Accepted Practice

Introduction to the use of specialized IV access devices

Specialized intravenous (IV) access devices are inserted by a physician or a nurse or other clinician who has had specialized training. These devices include peripherally inserted central catheters (PICCs), implantable venous access devices, and central venous catheters (CVCs). Specialized access devices are most often used for:

  • frequent or recurrent blood sampling for laboratory tests
  • an alternative to poor peripheral venous access
  • delivery of vasoactive medications
  • infusion of total parenteral nutrition (TPN)
  • large-volume or recurrent blood transfusions
  • long-term infusion of medications, such as antibiotics or chemotherapy
  • continuous monitoring of central venous pressure
  • assessment of hypovolemia or hypervolemia
  • placement of a pulmonary artery catheter
  • a transvenous pacemaker

Peripherally inserted central catheters (PICCs)

PICCs are especially useful for IV therapy to help manage chronic health problems at home. In acute-care settings, a PICC can provide central access with fewer and less severe complications than can develop with central venous catheters. The most common complications of a PICC are phlebitis and catheter occlusion. PICC lines are ideally inserted percutaneously into the cephalic or basilic anticubital fossa, then advanced into the superior vena cava. Single- and double-lumen catheters are the most common, although the newer triple-lumen PICC devices are available in some facilities.

Placement of a PICC is contraindicated for patients who have sclerotic veins and in extremities affected by mastectomy or radial artery surgery, a hemodialysis graft, or an arteriovenous fistula. Patients with PICC lines should not have blood-pressure measurements, venipunctures, or injections in the extremity with the PICC.

Specific care of a PICC site is detailed in each agency’s policies and procedures, but in general, it is recommended that you assess the insertion site and upper extremity at the start of each shift and every 4 to 8 hours or as indicated by the patient’s condition. Look for signs and symptoms of phlebitis, thrombophlebitis, venous occlusion, and infiltration:

  • pain along the vein
  • erythema
  • edema at the puncture site
  • ipsilateral (same-side) swelling of the arm, neck, or face
  • a change in arm circumference of more than 0.8 in (2 cm) from baseline

Administration of medications via a PICC

To ensure placement of the catheter in the vascular space, assess for venous blood return and patency before beginning any IV infusion. When performing any task related to a PICC, be sure to adhere to the level of aseptic technique detailed in your agency’s policies and procedures. Connect a normal saline-filled 10-mL syringe to the catheter’s access port, release the catheter’s clamp, and gently aspirate to verify blood return. Flush with up to 10 mL of normal saline using a “push-pause” motion. This technique causes the flush solution to swirl within the catheter, which clears the line and maintains patency. Avoid using syringes with less than a 10-mL volume for flushing or instilling medication. Smaller syringes exert pressure exceeding 40 psi per square inch and may cause catheter rupture or fragmentation with possible embolization. After flushing the line, continue with medication administration or IV infusion. Always cleanse the access port before attaching the infusion tubing or the medication syringe.

Adequate flushing after medication administration is the most important factor for preventing the occlusion of a PICC by blood, fibrin, or medication residue. Using a 10-mL syringe filled with normal saline, inject the saline, again using the push-pause motion to create turbulence within the catheter. Your agency’s policy and the particular catheter in use determine the frequency of flushing and the solution and volume required to maintain catheter patency. Also, your agency may supply one of many anti-reflux Luer-activated devices designed to keep blood from flowing into the catheter’s lumen.

Implantable venous access devices

An implanted venous access device, or port, is surgically implanted in a cutaneous pocket, usually in the chest wall. The device consists of an internal catheter connected to the patient’s venous system, and a reservoir covered by a disc 0.8 to 1.2 in (2 to 3 cm) in diameter and totally implanted under the skin. The disc, or septum, is accessed with a noncoring needle, which allows for repeated accessing without damage to the silicone core. The septum is capable of resealing following de-access. Ports provide venous access for intermittent or continuous infusions while keeping a patient’s body image intact when not being accessed. Ports are commonly used for patients requiring long-term IV access, such as those receiving chemotherapy or blood products, and for blood sampling.

Administration of medications via an implanted venous access device

Only nurses with specialized training should access and de-access an implanted device. Once the device is accessed, the noncoring needle is stabilized and secured to the skin over the septum and a dressing applied according to the agency’s policy. The device extension tubing is primed and locked.

Medication administration is similar to other venous-access processes: Cleanse the extension tubing port and proceed with the medication-administration procedure. During continuous or intermittent IV infusions, assess the port device for patency and signs of infiltration every 4 hours and as needed. Instill push medications at the rate recommended for the specific medication.

Following medication administration, flush the extension tubing with 10 mL of normal saline. As with all central access catheters, avoid using syringes with less than a 10-mL volume for flushing or instilling medication. To ensure patency of the device, follow the saline flush with heparin as specified in your agency’s policy.

Central venous catheters

Central venous catheters are most often placed in the internal jugular or subclavian vein, then advanced into the superior vena cava. They are placed by physicians or advanced practice nurses or other clinicians specially trained in the procedure. The catheter can have two, three, or four lumens spaced along the catheter. Each lumen has a designated purpose, depending on its location along the catheter. Because the distal lumen of the catheter lies nearest the right atrium, information about right-heart filling pressure and right-ventricular function and volume can be estimated when the associated port is connected to a transducer or water-manometer system. Other lumens are used for parenteral nutrition, continuous or intermittent fluid infusions, vasoactive medications, and blood products.

The most common complication related to central venous catheters is infection. Assess the insertion site for signs of inflammation or infection at the start of each shift and every 4 to 8 hours or as indicated by the patient’s condition. Learn about your role in central-line infection prevention, and follow your agency’s policy for site care.

Medication administration via central-line catheters

Infusing medication and fluids through a central line is similar to the process used with a PICC. Always follow your agency’s policies for asepsis when making connections to the access port. If the port is to be locked following medication administration, it is typical to flush the line with 10 mL of normal saline using the push-pause technique and then to secure the line clamp. Follow your agency’s policy for the frequency, solution, and volume to be used to maintain the line’s patency.

Beyond the basics

The clinical use of specialized intravenous access devices requires focused education and competency training beyond the scope of this module. These advanced skills include patient-safety considerations and infection-control practices, prevention and recognition of unexpected outcomes, and comprehension of hemodynamic values.