Vascular Access Clinical Pathway — Emergency Department

Guidelines for When to Consider Central Venous Access

Patients with one or more of the following may benefit from having a central venous catheter (CVC) placed. Consult Vascular Access Team [VAS] or Interventional Radiology [IR] for further recommendations.

Therapy/Indication Anticipated Duration
Difficult Access (per definition) All
Non-irritating Medications/Fluids > 72 hours
Irritants/Vesicants > 48 hours
PPN/TPN > 72 hours
Calcium > 1 dose
Transfusions > 48 hours
Multiple Medications and/or Compatibility Issues Always consider
Frequent Venous Blood Sampling > 48 hours

Concern for Renal Failure

Venous Preservation		 > 24 hours

Related Procedures

Central Venous Catheter Selection

Definition of CVC includes: PICC, non-tunneled central catheter (‘temporary CVC’), tunneled cuffed central catheter (e.g. Broviac), implanted port, and umbilical venous catheter.

Selection of the most appropriate central line for a patient is a collaborative process between the patient’s care team and the inserting provider, with decision support available from VAS/IR teams. As the ordering provider, consider the following:

Catheter Type PICC:
  • Patient requires continuous fluid therapy > 72 hours and/or intermittent meds > 48 hours up (e.g. IV antibiotics)
  • Patient requires administration of vesicant(s) and irritant(s) (see table above for duration of therapy information) up to several weeks to months
  • Could be placed in the presence of a bloodstream infection if absolutely necessary (though not optimal). Please consider ID consult.
  • Difficult access
Non-Tunneled Central Catheter:
  • Patient requires multiple points of access for multiple infusates/therapies/monitoring (e.g. ICU patient)
  • Patient requires central access but anticipated duration < 14 days
  • Emergent access (including emergent short term apheresis and dialysis)
  • Difficult access
Tunneled Cuffed Central Catheter:
  • Patient requires long term continuous IV therapy (e.g. TPN dependent patient, active BMT patient etc.)
  • Patient requires long term administration of vesicant(s) and irritant(s) (see table above for duration of therapy information)
  • Should not be placed in the presence of a bloodstream infection
  • Long-term apheresis
  • Long-term dialysis
Port:
  • Patient requires long term intermittent infusion therapy (e.g. solid tumor patient)
  • Chronic patient with limited access requiring intermittent treatment therapies (e.g. Cystic Fibrosis patient or Sickle Cell patient or metabolic patient)
  • Should not be placed in the presence of a bloodstream infection
    Apheresis patient
Umbilical venous catheter:
  • Neonates, typically placed at birth or within first few days of birth
  • Can be used for continuous infusions and intermittent medications
  • Should be removed by 10-14 days (CLABSI risk increases beyond this period)
Number of Lumens
  • Select a line with the fewest necessary lumens to meet the needs of the patient. Additional lumens provide extra portals of entry for infection and are associated with an increased risk of thrombosis.
  • Consult pharmacy and nursing regarding infusate compatibility.
  • Consider need for frequent blood draws or transfusion therapy.
Preference for Line Location
  • Line location should be as far from any potential source of contamination as possible.
  • Increased thrombosis rate is associated with lines placed in the femoral vein versus the upper extremity.
  • For incontinent patients or patients with ileostomy/colostomy, preferred line location may be upper extremity, and/or line entry located away from potential ostomy contamination.
  • For patients with tracheostomy or chronic drooling, preferred line location may be lower extremity, and/or line entry located away from potential contamination (discuss chest access with IR).
  • If head and neck vessels should be spared the risk of clot formation (e.g. single ventricle physiology for future cardiovascular surgery), preferred line location may be lower extremity.
  • For patients with renal compromise, consider Nephrology consultation. If progressive renal disease, avoid lower extremities unless absolutely necessary as a renal transplant requires patent iliac vessels. Also consider avoiding arms and subclavian locations as they may be needed for AV fistula creation. The best option may be IR placement of a small bore PICC line tunneled in the internal jugular vein.
  • For patients with a mediastinal mass, avoid upper body vessels. Patient may require imaging to confirm vessel patency.
  • For toddlers or behaviorally challenged children with need for long-term home access, consider feasibility of line placement exiting out the back. This is technically very challenging and should be discussed directly with the IR team in advance of placement.
  • For emergent apheresis or dialysis, right sided internal jugular vein is usually preferred location due to caliber and stiffness of catheter used.
Additional Line Considerations Antibiotic Impregnated Catheters:
  • Typically impregnated with rifampin and minocycline; impregnation is thought to be effective for a finite period (weeks to months).
  • Types: All non-tunneled central catheters available for insertion at CHOP are antibiotic-impregnated. Antibiotic-impregnated PICCs are available in sizes 3 Fr and greater. Antibiotic-impregnated cuffed tunneled catheters (e.g. Broviacs) are also available in selected sizes.
  • Consider insertion in patients with prior history of CLABSIs or other risk factors for CLABSIs. Discuss patient eligibility with VAS/IR.
  • Ethanol lock compatibility with these types of catheters is unknown. If you anticipate need for ethanol locks, please include that consideration in your discussion with VAS/IR.
Lock Therapy (Ethanol or Antibiotic): Power Injectable Catheters:
  • Power-injectable catheters are needed for performance of certain types of contrast imaging studies.
  • Power-injectable ports are identified by radiographic marking [CT] or by text on external portion of the line.
  • For CVCs inserted at other institutions, consult VAS to identify if catheter is power-injectable.
Transfusion Therapy:
  • Transfusions can be administered through PICCs ≥ 2.6F red lumen. 1.9F PICCs are not eligible for transfusions.

Abbreviations

  • CLABSI: Central line associated bloodstream infection
  • CVC: Central Venous Catheter
  • VTE: Venous thromboembolism
  • PIV: Peripheral IV
  • PN: parenteral nutrition
  • PICC: peripherally inserted central catheter
  • IR: Interventional Radiology
  • VAS: Vascular Access Service