UKOMNAS PDVF cheat sheet

Vascular access device (VAD) categories: peripheral cannula, midline catheter, peripherally inserted central catheter (PICC), centrally inserted central catheter (CICC), implanted port, tunnelled catheter.

PDVF (peripherally inserted device / vascular access) practitioner scope typically covers ultrasound-guided peripheral and central insertion, tip confirmation, dressing and catheter care, and complication triage under local policy.

Device selection rule: match dwell time, infusate characteristics (osmolarity, pH, vesicant status), and vessel suitability; peripheral cannula for short therapy, midline for weeks, PICC/CICC for weeks to months.

Osmolarity threshold for peripheral administration is commonly cited as ≤900 mOsm/L; pH range for peripheral tolerance is approximately 5–9.

Vesicant drugs (e.g. anthracyclines, vinca alkaloids, some contrast agents) require central access with confirmed tip position before infusion.

The PDVF role is governed by local competency frameworks, delegation, and scope of practice; insertion without documented competence and consent is outside scope.

Bundle concept: insertion bundle (hand hygiene, maximal barrier, skin antisepsis, optimal site selection, daily review) plus maintenance bundle reduces catheter-related bloodstream infection.

Accountability: the inserting practitioner remains responsible for documentation, tip verification, and escalation of abnormal findings to the treating team.

Upper limb venous drainage: cephalic vein (lateral, into axillary), basilic vein (medial, joins brachial veins to form axillary), median cubital vein connecting them at the cubital fossa.

Cephalic vein is preferred for PICC when suitable because of straighter course; basilic vein has a sharper angle at the axillary junction and lies near the brachial artery and median nerve.

The brachial artery and median nerve run close to the basilic vein in the antecubital fossa; puncture risk requires ultrasound identification before needle advancement.

Central venous anatomy: superior vena cava formed by union of right and left brachiocephalic veins; SVC drains into right atrium at the cavoatrial junction.

Cavoatrial junction is the ideal central tip landmark, approximately 2–3 cm below the carina on chest radiograph.

Vein assessment: diameter, depth, compressibility, valve presence, tortuosity, and continuity; a compressible anechoic lumen with thin walls indicates a patent vein.

Arterial versus venous ultrasound: arteries are non-compressible, pulsatile, thicker-walled; veins compress fully with light probe pressure.

Patient factors affecting vessel calibre: hydration, previous cannulation, chemotherapy, limb surgery, lymphoedema, and renal fistula protection (avoid fistula arm).

Pre-procedure assessment includes indication, therapy duration, infusate properties, allergy history (chlorhexidine, lidocaine, latex), anticoagulation, and coagulopathy.

Coagulation thresholds are local-protocol dependent; typical guidance for PICC insertion is INR ≤1.5 and platelet count ≥50 ×10⁹/L, with individual risk assessment for higher values.

Informed consent elements: nature of procedure, benefits, risks (infection, thrombosis, bleeding, malposition, pneumothorax for CICC), alternatives, and right to withdraw.

Consent must be obtained by a competent practitioner, documented, and obtained before sedation or premedication where the patient's capacity is affected.

Contraindications: active infection at site, thrombosis of target vein, ipsilateral mastectomy with lymphoedema, arteriovenous fistula arm, and inability to obtain consent in a patient lacking capacity without legal framework.

Anticoagulation management: assess last dose and renal function; ultrasound-guided technique reduces arterial puncture risk but does not eliminate bleeding risk.

Site selection rule: use the dominant arm where possible, avoid antecubital crease for long dwell, and assess both arms with ultrasound if first attempt fails.

Pre-procedure checklist: identity, allergies, consent, vein mapping, equipment availability, sterile field preparation, and rescue equipment (including ultrasound and tip confirmation device).

Maximal sterile barrier precautions for central line insertion: sterile gown, sterile gloves, cap, mask, and full-body sterile drape.

Skin antisepsis: 2% chlorhexidine in 70% alcohol is preferred; allow to dry completely (typically 30 seconds for skin, longer for moist sites) before puncture.

Hand hygiene per WHO 5 Moments; alcohol-based rub for routine, soap and water for visible soiling and spore-forming organisms (e.g. C. difficile).

Hub disinfection: scrub the access port with 70% alcohol or chlorhexidine for at least 15 seconds and allow to dry before accessing.

Aseptic non-touch technique (ANTT) distinguishes key parts (must remain sterile) from non-key parts; key parts are protected throughout.

Dressing: sterile transparent semi-permeable dressing changed every 7 days, or sooner if soiled, loose, or damp; gauze dressings changed every 2 days.

Catheter-related bloodstream infection (CRBSI) diagnosis: same organism from peripheral blood and catheter tip or differential time to positivity; requires culture before antibiotic initiation.

Insertion site selection: avoid femoral site for central access where possible due to higher infection and thrombosis risk; subclavian has lower infection but higher pneumothorax risk.

Peripheral cannula gauges: 14G (large, rapid flow), 16G, 18G, 20G, 22G, 24G (small, paediatric/neonate); choose the smallest gauge that meets flow requirement.

Flow rate is proportional to the fourth power of radius (Poiseuille); a 14G delivers far higher flow than a 22G at the same pressure.

Ultrasound-guided peripheral cannulation: identify vein in short axis, confirm compressibility, enter at 15–30° angle, watch needle tip enter the lumen, then thread the cannula.

Tip visualisation: in short-axis view, confirm needle tip by seeing the tip indent the vein wall; avoid advancing without tip identification to prevent through-and-through puncture.

Deeper veins may require a longer cannula (e.g. 48 mm) to reach the lumen; standard 25 mm cannula may be inadequate at depth >1 cm.

