Central Vascular Access Device Complications

Central vascular access

device complications The nurse’s role at each point of care

By Dawn Berndt, DNP, RN, CRNI®, and Marlene Steinheiser, PhD, RN, CRNI®

Editor’s note: This article was devel- The Infusion Nurses Society (INS) Regardless of insertion site, the cath - oped in partnership with the Infu- states that patient safety requires e ter tip is located in the superior or sion Nurses Society (ins1.org). The clinicians to be competent at rec- inferior vena cava, preferably at its Infusion Therapy Standards of Prac- ognizing signs and symptoms of junction with the right atrium. tice, published in the Journal of In- VAD-related complications during Nontunneled CVADs can be vas- fusion Nursing (2016), were used as insertion, management, and remov - cular or nonvascular. They’re insert- a guiding reference. Please see the al, and to intervene appropriately. ed by puncture directly through the September issue of American Nurse This article presents an overview skin and into the intended location. Today for an article on complica- of CVAD terminology and common None of the devices should remain tions of peripheral vascular access complications and discusses the in a subcutaneous tract. devices. nurse’s role during insertion; care, Tunneled cuffed catheters have use and maintenance; and discon- a segment of the catheter lying in a APPROXIMATELY 5 million central tinuation. subcutaneous tunnel, where tissue vascular access devices (CVADs) are grows into the cuff for securement. inserted into U.S. patients every Terminology The skin and vein exit sites are sep- year, and at least 85% of hospital- Before managing CVAD complica- arated by the tunnel. ized patients receive some form of tions, nurses must understand the Implanted vascular access ports I.V. therapy. The widespread use of relevant terminology. are surgically placed in a vessel, CVADs presents considerable chal- body cavity, or organ attached to lenges for nurses when managing Common CVADs a reservoir located under the skin. associated complications. Peripherally inserted central cath e - They have no external lumen until Vascular access device (VAD) ters (PICCs) are inserted through it’s accessed for use with a noncor- complications may delay treatment, arm or neck veins in adults and ing needle that has an integral ex- damage vessels, limit options for children; in infants, they may be tension set. future vascular access, cause pain inserted through scalp or leg veins. and illness, decrease or impair CVAD duration quality of life, and increase mor- The INS doesn’t recommend a spe- bidity and mortality, length of stay, cific VAD dwell time duration. In- and medical costs. All VAD types CNE stead, the Infusion Therapy Stan- 1.67 contact are subject to complications that hours dards of Practice state: may occur throughout the life of • Standard 44.2 VADs are removed the device. Risk factors for CVAD- LEARNING O BJECTIVES if a complication can’t be re- associated complications include 1. Describe how to prevent central solved, at discontinuation of in- disease state, concurrent infection, vascular access device (CVAD) com- fusion therapy, or when they’re presence of immunosuppression or plications. no longer deemed necessary. immunodeficiency, therapeutic reg- 2. Discuss how to manage CVAD com- • Standard 44.3 VADs aren’t re- imen and type of infusate, pro- plications. moved based solely on length longed hospitalization, and age- of dwell time because no known related or developmental-stage fac- The authors and planners of this CNE activity have optimum dwell time exists. disclosed no relevant financial relationships with tors (such as fragile skin, changes in any commercial companies pertaining to this ac- cognition/orientation, dexterity, and tivity. See the last page of the article to learn how Aseptic vs. sterile ability to communicate/learn) that to earn CNE credit. Aseptic technique is a primary infec- might impact the ability to maintain Expiration: 10/1/22 tion prevention method for keeping and use the VAD safely. objects and areas free from micro -

6 American Nurse Today Volume 14, Number 10 AmericanNurseToday.com Insertion-related complications During central venous access device (CVAD) insertion, nurses must recognize the risk factors, signs, and symptoms of complications and apply prevention and intervention measures.

