1. Extended-Dwell PIVs: “A New Tool in the Toolbox” The Emerging Evidence
Karoline Draper MSN VA-BC

2. Disclosures Clinical Specialist with Access Scientific

3. 2016 INS Standards of Practice Review Vascular Toolbox
Objectives
2016 INS Standards of Practice
Review Vascular Toolbox
Define Extended Dwell Catheter
Discuss Ultrasound Guided PIV data
Review Current EDC Options
Concerns with EDC

4. INS Standards of Practice
“Use the venous site most likely to last the full length of the prescribed therapy, using the forearm to increase dwell time, decrease pain during dwell time, promote self-care, and prevent accidental removal and occlusions.” Infusion Therapy Standards of Practice. 2016: S54

5. Today’s Toolbox (In-Patient, Non-cuffed VADs)
Peripheral IVs (PIVs) >300 Million Sold (US)
((Gaping Void))
Midlines (MLs) Fastest Growing VAD Sector
CVADs PICCs & CVCs total >8 million
Others (e.g. Acute hemodialysis, etc.)

6. Peripheral IV Catheters PIVs
History: 1950s First Over-Needle IV Catheter— It was PVC, 2 inches long, 16 gauge The Evidence Base: Bloodstream Infection /1000 c-d Total Complications 47-65% Average Dwell Time (w/SL) hrs. Phlebitis 7-70% Infiltration 7-27% Dislodgement 16-47% First Attempt Success < 50% Completion of Therapy 47% Remember: These are PERCUTANEOUS PIVs

7. Vascular Access Tool Box Filling the Void
Florence Nightingale: “Give me the proper tools, fresh air and sunshine, and I can cure even the sickest and most downfallen…” Yesterday……….PIVs & CVADs Today……………PIVs, UGPIVs, MLs & CVADs Tomorrow……….PIVs, UGPIVs, UGEDCs, EDCs, MLs & CVADs

8. What is an “Extended-Dwell PIV or EDC?”
Criteria:
Longer than a PIV. Shorter than a midline:
PROVEN AVERAGE (MEAN) DWELL TIME > 96 HOURS
Power-Injectable
Low Complications, High Completion of Therapy
High (>80%) first-attempt success rate
Ideally, blood drawable
Ideally, anti-infective
Bierman SB. A New Tool for the Vascular Access Toolbox. Infection Control Today 2017;21(7):30-32.

9. Why do we need an Extended-Dwell PIV?
Traditional PIVs (1.88”). are NOT WORKING in DIVAs, requiring ultrasound-guided PIVs and extended peripheral IV therapy:
For U/S guided PIVs:
Median survival = 26 hours
Overall FAILURE RATE = 44%
42% Infiltrated
23% Dislodged
33% “Were not flushing”
FAILURE RATE AT ONE HOUR = 10%
Khan MS, Sabnis VB, Phansalkar DS, Prasad SP, Karnam AHF. Use of ultrasound in peripheral venous catheterization in adult emergency and critical care units. Anaesth Pain & Intensive Care 2015;19(3):
Fields, JM; Dean, AJ; Todman, RW; Au, et al. "The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity." (2012). Department of Emergency Medicine Faculty Papers. Paper 13.

10. And yet, U/S-Guided PIVs do offer significant benefits…
High “Success Rates” (not necessarily first-attempt success)
Reduced need to place CVADs (3 studies)
Removal of existing CVCs (fewer central line days)
Patient Satisfaction (fewer needle sticks)
Khan MS, Sabnis VB, Phansalkar DS, Prasad SP, Karnam AHF. Use of ultrasound in peripheral venous catheterization in adult emergency and critical care units. Anaesth Pain & Intensive Care 2015;19(3):
Fields, JM; Dean, AJ; Todman, RW; Au, et al. "The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity." (2012). Department of Emergency Medicine Faculty Papers. Paper 13.
Constantino TG, Parikh AK, Sata W, et al. Ultrasonography-Guided Peripheral Intravenous Access Versus Traditional Approaches in Patients With Difficult Intravenous Access. Annals of Emergency Med. 2005;46(5):

11. Which is why MAGIC includes indications for U/S-guided Peripheral Catheters
For patients with:
One or more failed attempts
Inability to identify veins visually, or
Veins identified are difficult intravenous access (e.g. forearm, antecubital or upper arm)
For contrast based upper extremity access…where visible veins to accommodate catheter size are not present.
5. Moreau N, Chopra V. Indications for peripheral, midline and central catheters: summary of the MAGIC recommendations. British Journal of Nursing, 2016, (IV Therapy Supplement) 25(8):S15-S24.

