Webinar Q&A

Session 5: Initial webinar date: Wednesday, January 24, 2018

Reducing PIVC Complications & Guiding Clinicians: Technology & the 5Ps

Q: It is also valuable if we ask patients about previous experience with the IV area?
Q: Do these guidelines change in a resuscitation scenario? Re: in mass traumas the surgeons request 14-16G x2?
Q: Can you use this tool in intensive care units? In PICU's where patients are just admitted? Do you have any pediatric assessment tool?
Q: I wasn't clear how the NIR technology can help with ``rolling`` veins? It can help identify it but are there tips on how to deal with it?
Q: Any information on best method/best practice of warming the limb?
Q: What brand of NIR device is the best? Any recommendations?
Q: What equipment can detect the depth the ultrasound or NIR? For patient who has increase BMI?
Q: Dr. Schears, are (near-infrared vein finders) being used for neonates?
Q: It is also valuable if we ask patients about previous experience with the IV area?

A: Yes, listening to our patients is critical. If they say “I’m always a hard stick,” or “I got stuck several times during my last admission,” this is one of the strongest predictors of them being difficult access. We should start with near-infrared vein visualization to assess their venous options and use this information to decide what access device would be best for them.

Q: Do these guidelines change in a resuscitation scenario? Re: in mass traumas the surgeons request 14-16G x2?

A: No, these guidelines are not meant for emergency situations where limited tries of peripheral access should be followed by intraosseous access. The guidelines provided by INS that we mentioned during the webinar are just that, suggestions and recommendations.

Q: Can you use this tool in intensive care units? In PICU's where patients are just admitted? Do you have any pediatric assessment tool?

A: Near-infrared with LED light can be used on any patient population. In ICU’s, PICU’s, there are no contraindication for its use. I use this technology for all my patients regardless of their location.

Q: I wasn't clear how the NIR technology can help with ``rolling`` veins? It can help identify it but are there tips on how to deal with it?

A: “Rolling veins” is an age old problem. NIR can help by revealing how the vessel is behaving under the skin. This technology gives active, real time feedback; so you see it as it happens. I think the best tip to deal with this is tightening and securing the vessel and skin as you make the insertion. As we know some patient’s skin can be very “tough”, tightening the skin and securing it the best you can as you make the insertion is probably going to give you the best outcome.

Q: Any information on best method/best practice of warming the limb?

A: Warming the skin can clearly vasodilate vessels and therefore cause them to often times “plump up” therefore making visualization more clear and the likelihood of cannulation more successful. I say if a clinician visualizes a target, they are going to be much more successful with cannulation. I have seen a variety of ways of warming the vessel. I would suggest you follow your hospital’s protocol to ensure patient safety.

Q: What brand of NIR device is the best? Any recommendations?

A: I cannot provide a specific product recommendation within the purview of the continuing education course. I can tell you that in evaluating near-infrared products, I believe the most important factors are clarity of the image, accuracy of the veins projected and the ability to perform a thorough pre-access assessment by locating valve and bifurcations and assessing the refill of the vein. Each manufacturer should be able to provide you information on how their product meets these criteria.

Q: What equipment can detect the depth the ultrasound or NIR? For patient who has increase BMI?

A: Again, I maintain for initial screening, the NIR devices are best to make a quick assessment. You would be surprised at the vessels that become visible under NIR that are not visible with the naked eye alone – even in obese patients and patients who third spaced fluid and have pitting edema. Ultrasound can, of course, look deeper than 10 mm.

Q: Dr. Schears, are (near-infrared vein finders) being used for neonates?

A: Neonates present a unique patient type, and near-infrared technology is being used regularly in the NICU. The great thing about the technology is that is works anywhere on the body, and NICU patients are often accessed in locations other than the upper extremities. You can use NIR on the feet and scalp too; just be sure to check for any eye safety warnings depending on the product.

Session 4: Initial webinar date: Wednesday, April 12, 2017

Understanding and Preventing Difficult Peripheral Venous Access.

Q: I recently saw a journal article that discussed NIR and non NIR placement of IVs that showed no significant increase of efficacy with the NIR. Sorry I don't have the cite but can you explain why that might be?
Q: What do you suggest for patients with very small veins when the catheters are all going to be larger than a third of the vessel, and it's for short term placement?
Q: Can you compare and contrast the risks associated with both NIR and US?
Q: I'm glad you mentioned toward the end about the patient saying they are difficult. I find many providers don't take them seriously. Do you find that so and is that a big interference?
Q: I have seen and personally felt providers applying tourniquets much too tightly and they don't seem to understand how that can seriously interfere with the process?
Q: Is a tourniquet required to use the NIR?
Q: Could you please repeat how the NIR process works?
Q: Can NIR detect nerves?
Q: I recently saw a journal article that discussed NIR and non NIR placement of IVs that showed no significant increase of efficacy with the NIR. Sorry I don't have the cite but can you explain why that might be?

