The CVAA Link: Summer 2022 by CVAA

THE CVAA

Newsletter of the Canadian Vascular Access Association

Summer 2022

CVAA / BD Award Winners First Place – National Winner & Regional Winner — Lollita Rahaman, William Osler Health System, Brampton, ON

Second Place – Regional Winner — Sandra VazGonsalves, Alberta Health Services – Peter Lougheed Centre, Calgary, AB The CVAA Board of Directors are pleased to announce the winners of the 2022 – CVAA/BD Excellence in Vascular Access Management & Infusion Therapy Award! The award recognizes the important contributions made in vascular access management and infusion therapy practice with a focus on peripheral IV therapy. Purpose of the award: • Promote safety and quality improvement in peripheral IV vascular access management and infusion practices for optimal patient outcomes • Recognize champions and trailblazers in Canadian vascular access management and infusion therapy practice • Raise the awareness of the impact of individual contributions to system wide results We had a great number of deserving applicants and the submissions were blindly reviewed by a committee of Board members. We are very pleased to announce the following recipients:

Third Place – Regional Winner — Kimberlei Dool, Chilliwack General Hospital, Chilliwack, BC

The regional and national recipient(s) received an education grant, to be used for educational pursuits and a registration for the CVAA conference where they were presented with the award. CVAA is appreciative of the initiative and support of BD Canada, one of our 2022 Platinum Corporate Members, and wish to thank them for funding this award.

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2022 Virtual CVAA Conference

Once again, we held our national conference fully virtual (April 27–29, 2022) and it was another great success, with our highest registration ever!! We presented our regular schedule of education through plenary and concurrent sessions, hands-on Skills Labs (yes, still hands on!), held engaging exhibit hall time, and also did our best to network and. We are very pleased with how the conference was received and the feedback has been terrific: “I thought it was all fantastic. Love the skills labs too.” “Interesting keynote presentations and concurrent presentations!” “Really It was over my expectation.” “Having the virtual platform has allowed me to attend, when I wouldn’t have been able.”

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This year, we included an outlet for creativity in our Delegate Kits for attendees to keep their hands busy while their minds focused on the education—and you delivered!! Check out how creative our members are:

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And for 2023, we have BIG NEWS! Not only are we hoping and hoping and planning to be together in person, we are partnering with WoCoVA for a Special Event! Please Save the Date for April 26–28, 2023 to join us in Toronto, ON, as we invite the world to join us.

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Have you considered putting your name forth for a Board of Directors position? We encourage you to think about it for 2023. In the meantime, hear from current Board members about how they came to the role and get to know them a bit. Here are the first available installments of the CVAA Meet the Board series: Carmen Cernusca

Brenda Gray

Janny Proba

Leanne Tremain

Fewer needle sticks and faster care have shown to significantly increase patient satisfaction. 1

The benefits of point-of-care ultrasound for PIV insertion

Improves quality of care and patient safety – by reducing risk and complications of vascular access devices

Minimizes costs – by reducing direct labor and materials

Increases efficiency –

by enabling a “one-stick” standard or “first stick success” and limiting time spent on multiple attempts and unnecessary line escalation

For additional information, please contact matthew.mister@fujifilm.com

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Enhances the patient and practitioner experience – by reducing the pain, fear, anxiety and frustration often associated with IV insertion

We were pleased to launch our new Journal Club this spring! Did you miss it? You can read the article and watch the recording here.

Save the Date for our summer Journal Club event: July 27, 2022 at 7:30 pm ET. Read the article here.

Smarter by design. Enhanced for technique. Introducing the BD Prevue™ II Peripheral Vascular Access System—a smart innovation in portable ultrasound vascular access devices.

Optimized vascular access is in sight

Patient care is fast paced and often critical. When it comes to placing an intravenous device, it's important that you do so efficiently and accurately. Introducing the BD Prevue™ II Peripheral Vascular Access System—a smart innovation in portable ultrasound vascular access devices. Designed with clinicians in mind, the BD Prevue™ II System features buit-in control across all elements—from the wide based probe and movable boom arm through vessel assessment tools and in unit tutorials—all so clinicians can focus on optimizing IV placement technique.

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PIVC insertion workshop On June 7, 2022, the McGill Vascular Access Student Club (VASC) held a workshop for peripheral intravenous catheter (PIVC) insertion in partnership with BD Canada. Student participants worked in small groups with educators to improve their confidence and competence in PIVC insertion. Prior to the event, students filled out a survey answering the following question: “Please rate your response to the following question: I feel confident that I can successfully insert a PIV on the first attempt”. Responses ranged from “strongly disagree” to “neutral”; no students agreed to the statement.

