JAVA | 2026 | Supplemental Issue

Chapter 5.3—Complication Identification & Management

Extravasation include localized swelling, burning, tightness, blanching, erythema, pain, or damp dressings. High-risk drugs may cause tissue damage even with small volumes. Early identification, symptom grading, and clinical context must guide escalation and management.

Summary of Evidence

Identification: Extravasation refers to the leakage of vesicants and irritating infusates into surrounding tissues, which can potentially cause inflammation, tissue damage, or necrosis. This risk is especially significant with vasopressors, hypertonic saline, contrast media, chemotherapeutic agents, and other noncytotoxic irritants. Even small-volume extravasation of certain agents can result in compartment syndrome or long-term soft tissue injury if not recognized and managed promptly.^6(IIa)

Common signs include localized swelling, burning pain, blanching, and altered dressing integrity. Although some extravasations may initially be painless, particularly in patients with sensory impairment or under sedation, these signs are often present. According to multiple reviews and observational studies, female gender, advanced age, catheter placement outside the antecubital fossa, small-gauge catheters, and power injection techniques increase the risk of extravasation.^{6(IIa),7(IVa),8(Ib)}

Regular site evaluation, especially in patients receiving vesicant or irritant infusions, is crucial. In the Atay study, many direct-care clinicians lacked formal training in extravasation recognition, emphasizing the importance of education and severity grading systems to improve early identification.^8(Ib)

Recommendation 2a: Antidote Awareness of High-Risk Infusates

Clinicians who prescribe, prepare, or administer high-risk medications through VADs must be aware of the appropriate antidotes, countermeasures, and protocols for those agents. Facilities should ensure that clinicians have access to these agents (e.g., hyaluronidase, phentolamine) and the education necessary for their timely and accurate use.

Recommendation 2b: Immediate Management of Extravasation

When extravasation is suspected or confirmed, clinicians must immediately stop the infusion, disconnect the tubing, and aspirate any residual drug through the catheter, if permitted by the protocol. The catheter should be left in place to permit administration of a pharmacologic antidote into the affected tissue if indicated. Use of the same catheter to deliver the antidote may reduce additional tissue trauma.

Recommendation 2c: Supportive Management of Extravasation

Following immediate stabilization, the affected limb should be elevated and monitored closely. Warm or cold compresses should be applied based on the physicochemical properties of the infused agent. Clinicians should assess for changes in pain, perfusion, swelling, and skin integrity. Pharmacologic treatments should be administered as indicated, and wound care or surgical consultation obtained for moderate-to-severe cases or signs of tissue compromise.

Summary of Evidence

Management: Extravasation injury management requires the rapid identification of the agent, a response tailored to the specific agent, and interdisciplinary collaboration. Although often viewed as a direct-care clinician’s responsibility, a safe and effective response begins before the infusion, with the clinician being aware of the antidotes, treatments, and protocols appropriate for high-risk medications. As Stefanos et al. have emphasized, timely access to agents such as phentolamine, hyaluronidase, and terbutaline can significantly reduce the severity of tissue damage, but this requires proactive preparation and staff education.^7(IVa)

When extravasation is suspected, infusion must be stopped immediately, and aspiration of residual drug through the catheter should be attempted when permitted. The catheter may be left in place to administer the antidote, a strategy that reduces the risk of additional tissue trauma and delays. Compresses, warm or cold, depending on the physiochemical properties of the infusate, should be applied promptly to limit local injury progression.^7(IVa),9(Va)

Ongoing care includes limb elevation, frequent reassessment, and escalation to wound or surgical services in the case of moderate-to-severe injury. In a 2020 integrative review, Taibi et al. found that protocolized multidisciplinary response, combined with timely pharmacological treatment administration, improved healing and reduced the incidence of long-term complications.^10(IIIb) Additional risk factors, such as high osmolarity, vasoconstrictive agents, and deep tissue penetration, warrant closer observation and early pharmacologic intervention.^{4(IVa),7(IVa),9(Va)} Garcia-Uribe et al. similarly found that local supportive measures plus timely antidote use prevented surgical intervention in patients with vasopressor extravasation.^{4(IVa),7(IVa),9(Va)}

Recommendation 3: Identification and Differentiation of Occlusion

Clinicians must assess all VADs for signs of occlusion, differentiating between complete and partial loss of flow. Occlusions should be further categorized as mechanical, thrombotic, or chemical based on clinical presentation and resistance pattern. Accurate identification supports timely intervention, appropriate escalation, and preservation of the device.

Summary of Evidence

Identification: Occlusion is a leading cause of VAD failure, with clinical presentations ranging from minor withdrawal resistance to complete flow obstruction. Differentiating between partial occlusion (e.g., sluggish flow, inability to aspirate) and complete occlusion (no infusion or aspiration) helps guide intervention. Authors of one study reported that 40% of occlusions in double-lumen peripherally inserted central catheters (PICCs) were partial, and many required pharmacologic or mechanical correction.^11(IIIb)

Occlusions should be further assessed for their likely etiology:

• Mechanical occlusion is often positional or product-related (e.g., kinked tubing, tight dressings, end-cap malfunction, pinch-off syndrome).
• Thrombotic occlusion may involve intraluminal clots, mural thrombus, or fibroblastic sleeve formation, often identified by resistance during flush or inability to withdraw blood.^12(Va)
• Chemical occlusion typically results from medication or solution incompatibilities, especially with lipid-based or alkaline agents, and may present with visible precipitate or sudden onset of dysfunction.

Matey and Camp-Sorrell outlined a structured algorithm for evaluating occlusion cause based on clinical cues, flow behavior, and catheter history. Correctly identifying the type and extent of occlusion supports early troubleshooting and can prevent premature catheter replacement.^13(IVa)

Recommendation 3a: Mechanical Occlusion Management

Clinicians should evaluate for mechanical causes of occlusion, including clamp position, tubing kinks, tight securement, endcaps, or malposition. Repositioning the patient or limb, visualizing the entire external segment, and replacing the needleless connectors (NCs) should be attempted before escalating to pharmacologic or imaging interventions.

Recommendation 3b: Thrombotic Occlusion and Thrombolytic Use

If thrombotic occlusion is suspected, thrombolytic instillation must be initiated per protocol. If function is not restored after 2 doses, clinicians should suspect another cause of occlusion.

Recommendation 3c: Chemical Occlusion (Precipitate Management)

When chemical occlusion is suspected and the causal agents can be identified, clinicians must consult the pharmacy and select appropriate disintegration agents. Antidotes must be administered in collaboration with licensed independent practitioners and pharmacists’ guidance to avoid catheter damage or patient harm.

Recommendation 3d: Imaging for Persistent Occlusion

If occlusion is unresolved after mechanical and pharmacologic interventions, imaging must be obtained to evaluate for pinch-off syndrome, catheter fracture, or tip migration.

Summary of Evidence

Management: Occlusion is a leading cause of VAD failure and must be systematically evaluated to prevent unnecessary catheter removal or patient harm. Identification of occlusion type, mechanical, thrombotic, or chemical, guides appropriate intervention. A structured algorithm for troubleshooting occlusions emphasizing initial mechanical checks, catheter repositioning, and escalation based on resistance pattern and clinical history.^13(IVa)

Mechanical occlusion is frequently positional and reversible with conservative maneuvers. Thrombotic occlusions require pharmacologic treatment, typically with alteplase, which restores function in the majority of cases with 1 or 2 doses.^14(Va) Hawes (2020) and others caution that repeated use of thrombolytics may indicate biofilm buildup, not thrombus, especially in long-term central devices.^15(IIIb)

Chemical occlusions, often underrecognized, require pharmacy collaboration to identify the incompatible agents and select the appropriate countermeasure. Mismanagement can damage the catheter or cause further obstruction. When catheter function cannot be restored, imaging such as chest x-ray, fluoroscopy, or ultrasound is essential to rule out structural or vascular complications.^13(IVa)

Recommendation 4: Identification of Dislodgement or Malposition

Direct-care clinicians are encouraged to assess for signs of catheter dislodgement and tip malposition routinely. Indicators include changes in external catheter length, securement malfunction, dressing disruption, pain or swelling, inability to aspirate blood, or altered flow rates during infusion. Assessment should include physical inspection, patient report, and comparison with baseline measurements or imaging when available.

Summary of Evidence

Identification: Catheter dislodgement and tip malposition can occur with any VAD and may present with subtle or nonspecific signs. External catheter length change, especially when not documented at insertion, is one of the most under-recognized indicators. In one study, visible migration was reported as a leading cause of accidental removal and tip displacement.^16(Vb) Authors of another study emphasized that PICC tip migration often goes undetected unless catheter length is routinely measured and recorded.^17(Vb)

Common symptoms of tip malposition include neck, jaw, or shoulder pain, ear gurgling during flush, or sudden loss of blood return or flow rate changes, especially in PICCs. In central lines, migration into the azygous, jugular, or contralateral subclavian veins can occur due to high intrathoracic pressures, coughing, or poor securement. These complications are more likely to be detected when securement is weak or breakaway connectors are absent.^15(Vb)

Recommendation 4a: External Length Change Evaluation

Any change in external catheter length from baseline should prompt immediate reassessment. Marking catheter length at insertion and documenting the baseline serves as a reference point for detecting potential displacement.

Recommendation 4b: Clinical Signs of Tip Migration

When tip migration is suspected, such as new onset of neck or shoulder discomfort (PICC), ipsilateral ear gurgling, or altered function, clinical signs should be documented, and the device should not be used until evaluated. Confirmatory imaging may be warranted.

Recommendation 4c: Imaging Assessment for Suspected Malposition

If clinical or external signs suggest malposition and no other cause is identified, diagnostic imaging must be obtained to confirm tip location. The catheter should remain unused until evaluation is complete.

Summary of Evidence

Management: When dislodgement is suspected, use of the device should be suspended until full assessment is completed. This includes physical inspection, patient report, and flow testing with non-forceful aspiration or flush. If these steps do not confirm patency, imaging must be obtained. Authors of two studies have outlined protocols recommending chest radiograph, fluoroscopy, or ultrasound to verify catheter tip position following any suspected malposition.^{13(IVa),18(IIIb)}

Devices that have migrated but are still functional may be salvaged depending on tip location, device type, and patient risk factors. Otherwise, replacement should be considered. Authors of studies have supported the use of engineered securement devices and breakaway connectors to reduce dislodgement and need for reinsertion.^16(Vb) Ongoing education and routine documentation of baseline catheter length also reduce the risk of undetected displacement.

Recommendation 5: Identify Lymphatic Complications

Clinicians must assess for signs of lymphatic leak during routine vascular access site evaluations, particularly in patients with femoral access, tunneled catheters, or deep subcutaneous tissue. Persistent dampness beneath the dressing, accompanied by the absence of overt bleeding, may indicate lymphatic disruption. Early identification and supportive management are crucial to maintaining site integrity and preventing further complications.

Summary of Evidence

Identification: Lymphatic leak is a rare but underrecognized complication of VAD placement, particularly when deep tissue disruption occurs during tunneling or in anatomically complex regions such as the femoral triangle. Although overt bleeding is usually noted and addressed promptly, persistent moisture beneath the dressing, without visible blood, may reflect a serous lymphatic fluid leak rather than hematoma or exudate from infection.^19(IIIb)

This complication is most frequently reported following tunneling of central venous catheters, subcutaneous port placement, or femoral vein access, especially in patients with low body fat, altered lymphatic drainage, or prior instrumentation. It may be confused with dressing saturation from sweat, poor securement, or minor bleeding, delaying appropriate intervention. In their discussion of site surveillance, Gohil et al. emphasized that damp dressings and nonvisible site changes require prompt investigation to distinguish emerging complications.^20(IIa)

Recommendation 5a: Supportive Management of Suspected Lymphatic Leak

When lymphatic leak is suspected, clinicians should reinforce dressing integrity, consider light compression if not contraindicated, and elevate the limb when feasible. Persistent or worsening leakage must prompt site reassessment and consideration of catheter relocation if securement or skin integrity is compromised.

