Upon completion of this module, the learner will be able to:
- Define vascular access devices (VADs), identify the various types of VADs, and the standards of intravenous care, and infection control measures following the Infusion Nurses Society (2016) Standards of Practice.
- Describe the different types of peripheral intravenous catheters (PIVs), their indications for use, site selection, nursing care and safety considerations, including complications and contraindications to insertion.
- Describe the different types of central vascular catheters (CVCs), their indications for use, site selection, nursing care and safety considerations, including complications and contraindications to insertion.
- Review three other types of VADs (apheresis catheters, intraosseous cannulation [IO], and arterial lines), their indications for use, site selection, nursing care and safety considerations, including complications and contraindications to insertion.
The purpose of this module is to provide an overview of vascular access devices in the adult patient, outlining the different types of catheters, their indications, benefits, risks, and complications, as aligned with best-practice standards to minimize complications and enhance patient outcomes.
Vascular access devices (VADs) are a core component of nursing practice and are widely used throughout healthcare settings. A vascular access device is a hollow tube inserted into a vein or artery, through the peripheral or central vessels. VADs are utilized for diagnostic or therapeutic reasons, such as blood sampling, central venous pressure readings, hemodynamic monitoring, administration of high-risk medications such as chemotherapy, antibiotics, fluids, total parenteral nutrition (TPN), and blood products (Nettina, 2019).
VADs are commonly divided into two main categories: peripheral intravenous (PIV) catheters and central venous catheters (CVCs). Short infusion catheters and midline catheters are the most common types of peripheral IV catheters, and these are usually placed within the veins of the arm. CVCs are placed within the central blood vessels, such as the superior vena cava (SVC), with several viable insertion sites. There are also a few other types of VADs that do not fall within either of those two categories. These include intraosseous cannulation (IO), apheresis catheters, and arterial lines. Table 1 lists the most common types of catheters according to category, and each device will be discussed further within the context of this module (Ignatavicius & Workman, 2015).
Types of Vascular Access Devices
(Ignatavicius & Workman, 2015; INS, 2016).
Standards of Intravenous Care
The Infusion Nurses Society (INS, 2019) is an international nonprofit organization within the field of infusion therapy, whose mission is to advance the delivery of quality infusion therapy to patients through evidence-based standards of practice, professional ethics, and education. The INS (2016) has published standards on intravenous therapy practices applicable to all patient care settings where vascular access devices are utilized to ensure that quality of care is delivered as a means to optimizing patient outcomes. INS (2019) is a leader in the field of infusion therapy, and hospitals and healthcare organizations utilize these guidelines as a resource when establishing institution policies and clinical practice guidelines for the placement, management, and use of vascular access devices.
According to INS (2016) standard 1.2, "infusion therapy must be provided in accordance with laws, rules, and regulations promulgated by federal and state regulatory and accrediting bodies in all patient care settings" (p. S11). Further, standard 1.3 states, "Infusion therapy practice is established in organizational policies, procedures, practice guidelines, and/or standardized written protocols/orders that describe the acceptable course of action, including performance and accountability, and provide a basis for clinical decision making" (p. S11). Therefore, this module will focus on the industry standards according to the INS Infusion Therapy Standards of Practice (2016). However, learners are encouraged to refer to their individual state's nurse practice act, as well as institutional policies and procedures regarding specific nursing practices as mandated by their organization (INS, 2016).
Vascular Access Device Selection
Insertion of any vascular access device requires an order by a physician or licensed practitioner. Selecting the appropriate vascular access device for a patient is an essential task of the clinician that requires a keen awareness of several patient factors. The goal is to choose the device that will best foster vessel health and preservation for the duration of the prescribed therapy (Campagna et al., 2018). Device selection is based on individual patient factors, the indications for the line, and the duration and frequency of the prescribed therapy. Further, patient-specific characteristics such as age, comorbidities, and vascular characteristics are also important factors when selecting an optimal VAD. Healthcare providers must take the time to choose the right line, for the right patient, at the right time (INS, 2016).
Infection Control Measures
Adherence to hand hygiene recommendations and the use of aseptic techniques during all aspects of VAD care is critical for all nurses and clinicians who have any contact with VADs. Hand hygiene should be performed using an alcohol-based hand rub or antimicrobial soap and water. Infection control measures before direct contact with any vascular device during device insertion and all dressing changes remain the most critical measures for the prevention of catheter-associated infections. Hand hygiene must be performed before and after patient contact, as well as when hands are visibly soiled. According to INS (2016), skin antisepsis must occur before inserting or accessing any VAD. The preferred skin antisepsis agent is >0.5% chlorhexidine in an alcohol solution. For patients with contraindications to chlorhexidine, appropriate alternatives include 70% isopropyl alcohol, iodophor (povidone-iodine), or tincture of iodine (INS, 2016). To ensure the full antimicrobial effect, the skin antiseptic agent must completely dry prior to accessing the lines or applying the dressing. The procedure and specific details of VAD asepsis are subject to individual variations as designated by the employing organization. Many institution policies enforce the use of chlorhexidine-impregnated dressing over CVCs to reduce the risk for central line-associated bloodstream infection (CLABSI) rates, particularly in high-risk patients, such as oncology patients who are immunosuppressed secondary to chemotherapy (Ignatavicius & Workman, 2015).
To aid in the provision of evidence-based practice (EBP) to improve health care quality, the Institute for Healthcare Improvement (IHI, 2019) established the concept of "clinical practice bundles." Bundles are short, concise, and straightforward guides intended to help nurses more consistently and reliably deliver evidence-based patient care. With interventions grounded in strong evidence, bundles offer a structured way of improving the processes of care and patient outcomes. There are several types of best practice bundles for CVC care, which are revised and adapted to the specifics of each healthcare organization. While there are differences according to institution policy, an extensive review of the literature reveals that the vast majority are premised on five essential components of care; all geared toward preserving the integrity of the VAD and preventing infection of peripheral catheters and central lines. Further, as of October of 2008, the Centers for Medicare and Medicaid Services (CMS) no longer reimburses for hospital-acquired conditions, which includes CLABSI. The Centers for Disease Control and Prevention (CDC, 2017), in collaboration with several other accredited organizations, developed guidelines for the prevention of CLABSI and other types of preventable healthcare-associated infections. The CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections were published in 2011 and underwent its most recent revision with published updates in 2017. The IHI guideline was published in 2012 and undergoes review periodically, but no publication revision or edits have been made since 2016. A comparison of these three guidelines reveals that recommendations are largely consistent and congruent. Refer to Table 2 for an overview of these critical aspects of VAD care according to the IHI, INS, and CDC guidelines (CDC, 2017; IHI, 2012; INS, 2016).
Five Core Components of CVC Care
Hand hygiene using correct technique
Hand hygiene should be performed using an alcohol-based hand rub in the following instances:
Before and after direct contact with the patient and intact or nonintact skin;
Before and after palpating the CVC site;
Before donning and removing gloves;
Before accessing, dressing, or performing any maintenance procedure on any central lines (avoid palpation of the site after the application of antiseptic to the skin);
Before and after any invasive procedure;
After using the bathroom;
Any time contamination is suspected.
Hand hygiene should be performed using an antimicrobial soap and water instead of an alcohol rub when hands are visibly contaminated or soiled, after providing care or having direct contact with a patient who has norovirus or spore-forming pathogen (such as Clostridium difficile infection), before eating, and after using the restroom.
Use maximal barrier precautions
Maximal barrier precautions should be used when inserting central lines. Central line insertion is a sterile procedure. The clinician inserting the line and those assisting should wear a cap, mask, sterile gown, and sterile gloves. A sterile drape should cover the patient head to toe, and a sterile dressing should be applied immediately following insertion.
Chlorhexidine skin antisepsis
Chlorhexidine skin antisepsis should be performed before the insertion of a CVC and when changing the dressing. The skin should be prepped with chlorhexidine 2% in 70% isopropyl alcohol. For patients with sensitivity to Chlorhexidine, a single-use povidone-iodine application is the recommended alternative. The site should be cleaned by pressing the sponge against the skin and scrubbing in a back-and-forth motion for at least 30 seconds. The antiseptic should dry on its own for maximal effect. Avoid wiping or blotting before puncturing the site or applying a new dressing.
Optimal site selection
The optimal site should be selected using the smallest gauge catheter and the minimal number of lumens required for the prescribed or anticipated therapies. The subclavian vein is preferred for non- tunneled catheters. The femoral vein should be avoided whenever possible due to a higher risk of infection, bleeding, and thrombosis. The rationale for the chosen site should be documented.
The line must be assessed daily for continued necessity and the potential for prompt removal. The line should be removed as soon as it is no longer clinically indicated.
