Venous access devices range from simple steel needles to sophisticated catheter/sensor assemblies. The selection of an appropriate venous access device (VAD) will consider the following factors:
- Disease process
- Medical history
- Patient safety and convenience
- Quantity and type of fluid to be infused
- The adequacy peripheral vessels
- Potential harm to vessel integrity
- Continuous central venous pressure monitoring or repeated venous blood sampling
- Dwell time
- Delivery of multiple incompatible medications
- Central venous catheter (CVC) - Single or multiple lumen CVCs are usually inserted via the internal jugular, axillary or subclavian veins and terminate in the superior vena cava. The femoral vein is used infrequently and those CVCs terminate in the inferior vena cava. CVCs require insertion by a physician. CVCs have the advantage of rapid insertion for the emergent delivery of fluid resuscitation. CVCs are available in larger lumen sizes allowing greater infusion volume and more reliable sample withdrawal than peripheral catheters. Some have been engineered to allow high pressure infusion of contrast media. Others can be tunneled from the insertion site to a subcutaneous access port. Tunneled CVCs can have a lower risk of infection but managing an infected tunneled CVC is more difficult than removing a temporary catheter.
CVCs have a greater risk of major insertion complications including: pneumothorax, air embolism, arterial puncture, hemorrhage, hematoma. Insertion sites including: internal jugular, subclavian, femoral vein have been associated with a greater risk of blood stream infections (BSI) than peripherally inserted central catheters.
- Peripherally Inserted
Central Catheter (PICC) - can be inserted into the basilic, cephalic, median cubital or brachial veins, usually above the antecubital fossa with the tip terminating in the lower 1/3 of the superior vena cava (SVC). PICC lines can remain in place for up to 1 year provided that there are no complications. PICCs placement in the SVC provides better hemodilution than shorter peripheral catheters and are therefore indicated for hypotonic, isotonic, hypertonic and vesicant therapy. Some PICCs are engineered to allow additional functions including high pressure injection (up to 300 psi) and central venous pressure (CVP) monitoring. CVP monitoring should be done using a 20 gauge or larger PICC.
PICC lines have been associated with higher incidence of deep vein thrombosis (DVT), probably due to the greater surface contact with venous tunica intima. A study completed in 2006 comparing PICCs to peripheral short catheter (PC) found that 6 (19.4%) of PICCs resulted in asymptomatic deep vein thrombosis (DVT). PCs had one DVT (3.4%). Asymptomatic superficial venous thrombosis occurred in 9 (29%) of PICCs and 13 (37.9%) of PCs. One PICC resulted in blood culture negative, Staphyloccocus epidermidis infection. Patient satisfaction was 96.8% for PICC patients and 79.3% of PC patients. Overall cost of per PICC patient was $690. Overall cost of per PC patient was $265*
In the recent past, PICCs were associated with high incidence of central line associated blood stream infections but that risk is likely diminished due to industry wide implementation of patient safety guidelines including the use of maximal sterile barrier precautions during insertion and improved skin prep and dressing techniques.
Peripheral intravenous catheters are VADs whose infusion tips reside outside of the superior or inferior vena cava.
- Short peripheral catheter - Commonly referred to as an IV catheter, are of two type: winged steel needles (butterflies or scalp needles) and short over-the needle catheters usually <3 inches in length.
- Midline catheter - Peripheral intravenous catheter which is inserted into the basilic, cephalic, or brachial veins usually above the antecubital fossa with the tip terminating not beyond the axillary vein. Midline catheters offer a longer dwell time and better hemodilution than the short peripheral IV catheters. Midline catheter dwell time is about 1-8 weeks. Midline catheters may be appropriate for delivery of isotonic or near isotonic solutions (250-350 meq/L) solutions with a pH of 5-9 (the same as shorter peripheral IV catheters). Midline catheters are not used for routine
blood drawing. As with all long catheters, blood pressure cuffs or tourniquets should not be used on the
arm where a midline catheter has been placed.
- Midclavicular catheter - Peripheral intravenous catheter which is inserted into the medial cubital or the basilic vein in the upper arm above the antecubital fossa with the tip terminating in the subclavian vein
near the center point of the clavicle. Midclavicular placement is not recommended due to increased risk of thrombphebitis. A midclavicular catheter is considered a peripheral catheter and is therefore limited to delivery of isotonic or near isotonic solutions (250-350 meq/L) solutions with a pH of 5-9 (the same as shorter peripheral IV catheters).