Venous access is a key component of the treatment strategies that patients receive upon admission to the hospital or other health care facilities. The use of venous access has expanded to outpatient care and ambulatory units. As a result of the general trend from inpatient to outpatient care to reduce health care costs, the use of long-term venous access has increased in the past decades. A wide variety of venous accesses are available ranging from minimally invasive (i.e., peripheral lines) to more invasive and complex methods (i.e., intraosseous and central lines), which can be tunneled, nontunneled, or implantable devices. Each type has specific indications, contraindications, and risks during insertion that need to be weighed against the benefits at the moment of choosing vascular access.^1,2

The first descriptions of intravenous (IV) devices and injections in animals date back to 1663 when Robert Boyle described for the first time the experiments done one decade earlier by Sir Christopher Wren Boyle, who was the first person to extend transfusions from animals to humans in London prisons. Thereafter, several professors and scientists developed principles that presently allow safe interventions in humans, which range from phlebotomy to more complex procedures such as blood transfusion, hemodialysis, and cardiopulmonary bypass.³

Peripheral access is commonly used for the short-term administration of medications and iso-osmolar solutions. Patients may experience venous sclerosis, infiltration, thrombosis, or the need for other higher osmolar solutions. In these instances, other alternatives for vascular access should be taken into consideration. Arteriovenous fistulas (AVFs) and central venous access are viable alternatives, especially for chronically ill and debilitated patients.

The main objective of this chapter is to describe the different types of venous accesses and their indications, contraindications, complications, and alternatives for specific patient populations. A brief description of pediatric considerations is also included.

Venous access devices are not innocuous to the host and can induce inflammatory reactions that can lead to thrombosis, phlebitis, and infection. The biomaterial used can elicit a reaction from contact with the immune system and endogenous microflora.³ The ideal IV access should lack immunogenicity (local and systemic) to avoid microbial adhesion and activation of the coagulation cascade.

Several adverse properties that lead to a higher risk of catheter-related complications have been described elsewhere in the literature, including positively charged surfaces that promote bacterial adhesion and platelet aggregation; hydrophilic catheters that may absorb fluid and change the catheter size and diameter⁴; and stiffness. which can lead to problems upon insertion or endothelial damage that may induce intravascular coagulation.³

The most common biomaterials used for the creation of hemodialysis AVFs are polytetrafluoroethylene (PTFE), which induces a chronic fibrosis around the conduit (patency rate, 70%–80% at 3 years)⁵ and silicone elastometer (Silastic), which is by far the most common material used for chronic indwelling vascular catheters because it has a low rate of thrombogenicity and platelet aggregation. Other materials such as polyvinyl chloride (PVC), polyethylene, and polyurethanes are not frequently used because of their strong association with induction of inflammatory reaction and stiffness of the catheters.³

Approximately 6% of long-term venous access become infected as a result of an interaction between the host, catheter, and microbes.^3,6 The simple presence of an intravascular catheter, which acts as a foreign body within the vein, increases the risk of local and systemic complications. Normal flora and opportunistic pathogens can become virulent in the presence of an indwelling catheter enabled by the formation of a gelatin-like matrix on the surface of the catheter biomaterial known as biofilm.⁷

This matrix is the result of an interaction between bacterial exopolysaccharides with the host immune system and the catheter materials.^3,7 Since initial studies almost 35 years ago, it has been long recognized that bacteria adhere to the surface of intravascular catheters through different mechanisms. Class I interactions are physical forces (e.g., hydrophobic) that facilitate bacterial adhesion and colonization of intravascular devices. Class II mechanisms are bonds by nonspecific covalent or polar interactions that together with class I represent the most common bacterial adhesion mechanisms. Class III mechanisms include more specific for pathologic bacteria, which, by the formation of surface adhesion molecules (microbial surface components recognizing adhesive matrix molecules [M-SCRAMM]), a receptor–ligand interaction occurs, resulting in biofilm colonization.³

The polysaccharide slime or biofilm has intrinsic properties that contribute to pathogenicity. It has been well recognized that it acts as a barrier and blunts the effect of antibiotics to the microorganism, masks bacterial antigenicity,^8,9 and interferes with phagocytosis.⁷ The most common microbes associated with catheter related sepsis are skin flora bacteria, particularly Staphylococcus epidermidis. Several methods have been investigated to reduce the incidence of catheter colonization and subsequent sepsis, including antibiotic catheter impregnation and biomaterial modification.³ Wilson³ proposed four strategies to prevent catheter infection, including exit site modification (topical antibiotics, silver cuffs, and subcutaneous tunnels), exit site elimination (Port-a-Cath, MediPort), bulk phase drug binding (Gelseal Dacron prosthesis), and surfactant-mediated drug binding (Bioguard catheters).

