S P E C T R U M

WINTER 2010 VOLUME 22 ISSUE 1

LITE: A national educational association for infusion therapy, vascular access,

home care, oncology, acute care and extended care

THE CHEST RADIOGRAPH — THE GOLD STANDARD?

By: Paul L. Blackburn
The gold standard for verification of catheter tip location has long been a chest radiograph. In fact, if you look at many of the
organizational guidelines or standards, radiographic tip confirmation is suggested. According to the INS Standards of Practice
(2006):
“42.5 Central catheter tip location shall be determined radiographically and documented prior to initiation of the prescribed therapy.”

But are chest radiographs really the gold standard or just a
well accepted standard of practice? In reality, there is no law
on the books in any U.S. state that requires a chest
radiograph to be completed prior to the use of a centrally
placed catheter. In many instances, other techniques for
central catheter tip confirmation are frequently used, such as
fluoroscopy at the time of catheter placement (okay so this is
just a moving form of x-ray, but nonetheless a different
modality), MRI, and transesophageal echocardiogram (TEE).
Recently, several new modalities have entered or are entering
the U.S. market in the form of Doppler and ECG catheter tip
placement.
Several studies report enhanced accuracy in optimal
catheter tip positioning with the use of cardiac electrical
signal detection (Alexander et al, 2010; Jeon et al, 2006).
This method is facilitated by ECG electrode attachment to
both the patient and catheter stylet. Catheter tip positioning
information is then provided during the insertion procedure
via observation of the shape and size of the P wave as the
catheter tip is threaded along specific anatomical locations
within the central vasculature (Jeon et al, 2006, p. 978-80).
In a more recent study, Jeon et al (2006) affirmed that the
tallest peaked P waves occurred with CVC tip location at the
cavoatrial junction, whereas the normally shaped P waves
occurred at the mid to upper SVC. Further observation
CONTINUED ON PAGE 4

