Table 3, Table 4)
  • patients with good veins (2, 17, 20) or DIVA (2)
  • preferred VAD for patients with haemophilia (86)
  • peripherally compatible chemotherapy < 3 months (2)
  • can be used for apheresis procedures (115)
  • GRADE Ib
• 5.1.2 Ultrasound guided (USG) PIVCs:
  • e.g. up to 7-8cm (5, 122)
  • non vesicants of dwell time of up to 28 days (2, 6, 7, 17, 20) (Table 3)
  • patients with DIVA (2, 7, 108)
  • alternative for regularly replaced standard PIVCs in paediatrics (123)
  • GRADE Ib
• 5.1.3 PIVCs with additional features:
  • retractable coiled guidewire for insertion (124).
  • wings and injection port (open port with no needleless connector) (125) or wings, injection port and instant blood flashback (126-128). NOTE: Analyses of the dwell time were not included.
  • different materials (129, 130)
  • cannula with outlet via holes on the side e.g. for computed tomography (131)
  • GRADE I
• 5.1.4 Midlines
  • suitable only for peripherally compatible infusates only e.g. green coded infusates
  • shorter term duration – days to weeks (2, 108, 132-136)
  • potential to reduce insertion of more invasive devices e.g. PICCs (17, 22, 137, 138) or repeated venepuncture over short term e.g. days to weeks (139)
  • avoid use with patients with a history of thrombosis, hypercoagu­lability (7).
  • GRADE Ib

5.2 CVADs

• 5.2.1 PICC
  • inpatient, ambulatory/outpatient or home settings (2)
  • paediatrics, adults to palliative care, including end of life care (2, 65, 92, 140-143)
  • for home parenteral nutrition (87), vesicants or inotropes (108), chemotherapy ≥3 months (2), haemodynamic monitoring for critically unwell patients (2, 94), autologous or allogeneic transplant (140)
  • tunnelled PICC: optimal exit site via tunnelling the catheter from the appropriate venepuncture site (for catheter to vein ratio) to area of comfort for the patient and flat area for dressing management reduces complications (144). Alternately, for patients with chest pathology impeding upper body placement, an alternative is PICC insertion via the femoral vein using intracavity ECG for optimal tip position, in the inferior vena cava above the level of the diaphragm (145)
  • complications, or vein size may vary according to right, left side or hand dominance (146, 147) with less complications on right side PICCs (59, 148)
  • GRADE Ib
• 5.2.2 TIVAD
  • inpatient, ambulatory/outpatient or home settings
  • longer term therapies (2) e.g. chemotherapy and preferred by patients for chemotherapy (35, 45, 54, 58, 74, 75, 83, 149-155) or high flow procedures e.g. apheresis (156, 157)
  • traditional site is anterior upper chest, alternative sites in paediatric and adult patients (158, 159): arm-TIVAD (7, 32, 160-165) e.g. for patients with breast cancer (50, 166-168), lateral chest in deltopectoral groove (169), trapezius region (170) or via different veins (171, 172) e.g. internal jugular, subclavian veins (173-175)
  • insertion with appropriate sedation, pain relief or distraction therapy, e.g. virtual reality (176) during and possibly after the insertion procedure (54, 71, 177-181)
  • GRADE Ib
• 5.2.3 tc-CICC
  • can be used for inpatient, ambulatory/outpatient or home settings
  • longer term therapies e.g. months/years, for SACTs, commonly via internal jugular, or when PICC is not feasible (1, 2, 182, 183)
  • GRADE Ib
• 5.2.3 CICC / FICC
  • inpatient use (7)
  • dhort term use (1, 2) unless tunnelled
  • e.g. parenteral nutrition, vesicant, inotropes (108), apheresis procedures (184)
  • GRADE Ib

6. Workplace factors

CNSA recommends the workplace facilitates implementation of a device selection strategy within clinical practice by:

• 6.1 Education of the healthcare team including the patient and family (19, 185). GRADE IV
• 6.2 Documentation of a device selection algorithm within patient health records and procedures. GRADE CC
• 6.3 Vascular access teams (VATs) if available, provide expert advice in the device selection process (9, 20, 22, 24, 36, 75, 117, 186-188). GRADE IV
• 6.4 Availability of a range of VAD types and appropriately educated and competent clinicians for insertion (7, 9). GRADE V

7. Evaluation

CNSA recommends the standardised daily assessment of a VAD via a validated tool, for example I-DECIDED to evaluate the VAD selection and the continued use of the VAD (1, 12, 18, 189).