Summary of Evidence

Management: The phenomenon of lymphatic leak is most often reported in the early postinsertion period, especially following catheter manipulation, power injection, or use of large-bore devices. Gras et al. noted that fluid accumulation beneath the dressing, when not attributed to blood, should raise concern for lymphatic leak, particularly in older adults or patients with fragile skin.^19(IIIb) Structured site assessment, including inspection and palpation, improves recognition of such complications before secondary issues such as dislodgement or localized infection occur.^20(IIa)

While no protocols specific to lymphatic leak management have been established, the principles of site protection and supportive care apply. Elevation may reduce lymphatic pressure, and conservative compression can support sealing of disrupted vessels when not contraindicated.^20(IIa) Reinforcing securement and maintaining a dry, intact dressings are essential to avoid further site compromise. If leakage persists beyond initial conservative efforts, catheter reassessment or relocation may be necessary to prevent downstream complications.^4(IVa)

Recommendation 6: Identification of Totally Implanted VAD Complications

Clinicians should routinely assess totally implanted VADs (TIVADs) for signs of complication or failure. Core elements of assessment include:

• Palpation to identify tenderness, pain, or chamber instability;
• Observation for site changes or leakage;
• Performance testing flush resistance or poor blood return;
• Patient-reported symptoms discomfort, burning, pressure.

Complications may be subtle or atypical, particularly in patients receiving chemotherapy, corticosteroids, or prolonged vascular access. Early identification enables intervention before more severe outcomes occur.

Summary of Evidence

Identification: TIVAD-related complications are uncommon but potentially severe. Early detection depends on routine clinical assessments, particularly in high-risk patients such as those undergoing chemotherapy, receiving corticosteroids, or experiencing tissue fragility due to cachexia or prior surgeries.^{21(IIIa),22(IIIa)}

Authors of several studies have emphasized the importance of direct palpation, performance testing, and patient-reported symptoms as key tools for early recognition. In a large single-center study, Mori et al. identified rotation, dislocation, and skin dehiscence as TIVAD-specific risks often detected during flushing or dressing changes.^23(IIIb) Tom et al. reported that education and assessment bundles improved detection of early infiltration, extravasation, leakage, and skin injury.^24(IIIb)

Particularly, TIVAD portal body (i.e., housing, reservoir, and chamber) rotation (flipping), portal body depth issues, and skin degradation were recognized more frequently when structured assessments, including palpation, inspection, and patient queries, were incorporated into routine care. These findings support the importance of comprehensive bedside evaluation in preventing complications such as infiltration, extravasation, infection, and tissue breakdown.^{4(IVa),21(IIIa),22(IIIa)}

Recommendation 6a: Infiltration or Extravasation

Clinicians must evaluate signs of infiltration or extravasation during each TIVAD access and infusion, especially when resistance, swelling, or patient discomfort is reported. Potential causes include dislodged or improperly placed needles, catheter fractures, or disconnection of the catheter from the portal body. Prompt cessation of infusion and diagnostic assessment are warranted if infiltration or extravasation is suspected.

Recommendation 6b: Malpositioned or Deep Chamber

Clinicians should suspect portal body malposition when the TIVAD septum is difficult to locate, access attempts are repeatedly unsuccessful, or flushing is impaired. Contributing factors may include deep implantation in obese patients, rotation (flipping), or migration of the TIVAD portal body. Imaging confirmation and specialty consultation should be pursued when access is unreliable.

Recommendation 6c: Skin Breakdown Over and Around the TIVAD Portal Body

Clinicians should assess the skin overlying the TIVAD portal body for signs of breakdown, thinning, infection, or ulceration. Progressive tissue erosion may expose the septum, increasing the risk of infection. Contributing factors include frequent access, steroid use, fragile skin, or infection. If skin breakdown is observed, port use must be discontinued, site care implemented, and surgical evaluation considered.

Summary of Evidence

Management: Effective management strategies must be tailored to the specific etiology, whether mechanical, physiological, or infectious in nature, and depend on early recognition, appropriate imaging, and multidisciplinary intervention. Though infrequent, these events can lead to treatment delays, tissue injury, or infection if not recognized and addressed early. Observational studies and retrospective reviews consistently report low but meaningful rates of catheter dislocation, portal body rotation, and skin breakdown requiring intervention.^{23(IIIb),25(IIIb)}

Effective management strategies rely on timely device reassessment, imaging when needed, and the appropriate discontinuation or replacement of the device. Multidisciplinary care, including surgical or radiologic consultation, is often required when structural failure or tissue compromise is confirmed. Education and access protocols may help reduce the severity of complications when they occur.^24(IIIb)

Recommendation 7: Identification of Persistent Pain or Altered Sensation

Clinicians should assess for persistent or atypical pain, numbness, burning, or altered sensation associated with any VAD. These symptoms may indicate nerve irritation, device malposition, circulation issues, or early signs of infection. Evaluation should include functional assessment of the device, inspection of the site, and inquiry into the quality, location, and duration of symptoms.

Recommendation 7a: Management of Pain or Altered Sensation

When pain or altered sensation persists beyond the expected postinsertion period or presents atypically, clinicians must escalate to appropriate specialty services for diagnostic imaging and further evaluation.

Concerning findings include dermatomal distribution, functional impairment, escalating pain, or symptoms that interfere with device use. Referral may include interventional radiology, neurology, or surgical consultation, depending on presentation and suspected etiology.

Summary of Evidence

While mild postprocedural discomfort is common after VAD insertion, persistent or atypical pain may signal underlying complications, including nerve impingement, mechanical irritation, or early infection. Observational data and surveillance guidelines emphasize the need for structured monitoring to detect these less visible issues before more severe complications emerge.^{26(IIb),27(IIIb)}

Protocols that incorporate patient-reported outcomes and standardized follow-up assessments support earlier identification of pain-related complications and facilitate timely escalation to specialty care. Persistent pain or altered sensation, especially when dermatomal, focal, or interfering with function, warrants clinical investigation and device reassessment.^28(IIIa)

Recommendation 8: Insertion Site Infection

Clinicians are encouraged to assess the vascular access insertion site for local signs of infection during every evaluation. Redness, tenderness, swelling, drainage, or localized warmth should prompt immediate investigation and intervention. Dressing materials and antiseptic agents should be adjusted based on skin integrity, and infectious disease consultation should be considered if the condition fails to improve.

Summary of Evidence

Localized infection at the vascular access site often presents with nonspecific symptoms, such as erythema, tenderness, or dressing saturation, but may progress to more serious complications if unrecognized. In a pooled analysis of 4 randomized controlled trials, Buetti et al. found that pain, redness, and discharge within the first 7 days were reliable early indicators of catheter-related infection, independent of dressing type or antiseptic used.^{4(IVa),29(IIIa)} Persistent moisture, poorly adherent dressings, and fragile skin further elevate infection risk.

Best practices recommend immediate evaluation of any new or worsening local symptoms. Adjustments may include switching to non-chlorhexidine gluconate antiseptics, applying absorptive or antimicrobial dressings, and escalating to wound care or infectious disease specialists. Structured documentation and frequent reassessment improve early identification and outcomes.^{4(IVa),19(IIIb)}

Recommendation 9: Recognize and Respond to Systemic Signs of VAD-Related Infection

Clinicians must assess all VADs as potential sources of infection when patients present with systemic signs such as fever, chills, rigors, hypotension, or elevated white blood cell count without an identifiable source. Evaluation should include site inspection, blood cultures (preferably paired), and prompt infectious disease consultation when catheter-related bloodstream infection (CRBSI) is suspected.

Summary of Evidence

CRBSIs can present subtly and progress rapidly, especially in immunocompromised patients or those with long-term central access. Systemic signs such as fever, chills, rigors, or hypotension often represent the first and only indication of infection. In a multicenter randomized trial of neutropenic patients, Biehl et al. found that chlorhexidine dressings significantly reduced probable CRBSI rates (10.4% versus 17.3%, P = 0.014), reinforcing the importance of preventive strategies and early identification of systemic signs.^30(Ia)

Accurate diagnosis is essential for both clinical safety and infection surveillance. In a systematic review, Larsen et al. found that publicly reported central line–associated bloodstream infection (CLABSI) rates underestimate true incidence by up to 4.4%, potentially delaying recognition and treatment. Guidelines recommend obtaining paired blood cultures (central and peripheral), prompt evaluation of the insertion site, and early involvement of infectious disease specialists when CRBSI is suspected. Failure to promptly address these signs can increase sepsis risk, hospitalization, and mortality.^31(IIb)

Recommendation 10: Isolated Fever With Indwelling Central VAD

Clinicians should not automatically remove a central VAD (CVAD) based solely on the presence of fever or suspected infection, without first conducting a comprehensive clinical assessment.

Summary of Evidence

Routine removal of a CVAD at the onset of fever, without further evaluation, may lead to unnecessary device loss, increased procedural risk, and disruption of therapy. In a comprehensive literature review, Patel et al. reported that high-performing interventions emphasized a staged approach to CVAD use, beginning with the appropriateness of placement, continuing through maintenance, and concluding with timely removal. The most effective CLABSI reduction strategies combined clinical assessment with consistent auditing and avoidance of default removal triggers such as fever alone.^32(Vb) Updated guidance from Society for Healthcare Epidemiology of America/Infectious Diseases Society of America/Association for Professionals in Infection Control and Epidemiology reinforces this patient-centered strategy, urging daily assessment of line necessity and emphasizing that CVADs should not be removed unless clinically indicated, such as when infection is confirmed or the device is no longer needed.^33(Va)

Recommendation 11: Recognize and Respond to Signs of Catheter-Related Thrombosis

Clinicians should assess catheter-related thrombosis (CRT) when patients with a VAD present with unilateral swelling, limb pain, erythema, engorged superficial veins, or catheter dysfunction. Suspicion of CRT should prompt confirmatory imaging (e.g., duplex ultrasound) and consultation with vascular medicine or hematology. Catheter removal may not be required and should be determined based on clinical stability, device functionality, and thrombosis severity.

Summary of Evidence

CRT is a common complication of peripherally and centrally inserted catheters, especially in oncology and critically ill populations. Signs include ipsilateral swelling, discomfort, venous distension, erythema, or loss of catheter function. In a single-center retrospective study, multiple risk factors for CRT were identified, including cancer, prior thrombosis, multiple insertion attempts, and a high catheter-to-vein ratio.^34(IIIb)

Authors of another study reported a 22.8% incidence of venous thromboembolism in nonanticoagulated patients with PICCs or midlines, and multiple systematic reviews confirming CRT risk across device types and care settings.^35(IIIb) The 2019 Kidney Disease Outcomes Quality Initiative guidelines and subsequent meta-analyses recommend individualized device selection and careful insertion planning for patients at risk of thrombosis. Confirmatory ultrasound and early hematology or vascular consult are essential for diagnosis and risk-aligned intervention.^36(IVa) Most cases are managed with anticoagulation, while catheter removal is considered based on clinical needs and device status.

Recommendation 12: Early Recognition of Cardiac Complications

It is strongly recommended to develop and implement standardized protocols to support early recognition and immediate management of cardiac complications, including arrhythmias and cardiac tamponade, in patients with central VADs.

Summary of Evidence

Cardiac complications related to CVADs, including tamponade, arrhythmias, and catheter migration, are rare but potentially fatal. In a multicenter retrospective study of over 400 adults receiving totally implantable VADs via the brachiocephalic vein, a low incidence of serious complications was reported, including cardiac tamponade, arterial puncture, pneumothorax, and post-insertion thrombosis. Early identification and structured follow-up were found to reduce unplanned removals.^37(IIIb) Authors of other retrospective reviews have emphasized the value of protocol-driven care in identifying and managing early signs of deterioration, including chest pain, hypotension, or infusion disturbance.

Structured training and competency assessments enhance insertion accuracy and minimize complications resulting from catheter malposition or migration.^38(Ib) Ultrasound guidance is highlighted across the literature as a key strategy to reduce mechanical injury during insertion, while prompt clinical recognition and imaging are essential to address postprocedural events. Infection-related complications may also signal catheter dysfunction and should be evaluated with cardiac complications in mind.^39(IIIb)

Clinical Considerations

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.