Medication administration, fluids, nutrition, and blood analysis all require adequate IV access. Since the invention of a resinous catheter with a steel introducer needle invented in the 1950s, plastic catheters have become the primary means for peripheral intravascular access.

Relevant Anatomy

Selection and placement of functional catheters requires knowledge of the venous anatomy. The dorsal venous arch is formed by the metacarpal and dorsal veins of the hand. These veins are capable of handling up to a 20-gauge catheter. The basilic vein runs along the ulnar side of the posterior forearm, and the cephalic vein runs along the radial side of the forearm. They each can accommodate up to a 16-gauge catheter. There is also the option of accessing the median veins through the mid-forearm or the accessory cephalic veins at the proximal radial side of the forearm. The median ulnar, basilic, and cephalic veins all converge at the antecubital space. This is used as an area for blood sampling; however, because of discomfort and limitations to mobility for the patient, is not a popular site to primarily select for continued venous access. The basilic and cephalic veins above the antecubital space are appropriate options but are more difficult to see¹⁰ (Figure 35-1).

Indications and Contraindications

As stated above, the need for medications, fluid, and nutrition infusion along with blood sampling and analysis necessitates the establishment of IV access. Peripheral access is still the preferred method even during cardiopulmonary resuscitation because peripheral access is quicker and easier to achieve.¹¹ Contraindications for peripheral IV access include massive edema, burns, sclerosis, phlebitis, and thrombosis. Relative contraindications involve sides on which a patient has undergone a radical mastectomy, dialysis grafts, involving sites of trauma, sites with overlying cellulitis, sites of shunts or fistulas, and sites in the feet and ankles.¹⁰

Complications of peripheral IV access include trauma to the vein and sclerosis. To assist in avoiding these complications, blood drawn for laboratory analysis can be taken from peripheral IV lines that are established. This requires that the infusion is off for at least 2 minutes, at least 5 cc of blood is discarded, and all tubes are filled completely to obtain an accurate bicarbonate level. This minimizes the number of times a patient’s veins are accessed, thereby decreasing the complications.^12,13,14

Peripheral Intravenous Central Catheters

A peripherally inserted central catheter (PICC) is appropriate for intermediate-term access requirements. The catheter is made of a thin biocompatible tube with a hub. The catheter is inserted percutaneously into a peripheral vein and fed into a central vein using radiographic guidance and confirmation. It is an appropriate catheter for frequent blood sampling over time as well as infusion of hyperosmolar solutions (e.g., total parenteral nutrition).¹⁵

Central venous access is generally not the initial access of choice and should be placed only in the presence of clear indications. Before placement, a thorough assessment of absolute or relative contraindications for placement should be performed and the appropriate consent obtained from the patient after detailing the risks, complications, benefits, and alternatives available (Figures 35-2 and 35-3).

Different access sites exist for central venous lines (CVLs). Each one differs in regard to ease of placement and patient comfort, with the right subclavian vein (SCV), right internal jugular vein (IJV), left SCV, and left IJV being the order of preference for central venous access.³ Is imperative to perform a detailed physical examination and obtain any pertinent vascular history before placing a CVL. The practitioner should identify any masses, feel for pulses, and check for scars that may represent previous interventions in the area of interest. If in doubt, venous Duplex ultrasonography should be used to perform mapping and to plan an appropriate venous access (Table 35-1).

Cutdown Method

Dissecting a vein for cannulation was first described by Heimbach and Ivey and most of the time is performed using the cephalic, basilic, saphenous, or internal or external jugular veins. Its use is preferred in coagulopathic and obese patients in whom the percutaneous approach may be relatively contraindicated or technically more difficult.

A simple Valsalva maneuver helps identify the external jugular vein (EJV). A transverse incision is made over the vein, and the platysma muscle fibers are bluntly dissected. The vein is isolated and proximal and distal control obtained with silk ties. The cephalad silk can be tied, and a small venotomy just below it is done to fit the catheter. After this has been placed and blood aspirated, the caudal silk is tied to keep the catheter in place. Then the incision is closed in layers and catheter position checked with chest radiography.

