Establishing and Maintaining Vascular Access
Summary of Key Points
• Three questions to ask when selecting a catheter system are: (1) Which device best meets the patient’s therapy and lifestyle needs? (2) How is the device most safely inserted and maintained? (3) What are the potential immediate and long-term complication risks?
• Types of central access systems are the traditional central line for short-term use, tunneled central lines for long-term use, surgically implanted infusion ports, and peripherally inserted central catheters.
• Vascular access devices can be placed using a number of anatomic sites to access the superior vena cava or inferior vena cava: the subclavian vein, internal jugular vein, external jugular vein, and femoral vein.
• Insertion can be performed via the Seldinger (closed) technique or by operative exposure of the vein (open technique).
• Short-term complications include vascular laceration, arterial puncture, pneumothorax (2%), hemothorax, and air embolus (overall placement complications should be <5%).
• Long-term complications include catheter exit site or tract infection, catheter-associated sepsis, cardiac arrhythmias, catheter colonization, catheter thrombus (~30%), fibrin sheath, extravasation, occluded catheter, and shearing of the catheter.
• Factors increasing the risk of catheter-associated infection include prolonged duration of indwelling time, multiple-lumen catheters, femoral locations, non–catheter-related bacteremia (in a neutropenic patient), the number of times the system is accessed, difficult catheter placement, and poor technique in catheter or port-site care.
