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Vein Illumination: Guiding the Way to Successful Vascular Access

Obtaining successful vascular access, even in patients without significant co-morbidities, is a challenging task even for the most skilled or experienced nurse. Dehydration, skin pigmentation, and patient non-compliance can add significant time or stick attempts to the vascular access procedure which may result in more drastic measures being taken such as placement of medically unnecessary peripherally inserted central catheters (PICC lines)  [1], [2].  These more invasive lines are typically only placed when the patient is receiving extended treatments such as chemotherapy, antibiotics, and/or parenteral nutrition; however, they are commonly used when a peripheral intravenous catheter cannot be placed due to failed access attempts.   Though vascular access can, ultimately, be achieved via PICC lines, this choice is undesired by physicians and hospitals as it may lead to complications such as arteriovenous fistula (AVF) failure and central line-associated blood stream infections (CLABSI) [3], [4].  When a patient requires vascular access of any kind, more often than not, PIV is the method preferred by nurses, physicians, hospitals, and of course, the patient.  

What can nurse managers do, outside of standard training methods and on the job experience, to improve this important patient care procedure?  The so-called “vein viewers” or “vein finders,” a class of vascular access assistive devices, came on the market about 8 years ago and have been widely used by medical professionals throughout North America and internationally to improve their peripheral vascular access success rates.  All of the vascular access assistive devices create images in an approximately similar fashion, but there are two general types: trans-illuminators and reflective, near-infrared (NIR)-based devices.  The latter of these, which uses light emitting diodes (LEDs) or lasers to show the user a pattern of blood vessels underneath the skin,  will be the focus of this article.

The functioning of NIR-based vascular access assistive devices is fairly simple: the device being used projects invisible NIR light onto a section of the skin which penetrates down to a variety of depths (dependent upon the device being used) where it is absorbed by oxy- and deoxyhemoglobin.  Any light that is not absorbed is reflected back to the device.  Almost instantaneously, a computer turns the information from the reflected NIR light into an image that is then projected back onto the skin.  This image is what the user sees to aid in the assessment of the vasculature.  

Visualization of vasculature is not the only feature that these devices can be used for.   Using the image, the clinician can assess flow rate and view valves and bifurcations.  Depending on the brand, some of these devices can be used to detect hematomas which may provide additional, post-stick information to the clinician.  Some brands allow visualization of a vein being flushed: as fluids such as saline are delivered to the patient, these fluids move the blood column which can, in turn, be seen moving up the vein.

Currently, there are several manufacturers of these medical devices and the devices, themselves, come in a few different formats.  Cart-based units such as the VeinViewer® Vision (Christie Medical Holdings, Inc., Memphis, TN [Christie]) offer bedside mobility and quick setup to the nurse.  Both VeinViewer Flex (Christie) and the AV300 and AV400 (AccuVein, Cold Spring Harbor, NY) are handheld models which allow for easy transport in non-traditional healthcare settings (e.g. EMS, home healthcare).  To provide a hands-free use format, VeinViewer Flex comes standard with an arm that can be mounted to a table, bed or IV pole.  An optional cart can be purchased from AccuVein for their handheld models which will allow for hands-free use as well.  The Veinsite by VueTek® Scientific (Gray, ME) is a vascular assistive device that the clinician wears on their head in much the same way that one would wear a helmet.  This model is distinct in that the clinician does not directly see the image on patient’s skin, but rather an image of the skin within the headset device itself.  Other vascular access devices that use NIR-based technology exist; however, these devices are not yet available for purchase in the United States.

Though these devices are similar in their technology and application, many healthcare facilities are moving towards evidence-based medical care and require proof that the technology to be purchased will provide the results promised [5].  Purchasing managers are now able to access a wealth of data on NIR-based vascular access assistive devices: all of the above-mentioned devices now have peer-reviewed literature published on their devices.   Additionally, new research is continually being presented, either as posters or oral abstracts at national nursing conferences such as Infusion Nurses Society or Association for Vascular Access and the devices are typically on display at these symposia by their respective companies for in-person, if not head-to-head, demonstration.  With all of the technical and practical information available, those in charge of making capital equipment purchases can feel comfortable knowing that they are making an informed choice.

In conclusion, NIR-based devices can help hospitals improve the vascular access process not only for their patients, but for themselves and their staff.  Though the technology is roughly equivalent between devices, the way in which that technology interacts with the clinician as well as the patient, in addition to the evidence supporting its use will ultimately help the purchasing manager to decide which device will help their facility the most.  Forming a good relationship with the company’s representative or distributor will go a long way to providing a purchaser with the most up-to-date information about the product and will provide the confidence needed to make that informed purchase.

Works Cited
[1]  H. Shokoohi, K. Boniface and et.al, "Ultrasound-guided Peripheral Intravenous Access Program is Associated with a Marked Reduction in Central Venous Catheter Use in Noncritically Ill Emergency Department Patients," Annals of Emergency Medicine, vol. 61, no. 2, pp. 198-203, 2013.
[2]  L. Hadaway, L. Dalton and L. Mercanti-Erieg, "Infusion Teams in Acute Care Hospitals," Journal of Infusion Nursing, vol. 36, no. 5, pp. 356-360, 2013.
[3]  M. El Ters, G. Schears and et.al, "Association Between Prior Peripherally Inserted Central Catheters and Lack of Functioning Arteriovenous Fistulas: A Case-Control Study in Hemodialysis Patients," American Journal of Kidney Disease, vol. 60, no. 4, pp. 601-608, 2012.
[4]  D. Hertzog and P. Waybill, "Complications and Controversies Associated with Peripherally Inserted Central Catheters," Journal of Infusion Nursing, vol. 31, no. 3, pp. 159-163, 2008.
[5]  K. Townsend, "The Impact of Comparative Effectiveness Research on the Medical Device Industry," SoCRA Source, no. May, pp. 41-45, 2013.

Pedagogy Guest Blog by Jessica Knowlton, MS CRA is the Associate Clinical Research Specialist for Christie Medical Holdings, Inc., manufacturer of VeinViewer. 

Jessica's professional background is in basic science research with experience in orthopaedics, DNA repair, and vaccine/nanotechnology-based adjuvant development, the latter of which netted several patents and peer-reviewed research articles.  She holds an advanced degree in Clinical Research Administration from Eastern Michigan University and, before accepting her current position, conducted clinical trials in ophthalmology at The University of Michigan and The University of Tennessee Health Science Center. 
Posted: 2/14/2014 9:58:06 AM
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