Complication Risk factors Signs and symptoms Prevention and interventions

Infection • Immunosuppression • Fever Prevention: (bacteremia/ or • Chills • Perform hand hygiene before placement and interventions. septicemia) immunodeficiency • General malaise • Prepare workspace before performing aseptic technique. • Severe chronic illness • Headache • Perform skin antisepsis at insertion site and to surrounding skin. • Multiple infusions • Increased pulse rate • Maintain aseptic technique throughout insertion and dressing • Extended hospital- • Flushed face processes. ization • Backache • Use maximal sterile barrier precautions during insertion. • Concurrent infection • Nausea • Disinfect needleless connectors before access using sterile alco- • Leukopenia • Vomiting hol wipes with or without chlorhexidine or a sterile alcohol cap. • Age (very young or • Hypotension • Maintain aseptic technique during all infusion therapy admin- very old) istrations and CVAD care. • Burns • Remove the CVAD when it’s no longer necessary. • Femoral insertion • Change administration set and add-on devices at recommend- site ed intervals. • Minimize the use of add-on devices. Interventions: • Notify the provider if infection is suspected. • If ordered, remove the catheter and culture to determine if it’s the infection source. • Obtain blood cultures as ordered. • Administer antibiotics as ordered.

Catheter • Failure to accurately • Absence of blood return Prevention: malposition verify anatomic loca- from all CVAD lumens • Use tip location technology during insertion procedure, obtain tion of catheter tip at • Changes in blood color and a chest x-ray, or view tip location under fluoroscopy. insertion and before pulsatility of blood return Interventions: use from all catheter lumens • Notify the provider of signs or symptoms associated with a • Failure to adequately • Difficulty with flushing or in- malpositioned CVAD; anticipate diagnostic tests to verify secure CVAD to pre- ability to flush CVAD catheter tip termination. vent catheter move- • Arterial and ventricular ar- • Provide the radiology department with clinical assessment in- ment rhythmias formation such as changes in blood pressure, heart rate, or • Blood pressure and/or heart respirations to enhance the ability to identify the problem. rate changes • Don’t infuse through the malpositioned CVAD until a proper • Shoulder, chest, or back pain tip position has been established. Obtain alternative vascular • Edema in neck or shoulder access if the infusion therapy can’t be stopped or delayed. • Respiration changes • Patient reports hearing a gurgling sound on the ipsi- lateral side • Paresthesia and neurologic effects due to retrograde infusion into intracranial venous sinuses

Nerve injury • Failure to avoid • Immediate sharp pain at Prevention: venipuncture sites venipuncture site • Know the anatomic position of veins, arteries, and nerves used associated with • Sharp shooting pain up or for CVAD insertion. nerve injury risk: down arm • Recognize that anatomic variations in these structures are • at or above the an- • Sensation of pain that common and can be complex, increasing the risk of tempo- tecubital fossa changes in severity depend- rary or permanent nerve injury during CVAD insertion. (median antecu- ing on needle position • Avoid probing with the needle during cannulation attempts. bital interosseous • Paresthesia in hand or finger- Interventions: nerve) tips • Stop the insertion procedure immediately. • antecubital fossa • Remove the CVAD. lateral and medial • Notify the provider. antebrachial • Collaborate with the provider for rapid interventions that may nerves reduce the risk of permanent injury. • subclavian and • Interventions may include elevation and/or thermal com- jugular sites presses. (brachial plexus • Fasciotomy may be indicated. nerve) • Consultation with a surgeon may be required.

