1. Peripheral vs Central Access

Peripheral access:

Includes short peripheral IVs (<6 cm) and midlines (8–20 cm).

• Peripheral IVs: Inserted in hand or forearm veins for short-term use (3–5 days). Use feet only when upper extremity access isn’t possible.
• Midlines: Placed in larger upper-arm veins for 1–4 weeks (up to 30 days max). They’re more durable but don’t reach central circulation.

Central access:

Catheters with the tip in central veins, classified as:

• Non-tunneled Centrally inserted CVC:
  • These include internal jugular, subclavian, and femoral central lines.
  • They are used for short-term access — usually less than two weeks.
  • Subclavian is preferred for short-term use because it’s more comfortable and has a lower infection risk, but we avoid subclavian lines in CKD or ESRD patients because they can cause venous stenosis and compromise future dialysis access.
  • Femoral central lines should be reserved for emergencies or when the internal jugular or subclavian sites aren’t possible.

Two special types of non-tunneled central lines deserve mention:

1. Temporary dialysis catheters: These are large-bore central lines used when a patient needs urgent dialysis or CRRT. They’re usually placed in the right internal jugular or femoral vein if IJ access isn’t possible. If the need for dialysis becomes long-term, these should be transitioned to a tunneled dialysis catheter, like a Permacath.
2. Cordis — also called an “introducer sheath”: This is a short, large-bore central line that provides rapid access to the central circulation.
   It’s used when we need fast fluid resuscitation, multiple infusions, or when placing a Swan-Ganz catheter in the ICU or OR. Cordis lines are meant for very short-term use — usually hours to a few days.

• PICC line (Peripherally inserted central catheter): These catheters re placed in the arm and their tips end in the superior vena cava. Can stay for weeks–months (up to 6) for prolonged IV therapy, TPN, chemo.
• Tunneled CVC (Hickman, Permacath): These are designed for long-term and frequent access — They run under the skin before entering the vein, which helps reduce infection risk. They’re commonly used for dialysis, parenteral nutrition, and ongoing chemotherapy.
• Implanted Port (Port-a-Cath): These are fully under the skin. They’re accessed only when needed, require very little day-to-day care, and can last for years — often permanently — when maintained well.

2. Venous Accesses Ranking

By invasiveness from least to most:

Peripheral IV → Midline → PICC → Non-tunneled CVC → Tunneled CVC → Implanted Port

By duration:

Peripheral IV (3–7 days) → Non-tunneled CVC (days–3 weeks) → Midline (1–4 weeks) → PICC (weeks–months) → Tunneled (months–years) → Port (>5 years)

By infection risk (lowest to highest):

Port ≈ Peripheral IV → Midline → Tunneled → PICC → Non-tunneled (Femoral highest)

By thrombosis risk (highest to lowest):

Subclavian (long-term) → PICC → Femoral → Port → Tunneled/IJ → Midline → Peripheral IV

By phlebitis risk (highest to lowest):

Peripheral IV → Midline → PICC → Others (minimal)

3. Choosing the Right Access

Always start with the least invasive line that meets your patient’s needs.

• Peripheral IV:
  • Default choice; suitable for most short-term infusions (including vasopressors, hypertonic saline, amiodarone ≤24h).
  • Use 18–20G or larger, and monitor closely.
  • If peripheral access fails → use ultrasound-guided IV, midline, CVC, or IO access based on context.

• Midline: Ideal for 1–4 weeks of non-vesicant therapy (e.g., 2-week IV antibiotics for MSSA).
• PICC: Use for > 4-week therapy, TPN, or multiple infusions.
• Non-tunneled CVC: For critical illness, RRT, TPN, or multiple drips.
  • Subclavian preferred short-term (except in CKD/ESRD).
  • Right IJ is preferred in CKD.
  • Femoral: emergencies only.
• Tunneled & Ports: For long-term access (HD, chemo, TPN). Ports for intermittent use, tunneled for continuous.

4. Contraindications

• Avoid limb placement (peripheral/midline/PICC) if:
  • Prior mastectomy/axillary node dissection
  • AV fistula/graft
  • DVT, severe venous obstruction
  • Infection, burn, wound, or prior radiation
• Avoid placing central lines at:
  • Infected or distorted insertion site
  • Ipsilateral chest tube, ICD, or pacemaker
  • Vein thrombosis or occlusion
• Special cases:
  • Coagulopathy: Safe if platelets ≥20K and INR ≤2. Use ultrasound.
    • 10–20K → transfuse one platelet unit if noncompressible site.
    • INR 2 → correct to ≤2 before placement.
  • Bacteremia:
    • Safe to place a new non-tunneled CVC if no existing catheter.
    • Avoid inserting new CVC if another one is present—remove the first one if it’s the suspected source (especially with S. aureus, Candida, or GNRs).
    • Do not place a tunneled or port until bacteremia clears.

5. Daily Care and Removal

• Ask daily: Does this patient still need the line?”
• Inspect daily:
  • Site: redness, pain, drainage
  • Dressing: clean, dry, intact
  • Catheter: secured, correct external length
• Maintenance:
  • Flush before/after meds; unused lumens daily
  • Change transparent dressings q7 days; gauze q2 days
  • Confirm tip placement (CXR or ECG-guided)
• Remove immediately if:
  • No longer needed
  • Suspected infection
  • Nonfunctional or malpositioned
• During removal:
  • Supine/Trendelenburg, have the patient hold breath/Valsalva, steady traction, occlusive dressing afterward.
  • If infection is suspected, culture the catheter tip.

6. Common Complications

• CLABSI:
  • Prevent with full sterile barrier, chlorhexidine prep, daily necessity checks, hub scrubbing, and prompt removal.
  • Suspect if fever or positive cultures >48h after insertion.
  • Draw cultures (line + peripheral), remove line, start empiric antibiotics.
• Thrombosis:
  • Most common with PICCs/subclavian lines.
  • Arm/neck swelling, pain, venous distention → confirm by ultrasound.
  • Treat with anticoagulation; remove only if infected or unnecessary.
• Mechanical Issues:
  • Pneumothorax: Get CXR post-subclavian or IJ.
  • Arterial puncture: Remove immediately, apply pressure for 10–15 minutes.
  • Air embolism: Trendelenburg + left lateral position, 100% O₂.
  • Malposition: Confirm and reposition before use.
• Catheter Dysfunction:
  • If sluggish or occluded → reposition, flush gently, or use Cathflo (2 mg, dwell 30–120 min).
  • Never force flush.

Special Scenarios

• CKD/ESRD: Avoid subclavian & PICCs; preserve future fistula veins.
• Cancer: Prefer ports for long-term intermittent therapy.
• Home IV therapy: PICCs are ideal—ensure patient education and home nursing follow-up.

Summary & Key Takeaways

• Start with the least invasive option.
• Midlines are underused—great for 1–4 weeks of therapy.
• PICC lines for long-term or outpatient IV therapy.
• Non-tunneled CVCs for emergencies and ICU patients.
• Remove lines early to prevent CLABSI.
• Avoid subclavian in CKD.
• Always confirm tip position before use.