Short peripheral and midline catheter

complications The nurse’s role at point of care

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

EDITOR’S NOTE: This article was devel- per arm via the basilic, cephalic, or prolonged hospitalization, and the oped in partnership with the Infu- brachial vein, with the internal tip presence of concurrent infections. sion Nurses Society (ins1.org), and located level to or near the level of Practice-related risk factors include the Infusion Therapy Standards of the axilla and distal to the shoulder. multiple venipuncture attempts, Practice, published in the Journal of The sequelae of peripheral VAD poor insertion technique/traumatic Infusion Nursing (2016), were used complications, including tissue in- insertion, inappropriate catheter size as a guiding reference. Watch for jury, infection, emboli, and extra- and length in relationship to the an article on complications of cen- vasations, can lead to impaired vessel, failure to adequately secure tral vascular access devices in our quality of life and increased mor- the catheter, inadequate mainte- October issue. bidity and mortality. All peripheral nance, poor hand hygiene, and venous access catheter types are poor sterile technique. PERIPHERAL vascular access device subject to complications that can (VAD) use is widespread in inpa- occur at any juncture in the life of Preventing and mitigating tient and outpatient settings. Short the device. complications peripheral catheters (SPCs), com- Peripheral VAD-associated com- Nurses play an important role at monly called “I.V.s,” are the most plications can be attributed to a specific points of care in the life of widely used VADs worldwide. In- number of patient-related risk fac- peripheral VADs: ternational data indicate that more tors, such as age, developmental • insertion than 1 billion SPCs are used annu- stage, disease state, presence of im- • care, use, and maintenance ally in hospitalized patients. A munosuppression or immunodefi- • discontinuation. resurgence in the use of midline ciency, type of therapy and infusate, Ongoing assessment to detect catheters provides yet another op- complication onset and to initiate tion for peripheral venous access. corrective action and therapeutic In the United States, at least 85% CNE management when complications of hospitalized patients receive some 1.62 contact occur are essential at each point. hours form of I.V. therapy. Although the use of peripheral VADs allows pa- LEARNING O BJECTIVES Insertion complications tients to receive I.V. therapy, which Skillful insertion of a peripheral VAD 1. Describe how to prevent peripheral can be life-sustaining or even life- vascular access device (VAD) com- ensures patient safety and proper saving, the devices also present a plications. device functioning. A poor insertion challenge when managing associ- 2. Discuss how to manage VAD com- technique can place the patient at ated complications. plications. risk for insertion-related complica- tions, including infection, tissue or Sequelae and complications The authors and planners of this CNE activity have vessel damage, therapy delay, and, disclosed no relevant financial relationships with SPCs and midline catheters are two any commercial companies pertaining to this ac- rarely, catheter embolism. Failures devices used to obtain peripheral tivity. See the last page of the article to learn how or complications at the point of in- venous access. SPCs are catheters to earn CNE credit. sertion also may require additional less than 3" (7.6 cm) long. Midlines Expiration: 9/1/22 insertions, increasing the risk for in- are catheters inserted into the up- fection and vessel depletion.

AmericanNurseToday.com September 2019 American Nurse Today 5 Peripheral VAD insertion-related complications Nurses must recognize the risk factors, signs, and symptoms of peripheral venous access device (VAD) insertion-related complications and apply prevention techniques and interventions as needed.

Complication Risk factors Signs and symptoms Prevention and management

Hematoma (and/or • Multiple venipuncture • Tissue discoloration Prevention: tissue damage) attempts/traumatic from blood infiltrating • Venipuncture should be performed by a clinician insertion the area with validated competency. • Fragile veins • Swelling as hematoma • Limit insertion attempts to one or two without • Inappropriately placed forms “digging” or repositioning the needle. tourniquet • Hematoma onset is • Use visualization technologies to aid in vessel and • Venipuncture in patients immediate or slow surrounding structure identification and VAD with a blood dyscrasia or depending on the insertion. in those who bruise easily amount of subcutaneous • Use a stabilization device on all VADs or apply a • Patients taking steroids tissue between the dressing with an integral stabilization feature. or anticoagulants vein and epidermis Interventions: • Accidental arterial • Remove the catheter immediately and apply puncture direct pressure to the area. • Elevate the extremity until bleeding stops. • Apply a dry sterile dressing to the site. • Monitor the site for breakthrough bleeding. • Monitor the extremity for circulatory neurologic and motor function.

