Venous access devices-managing common problems

Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

Oncology Nursing Consultant

New Orleans, LA

LisaSchulmeister@hotmail.com

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.