Meeting Notes taken from

2016 Association for Vascular Access (AVA) Annual Meeting

(Sep 15-19, 2016)
Presentation (not
Presentations
Midline/PICC
Midlines:
Adding value
and reducing
risk
Presenter:
Stephanie
Wittwer

Midline
catheters: are
they safe

Picking the right

PICC: does
catheter
material and
design impact
PICC outcomes
Presenter:
Tricia Kleidon

a complete list)
Take home message

A significant increase in the use of Midline in the last 3 years

First midline appeared in 1989 but it was taken off market due
to material causing adverse events
Types of Midlines
Non-trimmable
Trimmable
8 or 10cm
20cm
Values and risks of Midlines
Value
Risk
Cost saving: BSI rate lower than
Venous thrombosis;
PICC and PIV, low DVT rate;
Difficult to
Reduce CLABSI;
recognize
No CXR needed;
infiltration;
Increased blood flow in upper arm; Phlebitis;
Vein preservation;
Infection/BSI;
Etc.
May be confused
with SL PICC
Presenter Teams Midline data
Of 4272 midlines, DVT rate: 0.35%; Infiltrated: 1.15%;
Occluded: 2.3%
Point: Retrospective midline audit including 261 midlines found 0
DVT
Results: Leaking 1.2%; DVT 0%; occlusion 1.5%; dislodged 5.4%;
phlebitis 6.2%
Suggestion: If the drug is likely to cause chemical phlebitis, dont
insert a midline;
Counterpoint: Midline versus ultrasound guided PIV in
presenters facility
2014
2015
2016
Cost saving
Midline usage 211
69
15
85k~142k
PIV usage
343
1183
1410
Use of midline requires complete assessment of the upper
extremity
Mindset of preserving upper arm vasculature for future access
Significant cost savings by using the forearm
PICC versus CVC: decreased cost to insert and lower insertion risk
profile
Modernization of PICC material: silicone, polyurethane, power
injectable, coated, impregnated
Design technology: distal valve, proximal valve, flex tip
Comparison study of polyurethane PICC versus Endexo
Results:
Cook TurboNavilyst Bioflo PASV
JeCT
Material
Polyurethane
Polyurethane with
Endexo
# of patients
34
33
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Presentations

Take home message

Aspiration occlusion
Complete occlusion
Local pain
Local redness
CLABSI
CVAD breakage
Complete
dislodgement
Thrombosis
Satisfaction

7
3
9
2
0
1
0

5
0
3
0
0
0
2

3
78~88 out of
100

1
86~94 out of 100

Conclusions:
Some small studies show polyurethane halves the risk of
failure as compared to silicone
Valve technology is promising
Endexo technology halves the risk of failure
Tip confirmation
A tip
Background:
confirmation
PICC tip malposition rates >20% (either too short or too long)
systems impact Need a less radiation exposure and shorter time procedure
on clinical
IR suites has high PICC placement success; bedside has 14%
efficiency-a
malposition rates
breakthrough in
Non-randomized study:
evidence (Bard
Sherlock 3CG versus Blind insertion/CXR tip confirmation
Sherlock 3CG tip
Tip location criteria: lower 1/3 SVC, or CAJ
confirmation
Sherlock: no need of X-ray confirmation, 3x less process steps,
system)
5x faster, 0 malposition, and cost-saving
An audience raised a concern that it is hard to use Sherlock in
some senarios
Cuf
Cuf or non Sriskandarajah et al. Thrombosis Journal (2015) 13:21
cuf: That is the
PICC
Long term skin tunneled
question
catheters
Thrombosis
5.8%
1.7%
Presenter:
rate
Michele Di
Infection
2.6%
0.4%
Giacomo
Step-by-step tunneling procedure with a no-cuff PICC
No-cuff PICC versus cuffed PICC
No-cuff PICC
cuffed PICC
Suitable for short/medium
Suitable for long term
term
No surgical cut down at
Not require securement
removal
device
An audience said his hospital has not used any cuffed catheter
recently because of the following reasons: have to be very
careful at 1cm proximity; cuff infection; need sedation upon
removal. He commented that the use of cuff would be rarer
and rarer because cuff causes more problems.
Another audience commented that 20% cuffed catheter did
not adhere, although he prefers a cuffed catheter for long
term.