Benefits

• Reduced phlebitis risk: Regular assessment for phlebitis—using validated scales—allows for early intervention, reducing severity and complications.^{27,40,41,42,43,44,45}
• Improved outcomes in malposition: Timely evaluation of internal catheter malposition allows for spontaneous or assisted correction, improving catheter function and reducing need for replacement.^46,47
• Enhanced patient safety: Routine assessment of catheter sites—including inspection for signs of phlebitis, infiltration, or malposition—allows for early recognition of complications and prompt intervention, reducing adverse outcomes.^{27,40,41,42,43,44,45}
• Enhanced skin injury management: The catheter-associated skin impairment algorithm improves provider confidence and consistency in managing skin damage.^4,48

Risks

• Missed signs of dislodgement: Failure to assess catheter stability and securement during dressing changes may result in unnoticed migration or malposition.^49,50,51,52
• Cardiac tamponade: Delayed recognition of signs like hypotension and jugular venous distension in CVAD patients may lead to life-threatening complications.^{37,38,39,53,54}
• Underrecognized CRBSI: Inconsistent assessment for bloodstream infection symptoms, such as fever and drainage, may delay diagnosis of catheter-related bloodstream infections.³²
• Topical therapy failure: Exit site infections may worsen if systemic antibiotics are delayed after failed topical treatment.^4,55

Implementation Considerations

• Validated tools improve reliability: Use of standardized scales (e.g., for phlebitis) ensures consistent documentation and early recognition of complications.^{27,40,41,42,43,44}
• Power flush utility: High-flow flush techniques have been shown to reposition malpositioned catheters with high first-attempt success rates.^46,47
• Routine tip verification: Internal malpositions may not show external signs—requiring protocols for imaging confirmation based on clinical suspicion.^46,47
• Use of site cultures and blood cultures: When an exit site infection is suspected, cultures help guide appropriate treatment and catheter management decisions.⁴
• Skin protection protocols: Recommendations include barrier films, nonalcohol antiseptics, and dressing changes based on skin condition severity.⁴

Barriers to Implementation

• Limited imaging access: Internal malpositions may go undetected in settings without access to timely imaging or experienced interpretation.^46,47
• Competency gaps: Providers may lack training in recognizing early cardiac, reducing timely intervention.^{38,39,53,54,56,57,58}
• Documentation variability: Without standardized assessment intervals and scales, symptom tracking (e.g., phlebitis or infiltration) may be inconsistent across providers.^{27,40,41,42,43,44}
• Clinical workload and documentation burden: Standardized assessments (e.g., for phlebitis) and frequent reassessments may be time intensive.^{27,40,41,42,43,44}

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26. Krein SL, Saint S, Trautner BW, et al. Patient-reported complications related to peripherally inserted central catheters: a multicentre prospective cohort study. BMJ Qual Saf. 2019;28(7):574–581. doi:10.1136/bmjqs-2018-008726.
27. 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.
28. Ray-Barruel G, Chopra V, Fulbrook P, et al. The impact of a structured assessment and decision tool (I-DECIDED®) on improving care of peripheral intravenous catheters: a multicenter, interrupted time-series study. Int J Nurs Stud. 2023;148:104604. doi:10.1016/j.ijnurstu.2023.104604.
29. 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.
30. Biehl LM, Huth A, Panse J, et al. A randomized trial on chlorhexidine dressings for the prevention of catheter-related bloodstream infections in neutropenic patients. Ann Oncol. 2016;27(10):1916–1922. doi:10.1093/annonc/mdw275.
31. Larsen EN, Gavin N, Marsh N, Rickard CM, Runnegar N, Webster J. A systematic review of central-line-associated bloodstream infection (CLABSI) diagnostic reliability and error. Infect Control Hosp Epidemiol. 2019;40(10):1100–1106. doi:10.1017/ice.2019.205.
32. Patel PK, Gupta A, Vaughn VM, Mann JD, Ameling JM, Meddings J. Review of strategies to reduce central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) in adult ICUs. J Hosp Med. 2018;13(2):105–116. doi:10.12788/jhm.2856.
33. Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2022;43(5):553–569. doi:10.1017/ice.2022.87.
34. 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.
35. Zohourian H, Schaubschlager T, Phan L, et al. Comparing incidence of thrombosis in PICC and midlines and evaluating the role of anticoagulation, site of insertion, and risk factors. J Assoc Vasc Access. 2019;24(1):38–44. doi:10.1016/j.java.2018.29.004.
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55. 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.
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Chapter 5.4—Management of Skin, Dressings & Securement

Maintaining dressing integrity and catheter securement requires thoughtful coordination of skin protection, product selection, and site assessment. This chapter integrates strategies for at risk skin, managing compromised skin, including medical adhesive–related skin injury (MARSI), catheter-associated skin injury (CASI), dermatitis, and tissue breakdown. Skin damage significantly affects patient comfort, dressing adherence, reliability of securement, and the risk of infection.

Dressing and securement of the vascular access device (VAD) are foundational elements of maintenance. Their effectiveness directly influences dwell time, infection risk, device stability, and patient comfort. Maintaining an intact dressing and securement system is not simply a matter of aesthetics; it is a core infection prevention strategy and a defense against complications such as dislodgement, thrombosis, and CASI.

By standardizing practices and matching products to clinical need, clinicians can reduce the frequency of unplanned dressing changes, support device function, and protect skin integrity. Optimizing dressing and securement is a critical component of safe and effective vascular access care across all settings.

Recommendation 1: Identify and Manage CASI

Clinicians must assess for skin injury, including CASI, MARSI, and contact dermatitis, during every vascular access site evaluation.

Summary of Evidence

Skin injury related to VADs is a frequent and preventable complication across all device types, including peripheral intravenous catheters (PIVCs), peripheral midlines (PMLs), and central venous access devices (CVADs). CASI, MARSI, and contact dermatitis may result from chemical irritation, adhesive trauma, pressure, or moisture trapped beneath dressings.^1(IIIa) These complications impair dressing adherence, increase infection risk, and can result in premature catheter removal. In a large-scale quality improvement (QI) initiative involving over 30,000 PIVCs, DeVries et al. demonstrated near elimination of MARSI and dressing disruption when clinicians used a bundle of sterile barrier film, adhesive enhancer, and staff education.^2(Va) Authors of 1 study emphasized that skin damage is most often related to dressing material, frequency of dressing change, antiseptic exposure, and removal technique.^3(IIIb)

Structured assessment tools such as the CASI algorithm support early recognition and guide product selection, escalation, and documentation (Appendix C).^1(IIIa) These frameworks improve consistency between providers and reduce the likelihood of delayed referral. When used alongside targeted education and product substitution (e.g., suspending chlorhexidine gluconate [CHG], switching to silicone-based dressings, or nonadhesive based securement), structured response protocols help preserve skin integrity and device function. Patients with fragile skin, repeated adhesive exposure, or chemical sensitivities are especially vulnerable to skin injury and may require early wound care consultation for healing and continued catheter use.^{1(IIIa),3–(IIIa,IIIb,IVa,IIIa)}

Recommendation 2: Intervention Strategies for Skin Compromise at the VAD Site

When skin impairment is present at or near the vascular access site, including weeping, oozing, granulation tissue, inflammation, or visible breakdown, clinicians must initiate a structured skin response protocol.

Summary of Evidence

Persistent moisture or exudate at the catheter insertion site increases the risk of skin maceration, dressing disruption, and microbial colonization. Granulation tissue, often caused by mechanical friction, chronic inflammation, or chemical irritation, is a sign of impaired tissue recovery and may reflect biofilm activity along the catheter tract. Inappropriate product selection, such as continued CHG use on broken or moist skin, can exacerbate tissue damage and interfere with healing.^{1(IIIa),4(IVa)}

Wound ostomy, and continence, nursing guidelines recommend immediate suspension of CHG products and transparent occlusive dressings when weeping or granulation is present, especially in patients with impaired skin integrity. Alternative dressings such as nonalcohol barrier films, non-CHG sterile gauze, or foam-based absorbent products may help manage exudate while protecting the catheter.^1(IIIa) Using a subcutaneous anchor securement system (SASS) for CVADs and PML will keep the catheter secure without the use of additional adhesive.^5(IIIa) In 1 observational study, delayed wound consults were associated with extended dwell times of compromised catheters, leading to unplanned removals and higher infection risk. Structured assessment tools, such as the CASI algorithm, help guide escalation and product substitution while preserving vascular access.^{1(IIIa),3(IIIb)}

Recommendation 3: Routine Dressing Change Intervals

Clinicians should adhere to standardized dressing change intervals to reduce infection risk and maintain dressing integrity:

• Transparent dressings: every 7 days or sooner if compromised.
• Gauze dressings: every 48 hours.
• CHG-impregnated dressings: 7 days if intact.
• Totally implantable VAD (TIVAD) dressing and noncoring needles: every 7 days or sooner if displaced.

Summary of Evidence

Authors of multiple studies and systematic reviews have supported the use of standardized intervals to minimize contamination and dressing disruption.^6(Ia),7(IVb) Variation in frequency was associated with increased skin injury and a higher risk of microbial colonization, reinforcing the need for interval-based protocols.^8(Ia)

Recommendation 4: Aseptic Technique for Dressing Changes

Dressing changes must employ appropriate aseptic nontouch technique (ANTT) based on device type and patient risk.

Summary of Evidence

The principle of ANTT emphasizes protecting key parts and key sites during all invasive procedures, including routine dressing changes.^{9(Va),10(IIa)} This structured approach is designed to minimize the risk of contamination, improve consistency across providers, and ensure safety without unnecessary use of full sterile fields.^11(IIIb) In foundational work, Rowley and Clare have established ANTT as a globally recognized standard for both insertion and maintenance procedures, with evidence supporting its role in reducing catheter-related infections and improving compliance with aseptic protocols.

Further support for ANTT is found in studies in which authors demonstrated that combining a structured technique with staff education and appropriate securement reduces dressing disruption and catheter dislodgement.^12(Va) McParlan et al. reported that adhesive and securement protocols built on ANTT principles significantly improved dressing integrity.^13(IIa) Schmutz et al. demonstrated that specific securement strategies effectively minimized accidental PIVC removal, highlighting the interdependence of technique and materials.^14(Ib)

Recommendation 5: Use of Antimicrobial Dressings and Discs

Antimicrobial dressings and discs should be used for:

• All VADs.
• Immunocompromised patients or those at increased infection risk.
• TIVAD needle insertion sites in immunocompromised patients.

Summary of Evidence

Sustained-release chlorhexidine at the catheter insertion site reduces colonization and infection risk. While authors of most studies have focused on CHG-impregnated dressings (e.g., sponge or gel matrix), adjunctive use of CHG discs placed beneath standard dressings is also a widely adopted method of antimicrobial site protection.^{15(IIb),16(IIa)}

Authors of systematic reviews and randomized trials have supported the infection prevention benefits of CHG dressings, particularly in high-risk populations such as intensive care unit, oncology, and immunocompromised patients. These products have been shown to reduce catheter-related bloodstream infections (CRBSIs) and extend dressing dwell time.^{16(IIa),17(IIb),18(Ia)}

Although head-to-head evidence comparing CHG discs and CHG-impregnated dressings is limited, both methods provide similar antimicrobial action and are endorsed in practice guidelines as part of infection prevention bundles. Authors of 2 studies looked at the advantages of CHG dressings for PIVCs showing a reduction in PIVC-BSI.^{19(Va),20(Ia)} Karlnoski et al. discussed the use of silver-plated dressings as an option to reduce central line–associated bloodstream infections.^21(IIIb)

Recommendation 6: Use of Adhesive Enhancers

To improve dressing adherence and reduce the frequency of unplanned dressing changes:

• Use adhesive enhancers (e.g., gum mastic liquid adhesive) for patients at risk for dressing lift due to moisture, skin oils, movement, or high friction areas.
• Apply enhancers in accordance with manufacturer guidance and allow them to dry fully before dressing application.
• Weigh the risk versus the benefit of tackifiers in patients with fragile skin.

