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Venous access devices-managing common problems






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Venous access devices-managing common problems Venous access devices-managing common problems Presentation Transcript

  • Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN Oncology Nursing Consultant New Orleans, LA [email_address] 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 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
  • Systemic infection
    • Actions to manage
      • Systemic antibiotics
      • Removal 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 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 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.
  • 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/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 of common complications. J Intrav Nurs 16 , 44-49.