2026 | Supplemental Issue | JAVA

Chapter 4.2—Site Selection

Optimal site selection is a critical component of safe and effective vascular access. The insertion site directly influences the risk of complications, including phlebitis, endothelial injury, thrombosis, catheter malposition, and mechanical failure. Areas of flexion (e.g., antecubital fossa, wrist) are associated with higher rates of dislodgement, occlusion, and patient discomfort.

A thorough evaluation of vessel condition, depth, diameter, and adjacent anatomy supports successful placement and improved outcomes.

All vascular access devices (VADs) require careful site selection to mitigate risks, including catheter-related bloodstream infection (CRBSI), thrombotic events, bleeding, and nerve injury.

Clinical decision-making must be grounded in a comprehensive, patient-specific assessment that integrates therapy indication, duration, vessel health, and anatomic risk. Evidence-based insertion practices enable clinicians to reduce complications, prolong catheter dwell time, and optimize device function.

Recommendation 1: Catheter-to-Vessel Ratio

Health care providers should consider selecting the smallest gauge or French size catheter that meets the prescribed therapy requirements while ensuring adequate blood flow within and around the catheter.

Summary of Evidence

A low catheter-to-vessel ratio (CVR) reduces the risk of mechanical phlebitis, endothelial trauma, and thrombus formation. Catheter flow through an internal lumen is necessary for infusate delivery and blood sampling, but flow around the outer diameter of the catheter is equally critical to preserving vessel health.^1(Vb) Excessive catheter outer diameters compared with vessel diameter ratios have been linked to endothelial irritation, thrombotic events, and early catheter failure.^1(Vb),2(IVa)

Authors of multiple studies have supported the use of smaller diameter catheters to reduce phlebitis, especially when the CVR remains below the 33%–45% threshold. Larger catheters or poor site selection significantly increase the risk of thrombosis, particularly in peripheral veins and low-flow central vessels.^{1(Vb),3(IIb),4(Vb,IIb)}

Recommendation 2: Structured Assessment Using Rapid Assessment of Vascular Exit Site and Tunneling Options

Clinicians may consider using a structured decision-making tool, such as Rapid Assessment of Vascular Exit Site and Tunneling Options (RAVESTO), to guide the selection of insertion sites and exit sites. This approach supports individualized care planning, especially in complex cases or vulnerable populations.

Summary of Evidence

In a 2021 publication, the authors introduced RAVESTO as a decision tool for complex vascular access.^5(Va) The RAVESTO protocol provides a structured framework for evaluating insertion and exit site alignment, particularly in patients with cognitive impairment, skin integrity issues, limited mobility, or a high risk of infection.^5(Va)

Recommendation 3: Chest-to-Arm Tunneling

Chest-to-arm (CTA) tunneling may be considered for patients requiring medium- to long-term central venous access when standard percutaneous catheter insertion results in suboptimal exit site location.

Summary of Evidence

The CTA technique offers an alternative for patients with challenging central access anatomy or skin integrity concerns, such as tracheostomy presence, breast surgery, or chest wall deformities. In a case series, CTA was successfully performed in patients requiring a low-profile exit site away from the chest. No intraprocedural complications (e.g., bleeding, misplacement, infection) were observed.^6(IIIb) The technique allows for improved exit site location while maintaining central venous tip positioning, reducing risks of dressing disruption, dislodgement, and patient discomfort. While larger prospective studies are needed, the CTA method presents a promising option for complex cases.

Recommendation 4: Blunt Tunneler Technique

Clinicians may consider using the blunt tunneler technique during peripherally inserted central catheter (PICC) or centrally inserted central catheter (CICC) insertion when repositioning the exit site improves dressing care, patient comfort, or securement.

Summary of Evidence

The blunt tunneler technique enables clinicians to relocate the exit site of the catheter without compromising access to a deeper or larger-diameter vessel. This approach is beneficial when the direct percutaneous site would result in:

Poor dressing adherence (e.g., groin, axilla)
Excessive movement or flexion (e.g., wrist, antecubital)
Skin integrity issues (e.g., scarring, moisture, ostomies)

Authors of 1 study demonstrated the successful use of blunt tunneling for PICC and CICC placements, including femoral vein access, with no early complications reported.^7(IIIb) The technique enhanced flexibility in exit site selection and supported patient-specific care planning, including nontraditional femoral applications, such as midthigh tunneling, in access-limited patients.^{7(IIIb),8(Vb)}

Recommendation 5: Subcutaneous Track

Subcutaneous track techniques may be used during peripheral midline or PICC insertion to access a larger-diameter vein while maintaining a single skin puncture and placing the dressing in a more stable and manageable location.

Summary of Evidence

This approach involves using a longer needle at a low angle to extend the distance between the skin entry site and the venous insertion site. In contrast with blunt tunneling, which redirects the catheter after venous access is achieved, the subcutaneous track technique adjusts the angle and depth of initial needle entry to reach an optimal vessel while preserving an appropriate external exit site.

This method is practical when:

The ideal vein is further from the optimal skin entry point.
The direct path would place the dressing in an undesirable location.
Vein selection is limited by previous access, thrombosis, or scarring.

Authors have reported reduced rates of^{9(IIIb),10(Ia),11(IIIb),12(Ib)}:

Central line–associated bloodstream infection (CLABSI)
Catheter dislodgement
Thrombosis

Additionally, authors of 1 study demonstrated that tunnel lengths of 4–6 cm struck the optimal balance between dwell time, comfort, and stability in oncology patients.^12(Ia)

Recommendation 6: Prioritize Axillary/Subclavian for CICC

When a CICC is required, clinicians should prioritize the axillary/subclavian vein region over the internal jugular and femoral veins when anatomically and clinically feasible. This site is associated with lower risks of catheter-related thrombosis (CRT) and CRBSI, and it offers advantages for long-term function, dressing integrity, and patient comfort.

Summary of Evidence

The axillary/subclavian vein region offers a favorable balance of accessibility, vessel diameter, and low complication rates for CICCs.

Authors of numerous studies and meta-analyses have supported^{13(IIa),14(IIIb),15(IIb),16(IIIa)}:

Lower colonization and CLABSI rates compared with internal jugular vein (IJV) and femoral veins.
Reduced CRT, particularly in high-risk populations.
Greater anatomical stability for long-term tunneled and implanted devices.

While some clinicians distinguish between ultrasound-guided axillary and landmark-guided subclavian, for the purpose of insertion outcomes, this anatomical segment is best treated as a single, functionally unified access site. The collective evidence supports axillary/subclavian access as the preferred first-line option for CICC placement in stable adult patients, especially when minimizing risks of infection and thrombosis is crucial.^{13(IIa),14(IIIb)}

Recommendation 7: Avoid Femoral Vein Access

The femoral vein should generally be avoided for short-term, nontunneled central venous access in adult patients when other sites are available.

Summary of Evidence

The femoral site presents the highest risk of infection among common central access locations. In a systematic review of intensive care unit (ICU) patients, femoral vein insertion was associated with higher CLABSI rates than axillary/subclavian and IJV access and with a greater risk of colonization by multidrug-resistant organisms such as Pseudomonas aeruginosa and Escherichia coli.^{13(IIa),17(IIIb)} Authors of another study noted increased local inflammation and bloodstream infection rates with femoral access in hematologic malignancy patients.^14(IIIb) Authors of a third study further reported that nonfermenting gram-negative bacilli were disproportionately isolated from femoral site-related infections.^18(IIIa) While femoral access remains useful in emergent or contraindicated upper body scenarios, it should be re-evaluated for replacement as soon as safer alternatives become available.

Recommendation 8: Central VADs Favor Right-Sided Venous Access

When placing central VADs (CVADs) that terminate in the superior vena cava (SVC), clinicians should favor right-sided access when anatomically and clinically feasible. This approach enhances tip trajectory, reduces the risk of malposition, and minimizes the likelihood of thoracic duct injury.

Summary of Evidence

Right-sided venous access is preferred for CVADs that terminate in the SVC, including PICCs, CICCs, tunneled catheters, and totally implanted VADs. The right innominate vein provides a straighter path to the SVC, improving tip accuracy and reducing malposition risk. In contrast, left-sided access traverses the longer, more angulated left brachiocephalic vein, increasing the chance of tip deviation into the azygos vein or other unintended vessels.^{19(IIb),20(IIIb)}

Left-sided access also carries a higher risk of thoracic duct injury, particularly in neck or chest insertions.^2(IVa)

Recommendation 9: Avoid Injury to High-Risk Structures

Clinicians should avoid vascular access insertion sites near major nerves, arteries, and lymph nodes whenever possible. Real-time ultrasound guidance is recommended to reduce the risk of incidental anatomical injury, particularly when working in high-risk anatomical regions.

Summary of Evidence

Anatomical regions containing major neurovascular structures pose a higher risk of injury during vascular access procedures. These include the brachial plexus, femoral nerve, and carotid or subclavian arteries. Injury to these structures can result in severe complications such as hematoma, thrombosis, ischemia, stroke, or neuropathy.^{21(IIIb),22(IIIb)}

Ultrasound guidance is the only commonly available bedside imaging modality that allows for real-time visualization of adjacent nerves and arteries, enabling clinicians to avoid high-risk zones.^23(IVa) Routine ultrasound guidance during catheter insertion has been associated with dramatically reduced complication rates, including near elimination of pneumothorax and arterial injury during tunneled dialysis catheter placements.^22(IIIb) Although nerve bundles and lymph nodes are not always visible with ultrasound, their avoidance should be prioritized when possible, especially in immunocompromised or oncology patients.^22(IIIb)

Recommendation 10: Radial Artery Site

The radial artery is the preferred site for arterial catheterization in adult patients due to its superficial location, robust collateral circulation, and lower risk of complications compared with femoral or brachial sites.

Summary of Evidence

Radial artery access is associated with fewer major complications (e.g., hematoma, ischemia, and infection) than femoral or brachial sites. Its anatomic location allows for easy palpation, real-time ultrasound guidance, and lower risk of limb ischemia due to the collateral support of the ulnar artery.^{24(Va),25(Ib),26(Ib)}

Authors of meta-analyses and randomized clinical trials comparing radial versus femoral or brachial approaches have shown:

Lower risk of major bleeding and limb-threatening ischemia with radial access.^{26(Ib),27(Ib)}
Higher first-attempt success rates and fewer complications when ultrasound guidance is used.^{25(Ib),28(Ia),29(IIIa)}
Improved patient comfort and mobility, particularly in awake, nonsedated patients.^30(Vb)
The superficial and accessible position of the radial artery also enables better infection control, easier dressing maintenance, and securement in most cases.^{31(IVa),32(IVb)}

Recommendation 11: Avoid Flexion Zones for Radial Artery Catheter Insertion

Radial artery catheters should be placed outside of areas of flexion (e.g., wrist crease) to reduce the risk of catheter kinking, occlusion, and dysfunction. Site selection should account for individual anatomical variability and support stable dressing and catheter function.

Summary of Evidence

Radial artery anatomy varies significantly between individuals. Cannulation sites in or near high-flexion zones, such as the wrist, are associated with higher rates of catheter dysfunction, including kinking, occlusion, and waveform loss.^{29(IIIa),32(IVb)} These areas are also more prone to dressing disruption, increased motion, and long-term complications such as localized vessel injury or CRT.^33(Ib)

Ultrasound imaging enables better assessment of radial artery depth and trajectory, facilitating placement in regions with less movement and more stable tissue planes, which improves device performance and patient comfort.^{25(Ib),26(Ib)}

The following points summarize potential benefits, risks, and implementation factors identified in the literature and practice experience. They are intended to guide clinical reflection and local adaptation rather than serve as prescriptive recommendations.

Clinical Considerations

Benefits

Reduced thrombosis risk with axillary/subclavian access: Selecting the axillary/subclavian vein over the internal jugular or femoral veins can reduce the risk of catheter-related deep vein thrombosis.^{15,34,35,36,37}
Lower infection risk with appropriate site selection: Subclavian vein access has the lowest colonization risk compared to internal jugular and femoral veins, reducing the risk of CRBSIs.^13,14,38
Decreased dislodgement and infection risk with tunneling tools: Use of the RAVESTO tool helps identify optimal exit sites for tunneling, lowering the risk of infection and dislodgement, particularly in high-risk patients.⁵

Risks

Higher malposition with left-sided access: Left-sided central lines, especially via the left IJV, are more prone to malposition due to anatomic challenges.^2,20
Increased nerve injury near dense nerve areas: Insertion near high-risk anatomical regions (e.g., brachial plexus or femoral nerve) increases the risk of nerve damage.^39,40
CRBSI variability by patient population: Although subclavian access reduces CRBSI risk in hematologic malignancy patients, it may not offer additional benefit over internal jugular access in transplant populations.^14,38

Implementation Considerations

Use smallest effective gauge: Using the smallest catheter gauge necessary helps maintain flow while reducing complications.⁴¹
Conduct risk stratification before placement: Assess risk factors such as age, malignancy, body mass index, and infusion characteristics when selecting the access site and device.^42,43,44
Prefer right-sided CVAD insertion: Right-sided CVAD placement is preferred to reduce malposition risk, unless contraindicated.^2,20

Barriers to Implementation

Inconsistent application of CVAD tunneling protocols: Limited familiarity with the RAVESTO tool or tunneling best practices may reduce clinician confidence in individualized exit site selection.⁵
Conflicting infection risk data in select populations: Conflicting findings regarding subclavian versus internal jugular access in specific populations (e.g., transplant patients) may complicate decision-making.^14,38

