Central Venous Access

Mary E. Hagle

Ann M. Cook

CENTRAL VENOUS ACCESS

Definition

A central venous access device (CVAD) or central venous catheter (CVC), commonly referred to as a central line, is a catheter placed into the central venous vasculature. The CVAD tip is placed in the lower third of the superior vena cava or at the atriocaval junction. Central venous access permits rapid administration of solutions for replacing vascular volume, as well as administration of all other types of solutions, including highly concentrated
or incompatible solutions. Another advantage of CVADs is that they may stay in place for weeks to years, depending on the type of CVAD.

Knowledge of the vascular system is essential for providing care to the patient with a CVAD. Vessels involved include the basilic, median cubital, brachial, cephalic, axillary, subclavian, external and internal jugular, and brachiocephalic veins as well as the superior vena cava (Figure 14-1).

Vascular Structures Used for Central Venous Access

BASILIC VEIN

The basilic vein is larger than the cephalic. It passes upward in a smooth path along the inner side of the biceps muscle and terminates in the axillary vein along with the brachial vein.

MEDIAN CUBITAL VEIN

Distally from the basilic vein is the median cubital vein, located at the site of the antecubital space.

BRACHIAL VEIN

The brachial vein merges with the basilic vein and becomes the axillary vein.

CEPHALIC VEIN

The cephalic vein ascends along the outer border of the biceps muscle to the upper third of the arm. It passes in the space between the pectoralis major and deltoid muscles. It terminates in the axillary vein, with a descending curve, just below the clavicle. The cephalic vein is occasionally connected with the external jugular or subclavian vein by a branch that passes from it upward in front of the clavicle.

AXILLARY VEIN

The axillary vein starts upward as a continuation of the basilic vein, increasing in size as it ascends. It receives the cephalic vein and terminates immediately beneath the clavicle, at the outer border of the first rib, at which point it becomes the subclavian vein.

SUBCLAVIAN VEIN

The subclavian vein, a continuation of the axillary vein, extends from the outer edge of the first rib to the inner end of the clavicle, where it unites with the internal jugular to form the brachiocephalic vein. Valves are present in the venous system until approximately 1 inch before the formation of the brachiocephalic vein.

EXTERNAL JUGULAR VEIN

The external jugular vein is easily recognized on the side of the neck. It follows a descending inward path to join the subclavian vein above the middle of the clavicle.

INTERNAL JUGULAR VEIN

The internal jugular vein descends first behind and then to the outer side of the internal and common carotid arteries. The carotid plexus is situated on the outer side of the internal carotid artery. The internal jugular vein joins the subclavian vein at the root of the neck.

At the angle of junction, the left subclavian receives the thoracic duct, whereas the right subclavian receives the right lymphatic duct.

FIGURE 14-1 Central vascular structures.

BRACHIOCEPHALIC VEIN

The brachiocephalic vein is formed by the union of the right or left internal jugular vein and the corresponding subclavian vein. The right brachiocephalic vein is approximately 1 inch long. It passes almost vertically downward and joins the left brachiocephalic vein just below the cartilage of the first rib. The left brachiocephalic vein is approximately 2.5 inches long and larger than the right. It passes from left to right across the upper front chest in a downward slant. These vessels join to form the superior vena cava.

SUPERIOR VENA CAVA

The superior vena cava receives all blood from the upper half of the body. It is composed of a short trunk 2.5 to 3 inches long. It begins below the first rib close to the sternum on the right side, descends vertically slightly to the right, and empties into the right atrium of the heart.

INDICATIONS FOR CENTRAL VENOUS ACCESS DEVICES

CVADs are indicated when peripheral venous access is unavailable or not recommended. CVADs are used for rapid administration of large volumes of fluids in a short period of time. This is possible because the catheter tip is in a large vessel that can distribute the fluid rapidly. Other indications for a CVAD are for infusing highly concentrated fluids, such as parenteral nutrition (PN), or vesicant or irritating drugs, such as antineoplastic medications and some vasopressors. Because the CVAD tip rests in an area with a rapid flow of a large amount of blood, prompt dilution occurs of the infusing fluid. Rapid dilution reduces the risk of chemical phlebitis and venous sclerosis. A highly concentrated solution is one with an osmolarity >600 mOsm/L or a pH <5 or >9. These solutions would be irritating or damaging to a peripheral vein (INS, 2011). When this is the case, a CVAD must be used to administer the solution. CVADs may have one or several lumens, thus permitting concurrent administration of needed medications, even if they are incompatible solutions (Figure 14-2). Additionally, CVADs can be used to administer all other types of therapies, such as blood components and antibiotics. Again, a CVAD may remain in place, without being replaced, for several weeks up to several years, depending on the type of CVAD.

Candidates for a CVAD include most individuals. Trauma patients requiring massive fluid replacements or in surgery requiring rapid administration of fluids would need a CVAD. Hospitalized patients are candidates for a CVAD when they are in need of venous access with poor peripheral veins, have multiple therapies that may be incompatible, or have infusions that are irritating or damaging to peripheral veins. Patients in home care or receiving infusion therapy in an ambulatory care clinic or infusion center, who require administration of continuous or intermittent infusions over a long period of time, may also require a CVAD. Frequent blood sampling is less painful using a CVAD. Last, CVADs may be inserted without general anesthesia.

FIGURE 14-2 Triple-lumen CVAD catheter (A) with cross-section (B) and side view (C).

