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NursingNursing ManagementManagement ofof VenousVenous AccessAccess Devices:Devices:

ComplicationsComplications andand TroubleshootingTroubleshooting

MimiMimi Bartholomay,Bartholomay, RN,RN, MSN,MSN, AOCNAOCN DeniseDenise DreherDreher,, RN,RN, CRNI,CRNI, VAVA--BCBC TheresaTheresa Evans,Evans, RN,RN, MSNMSN SusanSusan Finn,Finn, RN,RN, MSN,MSN, AOCNSAOCNS DebraDebra Guthrie,Guthrie, RN,RN, CRNICRNI HannahHannah Lyons,Lyons, RN,RN, MSN,MSN, AOCNAOCN JanetJanet Mulligan,Mulligan, RN,RN, MS,MS, VAVA--BCBC CarolCarol TyksienskiTyksienski,, M.S.,R.N.,N.PM.S.,R.N.,N.P

Mulligan, RN, RN, MS, MS, VA VA - - BC BC Carol Carol Tyksienski Tyksienski ,

TheThe ThreeThree BiggiesBiggies

PhlebitisPhlebitis

Three Biggies Biggies … …   Phlebitis Phlebitis   Extravasation Extravasation

ExtravasationExtravasation

InfiltrationInfiltration Dilantin extravasation Images retrieved from www.iv ‐therapy.net 10/6/09
InfiltrationInfiltration
Dilantin extravasation
Images retrieved from www.iv ‐therapy.net 10/6/09

PhlebitisPhlebitis inin PeripheralPeripheral IVsIVs

PhlebitisPhlebitis hashas longlong beenbeen recognizedrecognized asas aa riskrisk forfor infection.infection. ForFor adults,adults, lowerlower extremityextremity insertioninsertion sitessites areare associatedassociated withwith aa higherhigher riskrisk forfor infectioninfection thanthan areare upperupper extremityextremity sites.sites. IntravenousIntravenous NursingNursing SocietySociety (INS)(INS) phlebitisphlebitis scale;scale;

  GradeGrade 00 nono symptomssymptoms GradeGrade 11 erythemaerythema atat insertioninsertion sitesite


GradeGrade 00 nono symptomssymptoms
GradeGrade 11 erythemaerythema atat insertioninsertion sitesite withwith oror withoutwithout painpain
GradeGrade 22 painpain atat insertioninsertion site;site; withwith erythemaerythema and/orand/or edemaedema


GradeGrade 33 painpain atat insertioninsertion site;site; withwith erythemaerythema and/orand/or edema;edema;
streakstreak formation;formation; palpablepalpable venousvenous cordcord
GradeGrade 44
painpain atat insertioninsertion site;site; withwith erythemaerythema and/orand/or edema;edema;

streakstreak formation;formation; venousvenous cordcord >> 11”” inin length;length; andand purulentpurulent
drainagedrainage

PreventionPrevention andand TreatmentTreatment ofof PhlebitisPhlebitis

Prevention:Prevention:

WhenWhen inin doubt,doubt, taketake itit outoutDilutionDilution ofof infusateinfusate DecreaseDecrease raterate ofof infusioninfusion PiggyPiggy--backbackwithwith mainlinemainline IVIV WarmWarm compresscompress toto promotepromote vasodilationvasodilation andand hemodilutionhemodilution DeviceDevice securementsecurement // stabilizationstabilization

 TreatmentTreatment  RemovalRemoval ofof cathetercatheter  ApplicationApplication ofof warmwarm
 TreatmentTreatment
 RemovalRemoval ofof cathetercatheter
 ApplicationApplication ofof warmwarm compressescompresses atat insertioninsertion sitesite
 DocumentationDocumentation ofof phlebitisphlebitis andand thethe subsequentsubsequent
treatmenttreatment

InfiltrationInfiltration

Definition:Definition: inadvertentinadvertent administrationadministration ofof nonnon--vesicantvesicant medicationmedication oror solutionsolution intointo thethe surroundingsurrounding tissuetissue (INS,(INS,

2011)2011)

Images retrieved from www.IV-therapy.net 10/6/09
Images retrieved from www.IV-therapy.net 10/6/09