References

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Gorski LA, Lynn Hadaway F, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(Suppl 1):S1–S224. doi:10.1097/NAN.0000000000000396.
Foor JS, Moureau NL, Gibbons D, Gibson SM. Investigative study of hemodilution ratio: 4Vs for vein diameter, valve, velocity, and volumetric blood flow as factors for optimal forearm vein selection for intravenous infusion. J Vasc Access. 2022;25(1):140–148. doi:10.1177/11297298221095287.
Sharp R, Carr P, Childs J, et al. Catheter to vein ratio and risk of peripherally inserted central catheter (PICC)-associated thrombosis according to diagnostic group: a retrospective cohort study. BMJ Open. 2021;11(7):e045895. doi:10.1136/bmjopen-2020-045895.
Ostroff MD, Moureau N, Pittiruti M. Rapid Assessment of Vascular Exit Site and Tunneling Options (RAVESTO): a new decision tool in the management of the complex vascular access patients. J Vasc Access. 2021;24(2):311–317. doi:10.1177/11297298211034306.
Annetta MG, Ostroff M, Marche B, et al. Chest-to-arm tunneling: a novel technique for medium/long term venous access devices. J Vasc Access. 2023;24(1):92–98. doi:10.1177/11297298211026825.
Giustivi D, Gidaro A, Baroni M, Paglia S. Tunneling technique of PICCs and midline catheters. J Vasc Access. 2022;23(4):610–614. doi:10.1177/11297298211002579.
Ostroff M, Moureau N. Review and case studies of midthigh femoral central venous catheter placement. J Assoc Vasc Access. 2018;23(3):167–175. doi:10.1016/j.java.2018.06.004.
Ostroff MD, Moureau NL. Report of modification for peripherally inserted central catheter placement: subcutaneous needle tunnel for high upper arm placement. J Infus Nurs. 2017;40(4):232–237. doi:10.1097/nan.0000000000000228.
Sheng Y, Yang LH, Wu Y, Gao W, Dongye SY. Implementation of tunneled peripherally inserted central catheters placement in cancer patients: a randomized multicenter study. Clin Nurs Res. 2024;33(1):19–26. doi:10.1177/10547738231194099.
Kim IJ, Shim DJ, Lee JH, et al. Impact of subcutaneous tunnels on peripherally inserted catheter placement: a multicenter retrospective study. Eur Radiol. 2019;29(5):2716–2723. doi:10.1007/s00330-018-5917-x.
Li J, Hu Z, Lin X, et al. A randomized controlled trial to compare peripherally inserted central catheter tunnel lengths in adult patients with cancer. Clin J Oncol Nurs. 2023;27(3):295–304. doi:10.1188/23.Cjon.295-304.
Arvaniti K, Lathyris D, Blot S, Apostolidou-Kiouti F, Koulenti D, Haidich AB. Cumulative evidence of randomized controlled and observational studies on catheter-related infection risk of central venous catheter insertion site in ICU patients. Crit Care Med. 2017;45(4):e437–e448. doi:10.1097/CCM.0000000000002092.
Heidenreich D, Hansen E, Kreil S, et al. The insertion site is the main risk factor for central venous catheter-related complications in patients with hematologic malignancies. Am J Hematol. 2022;97(3):303–310. doi:10.1002/ajh.26445.
Wu S, Huang J, Jiang Z, et al. Internal jugular vein versus subclavian vein as the percutaneous insertion site for totally implantable venous access devices: a meta-analysis of comparative studies. BMC Cancer. 2016;16(1):747. doi:10.1186/s12885-016-2791-2.
Belloni S, Caruso R, Cattani D, et al. Occurrence rate and risk factors for long-term central line-associated bloodstream infections in patients with cancer: a systematic review. Worldviews Evid Based Nurs. 2022;19(2):100–111. doi:10.1111/wvn.12574.
Hafeez SB, Ahmed A, Akhtar A, et al. Catheter-related bloodstream infection with femoral central access versus internal jugular access in patients admitting to medical intensive care unit. Cureus. 2022;14(9):e29416. doi:10.7759/cureus.29416.
Buetti N, Ruckly S, Lucet JC, et al. The insertion site should be considered for the empirical therapy of short-term central venous and arterial catheter-related infections. Crit Care Med. 2020;48(5):739–744. doi:10.1097/CCM.0000000000004270.
Sun X, Bai X, Zhang Y, et al. Perioperative and postoperative complications of ultrasound-guided totally implantable venous access ports via the brachiocephalic vein in patients with cancer: a prospective study. J Cancer. 2021;12(5):1379–1385. doi:10.7150/jca.55343.
Ablordeppey EA, Huang W, Holley I, Willman M, Griffey R, Theodoro DL. Clinical practices in central venous catheter mechanical adverse events. J Intensive Care Med. 2022;37(9):1215–1222. doi:10.1177/08850666221076798.
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Aurshina A, Hingorani A, Hingorani A, Marks N, Ascher E. Routine use of ultrasound to avert mechanical complications during placement of tunneled dialysis catheters for hemodialysis. J Vasc Surg Venous Lymphat Disord. 2019;7(4):543–546. doi:10.1016/j.jvsv.2018.12.016.
Pitts S, Ostroff M. The use of visualization technology for the insertion of peripheral intravenous catheters. J Assoc Vasc Access. 2019;24(3):10–14. doi:10.2309/j.java.2019.003.007.
Williams C, Pasrija D, Pierre L, Keenaghan M. Arterial lines. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2025.
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Gu WJ, Wu XD, Wang F, Ma ZL, Gu XP. Ultrasound guidance facilitates radial artery catheterization. Chest. 2016;149(1):166–179. doi:10.1378/chest.15-1784.
Moussa Pacha H, Alahdab F, Al-khadra Y, et al. Ultrasound-guided versus palpation-guided radial artery catheterization in adult population: a systematic review and meta-analysis of randomized controlled trials. Am Heart J. 2018;204:1–8. doi:10.1016/j.ahj.2018.06.007.
Bhattacharjee S, Maitra S, Baidya DK. Comparison between ultrasound guided technique and digital palpation technique for radial artery cannulation in adult patients: an updated meta-analysis of randomized controlled trials. J Clin Anesth. 2018;47:54–59. doi:10.1016/j.jclinane.2018.03.019.
Zhang S, Liu T, Liu Y, Mei W. Effect of ultrasound angle for radial artery cannulation in adults: a randomized controlled trial. Minerva Anestesiol. 2022;88(4):230–237. doi:10.23736/S0375-9393.22.16090-6.
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Bardin-Spencer AJ, Spencer TR. Arterial insertion method: a new method for systematic evaluation of ultrasound-guided radial arterial catheterization. J Vasc Access. 2021;22(5):733–738. doi:10.1177/1129729820944104.
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Heidenreich D, Hansen E, Kreil S, et al. Influence of the insertion site on central venous catheter-related complications in patients undergoing allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant. 2020;26(6):1189–1194. doi:10.1016/j.bbmt.2020.02.007.
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Chapter 4.3—Vessel Preservation Considerations

Preserving vessel health is a core priority in vascular access practice, especially for patients requiring multiple or long-term therapies. Repeated cannulation attempts can lead to thrombosis, infiltration, endothelial damage, and eventual loss of viable access sites, compromising both treatment delivery and patient outcomes.

Common causes of failed cannulation include inadequate assessment, poor technique, inaccurate vessel identification, and suboptimal site selection. These risks are amplified in patients with difficult intravenous access (DIVA), where unsuccessful attempts increase discomfort, delay therapy, and jeopardize future access options.

Although insertion-related complications are addressed in a separate section, this chapter focuses on preserving vessel integrity through the selection of appropriate devices, real-time imaging guidance, and timely escalation when challenges arise. These strategies support safer insertions, reduced complication rates, and the preservation of vessel health.

Recommendation 1: Escalation in DIVA patients

In patients with DIVA, clinicians should escalate to the use of advanced insertion techniques, a vascular access specialist, or both before failed attempts.

Summary of Evidence

DIVA is associated with increased risk of multiple failed insertion attempts, vessel trauma, and early catheter failure. Authors of studies have shown that repeated blind or unsuccessful insertions contribute to loss of viable access sites, increased infection risk, and delays in care delivery.^1(IIa),2(Ib)

Escalation to trained clinicians using ultrasound-guided or advanced insertion techniques improves first-attempt success and preserves vessel health, especially in high-risk patients.^{3(Ib),4(Ib),5(Ib)} Proactive escalation may reduce the need for premature central access and improves patient satisfaction.^6(Ib)

Recommendation 2: Ensure Adequate In-Vessel Catheter Length for All Peripheral Insertions

For all peripheral vascular access device (PVAD) insertions, clinicians should select an appropriate device length for the target vessel and ensure that a sufficient portion of the catheter resides within the vessel to promote stability and reduce the risk of infiltration, dislodgement, and early catheter failure. Clinical guidance suggests that, when feasible, at least two-thirds of the catheter should reside within the vein lumen.

Summary of Evidence

Adequate in-vessel catheter length is a key determinant of secure device placement and long-term function. Clinical guidelines and vascular access literature recommend that at least two-thirds of the catheter length reside within the vessel lumen to reduce the risk of complications such as infiltration, dislodgement, or mechanical failure.^7(IVa)

This principle applies to all patient populations but is especially critical for patients with deep, mobile, or difficult-to-access veins or arteries, where standard-length devices may not provide sufficient purchase. Longer peripheral catheters (5–6 cm) have been shown to reduce failure rates, especially in settings where ultrasound guidance is used to reach deeper vessels.^2(Ib)

Tailoring device length to vessel characteristics improves both clinical outcomes and patient experience.

Recommendation 3: Catheter-to-Vessel Ratio for Thrombosis Risk Reduction

Clinicians should ensure that the catheter-to-vessel ratio (CVR) does not exceed 45%, with a preferred target of <33%, to reduce the risk of catheter-related thrombosis.

Summary of Evidence

CVR quantifies the percentage of the vein lumen occupied by the catheter. Authors of studies have shown that a CVR >45% doubles the risk of thrombosis, particularly in patients with malignancy or hypercoagulable states.^{8(IIIb),9(Vb)}

Maintaining a CVR <33% reduces stasis, improves hemodilution, and supports long-term catheter function. Special caution is required in patients receiving chemotherapy, with reverse taper catheters, or known vascular compromise. Device choice and vein selection must be made concurrently to minimize risk.^{8(IIIb),10(IIb)}

Clinical Considerations

Benefits

Improved safety and satisfaction: Ultrasound guidance improves needle accuracy, reduces complications and delays, and increases first-attempt success, leading to better outcomes and greater patient comfort.^5,11,12
Economic efficiency: Despite initial costs, ultrasound use results in long-term savings through reduced complications, more efficient clinician time use, and decreased waste of supplies from failed attempts.^5,11,12,13

Risks

Financial and operational burden: The initial purchase of ultrasound equipment, ongoing maintenance, and associated supply costs (e.g., gel, probe covers) represent a significant investment.¹⁴ Additionally, the setup, use, and cleanup of ultrasound machines can extend procedure time.^15,16
Training burden and skill loss: Ultrasound-guided access requires ongoing training, and reliance on ultrasound may reduce landmark-based skills needed in some settings.^11,13,15,17
Visualization limitations: Certain anatomical areas, such as the subclavian region, may be more difficult to visualize with ultrasound, potentially complicating catheter placement.¹¹

Implementation Considerations

Competency and training: Ongoing training and competency validation in ultrasound-guided vascular access are essential to ensure safe and effective use.^11,13,15,17
Implementation consideration—equipment availability and support: High-quality, functional ultrasound machines must be consistently available. Institutions should establish regular maintenance schedules, ensure adequate supplies (e.g., probes, gel, disposable covers), and have protocols for prompt repair or replacement.^10,13

Barriers to Implementation

Cost and revenue impact: Upfront costs for ultrasound equipment and training may temporarily reduce revenue. The need for ongoing investment in maintenance and training further challenges implementation, particularly in resource-limited settings.^14,18
Cultural resistance and perceived skill loss: Clinician resistance to change and reliance on traditional landmark-based techniques can hinder adoption. Some also fear that increasing ultrasound use may erode their manual skills.^12,14
Limited device access and planning gaps: Inadequate availability of alternative vascular access devices and lack of care plans for patients with limited options may complicate efforts to avoid high-risk placements, such as catheters with a CVR >45%.^14,18

References

Carr PJ, Rippey JCR, Cooke ML, et al. From insertion to removal: a multicenter survival analysis of an admitted cohort with peripheral intravenous catheters inserted in the emergency department. Infect Control Hosp Epidemiol. 2018;39(10):1216–1221. doi:10.1017/ice.2018.190.
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Baion DE, La Ferrara A, Maserin D, et al. Mono- and bi-plane sonographic approach for difficult accesses in the emergency department—a randomized trial. Am J Emerg Med. 2023;74:49–56. doi:10.1016/j.ajem.2023.09.018.
Mishra A, Kumar M, Kumar N, Goyal K, Soni KD, Yadav A. Short-axis versus long-axis approach for ultrasound-guided vascular access: an updated systematic review and meta-analysis of randomised controlled trials. Indian J Anaesth. 2023;67:S208–S217. doi:10.4103/ija.ija_965_22.
Salleras-Duran L, Fuentes-Pumarola C, Fontova-Almató A, Roqueta-Vall-Llosera M, Cámara-Liebana D, Ballester-Ferrando D. Pain and satisfaction perceptions of ultrasound-guided versus conventional peripheral intravenous catheterization: a randomized controlled trial. Pain Manag Nurs. 2024;25(1):e37–e44. doi:10.1016/j.pmn.2023.07.010.
Sung JM, Jun YE, Jung YD, Kim KN. Comparison of an ultrasound-guided dynamic needle tip positioning technique and a long-axis in-plane technique for radial artery cannulation in older patients: a prospective, randomized, controlled study. J Cardiothorac Vasc Anesth. 2023;37(12):2475–2481. doi:10.1053/j.jvca.2023.08.138.
Gorski LA, Lynn Hadaway F, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(Suppl 1):S1–S224. doi:10.1097/NAN.0000000000000396.
Sharp R, Carr P, Childs J, et al. Catheter to vein ratio and risk of peripherally inserted central catheter (PICC)-associated thrombosis according to diagnostic group: a retrospective cohort study. BMJ Open. 2021;11(7):e045895. doi:10.1136/bmjopen-2020-045895.
Spencer TR, Mahoney KJ. Reducing catheter-related thrombosis using a risk reduction tool centered on catheter to vessel ratio. J Thromb Thrombolysis. 2017;44(4):427–434. doi:10.1007/s11239-017-1569-y.
Kanno C, Murayama R, Abe-Doi M, et al. Development of an algorithm using ultrasonography-assisted peripheral intravenous catheter placement for reducing catheter failure. Drug Discov Ther. 2020;14(1):27–34. doi:10.5582/ddt.2019.01094.
Blanco P. Ultrasound-guided peripheral venous cannulation in critically ill patients: a practical guideline. Ultrasound J. 2019;11(1):27. doi:10.1186/s13089-019-0144-5.
Saugel B, Scheeren TWL, Teboul JL. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care. 2017;21(1):225.
van Loon FHJ, Buise MP, Claassen JJF, Dierick-van Daele ATM, Bouwman ARA. Comparison of ultrasound guidance with palpation and direct visualisation for peripheral vein cannulation in adult patients: a systematic review and meta-analysis. Br J Anaesth. 2018;121(2):358–366. doi:10.1016/j.bja.2018.04.047.
Lee D, Kim JY, Kim HS, Lee KC, Lee SJ, Kwak HJ. Ultrasound evaluation of the radial artery for arterial catheterization in healthy anesthetized patients. J Clin Monit Comput. 2016;30(2):215–219. doi:10.1007/s10877-015-9704-9.
Tran QK, Fairchild M, Yardi I, Mirda D, Markin K, Pourmand A. Efficacy of ultrasound-guided peripheral intravenous cannulation versus standard of care: a systematic review and meta-analysis. Ultrasound Med Biol. 2021;47(11):3068–3078. doi:10.1016/j.ultrasmedbio.2021.07.002.
Seyhan AU, Ak R. Ultrasound guidance versus conventional technique for radial artery puncture in septic shock patients: a pilot study. J Vasc Access. 2023;24(1):133–139. doi:10.1177/11297298211023299.
Yalçınlı S, Karbek Akarca F, Can Ö, Uz İ, Konakçı G. Comparison of standard technique, ultrasonography, and near-infrared light in difficult peripheral vascular access: a randomized controlled trial. Prehosp Disaster Med. 2022;37(1):65–70. doi:10.1017/S1049023X21001217.
Little A, Jones DG, Alsbrooks K. A narrative review of historic and current approaches for patients with difficult venous access: considerations for the emergency department. Expert Rev Med Devices. 2022;19(5):441–449. doi:10.1080/17434440.2022.2095904.

Chapter 4.4—Patient Positioning

Patient positioning is a critical but often underappreciated component of successful vascular access insertion for all vascular access devices (VADs). It affects vein visualization, catheter trajectory, procedural efficiency, and patient comfort. While certain positions, like supine or Trendelenburg, are often used as defaults, many patients cannot tolerate these postures due to clinical or anatomical limitations.

Unlike other insertion elements that lend themselves to standardized workflows, positioning must remain highly individualized, shaped by the patient’s condition, body habitus, care environment, and the provider’s experience. Across surgical, home care, and emergency settings, clinicians must tailor positioning strategies to the unique needs of each patient. This chapter offers practical guidance and evidence-based positioning strategies across common scenarios but emphasizes a core truth: No one-size-fits-all approach exists. Successful access requires flexibility, clinical judgment, and a willingness to think beyond the supine.

General Principles of Positioning for Vascular Access Success

Promote vein visibility and needle trajectory without causing discomfort or harm.
Consider neutral limb positioning to avoid tension or compression.
Prioritize anatomical alignment (e.g., shoulder retraction for axillary access).
Avoid high-flexion joints.
Adapt to the care environment (hospital bed to kitchen table).
Never compromise airway, perfusion, or patient stability for access convenience.

Recommendation 1: Comfortable Arm Position for Peripherally Inserted Catheters

A stable, comfortable patient arm position should be maintained during insertion of all peripherally inserted catheters to support vein access, facilitate catheter advancement, and reduce the risk of malposition or mechanical complications.

Summary of Evidence

Arm positioning influences cannulation success, catheter stability, and tip location, particularly for peripheral midline (PML) and peripherally inserted central catheter (PICC) insertions. Changes in limb position can alter catheter trajectory and cause tip migration, particularly a cephalad shift in PICCs.^{1(IIIb),2(IIb)} Maintaining a comfortable, stable arm position during and after insertion improves catheter trajectory and reduces the likelihood of kinking, malposition, or migration.^3(Ia)

In addition, supine positioning has been shown to increase vein diameter, visibility, and palpability compared with seated positioning, improving access success rates, even in difficult intravenous access patients. In a prospective trial of healthy adults, researchers found a statistically significant increase in forearm vein cross-sectional area and visibility when patients were supine with a tourniquet, supporting this as a preferred position for peripheral intravenous catheter insertion when possible.^4(IIb)

Recommendation 2: Trendelenburg Position for Internal Jugular Vein Access

Trendelenburg positioning may be used to improve success rates during internal jugular vein (IJV) catheterization by enhancing venous distension and reducing air embolism risk.

Summary of Evidence

Trendelenburg positioning increases venous filling and cross-sectional vein diameter, which improves the likelihood of successful IJV cannulation.^5(IIa) However, many critically ill patients do not tolerate this position due to cardiorespiratory compromise or increased intracranial pressure, limiting its application.^6(IVb)

Recommendation 3: Positioning Considerations for Obese Patients Requiring Axillary/Subclavian Access

For obese patients undergoing axillary/subclavian vein catheterization, a neutral or slightly extended head position with gentle midshoulder retraction may enhance vessel accessibility and procedural success.

Summary of Evidence

In patients with increased body habitus, excess soft tissue can obscure vascular landmarks. Adjusting head and shoulder position improves thoracic inlet alignment, increases axillary/subclavian vein cross-sectional area, and improves ultrasound visualization and cannulation success.^7(IIa)

Recommendation 4: Upright Insertion for Patients Unable to Lie Flat

For patients unable to tolerate a supine position due to respiratory compromise, musculoskeletal limitations, or other clinical factors, clinicians may consider performing catheter insertion in a seated or semiupright position when feasible and safe to do so.

