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Venous access is a key component of the treatment strategies that patients receive upon admission to the hospital or other health care facilities. The use of venous access has expanded to outpatient care and ambulatory units. As a result of the general trend from inpatient to outpatient care to reduce health care costs, the use of long-term venous access has increased in the past decades. A wide variety of venous accesses are available ranging from minimally invasive (i.e., peripheral lines) to more invasive and complex methods (i.e., intraosseous and central lines), which can be tunneled, nontunneled, or implantable devices. Each type has specific indications, contraindications, and risks during insertion that need to be weighed against the benefits at the moment of choosing vascular access.1,2
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The first descriptions of intravenous (IV) devices and injections in animals date back to 1663 when Robert Boyle described for the first time the experiments done one decade earlier by Sir Christopher Wren Boyle, who was the first person to extend transfusions from animals to humans in London prisons. Thereafter, several professors and scientists developed principles that presently allow safe interventions in humans, which range from phlebotomy to more complex procedures such as blood transfusion, hemodialysis, and cardiopulmonary bypass.3
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Peripheral access is commonly used for the short-term administration of medications and iso-osmolar solutions. Patients may experience venous sclerosis, infiltration, thrombosis, or the need for other higher osmolar solutions. In these instances, other alternatives for vascular access should be taken into consideration. Arteriovenous fistulas (AVFs) and central venous access are viable alternatives, especially for chronically ill and debilitated patients.
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The main objective of this chapter is to describe the different types of venous accesses and their indications, contraindications, complications, and alternatives for specific patient populations. A brief description of pediatric considerations is also included.
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MOLECULAR PROPERTIES OF VENOUS ACCESSES
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Venous access devices are not innocuous to the host and can induce inflammatory reactions that can lead to thrombosis, phlebitis, and infection. The biomaterial used can elicit a reaction from contact with the immune system and endogenous microflora.3 The ideal IV access should lack immunogenicity (local and systemic) to avoid microbial adhesion and activation of the coagulation cascade.
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Several adverse properties that lead to a higher risk of catheter-related complications have been described elsewhere in the literature, including positively charged surfaces that promote bacterial adhesion and platelet aggregation; hydrophilic catheters that may absorb fluid and change the catheter size and diameter4; and stiffness. which can lead to problems upon insertion or endothelial damage that may induce intravascular coagulation.3
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The most common biomaterials used for the creation of hemodialysis AVFs are polytetrafluoroethylene (PTFE), which induces a chronic fibrosis around the conduit (patency rate, 70%–80% at 3 years)5 and silicone elastometer (Silastic), which is by far the most common ...