Vascular Access Device Selection, Insertion, and Care
Match the device to the therapy
Selection is driven by duration, solution characteristics, vessel quality, and patient preference. Peripheral short catheters suit short-term, non-irritating therapy. Midlines terminate in the basilic, cephalic, or brachial vein - they are not for vesicants, continuous vesicant therapy, solutions with pH below 5 or above 9, or osmolality above about 600 mOsm/L. PICCs and other central catheters terminate in the lower third of the superior vena cava or cavoatrial junction and can carry hypertonic, caustic, and vasoactive therapy. Consider catheter-to-vein ratio (roughly 45% or less) to reduce thrombosis risk.
Insertion essentials
Skin antisepsis with chlorhexidine gluconate, maximal sterile barrier precautions for central catheters, ultrasound guidance for vessel assessment, and confirmation of tip location before use. For PICCs, verify tip position by radiograph or other approved method and measure the external catheter length for later comparison.
Ongoing care
Scrub the hub with an appropriate antiseptic for the recommended contact time and allow it to dry. Flush with preservative-free 0.9% sodium chloride using a syringe size appropriate to the device (typically 10 mL for central catheters to avoid excessive pressure). Use pulsatile flushing and maintain positive pressure. Stabilize the device, protect the dressing, and assess the site at least every shift and before each use.
Trap: midline and PICC questions that hinge on "central vs peripheral" - many stem from a mislabeled device.
Worked example: A patient needs 3 weeks of vancomycin plus a continuous norepinephrine infusion. Answer: central catheter (PICC), not a midline or peripheral IV, because of duration plus vasopressor therapy.