Tools of the Trade
Central Venous Access Devices:
How to Manage Complications
By Tiffani Klein, RN
While there are some risks associated with central venous access devices (CVAD), the benefits far outweigh the associated risks and the bedside nurse needs to arm herself with knowledge to dodge any potential risks. To improve comprehension of what can go wrong and how to handle the situation, an introduction to the basic types of CVADs is provided in the accompanying Table.
Before using any of these devices, a chest X-ray must be performed to ensure proper tip placement. Optimum placement is the mid proximal third of the superior vena cava (SVC). If the tip is in the upper portion of the SVC, a thrombus can develop due to irritation of the vein wall. If the tip is in the lower portion of the SVC, cardiac dysrhythmias can develop.
Sepsis, air embolism and venous thrombosis are the three most critical complications that can occur with CVADs. That's why having the appropriate knowledge is so important to prevent any problems.
Sepsis, which occurs when bacteria enter the bloodstream at the insertion site, is the most common complication and can be fatal. Some risk factors include:
* Poor insertion technique: A sterile field must be maintained at all times. The skin must be prepared adequately before insertion. Alcohol is used first to remove Staphylococcus epidermidis followed by povidone-iodine to remove Candida.
* Dressing changes: A transparent dressing is the optimum choice allowing for visualization of the insertion site. Change this dressing every seven to 10 days if it remains clean, dry and intact. If gauze dressing is utilized, change this dressing every 24 hours. Sterile technique must be maintained during all dressing changes.
* Jugular or femoral insertion sites: These sites are difficult to maintain a clean, dry and occlusive dressing. Both locations contain copious amounts of bacteria.
Assess the insertion site daily. Signs and symptoms include redness and tenderness with possible purulent drainage. Fever spikes, changes in vital signs and malaise may be observed. Some patients may be asymptomatic due to immunosuppression or leukopenia.
Should any of the aforementioned symptoms develop, culture the catheter. Aspirate 10 mL of blood through the CVAD and another 10 mL of blood through a peripheral site. If you discontinue the CVAD, place the tip in a sterile container to be forwarded to the lab. A physician may order the catheter to be removed and restarted elsewhere.
Another critical risk is air embolism, occurring when an air bolus enters the bloodstream and travels to the lungs, heart or brain, inducing brain damage or death. This risk is increased during insertion or discontinuation of a CVAD and cap or tubing changes. Changes in the intrathoracic pressure such as coughing, sneezing, laughing or a deep breath can result in an air embolism whenever there is a break in the system above the level of the heart.
Signs and symptoms include respiratory distress, increased heart rate with a thready pulse, cyanosis, hypotension or changes in the LOC. Upon auscultation, you may hear a churning murmur over the precordium. The patient may be pale and anxious and complain of chest or shoulder pain. This is an emergency, and you need to know what to do.
First, clamp the catheter with a hemostat or pinch it at the proximal end to prevent additional air entry. Second, turn the patient onto the left side and place in Trendelenburg position, allowing air to collect in the right atrium, and preventing obstruction of blood flow to the right ventricle and the lungs. Third, have a colleague call the doctor, respiratory stat and obtain the crash cart. Fourth, administer oxygen nasal cannula, start a peripheral line, and attach patient to the portable cardiac monitor and pulse oximeter. In this case, the physician may order 100 percent oxygen via facemask and an ECG, as well as aspirate the air with an intracardiac needle.
How can this risk be decreased?
During catheter insertion, discontinuation or when changing caps and tubings, have the patient lie flat and perform the Valsalva maneuver to increase intrathoracic pressure. Upon discontinuation of the catheter, use a gel-based ointment to shield the insertion site. Dress the site with an occlusive dressing and assess every 24 hours. Once a scab has formed, the site is effectively sealed. Consider using self-capping claves, infusion pumps that indicate "air in line," or air-eliminating filters.
The final complication, venous thrombosis, occurs as a result of injury to the inner layer of the vein. The body responds with an increase in platelets and fibrin, resulting in clot formation.
Signs and symptoms to look for include edema in the affected extremity as early as 48-72 hours post-insertion. Edema develops because the clot is blocking blood flow back to the heart. Intravenous solutions will not infuse with gravity or the pump may indicate an occlusion. If timely intervention is not initiated, the edema will ascend into the chest and neck. If the thrombus is obstructing blood return from the head, you will observe a flushed and edematous face. What should you do?
Stop the infusion and notify the physician. Anticoagulants will most likely be utilized after a venous scan confirms thrombus formation. Thrombolytic therapy may be required. It is recommended to leave the CVAD in place until the thrombus is resolved to avoid dislodging the thrombus. *
Tiffani Klein is a managing member of Cape Infusion Support Systems LLC, Marmora, NJ.
TABLE: Types of CVADs
NON-TUNNELED CENTRAL CATHETER
* Short-term access located in the jugular, subclavian or femoral vein PICC (peripherally inserted central catheter)
* Short- to long-term access located in the antecubital fossa or upper arm
* Usual dwell time is three to 12 months
* Surgically implanted long-term access with external catheter located on the chest wall
* Surgically implanted long-term access with a plastic reservoir beneath the skin of the chest wall or upper arm