Catheter embolism • Defective catheter • Signs and symptoms Prevention: • Needle reinsertion during vary depending on • Inspect the catheter for defects before insertion. placement of over-the- location of catheter • Prohibit reinsertion of over-the-needle catheters needle catheters fragment; often, no (for example, pulled backward then advanced signs are apparent forward, causing the catheter to be pierced or • When VAD removed, tip severed). fragmentation noted or Interventions: entire catheter not intact • Notify the provider immediately. • If the catheter breaks during removal, apply a tourniquet above the insertion site and place the patient on bedrest. • Obtain radiographic images as ordered. • Monitor the patient for distress or other noticeable changes.

Infection • Immunosuppression or Local: Prevention: immunodeficiency • Pain, swelling, or • Perform hand hygiene before all patient contact • Severe chronic illness inflammation at as described in the organization’s policy or • Multiple infusions insertion site guidelines. • Extended hospitalization • Discolored tissue of • Prepare the workspace before performing clean • Concurrent infection surrounding area, aseptic technique. • Leukopenia purulent drainage • Perform skin antisepsis at the intended insertion • Patient’s age, medical Systemic: site and surrounding skin. condition, and acuity • Fever • Maintain aseptic technique throughout the • Burns • Chills insertion and dressing processes. • General malaise Interventions: • Headache • Culture drainage (if present) at the site before • Increased pulse removing the catheter. • Flushed face • Remove the catheter and culture it to determine • Backache if it’s the source of infection. • Nausea • Administer antibiotics as ordered. • Vomiting • Monitor the site until the infection resolves. • Hypotension

Source: Alexander et al. 2014

6 American Nurse Today Volume 14, Number 9 AmericanNurseToday.com Skillful insertion of a peripheral VAD ensures Insertion-related infection can re- patient safety and accompanied by pain, erythema, sult from inadequate handwashing, edema, streak formation, and/or workspace preparation, or skin anti- proper device palpable cord. It’s caused by en- sepsis before insertion and failing to functioning. dothelial cell inflammation of the maintain aseptic technique through- vessel and is classified as chemi- out the process. Vessel, nerve, and tis- present as localized site infections cal (chemicals in the infusate), me- sue damage can occur if the catheter or systemically as bacteremia or chanical (presence of the catheter isn’t adequately secured or if probing septicemia, which are considered within the vessel, catheter piston- or multiple insertion attempts occur. catheter-related if the same micro - ing or movement, inadequate vein- Hematomas arise when an adjacent organism is isolated both in the to-catheter ratio, or traumatic in- vessel is pierced or when the vein is blood and on the catheter surface. sertion), or bacterial (presence of penetrated through the vessel’s back CR-BSIs are frequently considered infection and inflammation affect- wall. Catheter embolism can occur if exclusive to central VAD use; how- ing the vein wall). (See Peripheral the needle is reinserted into over-the ever, patients with SPCs and mid- VAD care, use, and maintenance needle catheters during cannulation, line catheters also are vulnerable. complications.) shearing or severing the catheter. In Infiltration and extravasation. addition to patient injury, these fail- Infiltration is the inadvertent instilla- Discontinuation complications ures add to the overall financial im- tion of infusate into the tissues ex- Complications associated with pe- pact for the patient and the health- ternal to the vessel; extravasation is ripheral VAD discontinuation in- care organization. (See Peripheral the inadvertent instillation of vesi- clude excessive bleeding, infection VAD insertion-related complications.) cant solution into the tissues exter- at the catheter insertion site after nal to the vessel. Infusates (infu- catheter removal, and, although Care, use, and maintenance sions) are all parenteral solutions rare, catheter embolism. Of these, complications administered into the vascular sys- infection and catheter embolism Detecting and preventing care-, use-, tem. Vesicants are defined as agents present the greatest risk for mortali- and maintenance-related SPC and or infusions capable of causing tis- ty or significant injury. Nurses and midline catheter complications re- sue damage. Infiltration or extrava- other healthcare personnel must be quire nursing vigilance. Routine pa- sation can be caused by damage to knowledgeable and diligent when tient and peripheral VAD assessment the vein intima, fragile patient vas- discontinuing a VAD and never de- is necessary to help ensure the pa- culature, catheter migration external viate from standards of practice. tient doesn’t experience any of the to the vessel, or thrombus forma- many use-associated complications. tion that causes vessel rupture or Vigilant care However, extended SPC and mid- retrograde flow exiting through the Peripheral VAD-associated compli- line catheter use and patient-related catheter insertion site. Catheter mal- cations pose serious risks for pa- risk factors can increase the chal- positioning external to the vessel tients, the extent of which may re- lenge of preventing complications may occur during or after insertion. sult in prolonged illness, extended such as catheter occlusion, infec- Skin injury. Loss of skin integri- lengths of stay in a healthcare set- tion, infiltration or extravasation, ty occurs for a variety of reasons, ting, permanent physical damage, skin injury, and phlebitis. including patient age and disease or even death. Knowledgeable, high- Occlusion. Catheter occlusions state. Some patients are sensitive ly skilled nurses are instrumental in typically are associated with central to skin-preparation agents or ele- mitigating and preventing peripher- VADs, but SPCs and midline cathe - ments contained in dressing mate- al VAD-associated complications. ters also can be affected. Occlusions rials. Nurses should assess for aller- Vigilant assessment and interven- can increase the risk of catheter-re- gies and must follow manufacturer tion at the point of catheter inser- lated bloodstream infections (CR- instructions when using any prod- tion, throughout the duration of BSI) and cause delays in the thera- ucts on the patient’s skin. To help catheter use, and at catheter discon- peutic regimen. All catheters must prevent skin injury, special atten- tinuation help ensure the safe care be flushed and locked appropriately tion should be paid to the dry patients deserve. to maintain patency and decrease time required for antiseptic and the risk of CR-BSI. site-preparation solutions, careful The authors work at the Infusion Nurses Society in Infection. Infection is a serious, application of the transparent dress- Norwood, Massachusetts. Dawn Berndt is the clinical potentially life-threatening peripher- ing by not stretching, and gentle education and publications manager and Marlene al VAD complication, and preven- dressing removal. Steinheiser is the director of clinical education. tion is essential to patient safety. Phlebitis. Phlebitis is inflamma- Visit americannursetoday.com/?p=57908 for a Peripheral VAD–related infections tion of the vein, which may be list of selected references.