Source: Alexander et al. 2014

AmericanNurseToday.com October 2019 American Nurse Today 7 organisms using sterile supplies, the insertion if aseptic technique is tential complication and respond barriers, and absolute separation of breached. immediately if the patient complains items that are sterile from those that of unusual pain or discomfort dur- aren’t. Dressing changes are per- Malposition ing insertion. Prompt intervention formed using aseptic technique. CVAD malposition occurs when the can mitigate or prevent permanent Sterile means that an environment catheter tip is located in an aber- nerve damage. Collaborate with the is free from living organisms. It’s rant position and no longer located patient’s provider to determine the achieved by destroying both good in the original vena cava or cavoa- best intervention. and bad organisms. Although the trial junction. Malpositions are cate- method used for dressing changes gorized as extravascular (catheter Care, use, and maintenance is often referred to as “sterile tech- tip is located outside of the vein in complications nique,” this is a misnomer because nearby anatomic structures such as CVADs must be regularly assessed a patient’s skin can’t be sterilized. mediastinum, pleura, pericardium, for local complications, the most or peritoneum) or intravascular common of which are air embolism, Insertion complications (catheter tip is located in a subopti- bacteremia and septicemia, occlu- Common insertion-related CVAD mal or aberrant position inside a sions, venous thrombus, phlebitis, complications include infection, and catheter malposition. The nurse catheter malposition, and nerve in- should assess the CVAD site visually jury. Patient disease state and phys- to observe skin color and compara- ical condition may increase risk The nurse should assess tive extremity size and use palpa- factors for complications, but with tion to detect swelling, warmth, swift recognition and intervention, the CVAD site visually to pain, tenderness, and drainage. To nurses can help prevent further pa- identify systemic complications, the tient harm. (See Insertion-related observe skin color and nurse should assess the patient for complications.) changes in temperature, heart rate, comparative extremity blood pressure, and patient reports Infection of unusual discomfort, pain, or sen- Infection is perhaps the most preva- size and use palpation to sation. The CVAD must be assessed lent, yet preventable, CVAD compli- for patency, integrity and function, cation. Infections may be localized detect swelling, warmth, and malposition or migration. (See at the CVAD site or be systemic. To Care, use, and maintenance com- prevent these complications, CVAD pain, tenderness, and plications.) insertion must be performed by a skilled clinician who adheres to in- drainage. Air embolism fection prevention protocols includ- Although primarily associated with ing using a central line bundle with CVAD discontinuation, air embolism the following interventions: vein). Intravascular CVAD malposi- can occur during care, use, and • Perform hand hygiene before tions are further categorized as ei- maintenance (for example, inadver- and at appropriate intervals dur- ther primary or secondary. Primary tent disconnection of the administra- ing the procedure. CVAD malposition occurs during tion set, failure to remove air from • Perform skin antisepsis using > the insertion procedure; secondary the set before use, or catheter frac- 0.5% chlorhexidine in alcohol CVAD malposition may occur at ture). Air embolism occurs when a solution (use chlorhexidine with any time during the catheter dwell bolus of air enters the vascular sys- caution in premature infants or time and is commonly referred to tem, creating an intracardiac airlock those under 2 months; consider as tip migration. Using visualization at the pulmonic valve and prevent- using povidone-iodine instead). technologies may prevent primary ing blood ejection from the right • Use maximal sterile barrier pre- CVAD malposition. side of the heart. The force of right cautions. ventricular contractions increases, • Avoid the femoral vein as an in- Nerve injury and small air bubbles break loose sertion site in adults. Nerve injuries during CVAD inser- and enter the pulmonary circulation, A second clinician trained in tion frequently are attributed to in- obstructing forward blood flow, CVAD insertion must observe the advertent puncture of nerve struc- which results in tissue hypoxemia. procedure and complete a standard- ture near the insertion site or along ized checklist. The observer’s roles the intended catheter tract. Clini- Bacteremia and septicemia and responsibilities include stopping cians should be aware of this po- Bacteremia (microorganisms in the

8 American Nurse Today Volume 14, Number 10 AmericanNurseToday.com Care, use, and maintenance complications During central venous access device (CVAD) care, use, and maintenance, nurses must recognize the risk factors, signs, and symptoms of complications and apply prevention and intervention measures. Catheter malposition also can be a complication during CVAD care, use, and maintenance. (See Insertion-related complications.)

