Vascular Access Device Selection and Central Line Safety
Key Points
- Device choice should match therapy duration, solution properties, vein condition, and patient status.
- PIVCs are short-term options, while midline and central access support longer or higher-risk therapies.
- CVC types (PICC, tunneled, nontunneled, implanted ports) have distinct indications and risk profiles.
- Central-line infection prevention and verification protocols are essential to reduce severe harm.
Pathophysiology
Vascular access introduces a foreign device into the bloodstream pathway. Mechanical trauma, chemical irritation, and microbial entry can cause local and systemic complications. Risk increases when device type does not match therapy intensity or duration.
Central access improves delivery of vesicants, high-osmolar solutions, and long-term therapies, but carries higher bloodstream infection and thrombosis risk if insertion and maintenance standards are not followed.
Classification
- Peripheral IV catheter (PIVC): Short-term peripheral access for many fluids and medications.
- Midline catheter: Longer peripheral option (days to weeks) when frequent PIV replacement is expected.
- Central venous catheter (CVC): Central access for high-risk infusates, hemodynamic monitoring, and prolonged therapy.
- Common CVC forms: PICC, tunneled catheter, nontunneled catheter, and implanted port.
Nursing Assessment
NCLEX Focus
Prioritize matching therapy requirements to the safest viable access route, then monitor line integrity and infection cues continuously.
- Review therapy plan: expected duration, infusion rate, vesicant potential, osmolarity, and need for multiple lumens.
- Assess vein quality, prior access history, mobility impact, and limb restrictions.
- Confirm insertion-site appropriateness and line-position verification where required.
- Reassess patency, dressing integrity, and early signs of infiltration, phlebitis, thrombosis, or infection.
Nursing Interventions
- Escalate from PIV to midline or central access when therapy profile exceeds peripheral safety limits.
- Use aseptic insertion/maintenance workflows and standardized line-access disinfection.
- Apply line-specific flushing, tubing-change, and dressing-change protocols.
- Promptly report and intervene for suspected CLABSI, catheter-associated thrombosis, or extravasation.
Device-Therapy Mismatch Risk
Using inadequate access for vesicants or prolonged high-risk infusions increases tissue injury and infection risk.
Pharmacology
| Drug Class | Examples | Key Nursing Considerations |
|---|---|---|
| vesicants | Vancomycin, dopamine, phenytoin | Prefer larger or central access when indicated; monitor closely for tissue injury cues. |
| antibiotics | Broad-spectrum IV agents | Long-course therapy may require durable access and strict line-infection prevention. |
Clinical Judgment Application
Clinical Scenario
A patient with fragile veins needs two weeks of IV antibiotics and intermittent vesicant therapy.
Recognize Cues: Repeated peripheral failures with planned prolonged treatment. Analyze Cues: Ongoing PIV attempts increase trauma and therapy interruptions. Prioritize Hypotheses: Device upgrade is needed to reduce complications and preserve treatment reliability. Generate Solutions: Collaborate for midline or central access based on medication profile and duration. Take Action: Implement line-care bundle and monitor for early complications. Evaluate Outcomes: Infusions proceed reliably with reduced access-related events.
Related Concepts
- peripheral-iv-access - Initial peripheral access principles and site selection.
- iv-insertion-and-iv-removal - Practical insertion/removal workflow and safety checks.
- peripheral-iv-therapy-complications - Local/systemic complication cues and escalation.
- catheter-related-bloodstream-infection - Bloodstream infection prevention and response priorities.
- infiltration-and-extravasation - Tissue injury recognition and immediate intervention pathway.
Self-Check
- Which factors should trigger escalation from peripheral to central access?
- Why are midlines not appropriate for certain high-risk infusates?
- Which daily checks reduce central-line complication risk most effectively?