ACVNU cheat sheet

Indications for vascular access: hemodynamic instability, need for vasoactive infusions, caustic or hyperosmolar therapy, inadequate peripheral access, and long-term antibiotic or nutrition therapy.

Central venous pressure is a pressure, not a volume; trends over time and response to a fluid challenge are more informative than any single value.

Absolute contraindication to peripherally inserted central catheter placement: inadequate or thrombosed upper-extremity veins; relative contraindications include ipsilateral mastectomy with lymph node dissection and severe coagulopathy.

Assess distal perfusion, sensation, and motor function before and after every catheter placement or dressing change; document pulse, color, temperature, capillary refill, and pain score.

Signs of catheter-related bloodstream infection: new fever or rigors, especially within 2 hours of infusing through the line, unexplained leukocytosis, and hypotension without another source.

For vasopressor administration, the preferred route is a central venous catheter; short-term peripheral use of dilute norepinephrine is acceptable in the ACVNU scope when central access is delayed and the site is monitored hourly.

Document insertion details: site, catheter type and gauge/French size, length inserted and external length, number of attempts, ultrasound use, and confirmation method.

Occlusion assessment: inability to aspirate blood but ability to flush suggests catheter tip against a vessel wall or fibrin sheath; inability to flush suggests thrombosis or pinch-off.

Monitor for air embolism during catheter removal and central line manipulation: sudden dyspnea, chest pain, hypotension, and a mill-wheel murmur warrant placing the patient in Trendelenburg and left lateral decubitus position.

Peripheral IV catheter selection: 14–16 G for rapid volume resuscitation or blood products; 18–20 G for most adult therapies; 22–24 G for small veins, older adults, or pediatrics.

Peripheral catheter dwell limits: replace peripheral IV catheters when clinically indicated rather than by routine schedule; remove any catheter with phlebitis, infiltration, or suspected infection immediately.

Central venous catheter tip location: cavoatrial junction or lower superior vena cava; tip in the right atrium increases risk of arrhythmia and cardiac perforation/tamponade.

Midline catheters terminate in the basilic, cephalic, or brachial vein of the upper arm; they are not appropriate for vesicant, hyperosmolar, or vasopressor infusions requiring central flow.

For implanted ports, use only a non-coring (Huber) needle; confirm needle placement by blood aspiration and flush before infusing.

Maintain catheter patency: flush with 10 mL or more of sterile 0.9% sodium chloride using a push-pause technique, and clamp while positive pressure is maintained for valved catheters.

Blood sampling from central catheters: discard the initial 5–10 mL (or per policy) to avoid dilution and contamination; never force a flush against resistance.

Dressing change frequency: transparent semipermeable dressing every 5–7 days, gauze dressing every 2 days, and any dressing that is damp, loose, or soiled should be changed immediately.

Removal of central venous catheters: place patient supine or Trendelenburg, remove during expiration or with Valsalva, apply occlusive dressing, and inspect the catheter tip for integrity.

Use a linear high-frequency transducer (typically 7–15 MHz) for superficial vessels; a lower-frequency curvilinear probe is needed for deeper structures.

In transverse (short-axis) view, a vein appears as a compressible, thin-walled, anechoic circle; an artery appears round, thick-walled, pulsatile, and non-compressible.

In longitudinal (long-axis) view, the needle shaft and tip are visible as a hyperechoic line entering the vessel lumen; this view helps confirm intraluminal tip position.

Color Doppler distinguishes vessel from nerve or thrombus: flow fills the lumen in a patent vessel; absence of color suggests thrombosis or misidentification.

Needle tip visualization: advance the needle while keeping the tip in view; if the tip is lost, withdraw to the skin and redirect rather than advancing blindly.

Anechoic structure that does not compress and shows no flow may be thrombus, a nerve, or an artery; correlate with pulsatility and Doppler before cannulating.

Confirmation of central line placement: ultrasound of the internal jugular vein showing the catheter in the lumen plus a bubble-agitation study or chest radiograph for tip position.

Pneumothorax after supraclavicular or internal jugular access: evaluate with lung sliding on ultrasound; absence of sliding suggests pneumothorax and warrants chest imaging.

Internal jugular vein lies deep to the sternocleidomastoid muscle and lateral to the carotid artery; the carotid is medial and should be identified by ultrasound before puncture.

Subclavian vein passes beneath the clavicle between the first rib and clavicle; its proximity to the pleura and subclavian artery makes pneumothorax and arterial puncture more likely.

