Central venous access devices

Central venous access devices (CVADs) are catheters inserted into peripheral veins or central veins in the chest, neck or groin, which travel through the venous system so the distal tip is positioned in the lower third of the superior vena cava, cavoatrial junction, or the upper right atrium. The catheter tip for CVADs inserted in the femoral vein is in the inferior vena cava, above the level of the diaphragm.^r CVADs provide reliable access to the venous system, are suitable for the administration of peripherally incompatible solutions, enable multiple or high-volume infusions of solutions and reduce the need for peripheral blood sampling.^r CVADs have numerous features: single or multiple lumens, valve (closed) or non-valved (open) at the distal or proximal ends, power-injectable or standard, reverse tapered or standard, trimmed, or standard and tunnelled or non-tunnelled.

This document provides information about:

1. CVAD selection 
2. Types of CVADs
   1. Short-term CVADs
   2. Intermediate-term CVADs
   3. Long-term CVADs
3. Key clinical practice points for all CVADs, and
4. Key clinical practice points for clinical procedures

CVAD insertion can be planned or emergent. Planned CVAD insertion is influenced by numerous and diverse interactive factors including:

1. Patient: diagnosis, acuity, medical history and co-morbidities, physical assessment, patient preference and lifestyle availability of sufficient, quality peripheral veins.
2. Device: type of CVAD, number of lumens, side (left or right), appropriate vein
3. Therapy: infusates (solutions or medications to be administered) including pH and osmolarity, irritant, vesicant, inotropes, percentage of protein, parenteral nutrition; compatibilities; duration and frequency of therapy - continuous, repetitive, prolonged; procedures – therapeutic apheresis procedures; location of therapy – inpatient, ambulatory unit, community.
4. Workplace: availability of different types of CVAD within a health care service, skills of inserters, access to health services providing CVAD maintenance, cost.

Emergent CVAD insertion may be required in intensive care units (ICU), emergency department or operating theatres where urgent venous access is required for supportive care or fluid resuscitation.

CVADs can be classified as:

Standardised CVAD terminology is critical for, communication between healthcare teams and organisations, and data collection linkage and sharing in the clinical and research setting.

Short-term CVADs are devices in situ for days and possibly longer if tunnelled. They are reviewed daily for continued need and removed as soon as they are no longer required.^rr

Centrally inserted central venous catheters (CICCs)

Centrally inserted central catheters (CICCs) previously central venous catheters (CVCs) are short-term devices inserted via the veins in the neck or chest including the jugular, subclavian, or axillary veins.

Features include:

• single or multiple lumens allowing for the administration of multiple, high volume or concurrent incompatible solutions or medications
• non-tunnelled as the catheter enters the vein near the skin puncture site or tunnelled catheter where the skin exit site is a distance from the venepuncture site to facilitate optimal dressing and securement application
• coated, bonded or impregnated with heparin, antimicrobials, silver, antiseptic

CICC/CVC- with chlorhexidine (CHG) disc, subcutaneous and adhesive engineeded securement device (ESD) and bordered semipermeable dressing	Tunnelled CICC/CVC- with CHG disc, subcutaneous and adhesive ESD and bordered semipermeable dressing
© E. Alexandrou 2020	© E. Alexandrou 2020

Femorally inserted central catheters (FICCs)

Femorally inserted central catheters (FICCs) are short-term CICCs inserted via the femoral vein. The catheter tip is located in the inferior vena cava above the level of the diaphragm.^r

These catheters can have single or multiple lumens, and are also non-tunnelled or tunnelled for optimal dressing and securement application.

Tunnelled FICC – exit site tunnelled to mid thigh, with CHG disc, subcutaneous and adhesive ESD, and bordered semipermeable dressing
© E. Alexandrou 2020

Apheresis-centrally inserted central catheters (A-CICCs)

Apheresis-CICCs are open, large bore catheters (10-18.5 Fr for adults and 6-8 Fr for paediatric patients) that tolerate high flow rates for: therapeutic procedures for treatment of chronic conditions, e.g. plasmapheresis, erythropheresis, photopheresis; and cellular collections (to produce a product), e.g. stem cells, lymphocytes, granulocytes.^r

These catheters can have a single, double or triple lumen – the third lumen has a smaller diameter to allow for administration of medications or fluids.

