Venous Access Devices

Venous access devices that can be implanted under the skin were introduced in 1982. They allow medications to be delivered directly into larger veins, are less likely to clot, and can be left in for long periods. Central venous access devices are small, flexible tubes placed in large veins for people who require frequent access to the bloodstream.

• Central venous access devices are often referred to as venous access ports or catheters, because they allow frequent access to the veins without deep needle sticks.
• Placement is usually in one of the large veins of the chest or neck, although placement can also be in the groin, if necessary.
• Venous access devices typically remain in place for long periods: weeks, months, or even longer.

Venous access devices are most often used for the following purposes:

• Administration of medications - Antibiotics, chemotherapy drugs, other IV drugs
• Administration of fluids and nutritional compounds (hyperalimentation)
• Transfusion of blood products
• Multiple blood draws for diagnostic testing

Venous access devices provide several advantages over regular IV lines, which are usually inserted in a small vein in the hand or arm.

• Venous access devices avoid problems that result over time from administering strong medications through small veins with regular IV lines, namely irritation of the vein and blood clots in the vein.
• A central venous device also avoids the inflammation and scarring that can occur in a vein after multiple needle sticks.
• A central access device increases comfort and reduces anxiety for people who require frequent venous access.

Central venous access devices are usually inserted in 1 of 3 ways.

• Catheters are inserted by tunneling under the skin into either the subclavian vein (located beneath the collarbone) or into the internal jugular vein (located in the neck). The part of the catheter where medications are administered or blood is drawn remains outside the skin.
• Unlike catheters, which exit from the skin, ports are placed completely below the skin. With a port, a raised disk about the size of a quarter or half dollar is felt underneath the skin. Blood is drawn or medication is delivered by placing a tiny needle through the overlying skin into the port or reservoir.
• Peripherally inserted central catheter (PICC) lines, unlike central catheters and ports, are not inserted directly into the central vein. A PICC line is inserted into a large vein in the arm and advanced forward into the larger subclavian vein.

A surgeon or surgical assistant in a surgical suite usually inserts central catheters and ports. An alternative is placement under the guidance of a special x-ray machine so that the person inserting the line can make sure that the line is placed properly. A PICC line can be put in at bedside, usually by a specially trained nurse.

Peripherally inserted central venous access devices have increasingly replaced traditional surgically placed central catheters. PICC lines usually cause fewer severe complications than central venous access devices.

IV access, whether by temporary traditional IV line, central catheter, port, or peripheral line such as a PICC, is becoming an important part of health care today.

• Uses for long-term venous access and the decision to have a port or catheter have become increasingly more complex.
• Individuals being treated using a venous access device should discuss the different choices with the primary care provider or the specialist providing treatment.

Problems that can occur during or after placement of a central venous access device include the following:

• Pneumothorax - Collapse of the lung because of injury from the needle used to insert the device into the subclavian or jugular veins
• Hemothorax - Bleeding into the chest because of injury to the blood vessels from the needle at insertion into the subclavian or jugular veins
• Cellulitis - Infection of the skin around the catheter or port
• Catheter infection - An actual infection of the device itself inside the vein
• Sepsis - Release of bacteria into the bloodstream from the device, causing a life-threatening infection (This often results from an infection of the device or from not using sterile techniques when using the device.)
• Mechanical problems - A device breaks or does not function correctly.
• Venous thrombosis - A blood clot in the vein that can cause swelling of the involved extremity (This is often called deep venous thrombosis or deep venous thrombophlebitis. This is dangerous because pieces of the clot may break off and travel to the lung, which can be life threatening.)
• Endocarditis - Bacteria or fungi from the device travel through the bloodstream to the heart valves, where they form an infection that can destroy the valve.

Pneumothorax/hemothorax: The following symptoms usually develop immediately following placement of a venous access device if pneumothorax or hemothorax has occurred:

• Shortness of breath
• Light-headedness
• Fainting
• Chest pain, especially when trying to take deep breaths
• Feeling unable to take a deep breath

Cellulitis

• Redness of skin around the device
• Tenderness of skin around the device
• Spreading area of redness and tenderness

Device infection or sepsis: An infection within the bloodstream may occur without any indication of a skin infection.

