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Vascular access: viewing the vein

Figure 1. Vein appearance on ultrasound

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However, there are always patients whose venous prominence is not improved following these techniques and their veins remain difficult or impossible to palpate. The clinician is often then reduced to performing a ‘blind’ technique and make educated guesses based on tactile sensitivity. This method of venous access has been frowned upon in the field of vascular access for central venous catheters since the introduction of guidelines from the National Institute for Health and Clinical Excellence (NICE) (2002), which suggest that ultrasound guidance be used to gain venous access. However, this is not the case in peripheral access and clinicians often continue to struggle to access compromised veins. The option of long-term vascular access devices such as midlines and peripherally-inserted central catheters can be considered for these patients. However, this option should not be taken lightly as there are additional risks such as infection, pneumothorax, air embolism, and arterial puncture, associated with insertion of these devices (Haider et al, 2009). The other option is the use of technology to aid venous access. Equipment to visualise veins range from ultrasound guidance to translumination technology. Some of these are expensive to purchase and require a period of training but this should be weighed up against the potential benefits to the patient.

Ultrasound guidance There is increasing evidence that the use of ultrasound (Figure 1) in peripheral access is effective. Using ultrasound can increase success rates and reduce complications such as multiple venepuncture attempts and inadvertent arterial puncture (Au et al, 2012). An additional benefit is a decreased time required for cannulation. The procedure of ultrasound guidance does

Figure 2. Vein viewing devices provide a visual ‘road map’

Box 1. Some reasons for compromised veins ■■ Previous intravenous therapy, e.g. chemotherapy ■■ Dehydration ■■ Extremes of age (older adults over 70 years of age or paediatrics) ■■ Obese patients ■■ Patients in peripheral shut down ■■ Intravenous drug abusers ■■ Limited limb choice owing to injury, burns, fistula and lymphoedema, etc. Source: Dougherty and Lamb, 2008

take time to perfect but Tokumine et al (2013) discussed their teaching methods of ultrasound guided venepuncture, that demonstrated a high success rate with low complications. In Doppler ultrasound, acoustic waves are transmitted and ultrasonic waves are reflected from blood vessels providing critical information about the vein’s location. As the device is moved along the patient’s arm, an acoustic beam is emitted through the transducer into the reflector. A benefit of Doppler is that it can determine the flow of blood and, therefore, distinguish arteries from veins. Positive results have been demonstrated with this type of technology (Whiteley et al, 1995).

Translumination technology There are many devices available that use light sources to aid venous access in peripheral veins and they work in similar ways. These devices include: VeinViewer, Venoscope®, Accuvein®, Veintector®, Veinlite®. They are usually battery powered, portable, and easy to use. They use either illumination, transillumination, highintensity lights, light-emitting diode (LED) or near infrared light which projects onto the subcutaneous tissue of the patient. The deoxygenated blood in the veins absorbs the light and veins appear as dark lines within the illuminated area. The Vein viewer® works by using a near-infrared light and a digital camera that projects real-time images on a patient’s skin. This provides a visual road map (Figure 2) to improve successful puncture. It is now also recognised that apart from simply visualising the vein, access is improved by stretching the skin and securing the vein during access. Many of these new devices claim to do all three of these things. There are a number of studies that demonstrate the benefits of these devices (e.g. Katsogridakis et al, 2008; Phipps et al, 2012) but further research is required.

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enepuncture and cannulation are procedures regularly carried out by health professionals and form a critical component of patient care. Venepuncture, or the collection of blood from a vein, is usually performed for laboratory analysis to assist with diagnosis and treatment of the patient. Cannulation, on the other hand, is indicated for the delivery of medicines, blood products, total parenteral nutrition, haemodynamic monitoring and blood sampling.Although these procedures are often uneventful, occasionally we are faced with patients who have no apparent superficial veins. These patients often experience multiple punctures before a vein is successfully accessed. A study by RobinsonReilly et al (2010) indicated that patients see vascular access as a ‘necessary evil’. Within this study, the patients described the process of gaining access as ‘unpleasant’ and ‘frightening’ with one patient even voicing the thought of refusing chemotherapy rather than continuing with the difficulties encountered during access attempts. As we begin to understand the impact that this procedure can have on patients with compromised veins (Box 1), we should be considering alternative methods to improve the care of this vulnerable group. There are many methods used to attempt to increase venous distension such as: ■■ Application of a tourniquet ■■ Lowering the extremity below the level of the heart ■■ Gentle tapping of the hand/arm ■■ Application of a warm compress or immersing the limb in warm water ■■ Using muscle action to force blood into the veins by asking the patient to grip and ungrip their hand repeatedly ■■ Considering the use of a glyceryl trinitrate (GTN) patch

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Innovations in vein viewing can be used to improve outcomes for patients with challenging vascular access

Conclusion By using these new devices a clinician could reduce multiple punctures, reduce equipment waste and improve the patient experience.With technological advancement, clinicians are in a position to change and adapt their practice (Kabakura do Amaral and Mandetta Pettengill, 2010). These new and promising innovations should be used to improve outcomes in intravenous therapy, particularly for patients with challenging vascular access. Taking this approach will help to provide excellence in practice while putting the patient first.  BJN In memory of the author’s father, Alfred D Burke, for whom venous access was an ongoing problem. Au AK, Rotte MJ, Grzybowski RJ, Ku BS, Fields JM

(2012) Decrease in central venous catheter placement due to use of ultrasound guidance for peripheral intravenous catheters. Am J Emerg Med 30(9): 1950-4 Dougherty L (2008) Obtaining Peripheral Venous Access. In: Dougherty L and Lamb J, eds. Intravenous Therapy in Nursing Practice, 2nd Edn. Blackwell Publishing. Oxford Haider G, Kumar S, Salam B, Masood N, Jamal A, Rasheed YA (2009) Determination of complication rate of PICC lines in oncological patients. J Pak Med Assoc 59(10): 663-7 Kabakura do Amaral CM, Mandetta Pettengill MA (2010) Using ultrasound to guide peripheral venipuncture in children: the importance of the technique for nurses. Acta paul enferm 23(4): 472-8 Katsogridakis YL, Seshadri R, Sullivan C, Waltzman ML (2008) Veinlite transillumination in the pediatric emergency department: a therapeutic interventional trial. Pediatr Emerg Care 24(2): 83-8 National Institute for Health and Clinical Excellence (2002) Guidance on the use of ultrasound locating devices for placing central venous catheters. NICE, London. http://tinyurl.com/bqelzky (accessed 16 October 2013) Phipps K, Modic A, O’Riordan MA, Walsh M (2012) A randomized trial of the Vein Viewer versus standard

technique for placement of peripherally inserted central catheters (PICCs) in neonates. J Perinatol 32(7): 498-501 Stein J, George B, River G, Hebig A, McDermott D (2009) Ultrasonographically guided peripheral intravenous cannulation in emergency department patients with difficult intravenous access: a randomized trial. Ann Emerg Med 54(1): 33-40 Robinson-Reilly M, Paliadelis P, Cruickshank M (2010) Research: This Won’t Hurt a Bit - the Lived Experience of Venous Access. ANJ 18(4): 19 Tokumine J, Lefor AT, Yonei A, Kagaya A, Iwasaki K, Fukuda Y (2013) Three-step method for ultrasoundguided central vein catheterization. Br J Anaesth 110(3): 368-73 Whiteley MS, Chang BY, Marsh HP, Williams AR, Manton HC, Horrocks M (1995) Use of hand-held Doppler to identify ‘difficult’ forearm veins for cannulation. Ann R Coll Surg Engl 77(3): 224-6

Linda J Kelly

Lecturer Adult Health University of the West of Scotland School of Health, Nursing and Midwifery

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