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Focus on Prevention of Vascular Access Device Complications: Prevention is the key for IV Devices
Focus on Prevention
of Vascular Access Device Complications Prevention is the Key for N Devices Nancy Moureau, BSN, eRNI
Calendar of
Upcoming
Events MAVAM UtUnnUdI Confmncl UA Mew DlIWII of Opportunity"
Ortan4o.R device site rotation may be extended for IHn infonMtion call1ll-51-MAVAM Identification and Prevention to 72 hours. As access sites are depleted over time, the temptation is to ith the wide range of vascu- allow the peripheral device to remain lar access devices utilized greater than 72 hours. Complications LatioIais LtMtnhi, "",. within the patient population, develop with peripheral cannula when tI(OftSIII5IS DM ConftIlIKt OIl tilt our goals should be focused on preven- site rotation is ignored. The Center for Saftty of Intrnnous DtIiwry Syshms" tion rather than reactive management of Disease Control's Guideline for PrevenPhonix,AI. complications. This article will provide tion of Intravascular Device-Related for mort information call '1,""Z9Z-ISI~ an overview of vascular access device Infections lists factors associated with (VAD) complications. Progressing from infusion-related phlebitis for peripheral digital veins in the hand to deep central venous catheters as: veins of the chest and neck, we will • Stiffness of the cannula material, Cana4ian Intmnous MunaAssociation Z"" address devices and complications pre- • Catheter size, Annula Conwntion sented at each level. VADs have com- • Site of insertion, Toronto.Can.a mon complications, which if antidpated, • Experience of personnel inserting for mort information call ~16-Z9Z-06l1 the device, may be prevented completely. The first level of venous access is • Duration of catheterization, the peripheral catheter. Inserted in the • Composition of infusate to be deliv2. Careful assessment, selection and veins of the hand, lower arm, antecuered, preparation of the vein chosen can bital region or occasionally the lower • Frequency of dressing change, help to reduce complications. extremities, these peripheral catheters • Catheter-related infection inddence, 3. Use of experienced personnel for insertion, use and maintenance has are the most commonly used devices • Skin preparation, for the administration of intravenous • Host. factors, and been shown to reduce complications. therapy. Short peripheral catheters are • Emergency room insertion. Experienced personnel may be better at identifying appropriate veins, underchosen when therapy is not expected Peripheral catheter preventative standing the type and need for meticuto exceed 5 days. Complications arise when peripheral therapy is extended measures that can be concluded from lous site prep, performing cap prep from a few days to a week or more. this list include: prior to use, acting on patient com1. Following the INS Standards that plaints and symptoms denocing impendAccording to the Intravenous Nurses Society (INS) 1998 Revised Standards state the cannula selected shall be of the ing complications, and performing site of Practice, peripheral cannula inser- smallest gauge and shortest length to rotation on schedule. Experienced pertion sites are to be rotated every 48 accommodate the prescribed therapy... sonnel access with fewer attempts; less hours. If supporting documentation and the vein selected shall accommo- risk of insertion related nerve damage demonstrating few complications is date the gauge and length of cannula and lower overall inddence of complipresent covering at least 3 months, the required by the prescribed therapy. cations. No more than two attempts at
IV Complication
Supplement to the Journal of Vascular Access Devices -
Summer 1999
cannulation per person applies to all continues over time these benefits may complications; some more serious than fall away, since veins used for periph- with the use of short peripheral catheperipherally inserted devices. 4. Complications increase when the eral access are depleted quickly, usually ters. Complications with midline catheduration of peripheral catheterization. within 7 days. The cost of a peripheral ters, such as pWebitis, do not present device will exceed the cost of a longer themselves as readily as those with exceeds 72 hours 5. Monitor the patient closely so that dwell catheter (e.g., midline or periph- short peripheral lines. When undeearly detection of symptoms that indi- erally inserted catheters) within 7-14 tected, these complications can be more cate impending pWebitis, infiltration or days, dependent on number of attempts severe and cause greater tissue damage. infection occurs. Symptoms of pain, and frequency of reqUired insertion site Choosing the appropriate line for the blanching of the skin, redness, or change. If an irritating or prolonged appropriate infusate can prevent chemswelling also indicate the development infusion must be done, a central venous ical pWebitis. Mechanical pWebitis can catheter may be a better choice, both be avoided by using the smallest gauge of a complication. 