12. Why do U/S-guided PIVs fail?
Because all the factors that cause ~50% of regular PIVs to fail are still active in U/S-guided PIVs: e.g., traumatic insertions, like back-walling, leading to phlebitis, infiltration, etc.
MATERIAL—Polyurethane softens quickly.
LENGTH—deeper vessels clearly need longer catheter.

13. So all we need is a longer PIV of the same polyurethane material. Right?
WRONG:
12cm Polyurethane IV (Seldinger)6
20.9% Thrombosis
11.4% Occlusion/phlebitis
2.3% Infiltration
6.35cm Polyurethane IV (over-needle)7
44% Failure Rate
Median Survival 26 hrs.
Clearly, it takes more than just a little more length and the same ‘ole material to make an effective EDC

14. How about adding a guidewire?
One well-studied 2.25” guidewire assisted, polyurethane PIV:
Average dwell time = 2.4, 4.4 days
This by definition is NOT AN EXTENDED DWELL CATHETER.
Chick JFB, Reddy SN, Chen JX, et al. A randomized comparison between an intravenous catheter system with a retractable guidewire and conventional intravenous catheters. J Vasc Access Nov 17;18(6):
Raio C, Elspermann R, Kittisarapong N, et al. A prospective feasibility trial of a novel intravascular catheter system with retractable coiled tip guidewire placed in difficult intravascular access (DIVA) patients in the Emergency Department. Intern Emerg Med 2017 Sep 14. DOI /s

15. So—if not just length and a guidewire--what does it take to make a TRUE EDC?
Reduction in central line utilization due to an ultrasound-guided, extended-dwell IV catheter
Method: This is a single-center, prospective cohort study extending from May 1 to June 30. The PIV used was either an 18g/1.88” or 20g/1.88” over-needle, polyurethane catheter as selected by the clinician at the bedside. The EDPIV used was a 3Fr/2.4” over-wire catheter. All lines were placed with sterile technique (including sterile probe cover) using the dynamic ultrasound method in the transverse axis. Skin antisepsis was achieved with 2% chlorhexidine gluconate. Securement was done with a 3.5 x 4.5 inch bordered transparent dressing.
Results: A total of 361 patients were observed: 278 UGPIVs, 83 UGEDPIVs. Average dwell time in the UGPIV group was 5.08 days (1-16 days) with 5.7% having their central lines removed upon placement of UGPIV. Average dwell time in the UGEDPIV group was 10.7 days (1-29 days) with 37.3% having their central lines removed upon placement of UGEDPIV. Numerous UGEDPIV patients were discharged home for antibiotics; had they been followed, the EDPIV dwell time may have been even longer. Central line utilization (i.e., percentage of central lines per overall patient days) decreased from 20.3% during the same period the previous year, during which EDPIVs were not used, to 17.2%--a 15.3% reduction.
Conclusion: The ultrasound-guided extended-dwell catheter outperformed the standard PIV, lasting over twice as long. Most important, during the trial period, 37.3% of patients receiving the UGEDPIV were able to have their central lines removed upon placement, resulting in a 15.3% decrease in central line utilization.10

16. What made the Difference?
Average Dwell Time = 10.7 days
Material Science: An entirely new catheter material—retains its tip longer, softens once in the vessel. NOT A POLYURETHANE, rather a blended co-polymer.
Atraumatic insertion method: These EDCs or EDPIVs were placed using an over-wire procedure that begins with a 24g angiocath. The guidewire has a smooth, plastic tip.
So, it is the combination of:
small gauge introducer needle,
well-engineered wire, AND MOST IMPORTANTLY…
a new and better material

17. What should I be most concerned about with EDCs?
Answer: INFECTION CDC (Guidelines 2011)--PIVs allowed to dwell past 96 hours, i.e. extended-dwell: “…the risk of CRBSIs with this strategy is not well studied.” (pg. 45) REMEMBER: Virtually ALL catheter-related bloodstream infections are BIOFILM INFECTIONS