Inside This Issue

• Letter from the President
• Golden Rules of IV Therapy
• LITE 2010 Annual Educational
Conference Preview
• LITE 2010 Preview: • Business Networking Skills for
Welcome to the Conference! Conventions and Meetings
• LITE 2010 Preview: Blood • Thank You to Our Sponsors and
Management Overview Exhibitors
 SPECTRUM
LITE EXECUTIVE
COMMITTEE
Patricia Luptak, RN, OCN, BSED, MS
President
Jefferson Regional Medical Center
412-469-7129
patricia.luptak@jeffersonregional.com
Diane DeStefano, RN, OCN, BSN
Presidential Advisor
Jefferson Regional Medical Center
412-469-5370
diane.destefano@jeffersonregional.com
Mary Ferris, RN, BSN, OCN, CRNI
Vice President
St. Clair Infusion Center
412-942-3559
mary.ferris@stclair.org
Denise Haught, RN, CRNI
Treasurer
Accredo Therapeutics
1-866-890-3395 ext. 82467
denise.haught@accredotx.com
Nancy Hrebenach, RN
Advisory Council
Jefferson Regional Medical Center
(retired)
412-844-0525
mema540@yahoo.com
Marjorie King, RN, BSN
Advisory Council
Washington Hospital (retired)
724-225-1698
ronking3@verizon.net
Page 2
LETTER FROM THE PRESIDENT
Dear Colleagues,
We are nearing the end of winter and looking
forward to spring and the renewal of life and
the warm weather. With that renewal of spirit in
spring, let’s think about the renewal of our
professional spirit and life. Education is such
an important part of growing personally and
professionally. Our mission at LITE is to
enhance your knowledge and help to expand
your horizons on many different aspects of
education related to vascular access and the Patricia Luptak, RN,
associated areas of healthcare. We embrace OCN, BSED, MS
your ideas and encourage you to contact us to President of LITE
share what you need from us as an
organization.
We would also encourage you to become involved with us personally!
We know that many of you would like to become involved in our
organization in planning our seminar or educational meetings, or
perhaps would like to teach a PICC class but don’t know how to become
involved. If that is the case, please e-mail info@lite.org or call 412-244-
4338. Remember, you do not have to live in the Pittsburgh area to
participate: We have conference call-in capabilities for our meetings.
LITE hopes to re-energize in this season of renewal with new ideas and
new members to carry our mission into the future. We look forward to
hearing from you, our members, because this is YOUR organization.
Take full advantage of your membership and the services we provide.
Happy Spring!
Sincerely,
Patty Luptak
President
“Nurses dispense comfort, compassion
and caring without even a prescription.”
Val Saintsbury
 Golden Rules
of
IV Therapy
By: Sue Masoorli, RN
President/CEO Perivascular Nurse Consultants
Vascular access devices and related infusion therapies are
the second highest category for nursing malpractice lawsuits.
This is probably due to the large number of patients receiving
infusion therapy at the hands of nurses and doctors who have
little or no training. The importance of nurses utilizing proper
insertion techniques, proper infusion techniques and proper
assessment techniques cannot be denied. Following these
golden rules will significantly improve patient safety and promote
patient satisfaction.
Rule No. 1
Avoid areas of joint flexion. The antecubital fossa, the wrist area
and the ankle area in neonates, should be avoided for the
insertion of peripheral IV devices.
Rationale:
These are considered areas of joint flexion. Flexing the joint will
increase the pistoning movement of the IV device within the vein.
Movement of the catheter can cause the catheter to puncture
the vein wall, resulting in the leakage of IV fluids into the
surrounding tissue. The risk of IV complications such as
infection, infiltration, extravasation, phlebitis, septic
thrombophlebitis and nerve injury have been well documented in
the nursing literature when IV devices are improperly inserted in
these areas.
DON’T MISS OUT ON LITE: RENEW NOW!
Does your membership expire soon? If so, be sure to renew so you won’t miss
out on any of LITE’s conferences, e-blasts and more!
Visit www.lite.org to renew your membership online, or print off a membership
application to fill out and mail in. Renew today!
Rule No. 2
Avoid the three inch area of the wrist over the distal radial bone.
The cephalic vein and radial nerve are very superficial in this
area. Avoid the three inch area on the ventral side of the arm,
just above the palm. The median nerve is very superficial in this
area.
Rationale:
Radial nerve injury is a commonly reported complication when
peripheral IV devices are inserted in these areas. When an IV
device is inserted and the patient complains of an “electric
shock” sensation or numbness and tingling, the nerve has been
touched by the needle. Remove the IV device immediately.
Complex Regional Pain Syndrome (CRPS) can be the result of a
needlestick injury to the nerve. Eliminating these two areas, for
the insertion of peripheral IV devices, will drastically reduce the
incidence of venipuncture related injuries.
Rule No. 3
All central venous catheter tips including PICC lines, implanted
ports, tunneled and non tunneled catheters must have
radiographic confirmation that the catheter tip is in the superior
vena cava prior to use. All nurses, who infuse IV fluids or
medications through any central venous catheter, are required to
know the correct anatomical location of the catheter tip prior to
use.
CONTINUED ON PAGE 4
 SPECTRUM
THE CHEST RADIOGRAPH — THE GOLDEN STANDARD?
CONTINUED FROM PAGE 1
concluded that biphasic patterns of the P waves confirmed
catheter tip location within the RA (Alexander et al, 2010, p.
490; Jeon et al, 2006, p. 982).
Who would have thought 10 years ago that an
understanding of how to read ECG’s would help ensure proper
placement of a vascular access device? Yet we now know
that when an ECG is used to verify placement, the ability to
verify location is improved. By utilizing placement with an
ECG, the nurse can verify the catheter has moved in the
correct direction; the catheter tip is placed at the correct
depth; and the patient’s exposure to risk is minimized.
GOLDEN RULES OF IV THERAPY
CONTINUED FROM PAGE 3
Rationale:
The superior vena cava is a large diameter straight vein with a
tremendous blood flow rate. Many organizations, including LITE,
AVA, ONS and INS have standards or guidelines stating that this
is the most appropriate location for all CVC catheter tips.
Complications such as thrombosis, catheter malposition and vein
perforation are significantly reduced and when catheter tips are
in the SVC. Confirmation of catheter tip placement can be
accomplished by x-ray or fluoroscopy.
Rule No. 4
Prior to using any central venous catheter, a 3 ml free flowing
blood return should be obtained.
Rationale:
All CVCs will develop biofilm and fibrin sheaths which can divert IV areas of infusion therapy and vascular access devices. She has
fluid pathways. The catheter tip should be confirmed in the SVC
which has a blood flow rate of 2000 mls per minute. The inability expert witness in nursing malpractice cases since 1990.
to obtain a 3 ml blood return is a clinical indication that the
catheter is malfunctioning. Instillation of a fibrinolytic drug will
dissolve the fibrin sheath resulting in a free flowing blood return
and the ability to reuse the catheter safely. Catheter fibrin
sheaths can cause retrograde drug flow around the outside
surface of the catheter, resulting in tissue damage.
Rule No. 5
Document the assessment of the vascular access site (peripheral
or central) at least every four hours for non vesicant infusions.
Rationale:
Documentation every four hours is evidence that the site was
assessed. “No signs of IV related complications observed” implies
the site and patient were assessed for all potential IV
complications and none were evident. A “check mark” can be
interpreted as the site was checked but not assessed. Nursing
clichés — such as “patient tolerated procedure well,” ‘IV infusing
well,” and “dressing clean, dry and intact” — have no legal or
clinical value.
Using these five rules, as part of routine nursing practice, will
improve patient outcomes related to vascular access devices and
related infusion therapies.
Page 4
Technological developments over the past 10 years have
changed the way clinicians place central catheters such as
PICCs, improved accuracy, and decreased insertion time. The
new ECG tip positioning technology will forever change the
way clinicians are placing PICCs and other central lines. It is
a technology that has been long awaited.
——————————————————————————————————————---
Paul L. Blackburn, RN, MNA, is the Director of Clinical
Services at Bard Access Systems. He has more than 25 years
of clinical practice in operating and recovery rooms, and he
also has more than 20 years of service as the Chief Nursing
Officer for the Utah Air National Guard, 151st Medical Group.
Suggested Reading
“Infusion Nursing Standards of Practice” January/February 2006
Infusion Nurse Society (INS) 315 Norwood Park South, Norwood,
MA 02062
Masoorli, S. (Nov/Dec 2007) “Nerve Injuries Related to Vascular
Access Insertion and Assessment” Journal of Infusion Nursing
Vol. 30 No. 6
Vesely, T. et al (2002) “The Diverse and Conflicting Standards
and Practices in Infusion Therapy” Journal of Vascular Access
Devices, Vol. 7 No. 3
———————————————————————————————————————
Sue Masoorli, RN, President/CEO of Perivascular Nurse
Consultants, Inc., has more than 30 years experience in the
presented nationally and internationally. She has served as an
Are you an expert on an
IV-related nursing topic?
Do you have a passion for
sharing knowledge with
others?
Then write an article
for Spectrum!
We’re currently accepting
submission for articles on ALL IV
nursing topics. Send your articles or
proposed ideas to
cprice@cmemanage.com.
LITE 2010 Annual Educational
Conference Preview