AmericanNurseToday.com September 2019 American Nurse Today 7 Peripheral VAD care, use, and maintenance complications Nurses should recognize the risk factors, signs, and symptoms for peripheral vascular access device (VAD) care-, use-, and maintenance-related complications and apply prevention techniques and interventions as needed.

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

Loss of skin • Fragile skin due to age, disease state, • Redness Prevention integrity or medication regimen • Excoriation • Allow antiseptic and skin-preparation agents to dry completely before • Patient sensitivity or allergy to glue • Blisters placing the dressing. or skin-preparation agents used dur- • Weeping • Follow the manufacturer’s instructions for dressing supplies. ing vascular access and dressing • Check the patient for allergies or sensitivities to dressing and skin- preparation agents before use. Interventions • Consult the provider and/or wound and skin specialist. • Consider using dressing supplies manufactured for sensitive skin.

Catheter • Catheter placement at site of flexion • Signs and symptoms vary depending Prevention embolism without joint stabilization device on location of catheter fragment • Inspect the catheter for defects before insertion. • Catheter defect • When VAD removed, tip fragmentation • Prohibit reinsertion of over-the-needle catheters (for example, pulling noted or entire catheter not intact backward then advancing forward, causing the catheter to be pierced or severed). Interventions • Notify the provider immediately. • If the catheter breaks during removal, apply a tourniquet above the insertion site and place the patient on bedrest. • Obtain radiographic images as ordered. • Monitor the patient for distress or other noticeable changes.

Occlusion • Solution container completely empties • Sluggish infusion or flushing Prevention • Inadequate flushing when adminis- • Inability to infuse or flush • Regularly assess VAD patency. tering medications, drawing blood, • Inability to obtain a blood return • Follow the organization’s flushing and locking guidelines. or locking the VAD • Ensure incompatible infusates aren’t administered through the same • Administration of incompatible med- catheter without adequate flushing between each instillation. ications Intervention • Kinked catheter or administration set • Remove catheter.