Summary of Evidence

In patients with orthopnea, dyspnea, or spinal deformities, upright positioning allows safe and effective insertion of PICCs, PMLs, or totally implanted VADs. Authors of studies have demonstrated that insertions in a seated position are feasible and safe when supine positioning is contraindicated.^8(IIb)

Recommendation 5: Prone-Dependent PICC Insertions

PICC insertion may be safely performed in the prone position when repositioning is not feasible due to patient condition (e.g., spinal injury, severe respiratory failure, or prone ventilation). Procedural success requires specific technique modifications and team coordination.

Summary of Evidence

Prone insertion of PICCs has been successfully described in case studies involving critically ill patients. Safe performance requires modification of technique, including lateral or posterior probe positioning, secure arm stabilization, and team-based coordination.^9(Vb) Imaging and tip confirmation may require alternate workflows.

Clinical Considerations

Benefits

Improved access in high-risk patients: Alternative positioning strategies, such as PICC-PORT placement in the sitting position or prone PICC insertion, offer safe and effective access for patients who cannot tolerate the supine position.^8,9
Increased procedural success: Techniques such as Trendelenburg positioning for IJV access and head/shoulder adjustment in obese patients improve vein accessibility and increase catheterization success rates.^5,7
Reduced malposition risk: Maintaining a neutral arm position and using real-time ultrasound with post-insertion imaging helps prevent catheter tip migration and malposition.^1,2,10

Risks

Contraindications to standard positioning: Critically ill patients may be unable to tolerate positions like Trendelenburg due to respiratory distress, hemodynamic instability, or increased intracranial pressure.⁶
Catheter migration due to patient movement: Body position changes post-insertion (e.g., sitting to supine) can result in catheter tip displacement, potentially compromising function or safety.¹
Procedural complexity: Techniques like prone PICC insertion require significant procedural adjustments and specialized skill, which may increase difficulty and error risk.⁹

Implementation Considerations

Patient assessment: Evaluate individual tolerance for positioning (e.g., Trendelenburg, supine, prone) prior to catheter placement to minimize complications.^5,6,8
Use of imaging and guidance: Employ real-time ultrasound and confirmatory imaging to ensure correct tip placement, especially in patients with altered body positions.¹
Staff training on modified techniques: Clinicians should be trained in alternative positioning methods (e.g., prone or sitting PICC placement) and how to adapt procedures accordingly.⁹

Barriers to Implementation

Limited expertise in nonstandard techniques: Lack of familiarity or training in prone or sitting-position catheter placements may limit adoption of these safe alternatives.⁹
Equipment and imaging constraints: Access to real-time ultrasound and postplacement imaging may be limited in some settings, affecting catheter tip verification.¹
Variability in patient cooperation: Patients unable to maintain steady or neutral positioning (due to agitation, discomfort, or physical limitations) may increase the risk of malposition or procedural failure.^1,2,10

References

Liu C, Jiang D, Jin T, et al. Impact of body posture change on peripherally inserted central catheter tip position in Chinese cancer patients. J Vasc Access. 2020;21(5):732–737. doi:10.1177/1129729820904833.
Cho CH, Schlattmann P, Nagel S, Schmittbuttner N, Hartung F, Teichgraber UK. Cephalad dislocation of PICCs under different upper limb positions: influence of age, gender, BMI, number of lumens. J Vasc Access. 2018;19(2):141–145. doi:10.5301/jva.5000809.
Ahn JH, Kim IS, Shin KM, et al. Influence of arm position on catheter placement during real-time ultrasound-guided right infraclavicular proximal axillary venous catheterization. Br J Anaesth. 2016;116(3):363–369. doi:10.1093/bja/aev345.
Yamagami Y, Inoue T. Patient position affects venodilation for peripheral intravenous cannulation. Biol Res Nurs. 2020;22(2):226–233. doi:10.1177/1099800419893027.
Garcia-Leal M, Guzman-Lopez S, Verdines-Perez AM, et al. Trendelenburg position for internal jugular vein catheterization: a systematic review and meta-analysis. J Vasc Access. 2023;24(2):338–347. doi:10.1177/11297298211031339.
Burghold CM, Hohenstein C, Rueddel H. Trendelenburg position in the ED: many critically ill patients in the emergency department do not tolerate the Trendelenburg position. Eur J Emerg Med. 2019;26(3):212–216. doi:10.1097/MEJ.0000000000000525.
Kim H, Chang JE, Won D, et al. Effect of head and shoulder positioning on the cross-sectional area of the subclavian vein in obese subjects. Am J Emerg Med. 2021;50:561–565. doi:10.1016/j.ajem.2021.08.013.
Narita A, Takehara Y, Maruchi Y, et al. Usefulness of peripherally inserted central catheter port system (PICC-PORT) implantation in the sitting position: a new technique for cases unsuitable for conventional implantation. Jpn J Radiol. 2023;41(1):108–113. doi:10.1007/s11604-022-01317-7.
Patrona-Aurand R, Lovett KA, Kochur K. Innovative positioning for peripherally inserted central catheter insertion on a prone patient. J Assoc Vasc Access. 2016;21(4):212–216. doi:10.1016/j.java.2016.06.004.
Ahn JH, Kim IS, Shin KM, et al. Influence of arm position on catheter placement during real-time ultrasound-guided right infraclavicular proximal axillary venous catheterization. Br J Anaesth. 2016;116(3):363–369. doi:10.1093/bja/aev345.

Chapter 4.5—Pain Management Strategies

Pain during vascular access device (VAD) insertion is often underestimated, especially in adult patients. While pediatric protocols routinely integrate analgesia and comfort techniques, pain management in adult vascular access remains inconsistent, frequently dismissed, or bypassed altogether.

For patients who require repeated access, such as those receiving chemotherapy, dialysis, or critical care, this oversight is more than discomfort; it is cumulative harm. Poorly managed pain leads to vasoconstriction, increased insertion attempts, elevated anxiety, and in many cases, mistrust and trauma that follow patients across care episodes.

Effective pain control is not optional. It improves procedural success, supports patient cooperation, and demonstrates respect for the patient’s experience. Pharmacologic options can be paired with nonpharmacologic techniques. These interventions are simple, evidence-based, and cost-effective.

However, barriers remain, such as time pressure, lack of protocols, and clinician bias, all of which contribute to undertreatment. Standardizing preprocedural pain strategies as part of routine VAD insertion planning reinforces the values of safety, dignity, and patient-centered care. Everyone deserves vascular access that is skilled and compassionate.

Recommendation 1: Use of Topical Anesthetics for Peripheral Access

Topical anesthetics, such as lidocaine sprays, vapocoolants, or anesthetic creams, may be applied aseptically before peripheral intravenous catheter (PIVC) insertion to reduce pain associated with skin puncture.

Summary of Evidence

A variety of topical agents are commercially available in both spray and cream formulations. Selection should be guided by local availability, regulatory approval, and clinical context. A Cochrane review of 12 randomized controlled trials found that vapocoolant spray reduced insertion pain by an average of 12.5 points on a 100-point visual analog scale compared with placebo or no treatment.^1(Ia) A second systematic review and network meta-analysis identified 2% lidocaine cream as the most effective topical agent, with pain score reductions of approximately 13% without compromising sterility or procedural success.^2(IIIa)

Recommendation 2: Use of Intradermal and Subcutaneous Local Anesthetic

Intradermal and subcutaneous lidocaine may be administered before the insertion of peripheral midlines, central VADs, and arterial catheters. It may also be used for PIVC insertions.

Summary of Evidence

Intradermal and subcutaneous infiltration with 1%–2% lidocaine provides deeper anesthesia than topical agents, particularly for insertions involving larger-bore needles or longer procedural duration. Authors of multiple trials have supported lower pain scores, improved patient satisfaction, and no increase in insertion difficulty or complications.^{2(IIIa),3(Ib)}

Intradermal or subcutaneous infiltration is based on the clinician’s assessment of the depth of the vessel, possible tunneling, or totally implanted VAD placement.^{2(IIIa),3(Ib)} In comparative studies, intradermal lidocaine was found to be as effective as topical anesthetic creams and more effective than a placebo for venous cannulation discomfort.^3(Ib),4(Ib)

Recommendation 3: Use of Nonpharmacologic Interventions

Clinicians may use nonpharmacologic interventions, such as distraction techniques, guided imagery, aromatherapy, or virtual reality (VR), as adjuncts to reduce anxiety and perceived pain during vascular access insertion.

Summary of Evidence

In a randomized trial, VR distraction combined with visual stimuli reduced insertion-related pain by 28% compared with standard care. A follow-up study combining VR, rose oil aromatherapy, and handholding reduced pain by 48%, with no workflow delays or complications.^5(Ia),6(IIb) These methods help modulate pain perception and improve patient experience.⁵

Recommendation 4: Assess and Confirm Adequate Anesthesia

Clinicians should assess and confirm adequate local anesthesia before proceeding with catheter insertion. If the patient experiences significant discomfort, pause to reassess the effectiveness or dosage of the anesthetic before continuing.

Summary of Evidence

Inadequate anesthesia leads to increased patient movement, distress, and procedure-related complications. Failure to address visible discomfort has been associated with higher rates of malposition, infiltration, and negative patient recall. Reinforcing anesthetic verification as a standard procedural checkpoint improves both clinical outcomes and trust in care.^{1(Ia),2(IIIa)}

Clinical Considerations

Benefits

Reduced procedural pain: Nonpharmacological methods such as VR, aromatherapy, and handholding significantly reduce pain during intravenous (IV) insertion, with up to a 48% decrease in pain scores reported.^5,6
Topical anesthetics, including vapocoolant sprays and 2% lidocaine, also effectively lower pain scores by 12.5%–13% on standardized scales.^1,2
Higher patient satisfaction: Both VR-based and topical anesthetic interventions are associated with improved patient comfort and satisfaction without interfering with procedural success.^1,2,5,6
Rapid onset and workflow compatibility: Topical agents like vapocoolants act quickly (within seconds to 2 minutes) and do not delay IV placement or compromise aseptic technique.^1,2

Risks

Limited generalizability: Evidence supporting VR and aromatherapy is promising but based on small studies; broader replication is needed before widespread adoption.^5,6
Potential allergic or skin reactions: Though rare, patients may experience skin irritation or allergic responses to topical anesthetics like lidocaine.^1,2
Distraction-related limitations: Some patients may find VR equipment uncomfortable or distracting in ways that interfere with cooperation during the procedure.⁵

Implementation Considerations

Training and protocols: Staff should be trained in the application of VR systems, topical anesthetics, and distraction techniques to ensure consistent use and patient safety.^1,2,5,6
Patient selection: Not all patients may be suitable for VR or aromatherapy (e.g., those with sensory sensitivities or respiratory issues); interventions should be tailored accordingly.^5,6
Integration into workflow: Both nonpharmacological and pharmacological interventions must be integrated into clinical routines without delaying IV insertion; authors of existing studies have reported compatibility.^1,2,5,6

Barriers to Implementation

Equipment availability and cost: VR headsets, optical illusion tools, and aromatherapy supplies may not be readily available in all settings, especially those with limited budgets.^5,6
Limited evidence for VR strategies: While initial findings are positive, the lack of large-scale studies may limit institutional buy-in or formal guideline endorsement.^5,6
Variable clinician adoption: Differences in provider familiarity, confidence, or perceived value of pain management adjuncts may hinder consistent use of these strategies.^1,2

References

Griffith RJ, Jordan V, Herd D, Reed PW, Dalziel SR. Vapocoolants (cold spray) for pain treatment during intravenous cannulation. Cochrane Database Syst Rev. 2016;4(4):Cd009484. doi:10.1002/14651858.CD009484.pub2.
Bond M, Crathorne L, Peters J, et al. First do no harm: pain relief for the peripheral venous cannulation of adults, a systematic review and network meta-analysis. BMC Anesthesiol. 2015;16(1):81. doi:10.1186/s12871-016-0252-8.
Rüsch D, Koch T, Spies M, Hj Eberhart L. Pain during venous cannulation. Dtsch Arztebl Int. 2017;114(37):605–611. doi:10.3238/arztebl.2017.0605.
Metry AA, Kamal MM, Ragaei MZ, Nakhla GM, Wahba RM. Transdermal ketoprofen patch in comparison to eutectic mixture of local anesthetic cream and subcutaneous lidocaine to control pain due to venous cannulation. Anesth Essays Res. 2018;12(4):914–918. doi:10.4103/aer.AER_166_18.
Basak T, Duman S, Demirtas A. Distraction-based relief of pain associated with peripheral intravenous catheterisation in adults: a randomised controlled trial. J Clin Nurs. 2020;29(5–6):770–777. doi:10.1111/jocn.15131.
Basak T, Demirtas A, Duman S. The effect of rose oil aromatherapy and hand-holding on pain due to peripheral intravenous catheter insertion. Explore (NY). 2024;20(1):62–69. doi:10.1016/j.explore.2023.06.002.

Chapter 4.6—Vein Visualization

Vein visualization is a foundational skill in vascular access practice, encompassing both technology-assisted techniques and manual assessment strategies. While ultrasound has transformed modern insertion practices by improving accuracy, safety, and first-attempt success, not all care settings or clinicians have access to this technology. For many patients and providers, especially those in ambulatory, home, or underresourced settings, reliance on visual, tactile, and positioning-based methods remains essential to identifying viable veins. When available and appropriately applied, ultrasound guidance is the gold standard for vascular access in patients with difficult intravenous access (DIVA), deep vessels, or high-risk anatomy. However, vein visualization should not be considered an ultrasound-or-nothing practice. Tools such as near-infrared (NIR) imaging, transillumination, and even simple moist heat and limb dependency techniques can enhance visibility and support successful cannulation. Success does not come from the tool alone but from the clinical judgment behind it.

Recommendation 1: Use Visualization Before All Vascular Access Insertions

Clinicians should assess and visualize the target vein before vascular access device insertion, using the most appropriate method available in their care setting. Visualization may include direct inspection, palpation, or technology-assisted modalities such as ultrasound or NIR imaging.

Summary of Evidence

Vein visualization before insertion improves first-attempt success and reduces procedural complications. Authors of multiple systematic reviews and randomized controlled trials have demonstrated that ultrasound guidance significantly increases the success of cannulation, especially in patients with DIVA.^{1(IIb),2(Ia),3(Ib)}

While visualization methods vary across clinical settings, all vascular access insertions should begin with an assessment of vein location, depth, and patency using the best available visualization technique, whether visual, tactile, or technology-assisted.^{1(IIb),2(Ia),3(Ib),4(IVa)}

Recommendation 2: Dynamic Ultrasound Guidance for Peripheral Intravenous Catheter Insertion

Clinicians should use dynamic (real-time) ultrasound guidance during vascular access insertion, particularly for patients with challenging intravenous (IV) access, deep vessels, or nonpalpable veins, to enhance cannulation success and minimize complications.

Summary of Evidence

Dynamic ultrasound guidance enhances first-attempt success, reduces the number of attempts, and lowers the risk of mechanical complications, including infiltration, arterial puncture, and catheter malposition. In a meta-analysis, van Loon et al. confirmed that dynamic ultrasound significantly outperformed palpation or landmark-based methods for PIVC insertion.^1(IIb)

Static ultrasound (where the vessel is located and marked but not actively visualized during cannulation) is less effective, especially in high-risk patients.^3(Ib) Dynamic use of ultrasound allows the clinician to continuously visualize the needle tip, vessel trajectory, and insertion angle, resulting in improved accuracy and patient safety.^{1(IIb),2(Ia),3(Ib),4(IVa)}

Authors of multiple studies have recommended assessing depth (<1.5 cm), nonthrombosed status, and straight trajectory prior to PIVC insertion. Preprocedural mapping also supports appropriate catheter length planning and optimizes the catheter-to-vein ratio, reducing thrombosis risk.^{5(IIIb),6(Vb)}

Recommendation 3: Dynamic Needle Tip Positioning

When using ultrasound to guide vascular access insertion, clinicians should employ dynamic needle tip positioning (DNTP) to enhance procedural accuracy and minimize the risk of mechanical complications.

Summary of Evidence

DNTP techniques are preferred over static or blind insertion approaches and should be used by trained personnel. DNTP refers to the continuous tracking of the needle tip under real-time ultrasound as it advances toward and enters the vessel. Compared with static techniques or short-axis scanning with out-of-plane insertions, DNTP improves tip visibility, trajectory control, and first-attempt success, especially for deep or difficult-to-access vessels.^2(Ia),4(IVa)

In a randomized controlled trial, Privitera et al. demonstrated that DNTP techniques, using either short- or long-axis guidance, significantly improved success rates and reduced complications in patients with difficult access.^7(Ib) This technique is increasingly promoted in vascular access literature as the preferred method for ultrasound-guided insertion.^{1(IIb),2(Ia),3(Ib),4(IVa),7(Ib)}

Recommendation 4: Ultrasound-Guided Insertion for Central Venous Access Devices

Clinicians should use dynamic ultrasound guidance during insertion of centrally inserted central catheters and peripherally inserted central catheters (PICCs) to reduce insertion-related complications and improve procedural success.