Following the approximately one hour of hands-on practice with wet arms at the June 7th workshop, students were sent a follow-up survey asking: After completion of the June 7th PIV event, please rate your response to the following question: “I feel confident that I can successfully insert a PIV on the first attempt”. All students responded “[I] agree”. Thanks to the generous donation of supplies from BD, the VASC will offer drop-in PIV insertion workshops beginning in the Fall of 2022.

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NEW Practice Primer We are excited to launch this new column in the CVAA Link where we provide step-by-step instructions and education. Here is the first installment: Ultrasound-guided Peripheral Venous Access Basics. Are you interested in sharing with Practice Primer? Email cvaa@cvaa.info to discuss!

Ultrasound-guided Peripheral Venous Access Basics David-Alexandre Morin, RN, CVAA (m), Epicc Intensive Care (c) Ultrasound guided peripheral venous access (UPVA) allows healthcare professionals to see veins that are not visible, even to trained eyes, to reduce the number of punctions and possible complications (Khan et al., 2015). This technique is increasingly observed in critical care settings and valuable for any patient with difficult venous access.

The screen

EQUIPMENT First of all, let’s demystify the ultrasound machine. The ultrasound machine includes an unlimited number of functions. Surprisingly, only a few functions on this device will be useful for ultrasound-guided peripheral venous access (UPVA). The basics you need to know involve the screen, the main (relevant) keys and the probes.

An ultrasound reproduces an image on a screen by a reflection of waves on structures, tissues and fluids. Denser substances, such as fatty tissues, appear as gray surfaces. Liquids, instead, are shown as blackened spots. Structures on the surface of the skin appear at the top of the screen and the deepest ones, at the bottom.

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Two essential keys There are only two essential function keys, DEPTH and GAIN, which can be found on a touch screen or sometimes on a keyboard as shown below.

These two images represent a single vein, at two distinctive depths. It is important to adjust the depth to facilitate our approach with the catheter. Gain The gain button allows us to lighten or darken the image projected on the screen by the ultrasound probe, as seen on the images below. Depth Properly adjusting the depth gives a more accurate image, as demonstrated on the image on the left. A precise adjustment allows us to see the superficial structures. On the other hand, when the depth is not adjusted properly (as shown on the image to the right) it demonstrates deep structures without the clarity needed for ultrasound peripheral venous access (UPVA). The adjustment allows us to explore up to 5 cm in depth. When the vein appears too small, it does not help to perform a puncture. In the left image, the better adjustment allows explorations at a depth of 1.5 cm, resulting in a vein that appears bigger on the screen. On the left side of the screen on the image on the right, you can see markers. These are measurement tools showing the depth. Graded in centimeters, the user can measure the depth of the vessels and their diameter. Basically, the idea is to adjust with the DEPTH key the ideal point in order to get the best view on the veins.

These photos show various darkness adjustments that the user could change easily to suit their visual preferences. With a low gain adjustment, the image is too dark to allow the identification of structures, as shown in the left photo. The photo in the middle shows a high gain adjustment, giving an image that is too bright. The power of the waves that return to the probe is too high and creates an illumination of the image. The idea with the gain adjustment is to refine the definition of the structures so we can identify the underlying structures more easily, as represented in the bottom photo.

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The ultrasound probes

These photos represent three different Sonosite linear type probes that offer the best vascular system’s resolution. Ultrasound machines include different types of probes. The probes in the left and right photos are particularly useful because they are smaller. They allow the user to obtain a superficial view, while being manipulated more easily. The probe in the middle photo is the one that we find on most ultrasound machines. For this reason, I find it preferable to start using this type of probe. Finding a cannulable vessel Using UPVA, length, depth and diameter are the three characteristics we look for in a cannulable vessel. Examine the length of the vein to ensure it does not have a bifurcation or other abnormality that could prevent proper insertion of the catheter. A vein length of 2 to 3 cm, is sought.

Differentiating the vein from the artery Many criteria allow the differentiation of a vein from an artery. An artery looks thicker and will be echogenic, giving the screen a whitish lining. It will not compress as easily as a vein, at least there will be some difficulty. An artery will be pulsating and will remain so when it is compressed. A vein will be less echogenic so will give a thinner appearance. Veins have a high compressibility and it will not pulse when being compressed. Sometimes when an artery is near a vein, the vein seems to pulse on the screen, so it is important to compress the vessels in order to differentiate them well (Komasawa et al., 2014).

With UVPA, we can reach deep veins, for example, depth of less than 2 cm should be considered with a shielded 1.88 (4.77 cm) catheter. A vein diameter greater than 3 mm allows an easier canulation. The key is to explore the vein to find the optimum of each of these three characteristics.