GRADE V

1.1 Summary of evidence

Education of the healthcare team including the patient and family is a cornerstone of clinical practice.

Education about a standardised, evidence-based approach to device selection for the individual patient and required prescribed therapy is critical (31, 71). An algorithm or decision making tree included in workplace procedures provides a consistent approach for implementation by all members of the healthcare team (8, 9, 17, 22-28) and considers cancer related therapies (19).

1.2 Practice Recommendation

CNSA recommends the patient, family and healthcare team are educated about appropriate vascular access device selection, considering all relevant factors that may influence the decision including systemic anticancer therapies (8, 9, 13, 17, 19, 22-31, 35).

GRADE Ib

2.1 Summary of evidence

The emergent or elective need for vascular access initially determines the most appropriate VAD (1, 2, 21). Peripheral intravenous cannulas, intraosseous or centrally inserted central catheters can be inserted in medical emergencies (1, 2, 17, 18, 23). Time to make an informed decision for elective insertions enables consultation and consideration of key factors which potentially impact the shared decision-making process. This should be accomplished within 24-48 hours from determining the need for intravenous therapy (3).

2.2 Practice Recommendation

CNSA recommends selection of the most appropriate vascular access device for elective insertion is accomplished within 24-48 hours from determining the need for intravenous therapy. Emergent VAD selection is determined by the medical needs of the patient (1-3, 5, 17, 18, 21, 23, 36).

GRADE Ib

3.1 Summary of evidence

Patient related factors which impact the suitability of one type of VAD compared to another include:

A. Patient choice, cognition, collaboration

A patient’s values, experiences and preferences are fundamentally important to consider during the device selection process (25, 30, 32, 33, 35, 37-79, 83). Other factors include their capacity for collaboration for VAD maintenance, social relationships and support, and health literacy (7, 80, 190).

B. Diagnosis

Consideration of a patient’s diagnosis, comorbidities and the associated pathophysiology influence the device selection process and inform which members of the healthcare team need to be consulted (for example nephrology, oncology/haematology, infectious diseases) include:

• acute and chronic renal failure e.g. Stage 3b or greater (2, 3, 6-9) will determine if veins will be required for future haemodialysis and exclude the use of peripheral veins
• oncology or malignant haematology disease (19, 20, 56, 58, 82-85)
• non-malignant haematological disorders e.g. haemophilia (20, 86)
• disorders of the gastrointestinal tract, conditions or surgery that may require short or long-term parenteral nutrition (2, 8, 11, 87-92).
• history of thrombosis (2, 24, 93, 94).
• diabetes with associated delayed healing and potential increased risk of infection (7, 23, 95).
• increased or decreased body mass index or body habitus (7, 42, 85, 96, 97).
• tracheostomy adjacent to a upper chest CVAD potentially increasing the risk of infection (7).

C. Venous assessment

Assessment of a patient’s peripheral and central veins is critical for device selection (2, 7, 17, 22, 98) including the number, visibility, palpability, and condition of veins (19, 99-110). Vein size, that is the diameter of the vein, is used when calculating the catheter to vein ratio (CVR): the proportion of the vein that the catheter or cannula occupies. This is relevant for PIVC and CVAD insertion (10) with CVR< 45% for adult patients diagnosed with cancer (111) and CVR<40% recommended for paediatric patients (13). Assessment can be graded, for example according to the number of veins (1, 100, 104), with or without a torniquet (107, 191), using different techniques e.g. assistive visual technology (ultrasound, NIR) (1, 2, 63, 95, 112-119), palpation, visual inspection (19) or description using key terms, which may be open to interpretation (18) e.g. excellent, good, sufficient, poor (17, 22, 103).

Venous assessment facilitates early identification of patients with difficult intravenous access (DIVA) to enable the selection of the most appropriate device from the outset (2, 18) which may include long PIVCs into deeper, larger veins via ultrasound, midlines (138) or CVADs (1). Short PIVC are avoided (7).

D. Age

Additional factors that require consideration when selecting the most appropriate VAD for paediatric patients include congenital heart disease or surgery, abnormal vascular anatomy, skin conditions e.g. epidermolysis bullosa (6, 21).

E. Pathology

Assessment of a patient’s blood pathology results include: (7)

• Coagulation profile and platelets for implanted and tunnelled VADs
• Full blood count e.g. neutrophils for the risk of infection
• Renal function e.g. acute or chronic dysfunction as identified earlier (2, 3, 6-9)

3.2 Practice Recommendation

CNSA recommends patient-related factors are considered during the device selection process including:

• 3.2.1 Patient choice including values, experiences and preferences, capacity for collaboration for VAD maintenance, social relationships and support, and health literacy (7, 25, 30, 32, 33, 35, 37-81).