Summary of Evidence

Ultrasound guidance significantly reduces the risk of arterial puncture, nerve injury, pneumothorax, and failed cannulation during central venous access procedures. It is the standard of care for internal jugular vein and axillary/subclavian vein access, as recommended by major guidelines and standards.^{1(IIb),2(Ia),3(Ib),4(IVa),7(Ib)}

Real-time visualization of vessel anatomy and needle advancement enables safer and more accurate cannulation, particularly in patients with altered anatomy, coagulopathies, or poor landmarks. DNTP techniques further enhance safety by minimizing misplacement and vessel trauma.⁷ For PICCs, ultrasound supports vein mapping, trajectory alignment, and selection of vessels with appropriate diameter and depth, especially in the upper arm.^{1(IIb),2(Ia),3(Ib),4(IVa),7(Ib)}

Recommendation 5: Ultrasound Guidance for Radial Artery Catheterization

Clinicians should use dynamic ultrasound guidance during radial artery catheter insertion to improve first-attempt success and reduce complications.

Summary of Evidence

Ultrasound guidance improves first-pass success, shortens procedure time, and reduces the risk of complications, including hematoma, posterior wall puncture, and vasospasm.^{1(IIb),2(Ia),3(Ib),7(Ib)} However, the radial artery is surrounded by nerves and sensitive tissues, and arterial puncture is consistently rated as more painful than other venous cannulation.^{1(IIb),2(Ia),3(Ib),4(IVa),7(Ib)}

Pain management is often overlooked in arterial procedures. The use of local anesthetic (e.g., lidocaine infiltration) prior to radial cannulation has been shown to reduce pain without impairing visualization or success.^8(Ib) Insertion near the wrist crease should be avoided when possible to reduce movement-related failure, improve dressing adherence, and enhance catheter stability.^{9(Vb),10(IVa)}

Recommendation 6: Use Ultrasound for Vessel Selection During PICC and Peripheral Midline Placement

Clinicians should use ultrasound to assess and select the optimal vein prior to peripheral midline (PML) or PICC placement. Vein selection should be based on vessel depth, diameter, compressibility, and trajectory, with preference given to sites that support catheter-to-vessel ratio, securement, and long-term function.

Summary of Evidence

Ultrasound provides a comprehensive assessment of the upper-arm vasculature before insertion. Proper mapping improves vein selection, minimizes insertion attempts, and reduces mechanical complications.^4(IVa),6(Vb) Authors of multiple studies have recommended assessing diameter (≥3 mm) and nonthrombosed status before PICC or PML insertion. Preprocedural mapping also supports appropriate catheter planning and optimizes the catheter-to-vein ratio, reducing thrombosis risk.^{5(IIIb),6(Vb)}

Clinical Consideration

Benefits

Increased insertion success: Ultrasound-guided IV catheterization improves first-attempt success rates and reduces the number of attempts, especially in DIVA patients.^7,11
Fewer mechanical complications: Ultrasound guidance reduces risks of arterial puncture, hematoma, and malposition, decreasing the need for postprocedural imaging.^7,12,13,14
Enhanced patient satisfaction: Ultrasound-guided catheterization is associated with higher satisfaction, particularly among patients with difficult access.¹¹

Risks

Increased catheter failure in high-risk patients: Ultrasound-guided PIVCs may have higher failure rates, possibly due to catheter length or placement in patients with poor vascular status.¹⁵
Longer procedure time: Ultrasound guidance slightly increases the time required for catheter placement (7.89 versus 5.1 minutes; P = 0.045).¹¹
No significant pain reduction: Despite fewer attempts, authors of studies have shown no statistically significant difference in pain scores between ultrasound and traditional methods.¹¹

Implementation Considerations

Training is essential: Successful outcomes depend on nurses being trained and competent in ultrasound-guided insertion techniques.¹¹
Catheter selection: Optimal catheter length improves dwell time and reduces failure.^11,15

Barriers to Implementation

Equipment and resource limitations: Lack of immediate access to ultrasound requires reliance on landmark methods.^1,3
Limited benefit in non-DIVA patients: In patients with easily accessible veins, landmark techniques may be faster and equally effective for PIVCs.^1,3,16,17
Increased failure in certain placements: Ultrasound-guided PIVCs may be more prone to failure when inserted in less favorable anatomical sites or in sicker patients.¹⁵

References

van Loon FHJ, Buise MP, Claassen JJF, Dierick-van Daele ATM, Bouwman ARA. Comparison of ultrasound guidance with palpation and direct visualisation for peripheral vein cannulation in adult patients: a systematic review and meta-analysis. Br J Anaesth. 2018;121(2):358–366. doi:10.1016/j.bja.2018.04.047.
Poulsen E, Aagaard R, Bisgaard J, Sørensen HT, Juhl-Olsen P. The effects of ultrasound guidance on first-attempt success for difficult peripheral intravenous catheterization: a systematic review and meta-analysis. Eur J Emerg Med. 2023;30(2):70–77. doi:10.1097/mej.0000000000000993.
McCarthy ML, Shokoohi H, Boniface KS, et al. Ultrasonography versus landmark for peripheral intravenous cannulation: a randomized controlled trial. Ann Emerg Med. 2016;68(1):10–18. doi:10.1016/j.annemergmed.2015.09.009.
Gorski LA, Lynn Hadaway F, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(Suppl 1):S1–S224. doi:10.1097/NAN.0000000000000396.
Sharp R, Carr P, Childs J, et al. Catheter to vein ratio and risk of peripherally inserted central catheter (PICC)-associated thrombosis according to diagnostic group: a retrospective cohort study. BMJ Open. 2021;11(7):e045895. doi:10.1136/bmjopen-2020-045895.
Spencer TR, Mahoney KJ. Reducing catheter-related thrombosis using a risk reduction tool centered on catheter to vessel ratio. J Thromb Thrombolysis. 2017;44(4):427–434. doi:10.1007/s11239-017-1569-y.
Privitera D, Mazzone A, Pierotti F, et al. Ultrasound-guided peripheral intravenous catheters insertion in patient with difficult vascular access: short axis/out-of-plane versus long axis/in-plane, a randomized controlled trial. J Vasc Access. 2022;23(4):589–597. doi:10.1177/11297298211006996.
Metry AA, Kamal MM, Ragaei MZ, Nakhla GM, Wahba RM. Transdermal ketoprofen patch in comparison to eutectic mixture of local anesthetic cream and subcutaneous lidocaine to control pain due to venous cannulation. Anesth Essays Res. 2018;12(4):914–918. doi:10.4103/aer.AER_166_18.
Imbrìaco G, Monesi A, Spencer TR. Preventing radial arterial catheter failure in critical care—factoring updated clinical strategies and techniques. Anaesth Crit Care Pain Med. 2022;41(4):101096. doi:10.1016/j.accpm.2022.101096.
Bardin-Spencer A, Spencer TR. Ultrasound-guided peripheral arterial catheter insertion by qualified vascular access specialists or other applicable health care clinicians. J Assoc Vasc Access. 2020;25(1):48–50. doi:10.2309/j.java.2019.003.008.
Salleras-Duran L, Fuentes-Pumarola C, Fontova-Almató A, Roqueta-Vall-Llosera M, Cámara-Liebana D, Ballester-Ferrando D. Pain and satisfaction perceptions of ultrasound-guided versus conventional peripheral intravenous catheterization: a randomized controlled trial. Pain Manag Nurs. 2024;25(1):e37–e44. doi:10.1016/j.pmn.2023.07.010.
Ye W, Li D, Ji X, et al. Real-time ultrasound-guided internal jugular vein cannulation by oblique-axis in-plane: practice at the Fourth Hospital of Hebei Medical University. Int J Clin Pract. 2021;75(2):e13673. doi:10.1111/ijcp.13673.
Raio C, Elspermann R, Kittisarapong N, et al. A prospective feasibility trial of a novel intravascular catheter system with retractable coiled tip guidewire placed in difficult intravascular access (DIVA) patients in the emergency department. Intern Emerg Med. 2018;13(5):757–764. doi:10.1007/s11739-017-1747-0.
Woodland DC, Randall Cooper C, Farzan Rashid M, et al. Routine chest x-ray is unnecessary after ultrasound-guided central venous line placement in the operating room. J Crit Care. 2018;46:13–16. doi:10.1016/j.jcrc.2018.03.027.
Carr PJ, Rippey JCR, Cooke ML, et al. From insertion to removal: a multicenter survival analysis of an admitted cohort with peripheral intravenous catheters inserted in the emergency department. Infect Control Hosp Epidemiol. 2018;39(10):1216–1221. doi:10.1017/ice.2018.190.
Busch JD, Vens M, Mahler C, Herrmann J, Adam G, Ittrich H. Complication rates observed in silicone and polyurethane catheters of totally implanted central venous access devices implanted in the upper arm. J Vasc Interv Radiol. 2017;28(8):1177–1183. doi:10.1016/j.jvir.2017.04.024.
Fosh B, Canepa M, Eaton M. Long-term venous access insertion: “the learning curve.” ANZ J Surg. 2016;86(12):1038–1041. doi:10.1111/ans.13338.

Tip navigation is a critical safeguard in every central vascular access procedure. Accurate catheter tip navigation and confirmation are essential to the safety and effectiveness of central vascular access device (CVAD) insertion. Proper placement within the cavoatrial junction (CAJ) or lower third of the superior vena cava (SVC; in the case of femoral approaches, the inferior vena cava), supports reliable infusion, minimizes complications, and ensures long-term device function.

When catheter tips are malpositioned, whether too proximal, too distal, or outside the target vessel, the risks of dysfunction and serious complications increase substantially. These events not only compromise therapy but also contribute to patient harm and additional health care burden.

Due to these consequences, the consistent use of reliable navigation and confirmation methods has become a cornerstone of best practice in vascular access. Multiple technologies are available, and their appropriate application enhances procedural safety, optimizes outcomes, and builds patient and clinician confidence in the device.

Recommendation 1: Confirm CVAD Tip Location Prior to Use

Clinicians must verify and document the final catheter tip location before initiating infusion therapy. Confirmation should be performed using appropriate technology based on the clinical setting.

Summary of Evidence

Proper catheter tip location, at the CAJ or lower third of the SVC, minimizes the risk of malfunction, arrhythmias, vessel erosion, and catheter-related ventricular tachycardia (CRVT). In a meta-analysis of 13 studies involving 4988 patients, intracavitary electrocardiogram (IC-ECG) guidance demonstrated greater accuracy and safety than landmark-based techniques, followed by chest x-ray (CXR).^1(IIIb) In another randomized controlled trial, Glauser et al. showed that 53.3% of peripherally inserted central catheters (PICCs) placed without imaging guidance required repositioning due to suboptimal tip location compared with only 6.7% in the fluoroscopy group.^2(Ia)

Recommendation 2: Intracavitary ECG for Tip Confirmation

When available, IC-ECG may be considered to confirm the central catheter tip location during insertion.

Summary of Evidence

IC-ECG is associated with higher tip positioning accuracy, lower malposition rates, and a reduced risk of CRVT compared with other techniques.^{3(Ib),4(Va),5(Ia)} Authors of multiple studies and meta-analyses have confirmed the ability of IC-ECG to detect the optimal tip position, especially at the CAJ.^{3(Ib),4(Va),5(Ia),6(Vb)}

When available, clinicians should use real-time catheter navigation systems to guide catheter tip placement during insertion.

Summary of Evidence

Tip confirmation systems have been evaluated and endorsed by national health organizations for their ability to improve insertion accuracy and reduce reliance on postprocedure imaging.^{4(Va),7(IVa),8(IIIb)} When used in combination with IC-ECG, these systems improve tip location consistency and may eliminate the need for fluoroscopy or chest radiography for many CVADs.^4(Va)

Clinical Considerations

Benefits

Improved tip accuracy: IC-ECG technology offers greater accuracy for catheter tip placement than CXR, with authors of a meta-analysis having shown better positioning accuracy (odds ratio: 2.88, P < 0.0001).⁹
Reduced need for imaging and repositioning: IC-ECG and navigation systems minimize the need for confirmatory chest radiographs, reduce repositioning, and allow for faster therapy initiation.^4,5,6,10
Enhanced safety and fewer complications: Real-time tip confirmation reduces malpositioning, which helps prevent cardiac complications such as arrhythmias and perforation.^{11,12,13,14,15}

Risks

Suboptimal outcomes without tip confirmation: In a randomized controlled trial, blind bedside PICC placement led to 53.3% of tips being suboptimal or nonoptimal compared with only 6.7% in the fluoroscopy-guided group.²
Reliance on additional imaging if the ECG signal is unclear: If a P wave is not detected with IC-ECG, clinicians must revert to chest radiography for tip verification, which may delay treatment.^6,16

Implementation Considerations

Combine with navigation systems: Use of IC-ECG in combination with navigation systems has been shown to improve ease and accuracy of CVAD placement.^7,8,17,18
Standardize postinsertion documentation: Accurate documentation of tip confirmation method, external catheter length, and technique supports long-term device safety and monitoring.¹⁹
Use real-time confirmation: Real-time IC-ECG confirmation should be the preferred method for bedside use when available, allowing for immediate therapy initiation.^4,10

Barriers to Implementation

Equipment cost and access limitations: Access to IC-ECG or navigation systems may be limited by cost or resource availability in some institutions.^4,7
Training and adoption lag: Proper use of IC-ECG and navigation systems requires training, and inconsistent adoption may lead to variable outcomes.^3,6
Dependence on alternate methods when ECG signal fails: When ECG signal cannot be obtained, reliance on CXR may be necessary, which introduces delay and radiation exposure.^16,20

References

Yu Y, Yuan L. The electrocardiographic method for positioning the tip of central venous access device. J Vasc Access. 2020;21(5):589–595. doi:10.1177/1129729819874986.
Glauser F, Breault S, Rigamonti F, Sotiriadis C, Jouannic AM, Qanadli SD. Tip malposition of peripherally inserted central catheters: a prospective randomized controlled trial to compare bedside insertion to fluoroscopically guided placement. Eur Radiol. 2017;27(7):2843–2849. doi:10.1007/s00330-016-4666-y.
Liu G, Hou W, Zhou C, et al. Meta-analysis of intracavitary electrocardiogram guidance for peripherally inserted central catheter placement. J Vasc Access. 2019;20(6):577–582. doi:10.1177/1129729819826028.
Pittiruti M, Pelagatti F, Pinelli F. Intracavitary electrocardiography for tip location during central venous catheterization: a narrative review of 70 years of clinical studies. J Vasc Access. 2021;22(5):778–785. doi:10.1177/1129729820929835.
Yin YX, Gao W, Li XY, et al. Randomized multicenter study on long-term complications of peripherally inserted central catheters positioned by electrocardiographic technique. Phlebology. 2020;35(8):614–622. doi:10.1177/0268355520921357.
Gullo G, Qanadli SD. ECG-based techniques to optimize peripherally inserted central catheters: rationale for tip positioning and practical use. Front Cardiovasc Med. 2022;9:765935. doi:10.3389/fcvm.2022.765935.
Dale M, Higgins A, Carolan-Rees G. Sherlock 3CG tip confirmation system for placement of peripherally inserted central catheters: a NICE medical technology guidance. Appl Health Econ Health Policy. 2016;14(1):41–49. doi:10.1007/s40258-015-0192-3.
Yamagishi T, Ashida H, Igarashi T, et al. Clinical impact of the Sherlock 3CG tip confirmation system for peripherally inserted central catheters. J Int Med Res. 2018;46(12):5176–5182. doi:10.1177/0300060518793802.
Yang WJ, Song MG, Seo TS, Park SJ. Effectiveness of mechanical recanalization for intraluminal occlusion of totally implantable venous access ports. J Vasc Access. 2023;24(3):430–435. doi:10.1177/11297298211034628.
Bidgood C. Improving the patient experience with real-time PICC placement confirmation. Br J Nurs. 2016;25(10):539–543. doi:10.12968/bjon.2016.25.10.539.
Yıldırım İ, Tütüncü A, Bademler S, Özgür İ, Demiray M, Karanlık H. Does the real-time ultrasound guidance provide safer venipuncture in implantable venous port implantation? J Vasc Access. 2018;19(3):297–302. doi:10.1177/1129729817752606.
Flumignan RLG, Trevisani VFM, Lopes RD, Baptista-Silva JCC, Flumignan CDQ, Nakano LCU. Ultrasound guidance for arterial (other than femoral) catheterisation in adults. Cochrane Database Syst Rev. 2021;10(10):CD013585. doi:10.1002/14651858.CD013585.pub2.
Sun X, Bai X, Zhang Y, et al. Perioperative and postoperative complications of ultrasound-guided totally implantable venous access ports via the brachiocephalic vein in patients with cancer: a prospective study. J Cancer. 2021;12(5):1379–1385. doi:10.7150/jca.55343.
Zhou C, Lu L, Yang L, et al. Modified surface measurement method to determine catheter tip position of totally implantable venous access port through right subclavian vein. J Vasc Surg Venous Lymphat Disord. 2021;9(2):409–415. doi:10.1016/j.jvsv.2020.07.004.
Wu S, Ren S, Zhao H, et al. Risk factors for central venous catheter-related bloodstream infections after gastrointestinal surgery. Am J Infect Control. 2017;45(5):549–550. doi:10.1016/j.ajic.2017.01.007.
Alexandrou E, Mifflin N, McManus C, et al. A randomised trial of intracavitary electrocardiography versus surface landmark measurement for central venous access device placement. J Vasc Access. 2023;24(6):1372–1380. doi:10.1177/11297298221085228.
Fiorini J, Venturini G, Colella S, et al. An integrated system for peripherally inserted central catheter tip confirmation in oncology and haematology patients. Prof Inferm. 2020;73(3):205–212. doi:10.7429/pi.2020.733205.
Pittiruti M, Scoppettuolo G, Dolcetti L, Emoli A. Clinical use of Sherlock-3CG for positioning peripherally inserted central catheters. J Vasc Access. 2019;20(4):356–361. doi:10.1177/1129729818805957.
Gorski LA, Lynn Hadaway F, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(Suppl 1):S1–S224. doi:10.1097/NAN.0000000000000396.
Ma M, Zhang J, Hou J, et al. The application of intracavitary electrocardiogram for tip location of femoral vein catheters in chemotherapy patients with superior vena cava obstruction. J Vasc Access. 2021;22(4):613–622. doi:10.1177/1129729820958334.