Daily CVC assessment should include, at minimum, the following components, which must be documented in the defined flowsheet within the patient's medical record:
Date, time, and insertion site;
Date of last needle, cap, infusion supplies change;
Confirmation of site placement, if indicated;
Daily review of line necessity, including the functionality of line, flush protocol, site appearance, blood return, as well as any complications.
(CDC, 2017; IHI, 2012, INS, 2016)
Regardless of the type of vascular access device utilized, documentation is a critical component of nursing practice. Documentation should be comprehensive, timely, and should include all of the following:
- Type, length, and size of the device;
- Date and time of insertion, and the number of attempts;
- Type of stabilization device;
- Patient tolerance of insertion;
- Identification of insertion site location;
- Radiographic confirmation of tip location, if indicated;
- Condition and appearance of potential site complication;
- Specific site preparation, infection control, and safety precautions as appropriate for the procedure;
- Device discontinuation, date, condition, site appearance, dressing applied, the reason for removal, and patient response (Campagna et al., 2018; INS, 2016).
Part I. Peripheral Vascular Access Devices
Short Peripheral IV Catheters
Short (or standard) PIV catheter insertion is one of the most common clinical procedures in hospitalized patients, as the vast majority have at least one PIV inserted per hospital stay (Alexandrou et al., 2018). PIVs are short length catheters, less than 3" (7.5cm), and intended for short-term therapy; typically, less than seven days, but the duration varies according to institution policy. There has been long-standing controversy regarding the length of time that is appropriate for a PIV catheter to remain in place. Infusion standards have historically recommended that PIVs in adult patients are rotated every 72 to 96 hours, and the CDC (2017) guidelines advise that there is no need to routinely replace PIV catheters more frequently than every 72 to 96 hours in asymptomatic adults with Category IB rank (strongly recommended). Short PIVs may remain until removal is clinically indicated, with definitive timelines deferred to institution policy (CDC, 2017). PIVs are inserted into the small veins in the dorsal and ventral surfaces of the upper extremities, including the metacarpal, cephalic, basilic, and median veins (INS, 2016). Refer to Figure 1 for an illustration of the veins within the upper extremity.
Veins of the Upper Extremity
(OpenStax College, 2013)
Catheters are available in a variety sizes, referred to as gauges (G); they range from smallest (24 G) to largest (14 G; INS, 2016). PIV gauge sizes are universally color-coded. Table 3 provides a general overview of PIV gauge sizes and common uses (Pedagogy Online Learning Systems, 2016).
PIV Gauge Sizes and Uses
The catheter size has been found to have an impact on device functionality. Among adult hospitalized patients, catheters of 18 G or larger were found to have increased rates of thrombosis and phlebitis, and catheters of 22 G or smaller were found to have higher rates of dislodgment, occlusion, and infiltration (INS, 2016). A 20 G catheter is the recommended size for adults for most clinical applications based on the evidence (Wallis et al., 2014). INS guidelines recommend that the smallest gauge that can accommodate the prescribed therapies and meet the patient's needs is selected (INS, 2016).
The site of PIV placement is premised on the clinical judgment of the nurse, who must consider individual patient factors and the clinical situation. INS (2016) recommends the placement of the PIV in an area of non-flexion, such as the forearm, to provide stability for the device and to reduce patient discomfort. Nurses should start distally in the hand and progress proximally to preserve peripheral access. Some therapies, such as vesicants, should never be infused through a hand, wrist, or antecubital vein. Securing the PIV to reduce movement of the catheter at the insertion site within the blood vessel is recommended, as this helps to reduce the risk of the PIV being inadvertently dislodged (Alexandrou et al., 2018). VADs should not be placed in the veins of an upper extremity on the same side as a previous breast surgery with axillary lymph node dissection or in the setting of lymphedema due to heightened risk for infection and thrombotic complication. Additional locations to avoid include an arm with an arterio-venous fistula (AVF), a current or recent infection such as cellulitis, a fracture, thrombus, or hemiparesis (Nettina, 2019).
Nursing Care of PIVs
The PIV site must be assessed regularly, which is at least once per shift for adult patients. Proper assessment involves monitoring for any signs of malfunction, infection, displacement, or pain. Best practice guidelines recommend the prompt removal of symptomatic devices, such as when phlebitis or other complications are suspected, as well as when the catheter is no longer required (Alexandrou et al., 2018). As highlighted earlier, accurate documentation regarding the insertion, maintenance, and removal of PIVs in the medical record is a requirement according to best practice guidelines and the majority of healthcare facilities’ policies (INS, 2016). PIVs have limitations with regards to which therapies can be safely administered through them. Short PIVs are not appropriate for continuous vesicant therapy, parenteral nutrition, and infusions with a pH less than five or greater than nine, or infusions with an osmolality higher than 900 mOsm/L (INS, 2016; Nettina, 2019).
The midline catheter (MC or midline) is a type of extended-dwell deep peripheral catheter intended for short-term therapy, which is generally four weeks or less. These catheters are inserted 1.5 inches above or below the antecubital fossa into the basilic, cephalic, or median cubital veins (Adams et al., 2016). The catheter varies in length, ranging from 3 to 8 inches (8 to 20 cm). It extends up the arm with the proximal tip resting in the upper arm, just distal to the axillary arch (Caprara, 2017). MCs should be considered for patients who need a medium to long-term intravenous therapy, particularly when the duration of therapy is likely to exceed six days (Ignatavicius & Workman, 2015).
MCs do not dwell in the central circulation, and they offer several advantages over central lines and standard PIV catheters. A midline reduces the need for repeated venipuncture in patients with difficult peripheral venous access and poses significantly lower complication rates when used in place of CVCs. Midlines are associated with a decreased risk for infection and catheter-related thrombosis, but also allow for prolonged use. Midlines are associated with reduced rates of phlebitis and infiltration from drug administration due to its close proximity to the axilla, which allows for increased hemodilution of medications (Adams et al., 2016). Some midlines are power injectable and can tolerate high flow rates, allowing for the use of iodinated contrast for contrast-enhanced radiographic studies, but this depends on the type of device inserted and according to institution policy. A midline is very similar to a peripherally inserted central catheter (PICC) line, which is a type of central line that will be discussed in the next section (Adams et al., 2016). Figure 2 provides a graphic depiction of the key distinction between a midline catheter and a PICC line.
The midline catheter is usually inserted in the patient's nondominant arm under ultrasound guidance. Ultrasound helps to decrease the risk of cannulation failure, arterial puncture, hematoma, and other complications. A chest x-ray is not required for catheter tip verification following insertion. The midline is anchored to the skin with tape, steri-strips, or similar device to reduce the risk of inadvertent dislodgement. The exit site should be covered with a transparent dressing at all times to decrease catheter infection. Most midline catheters need to be replaced every 28 to 30 days, but some can dwell in place longer (Nettina, 2019). It is crucial to refer to the device's manufacturing guidelines and institution policy for a specific timeline for the replacement of these catheters (INS, 2016).
Extended-Dwell Peripheral IV Catheters (ED-PIVs)
ED-PIVs are very similar to midline catheters except that they are shorter in length than most midline catheters, ranging from about 6 to 8 cm on average, yet may extend up to 15 cm. They are FDA-approved devices that have a dwell time of 29 days, and are considered ideal alternatives for patients who have difficult peripheral venous access but require extended intravenous therapy. This device is particularly useful in emergency department settings as they can be placed at the bedside by specially trained and certified IV nurses. The use of ultrasound guidance with PIV insertion has been shown to improve the success of insertion with reduced premature catheter failure rates (Bahl et al., 2019).
Nursing Care of Midline Catheters
Nursing care of midline catheters includes measuring and documenting arm circumference. The arm circumference should be measured before the insertion of the catheter and when clinically indicated. Measurements are taken to monitor for an increased circumference of the extremity due to edema, which is a warning for the presence of deep vein thrombosis (DVT). The measurement should be taken about 10 cm above the antecubital fossa (INS, 2016). Basic flushing protocols include the use of 10-20ml of 0.9% preservative-free saline solution following each infusion. The line should be flushed every 12 hours when used for intermittent infusions. Since many midline catheters are equipped with a valve system, which prevents the backflow of blood, many do not require heparin flushing to maintain patency (Adams et al., 2016). The transparent dressing should be changed once per week, or sooner if visibly soiled, loose, or damaged (Nettina, 2019).
Midline Catheter Limitations
Midlines should not be used for continuous vesicant therapy, parenteral nutrition, or the administration of certain types of antibiotics, such as erythromycin (Erythrocin), vancomycin (Vancocin), or nafcillin (Penicillin). Dextrose concentrations greater than 10% are contraindicated, as well as infusions with a pH less than five or greater than nine or with an osmolality greater than 600 mOsm/L (Nettina, 2019). A midline catheter should not be placed in patients with a history of thrombosis, hypercoagulable blood clotting disorders, or those with decreased venous flow. Blood samples should not be drawn from a midline catheter. Nurses and caregivers should be taught to avoid performing any blood pressures or venipunctures on an extremity with a midline inserted. Similar to PIV restrictions, the MC should not be placed within an arm that is status post axillary lymph node dissection (INS, 2016).
