Part 2: Insertion Techniques and Site Care

1. Pre-Insertion Planning

1.1 Informed Consent

Informed consent should be obtained before CVAD placement, with discussion of:¹²

• The type of device being placed and rationale for selection
• Alternatives considered and reasons for recommendation
• Procedural risks including bleeding, pneumothorax (for subclavian and jugular approaches), arterial puncture, nerve injury, air embolism, arrhythmia, and malposition
• Device-specific long-term risks including infection, thrombosis, and mechanical complications
• Expected benefits relative to the patient’s treatment plan
• Anticipated dwell time and maintenance requirements
• The patient’s right to refuse or request removal at any time

For oncology patients, consent discussions should also address the anticipated need for repeated access over the treatment course, the impact of the device on daily activities and body image, and the expected timeline for removal after treatment completion.³

1.2 Pre-Procedure Assessment

Laboratory Assessment:

Imaging Review:

• Review recent chest imaging for mediastinal pathology, pleural effusions, or SVC obstruction
• Evaluate for venous anomalies identified on prior cross-sectional imaging
• Assess for evidence of prior central venous thrombosis or stenosis
• Review prior CVAD placement records for insertion sites used and any complications

Medication Review:

• Anticoagulants and antiplatelet agents (timing of last dose)
• Agents affecting wound healing (bevacizumab — recommend waiting ≥28 days after last dose before elective port placement due to impaired wound healing)⁴
• Immunosuppressive agents (assess infection risk context)

1.3 Timing Relative to Cancer Treatment

Chemotherapy:

• Ideally, CVADs should be placed before initiation of myelosuppressive chemotherapy to allow insertion during optimal blood counts
• When chemotherapy has already begun, timing insertion during count recovery (nadir + 7–10 days) is preferred
• Urgent insertion during neutropenia or thrombocytopenia may be necessary and can be performed with appropriate supportive care

Anti-Angiogenic Agents:

• Bevacizumab impairs wound healing. The expert panels recommend that port placement be completed at least 28 days before initiating bevacizumab, or that insertion wait until ≥28 days after the last bevacizumab dose.⁴
• Similar considerations apply to other anti-angiogenic agents (ramucirumab, aflibercept)

Radiation Therapy:

• If possible, CVAD placement should precede or follow chest wall radiation to avoid inserting through irradiated tissue
• Active skin reaction (radiation dermatitis) at the planned insertion site is a relative contraindication

2. Insertion Technique

2.1 Maximal Sterile Barrier Precautions

All CVAD insertions — whether port placement, tunneled catheter, nontunneled CVC, or PICC — require maximal sterile barrier precautions as a mandatory component of CLABSI prevention bundles:⁵⁶

• Hand hygiene with antimicrobial soap or alcohol-based hand rub
• Cap (covering all hair)
• Mask (covering nose and mouth)
• Sterile gown
• Sterile gloves
• Full-body sterile drape (covering the patient from head to toe)

Non-compliance with maximal barrier precautions is associated with significantly increased CLABSI rates and is not acceptable in any care setting.

2.2 Skin Antisepsis

Agent of Choice:

Chlorhexidine gluconate (CHG) in an alcohol base (typically 2% CHG in 70% isopropyl alcohol) is the recommended skin antiseptic agent for all CVAD insertions.⁵⁶ This recommendation is supported by multiple randomized controlled trials and meta-analyses demonstrating superiority of CHG-alcohol over povidone-iodine for reducing catheter-related bloodstream infections.

