Vessel health and Preservation

Version 1: January 2024

Vessel health and preservation (VHP) described by Moureau and colleagues in 2012 is an evidence based, standardised strategy implemented in a healthcare organisation for the proactive, timely and standardised insertion and management of vascular access devices (VADs) for the individual patient and prescribed therapy (1). The aim is to minimise pain, distress, and harm to the patient and maximise first time success to preserve vein health for current and future needs (1-4)

Due to the disease process, side effects of prescribed therapies (5) and frequent, repetitive or prolonged blood sampling requirements, patients with cancer have complex venous access requirements from the outset. The duration of therapies is potentially prolonged, months, years or indefinitely to control metastatic disease. VAD management may transverse numerous different healthcare teams and settings including inpatient, high acuity, ambulatory unit, subacute community care or home care. Therapies can damage the tunica intima, inner lining of the vein including vesicant and irritant chemotherapy, clinical trial medications, supportive therapies for example antibiotics, mannitol, parenteral nutrition, and procedural drugs, such as contrast media. This is related to their irritant, vesicant, osmolarity and pH properties (5,6). Consequently, patients with cancer have a higher risk of poor vein health and venous depletion. Therefore, proactive, timely and informed VAD management from the start is critical (5)

TERMINOLOGY

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

SUMMARY OF RECOMMENDATIONS

CNSA recommends a vessel health and preservation (VHP) strategy is incorporated in workplace procedures including:

1. The patient and family are core partners within the healthcare team in a VHP strategy, including the vascular access team, nurses, medical staff, pharmacy, interventional radiology, and nephrology and infectious diseases as appropriate (3,7-10).

GRADE Ib

2. The informed healthcare team using standardised management. VHP is a complex process that must be managed by an educated and competent healthcare team including the informed patient and family (1,4,5,11).

GRADE Ib

3. Pre-insertion: VHP is the proactive, timely and standardised VAD insertion and management of the individual patient including (1, 12-14):

  • 3.1 Time factor – emergent or elective insertion
  • 3.2 Patient related factors - vein assessment
  • 3.3 Therapy-related factors: peripherally or centrally compatible infusates
  • 3.4 VAD-related factors: available VAD types within a workplace
  • 4.5 Assessment: regular assessment for continued use, complications

GRADE V

4. Insertion. The insertion procedure is completed in a timely manner, utilising evidence-based practices and technology, facilitating patient comfort (15,16) and by educated and competent clinicians (2,12,17-23)

GRADE II

5. VAD management. Standardised, evidence-based VAD management including patient education, pain and anxiety management, regular assessment and procedures to maintain VAD dressing, securement and patency to reduce the risk complications is essential (12,24-27).

GRADE V

6. Removal: when the VAD is no longer required or unresolved complications (1,12,13)

GRADE V

7. Evaluation: an integral component of any VAD related quality improvement initiative or practice changes (1,12,28)

GRADE V

VESSEL HEALTH AND PRESERVATION

The VHP framework is a comprehensive approach to VAD management, including device selection, insertion, management and removal (12). The aim is to minimise damage to veins caused by repeated cannulations, blood sampling and side effects of prescribed therapies (1), which can span many weeks, months or indefinitely for patients with chronic conditions such as cancer. It is essential the VHP process is proactively implemented in a timely manner (1), prior to the commencement of therapy. Damage to veins from insertion of inappropriate devices for the individual patient and prescribed therapies, for example, infusion of centrally compatible infusates via a PIVC or damage to veins and local tissues from extravasation must be prevented.

1. THE PATIENT: PARTNERS WITHIN THE HEALTHCARE TEAM

1.1 Summary of evidence

The patient appears to be a forgotten player in the VHP process. Patient preference was identified in supplementary information in two VHP frameworks (5,7). Carr (2018) states to include the patient for PIVC insertion where possible (29). Otherwise, the patient and their thoughts and preferences were missing in VHP literature.

The patient and family, for example parents of paediatric patients are a core member of the healthcare team (3, 4, 9, 30-32) and the success of VADs, and longer term CVADs for patients with cancer is dependent on informed patient and participation (9, 33-37). Patient related factors such as lifestyle, work and sporting interests, body image, adherence required for VAD maintenance, previous experiences and family support are important factors requiring consideration in the device selection process (7, 10, 30, 38-42) . Communication with and education of the patient and family is key to the entire process (4, 43-49) .