Complication Risk factors Signs and symptoms Prevention and interventions

Air embolism • Use of administration sets or • Sudden onset of dyspnea Prevention: (not associated add-on devices without Luer • Coughing • Maintain a closed system and ensure that connectors are tightened on all segments of the with lock connectors • Chest pain administration set. discontinuation) • Failure to tighten Luer lock • Hypotension • Ensure syringes contain intended fluid to prevent inadvertent injection of air into a port. connectors on preconnected • Tachyarrhythmias • Don’t allow solution container on the pump to empty without automatic shut-off. administration sets • Wheezing • Don’t use infusion pumps without air-in-line safety alarms. • Use of infusion pumps with- • Tachypnea • Prime all administration and extension sets to remove air from the system before use. out functioning air-in-line • Altered mental status • Ensure the CVAD is securely clamped when disconnecting and reconnecting a new adminis- detectors • Altered speech tration set, needleless connector, or other add-on device. • Inadvertent disconnection of • Changes in facial appearance Interventions: CVAD from needleless con- • Numbness • Immediately place the patient on his or her left side with the head lower than the heart. nector or administration set • Paralysis • Identify the cause and quickly prevent additional air from entering the circulation by closing without closing clamp • A loud continuous churning sound the breach in the administration set and/or stopping the infusion pump. heard over precordium during aus- • Immediately notify the provider. cultation • Administer oxygen. • Check the patient’s vital signs, oxygen saturation, and cardiac rhythm.

Infection • Immunosuppression or im- • Fever Prevention: (bacteremia/ munodeficiency • Chills • Perform hand hygiene before CVAD placement and before providing CVAD-related interventions. septicemia) • Severe chronic illness • General malaise • Disinfect needleless connectors before access using a sterile alcohol wipe with or without • Administration of multiple • Headache chlorhexidine or a sterile alcohol cap. infusions • Increased pulse rate • Maintain aseptic technique during all infusion therapy administrations and CVAD care. • Extended hospitalization • Flushed face • Remove the CVAD when it’s no longer necessary. • Concurrent infection • Backache • Change the administration set and add-on devices at recommended intervals. • Leukopenia • Nausea • Minimize the use of add-on devices. • Age (very young or very old) • Vomiting Interventions: • Burns • Hypotension • Notify the provider if an infection is suspected. • If ordered, remove the catheter and culture to determine if it’s the infection source. • Obtain blood cultures as ordered. • Administer antibiotics as ordered.

Catheter • Catheter placement at site of • Symptoms vary depending on loca- Prevention: embolism flexion without joint stabi- tion of catheter fragment but may • Inspect the catheter for defects before insertion. lization device include cyanosis, dyspnea, chest • Prohibit reinsertion of over-the-needle catheters (pulled backward then advanced forward), • Catheter defect pain, hypotension, tachycardia, which can pierce or sever the catheter. • Use of scissors or other sharp increased central venous pressure, • Avoid using scissors or other sharp implements near the catheter. implements near the fainting, or loss of consciousness • Don’t forcefully flush an occluded catheter. catheter • Upon removal of the CVAD, tip Interventions: • Catheter rupture from forced fragmentation noted or entire • Immediately notify the provider. injection (flushing forcefully catheter not intact • Monitor the patient for level of consciousness, blood pressure, pulse oximetry, pain, heart when occluded or power in- rate, and cyanosis. jection for computed tomog- • Prepare the patient for radiography and surgery if necessary. raphy scans)

Occlusion • Allowing solution container • Sluggish infusion or flushing Prevention: to completely empty • Inability to infuse or flush • Assess patency of the CVAD regularly. • Inadequate flushing when • Inability to obtain a blood return • Follow the organization’s flushing and locking guidelines. administering medications, • Ensure that incompatible infusates aren’t administered through the same catheter without drawing blood, or locking adequate flushing between each instillation. the CVAD • Act promptly to perform catheter clearance on sluggish or occluded catheters. • Administration of incompati- Interventions: ble medications Evaluate/identify cause of the occlusion. • Kinked catheter or adminis- • Mechanical: tration set • External: tight suture, catheter clamped, clamp not attached correctly, kinked tubing, filter obstruction • Internal: catheter malposition, kinked catheter, pinch-off syndrome (see table on page 7 for definition) • Nonthrombotic: lipid buildup for patients receiving 3-in-1 parenteral nutrition admixtures, drug precipitate

AmericanNurseToday.com October 2019 American Nurse Today 9 Care, use, and maintenance complications

Complication Risk factors Signs and symptoms Prevention and interventions

• Thrombotic: the most common occlusion type due to fibrin buildup, thrombosis within the catheter lumen or surrounding catheter tip (intraluminal occlusion or fibrin sheath/tail) • Manage/treat the occlusion. • Instill the appropriate catheter-clearance agent (precipitate clearing or declotting agent) for nonthrombotic and thrombotic occlusions. • Correct mechanical occlusions by changing filters, removing catheter kinks, unclamping catheter, or removing sutures and replacing with an engineered catheter-stabilization device.

