Allergic to Newbie IVs

ALLERGIC TO NEWBIE IVs – HEREDITARY HEMORRHAGIC TELANGIECTASIA

Angelique Gaston BSN RN VA-BC™ | Saint Joseph Mercy Health System

Many patients we care for every day as vascular access specialists should be wearing medical alert bracelets declaring “Allergic to Newbie IVs.” Sometimes we can get to the patients before multiple attempts are made to achieve vascular access, sometimes we can’t. Even when we are there to intervene, convincing the attending physician that our opinion is based on science and experience can be difficult. The first step is to alert the staff that the patient is a hard stick, then have the VAT support the patient during catheter placement from assessment to device securement.

A 30-year-old obese female entered an emergency department (ED) after coughing blood from her tracheostomy. The patient was alert and oriented x 4, speaks in complete sentences, is married, and lives at home with her family. There were multiple attempts by the ED staff to obtain a peripheral vascular access device (PVAD) that were unsuccessful. As a result, the vascular access team (VAT) was called to assess.

Arriving to the ED, the VAT scanned the chart and reviewed the patient’s history. This patient was well known to the VAT because of her fragile vascular system. During previous visits, the patient had multiple PVADs that would only last hours for mysterious reasons. With further investigation, the specialist discovered that the patient had Hereditary Hemorrhagic Telangiectasia (HHT), also referred to as Olser-Weber-Rendu syndrome.

This syndrome is a rare autosomal dominant vascular disorder that often leads to excessive bleeding. The condition causes the development of arteriovenous malformations (AVMs). Common problems associated with this vascular disorder include epistaxis, gastrointestinal bleeding, and iron deficiency. In addition, the brain, lungs, and liver are frequently affected in patients with HHT.

The VAT advocated for this patient to receive a central vascular access device (CVAD) as the initial vascular access. The ED physician was initially resistant until she received the facts about the patient’s history from a vascular access specialist’s perspective. The patient would be admitted to the intensive care unit and continued to cough up large quantities of blood through her trach. Despite the information on vascular fragility and superior vena cava syndrome history, the ED physician had an intern prepared to place the CVAD. The VAT requested that the physician attempt the femoral placement instead of a novice. At this point, the patient advocated for herself and asked: “Can the most experienced person in the room place the line.” The physician then instructed the resident to place the CVAD in the left femoral area. The resident struggled with the initial stick to reach the deep vessel using real-time ultrasound but eventually implanted the line successfully. CONTINUED ON PAGE 20