ABOUT 8% of hospitalized patients require a central venous access device (CVAD): nontunneled central venous catheters (CVCs), including peripherally inserted central catheters (PICCs), and implanted CVCs, including tunneled catheters and totally implantable venous access devices.1 The choice of CVAD and insertion site is based on the patient's anatomy, the type and duration of therapy prescribed, infection risk, and other patient factors.1 This article is a review for nursing students of the purpose, indications, and nursing considerations for each type of CVAD.
CVC basics
A CVC is classified based on how long it is used (short-term, mid-term, or long-term), the type of insertion (central or peripheral), the insertion site (jugular, subclavian, femoral, or brachial), number of lumens (single, double, or triple), and whether the catheter is tunneled or totally implantable.1 CVCs are most commonly named by their insertion site and the number of lumens. For example, a triple-lumen catheter in the subclavian vein may be called a triple-lumen subclavian CVC. CVCs may be tunneled for long-term use (3 months or longer) or nontunneled for short-term use (up to 14 days).1
Indications for a CVC include inadequate peripheral access; administration of medications with high osmolarity, irritants, and vesicants such as vasopressors; chemotherapy; and parenteral nutrition that cause phlebitis if administered in peripheral veins. Other indications include hemodynamic monitorng, high flow volumes such as hemodialysis and plasmapheresis, and short-term emergency access.1
Nontunneled CVCs
The distal tip of a CVC inserted into a vein in the upper body terminates in the cavoatrial junction (CAJ), the point where the superior vena cava meets the right atrium. CVCs inserted in the femoral vein terminate in the inferior vena cava above the level of the diaphragm.2 These devices may be inserted in the OR or at the bedside by a physician or advanced practice provider.
PICCs are inserted into a peripheral vein but terminate in a central vein. These CVCs are inserted into the basilic, cephalic, or brachial veins of the upper arm. Once inserted, the distal tip rests in the superior vena cava without entering the right atrium. PICCs can be inserted in the OR or at the bedside by a physician or an appropriately prepared nurse using sterile technique with ultrasound to guide placement. Radiographic imaging is used to confirm placement.
A PICC can have one, two, or three lumens, although recent findings indicate lower infection rates with single-lumen PICCs as opposed to those with double or triple lumens.3 Once in place, the PICC is either sutured or secured using a stabilization device. An occlusive sterile dressing is applied and the PICC can remain in place for 6 months to a year if no complications arise.4
Possible complications associated with PICCs include infection, upper extremity venous thrombosis (UEVT), and air embolism. UEVT is a risk specific to PICC use. The inserting clinician will document the circumference of the arm 10 cm above the antecubital fossa. If UEVT is suspected, the nurse can repeat and compare the measurement to confirm the presence of edema.2
Tunneled CVCs
Typically inserted into an incision in the chest, tunneled CVCs traverse a subcutaneous tunnel between the catheterized vein and the skin exit site. The CVC distal end rests in the CAJ. Tunneling the catheter under the skin gives it stability and reduces infection risk during prolonged I.V. therapy.1
Tunneled CVCs are placed in the interventional radiology suite or OR and patients are typically sedated for the procedure. After insertion, the catheter is sutured in place. Tunneled CVCs can have one, two, or three lumens. Some catheters may have retention cuffs to reduce infection risk and prevent accidental removal.
Totally implanted CVCs (ports)
Inserted in the OR, implanted ports allow long-term venous access (up to years) and have the lowest infection rate of any CVAD.5
Ports are typically placed in the upper chest of adult patients, but they may also be placed in the upper extremity, abdominal wall, and lower extremity.1 The port's catheter passes from the cannulated vein beneath the skin and attaches to a subcutaneous infusion port or reservoir that is placed into a subcutaneous pocket.1 Ports are most commonly used for patients receiving long-term chemotherapy. Single- and dual-port devices are available and are accessed through the skin using a noncoring needle.5
Preventing infection
CVCs are the most frequent cause of healthcare-associated bloodstream infections.6 If not prevented, central-line associated bloodstream infections (CLABSIs) result in increased length of hospital stay, increased cost, and increased patient morbidity and mortality. To help prevent CLABSIs, clinicians are charged with following proper insertion practices, handling and maintaining CVADs appropriately, and removing any unnecessary CVADs. For more information on strategies to prevent CLABSIs, a checklist from the CDC is available at http://www.cdc.gov/hai/pdfs/bsi/checklist-for-CLABSI.pdf.
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