PICC Catheter vs. Midline Catheter
Complications Associated with Peripheral IVs
PIVs are associated with high rates of complications, including insertion difficulty, phlebitis, infiltration, occlusion, dislodgment, and catheter-associated bloodstream infections. Several studies demonstrate that up to 90% of PIVs are prematurely removed due to failure before the completion of the prescribed therapy (Alexandrou et al., 2018). Once the initial catheter fails, vascular access becomes increasingly problematic, and patient safety may be jeopardized (Bahl et al., 2019). Refer to Table 4 for an overview of the most common types of PIV complications.
Common Complications of PIV Therapy
(Campagna et al., 2018; Nettina, 2019; Spencer & Gilliam, 2015)
Part II. Central Venous Catheters
A CVC is commonly referred to as a central line and is an indwelling device that is inserted into a vein of the central vasculature. It is a thin, flexible tube inserted by a puncture directly through the skin into the intended large vein, often in the neck, chest, arm, or groin. It is threaded through the vein until the tip of the catheter reaches a large vein near the heart. The catheter empties in or near the heart, allowing the catheter to give the needed treatment within seconds (CDC, 2019). The site where the central line leaves the skin is called the exit site. The CVC may have one, two, or three lumens, and the end of each lumen is covered with a cap. Each lumen of the CVC is treated and managed as a separate catheter, and every lumen must be flushed according to the defined protocol. Multiple lumens allow for the administration of multiple medications, including incompatible drugs, which may be safely infused through separate lumens simultaneously (Ignatavicius & Workman, 2015).
CVCs are long term devices and can remain in place for extended periods, often ranging from months to years. They are used for the administration of medications, fluids, parenteral nutrition, and blood products. They allow for the safe and continuous administration of vesicant or irritant therapy, including chemotherapy, antibiotics, stem cell transplantation, potassium chloride, and high concentration of dextrose infusions. Central lines allow treatments to move quickly into the bloodstream, and the line can be used and reused many times (Lippincott, 2019). Unlike peripheral catheters, a CVC may also be used to draw blood tests and for hemodynamic monitoring. CVCs may be used in inpatient, outpatient, and community settings. However, they are most commonly used in intensive care units (ICUs) for critically ill patients who require acute or critical care resuscitation and complex infusion therapies or treatments (Leib et al., 2019). Patients with a history of difficult peripheral venous access due to extensive prior PIV therapy, surgery, or previous tissue damage where vascular site selection is limited are also indications for CVC placement (Ignatavicius & Workman, 2015). CVCs may be inserted by specially trained and certified registered nurses (RN), advanced practice nurses (APRN), including nurse practitioners (NP) and certified registered nurse anesthetists (CRNA), or physicians. Some CVCs require surgical placement in the operating room or interventional radiology department, whereas others may be inserted at the bedside (McDiarmid et al., 2017).
The type of CVC inserted depends on many factors such as the prescribed therapy, the anticipated duration of therapy, history of any prior lines, patient complexity, and overall clinical status. Additional factors such as the care setting, cost, and patient, caregiver, and family preference are also considered. Site selection is based on several factors including the patient's condition, age, diagnosis, comorbidities, condition of the vasculature at and surrounding the intended insertion site, condition of the skin at the intended insertion site, history of prior venipunctures or access devices, type and duration of infusion therapy, and patient preference. To reduce CLABSI's, clinicians are advised to select the device with the smallest gauge and least number of lumens necessary to complete the prescribed therapy (INS, 2016).
General Nursing Care of CVCs
Nursing care of patients with CVC devices is multifaceted and complex, and responsibilities range across the spectrum of care from line placement to removal, with various responsibilities in between. CVC care requires astute clinical judgment, assessment, and training in order to ensure competency in the management and care of each type of device. Central lines serve critical roles in restoring the health of acutely and critically ill patients, with more than five million CVCs inserted each year in the United States. Despite the relatively widespread use of central lines, they are not without risks and complications (Kornbau et al., 2015). The primary responsibility of the nurse caring for those with CVCs is to safeguard patient care through the consistent use of EBP interventions to reduce the risk for complications, such as infection (INS, 2016).
The below list are the most common types of CVCs, which will each be outlined within the next section:
- Peripherally inserted central catheter
- Tunneled IV catheter
- Non-tunneled IV catheter
- Implantable port
Peripherally Inserted Central Catheter (PICC)
A PICC is a CVC that is inserted in the basilic, cephalic brachial, or median cubital veins in the upper arm. However, the basilic vein is generally the preferred vein. The line is threaded through the vein so that the catheter tip is located in the lower segment of the SVC (INS, 2016). A PICC is indicated for long-term access, and the dwell time varies from weeks to months but can remain in place for more than a year if proper care is provided. PICCs are usually chosen for patients requiring IV therapy ranging from one week to one year. INS guidelines recommend placement of a PICC line early in the course of therapy before veins are damaged from multiple venipunctures and infusions. Since it is a central line, nearly all infusion therapies and medications can be administered through a PICC, and the line may also be used for laboratory blood draws (INS, 2016).
PICC line insertion is a sterile procedure and requires formal training, as successful placement is highly dependent on the technique of the individual inserting the line. PICC lines are most commonly inserted by vascular teams led by specially trained PICC-certified nurses. PICC lines are inserted at the bedside or in the interventional radiology department under fluoroscopy guidance. A chest x-ray is required to confirm the placement of the catheter tip in the lower SVC before the PICC line is used. Clinicians should avoid placement of the catheter tip in veins distal to the SVC, as this is associated with much higher rates of thrombosis than when the tip is located in the SVC (Ignatavicius & Workman, 2015).
Catheter sizes range from 2F to 6F, and the catheter length is approximately 40-60 cm long but is cut to the patient's size at the time of insertion. PICC lines are available in single, double, and triple lumens catheters; however, multi-lumen PICC lines have been shown to have twice the rate of complications as single-lumen catheters (Paje et al., 2019). Since each additional lumen heightens the risk for infection and complication, INS guidelines recommend that the least number of lumens necessary for the prescribed therapy are inserted. Further, larger gauge PICCs are associated with increased risk for venous thrombosis, so the smallest lumen possible is also advised (INS, 2016).
There are two basic types of PICC lines: valved and non-valved (open-ended). Valved PICCs are more common and have a pressure activated safety valve (PASV) (Groshong®) located at the end of the catheter, which is called the hub. A PASV can also be placed on other types of CVCs, such as a tunneled or non-tunneled CVC. The line has a slit in the tubing near the end of the tube, and it opens only when blood is withdrawn or when fluid is infused. The valve remains closed when not in use, as the line essentially "self-seals." Therefore, PICC lines with PASV do not require clamps, and the PASV functions as a regulator that prevents the backflow of blood into the catheter. Valved PICCs may have more than one line and are considered saline-only lines, as they do not require heparin flushing to ensure patency is maintained. Therefore, these are excellent alternatives for patients who have heparin allergies or other medical contraindications to heparin therapy. Open-ended PICC lines do not have a valve or a slit in the tubing. The end of the PICC tubing remains open and requires a clamp to close off the line. The clamp should always remain in place when the line is not in use as it prevents blood from backing up in the tubing (Zerla et al., 2015). Figure 3 displays a valved PICC which has a PASV hub on the end of the catheter. Figure 4 is a photograph of an open-ended PICC with clamps.
Valved PICC Line
Non-Valved PICC Line
Contraindications to PICC line
The insertion of a PICC line is contraindicated in extremities affected by any of the following:
- Status post axillary lymph node dissection;
- Presence of arm edema or lymphedema;
- Deep venous thrombosis [DVT] or superficial venous thrombosis [SVT];
- Tissue damage including fracture, cellulitis, or burns;
- Newly implanted pacemaker or defibrillator;
- Arm affected by cerebrovascular accident [CVA] including paralysis, weakness, loss of function or sensation;
- Dialysis catheter (AVF) located in same extremity (INS, 2016; Leib et al., 2019).
Pros and Cons of PICC lines
Anesthesia is not required for insertion or removal of PICC lines, which makes insertion less complicated, less expensive, and less risky for the patient. The catheter size for the vast majority of PICC lines is relatively small, and the insertion site into the upper arm eliminates the risk of complications such as pneumothorax or injury to the vessels within the neck as associated with placement of other types of central lines (Caprara, 2017). PICC lines are removed by specially trained PICC-certified nurses, APRNs, or physicians at the bedside. When properly cared for, they pose low infection rates when compared with other types of CVCs due to insertion within the upper extremity. PICC lines reduce the need for multiple venipuncture and IV sticks, thereby enhancing patient satisfaction. PICC lines contribute to decreased length of stay in the hospital, as they allow for IV therapy in non-acute settings, such as home care, skilled nursing facilities (SNF), and hospice (Ignatavicius & Workman, 2015).