6. Avoid the infusion of hyperosmo- economically and for reducing the size to accommodate the therapy. Following meticulous insertion procedures, lar (those greater than 500mOsrn/mL, potential for complications. using strict prinCiples of sterility and such as PPN and TPN), irritants (e.g., maximum drapes for these longer dwell vancomycin, dopamine), solutions with Midline or Midclavicular catheters can reduce the incidence of a pH under 5 or greater than 9, or Placed Catheters bacterial pWebitis and infection. vesicants via these peripheral catheters. s we proceed up the arm, With the longer dwell time, midline Many peripheral devices are used to deeper into the peripheral catheters do develop fibrin sheaths, and infuse irritating solutions despite the increased incidence of pWebitis. While - _..... veins of the antecubital fossa various forms of thrombosis with few there is some degree of safety with use and upper arm, midline catheters come symptoms. A thrombus can easily form of peripheral catheters with easy detec- into use. Midline catheters are 3-8 inch at the end of a catheter as a result of tion of problems and frequent rotation, peripheral catheters, terminating in the irritating infusates. When a thrombus complications resulting can be signifi- veins of the proximal portion of the goes undetected the catheter and vessel cant. Any peripheral device infusing extremity and are beneficial due to can become occluded. Complete vessel any of the irritating solutions listed longer dwell time over short peripheral occlusion in the upper arm can impact above may develop complications. The catheters. INS Standards describe the circulation to a greater degree than in question remaining with infusion of midline insertion site as no more than 1- the lower hand and arm. Frequently the these solutions is how long will the 1.5 inches above or below the antecu- only symptom of thrombosis develop- . bital fossa. Optimal dwell time for ment is clear leakage at the site or percomplication take to develop. 7. One of the most important mea- midline catheters has been noted at sistent withdrawal occlusion (PWO) that sures for preventing catheter-related under 4 weeks, 2 to 4 weeks per the occurs when blood return is not infections is site preparation. INS Stan- INS. Complications most commonly achieved upon aspiration. A flap can dards state that a peripheral cannula associated with midline catheters include: form over the end of the catheter preventing blood return and providing an insertion site shall be aseptically • PWebitis, excellent indicator for thrombus develcleansed with an antimicrobial solution • Occlusion/clotting, prior to cannula placement. Approved • Breakage, opment. Early intervention with a thrombolytic can resolve the thrombus antimicrobial solutions include 70% • Leakage at the site, and and prevent complete occlusion. alcohol, 10% poVidone iodine, tincture • Infection. of iodine 2%, and cWOIhexidine. AppliThrombolytics can be used as a locking Prevention of complications related to solution, left overnight and aspirated in cation of alcohol after an iodine solution has a negative effect, as it removes the the use of midline catheters can occur the morning. (Check the manufacturer's residual action of iodine. CWorhexidine with careful patient selection, as with directions.) Refer to the manufacturers has demonstrated action superior to any short peripheral catheters, not delivering information on lumen size, adding 0.2 of the other prepping solutions. While infusates with an osmolarity that to 0.3cc overfill to resolve persistent used at some beta testing sites, the 2% exceeds 500mOsrn/mL and have a pH withdrawal occlusion. cWorhexidine solution is not yet com- of between 5 and 9. Midline catheters Midclavicular lines are inserted in the mercially available in the United States. are frequently misused. Midline cathe- same manner as midlines with a termiOther complications associated with ters are very convenient and usually do nal tip within the chest, usually in the peripheral access include nerve dam- not require x-ray confirmation; how- subclavian vein. X-ray placement check age, arterial access, infiltration, emboli, ever, convenience should not be the for midclavicular catheters is considered and extravasation. only reason that this type of device is optimal but optional, according to the chosen. The concept that whatever 1996 INS Position Papers. Numerous Peripheral cannulae are the most frequently used of all intravenous devices goes into a short peripheral can also articles have been published on because of their ease of insertion, seem- infuse through a midline catheter is a increased risk with midclavicular line ingly low cost supplies and abundant myth. Certainly anything can go placement. In addition to the midline choice of veins. As peripheral therapy through a midline, but not without complications, midclavicular catheter
2
Practical
Access
Central Une Complication
Cause Bacterial growth and access into or onto the central line through hands, skin, infusate, or contaminated syringe/needle. Open lines no end cap, cap falls off, cap on floor placed back on line, dirty hands touching everything. Poor site prep. Contaminated field on insertion, failure to use maximum drapes for cen· tral line insertion.
