Navigating venous access: A guide for hospitalists

Abstract

Venous access is the foundation for safe and effective hospital-based care. Inpatient providers must have a deep knowledge of the different types of venous access devices (VADs), their relative indications, contraindications, and appropriateness. However, such knowledge is difficult to come by and usually only gleaned through years of clinical experience. To bridge this gap, we provide an in-depth summary of the relevant anatomical considerations, physical characteristics, advantages, and disadvantages of VADs commonly used in the hospital setting. In doing so, we seek to improve the safety and share the science of vascular access with frontline clinicians. To aid decisionmaking, we conclude by operationalizing the available data through algorithms that outline appropriate vascular access for the hospitalized patient. Reliable venous access is fundamental for the safe and effective care of hospitalized patients. Venous access devices (VADs) are conduits for this purpose, providing delivery of intravenous medications, accurate measurement of central venous pressure, or administration of life-saving blood products. Despite this important role, VADs are also often the source of hospital-acquired complications. Although inpatient providers must balance the relative risks of VADs against their benefits, the evidence supporting such decisions is often limited. Advances in technology, scattered research, and growing availability of novel devices has only further fragmented provider knowledge in the field of vascular access. 1 It is not surprising, then, that survey-based studies of hospitalists reveal important knowledge gaps with regard to practices associated with VADs.2 In this narrative review, we seek to bridge this gap by providing a concise and pragmatic overview of the fundamentals of venous access. We focus specifically on parameters that influence decisions regarding VAD placement in hospitalized patients, providing key takeaways for practicing hospitalists. METHODSTo compile this review, we systematically searched Medline (via Ovid) for several keywords, including: peripheral intravenous catheters, ultrasound-guided peripheral catheter, intraosseous, midline, peripherally inserted central catheter, central venous catheters, and vascular access device complications. We concentrated on full-length articles in English only; no date restrictions were placed on the search. We reviewed guidelines and consensus statements (eg, from the Center for Disease Control [CDC] or Choosing Wisely criteria) as appropriate. Additional studies of interest were identified through content experts (M.P., C.M.R.) and bibliographies of included studies.

When Is Parenteral Nutrition Appropriate?

“…Yet at the same time, strategies for reducing central line–associated bloodstream infection (CLABSI) uniformly recommend limiting the use of CVADs in acute care settings, thus increasing pressure to rely on PIVs whenever possible 1 , 2 , 8 . ‐ 10 Improvements in the design of peripheral midline catheters, which can remain in place for 29 days, may offer an alternative to conventional PIVs, but these devices are still prone to phlebitis, and no research has studied the use of these devices for peripheral PN 10 , 11 . Moreover, the location of these devices in a deeper vein may mask signs and symptoms of phlebitis, such as redness or pain.…”

“…As shown in Table 5.2, the complication profile varies with each type of CVAD, with some devices better suited for PN administration than others 1 . ‐ 3 , 8 ‐ 13 , 24 ‐ 30 An individualized approach to selecting the CVAD for PN administration that incorporates pertinent clinical information with a careful assessment of the risk/benefit profile of the device is essential to promoting optimal outcomes in patients receiving PN therapy. After the CVAD for PN administration is selected and inserted, meticulous attention to maintenance strategies aimed at preventing complications is essential 8 .…”

Short- and Intermediate-Term Use of Peripherally Inserted Central Catheters in Europe: A Systematic Literature Review

“…Venous access devices (VADs) are catheters that consist of a hub to provide access to connectors, a hollow tube divided into one or many sections (lumens), and a tip terminating within a peripheral or central blood vessel. 1 VADs can be classified as central venous access devices (CVADs), peripheral intravenous catheters (e.g., midlines or peripheral intravenous catheters [PIVCs]), or implanted ports, based on the site of entry and location of the catheter tip. 1 CVADs allow for central access, with tip termination in the lower portion of the superior vena cava at the cavoatrial junction.…”

“…1 VADs can be classified as central venous access devices (CVADs), peripheral intravenous catheters (e.g., midlines or peripheral intravenous catheters [PIVCs]), or implanted ports, based on the site of entry and location of the catheter tip. 1 CVADs allow for central access, with tip termination in the lower portion of the superior vena cava at the cavoatrial junction. 1 Centrally inserted central catheters (CICCs) are CVADs that enter directly into veins of the neck or chest.…”

“…1 CVADs allow for central access, with tip termination in the lower portion of the superior vena cava at the cavoatrial junction. 1 Centrally inserted central catheters (CICCs) are CVADs that enter directly into veins of the neck or chest. Peripherally inserted central catheters (PICCs) are CVADs that enter through peripheral veins of the upper arm but terminate in the proximity of the cavoatrial junction.…”