INSINS InfiltrationInfiltration ScaleScale

GradeGrade 00 -- nono symptomssymptoms

GradeGrade 11 -- skinskin blanched,blanched, edemaedema << 11inin anyany direction,direction, coolcool toto touch,touch, withwith oror withoutwithout painpain GradeGrade 22 -- skinskin blanched,blanched, edemaedema 11--66inin anyany direction,direction, coolcool toto touch,touch, withwith oror withoutwithout painpain GradeGrade 33 -- skinskin blanchedblanched andand translucent,translucent, grossgross edemaedema >>

66inin anyany direction,direction, coolcool toto touch,touch, mildmild toto moderatemoderate pain,pain, possiblepossible numbnessnumbness GradeGrade 44 -- skinskin blanchedblanched andand translucent,translucent, skinskin tighttight andand leaking,leaking, discolored,discolored, bruisedbruised andand swollen,swollen, grossgross edemaedema >> 66inin anyany direction,direction, deepdeep pittingpitting tissuetissue edema,edema, circulatorycirculatory impairment,impairment, moderatemoderate toto severesevere pain,pain, infiltrationinfiltration ofof ANYANY amountamount ofof bloodblood product,product, irritant,irritant, oror vesicant.vesicant.

amount of of blood blood product, product, irritant, irritant, or or vesicant. vesicant.   

TreatmentTreatment ofof InfiltrationInfiltration

DiscontinueDiscontinue infusioninfusion ElevateElevate extremityextremity WarmWarm compresses,compresses, NOTNOT HOT,HOT, forfor normalnormal oror highhigh pH/alkalinepH/alkaline solutionsolution (ex:(ex: D5W)D5W) ColdCold compressescompresses forfor lowlow pH/acidicpH/acidic solutionssolutions (( ex:ex: vancovanco)) **Caution**Caution withwith infiltratedinfiltrated solution;solution; ex.ex.-- morphinemorphine PCAPCA resumptionresumption withwith subcutaneoussubcutaneous morphinemorphine infiltrateinfiltrate DocumentationDocumentation ofof infiltrateinfiltrate andand subsequentsubsequent treatmenttreatment

  Documentation Documentation of of infiltrate infiltrate and and subsequent subsequent treatment treatment

ExtravasationExtravasation

InadvertentInadvertent administrationadministration ofof vesicantvesicant medicationmedication oror solutionsolution intointo thethe surroundingsurrounding tissuetissue (INS,(INS, 2011)2011) DefinitionDefinition ofof aa vesicantvesicant drugdrug anyany IVIV drugdrug thatthat cancan causecause blistering,blistering, severesevere tissutissuee injuryinjury oror tissuetissue necrosisnecrosis whenwhen extravasatedextravasated

Image retrieved from www.IV-therapy.net 10/6/09
Image retrieved from www.IV-therapy.net 10/6/09

ExtravasationExtravasation

ExtravasationExtravasation shouldshould alwaysalways bebe gradegrade 44 onon thethe infiltrationinfiltration

scale.scale. ThisThis includesincludes anyany amountamount ofof vesicant,vesicant, bloodblood product,product, oror irritant.irritant. IncidenceIncidence isis similarsimilar forfor peripheralperipheral andand centralcentral lineline administrationadministration

RiskRisk factors,factors, suchsuch asas fragilefragile vessels,vessels, locationlocation ofof peripheralperipheral iviv,, oror cathetercatheter integrityintegrity areare thingsthings toto considerconsider

AntidotesAntidotes maymay bebe used;used; referrefer toto clinicalclinical resourcesresources forfor

guidance,guidance, andand obtainobtain orderorder ifif indicatedindicated ManyMany nonnon--chemotherapychemotherapy agentsagents havehave vesicantvesicant propertiesproperties (e.g.(e.g. Dopamine,Dopamine, Epinephrine,Epinephrine, GentamycinGentamycin,, MannitolMannitol)) ExtravasationExtravasation isis stillstill possible,possible, eveneven inin thethe presencepresence ofof aa positivepositive bloodblood return.return.

