Module 09: Caring for Central Vascular Access Devices (CVAD)

The patient has a tunneled CVAD. When cleaning the exit site, the nurse noticed purulent drainage and redness. The nurse reviewed the patient's medical record and noted he has had a fever for the last 24 hours and today his white blood cell count is elevated. The patient appears less alert, and his urine output is decreased. His medication administration record indicates that he has been receiving parenteral nutrition. What actions should the nurse take? (Select all that apply.) A. Prepare to administer antibiotics if ordered; check allergies. B. Prepare to obtain blood cultures. C. Disregard, because tunneled CVADs are less likely to develop an infection than percutaneous CVADs. D. Obtain x-ray examination. E. Prepare to administer an antidote. F. Notify the health care provider.

A B F The patient has symptoms of a localized and systemic infection. The nurse needs to contact the health care provider for further orders. These may include obtaining blood cultures and administering antibiotics. Removal of the catheter by the health care provider is a possibility. An antidote is inappropriate in this circumstance. An x-ray examination is unnecessary because symptoms of displacement are absent. Even though percutaneous CVADs are at greater risk for developing an infection, these symptoms require intervention. The patient is at increased risk for infection because of immunosuppression from parenteral nutrition.

Choose the supplies the nurse will need to perform a dressing change of a central vascular access device (CVAD). (Select all that apply.) A. Sterile gloves. B. Syringes (10 mL). C. Transparent or gauze dressing (and tape). D. Mask(s). E. Clean gloves. F. Antimicrobial swabs. G. Saline flush.

A C D E F The equipment the nurse will need to perform a dressing change of a central vascular access device includes the following: sterile and clean gloves, antimicrobial swabs, transparent occlusive dressing or sterile gauze dressing/tape, and mask(s).

The nurse is performing a dressing change for a central vascular access device (CVAD). The nurse performs hand hygiene and applies clean gloves and a mask. The nurse removes the old dressing with the nondominant hand pulling in an upward direction, noting drainage and appearance of insertion site. The nurse inspects the catheter and hub for intactness, removes clean gloves, and performs hand hygiene. The nurse opens the dressing kit and applies clean gloves. The nurse cleans the exit site with chlorhexidine gluconate (CHG) swabs using friction in a back-and-forth motion and applies a transparent dressing. The nurse labels the dressing with date, time of dressing change, and initials. The nurse disposes of soiled supplies, removes gloves, performs hand hygiene, and documents the procedure. Which of the following actions made by the nurse require correction? (Select all that apply.) A. The time between swabbing the sit

A C F Clean gloves are worn to remove the old dressing and sterile gloves are worn to clean the site and apply a new dressing. The old dressing should be removed in the direction the catheter was inserted to avoid pulling on the catheter. Cleaning the site in a horizontal plane, then a vertical plane, followed by a circular motion, allows penetration of the antiseptic solution into the cracks and fissures of the epidermal layer of the skin to prevent infection. The nurse should allow the chlorhexidine to remain on the skin for at least 30 seconds, and if povidone-iodine is used, it should be allowed to dry for 2 minutes or longer (allowing to dry completely promotes maximum bactericidal effectiveness and allows new transparent dressing to adhere to skin). To provide a means to determine when the next dressing change is due, the nurse should label with date, time of dressing change, and initials.

1. The nurse is preparing to obtain blood from a CVAD and then change the dressing. Nursing care would be correct if which syringes are used? A. 10-mL syringes. B. 1-mL syringes. C. 60-mL syringes. D. 3-mL syringes.

A Correct Avoid using a syringe less than 10 mL because the psi pressure it exerts is too great. A 60-mL syringe is too large.

The patient puts on the call light and states that his hospital gown feels wet. The nurse determines there is a break in the catheter and it is leaking. What is the initial action the nurse should take? A. Clamp the catheter near insertion site and place sterile gauze over break or hole. B. Notify the health care provider and prepare the patient to return to surgery for placement of a new central vascular access device. C. Have the patient cough and deep breathe; raise patient's arm over head. D. Obtain blood cultures and remove catheter.

A Correct The nurse should first clamp the catheter between the break and the patient (usually near the insertion site) and place sterile gauze over the break or hole until repaired. Although the health care provider will be notified, if the catheter cannot be repaired, it may be removed and a new one inserted. Obtaining blood cultures and removing the catheter would be an intervention for infection at the exit site or for possible sepsis. Having the patient cough and deep breathe and raise his or her arm would be a possible intervention for an occlusion.