March 11-12, 2010

Holiday Inn Washington-Meadow Lands
Washington, PA

LITE 2010 PRESENTERS

Therese Austin, MS, RD, LD,
CNSD
Coram Specialty Infusion
John Costa, RN
Bard Access Systems
Margy Galloway, RN, BSN, OCN,
CRNI
Saint Luke’s Hospital
Colleen Littrell, RN, BSN
Saint Luke’s Hospital
Lynn Manly, RN, CRNI
Navilyst Medical
Julie May, RN, MSN, CNS, CRNI
Bard Access Systems
Brenda McKay, RN, BSN, CRNI
Dr. James McCann, D.O.
Teredesai, McCann & Associates
Jamie Santolucito, RN, CRNI
Oregon Health & Science
University Hospital
Nancy Sims, RN, BSN, OCN
UPMC Cancer Center
 SPECTRUM Page 6

LITE 2010 PREVIEW: Special Thanks

WELCOME TO THE CONFERENCE! to Our LITE2010
By: Patricia Luptak, RN, BSEd, MS, OCN Sponsors
Imagine a setting where you can learn the newest techniques and
information about vascular access, network with colleagues, and have BARD Access Systems
fun shopping or trying your luck at the slot machines! LITE’s 38th Annual
Educational Conference will provide just that setting for you as we move Coram Specialty Infusion
our annual conference to the Holiday Inn Washington-Meadow Lands,
just south of the City of Pittsburgh, located across from the Meadowlands Interim Healthcare
Racetrack & Casino.
The Education Committee has again worked hard to provide some Navilyst Medical
great speakers and themes covering a wide variety of topics. This
conference has something for everyone, beginning with moving into a St. Clair Hospital
whole new dimension of catheter tip verification with ECG to transitioning
patients from parenteral nutrition from acute care to home care. There
will be a chance to visit with many different vendors and “play” with some
University of Pittsburgh
of the newest tools and ideas in healthcare. The annual Anna McGrath Medical Center Cancer Center
Dinner will give you a chance to network and enjoy a wonderful dinner as
we award one of our colleagues for their outstanding service, dedication,
and promotion of LITE. And our facility will provide shuttles to the Exhibitors
Meadows or to the Tanger Outlets for a wonderful shopping experience,
the perfect mix of education and FUN! BARD Access Systems
For more information and details about the speakers and topics,
check out the website at www.lite.org. We hope to see many new faces
on March 11 and 12: We want YOUR feedback on how to make LITE BeautiControl
great, and we want a chance to network with you and find out what goes
on in your world of healthcare. See you in March!! Centurion Medical Products

Clinical Technology Inc.