One of the most important complications associated with PICC lines is an increased risk for venous thrombosis, particularly DVT. PICC lines carry a substantial risk for upper extremity DVTs when compared with other central lines and are also associated with increased risk for central vein stenosis (Chopra et al., 2019). Careful consideration should be given before inserting a PICC line in patients who have cancer or are critically ill due to the hypercoagulability that often accompanies a cancer diagnosis, as well as an increased risk for CLABSI in hospitalized patients (INS, 2016).
National guidelines strongly recommend that PICC line insertion is avoided in patients who may require hemodialysis in the future, such as patients with advanced chronic kidney disease. Autogenous AVF is the most common vascular access device used for long-term hemodialysis, as it is the most durable and poses the least complications. Evidence demonstrates that there are higher rates of AVF failure in veins that have previously been subjected to insertion of a PICC line, or other types of indwelling vascular catheters (Paje et al., 2019). While AVF and hemodialysis catheters will not be covered within this module, it is essential to consider the potential for future need of catheters such as these before inserting a PICC line in a patient (Herc et al., 2017).
Other potential complications associated with PICC lines include malposition, thrombophlebitis, bleeding at the access site, and nerve damage. PICC lines have been reported to cause Horner's syndrome, which is manifested by eye changes secondary to inflammation of cervical sympathetic nerves from catheter placement. Horner's syndrome has been reported as associated with the trauma from the insertion technique and vein thrombosis. Since the PICC catheter hangs externally from the arm, the line must be wrapped and secured before bathing and showering to preserve the integrity of the dressing and reduce the risk of infection. Patients should be counseled to avoid heavy lifting, which can lead to muscle contraction and catheter dislodgement or lumen occlusion (Ignatavicius & Workman, 2015).
Nursing Care of PICC lines
Aseptic technique is advised with each encounter, and all clinicians who utilize a PICC line should be appropriately trained and competent in its use. Since the PICC is placed within a large vessel, blood return should always be brisk and substantial (INS, 2016). The PICC line requires daily flushing protocols with a 10-mL syringe, which is the minimum size syringe that can safely be used with the device. The line should be flushed at least daily, but most protocols call for flushing once every 12 hours, with 10 mL of 0.9% sodium chloride to maintain patency and prevent the line from clotting when not in use. It must also be flushed following any infusion, bolus injection, or following blood withdrawal to clear the line of any residue, as flushing helps to reduce the buildup of fibrin and platelets. Blood present in the catheter lumen also contributes to the risk for infection (INS, 2016). A transparent dressing should cover the PICC insertion site and the hub at all times as part of EBP for infection control. Dressing changes are required for proper PICC line care, at least once every seven days, or sooner if the dressing becomes soiled, wet, loose, or dirty (Nettina, 2019).
Open-ended PICC lines should remain clamped when the catheter is not in use. Extension tubing must be clamped when the infusion is not being administered and taped securely to the patient's arm (Nettina 2019). The patient's arm circumference should be measured prior to the insertion of the PICC and when clinically indicated. This practice is performed to assess for the presence of edema, which could indicate the development of a DVT. The measurement should be taken about 10 cm above the antecubital fossa. Nurses should routinely assess for infiltration and extravasation, which require immediate intervention to prevent morbidity (INS, 2016).
PICC Line Removal
The PICC line should be promptly removed when it is no longer essential (CDC, 2017). The patient should be placed in a supine flat or Trendelenburg position for PICC line removal unless this positioning is contraindicated. While an air embolism is a rare complication of a PICC line removal, precautions should still be taken. After removing the occlusive dressing, anchoring devices, and sutures, the PICC line should be removed gently and firmly, while having the patient exhale or hum. The PICC line should never be forcibly removed if met with resistance, as catheter fracture and embolization may ensue. Instead, the nurse should contact the licensed practitioner or physician for assistance. If any piece of the catheter is retained within the vein, it may require removal through endovascular techniques to reduce the risk of infection, thrombosis, and migration of the fragment of the catheter. Therefore, immediately following the removal of a PICC line, the catheter tip should be examined to ensure it was removed fully intact (Ignatavicius & Workman, 2015). An occlusive sterile dressing with antibiotic ointment should be applied and firmly held with pressure on the site for a minimum of two minutes, or until bleeding subsides. For patients who are on anticoagulation therapy, pressure may need to be applied for up to five minutes (UC San Diego Health, 2016). The vascular access site should be monitored for 48 hours to detect any signs of post-infusion phlebitis, bleeding, or infection. If the patient is being discharged, the patient and/or caregiver should be provided with written instructions about monitoring for signs and symptoms and whom to contact if these occur (INS, 2016).
Tunneled Central Venous Catheter
A tunneled central catheter is surgically implanted in a central vein in the neck or chest and then subcutaneously tunneled to an exit site in the chest wall. As demonstrated in Figure 5, the vein entry site is located on the upper chest, and the exit site is located between the third or fourth intercostal space where the catheter exits the tunnel. The tip of the catheter rests in the SVC. A device called a Dacron cuff is positioned within the tunneled portion of the catheter, approximately 2 to 3 cm from the exit site. Tissue grows around the cuff to create a mechanical barrier against microorganisms and also helps to anchor the catheter in place (INS, 2016). The separation between the point where the catheter enters the vein and where it exits the skin is intended to reduce the risk for infection by preventing organisms on the skin from reaching the bloodstream (Ignatavicius & Workman, 2015).
Tunneled Central Venous Access Device
Tunneled CVCs are used for patients who require long-term access, generally greater than 30 days for infusion therapy, antibiotics, chemotherapy, or blood products. Tunneled CVCs are also used when parenteral nutrition is indicated for months or longer (Sousa et al., 2015). Tunneled CVCs may also be used when a PICC line is not a feasible option for the patient. All medications, including vesicant therapy, can be safely administered through a tunneled catheter. The line may be used for blood sampling, and it may be single, double, or triple lumen (INS, 2016). Similar to PICC lines, there are two main types of tunneled CVCs: PASV (closed-ended) and small bore (open-ended). The functionality is very similar to valved- and non-valved PICC lines, as described in the prior section. In clinical practice, the most common devices include the Hickman®, Broviac®, and Groshong®, which were each named for the physicians who developed them (Nettina 2019).
The Groshong® tunneled CVC is a closed-ended system that has a patented three-position valve (or valves) which allows fluids to flow in or out but remains closed when not in use. The valve is located near the closed, catheter tip (hub) and serves as the gatekeep to allow or prevent the infusion of fluid or aspiration of blood. When not in use, the valve restricts blood from backflowing, as well as reduces the risk for air embolism by remaining closed. This mechanism helps to maintain catheter patency and reduces the need for heparin. When aspirating from the catheter, such as during blood sampling, the negative pressure in the catheter causes the valve to open inward, allowing for the retrieval of the specimen (Bard, 2015).
Similarly, positive pressure into the catheter by gravity, an infusion pump, or syringe will open the valve and allow for the infusion to flow into the catheter. Whenever the catheter luminal pressure returns to normal, the valve closes. The valved system enhances patient safety and is also more cost-effective than open-ended catheters, as it reduces the cost of ongoing catheter maintenance. Whenever blood is aspirated from the catheter or something is infused into the catheter, it must be flushed with a 10 ml syringe with 0.9% sodium chloride to clear blood from the lumen and allow the valve to return to its normal closed position. Similar to open-ended PICC lines, small-bored tunneled CVCs, such as Hickman® catheters, require clamps to prevent the backflow of blood. Clamps must remain closed unless a pressure activated safety cap is applied to the end of the line (Bard, 2015). Table 5 compares the main differences between the two types of lines.
PASV versus Small-Bore Tunneled CVCs
Contraindications to Tunneled CVCs
Insertion of a tunneled CVC is contraindicated in patients with active septicemia due to the risk for colonization of the device with the infectious agent. Insertion is contraindicated in patients with severe coagulopathies, as evidenced by an elevated international normalized ratio (INR) of greater than 1.5, or a platelet count less than 50,000 due to the risk for hemorrhage from the target vessel (Clark et al., 2016). Other potential contraindications include skin infection overlying the intended insertion site, obstruction secondary to thrombus within the intended vein, or stenosis of the vein (Tse & Schick, 2019).