Apheresis catheter –  triple lumen, low internal jugular approach with CHG disc, subcutaneous and adhesive ESD, bordered transparent dressing	Apheresis catheter  –  low internal jugular approach with CHG disc, adhesive ESD and bordered semipermeable dressing
© E. Alexandrou 2020	© E. Alexandrou 2020

There are no optimal dwell times for intermediate-term CVADs to remain in situ.^r They may be indwelling for weeks to months and possibly for more than a year.

Peripherally inserted central venous catheters (PICCs)

Peripherally inserted central catheters (PICCs) are catheters inserted in the peripheral veins in the upper extremity. The catheter tip is located in the lower third of the superior vena cava, cavoatrial junction or upper right atrium.^r

Features include:

• Valved or non-valved​
  • Valved: valve present at the internal, distal end of the catheter or the external, proximal end
  • Non-valved catheters have an open distal end, require an external clamp
• Tunnelled or non-tunnelled
  • Tunnelled: venepuncture where the vein has the greatest diameter (e.g. closer to the axilla) and exit site tunnelled to optimal site on the middle section of the upper arm^r
  • Standard / non-tunnelled: venepuncture site is in close proximity to venepuncture site

• Power-injectable or standard
  • Power-injectable PICCs - tolerate increased pressure exerted by computed tomography (CT) technology's contrast injection
  • Standard PICCs - do not tolerate increased pressure and will fracture if used for CT scans contrast injection

• Trimmed or standard 
  • Standard (untrimmed) catheters: can feature (a) open tip, (b) tapered catheter tip, or (c) staggered exit points for dual lumen catheters for concurrent administration of incompatible medications or fluids
  • Trimmed catheters: distal end of catheters cut to appropriate length for the individual patient to minimise excessive external length
• Reverse tapered or standard
  • Reverse taper: wider catheter diameter at the skin exit site, smaller at venepuncture site (decreased risk of catheter kinking at skin exit point and venous thrombosis due to smaller catheter diameter in the vein) 
  • Standard: same diameter for the entire length of catheter

Double lumen PICC, untrimmed – adhesive ESD with semipermeable dressing	Power-injectable double lumen PICC – untrimmed with CHG gel bordered semipermeable dressing
© K. Curtis 2021	© K. Curtis 2021

Long-term CVADs may be in situ for months to years.^r Common types of long-term CVADs are tunnelled cuffed-centrally inserted central catheters (tc-CICCs) and totally implantable venous access devices (TIVADs) / portacaths. These devices can be standard or power-injectable, single or multiple lumen (or double TIVAD).

Tunnelled cuffed-centrally inserted central catheters (tc-CICCs)

Tunnelled cuffed centrally inserted central catheters (tc-CICCs) are inserted into a central vein, commonly the jugular vein, and are tunnelled subcutaneously to the exit site on the central anterior chest wall. A cuff on the catheter within the tunnel becomes enmeshed with fibrous tissue in the weeks after insertion which assists to anchor the catheter and prevent accidental dislodgement and acts as a mechanical barrier to ascending bacteria.^r  The distal end of the catheter, as per all CVADs, is located in the lower third of the superior vena cava, cavoatrial junction or upper right atrium.

Tunnelled cuffed-centrally inserted central catheter – adolescent patient with subcutaneous ESD and bordered semipermeable dressing	Tunnelled cuffed centrally inserted central catheter – adult patient, CHG gel bordered semipermeable dressing
© Interrad Medical 2020	© K. Curtis 2021

Totally implanted venous access device (TIVAD) / port-a-cath

A TIVAD consists of two parts:

1. Body: small, hard-walled chamber with self-sealing septum, inserted into a subcutaneous pocket on the anterior chest wall under the clavicle or inner upper arm (for appropriate diameter vein in upper arm)
2. Tunnelled catheter: attaches to the TIVAD/portacath body, tunnelled to venepuncture site, e.g. jugular vein, and the distal tip in lower third of the superior vena cava, cavoatrial junction or right atrium

TIVADs are only accessed by a non coring needles. Most ports are designed for 1000 to 2000 punctures with a non-coring needle.

