Devices are secured to prevent movement, which reduces the risk of phlebitis, infiltration, infection and migration (Gorski et al. [181], McGoldrick [305], Moureau and Iannucci [334], Schears [402], Yamamoto et al. [478]). This can be achieved by suturing, taping or use of securing devices (Figure 17.7). These all require a dressing over them. The stabilization device should be used in a manner that does not interfere with the assessment and monitoring of the access site (McGoldrick [305]).

The choice of dressing is usually based upon what is most suitable for a particular VAD site or type of skin. An intravenous dressing is applied to minimize contamination of the insertion site and provide stability of the device (Dougherty [123], Jeanes and Martinez‐Garcia [229]). Therefore, the ideal intravenous dressing should:

There are two main types of dressing: dry, sterile, low‐linting gauze dressings and transparent dressings. A dry, sterile, low‐linting gauze dressing secured with the minimum of hypoallergenic tape is most suitable for patients with skin that is prone to allergy or is thin and tears easily, as transparent dressings can damage the skin if not removed correctly. Always follow the manufacturer's instructions when removing transparent IV film dressings. International and local clinical practice guidelines rarely acknowledge or provide recommendations for how to effectively dress and secure VADs within complex situations (Broadhurst et al. [50]). Medical adhesive‐related skin injury (MARSI) is a term used for skin reactions or manifestations of cutaneous abnormality related to medical adhesive that persist for 30 minutes or more after removal of the adhesive (Hitchcock and Savine [212], McNichol et al. [308]). The following can predispose patients to a high risk of skin injury:

Early recognition of MARSI enables early intervention and specialist advice and thus is key in order to prevent the loss of skin integrity. The use of algorithms that consider all elements of IV dressing (i.e. skin decontamination, skin protection, what to do in the event of a known sensitivity or allergy to specific decontamination or dressing products, and the appropriate referral for specialist input) has been found to be effective in preventing MARSI in clinical practice (Hitchcock and Savine [212]).

The benefits of transparent dressings are that:

This means that the dressing allows moisture vapour transmission, which is an important factor related to the risk of infection, as collection of moisture enhances the proliferation of micro‐organisms and the risk of skin damage due to skin maceration (CET [68], Loveday et al. [278], O'Grady et al. [362]).

Comparisons of infection rates when transparent dressings and sterile gauze are used have shown that there is no significant difference in peripheral devices, and that infection rates may be reduced in CVADs (DH [117], Maki and Ringer [292], RCN [381]). CVAD dressings must be removed and replaced within 24 hours following insertion of the catheter (Dougherty [123], Ryder [393], RCN [381]). This is due to the bacterial colonization, or ‘biofilm’, which occurs 6–18 hours following insertion (Ryder [394]). Transparent dressings should be changed every 7 days unless the manufacturer recommends otherwise or the integrity is compromised – that is, when the dressing is damp, loose or soiled (Gorski et al. [181], Loveday et al. [278], RCN [381]). If gauze is used, it must be replaced when the dressing becomes damp, loose or soiled or when inspection of the site is necessary (Loveday et al. [278], RCN [381]). When the dressing is changed, the insertion site should be inspected for inflammation and/or discharge and the condition of the skin documented (DH [117]).

There are also dressings impregnated with chlorhexidine gluconate (CHG) (e.g. protective disc impregnated with CHG or CHG gel integrated into the dressing) and ionic silver alginate pads, both of which may also be considered for placement at the catheter–skin junction. This is done to protect the extraluminal pathway and eliminate or reduce the incidence of infection (Hill et al. [211], McGoldrick [305]). Tissue adhesives (surgical glue (cyanoacrylate) or metallic powder) can be applied to the site to reduce bleeding at the insertion site, which may enable the dressing to be left in place for at least 7 days following insertion and reduce extraluminal contamination (Corley et al. [88], Jeanes and Martinez‐Garcia [229], Scoppettuolo et al. [407], Simonova et al. [415]). There is no need to change a CVAD dressing 24 hours post‐insertion if tissue adhesive was applied or impregnated discs were used post‐CVAD insertion as they prevent bacterial contamination while facilitating haemostasis (Corley et al. [88]).

