Catheter Connection

A multi-center study in critical care

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Many published stud~ ies have documented _ that the incidence of upper extremity DVT is increasing. Of all upper extremity DVTs diagnosed, about 3<1'/0 to 40% are attributed to the presence of some type of central venous catheter. Pulmonary emboli can occur when d,e catheter is removed, but it also may happen during the indwelling time for the catheter, with or without clinical signs and symptoms.

patients found 69 of 208 (33%) patients with catheter-related dlromboses associated with internal jugular and subclavian insened catheters. Diagnosis of the thrombus was made by calor Doppler ultrasound immediately before removal or within 24 hours after catheter removal. None of these patients presented with clinical signs or symptoms of DVT. Repons indicate about 12% of all upper extremity DVfs result in an incidence of a PE. One prospective study of 86 patients had catheter-related upper extremity DVT diagnosed with venography, ultrasound or both. Of these, 13 patients had PE confirmed by a positive lung 5<."n, and of these 13, only 4 had clinical signs and symptoms of PE. When DVT was diagnosed, the patient was started on heparin infusion. Two patients died suddenly within a week after the heparin was begun and massive PE was found on autopsy. Unfonunately this study did not repon when the eve was removed, so no conclusioll5 can be made about whether the

REFERENCES Monreal M, Lafoz E, Ruiz j, Valls R,

A1astrue A. Upper-extremity deep venous

venous thrombosis in a community teaching hospital. Heart & Lung 2000;

thrombosis and pulmonary embolism: A

29(2), 113-117.

prospective study. Chest 1991; 9'X2} 280-

Luciani A, Clement 0, Halimi P, GoudOl D, Portier F, Bassot v, Luciani J, Avan p. Frija G, Bonfils P. Catheter-related upper extremity deep venous thrombosis in cancer patients; A prospective srud

283. Black MD, French G ), Rasuli P, Bouchard AC. Upper extremity deep

venous thrombosis: Under diagnosed and potentially lethal. Chest 1993; 103(6} 1887-1890. Monreal M, Raventos A, Lerrna R, Ruiz J, Lafoz E, Alastrue A,> Uamazares j.

Pulmonary embolism in patients with

upper e:xtremUy DVTassociated to venous central lines - A prospective study. Thrombosis and Haemostasis 1994; 72: 548-550. Stephens MB. Deep venous thrombosis of the upper extremity. American

based on doppler us. Radiology 2001; 220(3} 655-660. Timsit J, Farkas J. Boyer j, Martin], Missit B. Renaud B. Cadet J. Central vein catheter-related thrombosis in intensive care patients; Incidence, risk factors, and relationships with C'J.theter-related sepsis.

Chest 1998; 114(1), 207-214.

Leebeek F, Stadhourders N, Stein D,

Family Physicim, 1997; 55(2} 533-539.

Gomez-Garcia E, Kappers-Klunne M. Hypercoagulability states in upperextremity deep venous thrombosis.

Marinella M, Kathula S, Markert R. Spectrum of upper-extremity deep

Ame--'ricanjournal of Hematology 2001; 67, 15-19.

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risk for a PE is gre'd.ter at removal or during the indwelling of the C'dtheter. The risk of catheter-related DVT and subsequent PE is related to numerous faclOrs. including the catheter's initial tip location, degree of vein trauma during insertion and dwell, and hypercoaguiability of the patient. We tend to think that the risk for PE would be greater during removal of the catheter, but no snldies document this. Based upon the studies that have been published, I believe your nursing staff is currently removing central venous cathelers with clinically silent upper extremity DVT. There also may be patients with small PE that do not produce any signs of respiratoty distress. When lhe palienl has clinical signs and symptoms of upper extremity DVT, there is no clear evidence to suppon the best management technique. Alternatives include catheter removal with no further treatmenC, cad,eter removal with anticoagulant therapy, anticoagulation using the symptomatic catheter, and thrombolytic infusion through the symptomacic catheter. Since che incidence of PE is not limited to those situations with documented evidence of DVT, all nurses removing central venous catheters should be prepared to immediately manage the situation if respiratory distress occurs. Your current practice of removing symptomatic catheters while the patient is in the Radiology Depanment presents challenges. What happens if these symptoms are found when a radiologist is not available in the depanment after regular hours? Your choices could be to have the attending physician remove the catheter at the bedside rather than the nurse or to have the patient wait until the regular working hours of the Radiology Depanment for removal. The diagnostic ultrasound would provide information about the size and location of the DVT prior to catheter removal. I would recommend esublishing a collaborative network including key physicians, vascular access nurses and risk managers to determine necessary changes in your current policies on catheter removal and the

