What is ‘vein preservation’? Most Google searches for “vein preservation” will yield results that involve patients with chronic kidney disease (CKD) and the placement of vascular access devices. However, as our population ages and we see a growing number of younger, sicker patients in the hospital, the term ‘vein preservation’ should encompass and be applied to all acutely ill patients. Simply put, vein preservation is the conscious effort to preserve (or not use) vessels for potential future use. For example, patients with advanced CKD or end-stage renal disease (ESRD) that are currently receiving hemodialysis, or may be in the future, should not have upper extremity peripherally inserted central catheters (PICCs) placed in the upper arms (unless permission is granted by the patient’s nephrologist) in order to preserve the vessels of the arms for future arteriovenous (AV) fistula or graft sites. Another population that often has advanced vascular access planning is oncology patients that will be receiving intravenous chemotherapy. Once a therapy regimen has been decided, select oncology patients see a general surgeon for placement of a subcutaneous port.
Incorporate vein preservation into the plan of care
How can we incorporate vein preservation into the plan of care for the rest of our patients? We should start by taking a look at each patient individually and consider some of the following conditions and comorbidities in the patient’s medical and surgical history that may influence vascular access decisions:
- Deep vein thrombosis (DVT), pulmonary embolism (PE), coagulopathies
- CKD, ESRD
- IV drug abuse
- Scar tissue
- Hardware from trauma or fractures
- Upper extremity or chest wall infections (cellulitis, joint infections)
- Steal syndrome or superior vena cava syndrome
- History of unsuccessful PICC or central line insertions
Next, we should determine the right access for the therapy prescribed. Interdisciplinary communication is necessary to develop the plan of care for the patient’s IV therapy. For example, should we consider something more than a peripheral IV line if the patient has poor peripheral access and the plan is for long-term IV antibiotics, or initiation of chemotherapy; or, does the patient only have one or two more days on IV therapy to complete treatment, and short peripheral access is most appropriate?
Communication is key
Communication is the key to preserving our patient’s vessels so we can continue to provide care throughout the lifespan. Similar to the algorithms being created for antibiotic stewardship, algorithms should also be considered for access stewardship.