To dissect the IJV, a 3- to 4-cm vertical incision is made 2 cm above the clavicle between the clavicular and sternal heads of the sternocleidomastoid muscle (SCM). The platysma muscle is divided, and the carotid sheath that is located deep in the incision is opened to expose the IJV. The vagus nerve lies posteromedially to the IJV, and the carotid artery lies medial. After it has been dissected free, proximal and distal control is achieved with vessel loops, and a purse-string suture is placed wide enough to allow passage of the central catheter. Then the incision is closed by layers and the position checked with chest radiography³ (Figure 35-4).

The cephalic vein can be accessed in different sites along its course within the arm. At the antecubital fossa, it can be accessed as a peripheral route or for PICC lines. In the deltopectoral groove, which is formed by the junction of the deltoid and pectoralis major muscle where the humerus meets the clavicle, a 3-cm incision is performed and the subcutaneous muscle dissected. The cephalic vein lies just above the fascia. A 2-cm segment is isolated. As with other vein cutdowns, proximal and distal control is obtained, a venotomy is performed, the catheter is placed, hemostasis is verified, and closure is performed. For lower extremity access, the saphenous vein can be dissected either at the groin for long-term access or at the ankle level for temporary access.

Percutaneous Method

Accessing a major vein percutaneously is the preferred approach in the absence of contraindications. The most commonly used veins for central access are the jugular (IJV and EJV), subclavian vein, and femoral vein. The percutaneous technique can reduce insertion time at the expense of potential complications of major vessel injury, bleeding, or hemopneumothorax.³ Therefore, placing venous catheters requires an accurate knowledge of the anatomy to avoid injury to surrounding neurovascular structures.

The Seldinger technique can be used in almost every patient requiring central venous access. It is recommended to place the patient as supine as possible with a slight Trendelenburg position to avoid air embolism and increase vein diameter. A towel can be placed under the shoulder blades to drop the shoulder and open the angle between the clavicle, sternum, and first rib. Anatomic landmarks are identified, and the use of ultrasound guidance is recommended. After preparation and draping of the puncture site is completed, the needle is advanced in a 45-degree angle. Some practitioners use a localizing needle before attempting to access the vein. When the vein is accessed, the syringe is detached, and placing the thumb in the needle to avoid air embolism, the guidewire is advanced into the needle. Placement can be checked at this time with fluoroscopy. The needle is removed, keeping the guidewire in place, and then a small skin incision is made at the entry site, large enough to allow passage of the catheter without resistance. Then the dilator is passed over the wire just deep enough to dilate the skin and subcutaneous tissue, and the catheter is threaded into the vein. The wire is pulled out, and the ports are aspirated and flushed. The catheter is secured in place, and dressings are applied over the top after hemostasis has been verified. Catheter placement at the atriocaval junction should be confirmed by fluoroscopy if available and a chest radiograph to rule out complications.³

The EJV is located along the lateral aspect of the neck, just deep to the platysma muscle. It courses anteriorly to the SCM to flow into the IJV at the base of the neck. It provides a temporary access site to the central circulation.

The IJV is located anterior and lateral to the common carotid arteries at the base of the neck. The right IJV has a shorter distance to the right atrium and a straighter course than the left IJV. Therefore, the right IJV is usually preferred over the left side for central cannulation. Another anatomic variant is that the right IJV is slightly farther away from the carotid artery than its counterpart.³ Percutaneous access to the IJV involves rotating the neck to the contralateral side for exposure and locating the apex formed between the clavicular and sternal heads of the SCM. The needle is directed at a 45-degree angle to the ipsilateral nipple, keeping negative pressure in the syringe as the needle is advanced anterior to the carotid artery. As soon as the vein is accessed, a guidewire passes into the needle and preferentially position is checked by fluoroscopy. Then the Seldinger technique is used to place either a temporary central line or a permanent hemodialysis catheter. Other approaches for IJV approach are the posterior approach (behind the posterior border of the SCM) and the anterior approach (anterior border of the SCM).³

Femoral vein cannulation is achieved by locating the femoral triangle high in the thigh and bounded superiorly by the inguinal ligament, laterally by the medial border of the sartorius muscle and medially by the medial border of the adductor longus. Within this triangle, the femoral vein lies medial to the femoral artery. The femoral pulse should be felt and the needle inserted medial to it with a 45-degree angle. As soon as the vein is cannulated, the angle of the needle is dropped to advance the guidewire.

