Central Venous Access and Peripherally Inserted Central Catheters
Domain 6: Central Venous Access and Peripherally Inserted Central Catheters
This domain tests indications, insertion principles, tip confirmation, and site selection for central devices.
Core rules
- Central access is indicated for non-peripherally compatible solutions, long-term therapy, vasopressors, concentrated electrolytes, poor peripheral access, and some sampling needs. Choose the device with the lowest risk that meets duration and therapy.
- CICC sites: internal jugular, subclavian, femoral. PICC sites: basilic, brachial, cephalic veins; the basilic is often largest and straightest. Avoid PICC in limbs with lymphoedema, infection, thrombosis, or dialysis fistula.
- Insertion uses maximal sterile barrier and ultrasound guidance where available. For PICC, measure external length, track the tip, and confirm tip position by imaging before use except in a defined emergency.
- Ideal tip: cavoatrial junction, not right atrium or high SVC. Malposition requires repositioning and re-confirmation.
- Secure with a sutureless device and sterile dressing; document site, length, tip confirmation, and complications.
Worked example
A PICC is inserted for six weeks of antibiotics. Post-procedure chest radiograph shows the tip in the right atrium. Reasoning: do not use it. Right atrial placement increases arrhythmia and perforation risk. Withdraw the catheter by the measured distance, re-confirm on imaging, and document the change.
Traps
Assuming PICC is automatically safer than CVC; using before tip confirmation; selecting a subclavian site in a dialysis candidate; ignoring catheter length; and failing to re-image after repositioning.