Why is patient medical history important and what are clinicians analyzing? Placing a Vascular Access Device (VAD) in a patient with the most successful outcome involves knowledge of the patient’s medical history, i.e., the patient’s chart. Vascular Access clinicians review the patient’s chart for basic information that identifies the patient receiving the VAD including the patient’s name, date of birth, facility and room number, and more advanced information such as laboratory data and the patient history all of which helps determines which line to place. This will best preserve the veins while mitigating side effects.
Why is laboratory data important?
The laboratory data is important information that not only helps select and place the VAD, but also identifies possible blood infections in the body that could delay line placement and possible clotting conditions in the blood that could lead to bleeding. The laboratory data considered remarkable is:
- The White Blood Cell Count (WBC) and the Blood Culture test results can indicate a possible infection. White blood cells fight infection and a high test result can indicate infection that may be due to a current blood stream infection (BSI) or central line-associated bloodstream infection (CLABSI). A Blood culture helps identify bacteria or fungi present in the bloodstream and how to treat it. If either the WBC or Blood Culture test indicates an infection, that would require a delay in line placement by 48 hours, i.e. a 48 hour “line holiday”, to prevent the new central line from possibly becoming infected. However, outside of a hospital setting this data isn’t always available, so it is important to evaluate the patient for symptoms that may indicate elevated WBCs, such as a fever or sweating, and enact the 48 hour delay in line placement if necessary.
- A line should not be placed if a patient is pending blood cultures until the results have arrived. An exception to this rule is if the benefits outweigh the risks of having a line placed. For example, an intensive care unit (ICU) patient who requires multiple medications and needs central access, a line would be placed including documentation that there were pending cultures, and the reason for the emergent line. In a situation with pending blood cultures or elevated WBCs, patient access can be given as a standard Peripheral IV (PIV) or Midline, but an advanced line such as a Peripherally Inserted Central Catheter (PICC), Internal Jugular (IJ), Femoral (Fem), or Large Bore would not be placed.
- The Blood Urea Nitrogen (BUN), Creatinine, and Glomerular Filtration Rate (GFR) can determine current kidney function and line placement. A dialysis patient or future dialysis patient will need to have the veins in their arms preserved, which would be the site for future fistula/graft placement. Vascular Wellness follows Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines for line placement such that if lab results show creatinine is equal to 2 or greater or GFR is below approximately 45, which indicates stage 3 Chronic Kidney Disease, approval of either managing physician or Nephrologist is required prior to placing a Midline or PICC.
- Platelet count and International normalized ration (INR) as both can indicate the body’s ability to clot. A platelet count that is low or an INR that is high, could lead to bleeding issues on insertion or later to in situ line bleeding. A platelet count that is low, limits the blood to form clots, and an INR that is high, delays the time it takes the blood to coagulate. Bleeding is usually a rare event, but it is a good test to review to be prepared for the potential occurrence if needed.
Why is the patient’s medical history important?
A patient’s history is important as it will also help determine the selection of the VAD. A patient will be contraindicated for a PICC or Midline, if they have a history of any of the following conditions:
- A patient who has had a kidney transplant will be contraindicated for a PICC/Midline. This is because this patient has an increased chance to have further kidney issues in the future, including another transplant, and upper arm vein preservation is essential as permanent dialysis utilizes upper arm veins for Arteriovenous fistula (AV) graft. See Kidney Disease and Renal Failure | Vascular Wellness for additional information. An IJ or Fem should be used in this case.
- A patient who has had a mastectomy with lymph node removal will be contraindicated for a PICC/Midline on whatever side the lymph nodes were removed. Lymph node removal results in less lymph nodes to filter the lymph, a clear fluid that filters waste throughout the tissues in the body. The waste builds up and can lead to lymphedema, an upper extremity swelling that will be permanent. See Vascular Access Patients Mastectomy | Vascular Wellness for additional information. In this case, an IJ or Fem should be used, as they are away from the mastectomy site, reducing the risk of lymphedema.
- A patient diagnosed with a deep vein thrombosis (DVT) or a DVT within three months of line placement will be contraindicated for a PICC/Midline as (a) the arm presenting with the clot is contraindicated and (b) placing a new line in the opposite arm of a patient with a DVT, could increase the risk of a new clot by approximately 80%. Vascular Wellness clinicians follow the American College of Chest Physicians (“CHEST”) guidelines when it comes to line placements for patients with DVTs or risk of DVTs. See Reduce the Risk of Upper Extremity DVTs | Vascular Wellness for additional information. Even if the patient has been on anticoagulants and the clot has been resolved for at least three months, an IJ or Fem is still the preferred line to limit thrombogenicity.
- A patient that is so contracted such that their muscles in their body have shortened and their arms won’t come out from the side of their body will be contraindicated for a PICC/Midline. This is because the likelihood of getting a PICC or Midline in the arm would be minimal. An IJ or Fem should be considered.
Why is the therapy plan important?
The therapy plan ordered by the managing physician, including the medication or fluid and its duration, is important as this also determines the catheter that will best preserve the veins. Therapy can consist of either non-toxic medications, neutral pH within 5 to 9 range and osmolarity below 900, or caustic medications, extreme pH less than 5 or above 9 and osmolarity above 500, such as antibiotics, chemotherapy, and IV nutrition feeding (Total Parenteral Nutrition)). Therapy guidelines recommended are:
- If the treatment duration is minimal, such as 1 to 2 days, and medications are non- caustic to veins, a PIV would be preferred.
- If the duration is beyond approximately 2 days and medications are non-caustic to veins, a Midline would be preferred to minimize needle sticks to the patient.
- If the duration is beyond 30 days, a PICC/CVC should be considered, as this line can remain in the patient for a much longer period of time.
- If the medications are caustic to veins, a PICC/CVC should be used regardless of any duration.
Vascular Wellness clinicians evaluate patients holistically including the laboratory report, patient history and treatment plan and use their best judgement to place the right line balancing various needs including patient safety. Vascular Wellness trains its clinicians to place various advanced lines and this gives them many options and solutions to meet virtually all the vascular access needs of the patient.