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]. 

 

Background

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]. 

  1. Maki DG, Goldman DA, Rhame FS. Infection control in intravenous therapy. Ann Intern

Med 1973; 79:867–87.

 

  1. Band JD, Maki DG. Steel needles used for intravenous therapy. Morbidity in patients

with hematologic malignancy. Arch Intern Med 1980; 140:31–4.

 

  1. Tully JL, Friedland GH, Baldini LM, Goldmann DA. Complications of intravenous therapy

with steel needles and Teflon catheters. A comparative study. Am J Med 1981;

70:702–6.

 

  1. Ryder MA. Peripheral access options. Surg Oncol Clin N Am 1995; 4:395–427.

 

  1. Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral

venous catheters. A randomized controlled trial. Ann Intern Med 1991; 114:845–54.

 

  1. Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a

prospective study utilizing molecular subtyping. Am J Med 1991; 91:197S–205.

 

  1. Parienti JJ, Thirion M, Megarbane B, et al. Femoral vs jugular venous catheterization

and risk of nosocomial events in adults requiring acute renal replacement

therapy: a randomized controlled trial. JAMA 2008; 299:2413–22.

 

  1. Moretti EW, Ofstead CL, Kristy RM, Wetzler HP. Impact of central venous catheter type

and methods on catheter-related colonization and bacteraemia. J Hosp Infect

2005; 61:139–45.

 

  1. Nagashima G, Kikuchi T, Tsuyuzaki H, et al. To reduce catheter-related bloodstream

infections: is the subclavian route better than the jugular route for central venous catheterization? J Infect Chemother 2006; 12:363–5.

 

  1. Ruesch S, Walder B, Tramer MR. Complications of central venous catheters: internal

jugular versus subclavian access–a systematic review. Crit Care Med 2002;

30:454–60.

 

  1. Sadoyama G, Gontijo Filho PP. Comparison between the jugular and subclavian vein as insertion site for central venous catheters: microbiological aspects and risk

factors for colonization and infection. Braz J Infect Dis 2003; 7:142–8.

 

  1. Heard SO, Wagle M, Vijayakumar E, et al. Influence of triple-lumen central venous

catheters coated with chlorhexidine and silver sulfadiazine on the incidence of

catheter-related bacteremia. Arch Intern Med 1998; 158:81–7.

 

  1. Richet H, Hubert B, Nitemberg G, et al. Prospective multicenter study of

vascular-catheterrelated complications and risk factors for positive

central-catheter cultures in intensive care unit patients. J Clin Microbiol

1990; 28:2520–5.

 

  1. Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related

bloodstream infection caused by percutaneously inserted, noncuffed central

venous catheters: implications for preventive strategies. Medicine (Baltimore)

2002; 81:466–79.

 

  1. Lorente L, Jimenez A, Iribarren JL, Jimenez JJ, Martin MM, Mora ML. The micro-organism

responsible for central venous catheter related bloodstream infection depends

on catheter site. Intensive Care Med 2006; 32:1449–50.

 

  1. Traore O, Liotier J, Souweine B. Prospective study of arterial and central venous

catheter colonization and of arterial-and central venous catheter-related

bacteremia in intensive care units. Crit Care Med 2005; 33:1276–80.

 

  1. Joynt GM, Kew J, Gomersall CD, Leung VY, Liu EK. Deep venous thrombosis caused by femoral venous catheters in critically ill adult patients. Chest 2000;

117:178–83.

 

  1. Mian NZ, Bayly R, Schreck DM, Besserman EB, Richmand D. Incidence of deep venous

thrombosis associated with femoral venous catheterization. Acad Emerg Med 1997; 4:1118–21.

 

  1. Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001; 286:700–7.

 

  1. Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous

catheters: effect of site of placement and catheter type. Infect Control Hosp

Epidemiol 1998; 19:842–5.

 

  1. Robinson JF, Robinson WA, Cohn A, Garg K, Armstrong JD, 2nd. Perforation of the great

vessels during central venous line placement. Arch Intern Med 1995;

155:1225–8.

 

  1. Trottier SJ, Veremakis C, O’Brien J, Auer AI. Femoral deep vein thrombosis associated

with central venous catheterization: results from a prospective, randomized

trial. Crit Care Med 1995; 23:52–9.

 

  1. Lorente L, Henry C, Martin MM, Jimenez A, Mora ML. Central venous catheter-related

infection in a prospective and observational study of 2,595 catheters. Crit

Care 2005; 9:R631–5.

 

  1. Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterisation vein stenosis in

haemodialysis: comparative angiographic study of 50 subclavian and 50 internal

jugular accesses. Nephrol Dial Transplant 1991; 6:722–4.

 

  1. Cimochowski GE, Worley E, Rutherford WE, Sartain J, Blondin J, Harter H. Superiority of the internal jugular over the subclavian access for temporary dialysis. Nephron 1990; 54:154–61.

 

  1. Barrett N, Spencer S, McIvor J, Brown EA. Subclavian stenosis: a major complication of

subclavian dialysis catheters. Nephrol Dial Transplant 1988; 3:423–5.

 

  1. Trerotola SO, Kuhn-Fulton J, Johnson MS, Shah H, Ambrosius WT, Kneebone PH. Tunneled infusion catheters: increased incidence of symptomatic venous thrombosis after

subclavian versus internal jugular venous access. Radiology 2000; 217:89–93.