1. The nurse is going to change the dressing on a patient's peripherally inserted central catheter (PICC) line when the nurse notices that the patient's arm appears swollen and is cool to the touch. The patient has been receiving IV parenteral nutrition through the PICC line. The patient states that the IV infusion pump has been "beeping" a lot, so he kept pushing the "silence" button on the pump. The nurse suspects extravasation. What actions should the nurse take? (Select all that apply.) A. Obtain blood cultures. B. Notify the health care provider. C. Stop the IV infusion. D. Administer appropriate antidote per protocol. E. Remove the PICC line. F. Scold the patient for touching the infusion pump.

B C D If extravasation occurs, the nurse should first stop the infusion. The nurse may administer the antidote per protocol for the vesicant drug and notify the health care provider. Warm compresses may also be applied to the site and emotional support provided to the patient. The PICC line should remain in place until the health care provider is notified, and then only qualified staff should remove the PICC line if ordered. Blood cultures are unnecessary; they are performed if infection is suspected. The patient may be informed of the purpose of the alarm on the infusion pump; scolding the patient is inappropriate.

1. Identify the uses of a central vascular access device. (Select all that apply.) A. Providing enteral nutrition. B. Obtaining blood samples. C. Infusing blood products. D. Administering chemotherapy. E. Providing parenteral nutrition. F. Reducing the patient's clotting time with repeated heparinization of catheter. G. Infusing medications. H. Administering intravneous (IV) fluids.

B C D E G H Vascular access devices are used to administer IV fluids, chemotherapy, and parenteral nutrition; to infuse medications and blood products; and to obtain blood samples. Enteral nutrition refers to using the gastrointestinal (GI) tract as a pathway for supplemental nutrients, rather than an application of a vascular access device. Although repeated heparinization may reduce the patient's clotting time, this is an unacceptable reason for inserting a vascular access device.

The nurse is going to start a continuous infusion on a patient who has a central vascular access device. The nurse is unable to flush the catheter. What actions should the nurse take? (Select all that apply.) A. Forcefully flush the catheter. B. Attempt to aspirate and flush again; if unsuccessful, notify health care provider. C. Reposition the patient. D. Have the patient cough and deep breathe. E. Flush with a smaller syringe—such as a 1- or 3-mL syringe. F. Make sure the tubing is kink free or unclamped.

B C D F In the case of an occlusion, the nurse can attempt several measures, such as having the patient cough and deep breathe, repositioning the patient, having the patient raise his or her arm, and making sure the tubing is kink free or unclamped. The nurse may then attempt to aspirate and flush the catheter again. If unsuccessful, notify the health care provider. The nurse should never use a syringe smaller than 5 mL because the psi pressure is too great and can damage the catheter or cause catheter migration. The nurse should avoid flushing the catheter forcefully because this could dislodge a thrombus.

A patient has been receiving chemotherapy via a percutaneous CVAD located in the right subclavian vein. The patient is complaining of pain and burning at the insertion site of the CVAD. The nurse notes erythema, edema, and a spongy feeling around the patient's right upper chest and neck area. Which actions would be appropriate for the nurse to take at this time? (Select all that apply.) A. Prepare to obtain electrocardiogram. B. Administer antidote per protocol. C. Stop chemotherapy administration. D. Turn patient onto left side with head down. E. Provide emotional support.

B C E The patient is demonstrating symptoms of extravasation. Appropriate actions of the nurse include immediately stopping the vesicant administration, administering the appropriate antidote per protocol, and applying cold/warm compresses according to specific vesicant protocol. An electrocardiogram would be in order if the CVAD is placed incorrectly, resulting in cardiac dysrhythmias. Turning the patient onto the left side with head down would be appropriate if an air embolism was suspected, not for extravasation.

A nurse informs the nursing assistive personnel (NAP) that the patient is to have a PICC line inserted. Which statement, if made by the NAP, indicates further instruction is needed? A. "I should not assess the blood pressure in the arm with the PICC." B. "The patient will be taken to surgery to have a PICC line inserted by the health care provider." C. "A chest radiograph needs to be taken before a PICC line can be used for the first time." D. "A PICC line can remain in place for several months as long as no complications develop."