Summary of Evidence

Dressing lift and unplanned changes increase the risk of contamination and catheter dislodgement.^{2(Va),22(IIIb),23(IIIb)} Adhesive enhancers such as gum mastic have been shown to significantly improve dressing adherence, especially in high-moisture environments or during prolonged dwell times.^2(Va) In a large-scale QI project, authors demonstrated that pairing adhesive enhancers with education and standardized products led to >96% dressing integrity and eliminated MARSI events in >30,000.^2(Va) These interventions reduce both cost and complication risk, supporting their inclusion in VAD maintenance protocols.^{2(Va),22(IIIb),23(IIIb)}

Recommendation 7: Skin Protection with Dressings

To decrease the risk of MARSI:

• Apply a sterile barrier film (skin protectant) prior to dressing application.
• Avoid nonsterile gauze, tape, or compression wraps that impair visualization or damage skin.
• Direct-care clinicians should be trained in dressing application and removal techniques to minimize skin trauma.

Summary of Evidence

MARSI is a common complication of vascular access care, especially in older adults and patients requiring frequent dressing changes.^{24(Ib),25(IIb),26(Va),27(IIIb)} Evidence supports the use of sterile barrier films to protect the stratum corneum, reduce removal trauma, and maintain dressing adherence.^25(IIb) Authors of clinical studies and consensus documents have shown that barrier film use results in fewer disruptions and less pain during removal, while preserving skin integrity. Training staff in correct dressing removal techniques, such as horizontal pull, skin support, and slow removal, also reduces the likelihood of skin tears and inflammation.^{24(Ib),26(Va)} Together, these practices promote safe, skin-friendly care.^{24(Ib),25(IIb),26(Va)}

Recommendation 8: Use of Engineered Securement Devices

All VADs should be secured using an appropriate securement device to minimize catheter movement, migration, and dislodgement. Engineered securement devices (ESDs) should be assessed for their ability to provide securement without introducing additional patient risk, such as skin injury or dressing disruption. Selection should be based on patient-specific factors, anticipated dwell time, and institutional outcome data.

Summary of Evidence

Securement is a critical component of vascular access care, directly impacting dressing integrity, catheter migration, and unplanned dislodgement. In a comparative study of adhesive versus subcutaneous anchor securement systems, researchers found that SASSs improved dressing integrity and significantly reduced catheter migration, supporting their role in securing CVADs without reliance on sutures.^{5(IIIa),13(IIa),28(IIIb)} Authors of another study demonstrated that the force required to dislodge a catheter varied significantly across securement methods, highlighting the mechanical impact of ESD selection on catheter stability.^14(Ib)

DeVries et al. reported improved dressing integrity and reduced device disruption following a large-scale QI initiative involving adhesive enhancers, an integrated securement device (ISD), and standardization of securement protocols, further supporting the role of ESDs as part of bundled care.^2(Va) In a 2024 meta-analysis, Xu et al. added moderate-certainty evidence that tissue adhesives prolong dressing durability but are associated with increased risk of skin damage, reinforcing the need for patient-specific assessment.^29(Ia)

Table: Engineered Securement Device (ESD) Types

Recommendation 8: Outcome-Driven Securement Strategies

Clinicians should routinely evaluate the effectiveness of VAD securement and adjust the securement strategy if repeated dressing disruptions, catheter migration, or device failure occur. Securement selection should reflect patient-specific factors, such as anatomical site, skin condition, expected dwell time, and history of adhesive-related complications.

Summary of Evidence

Securement-related complications, including migration, dislodgement, and dressing failure, are commonly associated with unplanned catheter removal and therapy interruption. Authors of multiple studies have demonstrated that securement strategies are not universally effective across all patient populations or settings. Structured protocols improve consistency, but individual response to securement products can vary substantially.^30(Vb)

Securement failure may be influenced by patient factors such as perspiration, mobility, or skin sensitivity. In a large QI initiative, DeVries et al. demonstrated reduced disruption and dressing failure after tailoring securement approaches to observed outcomes and incorporating adhesive enhancers.^2(Va) In a systematic review, Xu et al. found that tissue adhesive, while effective in neonates and some pediatric populations, carries a higher risk of skin injury in adults and does not offer consistent securement for CVADs on its own.^29(Ia)

Clinical Considerations

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.

Benefits

• Reduced CRBSI risk: Routine dressing care, securement, and needle changes help minimize contamination and infection risk, particularly CRBSI.^{31,32,33,34,35,36,37,38,39}
• Improved securement and dressing integrity: Routine care and assessment of dressing integrity, securement stability, and timely needle replacement enhance patient comfort, reduce the risk of dislodgement or migration, and support safe, continuous access.^{13,40,41,42,43,44,45,46}
• Skin integrity and comfort: Routine dressing care with the use of silicone adhesive removers, barrier films, and sutureless securement devices helps preserve skin integrity by reducing MARSI, minimizing pain and anxiety during dressing changes, lowering the risk of infection, and protecting against skin breakdown from secretions or bodily fluids.^{2,25,26,31,34,35,36,37,47}

Risks

• Skin damage: Repeated or aggressive dressing changes, particularly when using improper adhesive removal techniques, can cause MARSI, inflammatory reactions, and skin tears, compromise of the skin barrier, and increase the risk of infection.^{1,2,22,26,47,48,49}
• CRBSI from contamination: Lack of dressing integrity and poor technique with care compromises the antimicrobial barrier, increasing the risk of CRBSI and external contamination.^{16,31,32,33,34,35,36,50}
• Dislodgement and migration: Poor dressing integrity and inadequate securement can lead to catheter dislodgement or migration, which increases the risk of infection, device failure and therapy delays.^{30,40,41,42,44,51,52,53,54,55,56,57,58,59,60,61,62,63,64}

Implementation Considerations

• Use of ANTT: Surgical ANTT should be used for CVADs, midlines, or immunocompromised patients, while standard ANTT may be appropriate for PIVCs and low-risk patients, with all dressings applied aseptically to ensure protection and minimize infection risk.^{16,31,32,33,34,35,36,65,66,67,68,69}
• Tailored intervals by device type: Protocols should specify dressing and defined intervals while allowing for earlier changes if contamination or malfunction occurs.^70,71,72
• Select appropriate securement method: Tailor use of ESDs in accordance with manufacturer guidelines and patient-specific factors such as mobility, skin integrity, and anatomical site.^{30,44,51,52,53,54,55,56,57,58,59,60,61,62,64}
• Routine site checks: Frequent checks of securement stability, dressing integrity, and patient comfort should be part of routine maintenance protocols.^40,41,42

Barriers to Implementation

• Inconsistent adherence: Suboptimal dressing adherence and inconsistent compliance with dressing or needle change schedules can compromise dressing integrity and increase infection risk.^13,73
• Resource constraints: Implementation of specialized dressing materials and advanced devices may be hindered by cost, limited reimbursement, procurement challenges, and staffing or inventory constraints, making it difficult for resource-constrained facilities to maintain routine care schedules.^{31,32,34,35,36,37,41,42,46,68,74}
• Training requirements: Effective use of adhesive dressings and securement devices requires proper training, but limited clinician familiarity with newer products and lack of ongoing education or protocol reinforcement can lead to inconsistent application, increased risk of MARSI or dislodgement, and reduced adoption.^{1,13,26,61,65,66,75}
• Variable outcomes: Standardizing care practices can be challenging due to variability in product performance, differences in patient skin condition and dressing frequency, and potential sensitivities to adhesive materials or CHG, all of which require site-specific outcome tracking and individualized dressing strategies.^14,26,47
• Resource and time demands: Adherence to individualized dressing change frequencies, CHG bathing protocols, and aseptic technique can place significant demands on staffing and supply resources.^2,6,48

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25. Chen YH, Hsieh HL, Shih WM. Applying skin barrier film for skin tear management in patients with central venous catheterization. Adv Skin Wound Care. 2020;33(11):582–586. doi:10.1097/01.ASW.0000717208.20481.a0.
26. Hadfield G, De Freitas A, Bradbury S. Clinical evaluation of a silicone adhesive remover for prevention of MARSI at dressing change. J Community Nurs. 2019;33(3):36–41.
27. Zhao H, He Y, Wei Q, Ying Y. Medical adhesive–related skin injury prevalence at the peripherally inserted central catheter insertion site. J Wound Ostomy Continence Nurs. 2018;45(1):22–25. doi:10.1097/WON.0000000000000394.
28. Brescia F, Pittiruti M, Roveredo L, et al. Subcutaneously anchored securement for peripherally inserted central catheters: immediate, early, and late complications. J Vasc Access. 2023;24(1):82–86. doi:10.1177/11297298211025430.
29. Xu H, Hyun A, Mihala G, et al. The effectiveness of dressings and securement devices to prevent central venous catheter-associated complications: a systematic review and meta-analysis. Int J Nurs Stud. 2024;149:104620. doi:10.1016/j.ijnurstu.2023.104620.
30. Krenik KM, Smith GE, Bernatchez SF. Catheter securement systems for peripherally inserted and nontunneled central vascular access devices: clinical evaluation of a novel sutureless device. J Infus Nurs. 2016;39(4):210–217.
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33. Duyu M, Karakaya Z, Yazici P, et al. Comparison of chlorhexidine impregnated dressing and standard dressing for the prevention of central-line associated blood stream infection and colonization in critically ill pediatric patients: a randomized controlled trial. Pediatr Int. 2022;64(1):e15011. doi:10.1111/ped.15011.
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36. Reynolds H, Gowardman J, Woods C. Care bundles and peripheral arterial catheters. Br J Nurs. 2024;33(2):S34–S41. doi:10.12968/bjon.2024.33.2.S34.
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38. Thate JA, Couture B, Schnock KO, Rossetti SC. Information needs and the use of documentation to support collaborative decision-making: implications for the reduction of central line–associated blood stream infections. Comput Inf Nurs. 2020;39(4):208–214.
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42. Whitehorn A. Chemotherapy Drug Extravasation: Prevention. JBI EBP Database. 2021;JBI-ES-24-2.
43. Corley A, Marsh N, Ullman AJ, Rickard CM. Tissue adhesive for vascular access devices: who, what, where and when? Br J Nurs. 2017;26(19):S4–S17.
44. Bugden S, Shean K, Scott M, et al. Skin glue reduces the failure rate of emergency department–inserted peripheral intravenous catheters: a randomized controlled trial. Ann Emerg Med. 2016;68(2):196–201. doi:10.1016/j.annemergmed.2015.11.026.
45. Rickard CM, Marsh N, Webster J, et al. Dressings and securements for the prevention of peripheral intravenous catheter failure in adults (SAVE): a pragmatic, randomised controlled, superiority trial. Lancet. 2018;392(10145):419–430. doi:10.1016/S0140-6736(18)31380-1.
46. Malek AE, Raad II. Preventing catheter-related infections in cancer patients: a review of current strategies. Expert Rev Anti Infect Ther. 2020;18(6):531–538. doi:10.1080/14787210.2020.1750367.
47. Barton A. Prevention of medical adhesive-related skin injury (MARSI) during vascular access. Br J Nurs. 2021;30(Suppl 2):1–8. doi:10.12968/bjon.2021.30.Sup2.1.
48. Marsh N, Webster J, Mihala G, Rickard CM. Devices and dressings to secure peripheral venous catheters to prevent complications. Cochrane Database of Systematic Reviews. 2015;(6). doi:10.1002/14651858.CD011070.pub2.
49. 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.
50. Apata IW, Hanfelt J, Bailey JL, Niyyar VD. Chlorhexidine-impregnated transparent dressings decrease catheter-related infections in hemodialysis patients: a quality improvement project. J Vasc Access. 2017;18(2):103–108. doi:10.5301/jva.5000658.
51. Barton A. Universal adhesive vascular access securement with Grip-Lok devices. Br J Nurs. 2020;29(8):S28–S33.
52. de Rosenroll A. Peripheral intravenous catheters: improving outcomes through change in products, clinical practice and education. Vasc Access. 2017;11(1):7–12.
53. Gravante F, Lombardi A, Gagliardi AM, Pucci A, Latina R. Dressings and securement devices of peripheral arterial catheters in intensive care units and operating theaters: a systematic review. Dimens Crit Care Nurs. 2020;39(5):242–250. doi:10.1097/dcc.0000000000000433.
54. Jeanes A, Martinez-Garcia G. Intravenous securement devices: an overview. Br J Healthcare Manage. 2016;22(10):488–492.
55. Karpanen TJ, Casey AL, Whitehouse T, Nightingale P, Das I, Elliott TSJ. Clinical evaluation of a chlorhexidine intravascular catheter gel dressing on short-term central venous catheters. Am J Infect Control. 2016;44(1):54–60. doi:10.1016/j.ajic.2015.08.022.
56. Luo X, Guo Y, Yu H, Li S, Yin X. Effectiveness, safety and comfort of StatLock securement for peripherally-inserted central catheters: a systematic review and meta-analysis. Nurs Health Sci. 2017;19(4):403–413. doi:10.1111/nhs.12361.
57. Mitchell ML, Ullman AJ, Takashima M, et al. Central venous access device securement and dressing effectiveness: the CASCADE pilot randomised controlled trial in the adult intensive care. Aust Crit Care. 2020;33(5):441–451. doi:10.1016/j.aucc.2019.10.002.
58. Molina-Mazón CS, Martín-Cerezo X, Domene-Nieves de la Vega G, Asensio-Flores S, Adamuz-Tomás J. Comparative study on fixation of central venous catheter by suture versus adhesive device. Enferm Intensiva (Engl Ed). 2018;29(3):103–112. doi:10.1016/j.enfi.2017.10.004.
59. Padilla-Nula F, Bergua-Lorente A, Farrero-Mena J, et al. Effectiveness of cyanoacrylate glue in the fixation of midline catheters and peripherally inserted central catheters in hospitalised adult patients: randomised clinical trial (CIANO-ETI). SAGE Open Med. 2023;11:20503121231170744. doi:10.1177/20503121231170743.
60. Pittiruti M, Scoppettuolo G, Dolcetti L, et al. Clinical experience of a subcutaneously anchored sutureless system for securing central venous catheters. Br J Nurs. 2019;28(2):S4–S14. doi:10.12968/bjon.2019.28.2.S4.
61. Rickard CM, Edwards M, Spooner AJ, et al. A 4-arm randomized controlled pilot trial of innovative solutions for jugular central venous access device securement in 221 cardiac surgical patients. J Crit Care. 2016;36:35–42. doi:10.1016/j.jcrc.2016.06.006.
62. Ullman AJ, Cooke ML, Mitchell M, et al. Dressings and securement devices for central venous catheters (CVC). Cochrane Database Syst Rev. 2015;2015(9):CD10367. doi:10.1002/14651858.CD010367.pub2.
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Chapter 5.5—Flushing, Locking, & Blood Sampling

