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- num ber 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