TIVADs can be:

1. single or double device (two separate septums with double lumen catheter)
2. standard or power-injectable
3. open or closed (valved) catheter

TIVAD/portacath in adult male patient – not accessed	TIVAD/portacath in adult female patient – not accessed	TIVAD/portacath in adult patient accessed with non-coring needle, semipermeable dressing
© K. Curtis 2021	© K. Curtis 2021	© K. Curtis 2021

Selection

• Aim: insertion of the most appropriate CVAD for the patient, and insertion of one device for the length of prescribed therapy^r 
• Insert a CVAD with the least number of lumens and smallest outer diameter required for the prescribed therapy^r

Insertion:

• Catheter to vein ratio is less than 45%: catheter occupies less than 45% of the vein to reduce the risk of thrombosis. For PICCs, the vein is measured using ultrasound, without a tourniquet, prior to insertion.^rr Refer to abstract
• Post-insertion care for a TIVAD: suture lines are covered by a sterile transparent dressing until healed, kept dry until sutures are removed/dissolve
• Catheter tip: positioned, reported and documented in the lower third of the superior vena cava, cavoatrial junction or upper right atrium prior to the first use after insertion^r

Infection Prevention:

• CVAD infection prevention maintenance bundle: incorporate essential practices to reduce the risk of CVAD related infection: 

1. ​Hand hygiene: remains the single most important practice to prevent CVAD-related infections.^rr Practise hand hygiene according to the Five Moments of Hand Hygiene
2. Aseptic Non Touch Technique^®: Use the appropriate aseptic non-touch technique (ANTT^®) for procedures, e.g. Standard-ANTT^® or Surgical-ANTT^®r for every patient, every CVAD, every time^r
3. Dressing: maintain clean dry and intact^rr
4. Needleless connector disinfection: vigorously scrub all surfaces and allow to fully air dry, every time for every CVAD for every patient, Including multiple accesses in the one episode, e.g. blood sampling^r
5. Assessment and documentation: refer to section below

• Single use equipment and solutions^r

Assessment and Documentation:

• CVAD requirement: regular assessment for the continued need of a CVAD and prompt removal when no longer required^r
  • Inpatients with short-term CVADs: review at least daily
  • Intermediate-term or long-term CVADs: regular review, e.g. key points in treatment regimens, transition onto maintenance therapy, cessation of active treatment

Aim: remove CVADs that are no longer required as soon as possible to prevent complications.

• CVAD assessment: at least once per shift and at each outpatient, ambulatory or clinic appointment, or each home-care visit.^r This includes the nine core assessment areas. Refer to the eviQ CVAD assessment resource document
• Documentation: is a critical component of care and is completed for the insertion procedure, all CVAD maintenance procedures, assessments, complications and interventions, and removal.^r  

Education:

Patient education is a continual process over the life of a CVAD, prior to insertion through to removal and includes the patient, their family/carer and the healthcare team.^rr

Patient education includes:

• Advantages and disadvantages, maintenance required and potential impact of the different types of CVADs for informed decision making
• Keep CVAD dressings dry: during showers, do not swim or immerse the dressing in water (bath)
• Check the dressing every day including: dressing is dry, clean and intact, exit site is free from pain, redness, discharge, swelling, burning, stinging, pruritus, rash and, needleless connector present, clean and intact
• PICC: avoid repetitive arm movement, e.g. tennis, golf and water sports
• What to do if the catheter fractures, cracks or needless connector detaches
• TIVAD: only to be accessed by educated and competent clinicians or family/carers
• Contact numbers for 24-hour support, what signs and symptoms to immediately act on, or when to wait until next day

Learn more about CVADs in eviQ Education CVAD modules

Recommendations include:

CVAD infection prevention maintenance bundle

Implement all practices which are essential to reduce the risk of CVAD related infection: 

1. Hand hygiene
2. Aseptic Non Touch Technique^®
3. Dressing: clean dry and intact
4. Needleless connector disinfection
5. Assessment and documentation