Hand washing, meticulous site prep on insertion and with dressing changes using approved prepping agents, in the order specified by INS (i.e., alcohol then povidone iodine). Catheters placed in less than sterile fashion should be replaced as soon as medically feasible. Only sterile caps placed on lines, no reuse. Completed infusions require end caps. Prep all injection caps or needleless caps before entry.
Use of small syringes, (e.g., Icc or 3cc), over-stretching of catheters, failure to secure the line, loosening of tape with heat and perspiration,
Use of small size syringes should be avoided due to their ability to produce psi levels in excess of 100 with little force. 5-1 Dcc syringes are to be considered with all central lines, PICCs and midlines. Smaller syringes may be used when absolutely necessary, after line patency has been confirmed. Leakage at the insertion site may indicate a breaklfraeture in the line, confirm by cathetergram to . avoid other complications
Excessive movement by the patient, coughing, vomiting, or accidental pull on catheter.
All central lines require x-ray check to confirm tip placement in the SVC. Patients should receive periodic x-ray confirmation if they experience tinnitis, rushing sounds in the ear, dizziness, feeling of fullness in the head, pain, and numbness or tingling. Cathetergram or venogram may be considered if problem cannot be pinpointed.
Blood, drug precipitates, or Iipids build up in a catheter and completely occlude the flow. Each time blood is withdrawn through a catheter, the risk of occlusion increases. Occlusion can also be due to a tight suture, kinked catheter, clamps, or other mechanical obstructions.
Turbulent positive pressure flushing to clear out catheters, performed on at least a daily basis. Push-pause, push-pause then continue flushing and disconnect or clamp the catheter.
Use clamps for catheter connect and disconnect. Never leave a catheter uncapped. Do not use small sized syringes to flush or administer meds. Secure the catheter well.
Air/Catheter
Catheter lumen left open to air, air flushed into a catheter in large enough quantity to cause venous flow change, or collecting in the heart chamber. Catheter breakage resulting in an embolus. Inappropriate insertion resulting in shearing of catheter and embolization.
Cardiac rupture, tamponade
Catheter malpositioned against the wall of the SVC or the innominate vein. If the catheter is inserted with the terminal tip in the right atrium, erosion through the heart wall can occur if the tip is against the heart wall.
The FDA working group established that central catheters must be confirmed by x-ray imaging, and the tip position should not be allowed to migrate or reside in the heart
Pain, swelling, numbness, tingling, leakage at the site- all caused by increased pressure in the vessel as a clot builds.
Persistent withdrawal occlusion or inability to aspirate blood is the first sign of clot formation with a catheter. Use of thrombolytics, such as urokinase, early will prevent occlusion and thrombosis development. Correct terminal tip placement is also vital for preventing thrombus formation.Any placement in the upper portion of the SVC, innominate or subclavian vein has a much higher incidence of thrombus formation (up to 68%)
Infection
BreakaaeI rupture
MalpositIoning
I) Ocdusion
Emboli,
Thrombosis
D
Prevention
Practical
Access
3
complications include malpositioning and thrombosis (at rates of 58 to 68% in two studies). Subclavian tenninal tip placement is considered suboptimal tip placement and carries a much higher incidence of thrombosis. As a result of the increased risk with midclavicular placement NAVAN published a position statement in the summer 1998 issue of JVAD supporting the use of only superior vena cava placement for VADs placed into the chest. Midclavicular catheters remain very controversial due to their terminal tip location, and its usage is diminishing. Prevention of midclavicular complications would be through utilization of superior vena cava terminal tip placement, changing the catheter into a peripherally inserted central catheter (PICC). Progress into the chest via the peripheral system follows the basilic or cephalic veins into the axillary, the subclavian, then the innominate veins that join to form the superior vena cava (SVC). Optimal central venous catheter tip placement is the lower third, distal portion of the SVC, or as close to the right atrium as you can get without entering it. Peripherally inserted central catheters (PICCs) are central catheters with all the benefits of peripheral catheters, without some of the disadvantages. Dwell time for PICCs is much longer than short peripherals, extending up to one year. Advantages focus on the less serious nature of the complications that occur with PICCs as opposed to other central lines. Vein identification is easier with peripheral access rather than the more risky access into the chest. Peripheral access avoids the risk of pneumothorax, damage to the nerves of the brachial plexus or those in the chest, and infection with lower heat and bacterial growth on the skin of the arms. When considering the risklbenefit ratio with central lines inclusive of PICCs and chest lines, PICC lines clearly have the greatest benefit with the least risk. Disadvantages with PICC lines are frequent occlusions due to the small diameter, risk of breakage, and frequency of phlebitis. Each of these disadvantages can be avoided by: • Using turbulent positive pressure
..
