Chapter 17: Vascular access devices: insertion and management
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Anatomy and physiology
Choice of vein
Careful evaluation and adequate assessment of the patient prior to attempting catheter placement go a long way to ensuring success. Both arms should be examined using ultrasound with a tourniquet in place (Figure 17.22). The PICC should preferably be inserted in the non‐dominant arm, although the use of the non‐dominant arm for PICC insertion has only a marginal impact on activities of daily living for patients (Sharp et al. [410]). It has been shown that ultrasonography can increase the chance of successful cannulation of the vein on the first attempt (Bodenham et al. [43], Lamperti et al. [260], LaRue [263], Moureau [329]) compared with using the traditional landmark method (using surface anatomical landmarks and knowing the expected anatomical relationship between the vein and its palpable companion artery) (Dougherty [123], NICE [349]). By using ultrasound, the nurse can position the transducer to obtain a transverse (cross‐sectional) or horizontal view of the vein, which may aid in the identification of arterial vessels as well as facilitating visualization of solid material, such as a thrombus, in the lumen of the vessel (Hadaway [194], Moureau [329], Weinstein and Hagle [465]) (Figures 17.23 and 17.24). Ultrasound can be used to assess vein health and lack of scar tissue or thrombosis by compressing veins with light to moderate pressure (healthy veins should easily compress); if the vein does not compress or collapse to light to moderate pressure or compresses in a lopsided way, thrombosis may be present in the vein (Dawson [107]).
Figure 17.22 Applying an ultrasound probe to the arm to locate veins.
Figure 17.23 Ultrasound images of veins on screen.
Figure 17.24 Ultrasound cross‐sectional image of the right internal jugular vein (IJV) without compression through the probe. Image orientation as seen from the head of the patient. The depth of field of the image is only 2.8 cm, so all structures are very superficial. CA, carotid artery; T, thyroid; TA, thyroid artery. Source: Reproduced from Hamilton ([198]) with permission of John Wiley & Sons.
The size of the vessels can be improved by use of a blood pressure cuff (Mahler et al. [288]). Choice of vein and vein diameter are vital to avoid thrombosis (Meyer [311]). Dawson ([106]) found that thrombosis rates were 57% in cephalic veins, 14% in basilic veins and 10% in brachial veins. Veins more suitable for venous access are ideally three times the diameter of the selected catheter (e.g., a 4 Fr catheter has a diameter of 1.33 mm and so requires a 4 mm or larger vein), which allows for adequate blood flow around the catheter, enables abundant dilution of infused drugs with the blood as they enter the circulation, and protects the vein walls from the catheter (Moureau [329]). Spencer and Mahoney ([425]) defined the catheter‐to‐vessel ratio as ‘the indwelling space or area occupied by an intravascular device inserted and positioned within a venous or arterial blood vessel’ (p.428). Measuring the vein diameter and choosing a catheter‐to‐vein (vessel) ratio of 45% or less may reduce thrombosis risk in PICCs and midlines (Gorski et al. [181], Moureau and Chopra [330], Nifong and McDevit [354], Sharp et al. [409]).
Movement of the catheter in and out of the insertion site contributes to the development of phlebitis and other complications. It is important to find a stable location at least 4 cm above the antecubital fossa to reduce the amount of catheter movement associated with this location (Dawson [106], Moureau [329]). Veins in the upper arm and specifically on the middle section of the upper arm offer stability and give the best results. Dawson ([106]) proposed the PICC Zone Insertion Method (ZIM) as a traffic‐light (red, green and yellow) system to enable a systematic approach to determining the ideal insertion site for PICCs in the upper arm. The green area is the ideal target zone and is located in the mid‐upper arm, above the antecubital fossa (red zone) and below the axilla (yellow zone). The final determination for the PICC insertion site should include ultrasound visualization of the best vein within the green zone (Dawson [106]) (Figure 17.25).
Figure 17.25 PICC Zone Insertion Method (ZIM). Source: Reproduced from Dawson ([106]) with permission of Elsevier.
The basilic and brachial veins
The upper basilic vein is the vein of choice for PICC insertions owing to its larger size, straighter course for catheter advancement and higher haemodilution capability (Bullock‐Corkhill [56], Gorski et al. [181], RCN [381]) (Figure 17.26). The basilic vein begins in the ulnar (inner aspect) part of the forearm, runs along the posterior, medial surface (back of the arm) and then curves towards the antecubital region, where it is joined by the median cubital vein. It then progresses straight up the upper arm for approximately 5–8 cm and enters the deep tissues. It ascends medially to form the axillary vein (Dougherty [123], Hadaway [194], Tortora and Derrickson [444]). This vein is the largest and straightest vein in the arm and presents lower risk of complication relating to access as it is not generally accompanied by an artery or a nerve.
Figure 17.26 Anterior view of the superficial veins.
The brachial veins (Figure 17.27) are located deep in the arm alongside the brachial artery and the median nerve (together, they form the brachial bundle) and are slightly smaller than the basilic vein (Hadaway [194], Tortora and Derrickson [444]). The brachial bundle is easy to locate with ultrasound as it has a configuration that resembles Mickey Mouse's head (i.e. one larger ‘head’ circle below and adjoining two larger ‘ear’ circles). The brachial veins advance up the arm deep within the muscle and join with the basilic vein or directly into the axillary vein (Moureau [329], Tortora and Derrickson [444]). Their proximity to the brachial artery means that there is a greater chance of arterial puncture and touching the median nerve.
Figure 17.27 Anteromedial view of the superficial veins of the arm and forearm. Source: Reproduced from Tortora and Derrickson ([444]) with permission of John Wiley & Sons.
The median cubital vein
The median cubital vein (see Figure 17.27) ascends from just below the middle of the antecubital region and commonly divides into two vessels, one of which joins the basilic and the other the cephalic vein (Tortora and Derrickson [444]). The median cubital vein is commonly used for blood sampling owing to its size and ease of needle entry. If a practitioner is having difficulty locating and/or cannulating the basilic vein, then the median cubital vein may be used as an alternative insertion route (Sansivero [398]). The catheter will then advance into the basilic (or cephalic) vein.
The cephalic vein
The cephalic vein begins in the radial side (thumb side) of the hand and ascends laterally (along the outer region of the forearm) into the antecubital region, where it forms a junction with the axillary vein. This vein is usually more accessible than the basilic but its size, its tortuous path and the sharp angle where it anastomoses with the subclavian make it more difficult to advance the catheter (Dougherty [123], Moureau [329]). Therefore, it presents a greater potential for catheter tip malposition (Dougherty [123], Weinstein and Hagle [465]).