Routine flushing, catheter locking, and blood sampling are fundamental aspects of vascular access device (VAD) care. These practices support safe medication administration, reduce the risk of catheter-related bloodstream infections (CRBSIs), and promote consistent device function. When performed correctly, they also contribute to accurate laboratory diagnostics and minimize unnecessary device manipulation or replacement.

Evidence-based flushing and locking protocols should be tailored to the type of device, patient population, and clinical setting. Techniques such as pulsatile flushing, appropriate lock solutions, and postdraw saline flushing help reduce the risk of contamination and maintain line functionality. Similarly, blood sampling from VADs, when clinically appropriate, requires strict aseptic nontouch technique, adherence to discard volume guidance, and thoughtful coordination with flushing practices.

Integrating these procedures into routine workflows, supported by clinician education and institutional standardization, enhances care consistency and patient safety. A well-designed flushing and locking protocol, coupled with standardized blood sampling practices, is a critical component of any vascular access maintenance strategy.

Recommendation 1: Flushing Technique

Clinicians should use a pulsatile (push-pause) flushing technique followed by positive pressure to reduce the risk of occlusion, contamination, intraluminal fibrin buildup, and infusate residue.

Summary of Evidence

Pulsatile flushing (push-pause) generates turbulent flow within the catheter lumen, which helps to dislodge medication residues, prevent fibrin sheath development, and reduce the risk of occlusion or biofilm formation.^{1(IIIb),2(Ib),3(IIb)} Positive pressure techniques should be used to help prevent retrograde blood reflux.^3(IIb) (Note: The direct care clinician needs to understand the specific catheter and needleless connector engineering to best prevent reflux.)

Standardizing flushing technique across clinical settings enhances care consistency and safety. Authors of several studies have supported the use of single-use prefilled, preservative-free 0.9% saline syringes with a barrel diameter of 10 mL or greater, which are recommended to standardize practice and minimize the risk of infection.^{3(IIb),4(IIIb)} Prefilled syringes with the appropriate volumes reduce the potential for dosing errors and improve workflow efficiency. Institutions should consider these techniques as a core component of their vascular access maintenance protocols.^4(IIIb)

Recommendation 2: Flushing Frequency and Volume

Flushing frequency and volume should be tailored to the type of VAD and its pattern of use. Clinicians should follow standardized protocols that specify minimum flushing volumes and appropriate intervals for continuous and intermittent device use.

Summary of Evidence

The frequency and volume of flushing play a critical role in maintaining catheter function and preventing complications such as occlusion or drug residue buildup. Regular flushing after medication administration or at defined intervals has been shown to support VAD patency. Recommended volumes differ by device type, with ≥10 mL of preservative-free saline used for CVADs and 3–5 mL for peripheral intravenous catheters (PIVCs).^{5(IIIb),6(IIIb)}

In a mixed-methods study, Norton et al. reported that nurses most frequently used 10 mL flushes for PIVCs and that higher flush volumes and frequencies were positively associated with end-of-shift catheter patency. This supports protocol-driven minimum volumes and highlights the need for continued education on flush timing, especially in the context of maintenance versus medication administration (see Table 1).^4(IIIb)

Recommendation 3: Flushing Solutions

Use preservative-free 0.9% normal saline as the standard flushing solution for all peripheral and central VADs unless otherwise indicated by device type, therapy, or patient condition.

Summary of Evidence

Flushing with 0.9% normal saline serves to clear the lumen of residual infusates, reduce intraluminal drug interaction, and confirm patency before or following therapy.^3(IIb) (Some medications are incompatible with saline flush [e.g. Diazepam, Amphotericin B]; check with your pharmacist for specific flush solution.)

This is distinct from locking, which is performed after the final flush when the device is not in active use and requires an indwelling solution to maintain patency over time.^{7(IIb),10(Ib)}

Authors of multiple studies have shown that 0.9% saline is effective for routine flushing of both peripheral VADs and central VADs, reducing the need for heparin and minimizing the risk of drug interaction, hypersensitivity, and heparin-induced thrombocytopenia.^{8(IIIb),11(IIb),12(Ib),13(IIa)} The use of preservative-free, single-use prefilled saline syringes is recommended to ensure accurate dosing and reduce the risk of contamination.^14(IIb)

Recommendation 4: Locking Solutions

Select locking solutions based on patient-specific risks, catheter type, clinical setting, and institutional protocols. Locking technique should follow a complete final saline flush, including sufficient volume to fill the entire lumen, and avoid reflux of blood. Locking solutions must be evidence-based and concentration-specific (see Table 2).

Summary of Evidence

Locking solutions are used to maintain catheter patency and reduce the risk of infection between catheter uses, particularly in long-term or intermittently accessed devices. Saline locks are suitable for most short-term devices. Still, patients with prolonged catheter dwell times or a history of complications may benefit from adjunct locking agents with antimicrobial, antibiofilm, or antithrombotic properties.^{8(IIIb),11(IIb),12(Ib),13(IIa),17(Vb)}

Table 1. Flushing Frequency and Volume by Device Type^a

^aNote: The flush volume should exceed the internal volume of the catheter lumen, plus any extension sets. Flushing volumes and frequencies are dependent on several factors, including the number of infusates administered in 24 h, catheter instructions for use, and patient-specific issues.^4,6,7,8,9,10

While heparin has historically been used for this purpose, authors of studies have shown no clear advantage over saline for routine locking and highlight bleeding risks at higher concentrations.^22(Ia) Citrate (4%) is a lower-risk alternative in patients with coagulopathy or high bleeding risk.^16(Ib) T-EDTA has emerged as a biofilm-disrupting option with the potential to reduce both infection and occlusion rates in long-term CVADs, especially in home parenteral nutrition populations.^17(Va)

Antimicrobial locks, such as taurolidine, gentamicin-citrate, vancomycin, or ethanol, may be appropriate in high-risk or salvage scenarios; however, their use should be guided by real-world outcome data, local protocols, and patient-specific factors, rather than routine preference.^{18(Ib),19(Ib),20(IIIb),21(IIb)} Regardless of the lock solution used, accurate volume calculation (to fill the entire catheter and extension set), adherence to aseptic technique, and elimination of reflux are critical to achieving safe and effective locking.

Table 2. Locking Solutions by Type, Concentration, and Supporting Study

Recommendation 5: Blood Sampling from VADs

When feasible, use peripheral venipuncture rather than VADs for blood sampling to reduce the risk of infection, occlusion, and sample contamination.

Summary of Evidence

Using VADs for blood sampling increases the risk of infection, intraluminal thrombus formation, and sample dilution or hemolysis, particularly when discard protocols are not followed.^{23(IIa),24(IIb),25(IIb)} Authors of a systematic review found that limiting VAD-based draws reduced adverse events and was associated with improved test accuracy when peripheral venipuncture was used instead.^{13(IIa),26(IIb)}

When blood draws through VADs are necessary, evidence supports using discard volumes tailored to the device (minimum discard equal to twice the fill volume):

• CICC: 5 mL.
• PICC: 3–5 mL.
• TIVAD: 5–7 mL.
• Hemodialysis catheter: 8–10 mL.
• PML/PIVC: 2–3 mL.

Authors of studies have also supported push-pull techniques and saline-only protocols in select cases, with some evidence suggesting 2 mL may be sufficient for certain labs when paired with a 10 mL flush.^{27(Ib),28(IIb)}

Following any blood sampling, a postdraw flush of 10–20 mL saline is advised to remove residual blood and maintain catheter patency. This step supports clinical alignment between this recommendation and flushing/patency practices.^9(IVa)

Clinical Considerations

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.

Benefits

• Decreased CRBSI Risk via antimicrobial locks: Ethanol, taurolidine, and T-EDTA locking solution (per IFU) significantly reduce CRBSI rates in patients with tunneled catheters and those on home parenteral nutrition.^{17,18,19,20,29,30}
• Improved patency with pulsatile flushing: Use of the pulsatile technique improves flushing effectiveness and reduces biofilm formation.^1,2,3

Risks

• Bleeding with heparin use: Even low-dose heparin carries bleeding risk; alternatives like citrate may be safer for at-risk patients.^15,31
• Resistance with antibiotic locks: Prolonged or inappropriate use of antibiotic locks (e.g., vancomycin, gentamicin) may contribute to antimicrobial resistance.²⁰

Implementation Considerations

• Tailored flushing based on catheter type: Flushing frequency and lock solutions should be catheter specific.^5,23,32
• Standardized protocols and training: Implement flushing protocols and regular training to ensure consistency and reduce catheter-related deep vein thrombosis by up to 67%.^33,34,35
• Multidisciplinary involvement: Engage nursing, vascular access teams, radiology, and pharmacy in flushing/locking strategies.^{34,35,36,37,38}

Barriers to Implementation

• Cost and access to antimicrobial locks: Advanced locking solutions like taurolidine and gentamicin-citrate may be cost-prohibitive or unavailable in some settings.^17,29,30
• Protocol adherence: Inconsistent training or lack of standardized protocols can compromise flushing or locking effectiveness.^33,34,35
• Lack of familiarity with emerging products: Clinicians may be unaware of or untrained in using novel lock agents like T-EDTA or taurolidine.^17,30