Practical
flushing practice (push-pause, push-pause) technique to avoid blood build up in the catheter. • Instilling thrombolytics upon failure to attain blood return, before complete occlusion of the line. • Considering different types of securement methods, taping practices, or PICC products to avoid breakage and possible embolization of the catheter. • Using the same strict sterile principles and maximum drapes as with midline insertions, slow threading and use of the smallest gauge catheter that will serve the therapy. Central catheters inserted through the chest wall come next as you follow the subclavian and innominate veins to the Svc. These central devices are subcutaneous ports, Hickman, Broviac, Quinton, and Hohn catheters, subclavian, jugular lines, and others. With the exception of subclavian and jugular lines, these central lines are tunneled and used for long term access. Subclavian and Jugular lines are nontunneled, short-term access. Risk is reduced with these nontunneled lines by considering dwell time of a week with good care, 7 t010 days with meticulous care and 14 days with expert care by an IV specialist. Complications occurring with the use of central lines of the chest are shown in Table 1.
Subcutaneously Implanted ports Implanted ports are inserted into the subcutaneous tissue of the chest, arm, or abdomen, and occasionally in the back. Then a catheter is threaded into the SVC, with the other end attached to the port itself. Single and dual septal ports are available with either an open-ended or a closed Groshong catheter ending. Advantages to using ports center on the implanted aspect. According to the Center for Disease Control's Guideline for the Prevention of Intravascular device-Related Infections, implanted ports carry the lowest risk of infection of all central lines placed in the chest area. When not in use, implanted ports are barely visible sitting under the skin. Complications with implanted ports occur if the port becomes movable, flips (changes ori-
Access
entation) under the skin, separates from the silicone catheter tubing, or becomes occluded. An implanted port that is not secured by multiple suture sites, and not sitting on a firm platfo or bone, may become loose an migrate. Difficulty accessing a port with the noncoring (huber) needle can result in infiltration or extravasation of fluid into the surrounding tissues. Confirmation of needle location in the septum, by the presence of blood return, is vital. Blood return is difficult to achieve with many ports due to residual blood and medication build-up, sludge, or fibrin formation in the septurn and catheter components (both intraluminal and extraluminal). Blood return can be maintained through turbulent positive pressure flushing, use of thrombolytics early in the indwelling period, when persistent withdrawal occlusion or sluggishness occurs, and through the use of sludge-free ports (e.g., Vortex Port, Horizon Medical Products). Implanted ports are longterm access devices with an excellent track record and low rates of infection. For implanted ports to become cost effective, and available for long-terrr use without complications, management should be focused on prevention rather than treatment of complications.
