Selection of Catheters and Sites


Peripheral and Midline Catheter Recommendations

In adults, use an upper-extremity site for catheter insertion. Replace a catheter inserted in a lower extremity site to an upper extremity site as soon as possible. 

In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used as the catheter insertion site [1, 2]. 

Select catheters on the basis of the intended purpose and duration of use, known infectious and non-infectious complications (e.g., phlebitis and infiltration), and experience of individual catheter operators [2–4]. 

Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasation occurs [2, 3].

Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed six days. 

Evaluate the catheter insertion site daily by palpation through the dressing to discern tenderness and by inspection if a transparent dressing is in use. Gauze and opaque dressings should not be removed if the patient has no clinical signs of infection. If the patient has local tenderness or other signs of possible CRBSI, an opaque dressing should be removed and the site inspected visually. 

Remove peripheral venous catheters if the patients develops signs of phlebitis (warmth, tenderness, erythema or palpable venous cord), infection, or a malfunctioning catheter [5]. 

Central Venous Catheters Recommendations

Weigh the risks and benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism, and catheter misplacement) [6–22].

Avoid using the femoral vein for central venous access in adult patients [7, 19, 20, 23].

Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled CVC placement [19–21]. 

No recommendation can be made for a preferred site of insertion to minimize infection risk for a tunneled CVC. 

Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein stenosis [22, 24–27].

Use a fistula or graft in patients with chronic renal failure instead of a CVC for permanent access for dialysis [28].

Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulation attempts and mechanical complications. Ultrasound guidance should only be used by those fully trained in its technique. [29–33]. 

Use a CVC with the minimum number of ports or lumens essential for the management of the patient [34–37]. 

No recommendation can be made regarding the use of a designated lumen for parenteral nutrition. 

Promptly remove any intravascular catheter that is no longer essential [38–41].

When adherence to aseptic technique cannot be ensured (i.e., catheters inserted during a medical emergency), replace the catheter as soon as possible, i.e., within 48 hours [6, 42–45]. 



The site at which a catheter is placed influences the subsequent risk for catheter-related infection and phlebitis. The influence of site on the risk for catheter infections is related in part to the risk for thrombophlebitis and density of local skin flora. 

As in adults, the use of peripheral venous catheters in pediatric patients might be

complicated by phlebitis, infusion extravasation, and catheter infection [46]. Catheter location, infusion of parenteral nutritional fluids with continuous IV fat emulsions, and length of ICU stay before catheter insertion, have all increased pediatric patients’ risk for phlebitis. However, contrary to the risk in adults, the risk for phlebitis in children has not increased with the duration of catheterization [46, 47]. 

The density of skin flora at the catheter insertion site is a major risk factor for CRBSI. No single trial has satisfactorily compared infection rates for catheters placed in jugular, subclavian, and femoral veins. In retrospective observational studies, catheters inserted into an internal jugular vein have usually been associated with higher risk for colonization and/or CRBSI than those inserted into a subclavian [6–16]. Similar findings were noted in neonates in a single retrospective study [48]. Femoral catheters have been demonstrated to have high colonization rates compared with subclavian and internal jugular sites when used in adults and, in some studies, higher rates of CLABSIs [9, 14–16, 19, 20, 49]. Femoral catheters should also be avoided, when possible, because they are associated with a higher risk for deep venous thrombosis than are internal jugular or subclavian catheters [17–19, 22, 50]. One study [7] found that the risk of infection associated with catheters placed in the femoral vein is accentuated in obese patients. In contrast to adults, studies in pediatric patients have demonstrated that femoral catheters have a low incidence of mechanical complications and might have an equivalent infection rate to that of non-femoral catheters [51–54]. Thus, in adult patients, a subclavian site is preferred for infection control purposes, although other factors (e.g., the potential for mechanical complications, risk for subclavian vein stenosis, and catheter-operator skill) should be considered when deciding where to place the catheter. 

In two meta-analyses, the use of real-time two-dimensional ultrasound for the placement of CVCs substantially decreased mechanical complications and reduced the number of attempts at required cannulation and failed attempts at cannulation compared with the standard landmark placement [29, 30]. Evidence favors the use of two-dimensional ultrasound guidance over Doppler ultrasound guidance [60]. Site selection should be guided by patient comfort, ability to secure the catheter, and maintenance of asepsis as well as patient-specific factors (e.g., preexisting catheters, anatomic deformity, and bleeding diathesis), relative risk of mechanical complications (e.g., bleeding and pneumothorax), the availability of bedside ultrasound, the experience of the person inserting the catheter, and the risk for infection. 

Catheters should be inserted as great a distance as possible from open wounds. In one study, catheters inserted close to open burn wounds (i.e., 25 cm2 overlapped a wound) were 1.79 times more likely to be colonized and 5.12 times more likely to be associated with bacteremia than catheters inserted farther from the wounds [55]. 

Type of Catheter Material. Polytetrafluoroethylene (Teflon ®) or polyurethane catheters have been associated with fewer infectious complications than catheters made of polyvinyl chloride or polyethylene [36, 253, 254]. Steel needles used as an alternative to catheters for peripheral venous access have the same rate of infectious complications as do Teflon® catheters [33, 34]. However, the use of steel needles frequently is complicated by infiltration of intravenous (IV) fluids into the subcutaneous tissues, a potentially serious complication if the infused fluid is a vesicant [34]. 

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