The first steps in provision of infusion therapy are selection and placement of the most appropriate type of vascular access device (VAD) to meet the patient's needs with a goal for preserving blood vessels and prioritizing vessel health as discussed in Chapter 1. A variety of factors guide the decision-making process, such as the characteristics of the prescribed infusate, expected duration of treatment, integrity of the patient's veins, patient age, history of infusion therapy, and patient preference. As discussed in Chapter 6, the peripheral IV catheter (PIVC) is often the first choice for short-term (e.g., usually less than 1 week) infusion needs. A midline peripheral IV catheter might be best if therapy is anticipated to last up to 2 weeks when the infusate is appropriate for peripheral administration. While a PIVC is often considered safer with less risk than a central vascular access device (CVAD), characteristics of the infusate (e.g., irritating/vesicant infusate, high-osmolarity solution) or other patient factors may make a PIVC an inappropriate choice, even if short-term infusion therapy is planned. A CVAD then becomes the necessary choice. Some guidelines indicating need for a CVAD rather than peripheral IV catheters include:

• Medications or solutions with high osmolarity (e.g., greater than 900 mOsm/L) or extremes of pH (acidic/alkaline)
• Vesicant drug infusions
• Continuous infusion therapy (e.g., parenteral nutrition [PN], fluid and electrolytes, blood or blood products)
• History of failed or difficult peripheral venous access, if use of ultrasound guidance has failed
• Long-term intermittent infusion therapy (e.g., any medication including anti-infectives in patients with a known or suspected infection)
• Episodic chemotherapy treatment
• Clinical instability of the patient and/or complexity of infusion regimen (multiple infusates) (Gorski et al., 2021, p. S76).

In this chapter, anatomy related to CVAD placement, appropriate device selection, catheter insertion, and care and maintenance are explored. Complications associated with CVADs are addressed in Chapter 9.

The nursing process is a six-step process for problem-solving to guide nursing action (see Chapter 1 for details on the steps of the nursing process related to vascular access). The following table focuses on nursing diagnoses, nursing outcomes classification (NOC), and nursing interventions classification (NIC) for patients with central vascular access. Nursing diagnoses should be patient specific and outcomes and interventions individualized. The NOC and NIC presented here are suggested directions for development of specific outcomes and interventions.

Sources: Ackley et al., 2020; Herdman et al., 2021

• The decision to place a CVAD is based on a thorough assessment that includes patient health problems, vascular integrity, type of prescribed infusion therapy, anticipated duration of IV therapy, and patient's needs/preferences with lifestyle.
• A CVAD is defined by placement of the catheter tip in the central vasculature, specifically in the lower superior vena cava (SVC), near its junction with the right atrium.
• The major categories of CVADs include nontunneled CVADs, PICCs, subcutaneously tunneled cuffed catheters, and implanted vascular access ports.
• CVAD features include catheter material, antimicrobial properties, presence of valves, number of lumens, and power injectability.
• The central line insertion bundle is followed with CVAD insertion; this includes a checklist to ensure that all procedures are properly followed during the insertion. If there is a breach, the procedure is stopped and restarted correctly.
• Although no specific limitations are set on CVAD dwell time, the following are guidelines for choosing a specific type of CVAD based upon anticipated duration of infusion therapy:
  • Nontunneled percutaneous catheters: Days to weeks, primarily in acute care settings
  • PICCs: Days to months, usually less than 1 year
  • Subcutaneously tunneled CVADs: Months to years
  • Implanted vascular access ports: Months to years
• After insertion of the central line, confirmation of proper tip location must be obtained before any infusion is administered.

Care and Maintenance Issues

• Regular site care and dressing changes are required. Site care for TSM dressings is performed minimally every 7 days. Site care when using gauze dressings is at least every 2 days. The use of chlorhexidine dressings is associated with a decrease in risk with short-term nontunneled CVADs.
• Nurses managing CVADs must be educated and competent in their use and care: Follow manufacturer guidelines; comply with agency protocols and policies; and be fully competent in the assessment, planning, intervention, and evaluation of the patient.
• CVADs are flushed with 0.9% sodium chloride to establish patency and between medications/solutions to prevent precipitation.
• Unused lumens of CVADs are locked to maintain patency between infusions. Locking solutions include 0.9% sodium chloride and low-concentration heparin and saline. Alternative solutions are considered for patients with a history of heparin-induced thrombocytopenia or frequent bloodstream infections.
• Needleless connectors must be disinfected properly before each use. Special products such as alcohol disinfection caps may be used.

Media Link: Chapter post tests and answers are provided on FADavis.com along with case studies and critical thinking activities.

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• American Nephrology Nurses' Association. (2018). Vascular access fact sheet. https://annanurse.org/practice/professional-practice/fact-sheets
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PROCEDURES DISPLAY 8-1
Discontinuation of a Short-Term Vascular Access Device (Nontunneled Catheter or Peripherally Inserted Central Catheter)

Note: If a culture of the catheter tip is ordered, see Chapter 2 Procedures Display.

Equipment Needed

• Gloves
• Suture removal set, if needed
• CVAD dressing kit

Delegation

This procedure cannot be delegated to an licensed practical/vocation nurse (LPN/LVN) or nursing assistive personnel (NAP). The nurse needs competency training for central venous access care and maintenance.