Site infection • Poor hand hygiene • Pain, swelling, and/or inflamma- Prevention: • Break in aseptic technique tion at insertion site • Perform hand hygiene as directed in organization’s policy. during dressing change • Discolored tissue of surrounding • Maintain a clean, dry, and intact CVAD dressing. • Use of contaminated equip- area; purulent drainage may be • Maintain aseptic technique during dressing change. ment present • Maintain a closed infusion system. • Inappropriate catheter • Assess the CVAD site regularly for warmth, redness, drainage, and pain. securement • Assess the patient for signs of infection, such as elevated temperature. Interventions: • Notify the provider if infection is suspected. • If ordered, remove the catheter and culture it to determine if it’s the source of the infection. • If there’s drainage at the site, obtain a culture before removing the catheter. • Initiate anti-infective therapy as ordered.

Infiltration/ • Failure to stabilize CVAD • Swelling in chest, neck, or extremi- Prevention: extravasation adequately ty with CVAD • Stabilize catheter to prevent movement at the insertion site. • Large-gauge catheter • Pain, burning, stinging during in- • Assess the catheter patency before and during medication administration. • Patient age (very young or fusion • Compare the insertion site extremity size with the same area on the opposite side. very old), medical condition, • Changes in skin color, blanching, • Assess the patient for pain. and acuity bruising, or redness on extremity • Use the smallest catheter possible to accomplish the intended therapy. • Administration of irritating with CVAD Interventions: infusate • Tight feeling, taut skin • Stop infusion immediately if infiltration/extravasation is suspected. • Inadequate CVAD insertion • Changes in skin temperature on • Aspirate fluid from the catheter with a small syringe. technique extremity with CVAD • Remove the catheter as directed. • Inadequate care and mainte- • Numbness, tingling • Elevate the extremity and apply heat as appropriate. nance practices • Fluid leaking from insertion site • Instill an antidote (sodium thiosulphate, dexrazoxane, phentolamine, hyaluronidase) when • Multiple manipulations of • Slow capillary refill warranted and as ordered by the provider. infusion delivery system • Impaired ability to move fingers, • Observe and assess the site for other complications, such as compartment syndrome, nerve • Extravascular catheter tip hand, or extremity injury, blisters, and tissue necrosis. location • Blisters • Damage to intima of the vein • Erosion of vessel by catheter • Thrombus formation around catheter • Catheter migration out of vessel

Loss of skin • Patient has fragile skin due • Redness Prevention: integrity to age (very young or very • Excoriation • Allow antiseptic and skin-preparation agents to dry completely before placing dressings. old), disease state, or med- • Blisters • Follow the manufacturer’s instructions on all dressing supplies. ication regimen • Weeping • Check for allergies or sensitivities to dressing and skin-preparation agents before use. • Patient is sensitive or allergic • Use a skin-barrier solution to reduce the risk of medical-adhesive–related skin injury. to glue or skin-preparation Interventions: agents used during vascular • Consult the provider and/or wound and skin care specialist. access and dressing • Consider using dressing supplies manufactured for sensitive skin.

Phlebitis: Me- Mechanical • Erythema at access site with or Prevention: chanical, chemi- • Inappropriate site selection without pain • Don’t place CVAD in an area of flexion without joint stabilization. cal, bacterial (area of flexion) • Pain at access site with erythema • Select a catheter gauge appropriate for the vein diameter. • Inadequate vein size for or edema • Adhere to aseptic techniques for insertion, care, use, and maintenance. catheter gauge • Streak formation • Secure the catheter with an engineered stabilization device. • Inadequate securement • Palpable venous cord • Use caution with infusion rates and potential irritants. • Traumatic insertion • Purulent drainage • Administer properly diluted medications. Chemical Interventions: • Rapid rate infusion • Initiate prompt removal of the CVAD as ordered if the vessel is warm to the touch, painful, or • Particulate matter red or has a palpable cord. • Extended catheter dwell time • Use a standardized phlebitis assessment tool.