Pros and Cons of Tunneled CVCs
Tunneled CVCs have lower infection rates when compared to non-tunneled CVCs, patients require fewer venipunctures, and the device can remain in place for years (CDC, 2017). There are also several benefits associated with the use of a PASV-valved line over an open-ended one, as the PASV valve functions to:
- Prevent blood reflux into catheter;
- Reduce the risk of air embolism and blood clotting;
- Reduce the need for flushing when not in use; the catheter only needs to be flushed once weekly with normal saline when not in use;
- Eliminate the need for heparin flushing;
- Eliminate the need for clamping;
- Enhance cost-effectiveness associated with catheter maintenance due to reduced need for flushing (Bard, 2015; Goossens, 2015).
Tunneled CVCs place restrictions on certain activities. Patients are advised to avoid swimming and contact sports such as football when the catheter is in place. Another disadvantage is that tunneled CVCs are inserted surgically, generally in the operating room, under conscious or local sedation, and must also be removed surgically (Nettina, 2019).
Nursing Care of Tunneled CVCs
Prior to using a tunneled CVC, an X-ray must be performed to confirm the correct placement of the catheter, and the nurse must have an active order from the licensed provider stating that the line may be used; although this varies according to organizational policy. The INS (2016) recommends that an initial sterile dressing is placed on the site following insertion. The dressing should be changed 24 hours following line insertion, and every seven days after that, or when visibly dirty, wet, or soiled. Once the insertion site has completely healed over, which is usually about 21 days following insertion, the line may be left open to the air and uncovered. The site does not require routine dressings in outpatient and community settings, as there are no evidence-based recommendations for routine site care and need for occlusive or sterile dressings. Clean gloves should be worn when accessing a tunneled catheter that has fully healed following insertion (INS, 2016).
The nurse must assess the patency of the catheter prior to each use, by aspirating a blood return, which should be brisk. Patency should be checked prior to the administration of any drug or infusion, and the line should also flush easily and without resistance. Syringes smaller than 10 ml should never be used to flush any type of tunneled CVC. The INS (2016) recommends that 10 mL syringe (or larger) be used for withdrawing blood samples or injecting into any tunneled CVC. Blood samples may be drawn from all types of tunneled CVCs (INS, 2016).
Medications can be given directly into the catheter, as tunneled CVCs are generally used for long-term intermittent or continuous therapies such as TPN, blood products, antibiotics, as well as vesicant medications, including chemotherapy (Ignatavicius & Workman, 2015). In cases where TPN is prescribed, a dedicated line must be allotted for the TPN infusion and labeled for TPN use. No other medications, infusions, or therapies should be infused through the dedicated TPN lumen due to increased risk for occlusion and infection. The nurse is also responsible for monitoring for signs of potential infection. Signs and symptoms of infection may include erythema, edema, pain or tenderness, drainage, fluid pocket in the subcutaneous tunnel, induration at the exit site or over the pocket, as well as signs of systemic illness such as elevated body temperature, chills, rigors, lethargy, disorientation, and confusion (INS, 2016).
As outlined in Table 5, valved tunneled CVC lines are considered saline-only lines, as they do not require heparin for flushing. When the line is not in use, it only needs to be flushed with 10 ml of 0.9% sodium chloride once per week. In contrast, each lumen of small-bore catheters must be flushed once daily, using a heparinized solution (INS, 2016; Bard, 2015). When properly cared for and infection control measures are taken, tunneled CVCs may remain in place indefinitely. Strict handwashing is essential prior to handling the catheter. A sterile technique must be used while accessing the catheter for taking blood cultures, changing the needle-free access device, and connecting or disconnecting infusion lines. In small-bore tunneled CVCs, the cap should be changed every seven days using aseptic technique. The patient or a caregiver can be trained on how to care for the site, including performing cap changes and flushing at home (CDC, 2017; INS, 2016).
Removal of Tunneled CVC
According to INS (2016) guidelines, the placement and removal of a tunneled CVC should be performed by "a licensed independent practitioner (LIP) who has validated competency operating within the state's rules and regulations for professional practice" (INS, 2016, p. S59). The line should be removed as soon as therapy is complete, and it is no longer required. The removal of the catheter is a surgical procedure, and sterile technique must be maintained throughout the process to reduce infection. The specific details outlining the removal of a tunneled CVC are subject to organizational policy; however, it is essential to ensure the complete removal of the subcutaneous cuff. If removal of the cuff is incomplete and any products are retained in the patient, they are at risk for subcutaneous abscess and delayed wound healing. INS guidelines recommend the use of fluoroscopy and ultrasound guidance to verify cuff location and facilitate surgical removal (INS, 2016).
Non-Tunneled Central Venous Catheters
Non-tunneled CVCs are small-bore catheters that are inserted percutaneously through the subclavian vein of the upper chest or the jugular veins of the neck, as demonstrated in Figure 6. With these devices, the catheter exits the skin in the vicinity of the venous cannulation site, which may be the jugular, subclavian, or femoral vein (Chopra et al., 2019). The subclavian vein is preferred in adult patients, rather than the jugular or femoral veins, as it is associated with a reduced risk for infection and catheter-related thrombus (INS, 2016; CDC, 2017). However, the subclavian should be avoided in patients who are at heightened risk for bleeding due to an inability to safely monitor or compress the venipuncture site (Ignatavicius & Workman, 2015). In patients with chronic kidney disease who may need AVF placement for future hemodialysis, the potential risks of central vein stenosis and venous occlusion when the subclavian vein is used should be cautiously considered. The internal jugular or external jugular may be potential alternative sites for these patients (INS, 2016). In patients where coagulopathy is a concern, compressible access sites such as the internal jugular and femoral vein should be considered (Kornbau et al., 2015).
Non-tunneled CVCs are usually 15 to 25 cm in length and can be single, double, triple, or quadruple lumen. Catheter placement is performed by a specially trained APRN or physician using sterile technique and is often inserted emergently at the bedside (Chopra et al., 2019). The catheter is often sutured in place for the duration of placement to prevent the catheter from migrating or being inadvertently dislodged. The tip of the catheter resides in the SVC, and a chest x-ray must confirm proper placement prior to use. They are intended for short term and temporary use, usually 5 to 10 days, and are most commonly used in emergent, trauma, and critical care settings in patients in which peripheral access is limited. They are not appropriate for home care or ambulatory clinic settings. The line can be used for continuous infusion therapy of medications, TPN, high dose potassium or other electrolyte replacement, blood products, antibiotics, and other intermittent therapies. Non-tunneled CVCs also allow for hemodynamic monitoring in patients who are critically ill. They are capable of tolerating large volume infusions, and therefore may be used in patients with hemorrhagic disorders or severe trauma where large volume blood products are needed (Ignatavicius & Workman, 2015).
Non-Tunneled Central Venous Access Device
Contraindications to Non-Tunneled CVCs
There are few, if any, absolute contraindications to non-tunneled CVC insertion, and recommendations vary based on the targeted insertion site and patient factors. Coagulopathies should be approached with caution and careful consideration. The general recommendation is to avoid placement of a non-tunneled CVC in patients with an INR of less than 2.0 or a platelet count of 50,000; however, values outside of these ranges are not absolute contraindications. In emergency settings, coagulopathies do not preclude non-tunneled catheter placement in clinically unstable patients (Lee & Ramaswamy, 2018). Some potential contraindications may include skin infection overlying the intended insertion site, obstruction secondary to thrombus within the intended vein, or stenosis of the vein (Tse & Schick, 2019). A history of surgical manipulation or trauma to the intended site is another potential contraindication, as well as trauma to other body parts. For example, a cervical spine collar is often a contraindication to the placement of an internal jugular non-tunneled CVC. In contrast, the presence of a pelvic binder can be a contraindication to the placement of a femoral CVC (Leib et al., 2019).
Pros and Cons of Non-Tunneled CVCs
Non-tunneled CVCs can be rapidly inserted at the bedside by trained professionals under ultrasound guidance. Placement does not require the use of anesthesia, and therefore, risks associated with anesthesia are eliminated. Since non-tunneled CVCs are designed for temporary and short-term use, an advantage is that they can be placed in the setting of systemic infection (Lee & Ramaswamy, 2018). Non-tunneled CVCs are responsible for the majority of catheter-related bloodstream infections. Therefore, it is critical to remove the line as soon as feasible to reduce infection risk, morbidity, and associated mortality (CDC, 2017). The use of multi-lumen catheters increases the risk of thrombosis formation and other complications, such as the risk for infiltration. Multi-lumen catheters are also unable to infuse fluids or blood products as quickly as single-lumen catheters (Chopra et al., 2019). Placement of a non-tunneled CVC in the internal jugular or subclavian carries a risk of lymphatic injury due to the anatomic location of the thoracic duct (Kornbau et al., 2015).