18. Polyurethane Standard polyurethane catheters have been
shown to bloom additives to their surfaces
during normal aging.
These surface additives are proven to
“facilitate bacterial attachment”
Nouman M, Jubeli E, Saunier J, Yagoubi N. Exudation of additives to the surface of medical devices: impact on biocompatibility in the case of polyurethane used in implantable catheters. J Biomed Mater Res A. 2016;104(12):
Nouman M, Saunier J, Jubeli E, Yagoubi N. Additive blooming in polymer materials: Consequences in the pharmaceutical and medical field. Polymer Degradation and Stability. 2017;143:

19. Have no fear… Other options are here
New technology removes dangerous surface additives and creates surface micro-texturing thereby inhibiting bacterial attachment1
70% reduction in bacteria and biofilm formation in comparison with a standard polyurethane catheter1
 1. Based on laboratory test results which may not be indicative of clinical results. Preclinical in-vitro evaluations do not necessarily predict clinical performance with respect to catheter-related bloodstream infection.
Pathak R, Bierman S, d’Arnaud P. Inhibition of bacterial attachment and biofilm formation by a novel intravenous catheter material using an in vitro percutaneous catheter insertion model.Medical Devices: Evidence and Research. 2018:11 427–432

20. How do I prevent biofilm formation on my EDC?
Usual infection prevention methods
Hand washing, drapes, chlorhexidine, etc.
Consider chlorhexidine-impregnated sponge or transparent dressing
Make an evidence-based decision--which catheter material has a published track record of zero to low CRBSIs?

21. Summing Up
The use of ultrasound guidance has created a new and growing need for a true EDC
Simply extending the length of standard PIVs or adding a guidewire does not suffice
New materials and insertion tools are necessary to TRULY achieve extended dwell times
As true EDCs appear, be cautious about CRBSI risk and take preventive measures

22. References
Bierman SB. A New Tool for the Vascular Access Toolbox. Infection Control Today 2017;21(7):30-32.
Khan MS, Sabnis VB, Phansalkar DS, et al. Use of ultrasound in peripheral venous catheterization in adult emergency and critical care units. Anaesth Pain & Intensive Care 2015;19(3):
Fields, JM; Dean, AJ; Todman, RW; Au, et al. The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity. (2012). Department of Emergency Medicine Faculty Papers. Paper 13.
Constantino TG, Parikh AK, Sata W, et al. Ultrasonography-Guided Peripheral Intravenous Access Versus Traditional Approaches in Patients With Difficult Intravenous Access. Annals of Emergency Med. 2005;46(5):
Moreau N, Chopra V. Indications for peripheral, midline and central catheters: summary of the MAGIC recommendations. British Journal of Nursing, 2016, (IV Therapy Supplement) 25(8):S15-S24.
Fabrizio E, Ferrari G, Molino P, et al. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. American Journal of Emergency Medicine 2012; 30, 712–716.
Dargin JM, Rebholz CM, Lowenstein RA, et al. Ultrasonography-guided perihperal intravenous catheter survival in ED patients with difficult access. American Jounral of Emergency Medicine 2010;28:1-7.
Chick JFB, Reddy SN, Chen JX, et al. A randomized comparison between an intravenous catheter system with a retractable guidewire and conventional intravenous catheters. J Vasc Access Nov 17;18(6):
Raio C, Elspermann R, Kittisarapong N, et al. A prospective feasibility trial of a novel intravascular catheter system with retractable coiled tip guidewire placed in difficult intravascular access (DIVA) patients in the Emergency Department. Intern Emerg Med 2017 Sep 14. DOI /s
Caparas JV, Valcorza C, Freeman R, et al. Reduction in central line utilization due to an ultrasound-guided, extended-dwell IV catheter. AACN National Teaching Institute & Critical Care Exposition, May Poster in press.
Nouman M, Jubeli E, Saunier J, Yagoubi N. Exudation of additives to the surface of medical devices: impact on biocompatibility in the case of polyurethane used in implantable catheters. J Biomed Mater Res A. 2016;104(12):
Nouman M, Saunier J, Jubeli E, Yagoubi N. Additive blooming in polymer materials: Consequences in the pharmaceutical and medical field. Polymer Degradation and Stability. 2017;143: