Teleflex is a global provider of medical products designed to enable healthcare providers to protect against infections and improve patient and provider safety. The company specializes in products and services for vascular access, respiratory, general and regional anesthesia, cardiac care, urology and surgery. Teleflex also provides specialty products for device manufacturers. The Teleflex family of brands includes arrow®, beere medical®, deknatel®, gibeck®, hudson rci®, kmedic®, pilling®, pleur-evac®, rüsch®, sheridan®, smd™, taut®, tfx oem® and weck®, all of which are trademarks or registered trademarks of Teleflex Incorporated or its affiliates. Teleflex Incorporated (nyse:tfx) has annual revenues of approximately $1.9 billion and serves healthcare providers in 140 countries.

For detailed information, see www.teleflexmedical.com

References available upon request.

TELEFLEX MEDICAL2917 Weck Drive Research Triangle Park, NC 27709

Mailing Address Teleflex Medical PO Box 12600 Research Triangle Park, NC 27709 Toll Free 866.246.6990 Phone 919.544.8000 Intl 919.361.3961

The PICC Wand is a registered trademark of Access Scientific, Inc. Teleflex is a registered trademark of Teleflex Incorporated. © 2011 Teleflex Incorporated. All rights reserved. 2009-0037 v1

PrInCIPLEs oF VAsCULAr ACCEss InsErTIon► ► ► ► ► ► ► ►

►

►►

Patient admitted to hospital

Standing order for VHP authorized

by MD within first 24 hours of patient

admission

Complete VHP Admission

Assessment

Initiate VHP Daily Assessment and

Tools

Insert selected device within 48

hoursPatient discharged Complete Evaluation

Tool

Device not necessary.

Discontinue/remove device

Include multiple disciplines in daily

assessment

Determine Vascular Access device necessity each day based on

assessment tool

Apply Daily Assessment

Tool throughout hospitalization during

daily rounds.

Yes, IV device still required for

treatment

►

how To UsE ThE VEssEL hEALTh AnD PrEsErVATIon (VhP) ProToCoL

DrIVIng CLInICAL PrACTICE To ThE nEXT LEVEL: A CoLLAborATIVE ProjECT on VEssEL hEALTh & PrEsErVATIon nAnCy MoUrEAU, bsn, CrnI, CPUI AnD nAnCy TrICk, rn, CrnI Accepted and Presented at the 2010 Association of Vascular Access Annual Scientific Meeting

Vascular access is a high volume, high impact clinical process. Insertion of an intravenous device is the most common invasive procedure performed with hospitalized patients. Unfortunately, little has been done to quantify or qualify an intentional process for vascular access selection and management for this common invasive procedure. Traditional intravenous access is reactive, painful and ineffective, often resulting in exhaustion of all peripheral veins prior to consideration of other access options. Evidence suggests clinical pathway models improve outcomes by reducing variations and establishing processes to evaluate and coordinate care thus minimizing fragmentation and cost. In 2008, a multidisciplinary summit convened to assess current clinical practice problems and create a proactive model for acute care management of vascular access. From that summit a new vascular access pathway approach was created based on published evidence, standards

and best practice guidelines. The protocol, called the Vessel Health and Preservation Protocol (VHP), is a systematic clinical pathway with measurable objectives incorporating patient-focused safety for The Right Line for The Right Patient at The Right Time™ approach. Timely, intentional proactive intervention for device selection implemented within 24 hours of admission to acute care, with device placement within 48 hours reaps reliable access, reduced delays in treatment administration and improved patient satisfaction. Vessel Health and Preservation is an approach to patient care utilizing Clinical Pathway Protocols to improve vascular access selection flow and reduce patient risk. Implementation of an organized approach to vascular access provides the educational, regulatory and clinical outcomes necessary for reliable vascular access and improved patient safety.

AbsTrACTA Vessel Health and Preservation Protocol has been developed to facilitate the selection of vascular access devices for all acute care patients regardless of point of entry.

The protocol is built on an intentional process, often recognized as a clinical pathway. This process incorporates national guidelines, recommendations and standards of practice for infection prevention and management of intravenous devices for inpatients. Evidence confirms that clinical pathways improve outcomes, reduce variations in procedures and reduce medical errors. The goal of this vascular access clinical pathway is to improve quality and consistency of care, reduce risks, increase patient satisfaction and increase the efficiency of resources and procedures. These goals are met by providing physicians/nurses/staff with a step-by-step protocol for selecting the best vascular access device for patients based on diagnosis, required therapies and the acuity level of the patient.

• Thisprotocolisinitiatedthroughastandardorderform signed by the attending physician.

• Atri-foldassessmentformiscompletedbynurseswithin the first 24 hours of patient admittance to the facility to systematically determine which vascular access device best meets the needs of this patient and which department should insert this device.

• Eachcentralvenousdeviceistheninsertedwiththe use of Central Line Checklist in keeping with implementation of the IHI central line bundle. Additionally, the combined efforts of nursing staff and physicians with daily assessment of the device will determine continued necessity and removal of device as soon as it is no longer medically necessary according to the 2002 Centers for Disease Control

Guidelines. Accepted and presented at the 2010 Association of Vascular Access Annual Scientific Meeting. The anticipated result of consistent use of this protocol is fewer vascular accesses per patient ensuring increased vessel preservation. Additionally, fewer accesses reduce hospital costs and increase patient satisfaction.

The Vessel Health and Preservation Protocol will improve consistency of selection, placement, and evaluation of vascular access devices for patients through the application of the protocol device throughout their treatment plan and help:

• Initiatecommunicationbetweendoctorandadmitting nurse to discuss patient-specific factors that affect vascular access (vital for transfer of information necessary to select best device for patient).

• Selecttheleastinvasivedevicewiththelowestriskwhich lasts the duration of the therapy

• Selectthemostappropriatedevicewithplacementwithin 48 hours of patient admission

• Selectthedevicethatmostadequatelydeliverstherapy with the least number of lumens

• PlacedeviceusingtheCentralLineInsertionChecklist while applying Central Line Bundle

• Assessdevicedailytoevaluatethehealthofthevessels, the functionality of the device and the continued need for the device

• Improvepatientsatisfactionwithplacementoffewerdevices and empowerment through education

• Removevascularaccessdeviceassoonasnolongermedically necessary

DEsCrIPTIon oF VEssEL hEALTh AnD PrEsErVATIon ProToCoL ThE VhP ProToCoL: TooLs/ForMs

standing order

• Physician-initiatedprotocol

• Directstheprocessandempowersnursingstaff

• Removevascularaccessdeviceassoonasnolonger medically necessary

Daily Assessment

• DailyAssessmentbynursingandmedicalstaff

• Determinationofnecessitywithmulti-disciplinary focus and medical rounds

1. Evaluate current hospital processes to identify gaps

2. Define goals for improvement

3. Present to administration for support

4. Select motivated safety conscious unit for 1st implementation

5. Educate all clinical staff with Vessel Health and Preservation

6. Start the protocol and begin educating patients

7. Evaluate and customize – ongoing

8. Establish champions in administration, nursing, pharmacy, medical staff

sTEPs oF IMPLEMEnTATIon

In an effort to establish an improved system for the “Right Line” (vein and device selection prior to venous access), the “Right Patient” (an individualized assessment for each patient), and the “Right Time” (daily assessment of line necessity), the G-9 Summit was held on August 10th and 11th, 2008. This Summit included a panel of multidisciplinary experts brought together to offer input into the development of the system protocol. With information from two IV team directors, a PICC team leader, a Pathologist, Nephrologist, Infection Disease Specialist, Nephrology Physician’s Assistant, Radiology PICC Nurse Practitioner, PICC IR manager and two experienced vascular access specialists acting as moderators, issues and problems related to venous access were discussed and needs identified. Subjects included vein preservation, complications with peripheral cannulae access and maintenance, current practices with IV access, identification of roadblocks and lack of knowledge with vascular access selection, multidisciplinary aspects, function of the physician, PA and nurse in the process, catheter usage and care, daily

assessment requirements, integration with computer functions and multidisciplinary educational needs.

ConsEnsUs wAs rEAChED on FIVE kEy PoInTs:

1. Educational programs are required to drive process changes for venous access best practice.

2. New and improved venous access processes need to be multidisciplinary.

3. The primary physician may drive the Right Line for the Right Patient at the Right Time by authorizing a process initiated by other disciplines.

4. The Summit group is committed to working toward completion of a final protocol that can be implemented in acute care.

5. In order to establish measureable outcomes for the protocol, trial sites must be selected to test the effective function of the final protocol. Summit participants are open to implementing the protocol at their respective facilities.

bACkgroUnDADMIssIon AssEssMEnT

• Individualevaluationofthepatientatadmission • Includesriskassessment

oUTCoME MEAsUrEs For VhP

• CommunicationinitiatedandStandardOrdersetsigned by physician within 24 hours of admission

• Compliancewithselectionofdeviceusingtri-foldwithin 24 hours; placement of selected device within 48 hours

• CompliancewiththeCentralLineInsertionchecklistfor each central VAD insertion

• AssessmentperformeddailyusingDailyAssessmentTool to evaluate the health of the vessels, the functionality of the device and the continued need for the device

• ImprovedoutcomesinreductionofPhlebitisandinfiltration demonstrated through daily assessment form

• Physicianandpharmacistprovideinputtowardcompletion of the daily vessel health assessment tool (multi-disciplinary appoach to patient treatment) for determination of treatment completion and device removal

• PatientsatisfactionmeasuredthroughPressGaneysatisfaction scores taken monthly and patient specific questions on daily assessment form

• Deviceremovedassoonasnolongermedicallynecessary

ConCLUsIon

Selecting the Right Line for the Right Patient at the Right Time is a necessity in today’s hospital environment. Providing reliable vascular access for today and tomorrow is vital to programs looking for optimal patient outcomes. Vascular access device insertion is the most common invasive experience patients have in acute care settings. The use of an evidence-based clinical pathway to guide an intentional protocol is long overdue. The application of a clinical pathway is not a new concept; it simply

has not previously been applied to vascular access. Transitioning from a reactive approach to timely assessment, planning and insertion generates higher patient and staff satisfaction. With the Vessel Health and Preservation Protocol, reduced number of lines placed and lower costs to treat the same patient population will be realized. The time is right for a vessel health and preservation protocol. Timely planning for today helps take care of patients tomorrow.

Evaluation: Venous Access outcomes

•Implementeducationalprogramsdriving ‘right line at the right time’

•Integrateintocredentialing and annual competency program

•Integratevascular access risk assessment into central line bundle

right Line for Venous Access

•ClinicalPathwaytoSelectDevice

1. Diagnosis

2. Therapy

3. Indication for Right Device

4. Perform Risk Assessment

right Time

•Dailyassessment process implemented

•Determineanychange in the acuity level of the patient

•Considerchemical&physical properties of the infusate

• Engageplanofactionbasedonstandingorders

• Applycentrallinebundletocareandmaintenance

right Patient

•AdmissionRisk Assessment

1. Risk Factors

2. Critical Factors and Acuity

3. Infusion Needs

•StandingOrderSet

•Multidisciplinary&InterdepartmentalCommunication

EDUCATIonDisch

arge Planning Treatmen

t Pla

n

ConCEPTUAL MoDEL

start of Care

re-

Evalu

ation 12

39

6

InTErnAL jUgULAr (Ij) LAnDMArks •Angleofmandible•Twoheadsofsternocleidomastoidmuscle•Clavicle•Externaljugularvein•Trachea

InsErTIon orIEnTATIon•Central: Insert needle at apex of

triangle formed by the two bodies of the sternocleidomastoid muscle and the clavicle. Insertion depth 3 cm–5 cm.

•Anterior: Insert needle at midpoint of sternal head of the sternocleidomastoid muscle approximately 5 cm from the angle of the mandible aiming toward the feet and ipsilateral nipple. Insertion depth 2 cm–4 cm.

•Posterior: Insert needle approximately 1 cm dorsal to the place where the EJ and the sternocleidomastoid muscle meet. Insertion depth 5 cm–7 cm.

ADVAnTAgEs•Largevesselsize•Easytolocate•Easyaccess•Short,straightpathtosuperiorvenacava

(right side) •Lowcomplicationrate

DIsADVAnTAgEs•Closeproximitytocarotidartery•Higherinfectionratecomparedwith

other sites•Problematicinpatientswithtracheostomies•Uncomfortabletopatient•Difficultdressingmaintenance

ADjACEnT AnAToMy•Carotidartery•Phrenicandvagusnerves•Pulmonaryapex•Thoracicduct

PoTEnTIAL CoMPLICATIons•Arterialpuncture•Variableextentofnervedamage•Pneumothorax•Pleuraleffusion•Chylothorax

EXTErnAL jUgULAr (Ej) LAnDMArks•Vesselispartofsurfaceanatomy

InsErTIon orIEnTATIon•Needlecanbeinsertedintovesselas

visualized on neck surface

ADVAnTAgEs •Easytolocate,visible

DIsADVAnTAgEs•Difficulttocannulate(vesselrolling,valves,

tortuous path)•Highercomplicationratecomparedwith

other sites (thrombosis, infection)•Problematicinpatientswithtracheostomies•Difficultdressingmaintenance

ADjACEnT AnAToMy•Carotidartery•Phrenicandvagusnerves•Pulmonaryapex•Thoracicduct(leftsideonly)

PoTEnTIAL CoMPLICATIons•Arterialpuncture•Variableextentofnervedamage•Pneumothorax•Pleuraleffusion•Chylothorax(Thoracicduct)

sUbCLAVIAn LAnDMArks•Clavicle•Twobodiesofsternocleidomastoidmuscle•Suprasternalnotch•Manubriosternaljunction

InsErTIon orIEnTATIon•Infraclavicular: Insert needle 2 cm–3 cm

caudal to midpoint of the clavicle at the point where the clavicle slants toward the manubrium. Insertion depth may extend to 10 cm.

•supraclavicular: Insert needle at 45-degree angle into the angle formed by the clavicle and the sternocleidomastoid muscle. Insertion depth 1 cm–4 cm.

ADVAnTAgEs•Largevesselwithhighflowrate•Lowerinfectionratecomparedwith

other sites•Easytomaintaindressing•Lessrestrictingforpatient

DIsADVAnTAgEs•Liesclosetothelungapex

(pneumothorax risk)•Closeproximitytosubclavianartery•Difficulttocontrolbleeding

(noncompressible vessel)•Potentialforpinch-offphenomenon•Difficulttovisualizeutilizingultrasound

ADjACEnT AnAToMy •Subclavianartery•Pulmonaryapex•Rightlymphaticduct•Costoclavicularligament,firstrib

PoTEnTIAL CoMPLICATIons•Arterialpuncture•Pneumothorax,pleuraleffusion•Chylothorax•Pinch-offphenomenon

AXILLAry LAnDMArks•Lateraltoclavicle•Inferiortotheaxillaryartery•Deltopectoralgroove•Deeptopectoralisminormuscle

InsErTIon orIEnTATIon•Ultrasound guided, transverse

(out of plane) Using a steep angle (45-90 degrees), in the

inferior-lateral portion of the deltopectoral groove, a needle is guided into the axillary vein. Insertion depth, 1.5-5cm.

•Ultrasound guided, longitudinal (in plane)

This approach utilizes a less steep angle, in the lateral portion of the deltopectoral groove. The shaft of the needle is visualized throughout the course of the insertion. Insertion depth, 1.5-5cm.

ADVAnTAgEs•Largevesselwithhighflowrate•Lowerinfectionratecomparedwith

other sites•Easytomaintaindressing•Easytocontrolbleeding

(compressible vessel)•Patientcomfort

DIsADVAnTAgEs•Potentiallyalongerlearningcurve

than the IJ vein•DeeperthantheIJvein•Proximitytotheaxillaryartery

ADjACEnT AnAToMy •Axillaryartery•Pleuralspace•Brachialplexus

PoTEnTIAL CoMPLICATIons•Arterialpuncture,hematoma•Pneumothorax•Nerveinjury

trachea

anterior jugular vein

internal jugular vein

external jugular vein

clavicle

suprasternal notch

manubrium

subclavian vein

clavicle

sternocleidomastoid muscle

external jugular vein

superficial cervical fascia

clavicle

axillary

sECUrE AnD DrEss ThE CAThETEr

Based on hospital policy, utilize the following method for catheter securement and dressing:•Cleanbloodorexudatesfromsiteusing

sterile saline or skin antiseptic solution.•Applyachlorahexidinesponge

dressing. •Securethecatheterutilizingsuturesor

manufactured stabilization device.•Applytransparentsemi-permeable

dressing securely over site and securement.

•Changethedressingatestablishedintervals and when visibly soiled or compromised.

VErIFy CAThETEr TIP PosITIon

Based on hospital policy, utilize one of the following methods for tip placement verification:•Radiographicimaging(ChestFilm,

Fluoroscopy)•PhysiologicalFeedbacksuchasEKG•Otherapprovedmethods.Appropriate tip placement for Central Venous Catheters other than Dialysis Catheters is in the lower one-third of the Superior Vena Cava or at the Cavoatrial Junction.

If catheter tip is malpositioned, reposition and reverify tip position.

sECUrE, DrEss AnD ConFIrM CAThETEr PLACEMEnT

Practitioners must become familiar with the signs, symptoms, interventions and preventive measures for catheter-related complications at all insertion sites.

InsErTIon sITEs, LAnDMArks AnD InsErTIon orIEnTATIon

CoLor kEy

ArTErIEs

nErVEs

VEIns

Reducing Risks: Avoid using Femoral Veins for Catheterization.

Assess all Central Venous Catheters and remove when no longer necessary.

bAsILIC VEIn

ADVAnTAgEs• Easyaccessforinsertionandcare• Maybemostprominentvesselinthe

antecubital fossa

ADVAnTAgEs• Easyaccessforinsertionandcare• Easytopalpateandlocatevisually

ADVAnTAgEs• Largevessel• Usuallyundamaged,eveninpatientswith

history of many IVs

DIsADVAnTAgEs• Maybelocatedtoofarmediallyorposteriorly,making

insertion and care difficult• Closeproximitytobrachialarteryandsomebranchesof

the internal cutaneous nerve

DIsADVAnTAgEs• Anatomymayvaryfromperson

to person•Maybedifficulttoinsertdueto

valve locations

MEDIAn CUbITAL VEIn

DIsADVAnTAgEs• Vesselmaybesmallwithatortuous

pathway• Joinsaxillaryveinatananglethatmay

make advancement difficult• Vesselnarrowsasitascendsthe

upper arm

CEPhALIC VEIn

DIsADVAnTAgEs• Deeplocation.Insertionrequiresultrasound

guidance• Proximitytomediannerveposesriskof

nerve injury

brAChIAL VEIn (Onlyusedwithultrasound-assistedinsertion)

ADVAnTAgEs• Largest,straightpathwayintheupperarm• Enhancedbypositioningthearmat

90-degree angle from body

References available upon request. See contact information on back of sheet.

thoracic duct

parotid gland

left brachiocephalic

carotid artery

external jugular vein

right brachiocephalic

internal jugular

vagus nerve

phrenic nerve

subclavian vein

subclavian artery

first rib

axillary

cephalic

superior vena cava

basilic

brachial

AnAToMy oVErVIEw

ULTrAsoUnD VEssEL AssEssMEnT AnD InsErTIon gUIDAnCE

Pre-assessment

• Visualizebothaxillaryveinsintheinfraclavicularfossa.