Application Technique:

1. Apply CHG-alcohol solution using a back-and-forth friction scrub
2. Scrub for a minimum of 30 seconds
3. Allow the antiseptic to dry completely before draping (approximately 2 minutes) — this drying time is essential for full antimicrobial efficacy
4. Do not blot, fan, or wipe the antiseptic dry

Contraindications to CHG:

• Known allergy to chlorhexidine (use povidone-iodine as alternative)
• Infants under 2 months of age (use povidone-iodine; CHG may be used with caution in premature infants when the risk-benefit ratio is favorable)
• Application to mucous membranes
• Active dermatitis or open wounds at the application site

2.3 Ultrasound Guidance

Real-time ultrasound guidance is the standard of care for all central venous catheter insertions and is strongly recommended for PICC placement:²⁷

Benefits in Oncology Patients:

• Improved first-attempt success rates
• Reduced number of needle passes and associated vessel trauma
• Lower pneumothorax risk (internal jugular approach)
• Identification of vein thrombosis or stenosis before attempted cannulation
• Assessment of catheter-to-vessel ratio
• Detection of anatomic variants
• Particularly valuable in patients with altered anatomy from prior surgery, radiation, or tumor involvement

Technique:

• Sterile ultrasound probe cover and sterile gel required
• Short-axis (transverse) view for initial vessel identification and needle guidance
• Long-axis (longitudinal) view may provide improved visualization of needle entry into the vessel
• Confirm venous identity by compressibility, respiratory variation, and/or Doppler flow characteristics
• Distinguish artery from vein before needle entry
• Measure vein diameter and calculate anticipated catheter-to-vessel ratio

2.4 Catheter Tip Positioning

Target Location:

The optimal catheter tip position for upper body CVADs is the lower third of the superior vena cava at or near the cavoatrial junction (CAJ). This position provides:²⁷⁸

• Maximum blood flow around the catheter tip (reducing thrombosis risk)
• Reduced risk of vessel wall contact and erosion
• Reliable position for power injection
• Optimal hemodilution of infusates
• Lower risk of cardiac arrhythmia than deeper right atrial positioning

For devices inserted via lower body sites (femoral, transhepatic, translumbar), the catheter tip should be positioned in the inferior vena cava above the level of the diaphragm.

Tip Confirmation Methods:

Intracavitary ECG (IC-ECG) Guidance:

IC-ECG-based tip confirmation during PICC placement has been associated with reduced thrombotic complications compared to traditional positioning methods and is recommended by the vascular access clinical practice guidelines.⁷⁸ The technique uses the guidewire or saline-filled catheter as an intravascular electrode, with the P-wave amplitude indicating catheter tip proximity to the sinoatrial node. The optimal position shows maximum P-wave amplitude at the CAJ.

2.5 Port Placement Technique (Operative)

Port placement is typically performed by surgeons or interventional radiologists under local anesthesia with conscious sedation, or under general anesthesia:³⁹

1. Patient positioning: Supine with slight Trendelenburg; head turned contralateral to insertion side
2. Vein access: Ultrasound-guided puncture of the internal jugular or subclavian vein using Seldinger technique
3. Guidewire advancement: Confirm intravascular position with fluoroscopy
4. Pocket creation: A subcutaneous pocket is created in the infraclavicular region (chest port) or upper arm (arm port) using blunt dissection, sized to accommodate the port body
5. Tunneling: A subcutaneous tunnel is created from the venotomy site to the port pocket
6. Catheter trimming: Cut to length based on measured distance from venotomy to the CAJ
7. Port connection: Catheter secured to port body per manufacturer instructions
8. Catheter advancement: Via peel-away sheath into central vein
9. Tip confirmation: Fluoroscopic or radiographic confirmation of tip at CAJ
10. Port testing: Flush with 10–20 mL of 0.9% sodium chloride; confirm aspiration of blood return
11. Wound closure: Port pocket and venotomy site closed in layers; steri-strips or skin adhesive applied
12. Post-procedure: Chest radiograph to confirm tip position and rule out pneumothorax

Arm Port Considerations:

Arm ports (placed in the upper arm with the catheter inserted via basilic or brachial vein) may be preferred by some patients for cosmetic reasons. Meta-analytic data suggest that total complication rates do not differ significantly between arm and chest ports in general oncology populations, though retrospective data in breast cancer patients specifically have shown increased symptomatic upper extremity DVT with arm ports compared to chest ports.¹⁰¹¹

2.6 PICC Insertion Technique

PICC insertion in oncology patients follows standard modified Seldinger technique under ultrasound guidance:²⁷