The SCV takes an acute turn two-thirds away from the sternal notch along the inferior border of the clavicle. The needle access site is located approximately 2 cm under the clavicle with the needle positioned perpendicular to the sagittal plane and parallel to the coronal plane directed toward the sternal notch.³ The SCV is located between the clavicle and the first rib, and the artery is located posterosuperior to the vein. The other approach for the SCV is the supraclavicular approach in which the needle is introduced at a 45-degree angle through the 90-degree angle formed by the lateral border of the SCM and the superior border of the clavicle aiming to the suprasternal notch.

Complications

Central venous access, as any other intervention, is not exempt of complications. Many occur as result of anatomic variations, technical considerations, or coagulation defects, and they should be addressed with the patient during the procedure consent. Several measures can be carried out to decrease the probability of complications such as careful technique with proper patient positioning, aseptic technique during access placement and handling, ultrasound-guided placement when feasible, and so on.

Complications can be broadly classified as acute or late. A relationship has been described between complications and physician’s inexperience. In a paper published by Bernard and Stahl, the complication of subclavian catheter insertion by inexperienced physicians (<50 procedures) was 8%, but in more experienced hands (>50), the complication was nearly 0%.¹⁶

Acute Complications. Most of the time, acute complications are associated with technical errors during catheter insertion. The needle, sheath, wire, or catheter may cause injury to blood vessels, nerves, pleura, airway, or lung during placement. Clinical manifestations may be evident at the time of the procedure, but a high index of suspicion should be maintained because they can also present hours after the catheter insertion. Most of them are not particularly lethal, but they may progress and become life threatening, especially in critically ill or debilitated patients (Table 35-2).

The incidence of these complications depends on site of placement and operator experience. The most common reported complication with subclavian catheters is pneumothorax and catheter sepsis while femoral accesses have a higher rate of thrombosis and infection.^3,17,18 When comparing complications between internal jugular versus subclavian catheterizations, Ruesch et al¹⁹ concluded that there are no differences in the incidence of hemopneumothorax and vessel thrombosis but that the former has more incidence of arterial punctures and a lower incidence of catheter malposition.²⁰

Pneumothorax. This complication occurs after the parietal or visceral pleura are traumatized with the access needle, allowing air to escape into the pleural space. This may cause partial or total collapse of the lung, but if there is a valve-like mechanism, a more life-threatening condition known as tension pneumothorax may ensue. This is a clinical condition manifested by decreased ipsilateral breath sounds, ipsilateral hyperresonance, mediastinal and tracheal deviation to the contralateral side, hypoxemia, and decreased venous return, leading to decreased cardiac output and hypotension. Symptoms may range from the patient’s being completely asymptomatic and showing only radiographic findings to acute, severe respiratory distress and cardiovascular collapse. The treatment of patients with these conditions depends on the patient’s status and the size of the pneumothorax. If the patient is asymptomatic and the pneumothorax is small (<15%), it can be managed conservatively with frequent assessments and follow-up chest radiographs. These patients can be placed on 100% fraction of inspired oxygen to reabsorb the pleural air and assessed frequently because the appearance of symptoms or any increase in size on the chest radiograph warrants some other form of treatment. If the pneumothorax larger than 15%, a thoracostomy tube is recommended. Central venous placement in both sides should never be attempted until pneumothorax on the contralateral side has been ruled out. If the patient shows signs of a tension pneumothorax, the appropriate course of treatment consists of oxygen administration, needle decompression in the second intercostal space midclavicular line, and placement of a thoracostomy tube³ (Figures 35-5 and 35-6).

Hemothorax. Accumulation of blood within the pleural space during central line placement is usually caused by a perforation of the back wall of the SCV or artery and parietal pleura with extravasation of blood around the lung. The clinical presentation may be subtle but may also be accompanied by some degree of respiratory distress; ipsilateral decreased breath sounds; dullness to percussion; and a chest radiograph showing blunting of the costodiaphragmatic angle, fluid layering in the pleural space, and widened mediastinum. Its treatment usually involves placement of a thoracostomy tube for drainage; most resolve with this intervention, but if the patient is hemodynamically unstable or has high chest tube output (>1500 mL on placement or more than 200–300 mL/hr for 4 consecutive hours), surgery may be indicated.³