Phlebitis Mechanical • Erythema at access site with or with- Prevention (mechanical, • Inappropriate site selection (e.g., area out pain • Do not place the VAD in an area of flexion without joint stabilization. chemical, of flexion) • Pain at access site with erythema or • Select the catheter gauge appropriate for vein size. bacterial) • Inadequate vein size for catheter edema • Adhere to aseptic techniques for insertion, care, use, and maintenance. 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 infusion rate • Initiate prompt removal of the VAD if the vessel is warm to the touch, • Particulate matter painful, or red, or if it has a palpable cord. • Extended catheter dwell time • Use a standardized phlebitis assessment tool. • Irritating medications or solutions • Consult the provider if phlebitis is suspected. • Medications improperly mixed or • Apply a thermal compress to the phlebitic area for 20 minutes three to diluted four times per day per the provider’s order. Bacterial • Chemical: Evaluate the infusion therapy and need for different vascular • Poor hand hygiene access or slower rate of infusion; determine if catheter removal is needed. • Poor aseptic technique when prepar- • Mechanical: Stabilize the catheter, apply heat, elevate the limb, and ing venipuncture site monitor for 24 to 48 hours; if signs and symptoms persist after 48 hours, • Poor catheter insertion technique consider removing the catheter. • Inadequate catheter securement • Bacterial: If bacterial phlebitis is suspected, remove the catheter.

Infiltration/ • Multiple manipulations of infusion • Pain, burning, stinging during infusion Prevention extravasation delivery system • Changes in skin color, blanching, bruis- • Use the smallest catheter in the largest vessel to accommodate the • Large catheter gauge and length ing, or redness near insertion site or on infusion. • Failure to adequately stabilize VAD same extremity • Avoid placing a catheter in areas of flexion and lower extremities in • Patient’s age, medical condition, and • Tight, taut skin adults. (Lower extremities may be cannulated in infants and toddlers acuity when appropriate.) continued

8 American Nurse Today Volume 14, Number 9 AmericanNurseToday.com Peripheral VAD care, use, and maintenance complications continued

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

• Irritating infusate administration • Swelling or edema in any direction • Avoid subsequent cannulations distal to a previous catheter site. • Poor VAD insertion technique from insertion site • Stabilize the catheter to prevent movement at the insertion site. • Inadequate care and maintenance practices • Changes in skin temperature on • Infuse irritating infusates in larger peripheral veins or consider • Extended dwell time extremity central vascular access. • Damage to vein intima • Numbness, tingling • Assess catheter patency before and during medication adminis- • Erosion of vessel by catheter • Fluid leaking from insertion site tration. • Thrombus formation around catheter • Slow capillary refill • Compare the insertion site extremity size with same area on the • Catheter migration out of the vessel • Impaired ability to move extremity or opposite side. digits • Assess the patient for pain. • Blisters Interventions • Stop the infusion immediately if infiltration/extravasation is suspected. • Aspirate fluid from the catheter with a small syringe. • Instill an antidote when warranted (e.g., sodium thiosulfate, dexrazoxane, phentolamine, hyaluronidase) as ordered by the provider. • Remove the catheter before or after antidote instillation as ap- propriate for the antidote order. • Elevate and apply thermal applications as appropriate. • Observe and assess the site for other complications such as compartment syndrome, nerve injury, blisters, and tissue necrosis. • Notify the provider as appropriate based on symptom severity.

Peripheral site • Poor hand hygiene • Pain, swelling, and/or inflammation at Prevention infection • Break in aseptic technique at the time of the insertion site • Perform hand hygiene as directed in the organization’s policy. insertion • Discolored tissue of surrounding area • Maintain aseptic technique when accessing the VAD. • Use of contaminated equipment • Purulent drainage • Maintain a clean, dry, and intact VAD dressing. • Inappropriate catheter securement • Maintain a closed infusion system. • Assess the VAD site regularly for warmth, redness, drainage, and pain. • Assess the patient for signs of infection (elevated temperature, confusion in elderly). Interventions • Notify the provider if an infection is suspected. • Remove the catheter and culture if ordered to determine if it’s the source of the infection. • If there is drainage at the site, culture it before removing the catheter. • Initiate anti-infective therapy as ordered.