For more information see eviQ Education CVAD modules (Module 3 Part 2)

Skin antisepsis and skin protection

• Patients with cancer potentially have a higher risk for skin impairment due to a multitude of factors including disease pathophysiology, comorbidities, side effects of anti-cancer therapies, potential nutritional deficits and dehydration, steroids, and/or neutropenia. Skin management for patients with CVADs can be complex
• Use 2% chlorhexidine gluconate and 70% isopropyl alcohol swab stick for skin antisepsis^rr
• Allow skin antisepsis agent to completely air dry before applying dressing materials.^r Do not blot excess, fan or blow dry
• For chlorhexidine allergy: povidone iodine can be used.^rr For chlorhexidine sensitivity: complete a full patient assessment
• Complete a full patient assessment at the first sign or symptom of any irritation, skin changes or patient discomfort. Skin management includes assessment, skin protection and patient comfort^r
• Ensure hair under dressing has been clipped (do not shave) to improve the adherence of the dressing

Learn more about CVADs and skin management in the eviQ Education CVAD modules and the CNSA Skin Management Algorithm

Dressings

• Use transparent, semipermeable dressing to cover the catheter exit site and TIVAD needle and extension tubing.^rrrr Next generation bordered polyurethane dressings with tough fabric borders and some with integrated securement have improved results in trials^rr
• Change transparent semipermeable dressings every 7 days or earlier if it contains exudate (ooze), is wet or lifting or causing patient discomfort.^r Gauze dressings are changed every 48 hours or earlier if required^rr
• Exit sites with excessive exudate: can be managed with sterile gauze dressing and change to semipermeable dressings when exudate has reduced,^r tissue adhesive at the catheter exit site for bleeding,^r and absorbent dressings and materials
• External catheter length: measure the external catheter at every dressing change and compare to length at the time of insertion. Document^r​
  • Aim: zero catheter migration – any migration should be investigated especially for paediatric patients

Read more about central venous access device - dressing and needleless connector change

Securement

• Ensure the catheter is secured at all times^r
• Sutures should be avoided^r unless for emergent situations
• Sterile strips are not adequate for catheter securement^r

Securement can include one or more of the following strategies:

• Engineered securement devices (ESD)
  • adhesive securement devices e.g. StatLock®, GripLoc®
  • subcutaneous securement devices e.g. SecurAcath®
• Integrated Securement Dressings e.g. Sorbaview Shield®
• Bordered, transparent semipermeable dressings may provide further catheter securement to engineered securement devices and also enhanced dressing integrity^rr
• Tissue adhesive: at exit site +/- under catheter anchor hub^r e.g. SecurePortIV™

Line care and line changes

• A closed system reduces the risk of infection e.g. by placing needleless injection connectors on each CVAD lumen. Exceptions include central venous pressure monitoring, rapid infusions or fluid resuscitation^r
• Disinfect all needleless connectors prior to each use, every time, with every patient and every CVAD^rr
• Replace needleless connectors on the catheter hub every 7 days or earlier if compromised by the presence of blood or as per manufacturers recommendations
• Label administration lines^r and secure to the patient at all times to prevent pulling on the dressing and dislodgement of the catheter or non-coring needle
• Use syringes and administration lines with a luer lock^rr
• Minimal connection and disconnection of intravenous administration lines, and access with additive lines or syringes. Every access of a closed system increases the risk of infection. Do not reconnect administration lines that have been disconnected^r
• Frequency of intravenous (IV) administration lines changes: refer to local guidelines. Recommendations vary according to the type of solution and infusion frequency^r including:
  • Continuous and intermittent infusions – every 7 days^r and refer to local guidelines
  • Parenteral nutrition – every 24 hours with the bag change, administer preferably via a dedicated lumen^r
  • Lipid – with every container change or at least every 12 hours^r
  • Blood products - at completion of the transfusion or every 12 hours if the transfusion is not complete ^r
  • Chemotherapy – discard upon completion of chemotherapy and flush maintaining a closed system. Refer to local institutional guidelines; variances exist according to different products used
  • Replace lines immediately on suspicion of contamination^r