Call For Eloquest Healthcare

Posters! Genentech USA

ICU Medical

Maximus Medical
This year's LITE meeting once again will feature a
poster area. This area is meant to be yet another Navilyst Medical
forum for sharing ideas and engaging in discussion.
Complex and extensive research projects are not Professional Disposables
necessary — just proven and practical solutions for International
challenges IV nurses face daily!
SonoSite, Inc.
Go to www.lite.org
The Leukemia and Lymphoma
for more information! Society
LITE 2010 PREVIEW:
BLOOD MANAGEMENT OVERVIEW
By: Colleen Littrell, RN, BSN
“There is no reason why anyone
would want to have a computer in their
home.” “Heavier than air flying machines
are impossible.” “Louis Pasteur’s theory
of germs is ridiculous fiction.” We would
accomplish many more things if we did
not think of them as impossible.
I am pleased to present information
regarding the principles of blood
management at the LITE Annual
Educational Conference in March 2010.
Blood Management is the appropriate
use of blood products and the utilization
of strategies to reduce or avoid the
patient’s exposure to blood products to
improve patient outcomes. There are
many ways to decrease blood usage. The
most effective ones entail a
multidisciplinary team approach and the
use of a combination of interventions,
which are often simple and at a low cost.
BUSINESS NETWORKING SKILLS
FOR CONVENTIONS AND MEETINGS
By: Debra Fine
Do you dread networking events, open
houses and other business related social
events? Does attending another open
house make you want to run inside your
own and lock the door? For business
professionals, these occasions represent
opportunities to develop business
friendships and broaden networks. Here
are a few techniques business people can
use to improve their small talk skills:
Be the first to say “Hello!” and
introduce yourself. Act as if you’re the
host and introduce new arrivals to your
conversational partner or partners.
Get somebody to talk about why
they’re attending the event and you’re on
your way to engaging them in
conversation.
Listen carefully for information that
can keep the conversation going.
Play the conversation “game”. When
someone asks, “How’s business?” or
“What’s going on?” Answer with more than
“Not much”. Tell more about yourself so
that others can learn more about you.
Be careful with business
acquaintances. You wouldn't want to open
Blood management programs are an
essential part of medical care and can
benefit potentially all patients. There is a
shrinking blood supply and a growing list
of risks and unfavorable patient
outcomes associated with blood
transfusions. Nurses have always had a
vital role in patient safety; this is
especially true in dealing with blood
products. Early identification of anemia
is essential. Education is necessary to
identify the cause of anemia and best
treatment plans for these patients.
Nurses also need education to recognize
blood transfusion adverse reactions and
knowledge of the reporting process if an
adverse event occurs.
At the LITE conference, I will discuss
the need for a blood management
program, the risks of blood products and
the nurse’s role in developing a plan for
the patient with anemia.
a conversation with: “How’s your job at (fill
in the blank)?” What if that person just got
fired or laid off? Be careful when you’re
asking about an acquaintance’s spouse or
special friend: you could regret it.
Don’t act like you’re an F.B.I. agent.
Questions like: “What do you do?” “Are
you married?” “Do you have children?”
and “Where are you from?” lead to dead
end conversations.
Show an interest in your
conversational partner’s opinion,
too. You’re not the only person who
has opinions about interest rates
and Alan Greenspan, imposing
sales tax on Internet purchases,
wearing white after Labor Day, the
merits of the Atkins, South Beach
and Weight Watcher’s diets.
Be prepared with exit lines.
You do need to move around and
meet others.
Every encounter involves risk. As
long as you keep looking for new
people to meet, and you show an
interest in other people, you can
develop business friendships and
enjoy lively conversations.
——————————————————————————
Colleen Littrell is a RN coordinator in the
Blood Management Program at Saint
Luke's Hospital in Kansas City, MO. She
interacts with inpatients, outpatients,
nurses and physicians throughout the
hospital, focusing on anemia prevention
and education. She is currently involved
in a process improvement project,
screening inpatients to determine their
risk for a blood transfusion. Colleen has
more than 20 years of nursing
experience at St Luke’s Hospital that
includes Oncology/BMT, Float Pool,
Medstar Program, Outpatient Infusion
Center and her present position with the
Blood Management Program. Find out
more about Blood Management at Ms.
Littrell’s educational session on March
11 at LITE2010.
Turn every conversation into an
opportunity for success!
——————————————————————————
Debra Fine is the author of The Fine Art of
Small Talk (Hyperion). She presents
keynotes and seminars on conversational
skills and networking techniques
internationally. Contact Debra at 303-
721-8266 or visit her web site at
www.DebraFine.com.
 It is the mission of the League of Intravenous Therapy
Education (LITE), a national educational association for
infusion therapy, vascular access, home care, oncology, acute
care, and extended care, to educate the health care
community.

LITE will accomplish this mission by:

• Promoting and providing professional opportunities through
scholarly activity, networking and educational seminars.
• Establishing guidelines that promote safe, efficient and cost-
effective intravenous therapy in a multitude of care settings.

Like the new Spectrum?

Let us know your thoughts about the new Spectrum!
Send your comments to the LITE Office at cprice@cmemanage.com.

CONTACT THE LITE OFFICE

1844 Ardmore Blvd. Phone: 412-244-4338
Pittsburgh, PA 15221 Fax: 412-243-5160
E-mail: info@lite.org

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