Site selection: dorsum of hand, forearm, and antecubital fossa; avoid areas of flexion, joints, and previously infected or phlebitic sites.

Peripheral cannula dwell: remove and re-site if no longer clinically indicated; routine replacement every 72–96 hours is not required if the device is functioning and asymptomatic.

Phlebitis grading (VIP score): 0 = none, 1 = erythema at site, 2 = pain/erythema, 3 = pain/erythema/induration, 4 = pain/erythema/induration/palpable cord, 5 = purulent discharge.

PICC insertion sites: basilic, cephalic, or brachial vein; basilic is largest and most commonly used, cephalic has smaller diameter and more valves.

Tip confirmation: intracavitary ECG (IC-ECG) and/or chest radiograph; IC-ECG detects the P-wave change at the cavoatrial junction and is increasingly used as primary confirmation.

CICC sites: internal jugular (preferred for lower pneumothorax risk), subclavian, femoral; landmark or ultrasound-guided technique.

Seldinger technique: needle puncture, guidewire insertion, dilator, catheter over wire, wire removal, confirmation of blood flow, securement.

Catheter tip should terminate in the lower SVC or cavoatrial junction; tip in the right atrium increases arrhythmia and tamponade risk.

PICC diameter: 4Fr–6Fr typical; choose the smallest lumen number and diameter that meets therapy needs to reduce thrombosis risk.

Power-injectable PICCs are rated for contrast injection at specified flow rates (e.g. 5 mL/s); non-power-injectable catheters must never be used for power injection.

Tunnelled catheters and implanted ports are indicated for long-term therapy (months to years), chemotherapy, and repeated blood sampling.

Air embolism: sudden dyspnoea, chest pain, hypotension; management is left lateral Trendelenburg position, 100% oxygen, and urgent medical review.

Catheter-related thrombosis: unilateral swelling, pain, collateral veins; confirm with duplex ultrasound and discuss anticoagulation and catheter removal.

Arterial puncture: pulsatile bright red blood, pain, haematoma; remove needle, apply pressure for at least 5–10 minutes (longer if anticoagulated), and escalate.

Pneumothorax after CICC: pleuritic chest pain, dyspnoea, reduced breath sounds; confirm with chest radiograph and manage per severity.

Catheter fracture or embolism: stop infusion, do not flush, apply a tourniquet proximally if peripheral, and arrange urgent retrieval.

Infiltration and extravasation: stop infusion, aspirate residual drug if possible, remove cannula, elevate limb, apply cold or warm compress per drug protocol, and document.

Cardiac arrhythmia during insertion: caused by guidewire or catheter in the right atrium; withdraw device and reposition, monitor ECG.

Phlebitis and infection: remove the device if severe phlebitis or suspected infection; culture the tip and obtain blood cultures before antibiotics.

Flush protocol: pulsatile flush with 10 mL or larger syringe for central catheters to reduce pressure damage; use positive pressure technique to prevent reflux.

Syringe size rule: never use a syringe smaller than 10 mL on a central catheter; small syringes generate high pressure and can rupture the catheter.

Lock solutions: heparinised saline (commonly 10 units/mL) or 0.9% sodium chloride per local policy; use saline for most peripheral cannulas.

Dressing change frequency: transparent semi-permeable every 7 days; gauze every 2 days; replace immediately if damp, loose, or soiled.

Securement: sutureless securement devices reduce migration and infection compared with sutures; use a stabilisation device plus dressing.

Removal: stop infusion, remove dressing and securement, withdraw catheter smoothly, apply pressure until haemostasis, inspect catheter integrity, and document.

Catheter integrity check on removal: confirm full length; if a fragment is missing, escalate for imaging and retrieval.

Blood sampling from central catheters: discard the first 2–3 mL (or per policy), then collect; avoid sampling from lines infusing incompatible drugs.

Minimum insertion documentation: date/time, operator, device type and gauge, site, number of attempts, ultrasound use, tip confirmation method and result, and patient tolerance.

Maintenance documentation: dressing change date, flush and lock, site assessment, and any complications or interventions.

Quality indicators: insertion success rate, first-attempt success, CRBSI rate per 1000 catheter-days, thrombosis rate, and complication rates.

Audit cycle: define standard, measure practice, compare with standard, implement change, re-audit; document findings and actions.

Incident reporting: all complications, near misses, and device failures should be reported through the local incident system for learning.

Competency maintenance: logbook of insertions, observed assessments, and annual update; scope of practice is defined by local policy and credentialing.

Consent and capacity documentation: record who consented, the discussion, and any legal framework used for patients lacking capacity.

Device registry and traceability: record lot numbers and device details for recall and infection investigation.

Duty of care: practitioners must act within their competence, seek supervision when needed, and escalate concerns about patient safety.

Consent law: valid consent requires capacity, sufficient information, and voluntariness; document the discussion and the patient's decision.

Mental capacity: assume capacity unless proven otherwise; assess understanding, retention, and communication of decision; use best-interests framework if lacking.

Confidentiality: share information on a need-to-know basis; disclose only with consent or where legally required (e.g. public health, court order).

Accountability: professional registration bodies (e.g. NMC, HCPC) require honesty, record-keeping, and reporting of errors.

Advocacy: raise concerns about unsafe practice through appropriate channels (line manager, freedom to speak up guardian, regulator).

Equality and non-discrimination: provide reasonable adjustments for disability, language, and cultural needs; use interpreters where required.

Scope of practice: expanding skills requires formal training, competency assessment, and governance approval; practising outside scope is a professional and legal risk.