Chapter 4.8—Skin Antisepsis and Sterility

Preventing infection during vascular access device (VAD) insertion is a cornerstone of safe practice. Catheter-related bloodstream infections (CRBSIs) and insertion-site infections are serious complications that increase patient morbidity, extend hospital stays, and escalate healthcare costs.

Because vascular access involves direct entry into the bloodstream, skin antisepsis and aseptic technique are critical defenses against microbial transfer. Although skin cannot be sterilized, standardized antisepsis and sterile insertion practices consistently reduce the risk of infection and reinforce patient safety. These infection-prevention principles form the foundation of all insertion workflows and underpin the recommendations that follow.

Recommendation 1: Perform Hand Hygiene Before Insertion

Clinicians must perform hand hygiene immediately before inserting a VAD, using an alcohol-based hand rub or antimicrobial soap and water. Hand hygiene is essential even when gloves are worn.

Summary of Evidence

Hand hygiene is a cornerstone of infection prevention, with substantial evidence supporting its role in reducing CRBSIs. Alcohol-based hand rub is preferred unless hands are visibly soiled, in which case soap and water are recommended. Meta-analyses and clinical guidelines consistently affirm their efficacy in reducing microbial burden and protecting both patient and provider.^{1(IIb),2(IIb),3(IVa)}

Recommendation 2: Use Chlorhexidine-Alcohol as First-Line Skin Antiseptic

Unless contraindicated, clinicians should use at least 2% chlorhexidine gluconate (CHG) in 70% isopropyl alcohol for skin antisepsis prior to VAD insertion. The antiseptic should be applied with gentle friction in all directions and allowed to dry completely.

Summary of Evidence

Single-use CHG in alcohol has been supported as the preferred skin antiseptic in multiple systematic reviews and clinical trials. Authors of an early study found CHG-alcohol superior to povidone-iodine (PVP-I) in reducing CRBSI and catheter colonization.^4(Ia) In a large randomized controlled trial, it was confirmed that CHG-alcohol led to significantly fewer local and catheter-related infections compared with PVP-I.^5(Ib) Gupta et al. found similar reductions in insertion-site complications in peripheral access. Combined, these findings reinforce CHG-alcohol as first-line unless contraindicated.^6(Ib) Authors of another study emphasized broad-spectrum activity and persistence on skin of CHG, which contributes to its superiority.^7(IVa)

Recommendation 3: Consider Alternatives for Sensitive or Damaged Skin

For patients with sensitive or compromised skin, clinicians may consider alternatives such as PVP-I, alcohol-free CHG, octenidine (OCT), or sodium bicarbonate-based cleansing agents.

Summary of Evidence

While CHG is widely used, it may not be suitable for all patients. Authors of early CHG studies noted that alternatives like PVP-I remain viable options, particularly in patients with known sensitivity.^4(Ia) In a pediatric study, lower infection rates were found when PVP-I was used in alcohol-intolerant populations.^8(IIIb) For patients with fragile or damaged skin, a cyanoacrylate seal provided similar control of exit-site colonization as chlorhexidine-releasing dressings, offering a CHG-free alternative for exit-site protection.^9(IIb) Authors of a comparative study of OCT and CHG regimens concluded that OCT may be equally effective with fewer skin reactions.^10(Ib)

Recommendation 4: Use Aseptic Nontouch Technique

Clinicians must use an aseptic nontouch technique (ANTT) during VAD insertion. ANTT requires protection of key sites and key parts by minimizing direct contact, using sterile fields, and adhering to either standard or surgical ANTT depending on procedure complexity.

Summary of Evidence

ANTT is endorsed as a global standard for safe aseptic technique. ANTT creators distinguish standard ANTT for peripheral insertion and surgical ANTT for complex insertions like peripherally inserted central catheter or centrally inserted central catheter.^{11(IIIb),12(Vb)} ANTT further emphasizes that consistent adherence to the principles reduces insertion-related infections and improves provider technique.^{12(IIIb),13(IIa)} In a pragmatic evaluation, researchers found sustained compliance with critical aseptic behaviors over 4 years postimplementation.^11(IIIb)

Recommendation 5: Apply Maximal Sterile Barrier for Central VAD Insertion

Clinicians must use maximal sterile barrier (MSB) precautions for all central VAD (CVAD) insertions. This includes a sterile gown, gloves, mask, cap, and full-body drape.

Summary of Evidence

MSBs are consistently linked with reduced CRBSI rates. Authors of an early study demonstrated that the use of full sterile precautions during central line insertion significantly reduced the risk of infection, especially in high-acuity settings.^14(Vb) The choice between full or partial barriers should be guided by insertion technique and clinical judgment, but full MSBs remain best practice for CVADs.^3(IVa)

Recommendation 6: Maintain Sterility During Ultrasound-Guided Insertion

During ultrasound-guided VAD insertion, clinicians must use sterile probe covers and sterile gel and disinfect probes between patients according to manufacturer and institutional protocols.

Summary of Evidence

Ultrasound probes and gel are recognized sources of contamination if not properly managed. Saugel et al. emphasized the use of sterile probe covers and gel as standards for real-time ultrasound-guided CVAD insertion.^15(Vb) Thompson and Garrett (2018) provided best-practice guidelines for probe disinfection and sheathing for vascular access teams.^16(IVb) Authors of another study demonstrated variability in disinfection practices across intensive care units, reinforcing the need for standardized approaches to reduce cross-contamination risk.^17(IIIb)

Clinical Considerations

Benefits

Reduced infection risk with CHG: Use of 2% chlorhexidine in 70% isopropyl alcohol significantly reduces CRBSIs and bacterial colonization due to its broad-spectrum activity and residual effect.^18,19,20,21
Lower phlebitis incidence with proper asepsis: Proper use of ANTT and skin antisepsis significantly reduces the risk of phlebitis and other insertion-related infections.^{12,22,23,24,25,26,27,28,29}
Flexible antiseptic options: Alternatives like PVP-I or OCT dihydrochloride offer effective skin antisepsis for patients with sensitivities to CHG or alcohol-based solutions.^8,9,10,21

Risks

CHG sensitivity and irritation: Some patients may develop allergic reactions or skin irritation to CHG or alcohol-based preparations, necessitating alternative agents.⁸
Medical adhesive-related skin injury from improper dry time: Failure to allow CHG to fully dry before applying dressings may increase the risk of medical adhesive-related skin injury.²¹
Inadequate skin disinfection: Incomplete adherence to antiseptic protocols (e.g., inadequate scrub or dry time) may lead to thrombophlebitis or infection.^5,6,21

Implementation Considerations

Agent selection based on patient condition: Clinicians should consider skin condition and allergy history when selecting antiseptic agents. CHG is preferred, but PVP-I, OCT, or even sodium bicarbonate solutions may be appropriate alternatives.^8,9,10,21
Appropriate barrier precautions: The choice between maximal and partial sterile barriers should be based on the invasiveness of the procedure and insertion technique used (e.g., Seldinger versus accelerated Seldinger).^3,14
Standardized application technique: Antiseptic agents should be applied using back-and-forth strokes for at least 30 seconds and allowed to dry completely to maximize efficacy and minimize complications.²¹

Barriers to Implementation

Variability in practice: Inconsistent use of ANTT or antiseptic protocols among clinicians can undermine infection prevention efforts.^{12,22,23,24,25,26,27,28,29}
Limited access to alternative agents: Facilities may not routinely stock alternatives like OCT or sodium bicarbonate-based solutions, limiting options for patients with sensitivities.^8,9,10,21
Misapplication of sterile field standards: Uncertainty or variability in when to use maximal versus partial barriers may lead to underprotection in higher-risk insertions.^3,14

References

Wichmann D, Belmar Campos CE, Ehrhardt S, et al. Efficacy of introducing a checklist to reduce central venous line associated bloodstream infections in the ICU caring for adult patients. BMC Infect Dis. 2018;18(1):267. doi:10.1186/s12879-018-3178-6.
Ista E, van der Hoven B, Kornelisse RF, et al. Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. Lancet Infect Dis. 2016;16(6):724–734. doi:10.1016/s1473-3099(15)00409-0.
Gorski LA, Lynn Hadaway F, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(Suppl 1):S1–S224. doi:10.1097/NAN.0000000000000396.
Lai NM, Lai NA, O’Riordan E, Chaiyakunapruk N, Taylor JE, Tan K. Skin antisepsis for reducing central venous catheter-related infections. Cochrane Database Syst Rev. 2016;7(7):CD010140. doi:10.1002/14651858.CD010140.pub2.
Guenezan J, Marjanovic N, Drugeon B, et al. Chlorhexidine plus alcohol versus povidone iodine plus alcohol, combined or not with innovative devices, for prevention of short-term peripheral venous catheter infection and failure (CLEAN 3 study): an investigator-initiated, open-label, single centre, randomised-controlled, two-by-two factorial trial. Lancet Infect Dis. 2021;21(7):1038–1048. doi:10.1016/S1473-3099(20)30738-6.
Gupta A, Nair R, Singh S, Khanna H, Bal A, Patrikar S. Compare the efficacy of recommended peripheral intravascular cannula insertion practices with a standard protocol: a randomized control trial. Med J Armed Forces India. 2022;78:S111–S115. doi:10.1016/j.mjafi.2022.01.004.
Selby LM, Rupp ME, Cawcutt KA. Prevention of central-line associated bloodstream infections. Infect Dis Clin North Am. 2021;35(4):841–856. doi:10.1016/j.idc.2021.07.004.
Sugiyama M, Iguchi A, Terashita Y, Ohshima J, Cho Y. Povidone-iodine lowers the incidence of catheter-associated bloodstream infection. Pediatr Int. 2019;61(3):230–234. doi:10.1111/ped.13759.
Gilardi E, Piano A, Chellini P, et al. Reduction of bacterial colonization at the exit site of peripherally inserted central catheters: a comparison between chlorhexidine-releasing sponge dressings and cyano-acrylate. J Vasc Access. 2021;22(4):597–601. doi:10.1177/1129729820954743.
Lutz JT, Diener IV, Freiberg K, et al. Efficacy of two antiseptic regimens on skin colonization of insertion sites for two different catheter types: a randomized, clinical trial. Infection. 2016;44(6):707–712. doi:10.1007/s15010-016-0899-6.
Clare S, Rowley S. Implementing the aseptic non touch technique (ANTT) clinical practice framework for aseptic technique: a pragmatic evaluation using a mixed methods approach in two London hospitals. J Infect Prev. 2018;19(1):6–15. doi:10.1177/1757177417720996.
Rowley S, Clare S. Aseptic non touch technique (ANTT): a critical competency in infection control. Infusion. 2020;26(1):22–27.
Rowley S, Clare S. ANTT standardisation facilitates new efficiencies with a novel partially-sterile standard-ANTT PIVC Pack. Br J Nurs. 2023;32(7):S4–S10. doi:10.12968/bjon.2023.32.7.S4.
Patel PK. Prevention of central line-associated bloodstream infections. J Clin Outcomes Manage. 2018;25(6):273–277.
Saugel B, Scheeren TWL, Teboul JL. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care. 2017;21(1):225.
Thompson J, Garrett JH. Transducer disinfection for evaluation and insertion of peripheral and central catheters for vascular access teams and clinicians. J Assoc Vasc Access. 2018;23(3):141–146.
van der Mee-Marquet N, Valentin AS, Duflot I, Farizon M, Petiteau A. Ultrasound guidance practices used for the placement of vascular accesses in intensive care units: an observational multicentre study. Eur J Med Res. 2023;28(1):528. doi:10.1186/s40001-023-01518-4.
Puig-Asensio M, Marra AR, Childs CA, Kukla ME, Perencevich EN, Schweizer ML. Effectiveness of chlorhexidine dressings to prevent catheter-related bloodstream infections. Does one size fit all? A systematic literature review and meta-analysis. Infect Control Hosp Epidemiol. 2020;41(12):1388–1395. doi:10.1017/ice.2020.356.
Velasquez Reyes DC, Bloomer M, Morphet J. Prevention of central venous line associated bloodstream infections in adult intensive care units: a systematic review. Intensive Crit Care Nurs. 2017;43:12–22. doi:10.1016/j.iccn.2017.05.006.
Afonso E, Blot K, Blot S. Prevention of hospital-acquired bloodstream infections through chlorhexidine gluconate-impregnated washcloth bathing in intensive care units: a systematic review and meta-analysis of randomised crossover trials. Euro Surveill. 2016;21(46):17.
Lai NM, Lai NA, O’Riordan E, Chaiyakunapruk N, Taylor JE, Tan K. Skin antisepsis for reducing central venous catheter-related infections. Cochrane Database Syst Rev. 2016;7(7):CD010140. doi:10.1002/14651858.CD010140.pub2.
Urbanetto JS, Muniz FOM, Silva RMD, Freitas APC, Oliveira APR, Santos J. Incidence of phlebitis and post-infusion phlebitis in hospitalised adults. Rev Gaucha Enferm. 2017;38(2):e58793. doi:10.1590/1983-1447.2017.02.58793.
Marsh N, Webster J, Larson E, Cooke M, Mihala G, Rickard CM. Observational study of peripheral intravenous catheter outcomes in adult hospitalized patients: a multivariable analysis of peripheral intravenous catheter failure. J Hosp Med. 2018;13(2):83–89. doi:10.12788/jhm.2867.
Heng SY, Yap RT, Tie J, McGrouther DA. Peripheral vein thrombophlebitis in the upper extremity: a systematic review of a frequent and important problem. Am J Med. 2020;133(4):473–484.e473. doi:10.1016/j.amjmed.2019.08.054.
Guanche-Sicilia A, Sanchez-Gomez MB, Castro-Peraza ME, Rodriguez-Gomez JA, Gomez-Salgado J, Duarte-Climents G. Prevention and treatment of phlebitis secondary to the insertion of a peripheral venous catheter: a scoping review from a nursing perspective. Healthcare. 2021;9(5):19.
Bahl A, Johnson S, Alsbrooks K, Mares A, Gala S, Hoerauf K. Defining difficult intravenous access (DIVA): a systematic review. J Vasc Access. 2021;24(5):904–910. doi:10.1177/11297298211059648.
Simões AMN, Vendramim P, Pedreira MLG. Risk factors for peripheral intravenous catheter-related phlebitis in adult patients. Rev Esc Enferm USP. 2022;56:e20210398. doi:10.1590/1980-220X-REEUSP-2021-0398en.
Clare S, Rowley S. Best practice skin antisepsis for insertion of peripheral catheters. Br J Nurs. 2021;30(1):8–14. doi:10.12968/bjon.2021.30.1.8.
Rowley S, Clare S. Standardizing the critical clinical competency of aseptic, sterile, and clean techniques with a single international standard: aseptic non touch technique (ANTT). J Assoc Vasc Access. 2019;24(4):12–17. doi:10.2309/j.java.2019.004.003.

Chapter 4.9—Stabilization and Vessel Enhancement

Achieving reliable vascular access requires more than good technique; it also depends on preparing the vein and supporting the surrounding anatomy. Joint stabilization and vessel enhancement are 2 often overlooked strategies that improve first-attempt success and preserve vascular integrity.