• Fever
• Shaking chills
• Vomiting
• Feeling lethargic or ill (malaise)
• Light-headedness, fainting

Mechanical problems

• Inability to pass fluid into the device
• Inability to draw blood from the device
• Pain with each attempt to inject into the device

Venous thrombosis: This blood clot of the vein may cause swelling of the arm or red streaking and tenderness of the associated vein.

Endocarditis, an infection of the heart valves, may cause the following:

• High fevers that come and go
• Weight loss
• Excessive tiredness
• Back pain
• Tender nodules on the tips of the toes or fingers

A blood-thinning medication (anticoagulant) is started if a blood clot develops. If the clot is very large or the person with a venous access device experiences recurring clots, the device will be removed.

If cellulitis is present, a prescription for antibiotics may be given.

If the intravascular portion of the device is infected, the device will be removed.

If a bloodstream infection (sepsis) is present, the person with the venous access device will be admitted to the hospital to receive IV antibiotics. If the infection is very severe, large amounts of IV fluids and medications may be needed to increase the blood pressure. The device may be removed.

If the device is not working properly, it may be repositioned or replaced. This may involve a minor surgical procedure.

If the device is blocked by a clot, in some cases a substance (such as streptokinase/urokinase) is injected into the device to dissolve the clot.

Call or visit a health care provider right away if a central venous access device is inserted and any of the following symptoms occur:

• Swelling of an arm or the area around the device
• Shortness of breath or chest pain
• Redness, pain, or tenderness around the device
• Redness or tenderness along the vein in the upper arm (especially if it is a PICC line)
• Unexplained fever
• Device malfunction
• Pain with injection/infusion into the device
• Difficulties with concentration, memory, reasoning, or staying awake (mental status changes)
• Excessive tiredness
• Unexplained weight loss

Go directly to the nearest hospital emergency department in any of the following circumstances:

• Inability to reach the health care provider
• Symptoms worsening or new symptoms appearing

In particular, shortness of breath, chest pain, or sudden changes in mental status may indicate a dire emergency, and the person with the venous access device should go to an emergency department immediately.

If a central venous access device is present, the health care provider, whether a primary care provider, specialist, or emergency provider, will have a heightened awareness of the problems that can occur. The provider will ask about symptoms and perform a physical examination.

Some of the following tests may be performed:

• Chest X-ray - Evaluates for improper device placement or complications such as pneumothorax or hemothorax
• Blood draw - Checks for infection
• Ultrasound exam of the arm vein - Performed if a clot is suspected
• Nuclear imaging study - Confirms that the device is properly placed and still working and/or excludes blood clots in the lungs

The venous access device can be removed when it is no longer needed, such as when the medical problem for which it was inserted has resolved.

Proper home care of a venous access device involves regular irrigation with a drug called heparin to prevent clotting (except with Groshong-type catheters) and attention to a sterile technique to keep the device free of infection.

• The person with the venous access device and a caregiver will be shown how to care for the device.
• Supplies will be provided or an explanation will be given for how to obtain supplies.
• Instructions will be provided in other ways to prevent problems with the device.
• In some cases, a home health agency can bring the supplies needed and provide support as the individual learns how the care for the device.

Follow any instructions given by the health care provider or nurse to care for a venous access device at home.

• Avoid heavy exertion or strenuous activity immediately after device placement.
• Change the bandages as directed.
• Inject heparin to keep the device working as directed.

To prevent problems, flush the venous access device with heparinized saline solution as directed.

To prevent infection, it is extremely important to be careful to maintain a sterile technique and follow the health care provider's instructions in cleaning the site where the device exits the skin.

Problems with venous access devices, when diagnosed, usually can be treated effectively.

Although there are risks associated with central venous access devices, the benefits of these devices usually outweigh the risks. Be aware of the possible complications, recognize the signs and symptoms early, and bring these to the attention of the health care provider. The complications usually can be treated successfully.