GRADE III

• 3.2.2 Diagnoses, comorbidities and the associated pathophysiology including:
  • Acute or chronic renal failure (2, 3, 6-9) GRADE V
  • Oncology or malignant haematology disease (19, 20, 56, 58, 82-85). GRADE III
  • Non-malignant haematological disorders e.g. haemophilia (20, 86). GRADE V
  • Disorders of the gastrointestinal tract, conditions or surgery that may require short or long-term parenteral nutrition (2, 8, 11, 87-92). GRADE Ib
  • History of thrombosis (2, 24, 93, 94). GRADE Ib
  • Diabetes (7, 95). GRADE IV
  • Increased or decreased body mass index or body habitus (7, 42, 85, 96, 97). GRADE IV
• 3.2.3 Venous assessment including:
  • Peripheral and central veins (2, 7, 17, 22, 98). GRADE Ib
  • Number, visibility, palpability, and condition of veins (19, 99-110). GRADE IV
  • Vein size: vein diameter to calculate catheter to vein ratio occupying <45% for adult patients diagnosed with cancer and <40% for paediatric patients (10, 13, 111). GRADE Ib
  • Using palpation or visual inspection (19). GRADE V
  • Using assistive visual technology, for example ultrasound, near infrared (1, 2, 63, 95, 112-119). GRADE IV
• 3.2.4 Age including paediatric patients with congenital or age related diagnoses (21). GRADE V
• 3.2.5 Pathology results including full blood examination, coagulation profile and renal function (2, 3, 6-9). GRADE Ib

4.1 Summary of evidence

Therapy-related factors that impact the appropriateness of one type of VAD compared to another include:

A. Type of therapy

Firstly, establish if the infusates are peripherally or centrally compatible. Some infusates are not safe for administration through peripheral veins as they can damage the lining of the vein and require central veins with large diameters and adequate haemodilution. Infusate characteristics that need to be considered are: osmolarity, pH, viscosity, vesicant, irritant, or vasoactivity of the infusate (1, 2, 7, 18, 31) (Table 2).

The number and compatibility of concurrent infusates also needs to be considered for type of VAD and the number of lumens required e.g. methotrexate, leucovorin are administered on a separate lumen (21). Collaborate with the pharmacist in the healthcare team during the device selection process as required (120).

Table 2. Summary of literature: infusate characteristics for administration in peripheral and central veins.

*Summary of evidence and not recommendations for practice

Published tools can colour code infusates according to the risk of damage, irritation or thrombosis of the vein, for example red, yellow or green which use a traffic light concept. Green or lower risk infusates are compatible for peripheral administration, peripheral administration with caution is recommended for the yellow coded or intermediate risk category and central administration is recommended for red or high risk category infusates (19, 21). Infusates can be categorised according to their vesicant, irritant, or non-vesicant properties (19).

B. Time-related factors

The speed of administration (2.5mL per hour to >100 mL /min for fluid resuscitation), duration of therapy (days, weeks, months, ongoing), frequency (intermittent – daily or 1-4 weekly, or continuously), intensity (for autologous or allogeneic bone marrow transplant) will determine whether peripheral or central administration is appropriate (1, 2, 6, 7, 121) e.g. large diameter VADs with multiple lumens into large veins for rapid fluid resuscitation, intermittent or peripherally compatible therapies via a PIVC or midline, continuous or intense therapies via a CVAD.

Recommendations for VADs according to the duration and type of therapy in the literature are summarised in Table 3 and Table 4.

Table 3. Summary of literature: VADs for administration of peripherally and centrally compatible infusates in adult patients

Table 4. Summary of literature: VADs for administration of peripherally and centrally compatible infusates in paediatric patients

C. Setting

Patients with cancer can transition between acute, ambulatory/outpatient, community and home settings during the administration of prescribed therapies. Consideration of therapy continuing on an outpatient basis, e.g. home parenteral nutrition, infusional chemotherapy or antibiotics needs to be considered during the device selection process (7, 16, 20).

D. Potential side effects of therapy

Bleeding, clotting, inflammation and infection risks associated with the adverse effects of prescribed therapy are considered during the device selection process (7) e.g. risk of considerable bruising with insertion of a tunnelled or subcutaneous CVAD or repeated needle access into a TIVAD in a thrombocytopenic or coagulopathic patient, infection risk of CVAD insertion during periods of profound neutropenia, or the infection risk between TIVADs and external catheters e.g. PICC, CICCs.