1. Vascular assessment: Ultrasound mapping of upper arm veins bilaterally; select vessel with optimal diameter and catheter-to-vessel ratio ≤45%
2. Site selection: Mid-upper arm preferred; basilic vein first choice
3. Preparation: Maximal sterile barrier precautions; CHG-alcohol skin antisepsis
4. Access: Ultrasound-guided needle entry into target vein
5. Guidewire insertion: Advance microintroducer guidewire
6. Catheter advancement: Thread catheter over guidewire to premeasured length
7. Tip confirmation: IC-ECG guidance during insertion or post-insertion chest radiograph
8. Securement: Apply engineered stabilization device (adhesive-based or subcutaneous anchor)
9. Dressing application: Sterile transparent semipermeable membrane (TSM) dressing
10. Documentation: Record vein accessed, catheter size (gauge and length), external catheter length at skin, number of attempts, tip confirmation method and result, and any complications

3. Site Care for CVADs in Oncology

3.1 Dressing Types and Selection

Transparent Semipermeable Membrane (TSM) Dressings:

TSM dressings are the standard of care for all CVAD sites as they allow continuous visualization of the insertion site while providing a barrier against moisture and microbial contamination.²⁵⁶

• Change TSM dressings at minimum every 7 days, or sooner if the dressing becomes damp, loosened, or visibly soiled
• Change immediately if integrity is compromised
• In patients with profuse diaphoresis or oozing at the insertion site, a gauze dressing may be temporarily substituted and changed every 2 days (or every 48 hours) until the site is suitable for TSM application

Gauze Dressings:

• Used when the insertion site is bleeding or oozing and a TSM dressing cannot adhere
• Must be changed every 2 days (48 hours)
• Exception: when gauze is used solely to support noncoring needle wings without obscuring the insertion site, and the gauze remains intact and visibly clean, the TSM dressing interval of 7 days may be maintained⁹

Chlorhexidine-Impregnated (CHG) Dressings:

CHG-impregnated dressings (e.g., CHG-containing gel pads) are recommended for CVAD sites in adult and pediatric patients over 2 months of age as an adjunctive CLABSI prevention measure:⁵⁶⁹

• Particularly important in oncology populations given immunosuppression
• For oncology patients, CHG-containing dressings should be employed around the insertion site when infusion duration exceeds 4 to 6 hours⁹
• Replace CHG dressings per manufacturer recommendations, typically at each dressing change
• Monitor for contact dermatitis (reported in approximately 5–8% of patients)

3.2 Dressing Change Procedure

Standard CVAD Dressing Change Protocol:

1. Perform hand hygiene
2. Don clean gloves; carefully remove existing dressing
3. Inspect the insertion site for signs of infection (erythema, swelling, tenderness, purulent drainage), dislodgement, or skin breakdown
4. Measure and document external catheter length (PICCs and tunneled catheters) — compare to insertion length to detect migration
5. Remove clean gloves; perform hand hygiene
6. Don sterile gloves (or use aseptic non-touch technique [ANTT] per institutional protocol)
7. Cleanse the site with CHG-alcohol using a back-and-forth friction technique for ≥30 seconds
8. Allow antiseptic to dry completely (approximately 2 minutes)
9. Apply CHG-impregnated dressing if indicated
10. Apply TSM dressing, ensuring complete coverage of the insertion site and securement device
11. Label dressing with date of change and clinician initials
12. Document procedure, site assessment findings, and external catheter length

Dressing Change Frequency Summary:

3.3 Securement

Proper catheter securement prevents dislodgement — a leading cause of secondary malposition and unplanned CVAD removal:²⁷

Engineered Stabilization Devices (ESDs):

• Preferred over sutures or tape for PICC and tunneled catheter securement
• Adhesive-based ESDs are changed at each dressing change
• Subcutaneous anchor devices provide additional stabilization and may reduce dislodgement rates; they remain in place for the catheter dwell time
• Sutureless securement reduces needlestick injury risk for clinicians

Sutures:

