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Michelle DeVries on Exploring Approaches ‘Beyond the Bundle’ to Help Decrease Vascular Access Device-Associated Infections

Fellow colleauge and infection prevention guru Michelle DeVries recently published in Infection Control Today and shares some evidence that it may be time to look beyond insertion and care & maintenance bundles to examine additional approaches that may be beneficial – for the patient and the institutions.

Exploring Approaches ‘Beyond the Bundle’ to Help Decrease Vascular Access Device-Associated Infections

#vascularaccess #FOAMva

Why is pH and Osmolality/Osmolarity important in vascular access? #FOAMva #vascularaccess

With a shift in the 2016 INS Standards of Practice to remove the pH of medication administration guideline, and despite swinging voters (clinicians) choices on the topic, I wanted to address the basic underlying science of the terminology. pH maybe no longer in the current SOP, but it still a serious factor that infusion therapy and vascular access specialists must take into consideration when assessing the patient for a device. There is more too it than meets the eye..


Published standards on acceptable IV fluid pH or osmolality values are somewhat harder to find; but becoming more frequently investigated and reviewed. A pH range of around 4 – 8 is mostly seen for todays’ commonly used IV fluids. Fluid pH doesn’t really matter from a systemic acid-base perspective (which depends entirely on the effective Strong Ion Difference (SID) and ATOT (total plasma concentration of inorganic phosphate, serum proteins and albumin) concentrations in the fluid), but fluid pH is likely to be important in the genesis of local effects.

The main concerns are the potential for the following;

  • haemolysis,
  • endothelial damage with platelet adherence and vessel occlusion,
  • extravasation,
  • inflammation,
  • tissue necrosis.

The question is complicated by the variable dilutional blood flow environments into which the IV fluid is infused/deposited. Worst case scenario is infusing fluids at extremes of pH and/or osmolality without co-infusions into a small peripheral veins, whereas you can administer fluid of almost any pH or osmolality by slow infusion centrally. Larger cubital fossa veins lie somewhere in between. Add in a mixture of various parenteral medications, all with their own elements of pH and Osmo, and things start to change notably.

It is important not to confuse osmolality with osmolarity. For example, you will find when you measure the osmolality of 0.9% sodium chloride that it is about 284 mOsm/kg (vs the quoted osmolality of over 300 mOsm/L). Baxter and other fluid manufacturers use the term ‘osmolality’ incorrectly here. Similarly the measured osmolality of Compound Sodium Lactate is 258 mOsm/kg, not 274. Osmolality is a function of particle activity as well as concentration. Ionic activity relative to concentration decreases with increasing total ionic concentration. Hence ionic activity is less than concentration (and thus osmolarity) except at infinite dilution. As you know osmolality is usually measured by freezing point depression.

In fact the below neutral pH of commonly used IV fluids is mainly due to dissolved atmospheric CO2. If PCO2 = 0, commonly IV fluids should have a neutral pH of around 7.0 at room temp, although phthalate anions from the PVC container may still drop it a bit below 7.0, and slight caramelisation of dextrose due to heat sterilisation may also occur.

If you want to read and understand more about acid-base, check out the links below;

Michael Bookallil’s Acid Base of the Blood

Repositioning of CVADs using high flow flushing technique – practice and cost review

Although it’s a little self-indulgent, I am also very excited. I just had a manuscript accepted for publication on repositioning of CVADs utilizing a high flow flushing technique (HFFT) in the Journal of Vascular Access. This is something I investigated and started monitoring a few years ago (after a discussion on its relatively unknown use) and decided to start writing a more formal paper on this technique. The manuscript has not been allocated an edition currently, but will be available as advanced online publication at the JVA website very soon.


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Updated list of Non-Cytotoxic Vesicants and Irritant medications

Many medications and drug therapies actually cause damage to the vessel wall – the endothelial layer (which in turn is only one cell layer thick) is the prime area that is predisposed to injury during exposure to the administered medication – here are the latest from the Infusion Nurses Society in regards to non-cytotoxic vesicant and irritant medication administration. Be mindful that many of these medications CANNOT be administered via a peripheral device, which includes midline catheters..


Development of an Evidence-Based List of Noncytotoxic Vesicant Medications and Solutions

Something I read recently on the science of teamwork

In today’s healthcare environment, interdisciplinary teamwork IS essential. However, often the driving process of collaboration, and as well as the teams overall diversity, creates a failure to thrive – often stagnating, sometimes buckling under the weight of internal conflict, or sometimes from external influential sources. This failure to thrive is not anyones fault, however, there is a need to understand what we are all to achieve and in doing so, know each team members goal and understand their role within the team. Find the gaps that allow problems to slip through the net. Filling these gaps will allow for greater cohesion within the team, allowing it to succeed.

Understanding the Styles

Each of us is a composite of four work styles, though most people’s behavior and thinking are closely aligned with one or two. All the styles bring useful perspectives and distinctive approaches to generating ideas, making decisions, and solving problems. Generally speaking:

Pioneers value possibilities, and they spark energy and imagination on their teams. They believe risks are worth taking and that it’s fine to go with your gut. Their focus is big-picture. They’re drawn to bold new ideas and creative approaches.

Guardians value stability, and they bring order and rigor. They’re pragmatic, and they hesitate to embrace risk. Data and facts are baseline requirements for them, and details matter. Guardians think it makes sense to learn from the past.

Drivers value challenge and generate momentum. Getting results and winning count most. Drivers tend to view issues as black-and-white and tackle problems head on, armed with logic and data.

Integrators value connection and draw teams together. Relationships and responsibility to the group are paramount. Integrators tend to believe that most things are relative. They’re diplomatic and focused on gaining consensus.

The four styles give teams a common language for understanding how people work.

Knowing how each team member in your team and looking for these traits in them will be an important consideration when creating or implementing teamwork process within an organization. Use it to the teams advantage, as it will give great all-round perspectives.

The difference between success and failure is a great team.

“Teamwork is the ability to work together toward a common vision. The ability to direct individual accomplishments toward organizational objectives. It is the fuel that allows common people to attain uncommon results.”  – Andrew Carnegie

How to be an inspiring leader..

apr17-25-15843859-1200x675A great article in HBR last week, focusing on how to be engaged AND inspirational.

Drawing insight from Eastern philosophy, someone once said, “If you want to change the way of being, you have to change the way of doing.”

Leaders can only change by doing things differently. The more often they behave in a new way, the sooner they become a new type of leader, an inspirational leader.

Go on, go out and be that leader..