 

  1. National Kidney Foundation. III. NKF-K/DOQI Clinical Practice Guidelines for Vascular Access: update 2000. Am J Kidney Dis 2001; 37:S137–81.

 

  1. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central

venous cannulation: meta-analysis. BMJ 2003; 327:361.

 

  1. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996; 24:2053–8.

 

  1. Froehlich CD, Rigby MR, Rosenberg ES, et al. Ultrasound-guided central venous catheter

placement decreases complications and decreases placement attempts compared with

the landmark technique in patients in a pediatric intensive care unit. Crit

Care Med 2009; 37:1090–6.

 

  1. Lamperti M, Caldiroli D, Cortellazzi P, et al. Safety and efficacy of ultrasound

assistance during internal jugular vein cannulation in neurosurgical infants.

Intensive Care Med 2008; 34:2100–5.

 

 

  1. Schweickert WD, Herlitz J, Pohlman AS, Gehlbach BK, Hall JB, Kress JP. A randomized,

controlled trial evaluating postinsertion neck ultrasound in peripherally

inserted central catheter procedures. Crit Care Med 2009; 37:1217–21.

 

  1. Clark-Christoff N, Watters VA, Sparks W, Snyder P, Grant JP. Use of triple-lumen subclavian catheters for administration of total parenteral nutrition. JPEN J Parenter

Enteral Nutr 1992; 16:403–7.

 

  1. Early TF, Gregory RT, Wheeler JR, Snyder SO Jr., Gayle RG. Increased infection rate

in doublelumen versus single-lumen Hickman catheters in cancer patients. South

Med J 1990; 83:34–6.

 

  1. Hilton E, Haslett TM, Borenstein MT, Tucci V, Isenberg HD, Singer C. Central catheter

infections: single-versus triple-lumen catheters. Influence of guide wires on

infection rates when used for replacement of catheters. Am J Med 1988;

84:667–72.

 

  1. Yeung C, May J, Hughes R. Infection rate for single lumen v triple lumen subclavian

catheters. Infect Control Hosp Epidemiol 1988; 9:154–8.

 

  1. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355:2725–32.

 

  1. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream

infections in the intensive care unit. Crit Care Med 2004; 32:2014–20.

 

  1. Lederle FA, Parenti CM, Berskow LC, Ellingson KJ. The idle intravenous catheter. Ann

Intern Med 1992; 116:737–8.

 

  1. Parenti CM, Lederle FA, Impola CL, Peterson LR. Reduction of unnecessary intravenous

catheter use. Internal medicine house staff participate in a successful quality

improvement project. Arch Intern Med 1994; 154:1829–32.

 

  1. Abi-Said D, Raad I, Umphrey J, et al. Infusion therapy team and dressing changes of

central venous catheters. Infect Control Hosp Epidemiol 1999; 20(2):101–5.

 

  1. Capdevila JA, Segarra A, Pahissa A. Catheter-related bacteremia in patients undergoing

hemodialysis. Ann Intern Med 1998; 128 (7):600.

 

  1. Mermel LA, Maki DG. Infectious complications of Swan-Ganz pulmonary artery catheters.

Pathogenesis, epidemiology, prevention, and management. Am J Respir Crit Care

Med 1994; 149:1020–36.

 

  1. Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related

infections by using maximal sterile barrier precautions during insertion.

Infect Control Hosp Epidemiol 1994; 15:231–8.

 

  1. Garland JS, Dunne WM Jr., Havens P, et al. Peripheral intravenous catheter complications in critically ill children: a prospective study. Pediatrics 1992; 89:1145–50.

 

  1. Garland JS, Nelson DB, Cheah TE, Hennes HH, Johnson TM. Infectious complications during peripheral intravenous therapy with Teflon catheters: a prospective study.               Pediatr Infect Dis J 1987; 6:918–21.

 

  1. Breschan C, Platzer M, Jost R, Schaumberger F, Stettner H, Likar R. Comparison of catheterrelated infection and tip colonization between internal jugular and subclavian central venous catheters in surgical neonates. Anesthesiology 2007; 107:946–53.

 

  1. Deshpande KS, Hatem C, Ulrich HL, et al. The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population. Crit Care Med 2005; 33:13–20; discussion 234–5.

 

  1. Durbec O, Viviand X, Potie F, Vialet R, Albanese J, Martin C. A prospective evaluation of the use of femoral venous catheters in critically ill adults. Crit Care Med 1997; 25:1986–9.

 

  1. Venkataraman ST, Thompson AE, Orr RA. Femoral vascular catheterization in critically ill infants and children. Clin Pediatr (Phila) 1997; 36:311–9.

 

  1. Sheridan RL, Weber JM. Mechanical and infectious complications of central venous cannulation in children: lessons learned from a 10-year experience placing more than 1000 catheters. J Burn Care Res 2006; 27:713–8.

 

  1. Stenzel JP, Green TP, Fuhrman BP, Carlson PE, Marchessault RP. Percutaneous central venous catheterization in a pediatric intensive care unit: a survival analysis of complications. Crit Care Med 1989; 17:984–8.

 

  1. Goldstein AM, Weber JM, Sheridan RL. Femoral venous access is safe in burned children: an analysis of 224 catheters. J Pediatr 1997; 130:442–6.

 

  1. Ramos GE, Bolgiani AN, Patino O, et al. Catheter infection risk related to the distance between insertion site and burned area. J Burn Care Rehabil 2002; 23:266–71.
Translate »