Tools have been developed to facilitate venous assessment and venous access device assessment. For example, the Venous Assessment Tool (VAT) consists of a series of risk factors and characteristics that can be assessed to determine whether cannulation will be easy, moderately difficult or hard (Figure 17.8). The VAT score can then be used in the algorithms ‘Deciding On Intravenous Access’ or ‘DIVA (Difficult Intravenous Access)’. This helps practitioners to bring together the proposed therapy and the type of venous access in order to identify the most suitable VAD (Wells [466]). The Vessel Health Preservation (VHP) system involves carrying out an assessment to ensure that the right device is used in the right patient at the right time (Hallam et al. [197], Moureau et al. [337], Trick [446]) (Figure 17.9). The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) is another tool designed to inform and improve clinical decision making with respect to VADs, in particular the use of PICCs (Chopra et al. [77]). These tools and their implementation aim to improve patient outcomes by defining best practices for device insertion, care and management through a systematic process involving the patient and the multidisciplinary team (Chopra et al. [77], Gorski et al. [181], RCN [381], Swaminathan et al. [431]).

Heparin inhibits the conversion of prothrombin to thrombin and fibrinogen to fibrin, thus inhibiting coagulation, and is therefore used to prevent the build‐up of fibrin. The standard strength is 10 international units (IU) per mL up to a total of 5 mL (50 IU) for all CVADs with the exception of implanted ports, where it is usual for the dose to be 100 IU/mL (500 IU total). A higher dose (1000 IU/mL) is used to maintain patency in dialysis‐type catheters. 0.9% sodium chloride is used to clean the internal diameter of the device of blood and drugs (Camp‐Sorrell et al. [60]). Recent guidance favours the use 0.9% sodium chloride over heparinized saline for flush and lock purposes for any type of non‐dialysis CVAD (Gorski et al. [181], Loveday et al. [278], RCN [381], Sousa et al. [423]). Urokinase is a fibrinolytic agent indicated for the lysis of blood clots in venous catheters that are occluded by fibrin clots. Usually, 10,000 IU is dissolved in sterile saline and instilled into the catheter every 10 minutes over 30 minutes. The drug and any clots are then aspirated and the process can be repeated if necessary (Syner‐Med [433]) (see Figure 17.4b).

Involving the patient in the decision‐making process is vital (Chittle et al. [76], Dougherty [123], Kelly [242]). Patients should be provided with individualized information and support in order to be involved in the clinical decision‐making process (Sharp et al. [410]). Patient choice about the device or even the site of insertion, for example use of the non‐dominant arm, results in better compliance with care of the device and monitoring of problems (Gabriel [161]). It also enables patients to cope better with the changes to their normal activities (Cooper et al. [87], Daniels [103]) and the impact on body image can be reduced by involving the individual in the choice and management of the device (Cooper et al. [87], Daniels [103], Dougherty [123], Kelly [242]).

Body image and a patient's lifestyle can be issues when a patient is living with a CVAD (Dougherty [123]). This is particularly true with an external catheter, which can be distressing and embarrassing for some patients (Hayden and Goodman [202], Kelly [242]). It can result in restrictions to normal daily activities (e.g. bathing) or involvement in sporting activities (e.g. swimming) (Cooper et al. [87], Gabriel [159], Molloy et al. [321], Robbins et al. [385]); some of these can be resolved by the use of an implanted device (Chernecky [72], Johansson et al. [232], Kelly [242]).

The following are ways in which a CVAD can affect body image:

The presence of a CVAD can also affect how others view the individual's roles and ability to function, particularly if the individual is attached to an infusion pump (Thompson et al. [438]). The psychological impact of an indwelling catheter on body image should not be overlooked, especially when patients are sexually active (Gabriel [159], Kelly [242], Oakley et al. [361]).