Bacteremia/ • Immunosuppression or immunodeficiency • Fever Prevention septicemia • Severe chronic illness • Chills • Perform hand hygiene before placement and before providing • Administration of multiple infusions • General malaise VAD-related interventions. • Extended hospitalization • Headache • Disinfect needleless connectors before access. • Concurrent infection • Increased pulse rate • Maintain aseptic technique during all infusion therapy adminis- • Leukopenia • Flushed face trations and VAD care. • Patient’s age, medical condition, and acuity • Backache • Remove VADs that are no longer needed. • Burns • Nausea • Change administration set and add-on devices at recommend- • Vomiting ed intervals. • Hypotension • Minimize the use of add-on devices. Interventions • Notify the provider if infection is suspected. • Remove the catheter and culture to determine if it is the source of infection. • Obtain blood cultures as ordered. • Administer antibiotics as ordered. Source: Alexander et al. 2014

AmericanNurseToday.com September 2019 American Nurse Today 9 CNE Short peripheral and midline catheter complications POST-TEST • CNE: 1.62 contact hours Earn contact hour credit online at americannursetoday.com/article-type/continuing-education/

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cation and Professional Development is accredited as a pro- ANA Center for Continuing Education and Professional Devel- vider of continuing nursing education by the American Nurses opment’s accredited provider status refers only to CNE activities Credentialing Center’s Commission on Accreditation. ANCC and does not imply that there is real or implied endorsement of Provider Number 0023. any product, service, or company referred to in this activity nor Contact hours: 1.62 of any company subsidizing costs related to the activity. The ANA’s Center for Continuing Education and Professional Devel- author and planners of this CNE activity have disclosed no rele- opment is approved by the California Board of Registered Nurs- vant financial relationships with any commercial companies ing, Provider Number CEP6178 for 1.94 contact hours. pertaining to this CNE. See the banner at the top of this page to learn how to earn CNE credit.

Please mark the correct answer online. c. Drainage at the site of insertion should 9. Which statement about extravasation be cultured after removing the and infiltration is correct? 1. Which of the following could cause a catheter. a. Extravasation is the inadvertent instilla- hematoma to occur during venipuncture? d. Drainage at the site of insertion should tion of infusate into the tissues external a. Reinserting a needle into an over-the- be cultured before removing the to the vessel. needle catheter catheter. b. Extravasation is the inadvertent instilla- b. Shearing or severing of the catheter tion of vesicant solution into the tis- c. Penetrating through the vessel’s back 5. When you discontinue your patient’s sues external to the vessel. wall midline catheter, you find that the tip is c. Infusate is a solution that can cause tis- d. Failing to properly cleanse the insertion fragmented. The first complication you sue damage. area would suspect is d. Vessicant is an agent administered into a. infection. the vascular system. 2. Hematoma prevention includes all of b. catheter embolism. except the following c. hematoma. 10. An SPC is a. having only clinicians with validated d. phlebitis. a. less than 3" (7.6 cm) long. competency perform venipuncture. b. less than 6" (15.2 cm) long. b. using a stabilization device or a dress- 6. Inadequate flushing of a peripheral c. inserted into the upper arm. ing with an integral stabilization fea- VAD when administering medications or d. located with its tip level to the axilla. ture. drawing blood could lead to c. limiting the number of insertion at- a. hematoma. 11. Which statement about infection and tempts to three or four and avoiding b. phlebitis. peripheral VADs is correct? “digging.” c. embolism. a. Infections related to peripheral VADs d. using visualization technologies to aid d. occlusion. are exclusively localized. in vessel identification during VAD in- b. Infections related to peripheral VADs sertion. 7. A risk factor for chemical phlebitis is can be localized or systemic. a. improperly mixed medications. c. Pre-existing leukocytosis is a risk factor 3. A peripheral VAD catheter breaks as b. slow infusion rate. for infection. you are removing it. You should c. inadequate securement. d. The number of infusions does not af- a. apply a tourniquet below the insertion d. wrong catheter gauge. fect risk of infection. site. b. apply a tourniquet above the insertion 8. To help prevent phlebitis in your pa- 12. To avoid skin problems in your patient site. tient who needs a short peripheral who will receive a midline catheter, you c. assist the patient to sit in a chair. catheter (SPC), you plan to plan to d. provide walking assistance to the a. choose a catheter gauge appropriate a. avoid sensitive skin dressing supplies. patient. to vein size. b. use standard dressing supplies. b. secure the catheter with hypoallergenic c. allow antiseptic and skin-preparation 4. Which of the following statements tape. agents to dry completely before plac- about infection of a peripheral VAD is cor- c. place the catheter in an area of flexion. ing the dressing. rect? d. use half the recommended amount of d. avoid allowing antiseptic and skin- a. Signs and symptoms of infection in- medication diluent. preparation agents to dry completely clude decreased heart rate. before placing the dressing. b. Signs and symptoms of infection in- clude hypertension.

10 American Nurse Today Volume 14, Number 9 AmericanNurseToday.com