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Complications of CVCs and their nursing management

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VOL: 97, ISSUE: 20, PAGE NO: 36

Liz Simcock, BA, RGN, is clinical nurse specialist for central venous access, Meyerstein Institute of Oncology, Middlesex Hospital, London

Various complications can arise during the management of patients with central venous catheters (CVCs).

Various complications can arise during the management of patients with central venous catheters (CVCs). It is vital that nurses are aware of the signs and symptoms of these so that they can take swift action to remedy the situation in the most appropriate way.

Air embolism

This is an emergency that can occur when air enters the circulation via the CVC.

Signs and symptoms

Acute onset of any or all of the following:

- Anxiety;

- Pallor/cyanosis;

- Shortness of breath;

- Rapid, weak pulse;

- Hypotension;

- Chest pain;

- Loss of consciousness.

Nursing management

- Clamp or pinch catheter proximal to air entry point immediately;

- Turn patient onto left side and position the patient with the head lower than the body if possible. This will encourage the air embolus to move to the right atrium, preventing it from obstructing blood flow to the right ventricle and lungs (Belcaster, 1997);

- Call for crash team or medical assistance.

Pneumothorax

This refers to the presence of air in the pleural cavity and can occur during insertion of the CVC, but may not be noticed until later. The severity of pneumothorax ranges from the clinically insignificant to the imminently life-threatening.

Signs and symptoms

- Increased respiratory rate;

- Respiratory distress;

- Tachycardia;

- Reduced oxygen saturation levels;

- Hypotension.

Nursing management

- Call for assistance and monitor vital signs;

- Nursing staff in acute settings with appropriate skills should react as they would to any emergency, according to the patient’s condition;

- Refer to medical staff with a view to chest X-ray and possible correction of pneumothorax.

Infection

Infection is one of the most frequent and serious complications associated with central-line catheters (Haller and Rush, 1992). Most catheter-related bloodstream infections are bacterial (predominantly staphylococci), but they may also be fungal, especially in severely immunosuppressed patients (Krzywda et al, 1999). Patients’ skin and health care workers’ hands are the predominant sources of pathogens (Hadaway, 1998). Micro-organisms migrate from the skin down the catheter tract and colonise the catheter tip. The catheter hub is also an important source of micro-organisms, especially in long-term catheters.

Infection may occur either within the catheter or at the exit site or skin tunnel. Risk factors are:

- Length of time the catheter is in situ (Cunha, 1995; Wilson, 1994);

- Inadequate preparation of catheter insertion site (Cook, 1999);

- Poor aseptic technique (Haller and Rush, 1992);

- Larger lumens, multiple lumens and stopcocks (Haller and Rush, 1992; Wilson, 1994);

- ‘To-and-fro’ motion of the catheter (Haller and Rush, 1992);

- Thrombosis, fibrin sheath or clot formation (Krzywda, 1999);

- Administration of total parenteral nutrition (Jones, 1998);

- Ineffective patient education (Richard-Smith and Buh, 1995);

- Inadequate training of nurses and carers and poor documentation (Richard-Smith and Buh, 1995; Haller and Rush, 1992);

- Material from which catheter is made. Teflon and polyurethane catheters appear to be most resistant to infection (Wilson, 1994; Hadaway, 1998). There is also evidence that catheters impregnated with chlorhexidine and silver sulfadiazine, or bonded with minocycline and rifampicin, are associated with lower risks of infection (Cook, 1999), though the Department of Health’s recent guidelines indicate that this is only in short-term catheters (

Signs and symptoms

- Pyrexia, rigor after flushing;

- Sore throat;

- Generally feeling unwell;

- Hypotension, tachycardia and shock.

At the exit site/in the skin tunnel:

- Redness/oedema;

- Pain;

- Discharge.

Nursing management

Infection is potentially life-threatening, especially in immunosuppressed patients. There is controversy as to whether successful treatment of a catheter-related bloodstream infection can occur without the removal of the catheter (Krzywda et al, 1999). Most authors recommend removal if there is no other evident source of infection or if blood cultures are positive (Haller and Rush, 1992). This is particularly important in the case of candidaemia, which is associated with a high morbidity (Jones, 1998).