Conclusion A very high percentage of patients in the hospital setting receive intravenous therapy in some form. All patients receiving intravenous therapy have vascular access devices in place. Vascular access devices are a necessary part of all care settings. Prevention and knowledge of preventative measures are crucial to reducing the incidence of complications. This overview of vascular access device complications was designed to provide an understanding of the measures that can be taken prior to the onset of complications. Education is a dynamic process. Long-term application of knowledge occurs when that education has been provided to meet a need. As situations occur or when colleagues have questions, refer back to this information to promote " more permanent understanding of th preventative measures for vascular access devices. •
of Vascular Access Device Complications Prevention is the Key for N Devices Nancy Moureau, BSN, eRNI
Calendar of
Upcoming
Events MAVAM UtUnnUdI Confmncl UA Mew DlIWII of Opportunity"
Ortan4o.R device site rotation may be extended for IHn infonMtion call1ll-51-MAVAM Identification and Prevention to 72 hours. As access sites are depleted over time, the temptation is to ith the wide range of vascu- allow the peripheral device to remain lar access devices utilized greater than 72 hours. Complications LatioIais LtMtnhi, "",. within the patient population, develop with peripheral cannula when tI(OftSIII5IS DM ConftIlIKt OIl tilt our goals should be focused on preven- site rotation is ignored. The Center for Saftty of Intrnnous DtIiwry Syshms" tion rather than reactive management of Disease Control's Guideline for PrevenPhonix,AI. complications. This article will provide tion of Intravascular Device-Related for mort information call '1,""Z9Z-ISI~ an overview of vascular access device Infections lists factors associated with (VAD) complications. Progressing from infusion-related phlebitis for peripheral digital veins in the hand to deep central venous catheters as: veins of the chest and neck, we will • Stiffness of the cannula material, Cana4ian Intmnous MunaAssociation Z"" address devices and complications pre- • Catheter size, Annula Conwntion sented at each level. VADs have com- • Site of insertion, Toronto.Can.a mon complications, which if antidpated, • Experience of personnel inserting for mort information call ~16-Z9Z-06l1 the device, may be prevented completely. The first level of venous access is • Duration of catheterization, the peripheral catheter. Inserted in the • Composition of infusate to be deliv2. Careful assessment, selection and veins of the hand, lower arm, antecuered, preparation of the vein chosen can bital region or occasionally the lower • Frequency of dressing change, help to reduce complications. extremities, these peripheral catheters • Catheter-related infection inddence, 3. Use of experienced personnel for insertion, use and maintenance has are the most commonly used devices • Skin preparation, for the administration of intravenous • Host. factors, and been shown to reduce complications. therapy. Short peripheral catheters are • Emergency room insertion. Experienced personnel may be better at identifying appropriate veins, underchosen when therapy is not expected Peripheral catheter preventative standing the type and need for meticuto exceed 5 days. Complications arise when peripheral therapy is extended measures that can be concluded from lous site prep, performing cap prep from a few days to a week or more. this list include: prior to use, acting on patient com1. Following the INS Standards that plaints and symptoms denocing impendAccording to the Intravenous Nurses Society (INS) 1998 Revised Standards state the cannula selected shall be of the ing complications, and performing site of Practice, peripheral cannula inser- smallest gauge and shortest length to rotation on schedule. Experienced pertion sites are to be rotated every 48 accommodate the prescribed therapy... sonnel access with fewer attempts; less hours. If supporting documentation and the vein selected shall accommo- risk of insertion related nerve damage demonstrating few complications is date the gauge and length of cannula and lower overall inddence of complipresent covering at least 3 months, the required by the prescribed therapy. cations. No more than two attempts at
IV Complication
Supplement to the Journal of Vascular Access Devices -
Summer 1999
cannulation per person applies to all continues over time these benefits may complications; some more serious than fall away, since veins used for periph- with the use of short peripheral catheperipherally inserted devices. 4. Complications increase when the eral access are depleted quickly, usually ters. Complications with midline catheduration of peripheral catheterization. within 7 days. The cost of a peripheral ters, such as pWebitis, do not present device will exceed the cost of a longer themselves as readily as those with exceeds 72 hours 5. Monitor the patient closely so that dwell catheter (e.g., midline or periph- short peripheral lines. When undeearly detection of symptoms that indi- erally inserted catheters) within 7-14 tected, these complications can be more cate impending pWebitis, infiltration or days, dependent on number of attempts severe and cause greater tissue damage. infection occurs. Symptoms of pain, and frequency of reqUired insertion site Choosing the appropriate line for the blanching of the skin, redness, or change. If an irritating or prolonged appropriate infusate can prevent chemswelling also indicate the development infusion must be done, a central venous ical pWebitis. Mechanical pWebitis can catheter may be a better choice, both be avoided by using the smallest gauge of a complication. 