When planning parenteral nutrition (PN), the proper choice, insertion, and nursing
of the venous access are of paramount importance. In hospitalized patients, PN can
be delivered through short-term, non-tunneled central venous catheters, through peripherally
inserted central catheters (PICC), or - for limited period of time and with limitation
in the osmolarity and composition of the solution - through peripheral venous access
devices (short cannulas and midline catheters). Home PN usually requires PICCs or
- if planned for an extended or unlimited time - long-term venous access devices (tunneled
catheters and totally implantable ports). The most appropriate site for central venous
access will take into account many factors, including the patient's conditions and
the relative risk of infective and non-infective complications associated with each
site. Ultrasound-guided venepuncture is strongly recommended for access to all central
veins. For parenteral nutrition, the ideal position of the catheter tip is between
the lower third of the superior cava vein and the upper third of the right atrium;
this should preferably be checked during the procedure. Catheter-related bloodstream
infection is an important and still too common complication of parenteral nutrition.
The risk of infection can be reduced by adopting cost-effective, evidence-based interventions
such as proper education and specific training of the staff, an adequate hand washing
policy, proper choices of the type of device and the site of insertion, use of maximal
barrier protection during insertion, use of chlorhexidine as antiseptic prior to insertion
and for disinfecting the exit site thereafter, appropriate policies for the dressing
of the exit site, routine changes of administration sets, and removal of central lines
as soon as they are no longer necessary. Most non-infective complications of central
venous access devices can also be prevented by appropriate, standardized protocols
for line insertion and maintenance. These too depend on appropriate choice of device,
skilled implantation and correct positioning of the catheter, adequate stabilization
of the device (preferably avoiding stitches), and the use of infusion pumps, as well
as adequate policies for flushing and locking lines which are not in use.