References

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26. Siegal DM, Manning N, Jackson Chornenki NL, Hillis CM, Heddle NM. Devices to reduce the volume of blood taken for laboratory testing in ICU patients: a systematic review. J Intensive Care Med. 2020;35(10):1074–1079. doi:10.1177/0885066618810374.
27. Villalta-García P, López-Herránz M, Mazo-Pascual S, Honrubia-Fernández T, Jáñez-Escalada L, Fernández-Pérez C. Reliability of blood test results in samples obtained using a 2-mL discard volume from the proximal lumen of a triple-lumen central venous catheter in the critically ill patient. Nurs Crit Care. 2017;22(5):298–304. doi:10.1111/nicc.12220.
28. Lokeskrawee T, Muengtaweepongsa S, Patumanond J, Sawaengrat C. Accuracy of laboratory tests drawn by pull-push method from central venous catheterization after routine flushing with 10 mL normal saline in patients with sepsis at the emergency department. Heliyon. 2021;7(6):e07355.
29. Goh TL, Wei J, Semple D, Collins J. The incidence and costs of bacteremia due to lack of gentamicin lock solutions for dialysis catheters. Nephrology (Carlton). 2017;22(6):485–489. doi:10.1111/nep.12960.
30. Lannoy D, Janes A, Lenne X, et al. Cost-effectiveness of taurolidine locks to prevent recurrent catheter-related blood stream infections in adult patients receiving home parenteral nutrition: a 2-year mirror-image study. Clin Nutr. 2021;40(6):4309–4315. doi:10.1016/j.clnu.2021.01.017.
31. Luman A, Quencer KB, Kaufman C. Pre-procedure thrombocytopenia and leukopenia association with risk for infection in image-guided tunneled central venous catheter placement. Tomography. 2022;8(2):627–634. doi:10.3390/tomography8020052.
32. Hawes ML. Assessing and restoring patency in midline catheters. J Infus Nurs. 2020;43(4):213–221. doi:10.1097/NAN.0000000000000376.
33. Walters B, Price C. Quality improvement initiative reduces the occurrence of complications in peripherally inserted central catheters. J Infus Nurs. 2019;42(1):29–36. doi:10.1097/NAN.0000000000000310.
34. Kim-Saechao SJ, Almario E, Rubin ZA. A novel infection prevention approach: leveraging a mandatory electronic communication tool to decrease peripherally inserted central catheter infections, complications, and cost. Am J Infect Control. 2016;44(11):1335–1345. doi:10.1016/j.ajic.2016.03.023.
35. Dynan L, Smith RB. Sources of nurse-sensitive inpatient safety improvement. Health Serv Res. 2022;57(6):1235–1246. doi:10.1111/1475-6773.13979.
36. 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.
37. Dibb M, Lal S. Home parenteral nutrition: vascular access and related complications. Nutr Clin Pract. 2017;32(6):769–776. doi:10.1177/0884533617734788.
38. Carr PJ, Higgins NS, Cooke ML, Mihala G, Rickard CM. Vascular access specialist teams for device insertion and prevention of failure. Cochrane Database Syst Rev. 2018;3(3):CD011429. doi:10.1002/14651858.CD011429.pub2.

Chapter 5.6—Connector & Safety Devices

Accessory devices such as needleless connectors (NCs), antiseptic barrier caps, and breakaway devices enhance the safety and function of vascular access systems. These components support closed systems, reduce the risk of contamination, and protect catheter integrity across various care settings.

NCs provide a protective interface at the hub, reducing manipulation and contamination risk when paired with standardized disinfection practices. Antiseptic barrier caps extend this protection by offering passive, continuous disinfection between accesses. Additionally, antireflux connectors help maintain unidirectional flow, thereby reducing occlusion and blood reflux events.

Breakaway devices protect against catheter damage and dislodgement by releasing under strain. Collectively, these products contribute to comprehensive vascular access care by reducing complications and supporting safe, consistent practice.

Recommendation 1: Use of Blood Culture Diversion Devices

It is reasonable to use blood culture diversion devices (BCDDs) during specimen collection when contamination is possible.

Summary of Evidence

Authors of a prospective, quasi-experimental study assessed contamination rates among intensive care unit (ICU) and non-ICU patients where phlebotomists used either traditional venipuncture or a BCDD. Use of the BCDD resulted in a 0% contamination rate across 11,202 samples compared with a 2.3% contamination rate from 4,759 traditional samples. The authors also reported a significant reduction in false-positive central line–associated bloodstream infection (CLABSI) diagnoses when BCDD were used, supporting their utility in improving diagnostic accuracy and avoiding unnecessary treatment.^1(IIIa)

Recommendation 2: Use of Breakaway Connection Systems

It is reasonable to consider the use of breakaway connector systems for patients who are confused, agitated, or ambulatory, to reduce the risk of mechanical complications.

Summary of Evidence

Breakaway devices are engineered to detach when subjected to a specific amount of tension, limiting catheter dislodgement or vascular injury. Authors of both a 2022 product review and 2024 pilot study demonstrated that breakaway systems reduce mechanical stress on peripheral catheters and mitigate external force transmission. While these findings support the theoretical benefit, more robust clinical studies are needed.^2(Vb),3(IIb)

Recommendation 3: Evaluation and Selection of NCs

Health care organizations should evaluate and select NCs based on available evidence, clinical performance, and practice alignment. Selection should include consideration of displacement type, occlusion risk, and contamination rates.

Summary of Evidence

Authors of a comparative study at a cardiac center found that neutral or positive-pressure NCs reduced occlusion and catheter-related bloodstream infection (CRBSI) rates relative to negative-pressure devices. Authors of additional studies have reported increased blood reflux and clot formation with negative-pressure models. Authors of a multicenter analysis showed that positive-pressure NCs significantly lowered CRBSI rates in ICU settings. However, labeling of displacement type does not always reflect real-world performance, and outcomes may vary between brands. Ongoing evaluation at the institutional level is essential for sustained product effectiveness.^{4(IIb),5(IIb),6(IIb,IIb)}

Recommendation 4: Manual Disinfection of NCs

Clinicians should disinfect NCs before each access using an alcohol-based antiseptic, applying sufficient friction for 10–15 seconds and allowing the surface to dry completely before use.

Summary of Evidence

Effective disinfection of NCs is essential to preventing intraluminal contamination and CRBSI. Authors of a randomized controlled trial found no significant difference between 70% isopropyl alcohol (IPA) and 2% chlorhexidine gluconate (CHG) in 70% IPA for surface decontamination, supporting the continued use of 70% IPA as a viable, efficient option.^7(Ia) Further researchers confirmed that 10–15 seconds of scrubbing with alcohol significantly reduces surface colonization, even under high bacterial loads, and mechanical friction is critical to disrupting biofilm on the connector surface.^{8(IIb),9(IIIb)} Drying time for 70% IPA was consistently shorter than that of CHG-alcohol combinations, offering practical advantages in clinical workflows.

Routine, standardized scrubbing of NCs remains a cornerstone of infection prevention, particularly in settings where antiseptic barrier caps are not feasible or not used consistently.^{8(IIb),9(IIIb)}

Note: Verify manufacturer guidelines in the use and availability of CHG to disinfect NCs.

Recommendation 4: Passive Disinfection of NCs

Clinicians should consider the use of antiseptic barrier caps for passive disinfection of NCs. (Note: Follow specific IFU for active disinfection requirement.)

Summary of Evidence

Antiseptic barrier caps are designed to provide continuous passive disinfection of the NC surface between uses. Authors of a systematic review and meta-analysis found that their use significantly reduced CLABSI rates, with a pooled risk ratio of 0.65 (95% confidence interval = 0.55, 0.76) across nearly 550,000 catheter days.^10(IIa) Authors of multiple randomized controlled trials demonstrated additional benefits, including lower bloodstream infection rates in hemodialysis and acute care populations and improved adherence to disinfection protocols.^{11(Ia),12(Ia),13(Ib)}

Clinical Considerations

The 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.

Benefits

• Lower reflux and clotting risk: Negative-pressure NCs are associated with increased reflux and higher clot formation, contributing to occlusions.⁴
• Reduction in CRBSI: Use of neutral and positive-pressure NCs and antiseptic barrier caps has been associated with a significant reduction in CRBSI rates.^{5,10,11,12,14}
• Passive disinfection: Antiseptic caps provide passive adjunct disinfection at the NC hub, outperforming manual scrubbing alone in infection prevention.¹⁵
• Prevents catheter dislodgement to preserve vascular access: Breakaway connectors reduce the risk of mechanical complications in confused, agitated, or ambulatory patients by releasing under controlled tension, thus avoiding the need for reinsertion.^2,3

Risks

• Displacement terminology variability: Product labels (e.g., positive, neutral, or negative) do not always match clinical performance, complicating product selection.^4,5,14
• Inconsistent disinfection technique: Suboptimal inadequate scrub duration or technique as well as inconsistent use of barrier caps may reduce the effectiveness of contamination prevention on connector surfaces thus increasing the risk of CLABSI.^7,8,9,10

Implementation Considerations

• Product-specific evaluation: Facilities should assess adjunct product performance at the institutional level to guide product selection based on clinical evidence and ensure staff are educated on proper application and replacement.^11,12,14
• Monitor compliance: Adjunct product usage offers visual confirmation to support compliance monitoring and quality assurance.^3,10

Barriers to Implementation

• Variable device performance: Brand-to-brand variation limits the ability to standardize expectations.^4,7,14
• Transition and compliance: Sustaining staff compliance may be challenging, as implementing new practices often requires cultural change and updates to existing protocols.^7,10,16
• Cost and availability: In resource-limited settings, adjunct devices may be perceived as non-essential due to initial cost concerns, limited availability, or lack of institutional funding.^2,17

References

1. Tompkins LS, Tien V, Madison AN. Getting to zero: impact of a device to reduce blood culture contamination and false-positive central-line–associated bloodstream infections. Infect Control Hosp Epidemiol. 2023;44(9):1386–1390. doi:10.1017/ice.2022.284.
2. Munoz-Mozas G. Solving the problem of IV dislodgement. Br J Nurs. 2022;31(2):S4–S7. doi:10.12968/bjon.2022.31.2.S4.
3. Bahl A, Clement V, DiLoreto E, et al. Evaluating the impact of external forces on peripheral intravenous catheter movement using ultrasound: a randomized pilot study. J Vasc Access. 2025;26(1):102–108. doi:10.1177/11297298231222052.
4. Doane MA, Kwong C, Proschogo N. Quantifying exposure to chlorhexidine from decontamination of peripheral intravenous injection ports. Acta Anaesthesiol Scand. 2023;67(3):356–363. doi:10.1111/aas.14189.
5. Schora D, Patel P, Barza R, et al. Positive and neutral needleless connectors: a comparative study of central-line associated bloodstream infection, occlusion, and bacterial contamination of the connector lumen. J Infus Nurs. 2023;46(3):157–161. doi:10.1097/nan.0000000000000506.
6. Sansalone A, Vicari R, Orlando F, et al. Needle-free connectors to prevent central venous catheter occlusion at a tertiary cardiac center: a prospective before and after intervention study. J Vasc Access. 2023;24(3):475–482. doi:10.1177/11297298211039653.
7. Slater K, Cooke M, Fullerton F, et al. Peripheral intravenous catheter needleless connector decontamination study—randomized controlled trial. Am J Infect Control. 2020;48(9):1013–1018. doi:10.1016/j.ajic.2019.11.030.
8. Devrim I, Demiray N, Oruc Y, et al. The colonization rate of needleless connector and the impact of disinfection for 15 s on colonization: a prospective pre- and post-intervention study. J Vasc Access. 2019;20(6):604–607.
9. Slater K, Fullerton F, Cooke M, Snell S, Rickard CM. Needleless connector drying time—how long does it take? Am J Infect Control. 2018;46(9):1080–1081. doi:10.1016/j.ajic.2018.05.007.
10. Gillis V, van Es MJ, Wouters Y, Wanten GJA. Antiseptic barrier caps to prevent central line–associated bloodstream infections: a systematic review and meta-analysis. Am J Infect Control. 2023;51(7):827–835. doi:10.1016/j.ajic.2022.09.005.
11. Brunelli SM, Van Wyck DB, Njord L, Ziebol RJ, Lynch LE, Killion DP. Cluster-randomized trial of devices to prevent catheter-related bloodstream infection. J Am Soc Nephrol. 2018;29(4):1336–1343.
12. Hymes JL, Mooney A, Van Zandt C, Lynch L, Ziebol R, Killion D. Dialysis catheter-related bloodstream infections: a cluster-randomized trial of the ClearGuard HD antimicrobial barrier cap. Am J Kidney Dis. 2017;69(2):220–227. doi:10.1053/j.ajkd.2016.09.014.
13. Taşdelen Öğülmen D, Ateş S. Use of alcohol containing caps for preventing bloodstream infections: a randomized controlled trial. J Vasc Access. 2021;22(6):920–925. doi:10.1177/1129729820952961.
14. Sansalone A, Vicari R, Orlando F, et al. Needle-free connectors to prevent central venous catheter occlusion at a tertiary cardiac center: a prospective before and after intervention study. J Vasc Access. 2023;24(3):475–482. doi:10.1177/11297298211039653.
15. Malek AE, Raad II. Preventing catheter-related infections in cancer patients: a review of current strategies. Expert Rev Anti Infect Ther. 2020;18(6):531–538. doi:10.1080/14787210.2020.1750367.
16. Sengul T, Guven B, Ocakci AF, Kaya N. Connectors as a risk factor for blood-associated infections (3-way stopcock and needleless connector): a randomized-experimental study. Am J Infect Control. 2020;48(3):275–280. doi:10.1016/j.ajic.2019.08.020.
17. Buzas B, Smith J, Gilbert GE, Moureau N. Home infusion pharmacy quality improvement for central venous access devices using anti-reflux needleless connectors to reduce occlusions, emergency room visits, and alteplase costs. Am J Health Syst Pharm. 2022;79(13):1079–1085. doi:10.1093/ajhp/zxac083.