B Correct A peripherally inserted central catheter (PICC) line may be inserted by specially trained nurses in the patient's room. The arm in which a PICC or midline catheter (MLC) is in place should be avoided when assessing blood pressure. Placement of a central vascular access device must be verified before use. A PICC line is ideal when the patient requires intermediate-length venous access (from longer than 7 days to several months).

Which action would be appropriate if incorrect placement of a PICC is suspected? A. Provide skin care using aseptic technique. B. Prepare for obtaining x-ray film. C. Slow all fluid administration. D. Administer oxygen as ordered.

B Correct If incorrect placement is suspected, stop all fluid administration until placement is confirmed. Notify the health care provider. Orders may be received to discontinue catheter or obtain x-ray film.

The nurse is changing the dressing over a triple-lumen CVAD and assesses the exit site. Which observation would be cause for concern and should be reported to the health care provider? A. Absence of exudate and swelling at insertion site B. Patient afebrile; redness and tenderness at exit site. C. Clamps are closed on each of the triple lumens D. Dried dark red blood noted on previous dressing

B Correct Redness and tenderness at the site are symptoms of a local infection and should be reported. If the patient had a fever, this may indicate the infection had become systemic as well. A small amount of dried blood is a normal finding and should be cleaned but does not require reporting. When not in use, each port should be clamped. The expected outcome is an absence of symptoms of infection, such as exudate, swelling, or redness at the placement site.

The nurse is sampling blood from an implanted venous port to be followed with a continuous IV infusion. Assuming all other steps are performed correctly, which of the following would require correction? A. Prior to drawing the blood sample, the nurse aspirates and discards 5 mL of fluid into a biohazard container. B. The nurse inserts the noncoring needle through the skin at a 45-degree angle and pushes down firmly until the needle hits the bottom of the portal chamber. C. When connecting the IV, the nurse covers the secured noncoring needle and insertion site with a transparent dressing and connects the primed IV infusion tubing, regulating the rate as ordered. D. When cleaning over the port septum, the nurse swabs the insertion site in a horizontal plane, then a vertical plane, followed by a circular motion from the middle outward.

B Correct The noncoring needle should be inserted at a 90-degree angle. All other steps are correct.

Identify possible complications of a PICC. (Select all that apply.) A. Immunosuppression. B. Sepsis. C. Fat embolism. D. Thrombosis. E. Air embolism. F. Phlebitis. G. Occlusion.

B D E F G Potential complications of a PICC include air embolism, thrombosis, occlusion, infection (systemic or local), phlebitis, and catheter migration. A fat embolism is unlikely. Immunosuppression may occur because of the administration of chemotherapy but fails to be a result of the insertion of a PICC.

The student nurse is going to flush a triple-lumen central line. The student nurse prepares three 3-mL syringes with normal saline and three 3-mL syringes with heparin flush solution. Another student nurse states that this is unacceptable for flushing a CVAD. Which statement is the correct rationale for this student's objection? A. "It is unnecessary to flush all three ports; flushing the distal port is adequate." B. "Heparin flush solution should not be used on a CVAD because it could cause coagulation problems in the patient." C. "A 3-mL syringe is unacceptable for flushing a CVAD because it exerts too high a psi pressure." D. "A 3-mL syringe is unacceptable for flushing a CVAD because it fails to hold an adequate volume of solution to clear the line completely."

C Correct A 3-mL syringe is unacceptable for flushing a CVAD because it the psi pressure it exerts is too great and could damage the catheter. Avoid using a syringe less than 10 mL. Heparin flush solution is acceptable to flush a CVAD to prevent clot formation in the catheter. Follow agency protocol. To maintain patency, all three ports should be flushed.

The nurse is sampling blood from a central vascular access device to be followed with a continuous IV infusion. Assuming all other steps are performed correctly, which of the following would require correction? A. The nurse cleans the hub with antiseptic solution and allows it to dry before attaching the syringe to obtain the blood sample. B. Prior to obtaining a blood sample, the nurse uses a 10 mL syringe to flush the port with 3 to 5 mL of preservative-free 0.9% normal saline. C. The nurse wipes the catheter hub with an antiseptic swab and withdraws 4 to 5 mL blood from the catheter, discarding it in trash. D. After connecting the primed IV tubing to the end of catheter, the nurse releases the clamp and regulates the IV infusion as ordered.