A: There have been numerous studies done evaluating the use of near-infrared (NIR) vein visualization and the results have varied. One thing to note is the variation in patient type and nursing experience level within these studies. Some studies have reported a high success rate in the control group; it would then make sense that you will see less impact from the NIR device. In the patient populations with a greater need, such as pediatric or renal patients, studies have shown a large improvement in success rates. There have been several studies that showed clinical significance. Aside from stick success rates, we should focus on the importance of a higher standard in patient assessment to prevent future difficult peripheral venous access.

It is important to realize that NIR technology is a tool that amongst the several advantages it provides, allows vein visualization, often for veins that you cannot clearly see (or at all) with the naked eye. If the metric that you are assessing is the ability to hit the vein, it does not make an individual any better at venous access than they would be with veins visible with just their eyes. Therefore you would never expect a clinician to be any more successful at access with NIR than they are with a readily visible vein. As with any technology, there is a learning curve so it will take some time to become proficient with the device. If you use NIR to its full capability, identifying valves, bifurcations and tortuosities and have a catheter to vein ratio of 1:3, I have no doubt that you will see fewer complications and prolonged dwell times with everything else equal.

Q: What do you suggest for patients with very small veins when the catheters are all going to be larger than a third of the vessel, and it's for short term placement?

A: If that is your only option, then you will be stuck using the smaller veins. If the patient needs longer term access and the patient has limited venous options, it would be quicker to use a midline or PICC to get them through their therapeutic course.

Q: Can you compare and contrast the risks associated with both NIR and US?

A: This is the kind of question I wish I were speaking with you directly as I am not totally sure what you mean. Both devices are FDA cleared, safe and are beneficial in so many ways. So I don’t really think about them in terms of risk from the device per se. There is of course a “risk” from less experienced individuals using them since during the learning process there may be more failed attempts with either device than there might be in more experienced hands. The dilemma is that a person can’t improve their skills unless they are regularly using them. I always recommend to people to get a phantom and practice first or attend training sessions to reduce the learning curve a bit. Also, if you have a more experienced person around that can give you pointers, your personal learning curve may not be as steep. Another potential challenge is that the novice inserter may be so focused on the technology, that they forget all they know about safe practice. They could potentially stick a patient in a way that doesn’t make anatomical sense or stick themselves with a needle if they are not careful. The clinician must remember traditional best practice. With either device, one still relies on our tactile sense during insertion and blood return into the catheter to assure we are within the vein. Also, following insertion, we would flush the catheter to reassure us that the catheter is fully functional.

Q: I'm glad you mentioned toward the end about the patient saying they are difficult. I find many providers don't take them seriously. Do you find that so and is that a big interference?

A: I always listen to patients and family members regarding the information they provide. A good historian is invaluable regarding helping the clinician to improve care and avoid prior pitfalls. One of the strongest predictors of difficult vascular access is a prior history of the same. Like all information we need to interpret it in the context of what we find during our own assessment, and in this way we will provide the best care possible.

Q: I have seen and personally felt providers applying tourniquets much too tightly and they don't seem to understand how that can seriously interfere with the process?

A: You are correct. Too tight of a tourniquet will reduce arterial flow and limit venous filling. Too loose of a tourniquet will not provide enough resistance of venous flow so that the vein will collapse when placing a catheter unless it is entered very carefully.

Q: Is a tourniquet required to use the NIR?

A: It is normal best practice to use a tourniquet to help engorge the vessel, but it is not required when using NIR. A clinician may want to do this in conjunction with NIR assessment, which can be easily incorporated into your clinical practice. The purpose of a tourniquet is primarily to maintain a lumen of the vein to facilitate insertion. If one is well practiced, you don’t need a tourniquet but the insertion technique must accommodate a more compressible venous target.

Q: Could you please repeat how the NIR process works?

A: Near-infrared (NIR) light, at approximately the same wavelength as pulse oximetry, is flooded onto the skin. Hemoglobin absorbs the NIR and surrounding tissue disperses it. Devices use this information to create and project a visible vein pattern image with which we can interact.

Q: Can NIR detect nerves?

A: NIR works be detecting hemoglobin; therefore, nerves would not be visible with this type of technology.

Session 3: Initial webinar date: Wednesday, August 17, 2016

Good Vein. Bad Vein. NIR and Choosing the Best PIV Access Site.

