Vascular access is essential for critically ill patients in the ICU. Nearly all patients will require some form of vascular device such as a PIVC, PICC, or CVC. While necessary, these devices carry risks of complications and infection if not inserted and managed properly. The document emphasizes that insertion is only a small part of device management, and more attention needs to be paid to the 99% of time the device is in use. It provides recommendations for proper device selection, insertion technique including use of ultrasound and micro-puncture, dressing and securement, and tip location to reduce risks and improve device longevity during the critical care stay.

1. VASCULAR ACCESS IN THE ICU

2. Vascular Access in the critical care
 Nearly all critically ill patients will have some form of vascular
device
 Includes PIVCs / PICCs / CVCs / Vascaths and tunnelled
devices.
 Over 15,000 central lines / PICCs inserted in NSW ICU’s
annually
 Typically the first invasive procedure attended when patient
admitted to an ICU
 Are not without risk
 Procedural complications and line associated infection
implicated in increasing mortality and morbidity risk
• Burrell T, Mc Laws ML, Murgo M, Calabria E, Pantle AC, Herkes R. Aseptic insertion of central venous lines to reduce bacteraemia: The Central Line Associated Bacteraemia in NSW Intensive Care Units (CLAB ICU) Collaborative. MJA. 2011 6 June 2011;194(11):583-7.

3. Insertion is only a small part of the life of the catheter!
 Patient assessment and preparation 20 minutes
 Actual catheter insertion 15 minutes
_________
35 minutes
 If average ICU line in place 6-9 days then insertion phase less
than 1% of the life of the line

4. Consider This
 We specifically target a moment that
accounts for < 1% of the life of the device
to reduce infection
 What is happening during the other 99%?
 How much do you value the dressing?
 Who owns the device?
 When inserting…think like a nurse!

5. Correct device and anatomical selection should be based
on:
 Vessel assessment
 Patient Assessment / History
 Training and skill of inserter
 Infuscate Characteristics
 Number of Lumens Required
• Moureau, N. L. (2019). Vessel health and preservation: the right approach for vascular access (p. 303). Springer Nature.
• Moureau, N. L., Trick, N., Nifong, T., Perry, C., Kelley, C., Carrico, R., . . . Harvill, M. (2012). Vessel health and preservation (Part 1): a new evidence-based approach to vascular access selection and management. The Journal of
Vascular Access, 13(3), 351-356.
Device Placement

6. However……Device placement in the
critically ill is based on:
 Urgency of Catheter
 Usually minimal vessel assessment
 Training / supervision of Inserter
 Presumed safety of traditional insertion
sites / techniques (Ultrasound verses
landmark)
 This can lead to devices failing
prematurely and clinical complications
Device Placement

7. Device Placement

8. Reducing complications / Improving Device Longevity
» No More BS (Blind Stick)
» Choose a flat surface
» Use Axillary Vein
» Use Micro-puncture
» No incision
» No catheter hubbing
» Use chlorhex sponge / dressing with adhesive
» Use sutureless securement
» Low cervical IJV
» Rotate catheter down
» Use tip location
Feeding the 99%

9.  Allows for better stabilisation of catheter
 Allows for better securement
 Allows for better dressing adherence
 Will reduce catheter kinks
 Will improve lumen patency
Choose a flat surface

10. Choose a flat surface
 More than 2 dressing changes associated
with 3 fold increase risk of BSI
 3 in 5 dressing changes were unscheduled
 Providing a flat surface / appropriate exit
site for catheter will make dressing more
adherent
 A good dressing and exit site location
should be part of your insertion bundle

11. Can you use subclavian vein as a flat surface?
 Technically yes – typically landmark technique –
but blind stick can increase procedural
complications…
 If your using ultrasound for ‘subclavian vein’ –
your technically poking the Axillary vein – think
of it as a ‘lateral subclavian’
 In patients where AxV is visible on ultrasound, a
much better option than landmark as you can
visualise your needle
 An ideal site for thin emaciated patients
• Martin, C., Eon, B., Auffray, J. P., Saux, P., & Gouin, F. (1990). Axillary or internal jugular central venous catheterization.
Survey of Anesthesiology, 34(6), 366.
• Bodenham, A., & Lamperti, M. (2016). Ultrasound guided infraclavicular axillary vein cannulation, coming of age.

12. Use the Axillary vein: Ultrasound guided out of plain
Video courtesy of Dr Jack Le Donne

13. Assess the veins
 Systematically assess vessels and
surrounding structures
 Rapid Assessment of Central Veins –
RaCeVa Protocol
 Rapid Assessment of Peripheral Vein –
RaPeVa Protocol
 Assessment of vascular structures – size,
patency and pathway
 Reduces risk of inadvertent puncture of
important structures
 Step by step process helps to ‘map’
catheter pathway Chapter 2: Right Assessment and Vein Selection in: Moureau N (2019). Vessel Health and Preservation: The Right Approach to Vascular
Access. Philadelphia: Nature Springer Publishing

14. Use Micro Puncture Technique
Micropuncture Kit Standard CVC Kit
Needle 21G 18G
Guidewire 0.018 inch 0.35 inch
Introducer 4 French nil
 Access site bleeding accounts for most procedure related
haemorrhages
 Micro puncture reduces risk of procedural related bleeding
due to the small size needle and guidewire
 Larger guidewire inserted through introducer (that is then
split)
 You can use a standard 4F PICC MST kit

