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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 access
|Overview of types of venous access |
|Intraosseous line (IO line)||Peripheral intravenous line (PIV)||Midline catheter ||Peripherally inserted central catheter (PICC)||Central venous line (CVL)|
|Clinical applications|| || || || |
|Advantages|| || || || || |
|Disadvantages|| || || || || |
Duration of use
| || || || || |
|Procedure|| || || |
|Complications|| || || || |
- Clinical applications 
- Procedure: See “Arterial line insertion.”
General principles 
Consider the following when choosing the appropriate vascular access device for a patient:
- Indication for vascular access (e.g., resuscitation, medication administration, )
- 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
- Begin with an attempt at .
- Consider 3 attempts.  if is not established after
- Prepare for if attempts at placing a or are unsuccessful.
- Advance quickly to central venous access based on resuscitation needs.
- Multiple vasoactive medications required: preferred
- Rapid large-volume infusion required: preferred
Peripherally administered medications 
- ≤ 5 days: PIV
- Critically ill and/or required:
- Other patients:
- 15–30 days:
- ≥ 31 days: , , or
Centrally administered medications 
- < 14 days: or
- ≥ 15 days: or
- ≥ 31 days: , , or
6 weeks. are intended to remain in place for at least
|Comparison of long-term central venous catheters |
Peripherally inserted central catheter (PICC)
| || |
|Tunneled central venous catheter (e.g., Hickman catheter)|
|Surgically implantable catheter (e.g., port-a-cath)|| || |
- Single or multiple lumens
- Variable lumen size
- MRI compatible
- High volume flow
- 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. 
- Vesicant agent: a drug that can result in tissue damage, blister formation, or necrosis when inadvertently injected into tissue around a vein 
- Irritant agent: a drug that can result in pain, inflammatory reactions, or ulcers when inadvertently injected into tissue around a vein 
- Neutral agent (nonvesicant): a fluid or drug that does not typically cause an acute tissue reaction when inadvertently injected into tissue around a vein 
- : an acidic or alkaline substance that can have both irritant and vesicant properties depending on its concentration
Risk factors 
- 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 
- 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)
Initial management is similar for infiltration and extravasation, however, extravasation can require some additional steps.
- Stop the infusion and disconnect the IV tubing (see “ ” 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. 
- 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 .
- Follow local protocols for and file reports as necessary with the .
Monitoring and supportive care
- Apply local cooling or warming 4 times a day for 20 minutes per session. 
- Provide pain management as needed.
- Reassess regularly until fully healed. Typically every 1–2 days for the first week, then weekly. 
Extravasation agent reversal 
There are no specific reversal agents for caustic substances.
- Vasopressors : Inject either phentolamine OR terbutaline then apply nitroglycerin topically
- Hyperosmolar solutions : hyaluronidase (off label) 
- Reversal agents and doses depend on the drug; consult a specialist for guidance.
- See “Extravasation of chemotherapeutic agents.”
- 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).