Many participants sent in questions for Dr. Schears during the live webinar session. Below are all of the questions and Dr. Schears’ answers.

Q: What angle would you use to insert an IV?
Q: How long does it take for a valve to recover/repair?
Q: Any tips for the infamous “rolling veins”?
Q: How superficial is the view? Would it show arteries?
Q: Can you use NIR to insert a midline?
Q: With ultrasound you can see the difference between a vein and a nerve. Can you see a nerve with NIR? What is the likelihood of hitting a nerve?
Q: As a member of the vascular access team at Duke, we use ultrasound for veins if we can’t feel it or see it. What are your thoughts?
Q: The ER/ICU at my hospital thinks all IVs must be placed emergently and doesn’t take the time to use NIR or ultrasound. Do you have any suggestions to help change the mindset? Our IV team utilizes both routinely.
Q: If you have a renal patient, shouldn’t you avoid the forearm?
Q: Are you a proponent of using local anesthesia for PIV access?
Q: We are told we have to have an antecubital IV for CTA's. Are you aware of any data to support that?
Q: How does one change the mindset of a hospital that does not have an IV Team or NIR? The patients are at a disservice because they are stuck multiple times by many staff.
Q: With NIR can you really determine size inside the vessel wall in order to determine adequate intraluminal size for the selection of appropriate size catheter? I've seen thick walls with small intraluminal space...
Q: Is it necessary to document vein size for PIVs? We can document vein size for PICCs using US but it doesn't appear we can measure vein size using NIR technology.
Q: Isn't depth perception a problem with these devices?
Q: Does the light affect the practitioner’s eyes in anyway? Does the light harm the naked eye?
Q: Are there any precautions in using NIR?
Q: Can you recommend specific brands for us to try?
Q: What angle would you use to insert an IV?

A: You should use your traditional technique for placing an IV when using NIR. A catheter should be inserted at a 15-30 degree angle depending on the depth of the vein. Remember you want to aim the tip of your needle for the exact center of the solid line that represents the projected image of the vein.

Q: How long does it take for a valve to recover/repair?

A: This will vary depending on the level of damage. Some will not recover and can be permanently damaged.

Q: Any tips for the infamous “rolling veins”?

A: One of the many advantages of NIR is that you can see motion of the vein in real time within the field of interest. Hence, as you are placing a PIV, you can determine how much traction is necessary to keep the vein stationary reducing the likelihood of rolling. The needle tip should always be directed toward the exact center of the projected vein. If the vein were to move (roll) one can easily redirect the needle tip as necessary. Since using NIR, I have not had an issue with rolling veins.

Q: How superficial is the view? Would it show arteries?

A: NIR will see up to 10mm deep depending on the patient, but I have seen some vessels as far as approximately 12mm. The thing to remember is that venous blood and arterial blood look the same under near infrared light. You still want to palpate to confirm. Arterial walls are also thicker and contain significant fibrous tissue which can block the absorption of the NIR.

Q: Can you use NIR to insert a midline?

A: NIR devices generally see veins up to 10mm deep making them ideal for peripheral IV access. You can also see blood patterns up to 15 mm deep. NIR may be useful for placement of a midline if the target vein is at these depths and the vein doesn’t have a thick fibrous cover to block the image.

Q: With ultrasound you can see the difference between a vein and a nerve. Can you see a nerve with NIR? What is the likelihood of hitting a nerve?

A: NIR vein visualization devices detect blood and would not show a nerve. Generally, if you use NIR to locate the exact location of the vein, that should decrease your chances of hitting a nerve. Of course, you also want to rely on your knowledge of anatomy to avoid areas with a greater concentration of nerves.

Q: As a member of the vascular access team at Duke, we use ultrasound for veins if we can’t feel it or see it. What are your thoughts?

A: Ultrasound and NIR are complementary technologies. Each offers significant advantages. Ultrasound can be more challenging to learn – especially if you do not use it routinely. NIR is easy to learn and easy to use. It also provides information regarding the patient’s veins that you cannot get with ultrasound as discussed in the webinar. Both tools are valuable and have their appropriate application in vein visualization.

Q: The ER/ICU at my hospital thinks all IVs must be placed emergently and doesn’t take the time to use NIR or ultrasound. Do you have any suggestions to help change the mindset? Our IV team utilizes both routinely.

A: The clinical situation will dictate whether an IV must be placed emergently. Whenever appropriate, we should be considering the patient’s vasculature as a limited resource that must be preserved. The use of vein visualization technology helps with vein preservation. Also, I find both devices actually make me faster and allow me to meet my situational vascular access goals for a given patient.

