CRNI Vascular Access Device Management 2 — Questions and Answers

Question 1: What is the recommended method for securing a peripheral IV catheter to prevent dislodgement?

Standard adhesive tape in a chevron pattern
Manufactured catheter stabilization device (engineered stabilization device) (Correct answer)
Sutures at the insertion site
Elastic bandage wrapped around the extremity

Correct answer: Manufactured catheter stabilization device (engineered stabilization device)

INS standards recommend manufactured engineered stabilization devices (ESDs) over tape to reduce catheter movement, decrease phlebitis, and prevent unplanned dislodgement.

Engineered stabilization devices (ESDs) such as StatLock or similar products are recommended by INS over traditional tape and sutures for peripheral IV catheter securement. ESDs provide consistent, reliable stabilization that reduces catheter movement (pistoning) within the vein, thereby decreasing mechanical phlebitis, infiltration, and unplanned catheter dislodgement. Studies show ESDs reduce complication rates by 40-70% compared to tape. Sutures are no longer recommended for peripheral IVs due to needlestick risk and potential for bacterial colonization at suture sites. The ESD should be applied according to manufacturer instructions, with the insertion site visible for assessment, and changed with each dressing change.

Question 2: When performing PICC tip confirmation, what landmark indicates proper placement on a chest X-ray?

Above the clavicle in the subclavian vein
Lower third of the SVC at or near the caval-atrial junction (Correct answer)
In the right atrium
At the level of the aortic arch

Correct answer: Lower third of the SVC at or near the caval-atrial junction

The ideal PICC tip position is in the lower third of the SVC at or near the caval-atrial junction, confirmed by chest X-ray before initiating infusion therapy.

PICC tip placement in the lower third of the SVC at or near the caval-atrial junction (CAJ) is the evidence-based standard supported by INS, AVA, and MAGIC guidelines. This position provides: optimal hemodilution of infusates (high SVC flow approximately 2 L/min), reduced thrombosis risk compared to higher SVC or brachiocephalic vein placement, and avoidance of cardiac complications (arrhythmias, perforation) associated with right atrial placement. On chest X-ray, the CAJ corresponds approximately to the right tracheobronchial angle or 2 vertebral bodies below the carina. ECG-guided tip placement (detecting the P-wave changes as the catheter approaches the sinoatrial node) is increasingly used for real-time confirmation during insertion.

Question 3: What is the correct procedure for accessing an implanted port?

Use any available gauge needle through the skin over the port
Palpate the port, cleanse with CHG, access with a non-coring (Huber) needle using sterile technique (Correct answer)
Access can be performed without skin antisepsis if the port was recently flushed
Use a standard hypodermic needle to access the port membrane

Correct answer: Palpate the port, cleanse with CHG, access with a non-coring (Huber) needle using sterile technique

Port access requires aseptic technique, CHG skin antisepsis, and a non-coring Huber needle to prevent damage to the port septum.

Implanted port access requires meticulous technique: 1) Palpate the port to identify the septum edges; 2) Cleanse the skin with CHG greater than 0.5% in alcohol using a 30-second scrub and allow to dry; 3) Don sterile gloves; 4) Stabilize the port between thumb and forefinger; 5) Access with a non-coring (Huber) needle perpendicular to the septum until the needle contacts the back wall of the portal chamber; 6) Confirm patency by aspirating blood return; 7) Flush with normal saline; 8) Apply a sterile dressing. Standard hypodermic needles core the silicone septum, creating a permanent channel that leads to leakage and premature port failure. Huber needles have a deflected point that parts the silicone rather than coring it, allowing the septum to reseal (rated for approximately 2000 accesses).

Question 4: How should the CRNI manage a central venous catheter with a suspected partial occlusion?

Forcefully flush with a 3 mL syringe to clear the occlusion
Use a gentle push-pull technique with a 10 mL syringe; if unsuccessful, instill alteplase per protocol (Correct answer)
Remove the catheter and insert a new one
Increase the infusion rate to push through the occlusion

Correct answer: Use a gentle push-pull technique with a 10 mL syringe; if unsuccessful, instill alteplase per protocol

Partial CVC occlusion should be managed with gentle flushing technique using an appropriate syringe size, followed by thrombolytic instillation if mechanical methods fail.

Managing partial CVC occlusion follows a stepwise approach: 1) Assess for positional causes (reposition patient/arm); 2) Attempt gentle flushing with a 10 mL or larger syringe using push-pull technique - NEVER use syringes smaller than 10 mL on central lines as they generate excessive PSI that can rupture the catheter; 3) If mechanical clearance fails, instill alteplase (CathFlo Activase) 2 mg in 2 mL per institutional protocol, dwell 30-120 minutes, then attempt aspiration; 4) If alteplase fails, a second dose may be tried; 5) Consult interventional radiology for fluoroscopic evaluation if pharmacological clearance fails. The CRNI should also assess for drug precipitate occlusion (treat with HCl for alkaline precipitates or NaHCO3 for acidic precipitates) versus thrombotic occlusion (treat with alteplase).

Question 5: What is the rationale for using ultrasound guidance during PICC insertion?

It is required by law for all PICC insertions
It improves vein visualization, increases first-attempt success, reduces complications, and aids in vein-to-catheter ratio assessment (Correct answer)
It is only helpful for obese patients
It replaces the need for chest X-ray tip confirmation

Correct answer: It improves vein visualization, increases first-attempt success, reduces complications, and aids in vein-to-catheter ratio assessment

Ultrasound guidance provides real-time vein visualization, enabling optimal vein selection, improved first-attempt success, and reduced mechanical complications during PICC insertion.

Ultrasound guidance has become the standard of care for PICC insertion, providing multiple benefits: real-time vein visualization for optimal site selection; assessment of vein diameter to ensure appropriate catheter-to-vein ratio (less than 45%); identification of anatomical variations, thrombosis, or stenosis before insertion; improved first-attempt success rates (over 95% vs approximately 75% without US); reduced number of attempts and associated patient discomfort; decreased mechanical complications (nerve injury, arterial puncture, hematoma); and real-time needle guidance during venipuncture. While it does not replace chest X-ray for tip confirmation (unless combined with ECG guidance or intracavitary ECG), it significantly improves the safety and efficiency of the insertion procedure.

Question 6: What is the CRNI's responsibility regarding midline catheter tip position?

Midline catheter tips should be in the SVC like PICCs
Midline catheter tips must remain in the peripheral vasculature, with the tip at or below the axillary vein level (Correct answer)
Midline catheters do not require tip verification
Midline catheter tips should be in the subclavian vein

Correct answer: Midline catheter tips must remain in the peripheral vasculature, with the tip at or below the axillary vein level

Midline catheters are peripheral devices with tips that must remain in the upper arm vasculature at or below the axillary vein level - they are NOT central venous access devices.

Midline catheters (8-20 cm length) are peripheral vascular access devices with tips positioned in the upper arm vasculature - typically in the basilic, brachial, or cephalic vein at or below the axillary vein level. They must NOT advance into the central vasculature (subclavian vein, brachiocephalic vein, or SVC). This distinction is critical because midlines cannot be used for: solutions with osmolality greater than 900 mOsm/L, continuous vesicant chemotherapy, parenteral nutrition, or solutions with extreme pH. If a midline tip migrates centrally, it becomes a functionally misplaced device requiring repositioning or replacement. The CRNI should verify tip position, document the external catheter length at insertion, and monitor for changes suggesting migration.

CRNI Vascular Access Device Management 2

What is the recommended method for securing a peripheral IV catheter to prevent dislodgement?