Another indication for a CVAD is to monitor central venous pressure (CVP). This is for detecting volume changes related to potential problems or to evaluate patient hemodynamic status, which is discussed in Chapter 15.

OVERVIEW OF CVAD TYPES

There are five main types of CVADs: nontunneled CVADs, peripherally inserted central catheters (PICC), tunneled CVADs, implanted ports, and implanted infusion pumps (Box 14-1). Their dwell time ranges from days to years, or indefinitely, until therapy is discontinued or a complication becomes evident. Improvements in catheter materials and properties, safety features, and device options have made this an ever-evolving field of technology. All CVADs are radiopaque, so tip placement may be verified and any adverse event may be detected, such as catheter embolism.

BOX 14-1 OVERVIEW OF CENTRAL VENOUS ACCESS DEVICES

Nontunneled CVAD	Large-bore catheter inserted percutaneously into central venous structure and sutured into place Used for short-term therapy, days to weeks Most complications seen with these CVADs	Nontunneled CVAD
PICC	Very-small-gauge catheter inserted percutaneously into an upper extremity vein and then threaded into the superior vena cava Used for short- or longterm therapy, 7 days to months Variety of types available, including a rapid flow/power injectable PICC Fewer complications than nontunneled CVADs	PICC
Tunneled CVADs	Catheter inserted into a central venous structure; the distal end is pulled through subcutaneous tissue (tunneled) for a short distance before exiting the skin Has a cuff, usually Dacron Used for long-term therapy, 6 months or more Frequently used: Broviac, Groshong, Hickman Fewer complications than nontunneled CVADs	Tunneled CVAD
Implanted Port	A tunneled catheter attached to a device with a hollow core, implanted into the subcutaneous tissue Used for long-term therapy Noncoring needle required to access port Variety of types: ○ May be a single or dual port ○ May be power injectable Fewest complications	Implanted port
Implanted Infusion Pump	A tunneled catheter attached to a device with a (a) refillable drug reservoir, (b) power source, and (c) septum/port for percutaneous access; implanted into the subcutaneous tissue around the lower abdomen or side Used for long-term therapy to artery, vein, or anatomical space Noncoring needle required to access port Variety of types based on energy source and number of ports Few complications	Implanted infusion pump

Illustrations courtesy of Elizabeth Hirschmann.

Catheter Materials

The ideal CVC would be composed of a material that inhibits thrombus formation, inserts easily, is chemically neutral, and is biocompatible. Catheters may be composed of polyurethane, silicone, elastomeric hydrogel, or Teflon®. Polyurethane is firm, allows for ease of insertion, softens after insertion, and is biocompatible so that tissues do not react to the material. It is less thrombogenic than materials used in the past. A thrombus forms as a result of intima irritation and reaction; softer materials are less irritating to the vein wall. The strength of the polyurethane allows for a thinner catheter wall and larger internal diameter when compared with same-sized silicone catheters. Silicone is more flexible, thus requiring special insertion techniques, and has increased biocompatibility. Elastomeric hydrogel catheters, primarily used in peripheral IVs, combine hydrogel and polyurethane to obtain the lowest coefficient of surface friction of the catheter, thus allowing for less thrombogenicity and decreased mechanical tissue trauma. The hydrogel allows the catheter to soften, whereas the polyurethane provides strength and prevents absorption of the infusate into the catheter.

Catheters and Thrombus Formation

Advancements in technology related to catheter materials and properties are aimed at reducing complications of catheter-related infections and thrombosis. Catheter-related bloodstream infection (CRBSI) occurs when microorganisms adhere to catheter materials and promote formation of a biofilm allowing cell proliferation, intercellular adhesion, and colonization. Polyurethane catheters have been associated with fewer CRBSIs than are silicone catheters along with decreased biofilm formation (CDC, 2011).

Thrombosis associated with CVCs has many contributing factors. Any foreign material in the bloodstream becomes coated with a protein and fibrin deposit as well as a biofilm. This in turn activates internal coagulation, causing platelet activation and platelet adherence to the catheter. Damage to endothelial cells at the puncture site also promotes platelet activation. Patients requiring CVCs often have activated coagulation systems because of trauma or severe disease, both of which promote the development of thrombosis. Thrombosis may be limited to a fibrin sheath formation or may be severe enough to occlude the vein. It may have no clinical significance or it may result in a fatal pulmonary embolism. Fibrin sheaths can lead to loss of function of the catheter and mediate bacterial adherence.

Antimicrobial and Antiseptic Catheters

Catheter properties aimed at reducing the complications of thrombosis and CRBSI include bonding with heparin or cefazolin; impregnating with silver sulfadiazine and chlorhexidine or small silver particles; and coating with minocycline and rifampin or silver. Multiple studies have demonstrated the effectiveness of these catheters at decreasing some CRBSIs in the short term due to the length of time the antimicrobial substance is released. Few studies have evaluated the use of heparin-coated catheters, but when examined, these catheters have demonstrated a decrease in CRBSIs.

Most of the literature has focused on chlorhexidine and silver sulfadiazine or minocycline and rifampicin. Studies have demonstrated decreased CRBSIs when compared with control catheters. Studies evaluating various silver technologies have been inconclusive. The Centers for Disease Control and Prevention (CDC) recommends use of antimicrobial or antiseptic-impregnated CVCs when the expected duration is for more than 5 days and a comprehensively implemented strategy to decrease rates of CRBSIs is ineffective (CDC, 2011). The strategy would need to include comprehensive education of those who insert and maintain the CVADs, use of maximum sterile barriers on insertion, and the use of a 0.5% chlorhexidine preparation for skin antisepsis. In such cases, use of these catheters may be cost-effective.