• Followmediallyasfaraspossible.

• Visualizethesupraclavicularandcervicalregions.

• Thevenousassessmentincludes:

- Vein diameter

- Round shape. Anything but round suggests an element of thrombosis.

- Depth

- Compressibility. This will confirm the venous nature and patency.

- Respiratory motion.

Post-assessment

• Checkingformalpositionisthemainreasonforpostinsertion assessment.

• Followinganaxillaryveininsertion,examinationofthe ipsilateral IJ vein during the procedure can be very helpful.

• Amalpositioncanberecognizedandcorrectedduringtheprocedure.

• LikewiseexaminingtheaxillaryveinduringIJinsertioncan lead to detection of malposition.

Ultrasound during insertion

• Essentiallyonecanvisualizetheneedletraversingthesubcutaneous tissue and entering the target vein.

• Theimportanceofperformingcentralvenousaccesswithimage guidance, as opposed to the anatomic landmarks-guided approach, cannot be emphasized enough.

► ► ► ► ► ► ► ►

►

►►

Patient admitted to hospital

Standing order for VHP authorized

by MD within first 24 hours of patient

admission

Complete VHP Admission

Assessment

Initiate VHP Daily Assessment and

Tools

Insert selected device within 48

hoursPatient discharged Complete Evaluation

Tool

Device not necessary.

Discontinue/remove device

Include multiple disciplines in daily

assessment

Determine Vascular Access device necessity each day based on

assessment tool

Apply Daily Assessment

Tool throughout hospitalization during

daily rounds.

Yes, IV device still required for

treatment

►

how To UsE ThE VEssEL hEALTh AnD PrEsErVATIon (VhP) ProToCoL

Disengage white cap to advance guidewire.

Advance guidewire through needle into vessel lumen. Gently snap white guide wire hub onto green needle hub.

Holding green needle hub still to ensure entire needle bevel is within the vessel lumen, rotate yellow hub to disengage dilator/sheath.

Continue to hold green needle hub still and advance dilator/sheath over needle and guidewire into vessel. Needle tip is now securely locked within dilator.

Unscrew blue spin nut from sheath hub and remove device leaving sheath in vein placing gloved thumb over sheath opening.

Thread the catheter slowly through the peelable sheath.

Insert needle into vein and observe Fast-Flash™.

Break away peelable sheath is removed after catheter is in place.

Reducing Risks: AST is designed to improve vascular access by reducing the risk of needle-stick injury, loss of cannulation, blood exposure and air/ wire embolism associated with Modified Seldinger Technique. 21Ga. Echogenic Needle

Dilator

Fast-Flash™

Peelable Sheath

Dilator Hub

Needle Hub

.018” Nitinol GuidewireACCELErATED sELDIngEr TEChnIqUE (see The PICC WAND® instructions for use for more detailed instructions.)

Thread tissue dilator with peelable sheath onto the wire and through the subcutaneous tissue using a slight twisting motion, to a depth sufficient to enter the vessel.

Catheter/Needle assembly may be used in place of the thin-wall introducer needle.

Immediately occlude catheter lumen to prevent air embolism or bleeding.

Advance wire through IV catheter. Warning: Do not cut spring wire guide.

Hold spring wire guide in place and remove IV catheter. Precaution: Maintain a firm grip on spring wire guide at all times.

Remove needle and syringe, leaving catheter in vessel. Warning: To avoid possible catheter embolus, do not reinsert needle into catheter.

