Vascular access

Last updated: June 13, 2023

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Summarytoggle arrow icon

Obtaining and maintaining vascular access is an essential component of medical care. Vascular access enables blood sample collection, hemodynamic monitoring, and administration of fluids, blood, and/or medications. Venous access can be obtained in peripheral veins, central veins, or the intramedullary space of bones. The location and type of venous access are chosen based on clinical urgency, intended use, and the anticipated duration of need. Long-term central venous catheters are typically used if venous access is required for 6 weeks or longer. Complications of vascular access include infection, thrombosis, harm to adjacent tissue, and extravasation or infiltration of infusing fluids and/or medications. Extravasation is treated with aspiration of the extravasated material, limb elevation, warm or cold thermal packs, and/or specific reversal agents. If extravasation of a medication causes significant tissue damage, consult with plastic surgery or orthopedic surgery for management.

Overview of vascular accesstoggle arrow icon

Venous access

Overview of types of venous access [2][3][4][5]
Intraosseous line (IO line) Peripheral intravenous line (PIV) Midline catheter [6][7] Peripherally inserted central catheter (PICC) Central venous line (CVL)
  • A hollow-bore needle inserted through skin and bone cortex into the bone marrow space and its venous plexus
  • A short flexible catheter inserted through the skin into a peripheral vein
  • A subtype of PIV
  • A long (∼ 20 cm) flexible catheter inserted through the skin via a peripheral upper extremity vein into the axillary vein
  • A subtype of CVL
  • A long flexible catheter placed through the skin via a peripheral upper extremity vein into a central vein
Clinical applications
  • Resuscitation
  • Resuscitation
  • Short-term fluid and medication administration
  • Blood sampling
  • Medium-term fluid and medication administration
  • Short-term fluid and medication administration
  • Long-term fluid and medication administration
  • Vesicant medication administration
  • Rapid placement
  • High first-attempt success rate
  • Low procedural risk
  • Simple placement
  • Low procedural risk
  • High fluid flow rates
  • High first-attempt success rate
  • Low procedural risk
  • Lower complication rate compared to PICC [8]
  • Lower procedural risk than other CVLs
  • Minimal infection risk
  • Allows infusion of both peripheral and centrally administered medications
  • Outpatient use possible
  • Facilitates administration of multiple medications
  • Longer duration of use
  • Outpatient use possible
  • Patient discomfort
  • Lower flow rates than PIV
  • Must be replaced within 24 hours
  • Blood sampling limitations [9]
  • Significant first-attempt failure rate [10]
  • Short-term use only
  • Requires insertion under imaging guidance
  • Easily dislodged
  • High phlebitis rate
  • Lower flow rate compared to other CVLs
  • Advanced procedural skills required
  • Severity of procedure-related complications is high
  • Flow rates may be slower than PIV

Duration of use

  • Hours [4]
  • Days [11]
  • 2–4 weeks [7]
  • Days to months

Arterial access

Choice of vascular accesstoggle arrow icon

General principles [6][13]

Consider the following when choosing the appropriate vascular access device for a patient:

  • Indication for vascular access (e.g., resuscitation, medication administration, invasive hemodynamic monitoring)
  • Urgency and expected duration of therapy and/or monitoring
  • Risks (e.g., complications of line insertion and/or maintenance, adverse effects of substance infusion)
  • Individual patient factors (e.g., age, prior experience, preferences)
  • Local protocols


Peripherally administered medications [6]

Centrally administered medications [6]

Long-term central venous accesstoggle arrow icon

Long-term CVLs are intended to remain in place for at least 6 weeks. [17]

Indications [17]

Types [5][17][18]

Comparison of long-term central venous catheters [5][18][19][20]
Description Advantages Disadvantages

Peripherally inserted central catheter (PICC)

  • Surgery is not required for insertion.
  • Low risk of procedural complications
  • Requires frequent flushes and dressing changes
  • Limited longevity
  • High risk of thrombophlebitis
  • Narrow lumen and long length limits the rate of fluid and medication administration.
Tunneled central venous catheter (e.g., Hickman catheter)
  • Requires surgery
  • Higher risk of CLABSI than surgically implanted catheters
Surgically implantable catheter (e.g., port-a-cath)
  • Proximal terminus is a subcutaneous reservoir that is accessed percutaneously.
  • Used for long-term administration of medications or fluids
  • Requires surgery
  • Painful to access

Variants [17]

  • Single or multiple lumens
  • Variable lumen size
  • MRI compatible
  • High volume flow

Complications [17]

  • Occlusion: e.g., mechanical, medication precipitation, thrombosis
  • Device fracture
  • External vascular thrombosis
  • Catheter-related infection
  • Central venous stenosis

Infiltration and extravasation injuriestoggle arrow icon

Definitions [21]

  • IV extravasation: leakage or unintentional administration of a vesicant medication into the tissue surrounding a vascular access device (e.g., PIV catheter or IO needle).
  • IV infiltration: leakage or unintentional administration of a nonvesicant solution or medication (e.g., saline) into the tissue surrounding a venous access device

Both IV infiltration and IV extravasation can result in significant injury and/or tissue damage (e.g., local necrosis, compartment syndrome) that can be life- or limb-threatening. Identify and manage these complications promptly. [22][23]


  • Vesicant agent: a drug that can result in tissue damage, blister formation, or necrosis when inadvertently injected into tissue around a vein [24]
  • Irritant agent: a drug that can result in pain, inflammatory reactions, or ulcers when inadvertently injected into tissue around a vein [25][26]
  • Neutral agent (nonvesicant): a fluid or drug that does not typically cause an acute tissue reaction when inadvertently injected into tissue around a vein [22]
  • Caustic agent: an acidic or alkaline substance that can have both irritant and vesicant properties depending on its concentration

Risk factors [23][27]

  • Patient-related
  • Procedure-related
    • Multiple attempts at venous access
    • High-pressure flow, e.g., rapid bolus with a large syringe
    • Unfavorable location of venous access device
    • Prolonged infusion times

Clinical features [22][23][27]

  • Tingling, burning, and/or pain at the venous access site
  • Localized swelling and/or redness (early signs)
  • Blistering, necrosis, and/or ulceration of adjacent tissue (late signs)

Management [23][25][27]

Initial management is similar for infiltration and extravasation, however, extravasation can require some additional steps.

Initial steps

  • Stop the infusion and disconnect the IV tubing (see “Troubleshooting IO access” for intraosseous infusions).
  • In case of extravasation:
    • Aspirate as much extravasated medication as possible from the venous access device.
    • Administer a specific reversal agent for an extravasated medication, if appropriate. [23][25]
  • Remove the venous access device.
  • Mark the boundaries of infiltration with a permanent marker.
  • Elevate the limb.
  • Consult plastic surgery or orthopedic surgery for large extravasations or signs of compartment syndrome.
  • Follow local protocols for responding to adverse events and file reports as necessary with the incident reporting system.

Monitoring and supportive care

Extravasation agent reversal [23][25]

There are no specific reversal agents for caustic substances.

Prevention [27]

  • Provide staff training on venous access device placement and medication administration.
  • Avoid high-risk venous access sites:
  • Following IV catheterization and prior to each infusion:
    • Check for blood return.
    • Flush with 10–20 mL of saline.
    • Inspect for signs of extravasation.
  • Consider central venous access for prolonged infusions (≥ 12 hours).

Referencestoggle arrow icon

  1. $Contributor Disclosures - Vascular access. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
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