Performance of a central venous access device (CVAD) is directly related to the position of the terminal tip of the catheter. CVAD safety and vein preservation are greatly impacted by tip positioning with device insertion and impacts the ability of the patient to receive prescribed therapy in a timely manner.
Central venous access device performance is directly related to the position of the terminal tip of the catheter because malposition of a catheter tip is associated with an increased risk of complications. Malpositioned catheters, positioned in a suboptimal location in the SVC or in the adjacent areas, are much more likely to develop thrombosis and catheter dysfunction in the form of occlusion. It is recommended to confirm proper tip location after insertion and prior to treatment.
Correct tip positioning of a vascular access device is determined by chest x-ray, tip location devices and EKG. Indications for each vascular access device contribute to the choice of device, function and tip position based on treatment plan.
Infusion Nurses Society Practice Recommendations: Tip Location
- Position the tip of the central vascular access device in the lower third of the superior vena cava at or near the Cavo atrial junction for adults and children.
- For upper body insertion sites, respiratory variation, arm movement, and changes in body position will cause the CVAD tip to move above or below the cavo atrial junction, indicating excursion into the upper right atrium. Tip location deeper in the right atrium near the tricuspid valve or in the right ventricle is associated with cardiac arrhythmias.
- For lower body insertion sites, the CVAD tip should be positioned in the inferior vena cava above the level of the diaphragm.
- For hemodialysis CVADs, proper location of the CVAD tip is at the mid-right atrium to avoid vessel and right atrial trauma and consequent complications.
Avoid placing tip of the CVAD outside the SVC or IVC (eg, innominate, brachiocephalic, subclavian, external, or common iliac veins), as this is associated with higher rates of complications. In rare circumstances, including anatomical or pathophysiological changes, these less-than-ideal tip positions might be clinically indicated.
For peripheral catheters, they are to remain in the periphery with the terminal tip below the level of the axillary vein for the upper extremity placement. The terminal tip of a peripheral catheter does not enter the chest or torso and, therefore does not require any verification following insertion.
Preventable Complications
Although malposition of a catheter is a well-known technical complication, malpositioned catheters often require reinsertion for proper placement to support safe delivery of care and minimize complications. Misplacement of the catheter does not only mean the incorrect vein, but it also includes catheters inserted in extra-venous positions such as in the arterial system, mediastinum, pleura, trachea, esophagus, etc.
According to the Infusion Nurses Society, tip location of a central vascular access device is determined radiographically or by other imaging technologies prior to initiation of infusion therapy. Although it is tempting to use a preferred common site and approach, knowledge of access techniques at multiple anatomic sites is important to meet patient needs while ensuring patient safety. Higher success rates and lower rates of mechanical complications are clearly related to operator experience and comfort with the use of ultrasound to guide placement. Anatomy is not universal, and variations exist from person to person. Assessment is the key to identifying anatomical variations and optimal vein and vascular access device site.
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