C Correct For antisepsis, the antiseptic solution should be allowed to dry completely. The CVAD should be clamped whenever entering or exiting the port with a syringe if it is unknown whether the CVAD is valved or not. Open and valved CVADs differ in recommendations for clamping before removal of injection cap and syringe(s) (e.g., Hickman versus Groshong). Also, the discard sample should be disposed of in a biohazard container, not the trash.

A patient with a CVAD suddenly develops dyspnea, tachycardia, and hypotension. Into which position should the nurse place the patient? A. Trendelenburg. B. Lying flat on right side. C. On left side with head down. D. High-Fowler's.

C Correct If an air embolism is suspected, place patient on left side with head down. This will help keep the air trapped in the right atrium so that it will not move in to the pulmonary circulation or the right side of the heart.

Which nursing intervention would be appropriate if the IV of a CVAD is not infusing properly and an occlusion is suspected? A. Use force in a pulsating manner to flush the catheter. B. Kink the catheter tubing and then quickly release. C. Have the patient deep breathe and cough. D. Flush before and after medication administration; avoid flushing between medications.

C Correct In the case of a possible occlusion, reposition the patient, have the patient cough and deep breathe, and raise the patient's arm over head. If the situation does not improve with these interventions, the health care provider may order a thrombolytic or solution to dissolve a precipitate. Avoid kinking the catheter to prevent occlusion. Do not flush against resistance. This could dislodge a thrombus or damage the catheter. To avoid precipitate formation, flush between medications also.

The nurse is preparing to administer continuous fluids through a central venous catheter, leaving the injection caps in place. Which step in the procedure requires correction? A. Perform hand hygiene; apply gloves and mask(s). Prepare a syringe with 10 mL normal saline. B. Use chlorhexidine and/or alcohol preparation swabs to cleanse injection cap. Insert needleless access device of syringe containing 10 mL normal saline, unclamp, and flush. C. Flush with 10 mL heparin flush solution and clamp. Regulate IV infusion. Dispose of soiled equipment. Remove gloves and document. D. Reclamp. Connect IV tubing to injection cap of catheter using needleless access device. (IV tubing should already be flushed with IV fluid.) Tape tubing connections.

C Correct It is unnecessary to flush with heparin because continuous fluids are going to be administered. It would be necessary to unclamp the port before regulating the IV infusion. Hand hygiene should be performed after removing gloves.

A student nurse is observing a staff nurse care for a CVAD. The student nurse asks why a large central vein is necessary for a CVAD. What is the best response by the nurse? A. "The large vessel lumen is less likely to develop clot formation than a small vein." B. "It is necessary to prevent the vein from collapsing when the catheter is inserted." C. "The large vessel lumen minimizes the risks of vessel irritation, inflammation, or sclerosis." D. "It has to be large enough for the catheter to fit."

C Correct The large vessel lumen minimizes the risk of complications related to vessel irritation, inflammation, or sclerosis.

What complication could occur if the nurse fails to clamp the catheter when the injection cap is removed on a CVAD? A. Hemorrhage from excessive heparin. B. Occlusion. C. Air embolus. D. Infection.

C Correct The nurse should clamp the catheter if the injection cap is removed, to prevent the entrance of air.

The nurse is unable to aspirate a blood return from the distal port of a triple-lumen CVAD and suspects an occlusion. What should the nurse do first? A. Insert a 10-mL syringe of preservative-free sterile normal saline and attempt to flush and aspirate rapidly and repeatedly. B. Attach a label to the port indicating it is occluded, and use a different port of the triple- lumen CVAD. C. Reposition the patient and have her raise her hand above her head; reattempt. D. Use a smaller syringe and attempt again.

C Correct The nurse should first reposition the patient, have her take a deep breath and cough, and/or have her raise her hand above her head then reattempt. A syringe smaller than 10 mL should not be used because this could damage the catheter as a result of the high psi. Rapidly and repeatedly flushing and aspirating could cause dislodgment of a thrombus. The nurse should first attempt measures to improve patency of the port before determining it is no longer able to be used. The health care provider may order an antithrombolytic if these measures are unsuccessful.

