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Vascular Access

INTRODUCTION

A central venous catheter (CVC) is any vascular access device whose tip terminates in a large vessel in the body, most commonly the superior vena cava or inferior vena cava. Because indwelling lines pose definite risks to patients, steps should be taken whenever possible to minimize the risk of complications. Always seek operators with skill and experience, employ ultrasound for guidance, take the time to properly position patients, and employ meticulous sterile technique. The indications and necessity for central venous access must be critically reviewed prior to proceeding with a CVC insertion and each CV must be regularly reassessed for ongoing necessity and promptly removed as soon as the risks exceed the benefits.

There are no absolute contraindications to CVC placement provided that the likelihood and severity of potential complications are outweighed by the benefits of immediate venous access. Given the severity of illness generally associated with the requirement of a CVC, establishing adequate venous access is frequently a matter of ensuring survival. Although it is common practice to check coagulation parameters and to correct abnormalities, many CVCs may be safely placed in patients with coagulopathies; an actively hemorrhaging patient may require immediate placement of a large bore catheter regardless of INR or platelet levels. Bacteremic patients without peripheral access may require CVC in order to receive proper intravenous antibiotic treatment and/or monitoring. These patients are at high risk for developing secondary catheter related-bacterial superinfection (CR-BSI) due to the seeding of the CVC from circulating bacteria. In these patients, waiting 48 hours or longer until the bacteremia has cleared prior to placing a CVC may not be feasible. For these patients antibiotic-impregnated catheters are highly recommended along with prompt removal of the CVC as soon as it is no longer required. See Table 120-1 for details on CVC indications and relative contraindications, site selection considerations, types of CVCs, and potential complications, and Table 120-2 for practical CVC placement tips and recommendations.

For patients requiring peripheral venous access with poor vascular options, portable real time 2D ultrasound may identify deep veins in the forearm, brachial, and shoulder, thereby avoiding, at least temporarily, the need for central venous catheterization. Veins should be compressible and nonpulsatile. Bedside ultrasound can also be used to visualize the superficial external jugular vein and facilitate placement of midline catheters. The tip of midline catheters is inserted into an upper arm vein, (usually brachial or cephalic), and does not extend beyond the axillary line. Although short 3 cm peripheral intravenous (IV) lines require replacement every 3 days, 20 cm long midline catheters may remain in place for a longer period of time and they are appropriate for all intravenous fluids that would normally be administered through a short peripheral IV. Although they cost the same as peripherally inserted central catheters (PICC) lines, they do not require a chest film postinsertion and may facilitate early discharge to another setting. ...

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