6. Avoid the infusion of hyperosmo- economically and for reducing the size to accommodate the therapy. Following meticulous insertion procedures, lar (those greater than 500mOsrn/mL, potential for complications. using strict prinCiples of sterility and such as PPN and TPN), irritants (e.g., maximum drapes for these longer dwell vancomycin, dopamine), solutions with Midline or Midclavicular catheters can reduce the incidence of a pH under 5 or greater than 9, or Placed Catheters bacterial pWebitis and infection. vesicants via these peripheral catheters. s we proceed up the arm, With the longer dwell time, midline Many peripheral devices are used to deeper into the peripheral catheters do develop fibrin sheaths, and infuse irritating solutions despite the increased incidence of pWebitis. While - _..... veins of the antecubital fossa various forms of thrombosis with few there is some degree of safety with use and upper arm, midline catheters come symptoms. A thrombus can easily form of peripheral catheters with easy detec- into use. Midline catheters are 3-8 inch at the end of a catheter as a result of tion of problems and frequent rotation, peripheral catheters, terminating in the irritating infusates. When a thrombus complications resulting can be signifi- veins of the proximal portion of the goes undetected the catheter and vessel cant. Any peripheral device infusing extremity and are beneficial due to can become occluded. Complete vessel any of the irritating solutions listed longer dwell time over short peripheral occlusion in the upper arm can impact above may develop complications. The catheters. INS Standards describe the circulation to a greater degree than in question remaining with infusion of midline insertion site as no more than 1- the lower hand and arm. Frequently the these solutions is how long will the 1.5 inches above or below the antecu- only symptom of thrombosis develop- . bital fossa. Optimal dwell time for ment is clear leakage at the site or percomplication take to develop. 7. One of the most important mea- midline catheters has been noted at sistent withdrawal occlusion (PWO) that sures for preventing catheter-related under 4 weeks, 2 to 4 weeks per the occurs when blood return is not infections is site preparation. INS Stan- INS. Complications most commonly achieved upon aspiration. A flap can dards state that a peripheral cannula associated with midline catheters include: form over the end of the catheter preventing blood return and providing an insertion site shall be aseptically • PWebitis, excellent indicator for thrombus develcleansed with an antimicrobial solution • Occlusion/clotting, prior to cannula placement. Approved • Breakage, opment. Early intervention with a thrombolytic can resolve the thrombus antimicrobial solutions include 70% • Leakage at the site, and and prevent complete occlusion. alcohol, 10% poVidone iodine, tincture • Infection. of iodine 2%, and cWOIhexidine. AppliThrombolytics can be used as a locking Prevention of complications related to solution, left overnight and aspirated in cation of alcohol after an iodine solution has a negative effect, as it removes the the use of midline catheters can occur the morning. (Check the manufacturer's residual action of iodine. CWorhexidine with careful patient selection, as with directions.) Refer to the manufacturers has demonstrated action superior to any short peripheral catheters, not delivering information on lumen size, adding 0.2 of the other prepping solutions. While infusates with an osmolarity that to 0.3cc overfill to resolve persistent used at some beta testing sites, the 2% exceeds 500mOsrn/mL and have a pH withdrawal occlusion. cWorhexidine solution is not yet com- of between 5 and 9. Midline catheters Midclavicular lines are inserted in the mercially available in the United States. are frequently misused. Midline cathe- same manner as midlines with a termiOther complications associated with ters are very convenient and usually do nal tip within the chest, usually in the peripheral access include nerve dam- not require x-ray confirmation; how- subclavian vein. X-ray placement check age, arterial access, infiltration, emboli, ever, convenience should not be the for midclavicular catheters is considered and extravasation. only reason that this type of device is optimal but optional, according to the chosen. The concept that whatever 1996 INS Position Papers. Numerous Peripheral cannulae are the most frequently used of all intravenous devices goes into a short peripheral can also articles have been published on because of their ease of insertion, seem- infuse through a midline catheter is a increased risk with midclavicular line ingly low cost supplies and abundant myth. Certainly anything can go placement. In addition to the midline choice of veins. As peripheral therapy through a midline, but not without complications, midclavicular catheter
2
Practical
Access
Central Une Complication
Cause Bacterial growth and access into or onto the central line through hands, skin, infusate, or contaminated syringe/needle. Open lines no end cap, cap falls off, cap on floor placed back on line, dirty hands touching everything. Poor site prep. Contaminated field on insertion, failure to use maximum drapes for cen· tral line insertion.