Nursing Care of Non-Tunneled CVCs
According to the CDC (2017), chlorhexidine-impregnated dressings with an FDA-cleared label that specifies a clinical indication for reducing catheter-related bloodstream infections are recommended. These dressings protect the insertion site of short-term, non-tunneled CVCs. The catheter should be assessed for continued need daily, as prompt removal is strongly advised when no longer necessary to reduce potential complications. The risk for infection and thrombosis rises with increased dwell time. INS (2016) standards advise that non-tunneled CVCs are monitored closely for complications and the presence of any of the following signs and symptoms, which must be reported to a licensed practitioner immediately:
- Pain or tenderness in unusual locations of neck, chest, or upper abdomen;
- Erythema or blanching at the insertion site;
- Changes in skin temperature at or surrounding the insertion site;
- Sudden or unusual respiratory and neurological changes;
- Leaking of fluid or purulent drainage from the puncture site;
- Resistance when flushing;
- Absence of brisk blood return;
- Changes in catheter function associated with arm position changes;
- Signs of systemic illness, such as elevated body temperature, chills, or rigors (INS, 2016, p. S92).
Removal of Non-Tunneled CVCs
Removal of non-tunneled catheters should be "performed either by or upon the order of a licensed independent practitioner (LIP) in accordance with state licensure rules and regulation and organizational policies" (INS, 2016, p. S59). The patient should be placed in a supine flat or Trendelenburg position for catheter removal unless this positioning is contraindicated. The line should never be forcibly removed if met with resistance, as catheter fracture and embolization may ensue. If any piece of the catheter is retained within the vein, it must be removed, which often requires the assistance of endovascular techniques, to reduce the risk of infection, thrombosis, and migration of the piece of the catheter. Therefore, immediately following the removal of a non-tunneled line, the catheter tip should be examined to ensure it was removed fully intact (Ignatavicius & Workman, 2015). An occlusive sterile dressing with antibiotic ointment should be applied and firmly held with pressure on the site for a minimum of two minutes, or until bleeding subsides. For patients who are on anticoagulation therapy, pressure may need to be applied for up to five minutes (UC San Diego Health, 2016).
Implantable Venous Access Devices (Port)
An implantable port is a central vascular access device that is surgically placed into a subcutaneous pocket of the anterior chest wall, about one inch beneath the collarbone, as demonstrated in Figure 7. It may also be implanted in the abdomen or upper arm, but these sites are less commonly used. Often referred to as a port-a-cath or mediport, the insertion of the device is performed under local anesthesia by a surgeon or interventional radiologist. The port consists of a thin, flexible catheter that is attached to a reservoir. The catheter is threaded into the central venous system via the subclavian, jugular, or femoral vein, and the tip of the catheter resides within the SVC. The reservoir can be made of plastic, stainless steel, or titanium and is about the size of a quarter in greatest diameter. It is covered with a self-sealing silicone septum that is designed to withstand multiple needle punctures (Lippincott, 2019). Ports may be single lumen or double lumen, and they may also be power injectable, and able to withstand high-speed injections of contrast for radiology imaging tests such as computed tomography (CT) scans or magnetic resonance imaging (MRI) scans (Sousa et al., 2015).
To access a port, a specialized needle called a non-coring (Huber) needle is inserted perpendicular to the reservoir, as demonstrated in Figure 8. Since the device itself cannot be visualized directly, it is palpated to identify placement. Accessing the port with a needle is required in order to administer fluids, antibiotics, medications, or to perform blood sampling. Ports are used for long-term infusion therapy and are associated with a low risk of infection. Aside from tunneled CVCs, implantable ports are the most common CVC chosen for chemotherapy administration, including continuous vesicant administration. An implanted port is similar to a tunneled catheter, except that the port is not visible like a tunneled catheter since it resides beneath the subcutaneous tissue. Ports do not require as much maintenance care and do not impede daily activities as PICC lines or tunneled catheters may (CDC, 2019).
Venous Access Port
Needle Access of Implantable Port
(Cancer Research UK, 2014)
Contraindications to Implantable Ports
Contraindications to the insertion of implantable VADs include bacteremia, positive blood cultures, and sepsis. Port insertion is also contraindicated in severe uncorrected coagulopathies, such as increased bleeding time and severe thrombocytopenia. Relative contraindications may include burns or trauma at the intended site. INS guidelines recommend the upper extremity as a potential alternative site for patients in whom chest ports cannot be implanted (INS, 2016).
Pros and Cons of Implantable Ports
There are several benefits to implantable ports, particularly in circumstances in which the patient's peripheral veins have been damaged due to recurrent needlesticks and IV placement. Ports can eliminate the need for multiple needlesticks, thereby reducing the fear associated with treatment in patients who require long term therapies. Since the port is hidden beneath the skin, it is considered the most cosmetically appealing of all the central lines (Lippincott, 2019). When used intermittently and proper aseptic technique is maintained during needle access, ports have a lower incidence of catheter-related bloodstream infections than other chest-accessed central lines. However, continuous port access has infection rates that are comparable to other long-term CVCs (CDC, 2019; INS, 2016). Implantable ports require less routine catheter care when compared to other devices, such as PICC lines. Further, ports only minimally restrict patient activity, as patients are permitted to bathe, shower, and swim when the port is not accessed (Lippincott, 2019).
Some disadvantages of implantable ports include the port insertion process, which requires a minor surgical procedure in the operating room or interventional radiology department (INS, 2016). Medication delivery requires needle access, which can be uncomfortable. However, patients may apply a lidocaine-based cream to the site approximately 45 minutes before needle access, which numbs the skin and reduces the discomfort associated with needle insertion (Lippincott, 2019). The most common complications associated with implantable ports include infiltration secondary to improper insertion, dislodgment of the needle, occlusion, thrombus, infection, catheter fracture, and catheter migration (INS, 2016).
Nursing Care of Implantable Ports
Ports can safely remain in place for months to years, but they require routine care so that they do not get blocked or clogged. While implantable ports may be used immediately following placement, the nurse must first ensure that catheter tip placement has been confirmed radiographically, such as with a chest x-ray. In most healthcare organizations, an order from a licensed provider is necessary in order to use the implanted device for the first time. Accessing the port is a sterile procedure and requires aseptic technique. Ports that are power injectable (i.e., able to be used for CT contrast injection) require the use of a specialized access needle equipped for power injection to ensure that the tubing and connections do not rupture or separate under the pressure of the injection (Lippincott, 2019). Adherence to aseptic technique includes several specific steps governed by national guidelines and institutional policy. According to INS (2016) guidelines, accessing an implanted port requires adherence to the following critical steps:
When implanted ports are not in use (i.e., not accessed with a needle), they do not require exit-site care and do not need dressings over the site. The nurse must continually monitor the site for any abnormalities at the insertion site, including redness, swelling, warmth, tenderness, or pain, which can indicate an infection (Lippincott, 2019).
Similar to most central access devices, a syringe size smaller than 10 mL should never be used to flush a port, as smaller syringes can create excessive pressure within the device and lead to catheter fracture. Each lumen of the port must be managed separately and flushed accordingly. The port should be flushed and aspirated for the presence of brisk blood return prior to each infusion or administration of medication to assess correct needle placement and catheter function. The port should also be flushed after each infusion to clear the catheter lumen and reduce the risk for occlusion of the catheter (INS, 2016). Following administration of the final infusion or medication, the port should be flushed and locked with preservative-free 0.9% sodium chloride and 5 mL of heparin 10 units/mL in a pre-filled syringe before removing the needle or de-accessing the port. This heparin lock solution reduces the risk of catheter occlusion (Lippincott, 2019). Ports that are accessed with a needle must be flushed daily if not being infused with continuous IV fluids. If the port remains in continual use, the dressing and non-coring needle should be changed at least every five to seven days, or when visibly soiled. When not in use, many ports only require needle access and flush once every four to eight weeks, but these timeframes are subject to change based on institution policy (INS, 2016).
Troubleshooting Common Port Problems
Nurses caring for patients with implanted ports should be trained in managing and troubleshooting common port problems. The inability to flush a port or obtain a brisk blood return is a commonly reported issue, and the etiology can vary. The port needle may not be correctly placed, the catheter may be lodged against the vessel wall, or a fibrin sheath (blood clot) may have developed at the catheter tip. Nurses need to understand how to troubleshoot these problems at the bedside. Interventions geared toward resolving some of the most common port problems include the following:
- Ensure correct needle placement within the port and that the needle is advanced through the septum;
- Reposition the patient or ask the patient to cough, raise arms, lay back, sit up, or take a deep breath, as these maneuvers can help dislodge the catheter from the vessel wall;
- The port may need to be re-accessed with a new needle;
- Notify the practitioner to obtain an order for a fibrinolytic agent to dissolve the clot. Refer to institution policy for specific details regarding appropriate fibrinolytic agent, instillation procedures, and contraindications;
- There is the potential for catheter rupture during and after power injection, which can lead to extravasation, catheter fragment emboli, and the subsequent need for port removal and replacement. Nurses are encouraged to be aware of potential catheter rupture if the patient exhibits signs of localized swelling, erythema, or develops acute onset of pain at the site (INS, 2016).