Avoiding flexion areas is sometimes unavoidable; insertion in these areas requires special attention. Without stabilization, catheter movement at flexion points can lead to phlebitis, dislodgement, or infiltration. Stabilization options may include splints, securement devices, and dressing techniques that maintain catheter integrity while preserving comfort, circulation, and visibility.

Similarly, vessel enhancement techniques, like moist heat, hydration, or limb positioning, can improve vein palpability and visibility, especially in patients with poor perfusion, deep veins, or fragile vasculature. These strategies are beneficial in patients with difficult intravenous access (DIVA) and should be individualized based on clinical context. Integrating both stabilization and enhancement techniques into preinsertion planning supports safer, more efficient, and more compassionate vascular access.

Recommendation 1: Joint Stabilization for Catheters Near Flexion Sites

When vascular access devices are placed near areas of flexion, clinicians should implement stabilization strategies to minimize catheter motion and prevent mechanical complications. Stabilization techniques must maintain patient comfort, ensure adequate circulation, allow for visualization of the insertion site, and minimize the risk of pressure injuries.

Summary of Evidence

In a prospective ultrasound study, Hebbard et al. found that 95% of peripheral intravenous catheters placed in the dorsum of the hand failed during wrist dorsiflexion, with an average tip displacement of 12.5 mm due to anatomical impingement.^1(IIIb)

Authors of another study reported that radial arterial catheters placed too close to the wrist crease are prone to securement failure and dislodgement, recommending a proximal insertion site for stability.

These findings support the role of stabilization, when placement near a joint is unavoidable, in preserving catheter function.^2(Vb),3(IVa)

Recommendation 2: Avoid Tourniquet Use with Fragile Veins

When cannulating fragile veins, clinicians may consider avoiding a tourniquet to prevent overdilation and reduce the risk of vein rupture.

Summary of Evidence

In patients with vessel fragility or thin subcutaneous tissue, the use of a tourniquet may overdistend superficial veins, thereby increasing the risk of rupture, infiltration, and phlebitis. In a pilot study of older adults, avoiding the tourniquet and using a lower insertion angle improved first-attempt success, reduced postinsertion complications, and preserved vessel integrity.^4(IIb)

Recommendation 3: Manual Traction for Vein Stabilization

For mobile superficial veins, clinicians may apply gentle manual traction below the insertion site to stabilize the vein and reduce lateral movement during needle entry. Excessive tension should be avoided to prevent vein collapse.

Summary of Evidence

Palpable superficial veins may shift during cannulation, leading to failed attempts or injury to the vein. Gentle manual traction, including thumb anchoring and skin tensioning, stabilizes the target vessel and improves needle control.^4(IIb) When paired with proper insertion angle, this technique enhances success and minimizes unnecessary trauma, particularly in mobile dorsal hand or cephalic veins.

Recommendation 4: Vein Enhancement Techniques

Clinicians may use vessel enhancement strategies, such as warm compresses, limb positioning, or gravity-assisted filling, to improve vein visibility and palpability before vascular access insertion.

Summary of Evidence

Vein enhancement methods improve vascular distension and are associated with higher first-attempt success rates, especially in patients with DIVA. While evidence quality is mixed, authors of observational and small interventional studies have supported the use of moist heat, dependent limb positioning, and hydration as safe, low-risk interventions that improve vein visibility.^3,4 These techniques should be adapted to the patient’s condition, insertion site, and care setting. Combining vein enhancement with ultrasound or infrared imaging may further optimize access.

Note: Heat should be applied cautiously to avoid patient injury. Commercially prepared warm packs or controlled warming devices are preferred. Improvised methods, such as heating wet towels in a microwave, must not be used due to the risk of burns and uneven heat distribution.

Clinical Considerations

Benefits

Reduced complications: Avoiding tourniquet use and manually stabilizing the vein reduces the risk of phlebitis and vein trauma in older patients.⁴
Improved first-attempt success: Manual stabilization techniques improve insertion accuracy, particularly in fragile, superficial veins, increasing the likelihood of first-attempt success.⁴
Increased catheter dwell time: Forearm site selection and low-angle insertion contribute to longer catheter dwell time and greater patient comfort.⁴

Risks

Technique variability: Manual stabilization and low-angle insertion may be inconsistently applied, leading to variation in outcomes or inadvertent vein trauma.⁴
Limited vein accessibility: In some older patients, suitable veins may not be accessible without a tourniquet, potentially complicating insertion.⁴
Operator dependency: Effectiveness of this approach depends heavily on the skill and technique of the individual clinician performing the insertion.⁴

Implementation Considerations

Training in stabilization techniques: Clinicians should be trained in manual vein stabilization, proper angle of insertion, and forearm site selection to reduce trauma and increase success.⁴
Patient-specific assessment: Individual vein characteristics and patient comfort should guide decisions around tourniquet use, insertion site, and technique.⁴
Monitoring protocols: Regular assessment for signs of phlebitis and documentation of catheter dwell time are necessary to ensure ongoing patient safety.⁴

Barriers to Implementation

Habitual reliance on tourniquets: Clinicians may be accustomed to standard tourniquet use and may resist adopting manual-only vein stabilization techniques.⁴
Limited experience with low-angle insertion: Some providers may lack confidence or training in low-angle insertion methods, especially for challenging older adult veins.⁴
Time and staffing pressures: Manual stabilization can be more time-consuming, which may be a challenge in high-volume or understaffed settings.⁴

References

Hebbard PD, Flinn P. Intravascular catheters—an ultrasound imaging based observational study of position and function. Anaesth Intensive Care. 2017;45(4):499–502. doi:10.1177/0310057X1704500414.
Imbrìaco G, Monesi A, Spencer TR. Preventing radial arterial catheter failure in critical care—factoring updated clinical strategies and techniques. Anaesth Crit Care Pain Med. 2022;41(4):101096. doi:10.1016/j.accpm.2022.101096.
Gorski LA, Lynn Hadaway F, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(Suppl 1):S1–S224. doi:10.1097/NAN.0000000000000396.
Büyükyılmaz F, Şendir M, Kuş B, Yaman Güçlü H. The effectiveness of a non-tourniquet procedure on peripheral intravenous catheterization in older patients: a pilot study. Contemp Nurse. 2020;56(5–6):405–416. doi:10.1080/10376178.2020.1801351.

Chapter 4.10—Insertion Complication Management

Vascular access procedures, while routine, are not without risk. A range of insertion-related complications can occur, each with the potential to delay therapy and compromise vascular integrity and safety. These complications include, but are not limited to, arterial puncture, hematoma formation, vasospasm, lymphatic injury, nerve injury, and insertion-related arrhythmias, all of which require prompt identification and intervention. Proper insertion technique, awareness of anatomical landmarks, and real-time imaging guidance can substantially reduce the likelihood of these adverse events.

Though uncommon, these complications may result in lasting morbidity if not promptly addressed. Nerve injury, for example, may present as immediate or delayed pain, paresthesia, or even loss of motor or sensory function. Air embolism can lead to cardiovascular, pulmonary, and neurological consequences, and even death. Complications are influenced by catheter size, insertion site, depth, and proximity to surrounding anatomy. Authors of studies have emphasized the importance of skillful technique, preprocedural anatomical assessment, and the use of image guidance to minimize risk.

Effective management of insertion-related complications requires early recognition, adherence to evidence-based intervention protocols, and ongoing staff education. By integrating preventive strategies into standard practice, including proper patient positioning, vein visualization technologies, and escalation pathways, clinicians can reduce complication rates, enhance procedural safety, and optimize outcomes in vascular access care.

Recommendation 1: Insertion Site Bleeding

To reduce postinsertion bleeding and minimize unplanned dressing changes, clinicians should apply direct digital pressure until hemostasis is achieved.

Summary of Evidence

Bleeding following vascular access device (VAD) insertion can compromise dressing adherence, increase the risk of infection, and lead to early dressing disruption or device replacement. After hemostasis is achieved, cyanoacrylate tissue adhesive has demonstrated benefit in controlling minor postinsertion bleeding, improving dressing stability, and reducing the need for unplanned dressing changes. In a review, Zhang et al. confirmed improved hemostasis and dressing integrity using cyanoacrylate in vascular access procedures.^1(IIb) In a retrospective analysis, Buetti et al. linked dressing disruption to an increased risk of infection, particularly in patients with an elevated body mass index.^2(IIb)

Recommendation 2: Monitor for Bleeding and Hematoma Postinsertion

Following insertion, vascular access sites should be closely monitored for bleeding and hematoma. The surveillance frequency should be tailored to the device type, insertion technique, and patient-specific factors.

Summary of Evidence

Postinsertion bleeding and hematoma formation can go unrecognized without routine monitoring. In a secondary analysis involving over 10,000 VADs, Ullman et al. found that timely documentation and assessment doubled the likelihood of early detection and intervention for skin and insertion site complications.^3(IIIb) Standardizing surveillance frequency, especially during the first hours postinsertion, enhances patient safety and supports early escalation if needed.

Recommendation 3: Respond to Unintended Arterial Puncture Immediately

If an artery is inadvertently punctured during insertion, withdraw the needle immediately and apply direct pressure for 5–10 minutes or until hemostasis is achieved.

Summary of Evidence

Unintended arterial puncture during vascular access insertion can result in hematoma, pseudoaneurysm, or severe hemorrhage. Prompt needle withdrawal and application of direct pressure are recommended to prevent progression of injury. Manual compression as the primary intervention for inadvertent arterial entry, avoiding catheter dilation or advancement into an artery unless intentional arterial access is indicated.^4(IVa)

Recommendation 4: Prevent Air Embolism During Insertion

Implement strategies to prevent air embolism during central vascular access insertion. These include Trendelenburg positioning (when safe), minimizing open lumens, using closed-system devices, and ensuring all connections are secure.

Summary of Evidence

Air embolism is a potentially fatal but preventable complication during central catheter insertion. Techniques such as Trendelenburg positioning, occlusion of open lumens, use of closed catheter systems, and vigilance during catheter handling have been shown to reduce risk. Brull et al. emphasized minimizing air entry risk during access procedures, while Pinho et al. described the effectiveness of closed ports and tip position control.^5(Va),6(IIb)

Recommendation 5: Respond to Guidewire Resistance Promptly

Maintain continuous control of the guidewire during insertion. If resistance is encountered or the wire cannot be withdrawn easily, stop the procedure and assess for kinking, looping, or entrapment.

Summary of Evidence

Guidewire-related complications are uncommon but potentially serious. Entrapment, embolization, or vessel trauma may result from excessive force or failure to recognize resistance. Maintaining constant control of the guidewire and pausing the procedure when resistance is met are essential safety measures. Evidence supports that guidewire looping, and vascular injury can be avoided by using gentle technique and stopping immediately when unexpected tension or binding occurs.^4(IVa),7(Vb)

Monitor cardiac rhythm during central catheter insertion. If arrhythmias occur, withdraw the guidewire or catheter slightly and reassess tip position.

Summary of Evidence

Arrhythmias during central venous access insertion typically occur when the catheter or guidewire enters the right atrium. These are usually transient but can progress if unrecognized. Real-time monitoring and immediate withdrawal of the device are associated with the resolution of rhythm disturbances. Authors of several studies have confirmed that repositioning resolves most insertion-related arrhythmias, while persistent events may require catheter removal.^{8(IIIa),9(Ib),10(IIIb)}

Recommendation 7: Nerve Injury Recognition and Response

If the patient reports sharp, radiating pain or involuntary movement during insertion, stop immediately and reassess. Do not advance the needle until anatomical safety is confirmed.

Summary of Evidence

Nerve contact during insertion may present as sharp pain, tingling, or involuntary movement. Proceeding after these signs can result in serious damage. Evidence supports halting needle advancement immediately and reassessing anatomical landmarks or using ultrasound. Early recognition and appropriate response reduce the likelihood of long-term sensory or motor dysfunction.^{11(IIIb),12(IIIb),13(Vb)}

Recommendation 8: Venospasm During Insertion

If venospasm occurs during insertion, consider warming the limb, reassessing the technique, or using vasodilators when clinically appropriate.

Summary of Evidence

Venospasm is a recognized contributor to insertion failure and catheter malfunction, often triggered by mechanical stimulation during placement or limb movement after insertion. In an ultrasound imaging study of 83 intravascular catheters (62 venous and 21 arterial), researchers observed that catheter-related obstruction was frequently due to impingement on the vessel wall or localized vessel spasm, particularly in areas of tortuosity or branching.^14(IIIb)

Recommendation 9: Lymphatic Injury During Insertion

If lymphatic fluid is observed during device insertion, remove the device immediately. Avoid attempts to flush or reposition and monitor the site for signs of infection or prolonged leakage.

Summary of Evidence

Lymphatic injury during central catheter insertion is rare but underreported. Accidental entry into a lymphatic vessel may cause persistent leakage, local swelling, or infection. Authors of studies have suggested that immediate device removal and site reassessment are essential, especially in high-risk anatomic regions. Early recognition reduces risk of delayed healing and lymphatic fistula.^4(IVb)

Clinical Considerations

Benefits

Early identification improves outcomes: Early recognition and intervention for nerve injuries postinsertion can prevent long-term disability and improve outcomes.^11,12,13
Ultrasound reduces complications: Preprocedural and intraprocedural ultrasound guidance improves accuracy, reduces complication rates, and avoids inadvertent puncture of critical structures.^15,16,17
Arrhythmia detection allows timely intervention: Continuous electrocardiography (ECG) monitoring during and after catheter insertion helps identify catheter-induced arrhythmias early, allowing timely repositioning or removal.^8,9,10,16

Risks

Nerve injury during insertion: Inadvertent nerve damage may result in sensory or motor deficits if not identified and managed promptly.^11,12,13
Lymphatic injury: Accidental puncture of lymphatic structures, such as the thoracic duct, may lead to persistent leakage, infection, or hospitalization.^16,17,18
Catheter-related arrhythmias: Catheter tip malposition may induce arrhythmias, which may resolve with repositioning but can persist and require catheter removal.^8,9,10,16

Implementation Considerations

Use ultrasound consistently: Preprocedural and intraprocedural ultrasound use enhances visualization and minimizes complications, especially in high-risk areas.^15,16
Clinician training: Ensure operators are trained in ultrasound, lymphatic anatomy, and arrhythmia recognition to improve procedural safety.^15,16

Barriers to Implementation

Variable access to ultrasound and ECG monitoring: Limited availability of imaging and cardiac monitoring equipment may hinder optimal insertion practices.^15,16,17
Inconsistent provider training: Lack of training in lymphatic anatomy and advanced ultrasound techniques can increase complication risk.^15,16

References

Zhang S, Guido AR, Jones RG, Curry BJ, Burke AS, Blaisdell ME. Experimental study on the hemostatic effect of cyanoacrylate intended for catheter securement. J Vasc Access. 2019;20(1):79–86. doi:10.1177/1129729818779702.
Buetti N, Souweine B, Mermel L, et al. Obesity and risk of catheter-related infections in the ICU. A post hoc analysis of four large randomized controlled trials. Intensive Care Med. 2021;47(4):435–443. doi:10.1007/s00134-020-06336-4.
Ullman AJ, Mihala G, O’Leary K, et al. Skin complications associated with vascular access devices: a secondary analysis of 13 studies involving 10,859 devices. Int J Nurs Stud. 2019;91:6–13. doi:10.1016/j.ijnurstu.2018.10.006.
Gorski LA, Lynn Hadaway F, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(Suppl 1):S1–S224. doi:10.1097/NAN.0000000000000396.
Brull SJ, Prielipp RC. Vascular air embolism: a silent hazard to patient safety. J Crit Care. 2017;42:255–263. doi:10.1016/j.jcrc.2017.08.010.
Pinho J, Amorim JM, Araújo JM, et al. Cerebral gas embolism associated with central venous catheter: systematic review. J Neurol Sci. 2016;362:160–164. doi:10.1016/j.jns.2016.01.043.
Rani A, Malik PK. Guidewire mishap: an avoidable iatrogenic complication. Indian J Crit Care Med. 2019;23(8):382–383. doi:10.5005/jp-journals-10071-23225.
Yıldırım İ, Tütüncü A, Bademler S, Özgür İ, Demiray M, Karanlık H. Does the real-time ultrasound guidance provide safer venipuncture in implantable venous port implantation? J Vasc Access. 2018;19(3):297–302. doi:10.1177/1129729817752606.
Flumignan RLG, Trevisani VFM, Lopes RD, Baptista-Silva JCC, Flumignan CDQ, Nakano LCU. Ultrasound guidance for arterial (other than femoral) catheterisation in adults. Cochrane Database Syst Rev. 2021;10(10):CD013585. doi:10.1002/14651858.CD013585.pub2.
Wu S, Ren S, Zhao H, et al. Risk factors for central venous catheter-related bloodstream infections after gastrointestinal surgery. Am J Infect Control. 2017;45(5):549–550. doi:10.1016/j.ajic.2017.01.007.
Nuttall G, Burckhardt J, Hadley A, et al. Surgical and patient risk factors for severe arterial line complications in adults. Anesthesiology. 2016;124(3):590–597. doi:10.1097/aln.0000000000000967.
Kim IJ, Shim DJ, Lee JH, et al. Impact of subcutaneous tunnels on peripherally inserted catheter placement: a multicenter retrospective study. Eur Radiol. 2019;29(5):2716–2723. doi:10.1007/s00330-018-5917-x.
Welyczko N. Peripheral intravenous cannulation: reducing pain and local complications. Vasc Access. 2020;14(2):6–15. doi:10.12968/bjon.2020.29.8.S12.
Hebbard PD, Flinn P. Intravascular catheters—an ultrasound imaging based observational study of position and function. Anaesth Intensive Care. 2017;45(4):499–502. doi:10.1177/0310057X1704500414.
Garcés-Carrasco AM, Santacatalina-Roig E, Carretero-Márquez C, Martínez-Sabater A, Balaguer-López E. Complications associated with peripherally inserted central catheters (PICC) in people undergoing autologous hematopoietic stem cell transplantation (HSCT) in home hospitalization. Int J Environ Res Public Health. 2023;20(3):1704. doi:10.3390/ijerph20031704.
Yu Z, Sun X, Bai X, et al. Perioperative and postoperative complications of supraclavicular, ultrasound-guided, totally implantable venous access port via the brachiocephalic vein in adult patients: a retrospective multicentre study. Ther Clin Risk Manag. 2021;17:137–144. doi:10.2147/tcrm.S292230.
Zhou X, Lin X, Shen R, et al. A retrospective analysis of risk factors associated with catheter-related thrombosis: a single-center study. Perfusion. 2020;35(8):806–813. doi:10.1177/0267659120915142.
Zhang Y, Zhao R, Jiang N, Shi Y, Wang Q, Sheng Y. A retrospective observational study on maintenance and complications of totally implantable venous access ports in 563 patients: prolonged versus short flushing intervals. Int J Nurs Sci. 2021;8(3):252–256. doi:10.1016/j.ijnss.2021.05.005.