Hand washing, meticulous site prep on insertion and with dressing changes using approved prepping agents, in the order specified by INS (i.e., alcohol then povidone iodine). Catheters placed in less than sterile fashion should be replaced as soon as medically feasible. Only sterile caps placed on lines, no reuse. Completed infusions require end caps. Prep all injection caps or needleless caps before entry.
Use of small syringes, (e.g., Icc or 3cc), over-stretching of catheters, failure to secure the line, loosening of tape with heat and perspiration,
Use of small size syringes should be avoided due to their ability to produce psi levels in excess of 100 with little force. 5-1 Dcc syringes are to be considered with all central lines, PICCs and midlines. Smaller syringes may be used when absolutely necessary, after line patency has been confirmed. Leakage at the insertion site may indicate a breaklfraeture in the line, confirm by cathetergram to . avoid other complications
Excessive movement by the patient, coughing, vomiting, or accidental pull on catheter.
All central lines require x-ray check to confirm tip placement in the SVC. Patients should receive periodic x-ray confirmation if they experience tinnitis, rushing sounds in the ear, dizziness, feeling of fullness in the head, pain, and numbness or tingling. Cathetergram or venogram may be considered if problem cannot be pinpointed.
Blood, drug precipitates, or Iipids build up in a catheter and completely occlude the flow. Each time blood is withdrawn through a catheter, the risk of occlusion increases. Occlusion can also be due to a tight suture, kinked catheter, clamps, or other mechanical obstructions.
Turbulent positive pressure flushing to clear out catheters, performed on at least a daily basis. Push-pause, push-pause then continue flushing and disconnect or clamp the catheter.
Use clamps for catheter connect and disconnect. Never leave a catheter uncapped. Do not use small sized syringes to flush or administer meds. Secure the catheter well.
Air/Catheter
Catheter lumen left open to air, air flushed into a catheter in large enough quantity to cause venous flow change, or collecting in the heart chamber. Catheter breakage resulting in an embolus. Inappropriate insertion resulting in shearing of catheter and embolization.
Cardiac rupture, tamponade
Catheter malpositioned against the wall of the SVC or the innominate vein. If the catheter is inserted with the terminal tip in the right atrium, erosion through the heart wall can occur if the tip is against the heart wall.
The FDA working group established that central catheters must be confirmed by x-ray imaging, and the tip position should not be allowed to migrate or reside in the heart
Pain, swelling, numbness, tingling, leakage at the site- all caused by increased pressure in the vessel as a clot builds.
Persistent withdrawal occlusion or inability to aspirate blood is the first sign of clot formation with a catheter. Use of thrombolytics, such as urokinase, early will prevent occlusion and thrombosis development. Correct terminal tip placement is also vital for preventing thrombus formation.Any placement in the upper portion of the SVC, innominate or subclavian vein has a much higher incidence of thrombus formation (up to 68%)
Infection
BreakaaeI rupture
MalpositIoning
I) Ocdusion
Emboli,
Thrombosis
D
Prevention
Practical
Access
3
complications include malpositioning and thrombosis (at rates of 58 to 68% in two studies). Subclavian tenninal tip placement is considered suboptimal tip placement and carries a much higher incidence of thrombosis. As a result of the increased risk with midclavicular placement NAVAN published a position statement in the summer 1998 issue of JVAD supporting the use of only superior vena cava placement for VADs placed into the chest. Midclavicular catheters remain very controversial due to their terminal tip location, and its usage is diminishing. Prevention of midclavicular complications would be through utilization of superior vena cava terminal tip placement, changing the catheter into a peripherally inserted central catheter (PICC). Progress into the chest via the peripheral system follows the basilic or cephalic veins into the axillary, the subclavian, then the innominate veins that join to form the superior vena cava (SVC). Optimal central venous catheter tip placement is the lower third, distal portion of the SVC, or as close to the right atrium as you can get without entering it. Peripherally inserted central catheters (PICCs) are central catheters with all the benefits of peripheral catheters, without some of the disadvantages. Dwell time for PICCs is much longer than short peripherals, extending up to one year. Advantages focus on the less serious nature of the complications that occur with PICCs as opposed to other central lines. Vein identification is easier with peripheral access rather than the more risky access into the chest. Peripheral access avoids the risk of pneumothorax, damage to the nerves of the brachial plexus or those in the chest, and infection with lower heat and bacterial growth on the skin of the arms. When considering the risklbenefit ratio with central lines inclusive of PICCs and chest lines, PICC lines clearly have the greatest benefit with the least risk. Disadvantages with PICC lines are frequent occlusions due to the small diameter, risk of breakage, and frequency of phlebitis. Each of these disadvantages can be avoided by: • Using turbulent positive pressure
..