1.2 Practice Recommendation

CNSA recommends the patient and family are core partners within the healthcare team, including the vascular access team, nurses, medical staff, pharmacy, interventional radiology, and nephrology and infectious diseases as appropriate (3, 7-10).

GRADE Ib

2. THE INFORMED HEALTHCARE TEAM USING STANDARDISED MANAGEMENT

2.1 Summary of evidence

VHP is a complex process that must be managed by an educated and competent healthcare team (11-13). A VHP process illustrated as a flow diagram or algorithm(1, 13) , in a series of tools (5), or graded recommendations by experts for the appropriate use of VADs based on numerous scenarios (50, 51) that are documented in workplace procedures facilitates their use by clinicians (13, 29). Nearly all (98.9%) of respondents in a national survey of cancer centres in Spain (5) identified the importance of a standardised, national, endorsed approach was critical to establish reliable and safe vascular access for the patient with cancer to prevent painful, distressing and repeated venepunctures (4, 5).

Workplace procedures and protocols implemented by competent clinicians reduces the risk of complications by up to 7-fold through timely, informed, and proactive management (5). Vein health is preserved for current and future use (13) and variations in management, potential errors, and complications are reduced (12) by preventing insertion of inappropriate VADs (29). For patients diagnosed with cancer, future VAD requirements may include their next cycle of chemotherapy, future lines of systemic anticancer therapies (SACTs), or an autologous or allogeneic transplant, inclusion in a clinical trial, treatment of secondary cancers or palliative control of metastatic disease. However, over 50% of cancer services in survey from cancer centres in Spain did not use such tools (5).

2.2 Practice Recommendation

CNSA recommends VHP is a complex process that must be managed by an educated and competent healthcare team including the informed patient and family (1, 4, 5, 11)

GRADE Ib

3. PRE-INSERTION: CORE COMPONENTS OF VHP

3.1 Summary of evidence

Selection of the most appropriate VAD for the individual patient and prescribed therapies (12, 13) is key to prevent complications and poor VAD-related outcomes for example extravasation, infection, and thrombosis (12). In 2016, Hallam and multidisciplinary colleagues established a comprehensive VHP framework based on Moureau’s VHP work (2012) to assist clinicians to make a proactive, timely and informed decision about the most appropriate VAD for the individual patient and prescribed therapy (1, 13). The core components of the algorithm include:

  • 3.1 Time - urgency. In the first instance VAD selection is determined by clinical need of the patient. Emergent or elective insertion will influence the type of VAD required for example PIVC, intraosseous or CICCs are inserted for time critical access (14).
  • 3.2 Peripherally or centrally compatible infusates. Osmolarity and pH after the appropriate dilution, concentration, speed or duration of administration, and vasoactivity of the prescribed or potential future administration of medications or solutions will indicate whether a PIVC or CVAD is suitable (13). Osmolarity >900 mOsmol/L and extremes of pH <5 or >9 after dilution, vesicants with short administration time e.g 10 minutes, vasoactive or infusional SACTs are recommended for administration through a CVAD (13, 14, 50, 52-58). This includes common supportive therapies in cancer care: parenteral nutrition related to the protein and glucose concentrations, antibiotics, and contrast media for computed tomography scans.
  • 3.3 Vein assessment. Peripheral veins of patients about to commence intravenous (IV) therapy are assessed using a standardised tool including palpability, visibility, number, and quality of the patient’s veins (5, 7, 13, 14, 52, 55, 56, 59). An infusate may be peripherally compatible, however a patient may not have palpable or visible peripheral veins for the insertion of a standard PIVC. Venous assessment is also vital in the management of patients with difficult intravenous access (DIVA) [link to DIVA page]. Advanced strategies are then introduced from the outset, not as a rescue measure (60).
  • 3.4 VAD type. Availability of a range of VAD types, educated and competent inserters, and the appropriate technology for the insertion procedure are considered (7, 12-14, 51, 56, 61)
  • 3.5 Regular assessment. Every VAD is assessed regularly for early detection of complications and assessment of continued need using a validated tool, for example the I-DECIDED tool for PIVCs (13, 62)