Read more about central venous access device - intravenous administration line change

Flushing and locking

• Patency assessment: aspiration of full blood and injection without resistance.^rr Refer to article for more information
• Flush solution: sodium chloride 0.9%, 10 mL and increase to 20 mL after blood products, medication administration, viscous fluids including parenteral nutrition, computerised tomography contrast, between incompatible solutions if clinically appropriate. Paediatrics: reduce volume as clinically appropriate for the individual patient, at least double the volume of the lumen^rr
• Flush technique: use a pulsatile technique and complete with the appropriate clamp-disconnection sequence according to the type of needleless connector, for every CVAD, every time.^rr Leave 0.5-1 mL of solution in the syringe to avoid "bottoming out" syringe which causes blood reflux into the catheter tip or use manufactured syringe with anti-reflux and pressure limiting features e.g. Posiflush™
  • Negative needleless connector: clamp while injecting the last 0.5 mL and before the syringe is disconnected to prevent blood reflux back into the catheter tip when the syringe is disconnected
  • Positive needleless connector: clamp after the syringe is disconnected to allow the internal mechanism to activate
  • Neutral needleless connector: no specific clamping procedure is required
  • Anti-reflux needleless connector: no specific clamping procedure is required
• Flush frequency: for lumens used intermittently or for unused lumens – before and after each use, in between incompatible solutions, and at least once per shift (one of the nine core CVAD assessments every shift) and before lock administration^r
• Lock solution: lock with sodium chloride 0.9%^r or as per local policy. Lock apheresis CICCs as per local policy / manufacturer’s instructions / instructions for use. It is critical to use a pulsatile technique and complete with the appropriate clamp-disconnection sequence according to the type of needleless connector, for every CVAD, every time, for every patient^rr
• Lock frequency varies according to the type of CVAD. For CVADs not in use: lock PICC and tc-CICC - weekly with dressing changes,^r TIVAD 4 to 6 weekly, or potentially longer when accompanied by regular monitoring of occlusion rates and thrombolytic medication administration rates^r
• Syringes: use 10 or 20 mL only^rr

Any signs of reduced patency, stop and promptly assess. Refer to CVAD Patency algorithm 

Read more about central venous access device - accessing and deaccessing or totally implantable venous access device - accessing and deaccessing

Blood sampling

• Use CVADs with > 4 Fr catheter for blood sampling. Smaller catheter lumens are at risk of occlusion^r
• When CVAD is in use, or if taking blood through a multi-lumen CVAD, stop all infusions (if clinically appropriate) and clamp all lumens prior to obtaining sample/s
• Discard the first blood sample (except when taking blood cultures)^r
• Some blood samples such as coagulation studies, electrolytes during parenteral nutrition administration and medication serum concentrations via a CVAD require special consideration
• Blood culture collection through CVADs require replacement of needless connectors prior

Read more about central venous access device - blood sampling 

Interventional Radiology and CVADs

• Power-injectable CVADs can be used for interventional radiology investigations e.g. CT scans^r
• Confirm CVAD is power-injectable prior to use for CT scans^rr including verbal confirmation by patient or patient CVAD identification card, documentation in medical record, scouting scan to view ‘CT’ on base of TIVAD body. For TIVAD, use power-injectable non-coring needle

PICCs

Care for patients with PICCs include:

• Avoid blood pressure, venepuncture and peripheral intravenous cannula insertion on the same arm with the PICC in situ 
• Ensure dressing stays dry during showering
• Avoid bandages or tight coverings over the PICC^r
  • tight elastic coverings can increase the risk of compressing the vein leading to vein wall irritation, phlebitis or thrombosis

TIVADs

• Access with non-coring needle and replace the needle every 7 days for continuous infusions^r
• Choose appropriate length and gauge non-coring needle for the patient – a needle that is too short may not reach through the septum into the cavity of the TIVAD / portacath body and a needle that is too long will not sit flat against the patient’s skin (increased risk of dislodgement)
• Cover an accessed TIVAD with a transparent semipermeable dressing including needle and first part of the extension tubing

Accessed TIVAD with dressing
© K.Curtis 2020

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