Anti-infective catheters may also be considered for patients who are neutropenic, have had a transplant, have severe burns, are on hemodialysis, or are critically ill. They should not be used if the patient has an allergy to silver, chlorhexidine, silver sulfadiazine, rifampin, or tetracycline (INS, 2011).

Catheter with Removable Introducer

Catheters with removable introducers are frequently made of polyurethane; a wide variety of products are available from today’s manufacturers. These products have been developed with safety standards in mind in an effort to minimize the incidence of needlestick injury.

The unit consists of an introducer catheter or syringe and needle and a catheter with stylet. A catheter with a removable introducer is a single-lumen catheter with a fairly easy method of insertion. Because thrombus formation can be a problem with polyurethane, this may not be the catheter of choice for long-term therapy. However, minimal thrombus formation has been reported with hydromer-coated polyurethane and longterm use.

Insertion should be done using ultrasound technology to visualize the vein. The syringe is removed and the catheter threaded through the needle. The needle is withdrawn from the vein and removed from the catheter by splitting the needle into two parts.

Catheter with Introducer and Guidewire

A safety catheter with an introducer and guidewire allows for the insertion of a multiplelumen silicone catheter. The unit consists of a syringe and needle or an over-the-needle catheter (ONC), a long central catheter, and a guidewire.

To insert the catheter, venipuncture is performed with the syringe and needle or safetytype ONC. The syringe or stylet is removed. The guidewire is threaded through the short catheter or needle, and the short catheter or needle is withdrawn (into a self-contained locking cover to avoid needlestick injury). The puncture site may be enlarged with a scalpel. The long catheter is threaded over the guidewire, which is then withdrawn, leaving the long catheter in the vein.

Tunneled Catheter Cuffs

Tunneled catheters are available with one or two small polyester fabric cuffs approximately 0.5 cm wide. These cuffs are made of the polymer Dacron and are commonly known as Dacron cuffs. Within weeks, the Dacron cuff becomes enmeshed in fibrous tissue securing the catheter in place. It lies within the subcutaneous tunnel 1 to 2 inches from the exit site. The cuff also inhibits migration of microorganisms into the tunnel. These measures reduce the risk of infection.

An antimicrobial cuff has been developed that provides stability while reducing the risk of infection. The cuff exhibits antimicrobial activity attributed to silver ions that are active for 4 to 6 weeks until they are absorbed (Bard). Another innovation to cuff design promotes tissue growth to help secure the catheter in place (Bard).

Catheter Tips and Valves

Catheters are available with open-ended or closed-ended tips. Open-ended catheters have a blunt tip. They require clamping when not in use. Most CVADs have this type of tip. Closed-ended catheters have a rounded closed tip with a side valve. The Groshong catheter has a rounded, closed tip and features a patented Groshong valve that opens inward for blood aspiration and outward for infusion but remains closed when not in use (Figure 14-3). Advantages of this type of catheter tip include the following:

Decreased risk of bleeding or air emboli
Elimination of catheter clamping
Elimination of the use of heparin in the catheter
Reduction of flushing between use; weekly flushing is all that is required

Catheters also are available with a pressure-activated safety valve (PASV) (Navilyst Medical). The valve is located in the catheter hub (Figure 14-4). The patented valve
opens with minimal positive pressure for infusion, yet requires four times as much negative pressure for aspiration. The PASV also reduces the reflux of blood into the end of the catheter during periods of increased CVP and decreases difficulties with poor blood return. Weekly saline-only flushing is needed, and the product is consistent with needleless systems. The valve may also be used with PICCs and midline catheters. It is important to note that changes in technique are needed when this type of catheter and valve are used. The catheter must not be clamped until after the syringe is removed or the valve will not function to prevent reflux. When the catheter is not in use, the catheter hub can be taped to the chest wall above heart level. This minimizes blood pressure at the catheter tip.

FIGURE 14-3 Groshong valve. (Courtesy of C. R. Bard.)

FIGURE 14-4 Pressure-activated safety valve. (Courtesy of Boston Scientific.)

EDUCATION AND TRAINING FOR HEALTH CARE PERSONNEL

It is recommended that health care personal, including licensed independent practitioners (LIPs) and nurses, be trained with an organized training program regarding all aspects of infusion therapy. In relation to CVADs, this would include site selection, device selection, insertion, maintenance, removal, and appropriate infection control measures. A variety of methods should be used to validate competency on an ongoing basis. This is not limited to, but would include, written tests, clinical scenarios, observations in a skills laboratory, and observed performance of the skill in a clinical setting (CDC, 2011; INS, 2011). It is important for nurses to know the standards related to insertion and maintenance of CVADs and thus to understand the needs of individual patients. Competence in monitoring patients with CVADs and in maintaining CVADs is critical. Since its inception, Infusion Nurses Society’ (INS) Clinical Competency Validation Program has been the ideal tool for clinicians seeking to validate their infusion skills in both acute care and alternate care settings (INS, 2013).

INFECTION PREVENTION AND CONTROL

In 1999, the often cited report by the Institute of Medicine (IOM), To Err is Human: Building a Safer Health System, sent a shock wave through the nation by reporting the unnecessary deaths occurring in health care settings to be as high as 98,000 annually (IOM, 1999). Since then, the IOM, the National Institutes of Health, The Joint Commission (TJC), the CDC, and others have focused on addressing the problems delineated in this report by improving processes and systems to affect change and improve patient outcomes. Preventing central line infections is one of the areas of focus as a result of this report.

