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- are subject to complications that 1.67 contact dards of Practice state: hours 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 complica- tions 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 in- fusion 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