4.2 Practice Recommendation

CNSA recommends therapy-related factors are considered during the device selection process including:

• 4.2.1 Type of therapy including:
  • Infusate/s characteristics (peripheral or centrally compatibility) including osmolarity, pH, viscosity, vesicant, irritant, or vasoactivity of the infusate (1, 2, 7, 18, 31). GRADE Ib
  • Number and compatibility of infusates (21). GRADE V
  • Consult pharmacist in the healthcare team as required (120). GRADE IV
• 4.2.2 Time related factors including:
  • Intensity e.g. (for autologous or allogeneic bone marrow transplant) (1, 2, 6, 7, 121). GRADE Ib
  • Frequency GRADE CC
  • Speed GRADE CC
  • Duration GRADE CC
• 4.2.3 Setting including potential transition between inpatient, outpatient, community or home, e.g. home parenteral nutrition, infusional chemotherapy or antibiotics (7, 16, 20). GRADE V
• 4.2.4 Potential side effects including bleeding, clotting, inflammation and infection (7). GRADE V

Refer to eviQ protocols for information about central or peripheral compatibility of SACTs for haematological cancers and solid tumour cancers.

5.1 Summary of evidence

A. PIVC

Clinical expertise is critical to determine whether a PIVC is appropriate (20). Carr and colleagues (2017) discussed the 80% rule: PIVCs are not inserted unless the clinician is 80% sure it will be used. The aim was to reduce the rate of PIVCs that were inserted and not used (203, 204). This was validated in an implementation study by Hawkins and colleagues (2018) increasing the insertion of clinically indicated PIVCs in the emergency department (205).

Standard (short) PIVCs are appropriate for:

• administration of peripherally compatible infusates (2, 7)
• for short duration (Table 3, Table 4)
• patients with good veins (2, 17, 20) or DIVA (2)
• and preferred VAD for patients with haemophilia (86)
• peripherally compatible chemotherapy < 3 months (2)
• conflicting information about blood sampling - frequent blood sampling ≤ 5 days (2) or recommended not for blood sampling (20)
• can be used for apheresis procedures (115)

Ultrasound guided (USG) PIVC

• e.g. up to 7-8cm (5, 122)
• non vesicants of dwell time of up to 28 days (2, 6, 7, 17, 20) (Table 3)
• patients with DIVA (2, 7, 108)
• alternative for regularly replaced and multiple standard PIVCs in paediatrics (123)

PIVC with additional features:

• retractable coiled guidewire for insertion: two studies investigating PIVCs with retractable coiled guidewires had conflicting results –
  • a randomised controlled study (RCT) of 248 surgical adolescent participants recorded considerably greater first time success rates and more patients completed therapy with PIVCs with guidewires compared to standard PIVCs (124)
  • a RCT in interventional radiology demonstrated no difference between the standard cannula and one with a retractable coiled guidewire, however this could be explained by the inserters having extensive experience with standard cannula, which additionally had blood control (206)
• wings and injection port (open port with no needleless connector): superior handling rating for insertion in large RCT compared to standard PIVC (125). Or improved first insertion success with a cannula with wings, injection port and instant blood flashback (126, 127) which facilitated more rapid feedback about blood return (128). Analysis of the dwell time was not included.
• different materials (129) and additional to this review, a systematic review of different materials (130)
• cannula with outlet via holes on the side e.g. for computed tomography (131)

B. Midline

Midlines are an alternative to the USG-PIVCs in deep veins, similarly they are used for the administration of peripherally compatible infusates only and are approximately 8-20cm in length (116). Midlines can be:

• inserted to potentially reduce the use of more invasive devices e.g. PICCs (17, 22, 137, 138)
• for shorter term duration – days to weeks (2, 108, 132-136)
• reduces repeated venepuncture over the short term e.g. days to weeks (139)
• high risk patients requiring more than five days of therapy e.g. patients with pneumonia, undergoing surgery, gastrointestinal bleed, respiratory disease (207)
• for the paediatric patient, the distal tip of midlines do not terminate in joint spaces, enter the central circulation, or enter the pelvic region (22)

Avoid the use of midlines for patients with a history of thrombosis, hypercoagu­lability related to the risk of thrombosis or renal disease for potential future haemodialysis (7).