Approximately 15 million CVAD days (the total number of days of exposure to CVADs by patients in a selected population) occur annually in intensive care units (ICUs) in the United States each year. Approximately 80,000 CRBSIs occur annually in ICUs with a total of 250,000 cases of bloodstream infections occurring in all areas of the hospital (CDC, 2011). Most CRBSIs originate from the catheter insertion site or the hub and increase the patient’s stay in the hospital (Mermel et al., 2009).

Several recommendations have been made and are being implemented to decrease the incidence of CRBSIs. One recommendation is to have an effective education program for all
health care providers and nurses inserting and maintaining CVADs as mentioned earlier (CDC, 2011; INS, 2011). Grouping key actions to prevent CRBSIs has been referred to as the Central Line Bundle (CDC, 2011; IHI, 2011; INS, 2011). These measures include optimal catheter and site selection (avoiding the femoral vein for a CVAD in an adult), appropriate hand hygiene (should be practiced before and after insertion site palpation, before and after insertion, and before and after donning and removing gloves), the use of chlorhexidine gluconate solution as a skin antiseptic, and maximal barrier precautions during insertion of the CVAD. This requires the use of a mask, cap, sterile gown, and sterile gloves for the health care provider and a sterile full body drape for the patient (CDC, 2011; IHI, 2011). Daily assessment of the need for the CVAD and prompt removal when indicated prevents infection (CDC, 2011). The Agency for Healthcare Research and Quality (AHRQ) developed a toolkit for preventing CRBSI; a daily audit form illustrates the best practices that should be followed (Figure 14-5). Reports of agencies implementing these actions and the reduction in adverse events, or the outcomes of monitoring adherence to procedures, all demonstrate the success of these interventions (Guerin, Wagner, Rains, & Bessesen, 2010; The Joint Commission, 2012; McMullan et al., 2013; Rupp et al., 2013).

CENTRAL VENOUS ACCESS DEVICE AND SITE SELECTION

CVAD selection requires a collaborative approach between health care team members and the patient. Considerations in access device selection include patient assessment, type of therapy, duration of therapy, type of CVAD, and patient’s values and preferences.

Device selection is guided by the principles of the least invasive, fewest lumens, and smallest gauge catheter that are appropriate for the therapy and able to last for the duration of the therapy. The risk of adverse events decreases with less invasive insertion techniques, and reduced risk of infection may be associated with fewer CVAD lumens (CDC, 2011). A large external catheter diameter may cause damage to the intima, impede venous flow around the catheter, and interfere with appropriate dilution of medications. The internal diameter of the catheter may affect flow rate and ability to draw blood samples.

The types of prescribed medication and nutrition therapy influence device selection as well. Multiple therapies that are incompatible require multiple lumens. Therapies that are irritants or of high osmolarity, acidity, or alkalinity can cause endothelial damage and increase risk of phlebitis and thrombosis. An algorithm assists with matching the appropriate device to the specific criteria (Figure 14-6).

Nontunneled CVADs are used for short-term therapy, are often placed when there is an emergent need for central venous access, and account for the majority of CRBSIs. The subclavian vein is the preferred site for nontunneled CVADs as it poses the least risk for complications (CDC, 2011).

PICC lines are used for therapies of 7 days or more and up to approximately 1 year. Recommended veins include the basilic, median cubital, cephalic, and brachial veins. Veins in the upper extremity should be avoided in patients with stage 4 or 5 chronic kidney disease. The extremity should be avoided on the same side where there has been breast surgery with axillary node dissection, radiation therapy, lymphedema, or in the affected extremity from a stroke (INS, 2011).

FIGURE 14-5 AHRQ CVC Maintenance Audit Form. (From Agency for Healthcare Research and Quality. [2013].)

FIGURE 14-6 Algorithm for central venous access device selection.

Tunneled CVADs (Hickman, Groshong, and Broviac are common trade names), implanted ports, and implanted infusion pumps are recommended when therapy is expected to be longer than 6 months.

For all types of CVADs in adults, the femoral vein should be avoided as it has high colonization rates of bacterial flora. Additionally, catheters should be placed as far as possible from any open wounds to decrease the risk of infection (CDC, 2011).

Patient Assessment and Informed Consent

Patient assessment includes health history and physical assessment. Medical conditions of concern, besides allergy status, include coagulation status, diabetes, renal disease, trauma, and previous CVCs. Other conditions to note are previous arm, neck, or chest trauma; surgery; or radiation. Physical assessment is needed for circulatory status, lymphedema, and skin integrity. For long-term CVADs, patient activity level and lifestyle must be considered. Any limitations of patient activity the device may create should be thoroughly discussed. Additionally, mental and emotional status, physical dexterity, and financial capacity to manage long-term care of the device must be assessed from the patient and/or family perspective.

Consent should be obtained by the health care provider performing the procedure, and confirmation of informed consent should be obtained by the nurse based on institutional policies and procedures (INS, 2011).

PREPARATION FOR CVAD INSERTION

Patient Education

Some of the information about the CVAD insertion technique will be explained to the patient during device selection. However, once the type of device is selected, specific education about the device and insertion is necessary. Explaining the reasons for the CVAD and the procedure for inserting it will allay fears and help the patient participate as much as possible. Engaging the patient and the family in all aspects of care, particularly infection prevention and control measures and maintenance of the CVAD, will help to improve patient outcomes (National Quality Forum, 2009).