10 American Nurse Today Volume 14, Number 10 AmericanNurseToday.com Care, use, and maintenance complications

Complication Risk factors Signs and symptoms Prevention and interventions

• Irritating medications and • Consult the provider if phlebitis is suspected. solutions • Apply a thermal compress to the phlebitic area for 20 minutes three to four times per day • Medications improperly with a provider’s order. mixed or diluted • Chemical: Evaluate the infusion therapy and the need for different vascular access or a slow- Bacterial er rate of infusion; determine if catheter removal is needed. • Poor hand hygiene • Mechanical: Stabilize the catheter, apply heat, elevate the extremity, and monitor for 24 to • Poor aseptic technique when 48 hours; if signs and symptoms persist after 48 hours, consider removing the catheter. preparing venipuncture site • Bacterial: If bacterial infection is suspected, remove the catheter as ordered. • Poor catheter insertion technique • Inadequate catheter securement

Venous • History of deep vein throm- • Pain in extremity with CVAD, Prevention: thrombosis bosis shoulder, neck, or chest • Ensure the catheter tip is in the superior vena cava at the cavoatrial junction for adults and • Presence of chronic diseases • Edema in the extremity, shoulder, pediatric patients with upper-body insertion sites. For lower-body insertion sites (pediatric associated with hypercoagu- neck, or chest patients and adults, when applicable), the catheter tip should be located in the inferior vena lable state • Erythema in extremity cava above the level of the diaphragm. • Surgical and trauma patients • Engorged peripheral veins on the • Use the smallest-diameter catheter possible to accomplish the intended therapy. • Critical care patients extremity, shoulder, neck, or chest Interventions: • Fluid volume deficit wall • Notify the provider if thrombus is suspected. • History of multiple CVADs • Difficult movement of neck or ex- • Obtain radiographic studies to confirm catheter placement and the presence of a thrombus. tremity • Initiate anticoagulant or thrombolytic therapy as ordered.

Source: Alexander et al. 2014 blood as identified by positive blood presence of a fibrin sheath, throm- catheter ratio, or traumatic inser- cultures) is considered catheter-relat- bus at the catheter tip, or position- tion), or bacterial (infection and in- ed when the same organisms are ing against the vessel wall. Inter- flammation affecting the vein wall). isolated from both the catheter and ventions for catheter clearance the blood. Most catheter-related should be performed as soon as Catheter malposition bloodstream infections are consid- possible when an occlusion is de- As previously noted, CVAD malpo- ered preventable. Prevention meas- tected. sition is the unintended placement ures include performing hand hy- of the catheter tip either internal or giene before and after conducting Venous thrombus external to the vascular system. In interventions; disinfecting needleless Although the CVAD is the primary CVADs, if the catheter tip doesn’t connectors with alcohol wipes, alco- contributing factor in catheter-relat- terminate in the lower third of the hol chlorhexidine wipes, or alcohol ed venous thrombosis, other multi- superior vena cava, the catheter is caps before accessing; maintaining factorial conditions may contribute, considered malpositioned. Extravas- aseptic technique during all infusion including the presence of a chronic cular malposition may cause infil- therapy administrations and during disease that creates a hypercoagula- tration/extravasation of the infusate all CVAD dressing changes; chang- ble state, genetic abnormalities af- in the mediastinum, hemothorax ing administration sets and add- fecting coagulation factors, immo- or pleural effusion if in the pleura, on devices at appropriate intervals; bility, pregnancy, surgery, a history or pericardial effusion or cardiac maintaining a closed infusion sys- of multiple CVAD use, and age-re- tamponade if in the pericardium. tem; and discontinuing CVADs when lated factors associated with the very Catheter malpositioning may occur they’re no longer necessary. young or very old. during insertion but can occur during the care, use, and maintenance Occlusion Phlebitis phase as well. CVAD occlusions, which may in- Phlebitis may be accompanied by crease the risk of catheter-related pain, erythema, edema, streak for- Discontinuation complications infection, are defined as partial or mation, and/or a palpable cord. It’s Primary complications associated complete obstructions of the cathe- caused by endothelial cell inflam- with CVAD discontinuation are air ter lumens that restrict blood aspi- mation of the vessel and classified embolism, excessive bleeding, in- ration or fluid injection into the as chemical (chemicals in the insertion site infection, and catheter catheter. Occlusions may occur in fusate), mechanical (presence of embolism (catheter embolism can response to catheter twisting or the catheter in the vessel, catheter occur when a portion of the cathe- kinking, medication precipitate, the movement, inadequate vein-to- ter separates or breaks off and re-

