Vascular access

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Obtaining and maintaining vascular access is an essential component of medical care. Vascular access enables blood sample collection, hemodynamic monitoring, and administration of fluids, blood, and/or medications. Venous access can be obtained in peripheral veins, central veins, or the intramedullary space of bones. The location and type of venous access are chosen based on clinical urgency, intended use, and the anticipated duration of need. Long-term central venous catheters are typically used if venous access is required for 6 weeks or longer. Complications of vascular access include infection, thrombosis, harm to adjacent tissue, and extravasation or infiltration of infusing fluids and/or medications. Extravasation is treated with aspiration of the extravasated material, limb elevation, warm or cold thermal packs, and/or specific reversal agents. If extravasation of a medication causes significant tissue damage, consult with plastic surgery or orthopedic surgery for management.

Venous access

Arterial access

• Clinical applications ^[2]
  • Continuous invasive blood pressure monitoring
  • Continuous cardiac output monitoring ^[12]
  • Frequent arterial blood gas sampling
• Procedure: See “Arterial line insertion.”
• Complications
  • Bleeding
  • Hematoma
  • Infection
  • Thrombosis
  • AV fistula
  • Pseudoaneurysm

General principles ^[6][13]

Consider the following when choosing the appropriate vascular access device for a patient:

• Indication for vascular access (e.g., resuscitation, medication administration, invasive hemodynamic monitoring)
• Urgency and expected duration of therapy and/or monitoring
• Risks (e.g., complications of line insertion and/or maintenance, adverse effects of substance infusion)
• Individual patient factors (e.g., age, prior experience, preferences)
• Local protocols

Resuscitation

• Begin with an attempt at PIV access.
• Consider IO access if PIV access is not established after 3 attempts. ^[14][15][16]
• Prepare for short-term central venous access if attempts at placing a PIV or IO line are unsuccessful.
• Advance quickly to central venous access based on resuscitation needs.
  • Multiple vasoactive medications required: triple lumen CVL preferred
  • Rapid large-volume infusion required: sheath introducer preferred

Peripherally administered medications ^[6]

• ≤ 5 days: PIV
• 6–14 days
  • Critically ill and/or invasive hemodynamic monitoring required: short-term CVL
  • Other patients: midline catheter
• 15–30 days: PICC
• ≥ 31 days: PICC, tunneled CVL, or surgically implanted catheter

Centrally administered medications ^[6]

• < 14 days: PICC or short-term CVL
• ≥ 15 days: PICC or tunneled catheter
• ≥ 31 days: PICC, tunneled catheter, or surgically implanted catheter

Long-term CVLs are intended to remain in place for at least 6 weeks. ^[17]

Indications ^[17]

• Chemotherapy
• Home TPN
• Antimicrobial therapy
• Hemodialysis

Types ^[5][17][18]

Variants ^[17]

• Single or multiple lumens
• Variable lumen size
• MRI compatible
• High volume flow

Complications ^[17]

• Occlusion: e.g., mechanical, medication precipitation, thrombosis
• Device fracture
• External vascular thrombosis
• Catheter-related infection
• Central venous stenosis

Definitions ^[21]

• IV extravasation: leakage or unintentional administration of a vesicant medication into the tissue surrounding a vascular access device (e.g., PIV catheter or IO needle).
• IV infiltration: leakage or unintentional administration of a nonvesicant solution or medication (e.g., saline) into the tissue surrounding a venous access device

Both IV infiltration and IV extravasation can result in significant injury and/or tissue damage (e.g., local necrosis, compartment syndrome) that can be life- or limb-threatening. Identify and manage these complications promptly. ^[22][23]

Substances

• Vesicant agent: a drug that can result in tissue damage, blister formation, or necrosis when inadvertently injected into tissue around a vein ^[24]
• Irritant agent: a drug that can result in pain, inflammatory reactions, or ulcers when inadvertently injected into tissue around a vein ^[25][26]
• Neutral agent (nonvesicant): a fluid or drug that does not typically cause an acute tissue reaction when inadvertently injected into tissue around a vein ^[22]
• Caustic agent: an acidic or alkaline substance that can have both irritant and vesicant properties depending on its concentration

Risk factors ^[23][27]

• Patient-related
  • Small, fragile, or sclerosed veins
  • Abnormal peripheral circulation: e.g., in patients with excised lymph nodes, peripheral vascular disease
  • Obesity
• Procedure-related
  • Multiple attempts at venous access
  • High-pressure flow, e.g., rapid bolus with a large syringe
  • Unfavorable location of venous access device
  • Prolonged infusion times

Clinical features ^[22][23][27]

• Tingling, burning, and/or pain at the venous access site
• Localized swelling and/or redness (early signs)
• Blistering, necrosis, and/or ulceration of adjacent tissue (late signs)

Management ^[23][25][27]

Initial management is similar for infiltration and extravasation, however, extravasation can require some additional steps.

Initial steps

• Stop the infusion and disconnect the IV tubing (see “Troubleshooting IO access” for intraosseous infusions).
• In case of extravasation:
  • Aspirate as much extravasated medication as possible from the venous access device.
  • Administer a specific reversal agent for an extravasated medication, if appropriate. ^[23][25]
• Remove the venous access device.
• Mark the boundaries of infiltration with a permanent marker.
• Elevate the limb.
• Consult plastic surgery or orthopedic surgery for large extravasations or signs of compartment syndrome.
• Follow local protocols for responding to adverse events and file reports as necessary with the incident reporting system.

Monitoring and supportive care

• Apply local cooling or warming 4 times a day for 20 minutes per session. ^[23][25]
  • Cooling: indicated for anthracycline, alkylating agents, nonvesicant agents, and TPN
  • Warming: indicated for vasopressors, contrast media, phenytoin, and vinca alkaloids
• Provide pain management as needed.
• Reassess regularly until fully healed. Typically every 1–2 days for the first week, then weekly. ^[27]

Extravasation agent reversal ^[23][25]

There are no specific reversal agents for caustic substances.

• Vasopressors : Inject either phentolamine OR terbutaline then apply nitroglycerin topically
  • Phentolamine (preferred) ^[23][28]
  • Terbutaline (off label) ^[28][29]
  • Nitroglycerin topically (off label) ^[23][28][29]
• Hyperosmolar solutions : hyaluronidase (off label) ^[23][25]
• Chemotherapy drugs
  • Reversal agents and doses depend on the drug; consult a specialist for guidance.
  • See “Extravasation of chemotherapeutic agents.”

Prevention ^[27]

• Provide staff training on venous access device placement and medication administration.
• Avoid high-risk venous access sites:
  • Small or sclerotic veins
  • Veins overlying a joint, in the antecubital fossa, in the lower limbs
  • Areas affected by lymphedema
• Following IV catheterization and prior to each infusion:
  • Check for blood return.
  • Flush with 10–20 mL of saline.
  • Inspect for signs of extravasation.
• Consider central venous access for prolonged infusions (≥ 12 hours).