There is no evidence for the safe administration of SACTs via a midline. The location of the midline catheter tip in a deeper vein compared to a PIVC (in a superficial vein) may lead to a delay in detecting an extravasation and potentially more extensive extravasation injury or injury of anatomical structures, for example arteries and nerves (139). Also cautious use of midlines in critical care settings for potential short-term administration of irritants in emergent situations until CVAD insertion is achieved (208).

C. CVADs

• CVAD characteristics include:
  • single or multiple lumens
  • standard or power-injectable
  • non-valved or valved (distal or proximal) (209)
  • tunnelled or non-tunnelled
  • standard or cuffed catheters
  • standard or coated e.g. anti-infective or antithrombotic coating (202)
  • totally implantable venous access devices – chest, arm
  • large diameter catheters for apheresis and haemodialysis procedures

CVADs are suitable for administration of peripherally compatible infusates and centrally compatible infusates, as noted in the section above (Table 3 and 4). CVAD uses include:

• PICC
  • can be used for inpatient, ambulatory/outpatient or home settings
  • paediatrics, adults to palliative care, including end of life care (2, 65, 92, 140-143)
  • home parenteral nutrition (87), vesicants or inotropes (108), chemotherapy ≥3 months (2), haemodynamic monitoring for critically unwell patients (2, 94), autologous or allogeneic transplant (140)
  • optimal exit site location via tunnelling the catheter from the appropriate venepuncture site (for catheter to vein ratio) to area of comfort for the patient and flat area for dressing management reduces complications (144). Alternately, for patients with chest pathology impeding upper body placement, an alternative is PICC insertion via the femoral vein using intracavity ECG for optimal tip position, in the inferior vena cava above the level of the diaphragm (145)
  • complications, or vein size may vary according to right, left side or hand dominance (146, 147) with less complications on right sided PICCs (59, 148)
• TIVAD
  • can be used for inpatient, ambulatory/outpatient or home settings
  • for administration of longer term therapies (Table 3), e.g. chemotherapy and preferred by patients for chemotherapy (35, 45, 54, 58, 74, 75, 83, 149-155) or high flow procedures e.g. apheresis (156, 157)
  • traditional site is on anterior upper chest, with alternative sites in paediatric and adult patients (158, 159): arm-TIVAD (7, 32, 160-165) e.g. for patients with breast cancer (50, 166-168), lateral chest in deltopectoral groove (169), trapezius region (170) or via different veins (171, 172) e.g. internal jugular, subclavian veins (173-175)
  • with appropriate sedation, pain relief or distraction therapy, e.g. virtual reality (176) during and possibly after the insertion procedure (54, 71, 177-181)
• tc-CICC
  • can be used for inpatient, ambulatory/outpatient or home settings
  • for administration of longer term therapies e.g. months/years, for SACTs, commonly via internal jugular, or when PICC is not feasible (1, 2, 182, 183)
• CICC / FICC
  • inpatient use (7)
  • short term use (1)
  • e.g. parenteral nutrition, vesicant, inotropes (108), apheresis procedures (184)

For patients with haemophilia, PIVCs are preferred compared to CVAD (86). CVADs are inserted if the patient has no active infections including severe dental problems, has no history of CVAD related thrombosis, the patient and family adhere with the maintenance requirements, and removed as soon as no longer required (86).

5.2 Practice Recommendation

CNSA recommends all types of VADs available within a workplace are considered during the device selection process potentially including:

5.2.1 Peripheral VADs

• Standard (short) PIVCs are appropriate for:
  • administration of peripherally compatible infusates (2, 7)
  • for short duration (Table 3, Table 4)
  • patients with good veins (2, 17, 20) or DIVA (2)
  • preferred VAD for patients with haemophilia (86)
  • peripherally compatible chemotherapy < 3 months (2)
  • can be used for apheresis procedures (115)
  • GRADE Ib
• Ultrasound guided (USG) PIVCs:
  • e.g. up to 7-8cm (5, 122)
  • non vesicants of dwell time of up to 28 days (2, 6, 7, 17, 20) (Table 3)
  • patients with DIVA (2, 7, 108)
  • alternative for regularly replaced standard PIVCs in paediatrics (123)
  • GRADE Ib
• PIVCs with additional features:
  • retractable coiled guidewire for insertion (124).
  • wings and injection port (open port with no needleless connector) (125) or wings, injection port and instant blood flashback (126-128). NOTE: Analyses of the dwell time were not included.
  • different materials (129, 130)
  • cannula with outlet via holes on the side e.g. for computed tomography (131)
  • GRADE I
• Midlines
  • suitable only for peripherally compatible infusates only e.g. green coded infusates
  • shorter term duration – days to weeks (2, 108, 132-136)
  • potential to reduce insertion of more invasive devices e.g. PICCs (17, 22, 137, 138) or repeated venepuncture over short term e.g. days to weeks (139)
  • avoid use with patients with a history of thrombosis, hypercoagu­lability (7).
  • GRADE Ib

