Vascular Access Decision Tree

At least 50% of central lines are unnecessary.

Routine peripheral cannulae (PIVC) replacement is unnecessary.

6 central line air emboli deaths were reported in NSW in the last 2 years. The real incidence is likely much greater, and they’re happening throughout the world. Clusters have also been recognised in Pennsylvania US. All cases are avoidable.

Air emboli represent a fraction of central line adverse events. Sepsis, tamponade, haemorrhage, pneumothoraces, accidental arterial dilation and other sequelae have major impact.

Currently patients may be more likely to die because of a central line than without one. We could reduce central line complications by half through reducing unnecessary insertions.

Many central lines are inserted because:
– we can
– to maintain skills
– concern about criticism for not inserting one
– belief we’ll qbe perceived as ‘better’ critical care doctors
– ‘that’s how we manage these cases’

Unnecessary insertion of central lines needs to become frowned upon much as unnecessary blood administration is today.

We’ll benefit from succinct centralised guidelines – (the MAGIC guidelines, and UKVHP Framework) appear among the best. We should look at improving on these and universal adoption.

Centralised reporting systems will help refine our management.

While waiting for these improvements, ask:

“Does this patient really need a central line or will a less invasive line serve as well?”

We have less invasive methods for fluid responsiveness. Drugs traditionally delivered via central lines may be infused using less invasive means – PICC, CAVAfix, midline, PIVC – an 18 G PIVC has a faster flow rate than all 3 central line lumens combined.

A cultural change in central line management will improve patient safety.

For more information click here.

3 thoughts on “Vascular Access Decision Tree

  1. I only insert a CVL if clinically indicated. Not for practice! Not for remuneration! Not to make my job easier! Always way up the risk benefit ratio.

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