A practical guide written from the perspective of an Operating Room Nurse.
The workflows, surgeon preferences, and nursing tips presented in this article are based on the author’s real clinical experience. Surgical techniques and operating room practices may vary depending on the surgeon, hospital, and institutional protocols.
What Is Vascular Access?
Vascular access refers to techniques used to place catheters into the venous system for long-term medication, chemotherapy, parenteral nutrition, hemodialysis, or frequent blood sampling.
Several types of central venous access devices are available, each selected according- to treatment duration, infection risk, and patient condition. The chapter introduces:
- Implanted Port (Port-a-Cath)
- Hickman Catheter
- Non-tunneled Central Venous Catheter (CVC)
- Peripherally Inserted Central Catheter (PICC)
These devices can be inserted through the internal jugular vein, subclavian vein, or peripheral upper-extremity veins depending on the indication.
📌Quick Facts
| Item | Details |
|---|---|
| Specialty | General Surgery / Vascular Surgery / Interventional Procedures |
| Anesthesia | Local anesthesia with sedation or monitored anesthesia care |
| Patient Position | Supine with Trendelenburg position (neck access) |
| Imaging | Ultrasound + Fluoroscopy |
| Main Instruments | Micropuncture set, Guidewire, Dilator, Peel-away sheath, Tunneling rod, Catheter |
Indications
1. Implanted Port
Used for patients requiring:
- Long-term chemotherapy
- Repeated intravenous therapy
- Long-term venous access
The catheter terminates in the superior vena cava while the port reservoir is implanted beneath the skin.
2. Hickman Catheter
A tunneled central venous catheter commonly used for:
- Chemotherapy
- Stem cell transplantation
- Long-term infusion
- Hemodialysis
Its subcutaneous tunnel helps reduce catheter-related infection.
3. Non-Tunneled Central Venous Catheter
Typically used for:
- Emergency vascular access
- Critical care
- Surgery
- ICU management
Usually inserted through the internal jugular or subclavian vein.
4. PICC
A PICC is inserted through the basilic, cephalic, or brachial vein of the upper arm.
Common indications include:
- Long-term antibiotics
- Chemotherapy
- Parenteral nutrition
- Difficult peripheral IV access
Patient Position
Internal Jugular Approach
- Supine
- Trendelenburg position
- Head turned slightly to the opposite side
- Entire neck prepared with sterile technique
Subclavian Approach
- Small roll beneath the shoulders
- Trendelenburg position
- Arms at patient’s side
These positions increase venous filling while reducing the risk of air embolism.
🕒Surgical Workflow
Step 1. Ultrasound-guided Venous Puncture
The target vein is identified using ultrasound.
A micropuncture needle is inserted until venous blood return is obtained.
Step 2. Guidewire Placement
A guidewire is advanced carefully into the superior vena cava.
Fluoroscopy confirms correct positioning.
Step 3. Skin Incision
A small incision is made at the puncture site.
For implanted ports or Hickman catheters, an additional chest incision is created for the port pocket or catheter exit site.
Step 4. Subcutaneous Tunnel
For tunneled catheters:
A tunneling rod creates a subcutaneous tunnel connecting the venous entry site to the chest incision.
The catheter is then pulled through this tunnel.
Step 5. Peel-away Sheath Insertion
The dilator and peel-away sheath are inserted over the guidewire.
After removing the guidewire, the catheter is advanced through the sheath.
Step 6. Peel-away Removal
The sheath is peeled apart while stabilizing the catheter to prevent migration.
Step 7. Catheter Tip Confirmation
Ideal catheter tip location:
- Lower Superior Vena Cava
- Cavoatrial Junction
Fluoroscopy confirms final placement.
Step 8. Port Pocket Creation
For implanted ports:
A subcutaneous pocket is created in the anterior chest wall.
The port chamber is connected to the catheter and secured with sutures.
Step 9. Flushing
The catheter is flushed with:
- Normal saline
- Heparinized saline (when indicated)
Patency is confirmed before closure.
🕒PICC Insertion Workflow
PICC insertion differs slightly from neck or chest approaches.
Typical steps include:
- Ultrasound identification of basilic or cephalic vein
- Peripheral venipuncture
- Guidewire insertion
- Dilator placement
- Peel-away sheath insertion
- Catheter advancement
- Peel-away removal
- Sterile dressing application
- Chest radiograph to confirm catheter tip
The catheter tip should terminate at the cavoatrial junction for optimal function.
Instruments Commonly Used
Access Set
- Micropuncture needle
- Syringe
- Guidewire
Dilatation
- Vessel dilator
- Peel-away sheath
Catheter
- Port catheter
- Hickman catheter
- PICC catheter
Additional Equipment
- Tunneling rod
- Port chamber
- Suture materials
- Heparin syringe
💎Operating Room Pearls
✔ Always confirm venous access using ultrasound before guidewire insertion.
✔ Never advance the guidewire against resistance.
✔ Confirm catheter tip position using fluoroscopy before fixation.
✔ Flush every lumen before completing the procedure.
✔ Prevent catheter contamination throughout the procedure.
⚠️Common Pitfalls
| Problem | Prevention |
|---|---|
| Arterial puncture | Ultrasound guidance |
| Pneumothorax | Proper needle angle and fluoroscopy |
| Catheter malposition | Continuous imaging |
| Catheter kinking | Gentle advancement |
| Infection | Strict sterile technique |
✅30-Second OR Checklist
✅ Ultrasound prepared
✅ Fluoroscopy available
✅ Guidewire confirmed
✅ Peel-away sheath ready
✅ Port flushed
✅ Tip position verified
✅ Dressing applied
Frequently Asked Questions
Why is the Trendelenburg position used?
It enlarges the central veins and reduces the risk of air embolism during venous cannulation.
What is the ideal catheter tip location?
The cavoatrial junction is generally considered the optimal position for central venous catheters.
Why use a tunneled catheter?
The subcutaneous tunnel reduces infection risk and improves catheter stability.
When is a PICC preferred?
PICC is preferred for patients requiring medium- to long-term intravenous therapy without the need for chest implantation.
Conclusion
Central venous access procedures—including implanted ports, Hickman catheters, non-tunneled CVCs, and PICCs—share fundamental principles: safe venous access, accurate guidewire placement, proper catheter positioning, and meticulous sterile technique. Understanding each insertion pathway and the associated equipment helps operating room staff support the procedure efficiently while minimizing complications.