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Presentations
Take home message
Practices and Guidelines
MAGIC-The
Chopra, Vineet, et al. "The Michigan Appropriateness Guide
Michigan
for Intravenous Catheters (MAGIC): results from a
Appropriateness multispecialty panel using the RAND/UCLA appropriateness
Guide for
method." Annals of internal medicine 163.6_Supplement (2015):
Intravenous
S1-S40.
Catheters
Rationale for MAGIC: how to choose a vascular access device
Methodology: evidence-based decision making process; literature
Presenter:
review and synthesis; 15 panelists; 665 individual scenarios for
Vineet Chopra
ratings
Results:
choice recommendations of PIV, US-guided PIV, Tunneled CVC,
Non-tunneled CVC, PICC, midline, and port based on the
proposed duration of use, type of infusates, patients with
difficult venous access, etc.
suggestions on the appropriate/inappropriate practices
Strength: Robust methodology, eminent experts from diverse
backgrounds, etc
Outcome: after implementation of MAGIC, participated Hospitals
have seen 48% drop in occlusion events, 32% drop in VTE and
CLABSI events, 59% drop in the use of PICCs for less than 5 days.
Estimated savings are $610,000.
Vascular Access
12 consensus statements for vascular access (VA) specialists
Consensus
1. Patient centered, multidisciplinary, and collaborative
Statements
2. Demonstrated knowledge and validated skill set
3. Recognize the complications and initiate interventions
4. Comprehend infection risks and apply prevention
procedures
5. Competent in use of VA devices
6. Perform a pre-procedure assessment
7. Perform insertion procedures in line with best practice
8. Knowledge and skill in device care and maintenance
9. Engage in the process of quality improvement
10. Uphold ethical codes
11. Educate all stakeholders
12. Commit to lifelong learning
Changing the
1. No more blind stick
CVC insertion
2. Where to insert? (recommend subclavian rather than
game: what else
internal jugular catheterization)
can we do? 16
3. Flat surface, minimal motion
recommendatio
4. Axillary vein
ns
5. Micropuncture (use 21 g instead of 18 g)
6. No incision (skin is the barrier to infection)
Jack Le Donne
7. No hubbing (leave some room between hub and skin)
8. Cut sponge
9. Sutureless securement
10. Dressing adhesive
11. Side of bed, not the head of bed
12. Low cervical IJV
13. Rotate down (otherwise the external portion will fall down
due to gravity)
14. Tip location (recommend ECG)
15. Intraosseous

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Presentations
The evolution of
vascular access:
our past, our
future, our AVA
Herbst Award
Winner: leading
change

Off-label or off
limits? Know
your risks!
Debate between
Russ Nassof and
Matthew D.
Ostroff

Take home message

16. ICU question (only RN know the details)
Evolution of vascular access;
Topics include infection prevention, pediatrics, interventional
radiology, education, and technology & innovation,
A hospital-acquired condition (HAC) is an undesirable situation or
condition that affects a patient and that arose during a stay in a
hospital or medical facility. It is a designation used by
Medicare/Medicaid in the US for determining MS-DRG
reimbursement. Currently there are 14 categories of HACs. HACs
associated with the Vascular Access field may include:
vascular catheter-associated infection
air embolism
blood incompatibility, etc.
18 hospitals have HAC score 10.
If you use a device in a way that is different from what the
manufacturer suggests, there must be a reasonable basis for
doing so, and it still must be within the range of acceptance
practice to meet the standard of care.
Off-label use can lead to medical malpractice if it fails to meet the
standard of care. The following factors must be considered before
the off-label use:
Learned intermediary
Infusion therapy standards
Supported by current hospital policy
Supported by local colleagues
Obtained informed consent of patient
Successful use by other learned intermediaries in the field
Urgency/best interest of patient

Exhibition (not a complete list)

Exhibitor
Products
Midline/PICC
Access
Powerwand
Scientific, LLC
XL midline
catheter

Technology or Features

Teleflex

Arrow Midline
catheter
Silicone PICC

Footprint
Medical Inc.
Fixation devices
Interrad
SecurAcath
Medical, Inc.
fixation
device
TIDI Products,
LLC

Grip-Lock
securement

0 CLABSI for 12,000 catheter days (catheter

material: ChronoFlex C-polycarbonate-based
urethanes)
No sheath is needed; dilator and catheter are
used together
No jagged tip, minimizing DVT
Coated with chlorhexidine (Chloragard
technology)
1.9 Fr for neonatal/pediatric patients

Dramatically reduced catheter dislodgement

rates as compared to adhesive securement
devices (0-1.5% versus 14-20%)
Eliminates costly suture needlestick risk
Sutureless central line securement

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Exhibitor
Starboard
Medical
Covalon
Technologies
LTD.