Patient education should include a description of the procedure, expected postprocedure discomfort, and the need for comfort measures. It may be necessary to use some form of premedication sedation for the procedure depending on the type of device, insertion site, and individual patient needs (Box 14-2). If a tunneled catheter, implanted port, or implanted
infusion pump is being inserted, offer the patient the opportunity to see and/or handle a sample of the CVAD that will be placed. This often helps to reassure many patients. Explain to the patient that he or she will be covered with a sterile drape, and the health care providers will wear gowns, caps, masks, and gloves.

BOX 14-2 PATIENT TEACHING FOR CVAD INSERTION AND MAINTENANCE

Assessment of patient’s readiness for learning, potential barriers to learninghealth literacy, and preferred learning style(s)
Rationale for CVAD placement and device options including length of therapy and impact on patient’s lifestyle
Discussion of the insertion procedure and maintenance of the CVAD: Include patient and health care provider responsibilities for the maintenance of the CVAD once inserted
Explanation of possible risks and complications of CVAD insertion and continued CVAD utilization
Emergency information includes what to do and whom to call if the external catheter is cut, breaks, cracks, or is accidently removed
When to return for follow-up appointments for assessment and maintenance of the CVAD
Use of multiple methods of instruction including written materials, multimedia presentations, hands-on opportunities, and interactive learning whenever possible

Follow-up evaluation of teaching includes

Assessment of patient and/or caregiver comprehension through discussion and return demonstration
Opportunities for patient and caregiver questions and/or concerns

Patient Positioning

If the catheter will be inserted by a subclavian approach, explain to the patient that he or she is positioned flat in bed with the head lowered and knees bent (Trendelenburg position). This position facilitates entry to the vein by distending the vein and increasing CVP and the venous blood supply. A rolled towel is placed under the back along the spinal cord and between the shoulders to hyperextend the neck and elevate the clavicle. For the jugular approach, the head is turned to the opposite direction and extended. This stretches and stabilizes the vein and accentuates the muscular landmarks. During a cephalic or brachial approach, abduction of the arm may be required to pass the catheter past the shoulder area. Explaining this to the patient before the procedure promotes patient cooperation when the uncomfortable position must be maintained.

Valsalva Maneuver

Practicing the Valsalva maneuver before the insertion also promotes cooperation when the patient is asked to hold her or his breath and bear down when the catheter is open to the air (INS, 2011).

Laboratory Tests

Prior to CVAD insertion, several laboratory tests for assessment may be needed. These include platelet count and international normalized ratio/prothrombin time (INR/PT). Any abnormal findings may require correction with vitamin K, fresh frozen plasma, or platelet concentrates before catheter insertion is attempted. This should be explained to the patient. Contraindications for a CVAD include

Abnormal coagulation studies
Septicemia
Anomalies of the central venous vascular structures
Thrombosis of the subclavian or brachiocephalic veins or the superior vena cava

INSERTION OF THE CENTRAL VENOUS CATHETER

CVAD insertion is a medical act. CVAD insertion and infusion therapy need to be initiated, changed, or discontinued with an order by a physician/LIP (INS, 2011). Insertion of some types of catheters, such as PICCs, may be delegated to specially trained RNs according to each state’s Nurse Practice Act. Additionally, the CDC (2011) made a strong recommendation to use ultrasound guidance for placing CVCs (if this technology is available) to reduce the number of cannulation attempts and mechanical complications. Of course, ultrasound guidance should only be used by those with validated competency.

EVIDENCE FOR PRACTICE

Actions to prevent infection during CVC insertion (CDC, 2011; The Joint Commission, 2012; Pronovost et al., 2006) include using a

Central line bundle, consisting of hand hygiene, maximum barrier precautions, chlorhexidine site disinfection, avoiding the femoral site, and promptly removing unnecessary CVCs
Procedure checklist to ensure adherence to proper practices
Process permitting a team member to stop the CVC insertion in nonemergent situations if evidence-based practices are not being followed

There are three basic approaches for CVC insertions. The veins used for entry are the subclavian vein and the internal or external jugular veins for most CVAD insertions; for PICCs, access to the vascular system is through the cephalic, basilic, brachial, or median cubital vein.

Subclavian Approach

The subclavian vein is the entry site of choice for nontunneled centrally inserted catheters and is recommended, if not contraindicated, to minimize risk of infection (CDC, 2011). This approach requires the shortest catheter length because it is closest to the superior vena cava. However, subclavian entry can foster major complications both during and after insertion.

The subclavian entry may be performed using the infraclavicular or supraclavicular approach. In both approaches, the catheter is inserted under the clavicle, aiming for the jugular notch. For the infraclavicular approach, the catheter is inserted at approximately the midpoint of the clavicle. For the supraclavicular approach, the catheter is frequently inserted at the base of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle. Contraindications to the subclavian approach may include the following:

Radiation skin damage at intended insertion site
Fractured clavicle
Hyperinflated lungs
Malignant lesion at the base of the neck or apex of the lungs

Internal Jugular Vein Approach

The internal jugular vein is preferred by many practitioners as the site of first choice for inserting a CVC. The constant anatomic location of the internal jugular vein makes it easier to catheterize than is the subclavian vein. The right internal jugular vein is usually chosen because it forms a straighter, shorter line to the superior vena cava. It also avoids the higher left pleura and thoracic duct.