If there is ever concern regarding proper needle placement, a radiographic dye procedure should be performed to confirm placement (Lippincott, 2019).
Removal of Implantable Venous Access Devices
According to the INS (2016) guidelines, removal of an implanted vascular access port is a surgical procedure performed by physician, APRN, or physician assistant with validated competency and as governed by the state's laws and regulations for professional practice and according to organizational policy. Removal is a sterile procedure, and the skin should be prepped with appropriate antisepsis. Immediately following the removal of the device and catheter, the catheter should be examined to ensure it has been removed fully intact. If any piece of the catheter is retained within the vein, it will require removal through endovascular techniques to reduce the risk of infection, thrombosis, and migration of the catheter piece (Ignatavicius & Workman, 2015). An occlusive dressing should be applied, and pressure should be held on the site until bleeding subsides. Bleeding is usually minimal with implantable port removal as it is a minor surgical procedure. As noted earlier, for patients on anticoagulation therapy, pressure may need to be applied for up to five minutes or until the bleeding subsides (UC San Diego Health, 2016).
Complications Associated with CVCs
As noted throughout this module, complications associated with CVCs are possible and can lead to significant morbidity and mortality if not treated timely and appropriately. Practitioners and nurses must remain vigilant for potential CVC complications, as they require prompt assessment and proper intervention. If left untreated, these can quickly progress to life-threatening problems (Sousa et al., 2015). Immediate complications are generally associated with the insertion procedure and technique and can include vascular, cardiac, or pulmonary problems. The number of unsuccessful insertion attempts is the most significant predictor of insertion-related complications. However, ultrasound guidance has significantly reduced the incidence of complications due to its assistance with precise placement of the catheter in the targeted location. Some of the most common insertion related complications include pneumothorax, hemothorax, hemorrhage due to erosion of an artery or vessel wall, cardiac tamponade, cardiac perforation, cardiac arrhythmias, and occlusion (Kornbau et al., 2015).
CVC-related risks extend throughout the catheter dwell time, and thrombosis, infection, and catheter dysfunction can occur at any time. CVCs disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. Since the catheter provides a portal of entry and direct pathway to the central venous system, an infectious agent can quickly spread throughout the bloodstream, making the patient critically ill (Haddadin & Regunath, 2019). A breach in sterile technique during the insertion procedure can lead to an infection of the catheter or surgical site, which can rapidly spread through the bloodstream. Infection can develop if the line is not adequately cared for or if sterile technique is breached. Bloodstream infections can induce hemodynamic changes, leading to organ dysfunction and sepsis, which can be fatal (CDC, 2017).
Indications for CVC Removal
Removal of a central line is usually indicated for the following reasons:
- Suppurative (septic) thrombophlebitis;
- Tunnel infection;
- Implantable port abscess;
- Bloodstream infection that continues despite 48–72 hours of adequate antimicrobial coverage; or infections with certain types of pathogens that have a high risk for infection recurrence (Sousa et al., 2015).
Part III. Other Types of Vascular Access Devices
Intraosseous (IO) Cannulation
Intraosseous cannulation provides access to the vasculature located within the long bones and is generally reserved for critically ill patients who require rapid access for stabilization in emergent situations (Petitpas et al., 2016). Historically reserved for children, IO devices are now considered acceptable for use within the adult population as well. They are most commonly seen in the event of pediatric cardiac arrest, as "pediatric advanced life support guidelines suggest the use of the IO route as the initial vascular access route" (INS, 2016, p. S120). Among adults, IO cannulation may be used in battlefield settings, trauma, hemorrhage, or the event of cardiac arrest when intravenous access is not available or unable to be obtained rapidly (INS, 2016). A 15 G needle (1.5 cm long) is indicated for children under 40 kg, whereas adults usually require a 15 G needle (2.5 cm long) for IO access. There are three categories of IO devices available, which include manual needles, impact-driven, and drill powered needles (INS, 2016, p. S121). These needles are designed specifically for IO access and are preferred because they have three key features that separate them from other access needles:
- Removable stylets that screw into the cannula to keep the needle from retracting during insertion;
- Short shaft to reduce the risk for accidental dislodgment;
- Graduations along the needle to help facilitate ease of insertion (Ignatavicius & Workman, 2015).
Figure 9 displays an example of an IO needle and Figure 10 demonstrates the placement of an IO catheter.
Intraosseous Catheter Placement
(Senior Airman Peter Reft, 2015)
The most IO common insertion sites among adults include the tibia and proximal humerus. The sternum should be avoided as it is too thin to accommodate the needle and could lead to pneumothorax and impede resuscitation efforts (Ignatavicius & Workman, 2015). Prior to placement of an IO device, the extremity should be restrained, and the skin should be prepped using aseptic technique with >0.5% chlorhexidine in alcohol solution, povidone-iodine, or 70% alcohol. Catheter insertion must be performed by a specially trained nurse or licensed clinician, who has training and skills to perform the procedure (Petitpas et al., 2016).
Nursing Care of IO Devices
The IO site must remain covered with a sterile dressing, and the device should be stabilized and secured to prevent movement out of the bone (Ignatavicius & Workman, 2015). Proper placement of the IO device can be confirmed by assessing needle positioning and the ability to easily flush at least 5 mL of 0.9% normal saline without signs of infiltration. The ability to aspirate blood or bone marrow may also be used to confirm needle placement; however, aspiration may be difficult in some patients, such as those with severe dehydration. Therefore, the absence of aspiration is not an indication of improper placement if other indications of appropriate placement are present (INS, 2016). Needle placement should be reevaluated before using the device each time, especially when highly irritating agents or large volumes will be infused. Site assessment must be ongoing and frequent (INS, 2016).
The same doses of IV fluids and medications that can be infused through a PIV may be infused through an IO device. However, an infusion pump is often required for rapid flow rates. IO devices become clogged or clotted with bone marrow more quickly than with PIV access; therefore, it should be connected to a continuous flow of IV fluids or frequently flushed to prevent occlusion (Ignatavicius & Workman, 2015). IO catheters should only be used during the immediate trauma or resuscitation period, while the patient is being stabilized, and alternative VAD is sought and established. IO catheter dwell time should be limited to a maximum of 24 hours (INS, 2016).
Complications of IO Cannulation
Complications associated with IO devices are uncommon but can include local infection at the site, infiltration, extravasation, catheter dislodgment, and compartment syndrome (INS, 2016). Compartment syndrome is a condition in which increased tissue pressure in a confined anatomic space causes decreased circulation to the area, which can lead to tissue hypoxia and pain. Nurses must monitor for discoloration, mottling, coldness, or swelling of the extremity, as without immediate intervention, damage can be permanent, and amputation of the limb may be required (Ignatavicius & Workman, 2015). Rarely, IO devices can lead to other serious complications such as fat emboli, iatrogenic fracture, and osteomyelitis (INS, 2016). The risk for osteomyelitis, or severe infection of the bone, increases when dwell time extends beyond 24 hours (Ignatavicius & Workman, 2015).
Contraindications to IO Insertion
The INS (2016) lists the following absolute contraindications to IO placement:
- Compartment syndrome in the extremity;
- Previously used IO site or a recently failed IO attempt;
- Fracture at or above the site;
- Prior orthopedic surgery or implanted orthopedic hardware;
- Infection, severe burns, open wounds, or tissue necrosis at or near the intended site;
- Local vascular compromise;
- Bone disease such as osteoporosis, osteopetrosis, and osteogenesis imperfecta (INS, 2016).
Apheresis is a process in which whole blood is removed from a patient and processed through a centrifuge machine that separates it into four components: plasma, platelets, red blood cells, and white blood cells. One of the blood components is isolated and removed, and the remaining components are reinfused into the patient (INS, 2016). During donor apheresis, such as when a healthy volunteer donates plasma or platelets, the procedure is usually performed using two large-bore peripheral IV catheters that are removed immediately following the donation. Figure 11 demonstrates an example of an apheresis machine. Several different therapeutic apheresis procedures are designed to remove, or treat, specific components of the blood, as outlined in Table 6.
(National Institute of Allergy and Infectious Disease [NIAID], 2016)
Types of Therapeutic Apheresis
Apheresis procedures are performed to treat of a variety of conditions including but not limited to the following:
- Solid organ transplantation for antibody mediated rejection allograft;
- Chronic myelogenous leukemia (CML);
- Guillain-Barre syndrome;
- Hemolytic uremic syndrome;
- Familial hypercholesterolemia;
- Chronic inflammatory polyneuropathy (CIPN);
- Goodpasture’s syndrome;
- Thrombotic thrombocytopenic purpura (TTP);
- Autoimmune conditions such as severe systemic lupus, psoriasis, and scleroderma (Stowell, 2019).
