7.2 Peripheral & Central Venous Line Access, Care & Complications

7.2 Peripheral & Central Venous Line Access, Care & Complications

Vascular access management is one of the most critical day-to-day responsibilities of nurses working across inpatient wards, emergency departments, and critical care units in Singapore. Compliance with Singapore Nursing Board (SNB) competencies and National Centre for Infectious Diseases (NCID) guidelines is mandatory to prevent preventable vascular access complications, including Central Line-Associated Bloodstream Infections (CLABSI) and vesicant extravasation injury.

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1. Peripheral Venous Cannulation: SNB Scope of Practice & Maintenance

Peripheral Intravenous Cannulation (PIVC) involves inserting a short catheter into a peripheral vein. In Singapore public healthcare institutions (SingHealth, National Healthcare Group, National University Health System), IV insertion and maintenance are governed by defined scope-of-practice standards:

• Registered Nurses (RNs): Certified to insert PIVCs, administer all approved IV bolus and continuous infusions (including vesicants and high-alert drugs), manage central lines, and perform blood sampling.
• Enrolled Nurses (ENs): May perform peripheral IV cannulation and administer designated IV fluids/medications only upon completing accredited institution-based certification courses and working under RN supervision.

Site Selection & Insertion Standards

1. Vein Selection: Preferred sites include upper extremity distal veins (metacarpal, cephalic, basilic veins). Avoid lower extremity veins in adults due to high risk of deep vein thrombosis (DVT) and thrombophlebitis. Avoid limbs with arteriovenous (AV) fistulas/grafts, lymphhedema (post-mastectomy), or active skin infections.
2. Catheter Gauge Selection:
   • 22G to 24G (Blue/Yellow): Fragile veins, pediatric patients, slow fluid infusions.
   • 20G (Pink): Routine IV fluids, elective surgical patients, antibiotic administration.
   • 18G (Green): Rapid blood product transfusions, trauma resuscitation, CT contrast administration.
   • 14G to 16G (Orange/Grey): Massive transfusion protocols, major vascular surgery.
3. Skin Antisepsis: Prepare skin with chlorhexidine gluconate 2% in 70% isopropyl alcohol using a friction scrub for at least 30 seconds, allowing complete air drying (minimum 2 minutes) to achieve effective antimicrobial action.

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2. Central Venous Access Devices (CVADs) & NCID Infection Control Bundles

Central Venous Access Devices terminate in the lower third of the superior vena cava (SVC) or at the cavoatrial junction. Common CVADs include:

• Nontunneled Central Venous Catheters (CVC): Inserted via internal jugular, subclavian, or femoral vein for short-term critical care.
• Peripherally Inserted Central Catheters (PICC): Inserted via basilic/cephalic vein into SVC for intermediate to long-term therapy (weeks to months).
• Implanted Ports (Port-a-Cath): Surgical reservoir placed in subcutaneous tissue for long-term chemotherapy/parenteral nutrition.

NCID CLABSI Prevention Insertion & Maintenance Bundle

To eliminate Central Line-Associated Bloodstream Infections, Singapore healthcare clusters enforce strict NCID evidence-based bundles:

CVAD Insertion Bundle:
  1. Hand hygiene prior to insertion.
  2. Max sterile barrier precautions (full mask, cap, sterile gown, sterile gloves, full-body drape).
  3. Chlorhexidine 2% in 70% alcohol skin prep (allow full air drying).
  4. Optimal site selection (Subclavian preferred over Internal Jugular; avoid Femoral site).
  5. Prompt removal of unneeded central lines.

CVAD Maintenance Bundle:
  1. "Scrub the Hub": Friction scrub of needleless connectors with chlorhexidine-alcohol wipes for 15 SECONDS and allow 15 seconds to dry prior to every access.
  2. Transparent Dressing Changes: Change transparent semi-permeable dressings every 7 days (or immediately if soiled, loose, or damp); gauze dressings changed every 48 hours.
  3. Chlorhexidine Sponge (Biopatch): Apply over insertion site to inhibit cutaneous flora.
  4. Flush Protocol: Flush unused lumens with 0.9% NaCl using a pulsating (push-pause) technique to create turbulent flow and prevent lumen occlusion.

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3. Complications of Intravenous Therapy: Early Detection & Management

Visual Infusion Phlebitis (VIP) Score

All peripheral cannula sites must be assessed at least once per shift and prior to medication administration using the standardized Visual Infusion Phlebitis (VIP) Score:

Infiltration vs. Extravasation

• Infiltration: Inadvertent leakage of non-vesicant fluid/medication into surrounding tissue, causing swelling, paleness, coolness, and local discomfort.
• Extravasation: Leakage of vesicant solutions (e.g., Noradrenaline, Dopamine, Calcium Chloride, Chemotherapy agents such as Doxorubicin) into subcutaneous tissue, leading to tissue necrosis, blistering, and sloughing.
  • Emergency Nursing Protocol for Extravasation:
    1. STOP the infusion immediately. Do NOT remove the cannula right away.
    2. Attach a syringe to the cannula and aspirate as much residual medication as possible.
    3. Administer drug-specific antidote (e.g., subcutaneous Phentolamine for alpha-adrenergic extravasation like Noradrenaline) through the cannula if ordered.
    4. Remove the cannula and elevate the affected limb.
    5. Apply cold compresses (for most vesicants) or warm compresses (for vinca alkaloids).
    6. Document the incident, notify the primary physician, and submit an electronic incident report (e-Report/Riskman).

Air Embolism Emergency Intervention

Air entry into a central line (due to disconnected tubing, un-clamped line during cap change, or deep inspiration during catheter removal) can cause a lethal air lock in the right ventricle.

• Clinical Manifestations: Sudden dyspnea, cyanosis, chest pain, hypotension, tachycardia, and a characteristic "mill-wheel" murmur.
• Immediate Nursing Actions:
  1. Clamp the central catheter tubing immediately.
  2. Place the patient in the Left Lateral Trendelenburg position (Durant's maneuver). This position causes air bubbles to rise toward the apex of the right ventricle, preventing blockage of the pulmonary artery exit tract.
  3. Administer 100% high-flow oxygen via non-rebreather mask to speed up nitrogen reabsorption.
  4. Call for emergency medical assistance / Medical Emergency Team (MET).