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Type of views The transverse view makes it possible to “slice” a vessel on the direction of its width. As with a CT scan, this cross-sectional view makes it possible to reproduce an image by “cutting” the area of interest into slices. To obtain this view, we must position the probe perpendicularly to the arm, as shown on the photo below. We must place the centre of the vein in the middle of the image. This accurately represents the marker in the centre of the probe, as shown on the left photo below. We have to adopt a firm and stable grip of the probe in order to stabilize the image on the screen. We have to bring the bevel of the needle as close as possible to the marker. Then, adjust the insertion angle in proportion to the depth of the vein by gently piercing the skin, constantly keeping your eyes on the screen. The idea is to learn to trust the image, it will guide you (Blaivas et al., 2003).

Essential components to succeed in the puncture • Avoid applying too much pressure with the probe to the tissues, when spotting. Excessive pressure flattens the vessels, underlying structures, and distorts the image on the screen. • Provide delicate movements with the probe. A single millimetre displacement with the probe will distort the image. • Adopt a firm and stable grip of the probe. • Apply careful adjustments of the screen’s functions (depth and gain). • Position the patient so they are stable and the arm to be punctured is at the right height. • Place the ultrasound machine to get a direct view of the screen. As set out, these components provide the basics of using ultrasound-guided peripheral vascular access. This valuable tool increases canulation success, which improves the experiences of vascular access professionals and their patients.

About the author The longitudinal view makes it possible to “slice” a vessel lengthwise. To obtain this view, the marker must be oriented toward the patient’s feet, as shown on the photo to the left below. This view is particularly useful when it comes to the time of inserting the catheter. It prevents from transfixing the vein by keeping an adequate angle and a complete view of the catheter during its insertion, as seen on the right photo (Blaivas et al., 2003; Stone et al., 2010).

David-Alexandre Morin, is an RN working in the Intensive Care Unit of the Hôtel-Dieu de Québec, and is the expert trainer in ultrasound guidance and peripheric access at the Centre Hospitalier Universitaire de Québec (CHU). Recently, he was involved in an innovative clinical project where he provided training on ultrasound-guided peripheral catheter installation in several settings, including the emergency department and intensive care and cardiac care units.

REFERENCES Blaivas, M., Brannam, L., & Fernandez, E. (2003, December). Short-axis versus long-axis

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approaches for teaching ultrasound-guided vascular access on a new inanimate model. Academic Emergency Medicine, 10(12), 1307–1311. Komasawa, N., Mihara, R., Hattori, K., & T. Minami, T., (2016). Evaluation of artery and vein differentiation methods using ultrasound imaging among medical students. British Journal of Anaesthesia, 117(6), 832–833. https://doi. org/10.1093/bja/aew371

Kreidieh, F. Y., Moukadem, H. A., & El Saghir, N. S. (2016). Overview, prevention and management of chemotherapy extravasation. World Journal of Clinical Oncology, 7(1), 87–97. doi:10.5306/wjco. v7.i1.87 Stone, M. B., Moon, C., Sutijono, D., & Blaivas, M. (2010). Needle tip visualization during ultrasound-guided vascular access: shortaxis vs long-axis approach. American Journal of Emergency Medicine, 28(3), 343–347.

BD has the only 3 in 1 Bedside PICC¹ insertion solution available in Canada* The Site~Rite™ 8 Ultrasound System with integrated Sherlock 3CG™+ Tip Confirmation System (TCS) is designed to simplify vascular access by enabling you to visualize PICC placements from beginning to end from the bedside.

Ultrasound Guidance

CVAA Guideline²

Visualization tool for vessel assessment and catheter insertion. Can customize ultrasound features for your personal preference.

Use ultrasound for vessel assessment (including catheter-to-vein ratio) and insertion

PICC Tip Tracking

CVAA Guideline²

Real time visualization of PICC tip location and orientation. PICC tip tracking is through pre-loaded magnetic stylet.

Use CVAD tip navigation technology, when possible, to assist in detecting CVAD malposition during insertions

PICC Tip Confirmation

CVAA Guideline²

ECG technology is used to confirm proper catheter tip placement without the need for a chest X-ray in patients with a P-wave that is present and identifiable.

Use technology to confirm tip location • Use electrocardiogram (ECG) technology, when possible (to decrease delay in infusion therapy, reduce patient exposure to radiation, and increase accuracy of tip location).

BD Bedside PICC kits with 3CG technology are available for PowerPICC™, and PowerPICC™ SOLO™² 1 2

Peripherally Inserted Central Catheter Canadian Vascular Access Association (2019). Canadian Vascular Access and Infusion Therapy Guidelines. Pembroke, ON: Pappin Communications.

*as of April 2022

BD–Canada, Mississauga ON L5N 0B3.

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