Section 5: Ongoing Assessment, Care, & Complication Management

Chapter 5.1—Assessment of Vascular Access Device Necessity

Regular assessment of the necessity of vascular access devices (VADs) is essential for safe and effective care. In inpatient settings, daily reviews help prevent prolonged catheter dwell times and reduce the risks of catheter-related bloodstream infections (CRBSIs), thrombosis, and mechanical complications. In outpatient and home care environments, VADs should be reassessed at each encounter to ensure ongoing need, especially for devices like totally implanted VADs (TIVADs) that may remain in place despite extended periods without use.

Incorporating device assessment into daily workflows and encounter-based evaluations supports infection prevention, minimizes device burden, and aligns with stewardship principles. Clear criteria for discontinuing or removing unused devices promote safety and optimize vascular access resources across care settings.

Recommendation 1: Inpatient Daily VAD Assessment

All VADs in inpatient settings should be assessed daily to determine continued necessity. Devices that are no longer required for therapy should be promptly removed.

Summary of Evidence

Prolonged catheter dwell without indication increases the risk of CRBSI, thrombosis, and mechanical failure. In a retrospective study of hospitalized patients, duration of centrally inserted central catheter (CICC) placement remained a significant risk factor for CRBSI even after prevention bundles were adopted.^1(IIIb) Authors of another study demonstrated that daily automated catheter day notifications significantly reduced total CICC days and CRBSI rates in the intensive care unit. These findings support embedding daily necessity checks into standard inpatient care.^2(IIb) Peripheral VADs, arterial catheters, and interosseous catheters all require ongoing assessment of need and removal when no longer required.^{3(Va),4(IVa),5(IVa),6(IIb)}

Recommendation 2: Encounter-Based VAD Assessment

At each outpatient or home care encounter, VADs should be evaluated for continued clinical indication. Devices without a current therapeutic need, including dormant TIVADs, should be reviewed for removal to prevent unnecessary risk.

Summary of Evidence

Although specific studies on outpatient TIVAD removal are limited, principles of device stewardship and infection prevention apply across care settings. Alanazi et al. reviewed VAD management strategies and highlighted that comprehensive bundles, including necessity review, effectively reduce CRBSI across multiple environments.^7(IIa) Educational and audit-based interventions have been shown to promote timely removal and appropriate use of VADs, reducing unnecessary exposure and complications.^8(IIIb)

Clinical Considerations

Benefits

Reduces infection and complications: Regular assessment and timely removal of VADs reduce risks of blood stream infection, thrombosis, and device failure.^7,9
Supports infection prevention strategies: Daily audits and removal of unnecessary devices are effective components of CLABSI prevention bundles.¹

Risks

Extended dwell time increases CRBSI risk: Prolonged catheter duration is associated with higher infection risk, even with prevention bundles in place.¹
Missed assessments in outpatient/home care: Without consistent review at each encounter, unnecessary device retention may lead to preventable complications.⁹

Implementation Considerations

Use automated tracking tools: Interventions like automatic catheter day notifications support timely reviews and reduce catheter duration.^2,10
Provider education on risk-based maintenance: Educating clinicians about patient-specific risk factors and device maintenance improves outcomes and reduces complications.^8,11,12

Barriers to Implementation

Inconsistent documentation or workflow gaps: Lack of integrated systems for catheter-day tracking may delay assessment or device removal.²
Variable adherence across care settings: Outpatient and home care environments may lack standardized protocols for daily VAD need review.^7,9

References

Pitiriga V, Bakalis J, Kampos E, Kanellopoulos P, Saroglou G, Tsakris A. Duration of central venous catheter placement and central line-associated bloodstream infections after the adoption of prevention bundles: a two-year retrospective study. Antimicrob Resist Infect Control. 2022;11(1):96. doi:10.1186/s13756-022-01131-w.
Bae S, Kim Y, Chang HH, et al. The effect of the multimodal intervention including an automatic notification of catheter days on reducing central line-related bloodstream infection: a retrospective, observational, quasi-experimental study. BMC Infect Dis. 2022;22(1):604. doi:10.1186/s12879-022-07588-9.
Ray-Barruel G, Rickard CM. Helping nurses help PIVCs: decision aids for daily assessment and maintenance. Br J N. 2018;27(8):S12–S18. doi:10.12968/bjon.2018.27.8.S12.
Gorski LA, Lynn Hadaway F, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(Suppl 1):S1–S224. doi:10.1097/NAN.0000000000000396.
Bardin-Spencer A, Spencer TR. Ultrasound-guided peripheral arterial catheter insertion by qualified vascular access specialists or other applicable health care clinicians. J Assoc Vasc Access. 2020;25(1):48–50. doi:10.2309/j.java.2019.003.008.
Philbeck TE, Puga TA, Montez DF, Davlantes C, DeNoia EP, Miller LJ. Intraosseous vascular access using the EZ-IO can be safely maintained in the adult proximal humerus and proximal tibia for up to 48 h: report of a clinical study. J Vasc Access. 2022;23(3):339–347. doi:10.1177/1129729821992667.
Alanazi TNM, Alharbi KAS, Alrawaili ABR, Arishi AAM. Preventive strategies for the reduction of central line-associated bloodstream infections in adult intensive care units: a systematic review. Collegian. 2021;28(4):438–446. doi:10.1016/j.colegn.2020.12.001.
Lin L, Li W, Chen C, Wei A, Liu Y. Peripherally inserted central catheters versus implantable port catheters for cancer patients: a meta-analysis. Front Oncol. 2023;13:1228092. doi:10.3389/fonc.2023.1228092.
Blanco-Mavillard I, Parra-Garcia G, Fernandez-Fernandez I, Rodriguez-Calero MA, Personat-Labrador C, Castro-Sanchez E. Care of peripheral intravenous catheters in three hospitals in Spain: mapping clinical outcomes and implementation of clinical practice guidelines. PLoS One. 2020;15(10):e0240086.
Buetti N, Ruckly S, Souweine B, Mimoz O, Timsit JF. Risk of infections in intravascular catheters in situ for more than 10 days: a post hoc analysis of randomized controlled trials. Clin Microbiol Infect. 2023;29(9):1200.e1201–1200.e1205. doi:10.1016/j.cmi.2023.05.025.
Ye W, Li D, Ji X, et al. Real-time ultrasound-guided internal jugular vein cannulation by oblique-axis in-plane: practice at the Fourth Hospital of Hebei Medical University. Int J Clin Pract. 2021;75(2):e13673. doi:10.1111/ijcp.13673.
Ullman AJ, August D, Kleidon T, et al. Peripherally Inserted Central catheter iNnovation to reduce Infections and Clots (the PICNIC trial): a randomised controlled trial protocol. BMJ Open. 2021;11(4):e042475. doi:10.1136/bmjopen-2020-042475.

Chapter 5.2—Postinsertion Monitoring

Postinsertion monitoring is a critical component of vascular access care. The hours, days, and weeks following device placement are marked by the highest risk for early complications, including bleeding, hematoma, infiltration, extravasation, and tip migration. Vigilant daily assessments help detect subtle changes before they become serious problems. This chapter outlines essential postinsertion surveillance strategies for all vascular access devices (VADs), emphasizing dressing condition, securement integrity, external length, and signs of malfunction or malposition. A structured approach to monitoring supports early intervention, minimizes patient harm, and promotes safe, uninterrupted therapy across all care settings.

Recommendation 1: Routine Postinsertion Monitoring

Direct-care clinicians must perform and document vascular access site, dressing integrity, and skin assessments at least once per shift in inpatient settings and at each encounter in ambulatory or home care sites. Monitoring should be based on patient risk, infusate, and the VAD.

Summary of Evidence

Routine assessment of vascular access sites is essential to prevent complications such as phlebitis, infiltration, extravasation, migration, and catheter-related bloodstream infections. In a retrospective cohort of 1,502 centrally inserted central catheter placements, structured clinician education and insertion protocols significantly reduced infection rates by 22% following implementation, with additional risk reduction tied to use of ultrasound and fewer puncture attempts.^1(IIIb) Similarly, Gohil et al. demonstrated that daily documentation of site condition using a standardized central line insertion site assessment (CLISA) scoring tool reduced early signs of inflammation and led to faster line removal decisions, reinforcing the value of frequent, structured assessments.^2(IIb) Authors of another study emphasized that nurse-led evaluations improve catheter patency and reduce the need for unplanned device replacements.^3(IIIb)

Recommendation 2: Core Components of VAD Site Evaluation

Each vascular access site assessment should include the following components:

Visual inspection of the insertion site, surrounding skin, limb comparison for edema;
Palpation (if not contraindicated) for tenderness, warmth, or subcutaneous edema;
Evaluation of dressing condition, including moisture, integrity, and visibility of the site;
Assessment of securement stability and changes in catheter external length;
Inquiry about patient-reported symptoms, such as pain, pulling, burning, or tightness;
Observation of catheter function, including flow resistance, backflow, or alarms.

Summary of Evidence

Complications are frequently preceded by subtle site changes, such as erythema, localized swelling, or dressing disruption, that may be overlooked without a structured assessment protocol.^4(IIIa) In a prospective observational study of 849 peripheral intravenous catheter in patients over 70, nurses performed site checks 3 times daily and identified local complication rates of 50.5 per 1000 catheter-days. Risk factors included hematoma, dressing disruption, and vancomycin administration, reinforcing the need for close inspection and consistent site care. The presence of local signs was also associated with a statistically significant increase in hospital stay duration, further validating the impact of structured site surveillance on patient outcomes.^5(IIb)

Recommendation 3: Monitoring External Length and Tip Position

Direct-care clinicians should monitor catheter external length and tip stability at regular intervals, particularly after insertion, patient repositioning, or clinical events that increase movement risk (e.g., seizures, transfers, pressure injection, or high-flow flushes). External length should be clearly documented using standardized methods, and any measurable change must prompt immediate assessment for possible migration, malposition, dislodgement, or mechanical dysfunction.

Summary of Evidence

Monitoring catheter external length and tip position is a critical component of postinsertion surveillance for all VADs. Changes often indicate migration, dislodgement, or kinking. These mechanical complications can lead to infusion into unintended vascular territory, thrombosis, endothelial injury, or device failure. In a prospective study of intensive care unit patients, Singh et al. reported malposition in 3% of central venous catheters, often triggered by manipulation or patient movement.^6(IIa) Similarly, Gohil et al. demonstrated that structured documentation of external length and site condition improved clinician response times and reduced dwell time of compromised catheters, thereby preventing sequelae such as bloodstream infections and infiltration.^2(IIb) Standards and guidelines, including those from the Infusion Nurses Society, recommend routine length monitoring, especially for peripherally inserted central catheters (PICCs), which are more susceptible to migration due to limb movement and longer catheter pathways.^{2(IIb),7(IVa)}

Evidence also highlights the clinical consequences of even small shifts in tip position. In a retrospective study of 177 central venous catheters, Smith et al. found that catheters with more than 2 cm of cranial migration were over 7 times more likely to become dysfunctional, with left-sided catheters migrating farther on average than right-sided catheters.^8(IIIb) Routine documentation of external length, coupled with site inspection and prompt escalation when changes are detected, allows early recognition of malposition or dysfunction. Structured protocols for reassessment following patient repositioning, seizures, transfers, or high-pressure infusions (e.g., pressure injection, high-flow flushes) further reduce the risk of unrecognized migration and support safe therapy delivery.^{1(IIIb),2(IIb)}

Recommendation 4: Monitoring for Bleeding, Hematoma, or Lymphatic Leak

Clinicians must routinely inspect vascular access sites for bleeding, hematoma formation, or evidence of lymphatic leak, especially during the first 24 hours after insertion and following interventions such as pressure injection or catheter manipulation. Any signs of swelling, ecchymosis, or persistent moisture beneath the dressing should prompt immediate investigation and intervention.

Summary of Evidence

While overt bleeding is often identified and managed promptly after VAD insertion, other forms of postprocedural fluid accumulation, such as hematoma and lymphatic leak, may be underrecognized. Hematomas can track into dependent tissue planes, particularly in older adults with fragile or lax skin, where discoloration and swelling may be masked beneath the limb. In a prospective study by Velioglu et al., early hematoma occurred in over 10% of central venous catheter insertions and was associated with coagulopathy, large-bore devices, and suboptimal compression technique.^9(IIIb)

Lymphatic leak, though less frequently documented, has been reported in cases involving deep tunneling, femoral access, and patients with low subcutaneous tissue. This complication may present as persistent dampness under the dressing without overt bleeding. Routine inspection, palpation, and securement reassessment, especially within the first 24–48 hours, support early identification and appropriate intervention to preserve site integrity and prevent device failure.^{2(IIa),5(IIb)}

Recommendation 5: Monitoring Tunneled Devices and Totally Implanted VADs

Clinicians must monitor the full course of tunneled VADs and totally implanted VADs (TIVADs) during each assessment, with specific attention to insertion site condition, tunnel tract integrity, needle stability (if applicable), and signs of infection or skin breakdown along the entire subcutaneous path. Long-term devices require ongoing evaluation even in the absence of recent use.

Summary of Evidence

Tunneled VADs and TIVADs require full-pathway evaluation during routine monitoring, not just visual inspection of the insertion site or needle hub. Complications such as tunnel tract inflammation, catheter migration, fibrin sheath formation, and pocket infections may develop insidiously, particularly when the device is not actively in use. In a retrospective study of 138 patients with tunneled catheters, Chouhani et al. reported a 46.7% overall complication rate, including tunnelitis, orifice infections, and sepsis.^10(IIIb) Delayed complications were significantly associated with longer catheter dwell times, prior tunneled catheter use, and comorbidities such as anemia or heart disease.^5(IIb)

Smith et al. further demonstrated that spontaneous tip migration, especially with left-sided TIVADs and tunneled catheters, was associated with an increased risk of catheter dysfunction and thrombosis. In their cohort, devices with more than 2 cm of cranial migration were over 7 times more likely to malfunction. These findings underscore the importance of ongoing monitoring of external length, tunnel tract condition, and subcutaneous pocket integrity.^8(IIIb) Even dormant ports require visual and tactile assessment for swelling, discoloration, or tenderness along the tract, as early detection prevents progression to more severe complications.

Recommendation 6: Postpressure Injection Monitoring

Clinicians should assess VAD function and insertion site condition immediately following any pressure injection procedure. Postpressure injection monitoring should include evaluation for signs of infiltration, dislodgement, tip migration, catheter rupture, and dressing disruption. Patients should also be asked about any pain, pressure, or unusual sensations they experience during and after the injection.