In addition to the indications described above, apheresis catheters can be used to give medications, fluids, blood products, chemotherapy, or nutrition through a vein. It may also be used for drawing blood (Delaney et al., 2016).
Apheresis catheters are designed for the exchange of large volumes of blood at high flow rates. Vascular access for apheresis is commonly performed through peripheral veins or CVCs, however arteriovenous (AV) fistulas and AV grafts are also viable options for patients requiring long-term treatment and repeated apheresis procedures. INS (2016) guidelines recommend the use of 16 G to 18 G peripheral catheters placed in antecubital veins for adults. Peripheral venous access is preferable because it can be performed immediately and without the potential for severe risks and side effects that are associated with the use of CVCs. However, CVCs are most often required in patients undergoing apheresis procedures due to small vein caliber, poor vascular tone, or the need for frequent procedures (Delaney et al., 2016). Central catheters are most commonly placed so that the tip of the catheter is within the lower one-third of the SVC, near the right atrium, where blood flow around the catheter tip is most rapid and encounters the least amount of resistance. They are usually inserted in an operating room or the interventional radiology department and require a chest x-ray to confirm catheter tip placement before use (Schwartz et al., 2016).
The type of apheresis machines, such as centrifugation-based or filter-based systems, must be taken into consideration when selecting the best type of VAD and location of placement. Peripheral veins are not appropriate for filter-based apheresis systems. PICC lines should not be used for therapeutic apheresis due to small internal diameters and the inability to accommodate blood flow rates. Non-tunneled or tunneled cuffed central VADs with a catheter size of at least 11.5 Fr is recommended for adults (Schwartz et al., 2016).
An arterial line is a thin, flexible tube that is placed into an artery and is most commonly used in operating rooms and ICU settings. Arterial lines are primarily inserted for hemodynamic monitoring, tracking constant blood pressure readings, frequent laboratory testing, and arterial blood gas sampling for acid-base status. They also allow for the continual monitoring of oxygen saturation and carbon dioxide levels in patients with respiratory failure. Arterial blood pressure is a measurement of the pressure exerted on the walls of the arteries. This mechanism has a direct effect on the perfusion of both oxygen and nutrients to the tissues and the removal of waste products from them (Ignatavicius & Workman, 2015).
Arterial lines are distinct from central lines in several ways. The arterial catheter is attached to a transducer system with pressure tubing and a pressure monitoring cable linked to a bedside or centralized cardiac monitor. A mechanical signal received by the transducer is converted to a waveform on the monitor. Often indicated in critically ill patients, arterial waveform analysis can be used to determine fluid responsiveness, as demonstrated in Figure 13.
Arterial Line Waveform Analysis
An arterial line can be inserted at the bedside by a specially trained nurse, licensed practitioner, or physician. The INS (2016) recommends the use of ultrasound guidance to help guide catheter placement and increase first-attempt success. The radial artery is the most common site of arterial catheter placement due to ease of accessibility. A 22 G catheter is recommended for adults, as it is associated with lower complication rates. The brachial artery, followed by the dorsalis pedis, are recommended alternate sites. Femoral and axillary sites are ill-advised due to heightened risk for infection and bleeding. Similar to central line placement, the insertion of an arterial line is a sterile procedure requiring appropriate skin antisepsis with >0.5% chlorhexidine in an alcohol solution. The practitioner is advised to wear a cap, mask, sterile gloves, and eyewear, and to use a large, sterile drape at the bedside (INS, 2016). Patients who are on anticoagulation therapy or have coagulopathies are at heightened risk for bleeding, and therefore, special precautions should be taken. Before puncturing the radial artery, it is critical to assess for adequate circulation in the hand and fingers, including the presence of radial and ulnar pulses, as well as pulse oximetry. Following insertion, the site should be covered with a transparent, sterile, occlusive dressing (Weiner et al., 2017).
Since arterial lines are inserted in an artery instead of a vein, they are generally not used to administer medications. Many injectable drugs can lead to severe tissue damage and even require amputation of the limb if administered into an artery rather than a vein (Weiner et al., 2017). An exception to this standard applies to the novel treatment modality of intraarterial chemotherapy administration, which is used to treat certain types of cancers, such as intraocular retinoblastoma and some types of liver tumors. Specialized intraarterial catheters allow for the infusion of a high concentration of chemotherapy directly to the tumor site. The arterial pathway bypasses venous circulation, preventing dilution of the drug or metabolism of the drug by the liver or kidneys. This method optimizes cell kill at the tumor site while minimizing systemic side effects from the chemotherapy. Unfortunately, this is not a viable option for all types of cancer. It is most commonly used within the hepatic and celiac arteries for the treatment of malignant liver tumors. Unlike other arterial lines which are usually placed at the bedside, arterial lines used for chemotherapy are inserted within the interventional radiology department under ultrasound guidance to ensure chemotherapy is delivered precisely to the targeted area of the tumor (Ignatavicius & Workman, 2015).
Contraindications to Arterial Lines
Arterial lines are contraindicated in the absence of a pulse or in patients exhibiting signs of compromised distal circulation. Trauma to the intended site, prior radial artery cannulation, or radial artery harvesting are also contraindications to arterial line placement (Weiner et al., 2017).
Pros and Cons of Arterial Lines
While arterial lines allow for more precise hemodynamic monitoring of patients, and are considered relatively safe, complications are possible. Thrombosis is the most common complication of arterial line placement and is more commonly associated with the narrow vessels of the distal circulation than in the larger central arteries. The incidence of thrombosis increases as the dwell time rises, as well as with increased length and gauge of the arterial catheter. Patients who have pre-existing hypercoagulable states, such as those with advanced malignancies, are also at higher risk for thrombosis. Another possible complication is air embolism, which can occur if air is externally introduced into the systemic circulation. Embolism can also occur due to dislodgment of a thrombus at the catheter site and can lead to extremity ischemia. This is commonly associated with peripheral catheters placed at the radial and brachial sites (Weiner et al., 2017). Arterial lines can pose many of the same risks as other vascular devices, including risk for infection, infiltration, bleeding from the insertion site, occlusion, and catheter migration. Life-threatening hemorrhage can ensue if accidental catheter disconnection occurs. Therefore, the use of a Leur-lok or similar device to ensure a secure junction at the end of all arterial catheters is advised to uphold patient safety (Ignatavicius & Workman, 2015). As with all other indwelling catheters, the risk for infection and complications heightens alongside increased dwell time (Weiner et al., 2017).
Nursing Care of Arterial Lines
The insertion site and areas distal to insertion must be monitored closely and frequently for warmth, loss of sensation, capillary refill, and pulses. The nurse should ensure that patients who have femoral arterial catheters have anti-embolic compression stockings in place to reduce the risk for thrombosis. The nurse should also ensure that the catheter has a Leur-Lok or similar device in place at all times (Ignatavicius & Workman, 2015). Arterial catheters are not routinely replaced or relocated to a new site at any specific or defined interval. The catheter is changed only when infection, malfunction, or other complication ensues. The dressing should be changed when it becomes soiled, wet, or loose. The need for the catheter should be reassessed daily, and the catheter should be promptly removed when it is no longer critical to the patient's recovery. It is advised that the maximum dwell time for femoral lines is five days and seven days for other sites. Transducers are generally replaced at 96-hour intervals, although learners are reminded to refer to manufacturing equipment and institution policy for definitive timeframes (Theodore et al., 2019).
Arterial Line Removal
Removal of an arterial catheter should be performed by a specially trained nurse or practitioner, depending on institution policy. Before removing the catheter, the patient's INR, partial thromboplastin time (PTT), and platelet counts should be checked. Whereas central venous catheters require Trendelenburg positioning to reduce the risk for air embolism, this is not necessary with the removal of arterial catheters. In patients who have a femoral catheter, the supine positioning is recommended during catheter removal so that adequate pressure can be maintained at the site (Theodore et al., 2019).
Aseptic technique is used during the removal of arterial catheters, and protective equipment, including a face mask with a shield, should be worn to protect oneself from splashing blood (INS, 2016). The catheter should be flushed before removal, and it should be removed in one steady movement. Pressure should be held for at least five minutes on the radial artery site with sterile gauze until bleeding subsides. For femoral sites, firm pressure should be applied for at least 10 minutes until the bleeding subsides. In many healthcare institutions, the tip of the arterial catheter is cultured following removal (Theodore et al., 2019). Refer to institution policy for specific details regarding arterial line removal.
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