Recommended action

- Refer to medical staff immediately, with a view to antibiotic therapy and/or removal of line;

- Take blood cultures from each line separately and peripherally (Haller and Rush, 1992); note that the fluid withdrawn from the CVC should be included in the blood cultures and not discarded, as in other blood tests (Jones, 1998);

- If blood cultures indicate a catheter-related infection, Department of Health guidelines state that the catheter should be removed. If continued venous access is required, a new catheter should be inserted at a different site (Pratt, 2001);

- Four-hourly temperature, pulse, respiration (TPR) and blood pressure (BP), if patient is in hospital.

At the exit site or in the skin tunnel:

- Take swab from the exit site for microbial analysis;

- Refer to medical staff to consider antibiotics and blood cultures (from each line separately and also peripherally);

- Daily inspection and cleaning of entry site with sterile 0.9% saline until infection is resolved;

- Four-hourly TPR and BP, if patient is in hospital.

Thrombosis

The presence of a CVC leads to a risk of thrombosis. Mechanical, chemical or bacterial factors can all contribute to the risk, as can poor catheter placement technique (Krzywda, 1999), insufficient flushing or inadequate flow through the catheter (Cornock, 1996). The risk is increased in patients who are pregnant, those who have diabetes or cancer, or those who have had surgery or chemotherapy (Hadaway, 1998).

Signs and symptoms

- Oedema at or around entry site (Cornock, 1996);

- Erythema (Cornock, 1996);

- Oedema of arm, neck and/or face, with associated pain, tingling or numbness (Kayley, 1997; Cornock, 1996);

- Distension of neck veins and/or peripheral vessels

- Catheter occlusion (Krzywda, 1999).

Nursing management

- Refer to medical staff immediately.

Catheter fracture

This may occur externally after accidental cutting of the line or repeated clamping outside a designated clamping area, or internally in tunnelled CVCs as a result of ‘pinch-off’ (to be covered in part four of this series). Internal fracture carries a risk of catheter embolism - a portion of the catheter shears off and is carried to the heart via the venous circulation.

Signs and symptoms

You should suspect external fracture if there is:

- Obvious fracture on inspection of line;

- Leakage of blood or fluids;

- Signs and symptoms of air embolism.

You should suspect internal fracture if there is:

- Pain, redness and/or swelling on flushing or administration of fluids;

- Partial or withdrawal occlusion;

- Signs of catheter embolism (that is, acute onset of any or all of the following: anxiety, pallor, cyanosis, shortness of breath, rapid weak pulse, hypotension, chest pain, loss of consciousness);

- Erythema, as in thrombosis (Cornock, 1996);

- Ipsilateral swelling of arm, neck and/or face with associated pain, tingling or numbness, as in thrombosis (Kayley, 1997; Cornock, 1996).

Nursing management

External fracture:

- Clamp catheter proximal to site of fracture;

- Refer to medical staff with a view to urgent removal of catheter;

- In tunnelled CVCs and peripherally inserted central catheters (PICCs), consider repairing catheter according to the manufacturer’s instructions, taking into account the patient’s vulnerability to infection.

Internal fracture:

- Stop any infusion immediately and clamp line;

- Refer to medical staff immediately, even when signs and symptoms of embolism are not evident;

- Internal fracture can be demonstrated by fluoroscopic X-ray investigation. Removal of the line is indicated if internal fracture is confirmed;

- If catheter embolism is suspected, this is an emergency. Respond to symptoms as you would to any acute medical emergency.

Incorrect position

Ideally, the tip of a CVC should lie parallel to the vein wall and float freely inside the bloodstream (Hadaway, 1998). Placement in the superior vena cava, with its copious blood flow and large diameter, is ideal for this purpose.

Fluoroscopic X-ray guidance may or may not be used during CVC insertion. When it is not, there is a risk that the catheter may be wrongly positioned, for example, with the proximal tip advanced too far into the atrium, jammed up against a vessel wall or fed into a neck vein.

