Terms and Definitions

Central catheters: Venous access device terminating in the inferior or superior vena cava regardless of insertion site. Appropriate venous access selection involves:

1. Patient safety and convenience
2. Quantity and type of fluid to be delivered:
   1. The larger the lumen the more volume can be delivered
   2. Hemodilution of fluid is required for hypo or hypertonic fluid and fluids with a of pH >9 or pH<5
3. Peripheral access compromise due to hypovolemia, shock, trauma, etc.
4. Need to monitor central venous pressure or repeatedly draw venous blood samples
5. Dwell time
6. Delivery of multiple incompatible medications

• Central venous catheter (CVC)- Single or multiple lumen catheter usually inserted via the internal jugular, subclavian, femoral vein and terminating in the inferior or superior vena cava. CVCs require insertion by a physician. CVCs have the advantage of rapid insertion for the emergent delivery of fluid resuscitation. CVCs are available in larger lumen sizes allowing greater volume infusion and more reliable sample withdrawal. They can also be made permanent by surgically implanting a subcutaneous access port and tunneling the catheter from the insertion site. CVCs have a greater risk of major insertion complications including: pneumothorax, air embolism, hemorrhage, hematoma. Insertion sites including: internal jugular, subclavian, femoral vein have been associated with a greater risk of blood stream infections (BSI)
• Peripherally Inserted Central Catheter (PICC) - can be placed into the basilic, cephalic, median cubital or brachial veins, usually above the antecubital fossa with the tip terminating in the lower 1/3 of the superior vena cava (SVC). PICC lines can remain in place for up to 1 year provided that there are no complications. PICCs placement in the SVC provides better hemodilution than shorter peripheral catheters and are therefore indicated for hypotonic, isotonic, hypertonic and vesicant therapy. Some PICCs are engineered to allow additional functions including high pressure injection (up to 300 psi) and central venous pressure (CVP) monitoring. CVP monitoring should be done using a 20 gauge or larger PICC. PICC lines are associated with higher incidence of thrombophebitis probably due to the greater surface contact with venous tunica intima. In the past, PICCs were associated with high incidence of central line associated blood stream infections but that risk is likely diminished due to industry wide implementation of patient safety guidelines including the use of maximum barrier precautions during insertion and new skin prep and dressing techniques.

Peripheral intravenous catheters: Venous access device whose tip resides outside of the superior or inferior vena cava

• Short peripheral catheter - Commonly referred to as an IV catheter, are of two type: winged-steel needles (butterflies or scalp needles) and short over-the needle catheters usually <3 inches in length.
• Midline catheter - Peripheral intravenous catheter which is inserted into the basilic, cephalic, or brachial veins usually above the antecubital fossa with the tip terminating not beyond the axillary vein. Midline catheters offer a longer dwell time and better hemodilution than the short peripheral IV catheters. Midline catheter dwell time is about 1-8 weeks. Midline catheters are appropriate only for delivery of isotonic or near isotonic solutions (250-350 meq/L) solutions with a pH of 5-9 (the same as shorter peripheral IV catheters).
• Midclavicular catheter - Peripheral intravenous catheter which is inserted into the medial cubital or the basilic vein in the upper arm above the antecubital fossa with the tip terminating in the subclavian vein near the center point of the clavicle. Midclavicular placement is not recommended due to increased risk of thrombphebitis. A midclavicular catheter is considered a peripheral catheter and is therefore limited to delivery of isotonic or near isotonic solutions (250-350 meq/L) solutions with a pH of 5-9 (the same as shorter peripheral IV catheters).

Some typical catheter placements are shown below. Identify the insertion points and tip placements of all 3 catheters?