Venous access: "What's it to you?".

Venous access has dramatically increased in importance over the last two decades and will be expected to remain an important component in the delivery of healthcare. The primary areas of healthcare that increasingly rely on venous access include hemodialysis, oncology for the administration of antineoplastic agents, infectious diseases for the provision of extended antibiotic courses, and multiple specialties that depend on the use of parenteral nutrient support. It is to be expected that as the sophistication of medicine progresses, reliance on methods of providing vascular access will continue to carry great importance while simultaneously serving as an Achilles’ heel to medical practice. This latter characteristic results from the rising prevalence of patients suffering from chronic conditions who require intensive or long-term parenteral services and exhibit access site “exhaustion.” Consequently, access site preservation should be a constant concern attendant to the placement of venous access devices. The importance of venous access is exemplified in the very extensive review provided by Vanek 1 in Part 1 in this issue and Part 2 in the June issue of NCP. The financial impact of this area alone amounts to well over a billion dollars annually when the collateral relationship that venous access has with other specialties and healthcare providers, including specialized nursing, radiology, surgery for the implantation, and care and long-term maintenance of these vascular access devices is considered. The current review provides a broad and detailed description of venous access including anatomical considerations and device options and their associated complications. Furthermore, the author tailors his presentation to the timeline required for venous access use (short-term versus long-term access) and to the specific therapeutic goals desired in various patient populations. Possibly, the most important aspect of his review is the emphasis that Vanek 1 places on complications associated with the various techniques used to gain vascular access. In this regard, catheter-related sepsis and venous thrombosis probably remain the most serious and challenging complications of venous access devices in clinical practice. Intravascular catheter-related infections are a major cause of morbidity and mortality in the United States. These infections result in substantially increased hospital costs, duration of hospitalization, and patient morbidity. The major risk factors, which influence development of infection, include patient-significant factors, site of catheter placement, associated connections of these devices, and pathogenicity of various microorganisms. For example, the mortality attributed to catheter-related Staphylococcus aureus bacteremia (8.2%) substantially exceeds the mortality attributed to coagulase-negative staphylococcal catheter-related bacteremia (0.7%). 2 Identification of these various factors and establishment of guidelines for the definition of catheter-related bloodstream infections has resulted in increased research efforts designed to reduce the incidence of these complications. Results of these efforts include protocols for the prevention of catheter-related infections during placement and algorithms for the management of these infections when they occur. 3 Additionally,