Even when X-ray guidance is used, the catheter may change position in the patient’s circulatory system. Changes in intrathoracic pressure, coughing, sneezing, Valsalva manoeuvre (such as during heavy lifting), vigorous use of extremities, forceful flushing or congestive heart failure can lead to migration of the tip (Hadaway, 1998).

Signs and symptoms:

- Partial occlusion, shown by sluggish or intermittent free-flow or by absence of flashback;

- Discomfort or other unexplained sensations during infusion or flushing;

- Engorgement of neck veins;

- Cardiac arrhythmias, which can occur when the tip of the CVC lies in the right atrium (Kazerooni and Cascade, 1999).

Nursing management

Incorrect placement may or may not be an indication for removal. With PICCs, cases have been documented where lines that had become looped within the venous system reverted to the proper position after several hours, though it is not clear whether this happened spontaneously or as a result of brisk flushing using a pulsing action (Banks, 1999). This could be tried before replacing a PICC.

If incorrect positioning is suspected:

- Refer to medical staff for chest X-ray and/or angiogram to investigate position of the line.

Catheter migration

This may be indicated by an increase in the external length of the catheter. With tunnelled CVCs, the cuff may fail to become fixed to the tissues and may become visible (see below).

Nursing management

- Using tape or sterile adhesive strips, secure the line to prevent further movement;

- Refer to medical staff for X-ray verification of tip position;

- The line may need to be removed, resutured or secured with sterile adhesive strips once confirmation of position is obtained.

Cuff dislodgement (tunnelled CVCs)

The cuff in a tunnelled CVC may become dislodged or fail to adhere to the tissues after insertion (Jones, 1998). If it becomes visible and has not adhered to the patient’s tissues there is a high risk of the catheter falling out, unless it is sutured or secured with sterile adhesive strips. There is also an increased risk of infection in the skin tunnel, which may lead to infection tracking up and into the vein.

Nursing management

- The line is usually removed and replaced (Jones, 1998), unless you wish to preserve it for one more treatment, such as chemotherapy.

Phlebitis (in PICCs)

Phlebitis (inflammation of a vein) occurs in patients with PICCs and may be mechanical or infective in origin.

Mechanical phlebitis may occur as a result of ‘particulate matter and damage to the venous intima during forceful insertion or excessive movement of the PICC’ (Todd, 1998). It is more likely to happen with larger bore PICCs in patients with smaller veins (Todd, 1998). (Nurses in our trust believe that advising patients to apply a warm compress, such as a hot flannel, to the arm proximal to the insertion site every few hours for the first two days after the PICC is placed helps to prevent mechanical phlebitis.)

Infective phlebitis can usually be differentiated from mechanical phlebitis by the presence of inflammation and exudate at the exit site.

Signs and symptoms

Mechanical phlebitis

- Pain, redness, warmth, venous cord (a hard, palpable, thrombosed vein), induration (hardness) and swelling occurring along the vein, usually within seven days of PICC insertion (Todd, 1998);

- Absence of purulent discharge.

Infective phlebitis

- Pain, inflammation, redness, warmth, venous cord, induration and/or swelling occurring along the vein;

- Purulent discharge;

- Positive swab cultures.

Nursing management

Mechanical phlebitis

- Take a wound swab in case the phlebitis is infective after all;

- Apply warm compresses every few hours;

- Encourage patient to keep arm elevated;

- Advise gentle arm exercise;

- Refer to medical staff to consider a non-steroidal anti-inflammatory for pain until phlebitis resolves;

- Consider line removal if these measures do not resolve the problem within 72 hours.

Infective phlebitis

- Take swab from exit site for microbial analysis;

- Refer to medical staff to consider removal or antibiotics and blood cultures (from each lumen separately);

- Daily inspection and cleaning of entry site with sterile 0.9% saline until infection is resolved;

- Four-hourly TPR and BP, if patient is in hospital;

- The line should be removed if the patient becomes acutely unwell or if the infection fails to respond to antibiotic therapy (Todd, 1998).

- Occlusion is the most common non-infectious complication of CVCs (Krzywda, 1999). The causes, signs, symptoms and management of occlusion are dealt with in depth in part four of this series.

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