External Jugular Vein Approach

The external jugular vein is observable and easily entered. Insertion complications are rare. The external jugular vein varies in size, and its junction with the subclavian vein is acutely angulated. It contains two pairs of valves: the uppermost pair is 4 cm above the clavicle and
the lower pair is located at the vein’s entrance to the subclavian vein. Because of these factors, central catheterization can be difficult. Because a short catheter may be inserted easily, central catheterization may be achieved by using an introducer with a guidewire. Entry into the superficial vein is performed by directing the catheter toward the ipsilateral nipple.

The main objections to any jugular catheterization are the following:

Catheter occlusion, resulting from the patient’s head movement, is a persistent problem.
Vein irritation also results from head movement, with a shorter catheter life as a consequence.
Maintaining an intact dressing on the area is difficult.
The idea of having a catheter in the neck may be aesthetically and psychologically disturbing to many patients and families.

CVAD Insertion Complications and Tip Placement Verification

Prevention is the best intervention for CVAD insertion complications. Patient safety initiatives include using two identifiers to ensure having the right patient, doing a preprocedure verification, and having systems in place for high-alert medications. A CVAD insertion checklist has been found to be effective and several examples are available (The Joint Commission, 2012). However, there are several potential complications that result from CVC insertion. Nursing surveillance during and after the procedure with prompt recognition of signs and symptoms of a complication and rapid response to the complication can keep patients safe. Table 14-1 outlines the major potential complications of CVC insertion with appropriate interventions.

Verifying the CVAD tip placement also prevents potential complications from mechanical trauma of the catheter against the cardiac wall or infusion of fluids, medications, or nutrition into nonvasculature or inappropriate vasculature. The preferred tip placement for all CVADs is at the junction of the superior vena cava and the right atrium. If the tip lies in the right atrium, atrial arrhythmias may occur as a result of the catheter irritating the chamber. Proper placement also decreases the incidence of dislodgment, vessel wall erosion and stenosis, and device dysfunction.

A chest radiograph or fluoroscopy is used to confirm tip placement. Fluoroscopy can be used to verify tip placement if this method is being used to insert the catheter. The chest radiograph, if used, is always obtained immediately after catheter insertion to rule out pneumothorax and to document tip placement. The catheter should not be used until tip placement is confirmed. The site should be observed for any signs of excess bleeding or swelling, and the patient’s breathing should be monitored for any signs of respiratory distress. Abnormal assessments or changes in patient condition should be reported immediately to the physician/LIP who inserted the CVAD, as should complications associated with central line placement.

TABLE 14-1 POTENTIAL COMPLICATIONS OF CVC INSERTION OR CVADs

Complications

Signs/Symptoms

Treatment

Embolus of Catheter, Thrombus, or Air

An embolus can be caused by catheter shearing, dislodgment of a thrombus, or air drawn into the central venous circulation during tubing disconnection.

Dyspnea, tachypnea, hypoxia, cyanosis, tachycardia, hypotension, precordial murmur, chest pain

Emergency situation

For a catheter embolus, apply tourniquet to upper arm.
For thrombus, anticoagulants and thrombolytic agents are ordered.
For air embolus, position the patient on left side in Trendelenburg position and give the patient oxygen (may require air aspiration from right atrium).

Notify physician/LIP immediately.

Catheter Occlusion

Catheter tip positioned against vein wall or valve
Mechanical: clamped or kinked catheter; tight sutures
Precipitate or lipid buildup
Thrombotic: fibrin tail, fibrin sheath, intraluminal occlusion, mural thrombus—may be due to inadequate flushing

Inability to infuse and/or aspirate; sluggish infusion or aspiration

Have the patient cough, raise arm, and change position.
Alleviate mechanical cause.
Flush catheter with normal saline using 10-mL syringe.
Consider flow study or other radiologic exam to determine source and site of occlusion.
Consider instillation of precipitate-clearing agent or instillation of thrombolytic agent for clot after discussion with physician/LIP and pharmacist, and with order.

Pinch-off Syndrome

Mechanical compression of a CVC catheter by the clavicle and first rib at the costoclavicular space; results in catheter compression or possibly catheter fracture with resultant catheter embolism. Catheter fracture may occur as the catheter weakens owing to the scissoring action of the clavicle and first rib on the catheter (Gorski, 2003a, 2003b).

Difficulty infusing or withdrawing fluids until the patient repositions shoulder or lies supine.

Symptoms of catheter fracture and embolism may include chest pain, palpitations, swelling, or pain with flushing.

Chest radiography with the patient upright and arms at side; confirmation is luminal narrowing

Catheter may be removed and reinserted carefully to stay within vein.

Thrombosis Related to CVC Compromising Blood Flow Through Superior Vena Cava (Also Known as SVCS)

May be caused by malposition of catheter, intima damaged on insertion, irritating drugs, venous stasis, increased blood viscosity, or hypercoagulability

Edema of the entire extremity, upper chest, and neck; tenderness or pain in affected extremity; inability to aspirate blood and/or infuse through the catheter; discoloration of extremity

Venogram to establish diagnosis; thrombolytics, anticoagulants, and elevate extremity

CVC may have to be removed.

Catheter-Related Infections

May result from contamination during insertion and/or maintenance; seeding from another site; migration of microorganisms along catheter

Local: erythema, induration, tenderness, purulent drainage from site Systemic: fever, chills.