Chapter 5.7—Removal Criteria & Procedures

The safe and timely removal of vascular access devices (VADs) is a critical component of vascular access management. While appropriate device selection and maintenance are essential to achieving positive outcomes, removal decisions must be guided by clear clinical criteria, procedural competency, and patient-centered planning. Unnecessary retention increases the risk of infection, thrombosis, mechanical failure, and other complications.

Removal may be indicated when therapy is complete, complications arise, or the device is no longer necessary for care. Conversely, removal may need to be delayed when the patient is clinically unstable or alternative access is not feasible. Understanding these contextual nuances is essential for risk-balanced decision-making.

Best practices in removal technique are essential for minimizing complications during the final stage of vascular access. Even the removal of a peripheral intravenous catheter (PIVC) can pose risks if done carelessly, including patient complications and occupational exposure for the clinician. Competency in removal supports patient safety, protects the direct-care clinician (DCC), and ensures the overall process of vascular access management is completed safely and effectively.

Recommendation 1: Indications for VAD Removal

Remove VADs when no longer clinically necessary or when the risk of complications outweighs the benefit of continued use. Prompt removal supports infection prevention, reduces thrombotic risk, and promotes vascular preservation.

Indications include:

• Completion of prescribed therapy;
• Suspected or confirmed catheter-related bloodstream infection (CRBSI);
• Symptomatic extensive thrombosis associated with the catheter:
  • Exceptions based on patient-specific factors;
• Occlusion or malfunction unresponsive to appropriate interventions;
• Catheter damage, fracture, or external or internal migration;
• Loss of access site integrity or complications.

Summary of Evidence

Early removal of malfunctioning or infected VADs is associated with a lower incidence of systemic complications such as CRBSI and catheter-related thrombosis.^{1(IIa),2(IIb),3(Ia)} Delayed removal in the presence of occlusion or malfunction has been linked to an increased risk of infusion failure, reinsertion delays, and vascular damage.^{4(IIIa),5(IIIb)}

Authors of several studies have supported an interdisciplinary approach when clinical necessity is unclear or when immediate removal may be unsafe due to patient acuity or lack of alternative access. This allows for individualized decisions that prioritize both immediate clinical needs and long-term vascular access planning.^{2(IIIb),5(IIIb)} Prompt removal following resolution of critical illness or completion of therapy helps avoid unnecessary dwell time, a known contributor to infectious and thrombotic events.^1(IIa),3(Ia)

Recommendation 2: Remove the VAD When Resolution Fails

When persistent occlusion, suspected or confirmed malposition, or catheter damage cannot be resolved through appropriate troubleshooting or salvage techniques, the VAD should be removed. Continued use of a nonfunctional or compromised catheter increases the risk of infection, thrombosis, infiltration, catheter embolism, and treatment failure.

Summary of Evidence

Unresolved catheter occlusion, despite thrombolytic therapy or mechanical clearing, signals a high likelihood of nonthrombotic occlusion or internal damage. In these cases, device removal is recommended to prevent escalation to bloodstream infection or catheter embolism.^{6(Vb),7(IIIb)}

Malposition, whether external (catheter migration) or internal (tip misdirection), cannot be assumed safe without verification. Use should be withheld until imaging or ultrasound confirms proper placement. If tip location cannot be confidently established or functionality remains impaired, device replacement is the safer course.^{8(IVb),9(IIIb)}

Visible or suspected catheter damage, such as fractures, leaks, or totally implanted VAD defects, compromises the integrity of the vascular system and poses risks for embolism or extravasation.^10(Vb) Salvage may be feasible for tunneled silicone catheters in select settings, but the default response should be prompt removal unless clinical conditions warrant a carefully considered exception.^{11(IIIa),12(IIIa)}

Recommendation 3: Ensure Clinician Competency in VAD Removal

Clinicians responsible for VAD removal must demonstrate competency in removal techniques specific to device type. Adherence to safety, standardized procedures, including positioning, site preparation, hemostasis, and postremoval monitoring, is essential to minimize complications and ensure optimal outcomes.

Summary of Evidence

The safe removal of VADs requires procedural proficiency and consistent adherence to established clinical protocols. Complications such as air embolism, bleeding, infection, and vessel trauma are preventable with correct technique and proper patient positioning.^{13(Vb),14(IVb),15(IVb)}

Key elements of safe removal include:

• Positioning: Supine or Trendelenburg for central VADs; supine or semi-Fowler for peripherally inserted central catheters; no specific positioning for PIVCs or peripheral midlines.
• Site preparation: Cleanse with chlorhexidine-alcohol unless contraindicated.
• Hemostasis: Apply firm, controlled pressure to achieve hemostasis while protecting tissue integrity.
• Clinician safety: Use techniques that minimize risk of blood exposure to the DCC.
• Site protection: Use occlusive dressing after hemostasis is achieved.
• Patient education: Provide clear instructions on post-removal care and signs of complications.

Competency-based training and periodic skills refreshers have been shown to reduce complication rates and improve consistency in practice. Postremoval protocols, including observation for bleeding, air embolism, or infection, should be followed in all care settings. In the event of suspected air embolism, immediate actions include left lateral Trendelenburg positioning and administration of high-flow oxygen, with activation of emergency protocols as indicated.^13(Vb)

Recommendation 4: Delay VAD Removal When Clinically Justified

VAD removal may be delayed when clinical circumstances demand continued access or present heightened procedural risks. In these situations, decisions should be guided by interdisciplinary collaboration, careful risk-benefit analysis, and proactive planning for future access needs.

Summary of Evidence

Immediate removal of a VAD may not be appropriate in specific scenarios, even if minor clinical complications are present (i.e., withdraw occlusion, change in external segment). These include patients with:

• Hemodynamic instability or critical illness, where ongoing vascular access is essential for life-sustaining therapy;
• No alternative access options, particularly in patients with vascular depletion or fragile anatomy;
• Coagulopathy or thrombocytopenia, where the bleeding risk outweighs the benefit of immediate removal.

In such cases, VAD retention may be cautiously continued with close clinical surveillance, therapeutic management, and coordination with vascular access specialists.

Proactive access planning is key. For patients with complex comorbidities (e.g., renal disease, history of chest radiation, prior central venous depletion), decisions regarding timing and method of removal must be balanced against future access needs. Collaboration among providers, including oncology, nephrology, interventional radiology, and direct care clinicians, ensures the right VAD is in place at the right time, and for the right reason.^{1(IIa),2(IIIb),5(IIIb)}

Recommendation 5: Align PIVC Removal with Clinical Indication

PIVCs should be removed when clinically indicated, not solely based on routine dwell time. Institutions that adopt a clinically indicated replacement strategy must ensure robust site monitoring, trained staff, and protocols that support the early detection of complications and the timely removal of PIVCs.

Summary of Evidence

Routine PIVC replacement every 72–96 hours has historically been used to reduce risk of phlebitis, infiltration, and infection. However, in a Cochrane review of 7,000+ patients, no significant differences were found in CRBSI, phlebitis, or mortality between routine and clinically indicated removal strategies.^3(Ia)

Clinically indicated removal likely reduces unnecessary catheter insertions, device-related costs, and patient discomfort, but only when supported by strong systems for monitoring and staff education. The I-DECIDED® tool is one structured assessment approach that has been shown to reduce idle lines, insertion site complications, and substandard dressing care (Appendix D).^16(Va)

Caution is warranted: Without clear institutional policies and daily site evaluations, clinically indicated replacement may lead to delayed recognition of local complications. Staff should be trained to remove PIVCs promptly if they are no longer needed or show signs of infiltration, extravasation, occlusion, phlebitis, pain, or infection.^17(Vb)

Clinical Considerations

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.

Benefits

• Reduced complication risk: Timely removal of malfunctioning or infected VADs based on patient-specific removal decisions, significantly reduces the risk of occlusion, thrombosis, and bloodstream infections.^1,2,18,19
• Improved patient outcomes: Interdisciplinary planning for VAD removal, combined with early detection of complications such as infection, bleeding, or air embolism, enhances patient safety and supports optimal outcomes when immediate removal is not feasible.^1,2,5,20
• Device longevity and function: Clear flushing protocols based on device function and patient status can preserve patency over time.^1,2,18,19
• Preservation of vascular health: Proactive planning for VAD placement and timely removal preserves vascular integrity, especially in patients with chronic conditions.^21,22

Risks

• Delayed removal consequences: Prolonged retention of dormant, nonfunctional or infected devices can lead to increased rates of infection, thrombosis, or systemic complications.^1,2,3,18,23
• Delayed complication recognition: Without clear monitoring or education, patients may miss signs of serious complications such as air embolism or infection.²⁰
• Procedural complications: Inadequate training or technique during removal can increase the risk of bleeding, air embolism, or catheter fracture.²⁰
• Inadequate assessment: Failing to evaluate underlying conditions (e.g., thrombosis) before removal may worsen clinical outcomes or result in unnecessary removal.^1,2,5

Implementation Considerations

• Use of clinical decision tools: Removal decision tools help standardize removal criteria and reduce idle catheters, site complications, and dressing failures.¹⁶
• Competency-based training: Ensuring staff are trained in safe removal procedures improves compliance with safety protocols and reduces complication rates.²⁰
• Patient education: Provide clear postremoval instructions regarding signs of infection, bleeding, and when to seek help.^2,24
• Interdisciplinary decision-making: Collaborate with the care team and patient to evaluate ongoing need for VADs and develop a maintenance or removal plan.^18,23

Barriers to Implementation

• Lack of proactive access planning: Reactive decision-making delays timely removal and increases the risk of inappropriate device use in vulnerable patients.^21,22
• Variability in practice: Inconsistent application of removal criteria and variability in clinician adherence to removal protocols, particularly in the absence of standardized guidelines, can lead to premature or delayed device removal and increased complication rates.^3,18,23
• Resource and staffing constraints: Insufficient interdisciplinary coordination and limited time for comprehensive assessment may hinder timely decision-making.^1,2,5
• Lack of standardized follow-up: Institutions may not have consistent processes for postremoval monitoring or patient follow-up.²⁰