The nurse is reviewing the sequence for performing a dressing change on a vascular access device. Which statement, by the nurse, indicates further instruction is needed? A. "I will wear sterile gloves to clean and apply the new dressing." B. "I should allow the antiseptic to dry completely before applying the transparent dressing." C. "I should avoid touching the Dacron cuff in a subcutaneous tunnel because this may cause dislodgement." D. "I will wear clean gloves to remove the previous dressing, and I will remove it in the direction the catheter was inserted."

C Correct The nurse should palpate the Dacron cuff in the subcutaneous tunnel to determine if it is stable and in the anticipated location and that there are no signs of infection such as tenderness or warmth at the site.

1. Which nursing diagnosis would be of most importance related to the insertion of a central vascular access device? A. Risk for fluid volume deficit. B. Self-care deficit. C. Potential for infection. D. Fluid volume excess.

C Correct The priority nursing diagnosis would be potential for infection. Aseptic technique is used when inserting and providing care of a CVAD.

A patient is to begin chemotherapy and there is discussion regarding placement of a CVAD. Which statement requires correction? A. The tunneled CVAD and implanted venous port are considered permanent. B. Implanted venous ports should be flushed monthly with heparin solution or 0.9% normal saline to maintain patency. C. Medications that have a high osmolality can be administered through a CVAD. D. An implanted venous port and a percutaneous CVAD require surgical placement.

D An implanted infusion port and a external tunneled CVAD require surgical placement. A percutaneous CVAD may be inserted at the patient's bedside. All other statements are true. An advantage of a multi-lumen CVAD is that it may be used to infuse incompatible solutions or medications and those with a high osmolality.

What is the primary advantage of a central vascular access device over the use of a peripheral IV? A. Sepsis is less likely to develop. B. It is unaffected by movement. C. Sterile technique is unnecessary. D. It can remain in place longer. E. There is an increased likelihood of extravasation.

D Correct A CVAD can remain in place for a longer period; therefore the patient is able to receive long-term therapy with repeated access to the venous system without frequent venipuncture.

1. How frequently should a transparent semipermeable membrane dressing be changed? A. Every 3 days and as needed. B. Every 2 days and as needed. C. Every 24 hours and as needed. D. Every 5 to 7 days and as needed.

D Correct A sterile gauze dressing should be changed every 2 days and as needed. A transparent semipermeable membrane (TSM) dressing may be changed every 5 to 7 days and as needed.

A patient with a CVAD has a suspected local or systemic infection. Which of the following actions would the nurse expect to perform at this time? A. The nurse will flush the CVAD with 10 mL of normal saline, aspirate 5 mL of blood and discard, aspirate another 5 mL of blood with a second syringe and send to the lab, and flush the port with another 10 mL of normal saline. B. The nurse will perform a dressing change using strict aseptic technique and assess the catheter exit site for exudate. C. The nurse will notify the health care provider of the patient's elevated temperature and white blood cell count and prepare to administer antibiotics immediately. D. The nurse clamps the port, inserts a syringe, unclamps, and aspirates 5 mL of blood and sends it to the lab in a biohazard bag. The nurse flushes the port with 10 mL of normal saline and leaves the port clamped.

D Correct Blood cultures are often obtained both peripherally and from the vascular access device in the occurrence of a local or systemic infection. Do not flush before drawing blood for blood cultures. If blood cultures have been ordered, do not discard any blood. Use initial specimen for blood cultures. Blood cultures should be obtained before the initiation of antibiotic therapy. Changing the dressing using aseptic technique is a preventive measure but not an appropriate intervention at this time.

If the patient has a triple-lumen catheter, from which port should you draw blood? A. Middle port. B. Proximal port. C. Peripheral port. D. Distal port.

D Correct If a central vascular access device (CVAD) has more than one lumen, blood specimens should be obtained from the distal lumen or per manufacturer's recommendation. The distal lumen typically is the largest-gauge lumen (Phillips and Gorski, 2014). The middle port is used for central venous pressure monitoring or intravneous (IV) infusions.

The patient asks the nurse how frequently the dressing will have to be changed over his central vascular access device. What is the correct response by the nurse? A. "The dressing only needs to be changed if it becomes loose, soiled, or damp." B. "The dressing will be changed every 3 days or when the health care provider orders." C. "When the initial dressing is removed, it will be replaced with a large Band-Aid." D. "The dressing of a central vascular access device should be changed when loose, soiled, or damp, but at least every 7 days since it is a transparent occlusive dressing." E. "The dressing of a vascular access device should be changed when loose, soiled, or damp, but at least every 24 hours since it is a gauze dressing."