AmericanNurseToday.com October 2019 American Nurse Today 11 Discontinuation complications During central venous access device (CVAD) discontinuation, nurses must recognize the risk factors, signs, and symptoms of complications and apply prevention and intervention measures.

Complication Risk factors (or causes) Signs and symptoms Prevention and interventions

Air embolism • Inability to place pa- • Sudden onset of dyspnea Prevention: tient in supine posi- • Coughing • Place patient in the supine position to ensure that the CVAD is tion during CVAD • Chest pain at or below the level of the heart. removal • Hypotension • Have the patient perform the Valsalva maneuver unless con- • Patient unable to • Tachyarrhythmias traindicated. perform Valsalva ma- • Wheezing • Apply digital pressure to the exit site until hemostasis is achieved. neuver during CVAD • Tachypnea • Use an occlusive dressing. Apply a sterile gauze dressing with removal • Altered mental status petroleum-based ointment to the exit site to seal the skin-to- • Failure to immedi- • Altered speech vein tract. ately place occlusive • Changes in facial appearance • Instruct the patient to lie flat for 30 minutes after removal. dressing after CVAD • Numbness Interventions: removal • Paralysis • Immediately place the patient on his or her left side with the • Patient unable to lie • A loud continuous churning head lower than the heart. flat for 30 minutes sound heard over precordi- • Prevent additional air from entering the circulation by applying after CVAD removal um during auscultation a sterile gauze dressing with petroleum-based ointment to the exit site to seal the skin-to-vein tract. • Immediately notify the provider. • Administer oxygen. • Check the patient’s vital signs, oxygen saturation, and cardiac rhythm.

Catheter • Defective catheter • Symptoms vary depending Prevention: embolism • Reinsertion of needle on location of catheter frag- • Inspect the catheter upon removal and verify that the length is (due to during placement of ment, but may include palpi- the same as at the time of insertion. damage) over-the-needle tations, arrhythmias, dysp- • Prohibit reinsertion of over-the-needle catheters (pulled back- catheter nea, cough, thoracic pain ward then advanced forward), which can pierce or sever the • Pinch-off syndrome* • Upon removal of the CVAD, catheter. • Power injection in tip fragmentation noted or • Don’t forcibly remove the CVAD against resistance. CVAD that isn’t la- entire catheter not intact Interventions: beled for this use • Immediately notify the provider if an embolism is suspected. • Place a tourniquet above the insertion site if the catheter breaks during removal. • Monitor the patient for distress.

*Pinch-off syndrome, although rare, occurs when the CVAD enters the costoclavicular space medial to the subclavian vein and is positioned outside the lumen of the subclavian vein in the narrow area bounded by the clavicle, first rib, and costoclavicular ligament. Catheter compression causes intermittent or permanent catheter occlusion and, because of the “scissoring” effect of catheter compression between the bones, can result in catheter tearing, transection, and catheter embolism.

