Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN
Oncology Nursing Consultant
New Orleans, LA
LisaSchulmeister@hotmail.com
Ve...
Common Venous Access Device Problems
 Thrombosis or fibrin sheath at catheter tip
 Catheter-related infection
 Catheter...
Overall complication rate
 1.8% - 14.4% (DiCarlo et al., 2001)
 Most common complications:
--- venous thrombosis
--- inf...
Most common reasons for device removal
(Fischer et al., 2008)*
 Infection (46%)
 End of treatment (34%)
 Thrombosis (11...
Education of healthcare providers
The most important strategy for the
prevention of venous access-related
problems (O’Grad...
Devices lacking blood return
 Place patient in supine position
 Use a 10 mL saline syringe to gently
“push-pull”
 53% s...
If repositioning and flushing are not
successful
 Attempt to withdraw blood using 20 mL
syringe
 Dye study or instill a ...
Fibrin sleeve or thrombus formation
Thrombotic complications (Kuter,
2004)
 Within days of insertion, most catheters
are coated with a fibrin sheath.
 Most ...
Local catheter-related infection
 Risk factors
--- Poor insertion or care technique
--- Superficial port placement
--- He...
Local (port pocket) infection
 Culture site
 Local wound care
 Systemic antibiotics
 Remove device if pseudomonas spec...
Local infection
 Actions to manage
Local infections most commonly due to
Staphlococcus epidermidis
 Frequent wound care
...
Systemic catheter-related infection
 Risk factors
--- Grade 4 neutropenia
--- Prolonged neutropenia
--- Administration of...
Systemic infection
 Actions to manage
Most common organism is coagulase-
negative Staphlococcus
 Quantitative blood cul...
Systemic infection
 Actions to manage
Systemic antibiotics
Removal of catheter with persistent fever
or bacteria for 3 ...
The Central Line Bundle
(Institute for Healthcare Improvement, 2006)
 Hand hygiene
 Maximal sterile barrier precautions ...
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%)
 contra...
Catheter tip in right internal
jugular 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
recent...
References
Di Carlo, I., et al. (2002). Totally implantable venous access devices implanted
surgically: A retrospective st...
Kuter, D. J. (2004). Thrombotic complications of central venous catheters in
cancer patients. Oncologist 9, 207-216.
Maki,...
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  • Venous access devices-managing common problems

    1. 1. Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN Oncology Nursing Consultant New Orleans, LA LisaSchulmeister@hotmail.com Venous Access Devices: Managing Common Problems
    2. 2. Common Venous Access Device Problems  Thrombosis or fibrin sheath at catheter tip  Catheter-related infection  Catheter malposition  Device damage or malfunction  Extravasation injury
    3. 3. Overall complication rate  1.8% - 14.4% (DiCarlo et al., 2001)  Most common complications: --- venous thrombosis --- infection
    4. 4. 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
    5. 5. Education of healthcare providers The most important strategy for the prevention of venous access-related problems (O’Grady et al., 2002).
    6. 6. 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)
    7. 7. 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
    8. 8. Fibrin sleeve or thrombus formation
    9. 9. 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.
    10. 10. Local catheter-related infection  Risk factors --- Poor insertion or care technique --- Superficial port placement --- Heat, moisture, friction while port is accessed
    11. 11. 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
    12. 12. 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
    13. 13. 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)
    14. 14. Systemic infection  Actions to manage Most 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
    15. 15. Systemic infection  Actions to manage Systemic antibiotics Removal of catheter with persistent fever or bacteria for 3 days with antibiotics, especially if Staphlococcus aureus
    16. 16. 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
    17. 17. Catheter malposition  May occur upon insertion  Catheter tips may migrate over time
    18. 18. 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)
    19. 19. Catheter tip in right internal jugular vein
    20. 20. Catheter tip perforating the superior vena cava (pleural effusion seen on CT)
    21. 21. Catheter tip that migrated and flipped in internal jugular vein
    22. 22. Catheter backing out of vein over time
    23. 23. Catheter that has completely backed out of the vein and is now coiled in the subcutaneous tissue
    24. 24. Catheter damage  May occur prior to or during insertion  May occur over time
    25. 25. Accidental nicking or piercing of the tubing upon insertion
    26. 26. Forauer et al., 2005 Twiddler’s syndrome
    27. 27. Catheter migration to the internal jugular vein with incomplete fracture
    28. 28. Pinch-off syndrome (compression between the clavicle and rib)
    29. 29. Extravasation injury  More common with implanted ports than percutaneous central venous catheters
    30. 30. Incomplete non-coring (Huber) needle placement
    31. 31. Misplacement of non-coring needle on rim of septum of port
    32. 32. Back-tracking of vesicant along the catheter to the venotomy site
    33. 33. Device separation
    34. 34. 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.
    35. 35. References Di 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/Implement theCentralLineBundle.htm.
    36. 36. 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 of common complications. J Intrav Nurs 16, 44-49.

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