5.2.2 CVADs

• PICC
  • inpatient, ambulatory/outpatient or home settings (2)
  • paediatrics, adults to palliative care, including end of life care (2, 65, 92, 140-143)
  • for home parenteral nutrition (87), vesicants or inotropes (108), chemotherapy ≥3 months (2), haemodynamic monitoring for critically unwell patients (2, 94), autologous or allogeneic transplant (140)
  • tunnelled PICC: optimal exit site via tunnelling the catheter from the appropriate venepuncture site (for catheter to vein ratio) to area of comfort for the patient and flat area for dressing management reduces complications (144). Alternately, for patients with chest pathology impeding upper body placement, an alternative is PICC insertion via the femoral vein using intracavity ECG for optimal tip position, in the inferior vena cava above the level of the diaphragm (145)
  • complications, or vein size may vary according to right, left side or hand dominance (146, 147) with less complications on right side PICCs (59, 148)
  • GRADE Ib
• TIVAD
  • inpatient, ambulatory/outpatient or home settings
  • longer term therapies (2) e.g. chemotherapy and preferred by patients for chemotherapy (35, 45, 54, 58, 74, 75, 83, 149-155) or high flow procedures e.g. apheresis (156, 157)
  • traditional site is anterior upper chest, alternative sites in paediatric and adult patients (158, 159): arm-TIVAD (7, 32, 160-165) e.g. for patients with breast cancer (50, 166-168), lateral chest in deltopectoral groove (169), trapezius region (170) or via different veins (171, 172) e.g. internal jugular, subclavian veins (173-175)
  • insertion with appropriate sedation, pain relief or distraction therapy, e.g. virtual reality (176) during and possibly after the insertion procedure (54, 71, 177-181)
  • GRADE Ib
• tc-CICC
  • can be used for inpatient, ambulatory/outpatient or home settings
  • longer term therapies e.g. months/years, for SACTs, commonly via internal jugular, or when PICC is not feasible (1, 2, 182, 183)
  • GRADE Ib
• CICC / FICC
  • inpatient use (7)
  • dhort term use (1, 2) unless tunnelled
  • e.g. parenteral nutrition, vesicant, inotropes (108), apheresis procedures (184)
  • GRADE Ib

6.1 Summary of evidence

Several factors that potentially impact device selection process include:

• Education and procedures: As discussed earlier, availability and frequency of education of the healthcare team including the patient, and inclusion of device selection algorithms within workplace policy is key to standardised, evidence-based device selection and the different types of VADs (19, 185).
• Vascular access teams (VATs) if available, provide expert advice in the device selection process (9, 20, 22, 24, 36, 75, 117, 186-188).
• Availability of different types VADs: is required for the device selection process (7-9). Not all workplaces stock all types of devices and have trained clinicians to insert the different VADs.

6.2 Practice Recommendation

CNSA recommends the workplace facilitates implementation of a device selection strategy within clinical practice by:

• 6.2.1 Education of the healthcare team including the patient and family (19, 185). GRADE IV
• 6.2.2 Documentation of a device selection algorithm within patient health records and procedures. GRADE CC
• 6.2.3 Vascular access teams (VATs) if available, provide expert advice in the device selection process (9, 20, 22, 24, 36, 75, 117, 186-188). GRADE IV
• 6.2.4 Availability of a range of VAD types and appropriately educated and competent clinicians for insertion (7, 9). GRADE V

7.1 Summary of evidence

Daily assessment of the continued need for a VAD, and assessment of complications via implementation of a standardised, validated tool is required, for example I-DECIDED (1, 12, 18, 189). Data collection from routine documentation in patient health records for example patient, VAD, dwell time, complications and removal can be used to evaluate vascular access outcomes and inform future quality improvement initiatives (19, 31).

7.2 Practice Recommendation

CNSA recommends the standardised daily assessment of a VAD via a validated tool, for example I-DECIDED to evaluate the VAD selection and the continued use of the VAD (1, 12, 18, 189).

GRADE V

REFERENCES for Device selection page – VHP topic

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