Products
product
Clik-Fix

Technology or Features

Withstand an 8lb pull force

IV ClearTM
Chlorhexidine and silver
antimicrobial
Breathable, waterproof, and transparent
clear silicone
adhesive
securement
dressing
BBraun
STEADYCare
Minimize catheter movement in the vein
extension set Decrease potential for catheter kinking
with wedge
catheter
stabilizer
Tip navigation and confirmation devices
Bard
Sherlock 3CG 5X faster than the blind insertion (34 m vs.
Tip
176 m)
confirmation
0 malposition rate (23% for blind insertion
system
CXR)
No CXR is needed
26% less costs
Teleflex
Arrow VPS
Visualize the catheter pathway
Rhythm
ECG tip confirmation
System
No calibration required
Vein Access
BK Medical ApS
Sonic Window Increase first stick success by providing clear
portable
images of vessels up to 3 cm deep
imaging
Small and easy to fit in a pocket
device
IV Monitor
ivWatch
ivWatch
Early detection of IV extravasations
Model 400
Continuously monitor the tissue around the IV
Needleless Connector
BD
BD needle 3-second disinfection
free
BD says to follow facilitys protocol
connectors
ICU medical
MicroClave
3-second disinfection with 70% isopropanol
CareFusion
MaxZero
3-second disinfection
needleless
Anti-reflux technology
connector
Swab
PDI
Prevantics
3.15% chlorhexidine Gluconate and 70% IPA
Swab
5-second scrub and 5-second dry
A randomized study shows a reduced
contamination rate compared with the 70%
IPA alone scrub (12% versus 39%)
Excelsior
SwabCap
Luer access valve cap with 70% IPA
Medical
Disinfect the valve 5 min after application and
maintain the disinfection status for 7 days
Filtration Devices
Pall Medical
Filtration
Prevent air embolism, thrombosis, enlarged

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Exhibitor
Apparel
Careandwear
CareAline

DryCorp

Products
device

Technology or Features
lipid droplets, and inflamation

Ultra soft
PICC line
cover
Wrap for
central lines,
G/G-J tubes;
Sleeve for
PICC lines
Waterproof
PICC
protector

Prevent pulling, breaking, dislodgement of the

lines

Prevent pulling, breaking, dislodgement of the

lines

Vacuum seal technology

Completely clean and dry
Patients can shower, swim and bathe

Electronic Poster (not a complete list)

Title
Take home message
Midline/PICC
Introduction of
Midline can be used for up to 29 days
Midline IV
options
Lowering
Background: Cleveland clinic, 2368 midlines in 2015, DVT rate was
midline
2.46%
associated DVT
Question: is DVT rate associated with the midline length?
through change
Results:
in practice
Period
# of
Length
DVT rate
midlines
9/1/15-12/31/15 705
20 cm
2.27%
1/1/16-4/30/16
699
15 cm
1.86%
A comparative
study between
CLABSI rate
Thrombosis rate
ChlorhexidineUncoated
1.43/1000
3.95/1000
coated
Chlorhexidine0.69/1000
1.49/1000
catheters and
coated
uncoated
Unit: per catheter days
catheters
Characteristics
Irritant, vesicant, hyperosmotic, mechanical considerations,
of common
excipients
infusates
Pediatric
Subcutaneous
Occurrence rate: 6-12% in authors institution
securement of
Question: Does subcutaneous anchor help as compared to
pediatric PICCs
standard dressing and adhesive securement?
dislogdement
Results: Subcutaneous anchor method resulted in no
dislodgement and infection.
Limitations: Patients must have adequate subcutaneous tissues.
Use Midlines in
Benefit: reduce CLABSI & cost
Pediatrics
Results: average dwell time is 176.4 hours = 7.35 days; no
infections; average number of attempts for placement: 1.75
Limitations: not suitable for patients with small upper arm veins
and who cannot cooperate with ultrasound
Optical
Infiltration: IV fluid/medication leak into surrounding tissue

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Title
Take home message
detection of
Extravasation: Vesicant leak into surrounding tissue
pediatric
infiltration
Swab
Swab (3.15%
Results: prior to the implementation, the infection rate in 2014
chlorhexidine
was 1.2/1000 central line days; 16 months after implementation,
Gluconate/70%
the infection rate was 0.1/1000 central line days.
alcohol) for
disinfection of
needleless
connector
Needless access 3.15% Chlorhexidine Gluconate and 70% isopropyl swab with a 5disinfection
second scrub and 5-second dry
standardization
Tip navigation and confirmation devices
Evaluation of
5 devices used in the trial: ultrasound based tip navigation;
the accuracy
electromagnetic tip navigation (Navigator); ECG-based tip
and costlocation + electromagnetic tip navigation (Sherlock 3CG); ECGeffectiveness of
based tip location and navigation (Delta); Pressure-based tip
different
location and navigation (Catfinder)
methods of tip
Results: best accuracy and clinical effectiveness
navigation
maximal cost-effectiveness
is more accurate, user-friendly, and more effective
than
Tip navigation by fluoroscopy should be avoided because of the xray exposure and very low cost-effectiveness
Vein Access
Near-Infrared
This technology projects a near-infrared light which is absorbed by
Vein
blood, reflected by surrounding tissues, and projects the image of
Visualization
the vessels on the patient skin.
Technology

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Notes taken by Mengping