D Correct The dressing of a vascular access device should be changed when loose, soiled, or damp, but at least every 48 hours if it is gauze dressing and every 7 days if it is a transparent occlusive dressing. Band-Aids should not be used because they are not occlusive and thereby increase the risk for infection at the insertion site of the catheter.

What is the purpose of the heparin flush solution in regard to care of a vascular access device? A. To reduce the incidence of clot formation at the exit site. B. To prevent precipitate formation when medications are administered. C. To prevent development of a system-wide infection. D. To maintain patency by reducing the incidence of clot formation.

D Correct The heparin flush solution is used to prevent clot formation at the catheter tip and thus prevent occlusion. The primary concern at the exit site is the development of infection. Incompatibility of medications results in precipitate formation. The catheter should be flushed well with normal saline before and after medication administration. Heparin prevents clot formation. A thrombolytic such as streptokinase may be ordered to dissolve a clot.

Because the patient's central vascular access device is used intermittently for fluid administration, the nurse flushes the infusion port with a 3-mL syringe filled with heparin flush solution to maintain patency. What action made by the nurse was incorrect? A. The nurse should have flushed the catheter with 2 mL of heparin flush solution instead of 3 mL. B. The nurse should always flush the CVAD with normal saline instead of heparin flush solution. C. The nurse flushed the catheter correctly. D. The nurse used a 3-mL syringe during the catheter flushing.

D Correct The nurse should avoid using a syringe less than 10 mL to minimize pressure during injection. A 3-mL syringe exerts too much psi pressure. If continuous infusion is not indicated, the nurse should heparinize the port to prevent thrombus formation by flushing with 5 mL heparin (100 units per mL or institution policy).

Which of the following patients may benefit from a long-term vascular access device? (Select all that apply.) A. A patient who is expected to require intravenous (IV) antibiotics for more than 7 days for a severe respiratory infection. B. A patient who will be managed at home for end-stage cancer with a continuous infusion of opioids for pain. C. A patient who is having major abdominal surgery and will require TPN administration. D. A patient who requires frequent long-term phlebotomy (blood draws) in the treatment of polycythemia. E. A pregnant patient with severe nausea and vomiting requiring fluid replacement therapy. F. A child undergoing surgery for a tonsillectomy.

A B C D Indications for a vascular access device include IV therapy anticipated for longer than 7 days, including transfusions, total parenteral nutrition (TPN) administration, long-term antibiotics, or continuous infusions such as opioids; infusion of vesicants or irritants, such as in chemotherapy; poor peripheral venous circulation; and frequent long-term phlebotomy. A child undergoing tonsillectomy, and a pregnant woman with nausea and vomiting would most likely only require short-term IV therapy, and therefore a long-term vascular access device would be unnecessary.

Choose the characteristics of a tunneled central vascular access device (CVAD). (Select all that apply.) A. May be single, double, or triple lumen. B. Inserted surgically with the patient in the operating room. C. Held in place with a Dacron cuff. D. Lower risk of infection than a nontunneled CVAD. E. Inserted through a large vein in the antecubital fossa and threaded into the tip of the superior vena cava. F. Inserted directly into a large vein. G. Catheter tip lies in the superior vena cava. H. May be inserted by a specially trained nurse. I. Catheter tip lies in the larger vessels of the upper arm. J. Inserted through subcutaneous tissue between the clavicle and nipple, then into a large vein, and threaded into the superior vena cava.

A B C D G J A tunneled central vascular access device is inserted by a health care provider with the patient in the operating room under local anesthesia. It is inserted through the subcutaneous tissue and then into a large vein and threaded into the superior vena cava. It is held in place by a Dacron cuff under the skin of the chest wall. Because the subcutaneous tunnel creates space between the end of the catheter and the actual vein, the risk of infection is lower. The catheter tip lies in the superior vena cava. These catheters have single, double, or triple lumens that allow simultaneous administration of several infusions. A percutaneous central venous catheter is inserted directly into a large vein. A peripherally inserted centra catheter (PICC) line is inserted through a large vein in the antecubital fossa and threaded into the tip of the superior vena cava. A PICC line may be inserted by a specially trained nurse. The catheter tip of a midline catheter (MLC) lies in the larger vessels of the upper arm.