Source: Alexander et al. 2014

mains in the patient after the CVAD stay, or lead to death. Diligent nurs- ed. Philadelphia, PA: Lippincott Williams & is removed). Air and catheter em- ing assessment and intervention is Wilkins; 2014. bolism present the greatest risk for instrumental at CVAD insertion, Infusion Nurses Society. Infusion therapy mortality or significant injury. Clini- care, use, maintenance, and discon- standards of practice. J Infus Nurs. 2016;39 cians must be prepared to initiate tinuation to prevent and detect the (suppl 1):S1-S159. emergency measures if necessary. onset of CVAD-associated complica- Joint Commission, The. Preventing Central Line–Associated Bloodstream Infections. A Standard nursing protocol for all tions and to initiate corrective ac- Global Challenge, A Global Perspective. Oak CVAD discontinuation must be fol- tion and therapeutic management Brook, IL: Joint Commission Resources; 2012. lowed to ensure patient safety. (See when complications occur. jointcommission.org/assets/1/18/CLABSI_Mo Discontinuation complications.) nograph.pdf The authors work at the Infusion Nurses Society in Takashima M, Schults J, Mihala G, Corley A, Diligent nursing care Norwood, Massachusetts. Dawn Berndt is the clinical Ullman A. Complication and failures of central CVAD-associated complications are education and publications manager, and Marlene vascular access device in adult critical care settings. Crit Care Med. 2018;46(12):1998-2009. serious patient safety events that Steinheiser is the director of clinical education. Ullman AJ, Marsh N, Mihala G, Cooke M, can prolong illness, cause perma- Selected references Rickard CM. Complications of central venous nent physical damage, increase Alexander M, Corrigan A, Gorski LA, Phillips access devices: A systematic review. Pedi- healthcare costs, extend length of L. Core Curriculum for Infusion Nursing. 4th atrics. 2015;136(5):e1331-44.

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Please mark the correct answer online. 5. Which statement about nerve injury 9. If the CVAD catheter breaks when it’s related to CVAD insertion is correct? being removed, you should 1. When a peripherally inserted central a. The antecubital fossa is associated with a. apply a nonocclusive dressing to the catheter (PICC) is placed in an upper-body a risk for nerve injury. insertion site. position, the tip should be located b. If nerve injury is suspected, the cathe- b. apply a warm compress to the inser- a. at the subclavian/ventricle junction. ter should be left in place for assess- tion site. b. in the subclavian vein. ment. c. place a tourniquet below the insertion c. at the cavoventrical junction. c. Probing to ensure proper vein location site. d. in the superior or inferior vena cava. reduces the risk of nerve injury. d. place a tourniquet above the insertion 2. Which of the following vascular access d. Interventions for nerve injury may in- site. clude elevation and/or cold compresses. devices (VADs) is accessed with a noncor- 10. After CVAD is removed, your patient ing needle? 6. Use of administration sets or add-on experiences signs and symptoms of air a. PICC devices with Luer lock connectors is a risk embolism. Fortunately, you know that you b. Implanted vascular access port factor for should immediately place the patient c. Nontunneled central VAD a. catheter embolism. a. on his or her right side with the head d. Tunneled, cuffed VAD b. air embolism. lower than the heart. 3. Which statement about the duration of c. occlusion. b. on his or her left side with the head a CVAD is correct? d. infiltration. lower than the heart. a. CVADs should be changed every 48 c. on his or her left side with the head 7. Appropriate management of mechani- higher than the heart. hours. cal phlebitis includes b. CVADs should be changed every 72 d. on his or her back with the head lower a. stabilizing the catheter. than the heart. hours. b. applying a cold compress. c. CVADs aren’t removed based solely on c. placing the extremity in a dependent 11. All of the following interventions for length of dwell time. position. suspected infiltration/extravasation are d. CVADs are removed when the dressing d. monitoring for 72 to 96 hours. correct except: needs to be changed. a. Elevate the extremity. 8. Which statement about discontinuing b. Stop the infusion immediately. 4. Before a CVAD is inserted, skin antisep- a CVAD is correct? sis should be performed with c. Aspirate fluid from the catheter with a a. The patient should perform the Valsal- large syringe. a. povidone-iodine for patients between va maneuver unless contraindicated. 12 and 18 years old. d. Instill an antidote when warranted and b. Apply a nonocclusive dressing after the ordered by the provider. b. povidone-iodine for adult patients. catheter is removed. c. > 0.25% chlorhexidine in alcohol solu- c. Be sure to have the CVAD above the 12. A risk factor for chemical phlebitis is tion for premature infants. level of the heart before removal. a. poor catheter insertion technique. d. > 0.5% chlorhexidine in alcohol solu- d. Have the patient lie flat for 10 minutes b. irritating medications and solutions. tion for adults. after removal. c. inadequate securement of the device. d. inadequate vein size for catheter gauge.

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