15. Use low IJ approach
 Mid to high neck approaches were used PRE
ULTRASOUND
 This was to reduce risk of lung puncture
 High neck IJs are difficult to manage and dress for
nursing staff and are a risk for infection
 Low approach allows the dressing of the catheter onto
the chest wall (flat surface), avoids gravity effect
 Reduces mechanical complications with vascaths and
CVVHDF

16. Central Zone Insertion Method - CZIM

17. Zone Insertion Method - PICC
 Important to optimise PICC placement in the ICU
 PICCs 2.5 times greater risk thrombosis in ICU patients
 More lumens = larger PICC catheter
 Catheter to vein ratio important to reduce risk
- 1/3 catheter to vein ratio is safe
- 4French PICC require minimum 4mm vessel
- 5 French PICC requires minimum 5mm vessel
 Optimise exit site to reduce failure and infection
 Green zone is the target area
 You can optimise catheter to vein ratio and exit site
with simple tunnelling technique

18. Use Tip Location – Optimal tip location
Too Short:
 Venous thrombosis
 Catheter malfunction
 Fibroblastic sleeve
 Vessel / Caval perforation
Too Long:
 Dysrhythmias
 Atrial perforation
 Tricuspid damage

19. Use Tip Location
» Optimal catheter tip position will increase catheter
survival rates and reduce complications
» Malpositioned CVADs can cause pain, increase risk of
thrombosis and increased risk of stenosis
» ECG technology can be used to navigate and place
catheter in the optimal position without the need for X Ray
in many instances
• Walker, G., Chan, R. J., Alexandrou, E., Webster, J., & Rickard, C. (2015). Effectiveness of electrocardiographic guidance in CVAD tip placement. Br J Nurs, 24(14), S4.
• Pittiruti, M., La Greca, A., & Scoppettuolo, G. (2011). The electrocardiographic method for positioning the tip of central venous catheters. J Vasc Access, 12(4), 280-291.

20. Use Tip Location
» Intracavitary ECG becomes lead II (white right arm lead)
» Intracavitary electrode is the tip of the catheter
» Based on changes to P wave progression of the catheter
is seen advancing through central veins
» Maximal P wave is the catheter close to SA node (Crista
Terminalis) – or Cavo Atrial Junction
• Walker, G., Chan, R. J., Alexandrou, E., Webster, J., & Rickard, C. (2015). Effectiveness of electrocardiographic guidance in CVAD tip placement. Br J Nurs, 24(14), S4.
• Pittiruti, M., La Greca, A., & Scoppettuolo, G. (2011). The electrocardiographic method for positioning the tip of central venous catheters. J Vasc Access, 12(4), 280-291.

21. Tip Location- What’s Required

22. Aiming for the CAJ

23. Alternative Options- Tunnelled Standard IJ Lines
 Can provide better stabilisation than standard low IJ
approach
 Can tailor exit site on chest wall
 Minimally invasive when using uncuffed CVC / PICC
 Provides flat surface for good dressing adherence
 Companies produce MST kits suitable for tunnelling
procedure (7F – 9F)

24. Alternative Options- Tunnelled Standard IJ Lines

25. Alternative Options- Femoral PICC Placement ….
 Femoral lines traditionally used for short term access
 Up to 3 fold greater risk of CLABSI (compared to SC and IJ)
 Not usually considered as an option for long term therapy
(except paediatrics)
 Minimal evidence to date on the effectiveness of
‘appropriately’ placed femoral lines
• Arvaniti, K., Lathyris, D., Blot, S., Apostolidou-Kiouti, F., Koulenti, D., & Haidich, A. B. (2017). Cumulative Evidence of Randomized Controlled and Observational Studies on Catheter-Related Infection Risk of Central Venous Catheter
Insertion Site in ICU Patients: A Pairwise and Network Meta-Analysis. Critical care medicine, 45(4), e437-e448.
• Zhang, J., Tang, S., Hu, C., Zhang, C., He, L., Li, X., & Xiao, J. (2016). Femorally inserted central venous catheter in patients with superior vena cava obstruction: choice of the optimal exit site. The journal of vascular access, 0.
• Kanter, R. K., Zimmerman, J. J., Strauss, R. H., & Stoeckel, K. A. (1986). Central venous catheter insertion by femoral vein: safety and effectiveness for the pediatric patient. Pediatrics, 77(6), 842-847.

26. Femoral PICC Placement ….
Traditional femoral lines:
• Inserted in emergent situations
• Puncture/Insertion site near inguinal
groove
• Difficulty with stabilisation / dressing
adherence
• Moist area – bad if incontinent
Tunnelled femoral PICC/CICC:
• Inserted under controlled situations
• Puncture site near inguinal groove
• Subcutaneous tunnel made 10cm distal to
puncture site (catheter exit point)
• Initial puncture site dressed and heals over by
primary wound intention quickly

27. Femoral PICC Placement ….
Traditional femoral line: Tunnelled femoral PICC/CICC:

28. Femoral PICC Placement ….
 Over 100 femoral PICCs inserted using the distal approach (since 2016)
 Primary reason for insertion: No viable vessels in the upper extremities /
central circulation
 Most were SL 4F PICCs
 Median Dwell 7 days (IQR: 4.75)
 Range: 2 days – 50 days
NO SYMPTOMATIC DVT / NO CLABSI

29. Inserting Chronic Catheters at the bedside

30. Thank You
Thank you to facilitators:
• Mark Sutherland
• Tanya Flynn
• Asmita Chand
• Anthony Marshall
• Evan Alexandrou
• Nic Mifflin
• Craig McManus
• Jess Butler
• Sarah Webb
• Felicity Mc Claren
• Vanno sou
• Teleflex
• Phillips