irrunediate actions to take when PE is suspected. Given the fact that PE and many other negative outcomes can be asscx::iated with catheter removal, I would identify the clinical experience required for nurses to accept this task. Should this task be limited to only IV nurses, only nurses with some degree of advanced experience, or will all

Tamie Andersen SEATTLE,

WA

Sarah L. Berg CHESHIRE,

CT

WaIter Bermeo Berrien SPRINGS, MI

nurses in your facility be expected [0 perfonn olis task' Other negative outcomes occurring with removal of central venous catheters include catheter emboli, air emboli, and bleeding. Your policy, procedures, and practice guidelines should include appropriate actions to prevent and manage these complications. I

would recommend additional education and documented competency assessment for the nurses expected to penonn catheter removal, regardless of what experience level is required to perfonn the procedure. Your task force may want to review the references provided when making their final decision.•

Sharon Goulding

Patricia J. Reilly

BI.ACKSTOCK,

ONT"

CANADA

EX TON,

D. Scott Graham GOFFSTO\flN, NH

Marilyn Green PIPE CREEK,

TX

PA

Ana Reyero .>\-IADRID,

SPAIN

Lucie Rissling KELOWNA,

BC, CANADA

Pamala Bisson

Ann Higgins

Mayme Lou Roetting

AJHHERST, NH

HALIFAX, NOVA SCOT/A,CANADA

CHICA GO, IL

DeborahJones

Vivian Rojas

Denise Braxton CINCINNA 1'1, OH

Linda Brickwood LONDON,

ONT.,

CANADA

Patricia Carlson KITCHENER, ONT., CANADA

Patricia Catudal ATTLEBORO, MA

Carol Clint BEL OIl',

WI

SOUTHINGTON,

CT

Mark Kislowski

GARNER,

Laurie Kofstad NASHUA,

NH

Eileen Koza

Glenda Saunders

Josee L'esperance Anna Liang

Carla Conner

Anne Malloy West

Sandra D'Amico VOORHEES,

Nj

Kathleen DiRamio NASHUA, NH

Marek Dobosz TORONTO,

ONT.,

CANADA

Amy Schrieb

BC,

OR

Robert A. Smaglla NASHUA, NH

GA

Donna L. Meyer VICTORIA,

PA

Angie Sims

NH

David H. Metzer KENNESA W,

SPRINGDAlE,

HILLSBORO,

Terri McLaughlin CONCORD,

HUDSON, NH

Keith L. Shoop

ROXBUR Y, MA

Alphonsine Cormier

DURHAM, NC

QUEBEC, CANADA

SAN FRANCISCO, CA

NE1'(1 BRUNSWICK. CANADA

Barbara Sargent

CANADA

BETHLEHEM, PA

FL

NC

FRIDLEY, MN

WATERLOO ONTARIO,

VARENNES,

CA

Lisa W. Sanders

METHUJ::N, MA

Mike ConneUy

TAMPA,

MODJ::STO,

CANADA

Jo Mitchell

Sarah Square BIRMINGHAM, AL

Chris Thomas STRONGSVILlE,

OH

Cindy Voorhis

jARRETTSVILLE, MD

HOL T,

MO

Judy L. Doroski

MicheUe Nelson

Vivian Whitehead

FRANKLIN, MA

jACKSONVILLE, FL

QUEENSBURY, NY

Michael Drafz

Steven F. Parry

Kristen Williamson

SAN DIEGO,

CA

Stanley L. "Van" Ehrhart MJ::MPHIS,

TN

Lisa Gorski MJ::QUON,

WI

SEA TTLE,

WA

PORTA GE, PA

Linda Pittendreigh TORONTO,

ONT.,

CANADA

Deb Yoder GAITHJ::RSURG,

MD

Suzanne Pogson CORDOVA,

TN

Summer

2002

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