Blood culture from catheter and a peripheral site; remove catheter if indicated; warm moist compresses

Appropriate antibiotic therapy may be ordered.

Damaged Catheter

May occur owing to small syringe used with excessive force; use of pins or scissors near catheter; needle puncture; hemostat with teeth used on catheter

Fluid leak from catheter; ruptured catheter; popping sound heard while flushing; burning or pain with flush or infusion

Notify physician/LIP if internally ruptured.

Remove catheter. If damage is external, clamp catheter proximal to tear and apply sterile dressing over tear. Repair if possible.

Catheter Tip Migration

May happen because of coughing, vomiting, or excessive activity

Referred pain in jaw, ear, or teeth, distended veins on side of malposition; flushing or sense of fullness in head during rapid infusions

Radiograph or flow study to verify tip placement. Consult with physician/LIP to determine next steps.

Mechanical Phlebitis

For PICCs, phlebitis at the insertion site is common during the 1st week after insertion. Redness at the IV site usually appears within the first 48 h after insertion and may last the 1st week. The incidence is 12.5%-23%.

Redness along the catheter line without induration, warmth, tenderness, or inflammation. The clinical signs will occur anywhere between the insertion site and the catheter tip location.

Other complications (infection, infiltration, or loss of catheter integrity) should be ruled out.

Warm moist compresses for 60 min three times daily to the affected area for 72 h
Rest and elevation of the extremity
Physician/LIP prescription for PO anti-inflammatory drugs, unless contraindicated

For mechanical phlebitis, the catheter may continue to be used for IV therapy. Observe for improvement within the first 24 h.

Continue heat application until complete resolution occurs, usually within 72 h.

Restrict movements to mild arm activity.

Extravasation From Implanted Port or Pump During Infusion or Cracked Catheter

Occurs if noncoring needle not completely inserted into reservoir or it becomes loose or dislodged during infusion of vesicant or irritant drugs; CVC may have cracked owing to excessive flush pressure or scissors/pins used near catheter

May have pain or burning in area, depending on the infusate

May have redness, edema, swelling, or difficulty infusing solution

Prevention is the best intervention: use external catheter for vesicant solutions, infuse only if blood return present or correct needle placement is verified.
Stabilize needle during infusion; check infusion frequently.
Teach the patient signs and symptoms of extravasation with instructions to call nurse if a problem.
If extravasation is suspected: Stop infusion.

Aspirate residual drug. Give appropriate antidote.

Apply heat or cold as indicated. Notify physician/LIP.

Follow up with the patient for observation of site, measure, and photograph site for evaluation.

Adapted from Andris et al. (1997); Arrants, Awillis, Stevens, et al. (1999); Bagnall-Reed (1998); Camp-Sorrell (2011); CDC (2011); Cook (2013); Forauer & Alonzo (2000); Gorski (2003a,2003b).

CVAD DESCRIPTIONS

An extensive description of nontunneled CVADs, PICCs, tunneled CVADs, and implanted ports is presented in Table 14-2. The table also includes insertion technique descriptions and considerations for uses, replacement, and recommendations. Since many nurses insert PICCS, a more complete description is included below, as well as more information on implanted ports and pumps. Once a CVAD is inserted, accurate documentation is critical to ensure communication of the insertion, patient tolerance of the procedure, and a record of the actual device specifications (Box 14-3).

Peripherally Inserted Central Catheters

A CVAD that offers a good choice between a short-term CVC and a long-term CVAD requiring a surgical procedure is a PICC. A PICC is a very small outer diameter catheter but as large as 18 gauge; it can have one to three lumens and is 55 cm long for adults. The length is necessary since it must reach from the area of the antecubital fossa to the superior vena cava. With an increasing need to use one catheter for multiple purposes, including injections for radiologic imaging, certain PICC types can accommodate power injections of up to 300 psi (pounds per square inch) at 5 mL/s (Hadaway, 2010). The power injectable catheters need to be adequately labeled for this purpose. Most catheters are capable of withstanding up to 40 psi. When a power scan is required, a power or pressure injection catheter must be used for the scan.

PICC Advantages and Considerations

The PICC has many advantages for patients and health care providers. These include the following:

May be inserted at the bedside or in radiology under fluoroscopy by either RNs or physicians/LIPs
Decreased risk of insertion-related complications compared with other CVADs
Lower infection rates than other CVADs
Better suited for young children or the elderly because of the small gauge
Cost-effective when compared with surgically placed CVADs

A PICC does require patient-related and therapy-related cautions. It is not suitable for rapid, high-volume infusions, and blood sampling may be difficult. A PICC may restrict arm movement as well as the patient’s lifestyle and activities. Also, blood pressures and

blood sampling should not be taken from the arm with a PICC insertion. The presence of any of the following conditions may be a contraindication for a PICC in that extremity:

TABLE 14-2 CVAD DESCRIPTIONS, INSERTION TECHNIQUES, AND CONSIDERATIONS

CVAD	Insertion Techniques	Considerations
Nontunneled CVAD Large-bore catheter percutaneously inserted directly into the subclavian, internal jugular, or femoral vein Length ≥8 cm Size: 14-22 gauge Single to multiple lumens Silicone, polyurethane Distal tip openings are open ended Options: radiopaque, antimicrobial, or heparin impregnated	Inserted by physician/LIP with validated competency Inserted using ultrasound technology for correct placement 15-degree Trendelenburg position assists with vein distension and prevention of air emboli	Recommended for short-term use (usually ≤6 wk) Appropriate for multiple therapies: ○ Continuous or intermittent infusions including antibiotics, blood products, vesicants ○ Multiple infusions as well as incompatible infusions ○ CVP monitoring ○ Emergency or critical situations—this catheter can accept rapid and high-volume fluid or medication infusions Subclavian site preferred Routine replacement not recommended Accounts for majority of CRBSIs
PICC Nontunneled CVAD inserted through peripheral arm vein into superior vena cava Length: ≥20 cm Size: 16-28 gauge Single and double lumen Silicone, polyurethane, or elastomeric hydrogel Distal openings may be open or closed ended Options: radiopaque, peripheral port, power injection	Inserted by physician/LIP or RN with validated competency Inserted into basilic, cephalic, or median cubital veins Inserted using ultrasound technology for correct placement	Recommended for therapy >7 d Can remain in place for up to a year Appropriate for multiple therapies: antibiotics, blood products, vesicants Often the CVAD of choice for home care patients receiving intermittent therapies and frequent blood draws Adequate flushing is necessary to maintain catheter patency Lower rate of infections than nontunneled CVADs If a power PICC is placed, may be used for rapid infusions for diagnostic studies Gravity flow rates will vary based on the gauge and the PICC material, with flow rates through a silicone catheter being slower than through one made of polyurethane.
Tunneled CVAD Flexible catheter inserted into the subclavian or internal jugular vein with tip in the superior vena cava and then tunneled under the skin exiting distally from insertion site. Length: 35-100 cm Size: 2.7-12.5 French Single to triple lumen Polyurethane, silicone, or combination Dacron cuff may have antimicrobial cuff Distal tip openings are open or closed ended Three-way safety valve (PASV) available Options: Broviac, Hickman, Groshong, power injection	Inserted by physician/LIP with validated competency Inserted using ultrasound technology for correct placemen Cut down or percutaneous puncture is used to access the vasculature. From central vasculature, the catheter is tunneled 3-5 cm through subcutaneous tissue to an exit site on the chest. A catheter cuff lies within the subcutaneous tunnel securing the catheter. Catheter is secured with absorbable sutures at the exit site	Recommended for frequent or continuous therapy lasting 6 mo or longer Appropriate for all types of infusion therapies Fibrous tissue forms around the Dacron cuff, anchors the catheter, and inhibits migration of microorganisms Lower rate of infections than nontunneled CVADs Open-ended catheters require clamping; closed-ended or valved catheters do not.
Implanted Ports Tunneled CVAD is attached to an implanted port with a self-sealing septum. The port is implanted into the subcutaneous tissue. Length: ≥8 cm Gauge: 4-12 French Single or dual lumen Silicone or polyurethane Port is made of plastic, titanium, polysulfone, stainless steel, or a combination. The port houses a self-sealing silicone septum. Diameter of the port body is 16.5-40 mm	Insertion is similar to tunneled catheter insertion with the additional step of creating a pocket through blunt dissection to accommodate the port. The port is sutured in the pocket to prevent port movement or from flipping over.	Septum can withstand 1,000-3,600 punctures, depending on the product. Port is accessed with special noncoring needle (often a Huber needle) as a sterile procedure. Access with the smallest needle gauge and length. Vascular access ports may be side entry or top entry. In a side-entry port, the needle is inserted almost parallel to the reservoir. In a top-entry port, the needle is inserted perpendicular to the reservoir. Lowest risk for CRBSI The port does not need site care when not in use. Flushed monthly when not in use Port device can cause artifact on diagnostic imaging studies.
Implanted Pumps Infusion device with a power source, refillable drug reservoir, and catheter that allows drug delivery to an artery, vein, or anatomical space Length: 76-114 cm Size: 6.5 French Single-lumen silicone catheter; may have separate port for direct access to the CVAD. Port is attached to the pump housing. Titanium pump and reservoir. Pump powered via pressurized gas or lithium battery Reservoir volume: 10-60 mL Flow rate preset or programmable Flow rate: 0.3-21.6 mL/d Silicone septum to refill reservoir Dose titration: reprogrammable or remove drug and replace with new concentration Designed for continuous, lowvolume, long-term therapy Some uses: intra-arterial infusion to the liver, intrathecal morphine, intrathecal baclofen	The pump is implanted surgically under anesthesia, usually in the abdomen, in a subcutaneous pocket just above or below the beltline. The catheter is connected to the pump and tunneled under the skin to the intended delivery site in the body. Pump preparation in the surgical suite is dependent on the type of pump and planned infusate.	The patient is evaluated at regular intervals depending on his or her therapy protocol for pump refills and response to therapy. Factors that influence flow rate: ○ Viscosity of solution ○ Arterial pressure on the catheter tip Several factors influence gas-powered pumps: ○ Body temperature ○ Pump reservoir volume MRI should not be done with implanted pumps. Patient education: Importance of returning for refill as scheduled, pump alarms, avoid traumatic physical activity around pump site, symptoms of pump malfunction (symptoms related to type of drug, such as withdrawal symptoms, excessive sedation, increase in underlying symptoms of the disorder, delivery of medication into the pump pocket, increased pain) Use strict aseptic technique when accessing pump. Use only access and refill kits designed for the pump with noncoring needles. Refill procedures are specific to pump. Know the pump model, reservoir size, and flow rate.
Adapted from Camp-Sorrell (2011); CDC (2011); Gorski and Czaplewski (2004).