• May be used for port pocket closure and initial tunneled catheter stabilization
• Should be removed when tissue ingrowth around the Dacron cuff of tunneled catheters is established (typically 2–4 weeks)
• Not recommended as sole long-term securement for PICCs due to suture site infection risk

Port Needle Securement:

• Noncoring needles accessing implanted ports must be secured with sterile tape strips or needle stabilization devices to prevent dislodgement
• Needle dislodgement from a port during vesicant chemotherapy infusion carries high risk of subcutaneous extravasation and tissue necrosis³⁹

3.4 Skin Antisepsis for Ongoing Site Care

At every dressing change, skin antisepsis should be performed using 2% CHG in 70% isopropyl alcohol.⁵⁶ Application requires:

• Back-and-forth friction technique (not circular)
• Minimum 30 seconds of active scrubbing
• Complete drying before dressing application (approximately 2 minutes)
• Avoidance of acetone or other organic solvents

For patients with CHG allergy, povidone-iodine is the alternative antiseptic. Allow povidone-iodine to dry completely (may require longer drying time than CHG-alcohol).

3.5 Site Assessment

Assessment Frequency:

• Inpatient: Every shift (every 8–12 hours) and before each infusion
• Outpatient infusion center: At each visit before initiating therapy
• Home infusion: Daily by patient or caregiver, with instructions to report changes
• At each dressing change

Assessment Parameters:

3.6 Oncology-Specific Site Care Considerations

During Neutropenia:

• Increased vigilance for subtle signs of infection (erythema may be absent in profoundly neutropenic patients)
• Low threshold for blood cultures and site cultures when infection is suspected
• CHG-impregnated dressings recommended throughout neutropenic episodes
• Some institutions increase assessment frequency during severe neutropenia (ANC <500/mm³)

During Thrombocytopenia:

• Gentle technique during dressing changes to minimize bleeding risk
• Avoid adhesive removal agents that may irritate fragile skin
• Consider medical adhesive-related skin injury (MARSI) prevention strategies including skin barrier films
• Apply gentle pressure to any oozing sites after dressing removal

During Active Skin Toxicity:

• Dermatologic toxicity from targeted agents (EGFR inhibitors, kinase inhibitors) or radiation may affect the skin around the CVAD site
• Consult dermatology or wound care specialists for management
• Avoid applying CHG or alcohol-based products to actively broken, weeping, or severely irritated skin
• Modified dressing protocols may be necessary

4. Bathing and Hygiene Protocols

4.1 General Principles

Maintaining an intact, dry, occlusive dressing is essential during bathing. Water exposure to the CVAD site increases infection risk.⁵⁶

PICCs and Tunneled Catheters:

• Shower with waterproof dressing cover or plastic wrap secured above and below the dressing
• No submersion in bath water, swimming pools, hot tubs, or natural bodies of water while the device is in place
• If the dressing becomes wet, change immediately

Implanted Ports (Deaccessed):

• Once the insertion site has fully healed (typically 2–4 weeks post-placement), patients may shower, bathe, and swim without restriction when the port is not accessed
• When accessed with a noncoring needle and dressing, the site must be protected from water exposure

5. Documentation Requirements

5.1 Insertion Documentation

The following information should be documented at the time of CVAD placement:²⁷

• Date and time of insertion
• Indication for device placement
• Device type, manufacturer, lot number, and unique device identifier
• Catheter material (silicone, polyurethane), number of lumens, gauge/French size
• Power-injection rating (for ports and PICCs)
• Insertion site and vein accessed
• Number of attempts
• Use of ultrasound guidance
• Skin antiseptic used
• Tip confirmation method and result (radiographic or IC-ECG)
• External catheter length at skin (PICCs and tunneled catheters)
• Total catheter length inserted
• Dressing and securement method applied
• Patient tolerance and any complications
• Provider performing the procedure

5.2 Ongoing Documentation

At each CVAD assessment and intervention:

• Site appearance and dressing status
• External catheter length (PICCs and tunneled catheters)
• Patency assessment (flush ease, blood return presence)
• Dressing change performed (date, antiseptic used, dressing type)
• Any complications identified and actions taken
• Patient education provided

References