Is CVAD considered IV access for Nitro conditions? (Scenerio)

Question#: 606

Question:

Is CVAD considered IV access for Nitro conditions? For scenario sake, let's say you attend a dialysis patient that has ischemic chest pain or acute cardiogenic pulmonary edema. Due to their other health implications, there is no reasonable site for IV access but they do already have a CVAD in place, and you are an ALS unit. Would it be reasonable to assume that this does count as IV access for nitro, in the rare event they have a hypotensive reaction requiring a bolus?



Thank you for your time.

Answer:

Hello,

Thank you for your MedicASK question.

After a discussion with the Medical Directors, the CVAD has been deemed appropriate where the Medical Directives say “IV access obtained” for first time Nitroglycerin use in the Cardiac Ischemia and Acute Cardiogenic Pulmonary Edema Medial Directives as there is evidence showing that Nitro is quite safe and patients are very unlikely to become significantly hypotensive. However, it is only to be accessed if the patient becomes critically ill.

For clarification, when reviewing the CVAD Medical Directive and associated section in the Companion Document, it states that, “The patient must be critically ill to access a CVAD device. This requirement is due to the associated risks involved with CVAD access.” More specifically, critically ill refers to cardiac arrest or near-arrest state. The associated risks they refer to when accessing a CVAD include: infection, air emboli, dislodgement, cardiac arrhythmias, pneumothorax, phlebitis, extravasation, infiltration, and/or hemorrhage. These complications can be very severe for the patient and therefore accessing a CVAD must be reserved only for those extremely critical interventions.

Lastly, in this rare type of call, a consult with BHP is always available to you if you ever require that extra support, discussion or review of how to access a CVAD safely.

We appreciate this forward thinking to provide symptom relief and excellent patient care. Thank you for bringing this question to our attention.

Have a great day,

Education Coordinator



References:

https://www.rppeo.ca/component/rsfiles/download-file/files.html?path=MOHCommunications%255CMedicalDirectives%255CALS_PCS_v4.9.pdf&Itemid=4487

https://www.rppeo.ca/component/rsfiles/download-file/files.html?path=MOHCommunications%255CMedicalDirectives%255CESC_Companion_Document_v4.9_final_v13_Jan_25_2022.pdf&Itemid=4487