Q: If you have a renal patient, shouldn’t you avoid the forearm?

A: The same precautions we use to avoid placement of PICC catheters in patients with renal failure should be used with other forms of vascular access whether one uses ultrasound or NIR assist.

Q: Are you a proponent of using local anesthesia for PIV access?

A: Any time one can reduce pain in a patient I believe it is a good thing. Lidocaine, straight out of the bottle, unbuffered can cause its own discomfort, even when injected with a fine needle. If one can achieve access with one stick and without a lot of catheter movement, one should question the value of an extra stick for sake of anesthesia. Unfortunately, the ideal topical solution for access analgesia does not exist in a commercially viable form. Experience varies with the use of local anesthesia and I personally have not used it often due to pain on injection.

Q: We are told we have to have an antecubital IV for CTA's. Are you aware of any data to support that?

A:  The American College of Radiology in their 2016 guidance for performing a computed tomography angiography (CTA) prefers the brachiocephalic vein in the right arm for injection of contrast. They support this position with the need to inject a significant volume of contrast media over a short duration, thus requiring good flow in a large vessel. The use of the antecubital fossa for standard PIV access is frowned upon in the INS guidelines as it is across a joint, subject to movement and difficult to detect an infiltration. Thus the two recommendations are in conflict and not likely to resolved soon. One must consider the purpose of the PIV, intended dwell time and be aware of potential complications before placement.

Q: How does one change the mindset of a hospital that does not have an IV Team or NIR? The patients are at a disservice because they are stuck multiple times by many staff.

A: Creating change within an organization can be very difficult. Decisions should always be made with the best interest of the patient in mind. Healthcare organizations should use vascular access teams to help provide optimal care and improve patient satisfaction. The use of NIR can help achieve these goals. There is an increased focus on reducing costs and improving quality in healthcare today. It is also mandated in the affordable care act. The use of NIR devices to improve vein visualization helps to decrease costs, improve the quality of the clinical outcome and patient experience. Providing supporting information with evidence regarding the improved clinical outcome, reduced costs and improved patient experience may help you help you to create the necessary change.

Q: With NIR can you really determine size inside the vessel wall in order to determine adequate intraluminal size for the selection of appropriate size catheter? I've seen thick walls with small intraluminal space...

A: Absolutely. NIR is seeing the blood within the vessel, not the vessel itself. So, you are getting a very accurate intraluminal size determination with some NIR devices.

Q: Is it necessary to document vein size for PIVs? We can document vein size for PICCs using US but it doesn't appear we can measure vein size using NIR technology.

A: It is not required to document vein size for PIV. The vein width projected onto the patient’s skin is very accurate depending on the brand of NIR.

Q: Isn't depth perception a problem with these devices?

A: When determining the depth of a vessel while using NIR, you should still palpate to help confirm the depth. You will want to maintain good technique. You are simply adding in an assistive device to make the experience that much better. Generally, the angle of insertion is not going to change significantly when you are inserting a peripheral IV.

Q: Does the light affect the practitioner’s eyes in anyway? Does the light harm the naked eye?

A: NIR devices project using different light sources; near-infrared is an invisible wavelength of light. They either use an LED light source, which is considered completely safe, or they use a class II laser light source, which may require eye protection. The LED’s can be bright, and therefore an irritation. You may want to avoid shining it in a patient’s eyes. The laser device does have potential for damage; patients may need to be given eye protection if shining near the eyes. Any devices with eye safety warnings clearly state this on the screen of the device and in the manual.

Q: Are there any precautions in using NIR?

A: NIR devices project using different light sources; near-infrared is an invisible wavelength of light. They either use an LED light source, which is considered completely safe, or they use a class II laser light source, which may require eye protection. The LED’s can be bright, and therefore an irritation. You may want to avoid shining it in a patient’s eyes. The laser device does have potential for damage; patients may need to be given eye protection if shining near the eyes. Any devices with eye safety warnings clearly state this on the screen of the device and in the manual.

Q: Can you recommend specific brands for us to try?

A: As this is a continuing education course for credit, we cannot mention specific brands. However, I do recommend when you are looking at different devices, you consider things like accuracy, ease of use and clinical evidence. Any manufacturer should be able to provide all of this information. In my experience, there is one brand that is the most accurate on the market.

Dr. Gregory Schears

Dr. Gregory SchearsDr. Gregory Schears is a Pediatric Intensivist and Anesthesiologist from Rochester, MN. He has a long standing passion for helping to improve vascular access and patient care. As a champion for IV teams, he has been integral in the development of protocol construction for best practices. Over 27 years, Dr. Schears has given numerous individual, local, national and international educational sessions related to vascular access.

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