If making skin-nick, enlarge cutaneous puncture site with cutting edge of scalpel positioned away from spring wire guide.

Withdraw peel-away sheath over catheter until free from venipuncture site. Grasp tabs of peel-away sheath and pull apart, away from catheter, until sheath splits down entire length. Advance catheter to final indwelling position and remove wire if present. Aspirate catheter to confirm blood return; flush and lock catheter based on hospital policy.

Remove the tissue dilator and wire as a unit, leaving peelable sheath in the vein. To control blood loss as you remove dilator, place gloved finger over the sheath opening.

Thread the catheter slowly through the peelable sheath. Warning: If you meet resistance, retract catheter, reposition arm and reattempt to insert catheter. When inserting the last 20 cm of a PICC, ask patient to turn head toward arm with PICC and tuck chin onto clavicle. This may minimize the chance of internal jugular placement.

MoDIFIED sELDIngEr TEChnIqUE

After administering local anesthetic, locate vein using thin-wall introducer needle attached to Raulerson syringe.

Verify venous access by inserting fluid-primed transduction probe into rear of Raulerson syringe and through syringevalves.Observeforvenousplacement via wave form obtained by a calibrated pressure transducer. Remove transduction probe.

Using the spring wire guide advancer, straighten J tip of spring wire guide, if used, and advance through rear of syringe plunger. Warning: To avoid severing or damaging wire, do not cut spring wire guide to alter length, nor withdraw spring wire guide against needle bevel.

Hold spring wire guide in place and remove Raulerson syringe. Precaution: Maintain a firm grip on spring wire guide at all times.

If making skin-nick, enlarge cutaneous puncture site with cutting edge of scalpel positioned away from spring wire guide.

If using tissue dilator, pass it over spring wire guide to enlarge site as needed. Warning: To avoid possible vessel wall perforation, do not leave tissue dilator in place as an indwelling catheter.

Thread tip of catheter over spring wire guide allowing Spring-Guide wire to exit hub.

Reducing Risks: There are two key benefits to using the Raulerson syringe. First, it lessens the exposure to blood and can lower the risk of air embolism. Second, it enables you to place the catheter in fewer steps, with less risk of dislodging needle from vessel.

Advance catheter into final indwelling position. Hold catheter and remove spring wire guide. Check lumen placement by aspirating through hub.

Grasping catheter near skin, advance into vein with a slight twisting motion. Warning: Maintain control of spring wire guide at all times to avoid wire embolization.

UsIng rAULErson syrIngE

After administering local anesthetic, locate vein using thin-wall introducer needle. Vessel may be prelocated with a smaller needle.

Immediately occlude needle lumen to prevent air embolism or bleeding.

Using a straightening tube, straighten J tip of spring wire guide, if used, and advance into vessel through needle. Warning: To avoid severing or damaging wire, do not cut spring wire guide. Withdraw spring wire guide through needle.

Hold spring wire guide in place and remove needle. Precaution: Maintain a firm grip on spring wire guide at all times.

Remove syringe. Confirm venous placement by using hemodynamic monitoring or checking for pulsatile blood flow. Warning: The color of blood is not always an accurate indication of venous entry.

If making skin-nick, enlarge cutaneous puncture site with cutting edge of scalpel positioned away from spring wire guide.

If using tissue dilator, pass it over spring wire guide to enlarge site as needed. Warning: Do not apply excessive force while advancing the dilator, spring wire guide damage can occur. Withdraw the dilator. The dilator should not be used as an indwelling catheter.

Thread tip of catheter over spring wire guide allowing spring wire guide to exit hub.

Advance catheter into final indwelling position. Hold catheter and remove spring wire guide. Check lumen placement by aspirating through hub.

Grasping catheter near skin, advance into vein with a slight twisting motion. Warning: Maintain control of spring wire guide at all times to avoid wire embolization.

sELDIngEr TEChnIqUE

PrInCIPLEs oF VAsCULAr ACCEss InsErTIon