Summary of Evidence

Pressure injection of contrast media places significant mechanical stress on all VADs, particularly PICCs and TIVADs. High-pressure flow can cause complications, including catheter rupture, infiltration, tip displacement, and dressing lift, especially if the device is not properly stabilized or rated for injection. In a case series reviewed by Wang et al., pressure injection-related complications included pain, resistance to injection, swelling at the site, and suspected device migration, reinforcing the need for immediate postprocedure evaluation.^11(IIIb)

Manufacturers specify maximum flow rates and pressure limits for pressure-injectable devices; however, real-world complications still occur due to improper flushing, the use of inappropriate TIVAD noncoring needles (noncoring needles and extensions not rated for pressure injection), or anatomical resistance. Prompt assessment following injection helps identify subtle signs of compromise that may not be apparent during the procedure. Monitoring should include both subjective symptoms (pain, pressure, and flushing difficulty) and objective findings (swelling, dressing disruption, and catheter length change), with escalation to imaging or device replacement as indicated.^{2(IIa),3(IIIb)}

Clinical Considerations

Benefits

Reduced complications through routine monitoring: Routine assessments of dressing integrity, securement, and insertion sites help detect early signs of infection, occlusion, or mechanical issues, improving outcomes.^12,13,14
Improved skin injury management: Use of the central VAD–associated skin impairment (CASI) algorithm improves provider confidence in identifying and managing insertion site complications.^7,15
Early intervention from real-time documentation: Documentation protocols postinsertion increase early detection and management of complications such as bleeding and hematoma.^4,16

Risks

Catheter dislodgement or migration: Without routine assessment, dislodgement or malposition may go unnoticed, compromising therapy.^12,13,14
Delayed skin complication recognition: Failure to assess for signs of skin impairment or exit site infections may increase the risk of worsening tissue damage.^7,15
Infection risk from poor incision care: Inadequate postinsertion wound care can raise the risk of catheter-related infections, especially for TIVADs with suboptimal tunnel length.^{16,17,18,19,20,21,22}

Implementation Considerations

Training in imaging and lymphatic anatomy: Staff education in ultrasound guidance and anatomic knowledge reduces error rates and enhances outcomes.^23,24
Standardized dressing and securement assessments: Regular checks during dressing changes ensure catheter stability and patient comfort.^12,13,14

Barriers to Implementation

Limited use of tools like CASI: Despite their benefits, tools like the CASI algorithm may be underused due to lack of awareness or training.^7,15
Documentation burden: Real-time documentation improves care but may strain clinician workload, especially in high-volume settings.^4,16

References

Hanauer LPT, Comerlato PH, Papke A, et al. Reducing central vein catheterization complications with a focused educational program: a retrospective cohort study. Sci Rep. 2020;10(1):17530.
Gohil SK, Yim J, Quan K, et al. Impact of a central-line insertion site assessment (CLISA) score on localized insertion site infection to prevent central-line–associated bloodstream infection (CLABSI). Infect Control Hosp Epidemiol. 2020;41(1):59–66. doi:10.1017/ice.2019.291.
Roszell SS, Rabinovich HB, Smith-Miller CA. Maintaining short peripheral catheter patency. J Infus Nurs. 2018;41(3):165–169. doi:10.1097/NAN.0000000000000276.
Ullman AJ, Mihala G, O’Leary K, et al. Skin complications associated with vascular access devices: a secondary analysis of 13 studies involving 10,859 devices. Int J Nurs Stud. 2019;91:6–13. doi:10.1016/j.ijnurstu.2018.10.006.
Gras E, Jean A, Rocher V, et al. Incidence of and risk factors for local complications of peripheral venous catheters in patients older than 70 years: empirical research quantitative. J Clin Nurs. 2023;32(15):5000–5009. doi:10.1111/jocn.16732.
Singh R, Patel N, Mehta N, Singh G, Patel N. Central venous catheterization-related complications in a cohort of 100 hospitalized patients: an observational study. J Acute Dis. 2023;12(4):169–172.
Gorski LA, Lynn Hadaway F, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(Suppl 1):S1–S224. doi:10.1097/NAN.0000000000000396.
Smith T, Kaufman C, Quencer K. Internal jugular central venous catheter tip migration: patient and procedural factors. Tomography. 2022;8(2):1033–1040. doi:10.3390/tomography8020083.
Velioğlu Y, Yüksel A, Sınmaz E. Complications and management strategies of totally implantable venous access port insertion through percutaneous subclavian vein. Turk Gogus Kalp Damar Cerrahisi Derg. 2019;27(4):499–507. doi:10.5606/tgkdc.dergisi.2019.17972.
Chouhani BA, Kabbali N, Chiba Bennani S, El Bardai G, Sqalli Houssaini T. Tunneled catheters in hemodialysis: Indications and complications. J Med Vasc. 2022;47(2):87–93. doi:10.1016/j.jdmv.2022.04.007.
Wang J, Xu X. Effects of high-quality nursing on complications of peripherally inserted central catheter placement in patients with leukemia. Am J Transl Res. 2022;14(5):3472–3480.
Whitehorn A. Evidence summary. Chemotherapy drug extravasation: prevention. The JBI EBP Database. 2021;JBI-ES-24-2.
Whitehorn A. Evidence summary. Medical adhesive injury: prevention. The JBI EBP Database. 2022;JBI-ES-1908-3.
Kollar C. Optimizing the effectiveness of short peripheral catheters. J Infus Nurs. 2021;44(3):163–175. doi:10.1097/nan.0000000000000426.
Broadhurst D, Moureau N, Ullman AJ, World Congress of Vascular Access Skin Impairment Management Advisory Panel. Management of central venous access device-associated skin impairment: an evidence-based algorithm. J Wound Ostomy Continence Nurs. 2017;44(3):211–220.
Salawu K, Arowojolu O, Afolaranmi O, Jimoh M, Nworgu C, Falase B. Totally implantable venous access ports and associated complications in sub-Saharan Africa: a single-centre retrospective analysis. Ecancermedicalscience. 2022;16:1389. doi:10.3332/ecancer.2022.1389.
Bertoglio S, Cafiero F, Meszaros P, et al. PICC-PORT totally implantable vascular access device in breast cancer patients undergoing chemotherapy. J Vasc Access. 2020;21(4):460–466. doi:10.1177/1129729819884482.
Wiley K. Evidence-based standards guide the use and maintenance of venous implanted ports. ONS Voice. 2017;32(8):39–39.
Shen Y, Zhang XP, Ge F, Huang H, Li L. Maintenance of totally implanted ports in Zhongshan Hospital: a best practice implementation project. JBI Database System Rev Implement Rep. 2016;14(4):257–266. doi:10.11124/jbisrir-2016-2517.
Wynne D. Your clinical guide to implanted ports and non-coring needles. Br J Nurs. 2021;30(Suppl 7):1–7. doi:10.12968/bjon.2021.30.Sup7.1.
Dai C, Li J, Li Q-M, Guo X, Fan Y-Y, Qin H-Y. Effect of tunneled and nontunneled peripherally inserted central catheter placement: a randomized controlled trial. J Vasc Access. 2020;21(4):511–519. doi:10.1177/1129729819888120.
Li J, Hu Z, Lin X, et al. A randomized controlled trial to compare peripherally inserted central catheter tunnel lengths in adult patients with cancer. Clin J Oncol Nurs. 2023;27(3):295–304. doi:10.1188/23.Cjon.295-304.
Garcés-Carrasco AM, Santacatalina-Roig E, Carretero-Márquez C, Martínez-Sabater A, Balaguer-López E. Complications associated with peripherally inserted central catheters (PICC) in people undergoing autologous hematopoietic stem cell transplantation (HSCT) in home hospitalization. Int J Environ Res Public Health. 2023;20(3):704. doi:10.3390/ijerph20031704.
Yu Z, Sun X, Bai X, et al. Perioperative and postoperative complications of supraclavicular, ultrasound-guided, totally implantable venous access port via the brachiocephalic vein in adult patients: a retrospective multicentre study. Ther Clin Risk Manag. 2021;17:137–144. doi:10.2147/tcrm.S292230.

Chapter 5.3—Postinsertion Complication Identification & Management

Timely intervention and clear escalation pathways are critical components of safe and effective vascular access management. Early recognition of complications, such as signs of infection, catheter malfunction, occlusion, infiltration, or phlebitis, can significantly reduce the risk of progression to more severe outcomes. Prompt, evidence-based responses preserve vascular access integrity, minimize patient harm, and support therapeutic continuity.

Adequate postprocedural care and regular monitoring are crucial for identifying emerging issues and initiating timely interventions. This includes thorough assessments, accurate documentation, and adherence to maintenance protocols. Standardized escalation pathways provide clinicians with defined steps for managing complications at the bedside, including criteria for consulting vascular access specialists, infectious disease specialists, or interventional radiology when indicated.

Escalation protocols should be tailored to facility resources and patient acuity, with built-in flexibility to address complex scenarios. For example, escalating from peripheral to central access or initiating diagnostic imaging for suspected deep vein thrombosis must be informed by clinical findings and individual patient risk. A structured response framework reduces treatment delays, ensures appropriate care transitions, and supports multidisciplinary collaboration.

By embedding escalation protocols into routine practice and education, health care teams can strengthen their ability to respond efficiently to complications. This proactive, systems-based approach enhances patient safety, preserves vascular access longevity, and improves patient outcomes.

Recommendation 1: Identify and Assess Infiltration of a Vascular Access Device

Clinicians must assess for infiltration during every vascular access device (VAD) evaluation. Common signs include localized swelling, coolness, blanching, discomfort, decreased infusion rate, and damp dressings. When infiltration is suspected, clinicians must assess the severity, stabilize the site, and escalate appropriately using institutional protocols and severity grading tools.

Summary of Evidence

Identification: Infiltration occurs when a nonvesicant solution leaks from the VAD into the surrounding tissue. Early signs include localized swelling, pallor, coolness, and a slowed infusion rate; however, symptoms may vary depending on infusion pressure, site location, and patient awareness. Mild infiltrations may be resolved with conservative measures, while severe cases can lead to tissue damage, pain, and functional impairment.^{1–3(IIIb, Va, IVb)} Structured grading tools, such as the Infusion Nurses Society (INS) infiltration scale, support consistent assessment and guide escalation pathways.^4(IVa)

In a large observational study of peripheral intravenous catheter complications, infiltration was one of the most frequently documented issues, particularly with catheters in place beyond 72 hours or without securement.¹ The use of transparent dressings, tape-only securement, and high-pressure infusions increased the risk. Early identification and consistent severity grading improve intervention timing and reduce the escalation to more severe tissue injury or catheter replacement.^{1,2,4,5(IIIb, Va, IVa, IIIa)}

Recommendation 1a: Immediate Actions for Suspected Infiltration

Clinicians must immediately stop the infusion if infiltration is suspected. The VAD should be assessed for function. If infiltration is confirmed, the device should be discontinued unless required for aspiration, and the site stabilized.

Recommendation 1b: Supportive Management of Infiltration

Following infiltration, clinicians should elevate the affected limb, assess for pain and circulation, and apply warm or cold compresses based on institutional guidance, infusate characteristics, and patient preference. The site should be monitored for changes in swelling, capillary refill, and skin integrity. Suspected compartment syndrome or worsening symptoms must prompt immediate escalation to a licensed independent practitioner.

Summary of Evidence

Management: Immediate cessation of infusion is the critical first step in managing infiltration, regardless of severity.^3(IVb) Continuing to infuse fluid into extravascular tissue increases the risk of skin and soft tissue damage. Structured response protocols consistently recommend stopping the infusion, assessing the affected limb, and stabilizing the site before proceeding with interventions. Guidelines also recommend avoiding flushing the catheter if infiltration is suspected, as this may worsen tissue injury.^{2,3(Va, IVb)}

Supportive interventions include elevating the affected limb, applying warm or cold compresses depending on the type of solution infused, and conducting circulatory and neurological assessments to detect early signs of compartment syndrome.⁴ Authors of one study have emphasized the importance of reassessment and escalation, especially when swelling is extensive, pain is severe, or symptoms worsen over time. Infiltration severity grading tools, such as the INS infiltration scale, support consistent clinical decisions regarding escalation, monitoring frequency, and documentation.^{2,4(Va, IVa)}

In a systematic review, infiltration was identified as one of the most common complications across peripheral VADs, reinforcing the need for preventative education and timely intervention when symptoms appear.^1(IIIb) Early stabilization and appropriate monitoring reduce the risk of progression to tissue injury, helping to preserve vessel integrity for future access.^{1–4(IIIb, Va, IVb, IVa)}

Recommendation 2: Identification of Extravasation Injury

Clinicians must assess for extravasation with every vascular access evaluation when administering vesicants. Signs of extravasation include pain, burning, swelling, redness, and skin changes at or near the insertion site.

2026 | Supplemental Issue | JAVA

Chapter 4.2—Site Selection

Recommendation 1: Catheter-to-Vessel Ratio

Recommendation 2: Structured Assessment Using Rapid Assessment of Vascular Exit Site and Tunneling Options

Recommendation 3: Chest-to-Arm Tunneling

Recommendation 4: Blunt Tunneler Technique

Recommendation 5: Subcutaneous Track

Recommendation 6: Prioritize Axillary/Subclavian for CICC

Recommendation 7: Avoid Femoral Vein Access

Recommendation 8: Central VADs Favor Right-Sided Venous Access

Recommendation 9: Avoid Injury to High-Risk Structures

Recommendation 10: Radial Artery Site

Recommendation 11: Avoid Flexion Zones for Radial Artery Catheter Insertion

Clinical Considerations

References

Chapter 4.3—Vessel Preservation Considerations

Recommendation 1: Escalation in DIVA patients

Recommendation 2: Ensure Adequate In-Vessel Catheter Length for All Peripheral Insertions

Recommendation 3: Catheter-to-Vessel Ratio for Thrombosis Risk Reduction

Clinical Considerations

References

Chapter 4.4—Patient Positioning

General Principles of Positioning for Vascular Access Success

Recommendation 1: Comfortable Arm Position for Peripherally Inserted Catheters

Recommendation 2: Trendelenburg Position for Internal Jugular Vein Access

Recommendation 3: Positioning Considerations for Obese Patients Requiring Axillary/Subclavian Access

Recommendation 4: Upright Insertion for Patients Unable to Lie Flat

Recommendation 5: Prone-Dependent PICC Insertions

Clinical Considerations

References

Chapter 4.5—Pain Management Strategies

Recommendation 1: Use of Topical Anesthetics for Peripheral Access

Recommendation 2: Use of Intradermal and Subcutaneous Local Anesthetic

Recommendation 3: Use of Nonpharmacologic Interventions

Recommendation 4: Assess and Confirm Adequate Anesthesia

Clinical Considerations

References

Chapter 4.6—Vein Visualization

Recommendation 1: Use Visualization Before All Vascular Access Insertions

Recommendation 2: Dynamic Ultrasound Guidance for Peripheral Intravenous Catheter Insertion

Recommendation 3: Dynamic Needle Tip Positioning

Recommendation 4: Ultrasound-Guided Insertion for Central Venous Access Devices

Recommendation 5: Ultrasound Guidance for Radial Artery Catheterization

Recommendation 6: Use Ultrasound for Vessel Selection During PICC and Peripheral Midline Placement

Clinical Consideration

References

Chapter 4.7—Tip Navigation and Confirmation

Recommendation 1: Confirm CVAD Tip Location Prior to Use

Recommendation 2: Intracavitary ECG for Tip Confirmation

Recommendation 3: Use Tip Navigation Systems

Clinical Considerations

References

Chapter 4.8—Skin Antisepsis and Sterility

Recommendation 1: Perform Hand Hygiene Before Insertion

Recommendation 2: Use Chlorhexidine-Alcohol as First-Line Skin Antiseptic

Recommendation 3: Consider Alternatives for Sensitive or Damaged Skin

Recommendation 4: Use Aseptic Nontouch Technique

Recommendation 5: Apply Maximal Sterile Barrier for Central VAD Insertion

Recommendation 6: Maintain Sterility During Ultrasound-Guided Insertion

Clinical Considerations

References

Chapter 4.9—Stabilization and Vessel Enhancement

Recommendation 1: Joint Stabilization for Catheters Near Flexion Sites

Recommendation 2: Avoid Tourniquet Use with Fragile Veins

Recommendation 3: Manual Traction for Vein Stabilization

Recommendation 4: Vein Enhancement Techniques

Clinical Considerations

References

Chapter 4.10—Insertion Complication Management

Recommendation 1: Insertion Site Bleeding

Recommendation 2: Monitor for Bleeding and Hematoma Postinsertion

Recommendation 3: Respond to Unintended Arterial Puncture Immediately

Recommendation 4: Prevent Air Embolism During Insertion

Recommendation 5: Respond to Guidewire Resistance Promptly

Recommendation 6: Insertion-Related Arrhythmias

Recommendation 7: Nerve Injury Recognition and Response

Recommendation 8: Venospasm During Insertion

Recommendation 9: Lymphatic Injury During Insertion

Clinical Considerations

References