Practical
flushing practice (push-pause, push-pause) technique to avoid blood build up in the catheter. • Instilling thrombolytics upon failure to attain blood return, before complete occlusion of the line. • Considering different types of securement methods, taping practices, or PICC products to avoid breakage and possible embolization of the catheter. • Using the same strict sterile principles and maximum drapes as with midline insertions, slow threading and use of the smallest gauge catheter that will serve the therapy. Central catheters inserted through the chest wall come next as you follow the subclavian and innominate veins to the Svc. These central devices are subcutaneous ports, Hickman, Broviac, Quinton, and Hohn catheters, subclavian, jugular lines, and others. With the exception of subclavian and jugular lines, these central lines are tunneled and used for long term access. Subclavian and Jugular lines are nontunneled, short-term access. Risk is reduced with these nontunneled lines by considering dwell time of a week with good care, 7 t010 days with meticulous care and 14 days with expert care by an IV specialist. Complications occurring with the use of central lines of the chest are shown in Table 1.
Subcutaneously Implanted ports Implanted ports are inserted into the subcutaneous tissue of the chest, arm, or abdomen, and occasionally in the back. Then a catheter is threaded into the SVC, with the other end attached to the port itself. Single and dual septal ports are available with either an open-ended or a closed Groshong catheter ending. Advantages to using ports center on the implanted aspect. According to the Center for Disease Control's Guideline for the Prevention of Intravascular device-Related Infections, implanted ports carry the lowest risk of infection of all central lines placed in the chest area. When not in use, implanted ports are barely visible sitting under the skin. Complications with implanted ports occur if the port becomes movable, flips (changes ori-
Access
entation) under the skin, separates from the silicone catheter tubing, or becomes occluded. An implanted port that is not secured by multiple suture sites, and not sitting on a firm platfo or bone, may become loose an migrate. Difficulty accessing a port with the noncoring (huber) needle can result in infiltration or extravasation of fluid into the surrounding tissues. Confirmation of needle location in the septum, by the presence of blood return, is vital. Blood return is difficult to achieve with many ports due to residual blood and medication build-up, sludge, or fibrin formation in the septurn and catheter components (both intraluminal and extraluminal). Blood return can be maintained through turbulent positive pressure flushing, use of thrombolytics early in the indwelling period, when persistent withdrawal occlusion or sluggishness occurs, and through the use of sludge-free ports (e.g., Vortex Port, Horizon Medical Products). Implanted ports are longterm access devices with an excellent track record and low rates of infection. For implanted ports to become cost effective, and available for long-terrr use without complications, management should be focused on prevention rather than treatment of complications.
Conclusion A very high percentage of patients in the hospital setting receive intravenous therapy in some form. All patients receiving intravenous therapy have vascular access devices in place. Vascular access devices are a necessary part of all care settings. Prevention and knowledge of preventative measures are crucial to reducing the incidence of complications. This overview of vascular access device complications was designed to provide an understanding of the measures that can be taken prior to the onset of complications. Education is a dynamic process. Long-term application of knowledge occurs when that education has been provided to meet a need. As situations occur or when colleagues have questions, refer back to this information to promote " more permanent understanding of th preventative measures for vascular access devices. •