Femoral vein lies medial to the femoral artery within the femoral sheath; the femoral head and inguinal ligament are key landmarks for safe puncture.

Cephalic vein runs along the radial side of the forearm; basilic vein runs along the ulnar side and is often the target for PICC placement.

Upper extremity veins drain to the subclavian, then brachiocephalic, then superior vena cava; the right internal jugular offers a relatively straight path to the SVC.

Veins have thin, compliant walls and low pressure; arteries have thick muscular walls and pulsatile high-pressure flow, which explains rapid hematoma formation after arterial puncture.

Vessel diameter and depth: veins distend with tourniquet or Trendelenburg positioning; avoid prolonged tourniquet time because it increases hemoconcentration and thrombosis risk.

Central venous pressure reflects right atrial pressure; normal range is approximately 2–8 mmHg (or 3–8 cm H2O); values are affected by intrathoracic pressure, positive pressure ventilation, and PEEP.

Arterial puncture: recognize by pulsatile backflow, bright red blood, and ultrasound confirmation; remove the needle and apply sustained pressure for at least 5–10 minutes (longer if coagulopathic).

Pneumothorax after central access: suspect with chest pain, dyspnea, decreased breath sounds, and tracheal deviation; confirm with chest radiograph or ultrasound and treat with needle decompression if tension.

Catheter-related thrombosis: suspect with unilateral arm swelling, pain, or collateral veins; confirm with duplex ultrasound; management includes anticoagulation and catheter removal if no longer needed.

Air embolism: place patient in Trendelenburg and left lateral decubitus, administer 100% oxygen, and aspirate air from the catheter if a central line is in place.

Infiltration and extravasation: stop the infusion, aspirate residual drug through the catheter, remove the catheter (except for certain antidote protocols), elevate the limb, and apply the appropriate antidote per policy.

Phlebitis grading: erythema, induration, and pain along the vein; remove the catheter and apply warm compresses; document grade and site.

Catheter fracture or embolization: if resistance is met during removal or the catheter appears incomplete, obtain imaging and consult interventional radiology; do not force removal.

Prevention of occlusion: use pulsatile flushing, avoid blood reflux, and use appropriate catheter-to-vein ratio; smaller catheters in larger veins reduce thrombosis risk.

Nerve injury during access: paresthesia during puncture suggests needle contact with a nerve; withdraw and redirect before injecting or advancing.

Maximal sterile barrier precautions for central line insertion: cap, mask, sterile gown, sterile gloves, and full-body sterile drape; hand hygiene before and after all line care.

Skin antisepsis: chlorhexidine gluconate 2% in 70% isopropyl alcohol is preferred for adults; allow to dry completely before puncture.

Scrub the hub: disinfect the catheter hub with 70% alcohol or chlorhexidine for at least 15 seconds and allow to dry before accessing.

Daily review of line necessity: remove central lines as soon as they are no longer indicated; this is a core element of central line-associated bloodstream infection prevention bundles.

Use a sterile, transparent, semipermeable dressing for central lines; change gauze dressings every 2 days and transparent dressings every 5–7 days, or sooner if soiled or damp.

Do not routinely replace central venous catheters to prevent infection; replace only when clinically indicated or when a specific complication requires it.

Needlestick safety: use safety-engineered devices, never recap needles, and report exposures immediately per occupational health protocol.

Hand hygiene is the single most effective measure to prevent healthcare-associated infection; perform before and after patient contact and before any catheter manipulation.

Informed consent for vascular access: document discussion of purpose, risks (bleeding, infection, thrombosis, pneumothorax), benefits, and alternatives, and confirm the patient's understanding.

Scope of practice: perform procedures only within the defined scope and institutional policy; seek supervision or escalate when the procedure exceeds competence or authorization.

Documentation of a procedure should include date/time, indication, consent, site, catheter type and size, number of attempts, ultrasound use, complications, confirmation method, and patient tolerance.

Patient identification: use two identifiers before any procedure or medication administration, and verify allergies, especially to chlorhexidine, lidocaine, or latex.

Confidentiality: protect protected health information and share only on a need-to-know basis, consistent with privacy regulations and institutional policy.

Error disclosure: report adverse events and near misses through the institutional reporting system and disclose to the patient or family per policy and ethical obligations.

Maintain competence: participate in continuing education, skills validation, and peer review; track insertion success and complication rates as quality indicators.

Advocacy: if a patient refuses a procedure or requests an alternative, respect autonomy, document the discussion, and involve the care team as appropriate.