venous access devices-managing common problems
TRANSCRIPT
Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN
Oncology Nursing Consultant
New Orleans, LA
Venous Access Devices:Managing Common Problems
Common Venous Access Device Problems
Thrombosis or fibrin sheath at catheter tip Catheter-related infection Catheter malposition Device damage or malfunction Extravasation injury
Overall complication rate
1.8% - 14.4% (DiCarlo et al., 2001)
Most common complications:
--- venous thrombosis
--- infection
Most common reasons for device removal (Fischer et al., 2008)*
Infection (46%) End of treatment (34%) Thrombosis (11%) Device dysfunction (6%)
*study of 385 consecutive patients
Education of healthcare providers
The most important strategy for the prevention of venous access-related problems (O’Grady et al., 2002).
Devices lacking blood return
Place patient in supine position Use a 10 mL saline syringe to gently
“push-pull” 53% success rate in 8,685 ports that
lacked a blood return (Goossens et al., 2007)
If repositioning and flushing are not successful Attempt to withdraw blood using 20 mL
syringe Dye study or instill a thrombolytic agent
(TPA) Cardiovascular Thrombolytic to Open
Occluded Lines (COOL) Efficacy Trial (Ponec et al., 2001): TPA injection restored catheter function 90% of the time
Fibrin sleeve or thrombus formation
Thrombotic complications (Kuter, 2004)
Within days of insertion, most catheters are coated with a fibrin sheath.
Most clots arise within 30 days. These clots can cause pulmonary
embolism (most are asymptomatic). Thrombosis of blood vessel increases the
risk of infection.
Local catheter-related infection
Risk factors
--- Poor insertion or care technique
--- Superficial port placement
--- Heat, moisture, friction while port is accessed
Local (port pocket) infection
Culture site Local wound care Systemic antibiotics Remove device if pseudomonas species or
atypical mycobacteria Do not use until signs of infection resolve
Local infection Actions to manage
Local infections most commonly due to Staphlococcus epidermidis
Frequent wound care Systemic antibiotic therapy Catheter may need to be removed if
there is a systemic infection (Staphlococcus aureus) along with local infection
Systemic catheter-related infection
Risk factors--- Grade 4 neutropenia
--- Prolonged neutropenia
--- Administration of total parenteral nutrition
--- Hematologic malignant disease
--- External catheters: 5% to 29% more common
--- Lack of education and training of healthcare
staff
(Maki et al., 2006)
Systemic infection
Actions to manageMost common organism is coagulase-
negative Staphlococcus Quantitative blood cultures from device and
peripheral draw Number of Colony Forming Units (CFU) of bacteria per
mL of blood drawn via the device is 10X or more than the peripherally drawn blood
>1000 CFU in the absence of a peripheral draw Catheter tip cultures positive
Systemic infection
Actions to manageSystemic antibioticsRemoval of catheter with persistent fever
or bacteria for 3 days with antibiotics, especially if Staphlococcus aureus
The Central Line Bundle(Institute for Healthcare Improvement, 2006)
Hand hygiene Maximal sterile barrier precautions during device
insertion Chlorhexidine skin antisepsis Optimal catheter site selection, with subclavian vein as
the preferred site for non-tunneled catheters Daily review of catheter necessity with prompt removal of
unnecessary catheters
Catheter malposition
May occur upon insertion Catheter tips may migrate over time
Catheter tips can migrate from the superior vena cava to the:
internal jugular vein (43%)
axillary vein (19%) contralateral innominate
vein (11%) right atrium of the heart
(9.5%) (Richardson & Bruso, 1993)
Catheter tip in right internaljugular vein
Catheter tip perforating the superior vena cava (pleural effusion seen on CT)
Catheter tip that migrated and flipped in internal jugular vein
Catheter backing out of vein over time
Catheter that has completely backed out of the vein and is now coiled in the subcutaneous tissue
Catheter damage
May occur prior to or during insertion May occur over time
Accidental nicking or piercing of the tubing upon insertion
Forauer et al., 2005
Twiddler’s syndrome
Catheter migration to the internal jugular vein with incomplete fracture
Pinch-off syndrome (compression between the clavicle and rib)
Extravasation injury
More common with implanted ports than percutaneous central venous catheters
Incomplete non-coring (Huber) needle placement
Misplacement of non-coring needle on rim of septum of port
Back-tracking of vesicant along the catheter to the venotomy site
Device separation
Summary
Vascular access-related complications are common occurrences.
Problems may occur even if the device was recently inserted.
Catheter patency and placement should be confirmed prior to administering medications, especially vesicant chemotherapy.
Nurses play a key role in preventing and detecting VAD problems and complications.
ReferencesDi Carlo, I., et al. (2002). Totally implantable venous access devices implanted
surgically: A retrospective study on early and late complications. Arch Surg 136, 1050-1053.
Fischer, L. et al. (2008). Reasons for explantation of totally implantable access ports: A multivariate analysis of 385 consecutive patients. Ann Sug Oncol 15, 1124-1129.
Forauer, A. R., Chen, Y., & Parks, R. (2005). A case of posttraumatic Twiddler’s syndrome. JVIR 16, 562-563.
Goossens, S. et al. (2005). Occlusion in totally implantable vascular acces devices. What is the incidence and what actions do nurses take to restore patency? Available at http://www.uzleuven.be/UZRoot/files/webeditor/poster_katherzorg/pdf.
Institute for Healthcare Improvement. (2006). Central line bundle. Available at http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheCentralLineBundle.htm.
Kuter, D. J. (2004). Thrombotic complications of central venous catheters in cancer patients. Oncologist 9, 207-216.
Maki, D. G., et al. (2006). The risk of bloodstream infection in adults with different intravascular devices: A systematic review of 200 published prospective studies. Mayo Clin Proc 81, 1159-1171.
O’Grady, N. P. et al. (2002). Guidelines for the prevention of intravascular catheter-related infections. Infect Control Hosp Epidemiol, 23, 759-769.
Ponec, D. et al. (2001). Recombinant tissue plasminogen activator (alteplase) for restoration of flow in occluded central venous access devices: A double-blind placebo-controlled trial---the Cardiovascular Thrombolytic to Open Occluded Lines (COOL) efficacy trial. J Vasc Interv Radiology, 12, 951-955.
Richardson, D., & Bruso, P. (1993). Vascular access devices—management ofcommon complications. J Intrav Nurs 16, 44-49.