References

1. 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.
2. Effendi M, Roberto A, Dale Slater E. Reducing central line–associated bloodstream infections in a burn intensive care unit: using a business framework for quality improvement. J Burn Care Res. 2023;44(5):1073–1082. doi:10.1093/jbcr/irad101.
3. Webster J, Osborne S, Rickard CM, Marsh N. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2019;1(1):CD007798. doi:10.1002/14651858.CD007798.pub5.
4. McGuire R, Coronado A. Evaluation of clinically indicated removal versus routine replacement of peripheral vascular catheters. Br J Nurs. 2020;29(2):S10–S16. doi:10.12968/bjon.2020.29.2.S10.
5. Kara A, Johnson CS, Murray M, Dillon J, Hui SL. Can the identification of an idle line facilitate its removal? A comparison between a proposed guideline and clinical practice. J Hosp Med. 2016;11(7):489–493. doi:10.1002/jhm.2573.
6. Hill J, Garner R. Efficacy of 4% tetrasodium ethylenediaminetetraacetic acid (T-EDTA) catheter lock solution in home parenteral nutrition patients: a quality improvement evaluation. J Vasc Access. 2021;22(4):533–539. doi:10.1177/1129729820946916.
7. Brodnik JE, Lieux SM, Serrano-Smith M, Bena JF, Siedlecki SL. PICC line occlusions: implications and opportunities for medical-surgical nurses. MEDSURG Nurs. 2023;32(5):305–310.
8. Matey L, Camp-Sorrell D. Venous access devices: clinical rounds. Asia Pac J Oncol Nurs. 2016;3(4):357–364. doi:10.4103/2347-5625.196480.
9. 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.
10. Selvakumar VPP, Acharya RP, Bhamri N. Pinch-off syndrome and fracture embolization: a preventable complication of TIVADS. Indian J Surg Oncol. 2019;10(1):77–79. doi:10.1007/s13193-018-0817-8.
11. Ait Hammou Taleb MH, Mahmutovic M, Michot N, Malgras A, Nguyen-Thi PL, Quilliot D. Effectiveness of salvage catheters in home parenteral nutrition: a single-center study and systematic literature review. Clin Nutr ESPEN. 2023;56:111–119. doi:10.1016/j.clnesp.2023.04.026.
12. Leiberman D, Stevenson RP, Banu FW, Gerasimidis K, McKee RF. The incidence and management of complications of venous access in home parenteral nutrition (HPN): a 19 year longitudinal cohort series. Clin Nutr ESPEN. 2020;37:34–43. doi:10.1016/j.clnesp.2020.03.025.
13. Levy SD, Oren-Grinberg A, McSparron JI. Paradoxical air embolus after removal of a central venous catheter. Ann Am Thorac Soc. 2016;13(10):1856–1857. doi:10.1513/AnnalsATS.201604-228CC.
14. JBI. Peripheral Intravenous Cannula: Removal. JBI EBP Database. 2022;JBI-RP-4796-3.
15. JBI. Recommended practice. Central venous access device (CVAD): removal. The JBI EBP Database. 2022;JBI-RP-4560-2.
16. Ray-Barruel G. I-DECIDED(®)—a decision tool for assessment and management of invasive devices in the hospital setting. Br J Nurs. 2022;31(8):S37–S43. doi:10.12968/bjon.2022.31.8.S37.
17. Takashima M, Cooke M, DeVries M, et al. An implementation framework for the clinically indicated removal policy for peripheral intravenous catheters. J Nurs Care Qual. 2021;36(2):117–124. doi:10.1097/NCQ.0000000000000507.
18. Slater K, Cooke M, Fullerton F, et al. Peripheral intravenous catheter needleless connector decontamination study—randomized controlled trial. Am J Infect Control. 2020;48(9):1013–1018. doi:10.1016/j.ajic.2019.11.030.
19. Sansalone A, Vicari R, Orlando F, et al. Needle-free connectors to prevent central venous catheter occlusion at a tertiary cardiac center: a prospective before and after intervention study. J Vasc Access. 2023;24(3):475–482. doi:10.1177/11297298211039653.
20. Porritt K. Peripheral Intravenous Catheter (PIVC) Care: Removal and Replacement. JBI EBP Database. 2022;JBI-ES-3965-5.
21. Janssens C, Goossens G, Grumiaux N, et al. Securing peripherally inserted central catheters (PICCs), results of the SecurAstaP study: a randomized controlled trial comparing SecurAcath® and StatLock®. Vasc Access. 2017;11(2):8–8.
22. Jarding EK, Flynn Makic MB. Central line care and management: adopting evidence-based nursing interventions. J PeriAnesthesia Nurs. 2021;36(4):328–333.
23. Sengul T, Guven B, Ocakci AF, Kaya N. Connectors as a risk factor for blood-associated infections (3-way stopcock and needleless connector): a randomized-experimental study. Am J Infect Control. 2020;48(3):275–280. doi:10.1016/j.ajic.2019.08.020.
24. McGuire R, Norman E. A best practice cost avoidance initiative. Br J Nurs. 2019;28(10):608–608.

Acronyms

Glossary

Adhesive Securement Device (ASD) An engineered securement device that secures a vascular access catheter to the skin using an adhesive base combined with a molded feature that engages the catheter’s stabilization platform. ASDs reduce catheter movement, dislodgement, and accidental removal, and are always used in combination with a sterile dressing. Replaced with each dressing change.

Adhesive Enhancer A product applied to the skin to improve dressing adherence, particularly in high-moisture or high-movement areas. Examples include gum mastic liquid adhesive.

Air Embolism The entry of air into the vascular system, which may obstruct blood flow and cause cardiovascular, pulmonary, or neurological complications. A preventable but potentially fatal catheter-related event.

Alcohol-Based Hand Rub (ABHR) A fast-acting hand antiseptic used for routine decontamination of hands when not visibly soiled.

Antiseptic Barrier Cap A cap containing an antiseptic agent (commonly alcohol or chlorhexidine-alcohol) is placed on a needle-free connector between uses to provide continuous passive disinfection of the connector surface. Must be replaced per manufacturer’s instructions for use.

Arterial Catheter A catheter is inserted into an artery, primarily for continuous blood pressure monitoring and arterial blood sampling. Not used for infusion of medications or fluids due to the risk of ischemic injury.

Aseptic Nontouch Technique (ANTT®) A standardized practice framework for aseptic technique that prevents contamination of key parts and key sites during vascular access insertion. ANTT® distinguishes between standard ANTT® (vital but lower-risk procedures, such as peripheral intravenous catheter insertion) and surgical ANTT® (for complex procedures, such as central vascular access device placement).

Practical Note: Placement of peripheral midlines (PMLs) often falls between standard ANTT® and surgical ANTT®. Facilities and clinicians vary in practice, with some treating PML insertion as an advanced peripheral procedure (standard ANTT®) and others applying the higher sterility safeguards of surgical ANTT®.

• Key Part — Any sterile component of equipment or device that must remain aseptic to prevent contamination.
• Key Site — Any patient site where a vascular access device enters the body or where the bloodstream is directly accessed.

Barrier Film (Skin Protectant) A sterile protective coating applied to the skin prior to dressing application. Barrier films reduce the risk of medical adhesive–related skin injury, minimize skin trauma on removal, and support dressing adherence.

Body Mass Index (BMI) A measure of body fat calculated from height and weight; used as a risk factor for vascular access complications, particularly thrombosis.

Blood Control Technology A safety feature in peripheral intravenous catheters that prevents blood leakage during insertion, reducing occupational exposure and contamination risk.

Bloodstream Infection (BSI) A laboratory-confirmed infection of the bloodstream, regardless of source. BSIs may be related to vascular access devices, other intravascular devices, or distant infections with hematogenous spread.

Practical Note: The term BSI is the broadest descriptor and does not imply a vascular access association unless otherwise specified (e.g., catheter-related BSI, central line–associated BSI).

Blunt Tunneler Technique A method of creating a short subcutaneous tunnel for a vascular access device using a blunt instrument after venous access has been achieved. This technique requires 2 skin punctures: one for vessel entry and another for the exit site. The catheter is then redirected through the tunnel to emerge at a new location.

Breakaway Connector or Breakaway Device A safety device placed in-line with a vascular access catheter that disconnects under controlled tension to prevent catheter dislodgement, damage, or patient injury.

Catheter-Associated Skin Injury (CASI) Skin damage resulting from the presence of a vascular access device or its securement, dressing, or stabilization products.

Catheter-Related Bloodstream Infection (CR-BSI) A clinical and microbiologic diagnosis of a bloodstream infection directly attributed to a vascular access device. CR-BSI requires strict evidence, such as identical organisms isolated from catheter and blood cultures or differential time to positivity. Unlike central line–associated BSI, CR-BSI can apply to any intravascular catheter (peripheral or central) and establishes the catheter as the confirmed infection source.

Practical Note: CR-BSI is rarely used for surveillance reporting but is essential in clinical practice and research to confirm causality between the device and infection.

Catheter-Related Deep Vein Thrombosis (CR-DVT) A thrombus involving a deep vein where a vascular access device is present. CR-DVT is the most common form of catheter-related thrombosis and may present with limb swelling, pain, or catheter dysfunction.

Practical Note: Whether labeled CR-DVT or catheter-related thrombosis, the management approach is usually the same: assess for extension, risk of embolization, and need for anticoagulation.

Catheter-Related Pulmonary Embolism (CR-PE) A pulmonary embolism that develops secondary to a thrombus originating from a catheter-related venous clot. CR-PE is less common than catheter-related deep vein thrombosis but clinically significant due to higher morbidity and mortality.

Practical Note: CR-PE is rarely tracked separately; most events are counted under catheter-related venous thromboembolism in research reports.

Catheter-Related Thrombosis (CRT) A blood clot that forms in association with a vascular access device (peripheral or central). CRT is a broad clinical descriptor and may involve superficial or deep veins. Diagnosis is typically confirmed by imaging (e.g., ultrasound, venography). CRT is widely used in clinical documentation and research but is not a formal surveillance category.

Practical Note: At the bedside, CRT is often the most useful shorthand for any catheter-related clot, regardless of depth or risk of embolization.

Catheter-Related Venous Thromboembolism (CR-VTE) An umbrella term that includes catheter-related deep vein thrombosis and catheter-related pulmonary embolism. In research, CR-VTE is frequently used as the broadest category when reporting catheter-associated clot events.

Practical Note: In everyday clinical care, CR-VTE and catheter-related thrombosis are often used interchangeably, though technically VTE implies the potential for embolization.

Catheter-Related Ventricular Tachycardia (CRVT) A potentially life-threatening arrhythmia that occurs when a central catheter tip is positioned too deeply within the right atrium or ventricle, leading to irritation of cardiac tissue. Proper tip placement and confirmation reduce this risk.

Catheter-to-Vessel Ratio (CVR) The ratio of a catheter’s external diameter to the diameter of the vessel in which it is placed. Higher CVRs (>33–45%) are associated with endothelial trauma, phlebitis, and catheter-related thrombosis.

Cavo-Atrial Junction (CAJ) The anatomical junction where the superior vena cava meets the right atrium. The CAJ is the recommended target for central vascular access device catheter tip placement, as it optimizes infusion dynamics while minimizing risks of arrhythmia, thrombosis, and vessel erosion.

Central Line–Associated Bloodstream Infection (CLABSI) A surveillance definition used primarily by the Centers for Disease Control and Prevention or National Healthcare Safety Network. CLABSI is diagnosed when a patient develops a laboratory-confirmed bloodstream infection and had a central vascular access device in place within the 48 hours prior, with no other identifiable infection source.

Practical Note: CLABSI reflects association rather than causation. It is used for surveillance, benchmarking, quality metrics, and regulatory reporting, not for guiding individual patient management.

Central Line Insertion Site Assessment (CLISA) A structured tool used to assess and document central line insertion sites for infection risk and complications.

Centrally Inserted Central Catheter (CICC) A central vascular access device inserted directly into a central vein (e.g., internal jugular, subclavian, femoral).

• Tunneled, cuffed CICC: A CICC placed through a subcutaneous tunnel and secured with a cuff.
• Tunneled, noncuffed CICC: A CICC placed with a subcutaneous tunnel but without a cuff.

Cephalad In anatomy, cephalad means “toward the head” or upper part of the body. In vascular access, cephalad migration most often refers to unintended upward movement of a catheter tip (e.g., a peripherally inserted center catheter) into the internal jugular vein, away from its intended position in the superior vena cava.

Chest-to-Arm (CTA) Tunneling A technique in which a catheter is tunneled from a chest insertion site to exit in the upper arm. This creates a low-profile exit site away from the chest while maintaining a central venous tip location.

Practical Note: CTA tunneling may be helpful in patients with tracheostomies, chest wall deformities, or breast surgery where a chest exit site is not feasible.

Chlorhexidine Gluconate (CHG) A broad-spectrum antiseptic, which is actually chlorhexidine digluconate, commonly used in combination with alcohol for skin preparation prior to vascular access insertion. CHG provides rapid antimicrobial activity and residual effect on the skin surface, making it the preferred first-line agent for infection prevention during vascular access procedures.