3.2 Practice Recommendation

 

CNSA recommends clinicians consider the core components of a device selection algorithm with the aim of VHP include

  • Assessment of the urgency of VAD insertion
  • Vascular access device selection
  • Appropriateness of medications and solutions for peripheral or central vein administration
  • Vein assessment
  • Consideration of workplace factors
  • Regular assessment of the VAD

 

GRADE: V

 

4. INSERTION

4.1 Summary of evidence

The insertion procedure is completed in a timely manner, utilising evidence-based practices and technology (25, 63) for example ultrasound, near infrared for PIVC insertion or intracavity electrocardiogram for CVADs to maximise first time success, minimize complications, facilitate patient comfort (4, 64, 65), and by an educated and competent clinician (2, 12, 17-22, 26). The insertion procedure is discussed with the patient so they are informed about the risks and benefits, what to expect and how to care for the VAD, and appropriate pain and anxiety management is employed for the individual patient, for example local anaesthesia, virtual reality, music therapy, hypnosis, topical thermal applications, parents holding the paediatric patient (4, 15, 21, 33, 47, 49, 64-95). Reducing insertion related complications reduces damage to veins and potential sequalae, for example repeated venepuncture, venous thrombosis, phlebitis or infection therefore preserving vessel health for potential use in the future.

4.2 Practice Recommendation

CNSA recommends the insertion procedure is completed in a timely manner, utilising evidence-based practices and technology, facilitating patient comfort (15, 16)) and by educated and competent clinicians (2, 12, 17-23).

GRADE II

5. VAD MANAGEMENT

5.1 Summary of evidence

To reduce the risk of infection and non-infection related complications, standardised, evidence-based VAD management including regular assessment, early detection of complications, and employing procedures to maintain VAD dressing, securement and patency is essential (12, 24-26). Regular assessment is once per shift for inpatients and each outpatient visit. Also education of the patient about the VAD, what signs, symptoms or complications to report, when and to whom (18). Regular review of pain management of VAD related procedures, for example TIVAD access is key to minimise patient anxiety and distress (27). Confident, knowledgeable and competent clinicians in VAD management is essential for patient confidence and contentment (21, 96, 97).

5.2 Practice Recommendation

CNSA recommends standardised, evidence-based VAD management including regular assessment and procedures to maintain VAD dressing, securement and patency to reduce the risk complications is essential (12).

GRADE V

6. REMOVAL

6.1 Summary of evidence

VAD removal occurs when the VAD is no longer required due to treatment completion or there are unresolved complications (1, 12, 13).

6.2 Practice Recommendation

CNSA recommends removing a VAD when it is no longer required (CVAD, PIVC) or unresolved complications (CVAD) (1, 12, 13).

GRADE V

7. EVALUATION

7.1 Summary of evidence

Evaluation is an integral component of any VAD related quality improvement initiative or practice change, for example implementation of a VHP strategy (12). Core data can be collated from routine documentation of VAD related care, for example the device selection process, insertion procedure, device details, assessments, procedures, complication assessment, management and outcomes, and removal details. Therefore, complete and standardised documentation is essential for data quality and subsequent analysis. A survey of Australian and New Zealand patients added 16 items that focused on complications, difficulties, experiences, preference and patient involvement (98). Both quantitative and qualitative data enables health systems to evaluate clinical practice and VAD related outcomes, employing workplace expertise and knowledge in conjunction with current evidence to inform ongoing quality improvement initiatives (1, 28).

7.2 Practice Recommendation

CNSA recommends evaluation is an integral component of any VAD related quality improvement initiative or practice changes (1, 12, 28).

GRADE V

SUMMARY

The patient and family are integral partners in the healthcare team. VHP education is critical, so all relevant components are incorporated in the device selection process and insertion of the most appropriate VAD for the individual patient for the duration of their therapy. Standardised management aligns with current evidence to reduce the risk of complications and the VAD is removed when no longer required. Evaluation of VADs and their outcomes are integral to the healthcare service delivery.

 

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