  ReferRefer toto MGHMGH NursingNursing PoliciPolicieses andand ProceduresProcedures TroveTrove


ReferRefer toto MGHMGH NursingNursing PoliciPolicieses andand ProceduresProcedures TroveTrove 0808--0202--0101

SignsSigns andand SymptomsSymptoms ofof ExtravasationExtravasation

EarlyEarly warningwarning signssigns ofof possiblepossible extravasationextravasation

SwellingSwelling Stinging,Stinging, burningburning oror painpain atat IVIV sitesite IVIV flowflow thatthat stopsstops oror slowsslows LeakingLeaking aroundaround thethe portport needleneedle LackLack ofof bloodblood returnreturn ErythemaErythema,, inflammationinflammation oror blanchingblanching

needleneedle LackLack ofof bloodblood returnreturn ErythemaErythema ,, inflammationinflammation oror blanchingblanching
needleneedle LackLack ofof bloodblood returnreturn ErythemaErythema ,, inflammationinflammation oror blanchingblanching
needleneedle LackLack ofof bloodblood returnreturn ErythemaErythema ,, inflammationinflammation oror blanchingblanching
needleneedle LackLack ofof bloodblood returnreturn ErythemaErythema ,, inflammationinflammation oror blanchingblanching
needleneedle LackLack ofof bloodblood returnreturn ErythemaErythema ,, inflammationinflammation oror blanchingblanching

OtherOther symptoms/damagesymptoms/damage resultingresulting fromfrom extravasationextravasation::

IndurationInduration VesicleVesicle FormationFormation NecroticNecrotic tissuetissue damagedamage cancan progressprogress forfor 66 monthsmonths SloughingSloughing Tendon,Tendon, nerve,nerve, jointjoint damagedamage blisteringblistering atat insertioninsertion sitesite ulcerationulceration isis usuallyusually seenseen 22--33 daysdays toto weeksweeks followingfollowing extravasationextravasation

      








ManagementManagement ofof ExtravasationExtravasation

TREATMENTTREATMENT

IMMEDIATELYIMMEDIATELY STOPSTOP INFUSIONINFUSION RemoveRemove tubingtubing fromfrom IV,IV, leaveleave cathetercatheter oror needleneedle inin place,place, attachattach syringesyringe toto IVIV cathetercatheter AttemptAttempt toto aspirateaspirate residualresidual drugdrug ElevateElevate extremityextremity NotifyNotify MDMD andand clinicalclinical resourcesresources asas soonsoon asas possiblepossible ApplyApply cold/heatcold/heat asas indicated.indicated. InIn General:General:

•• AllAll drugsdrugs exceptexcept VincaVinca alkaloids,alkaloids, etoposideetoposide,, andand
•• AllAll drugsdrugs exceptexcept VincaVinca alkaloids,alkaloids, etoposideetoposide,, andand
catecholaminescatecholamines……applyapply ICEICE forfor 1515--2020 minutesminutes (minimum(minimum ofof
QID)QID) forfor 4848 hrshrs
•• ForFor vincavinca alkaloids,alkaloids, etoposideetoposide andand catecholaminescatecholamines……applyapply
heatheat forfor 1515--2020 minutesminutes (minimum(minimum ofof QID)QID) forfor 4848 hourshours

ReferRefer toto MGHMGH NursingNursing PoliciesPolicies andand ProceduresProcedures TroveTrove
0808--0202--0101 oror CALLCALL PHARMACYPHARMACY forfor specificspecific antidoteantidote

ExtravasationExtravasation ManagementManagement

DOCUMENTATIONDOCUMENTATION

MedicalMedical recordrecord SafetySafety reportreport

PostPost extravasationextravasation care:care:

DocumentDocument andand considerconsider photographingphotographing sitesite InstructInstruct patientpatient aboutabout cold/heatcold/heat applicationapplication PatientPatient andand familyfamily educationeducation ofof symptomssymptoms toto reportreport immediately,immediately, carecare ofof site,site, followfollow--upup appointmentappointment ifif neededneeded AnticipateAnticipate consultconsult toto plasticplastic surgerysurgery oror dermatologydermatology PRNPRN

Anticipate Anticipate consult consult to to plastic plastic surgery surgery or or dermatology dermatology PRN PRN

Port extravasation

Used with permission from Lisa Schulmeister 1/2011
Used with permission from Lisa Schulmeister 1/2011
Used with permission from Lisa Schulmeister 1/2011
Used with permission from Lisa Schulmeister 1/2011

OtherOther PotentialPotential ComplicationsComplications ofof CentralCentral VADsVADs

CentralCentral LineLine InfectionInfection

LineLine sepsissepsis PortPort pocketpocket infectioninfection

CatheterCatheter occlusionocclusion

FibrinFibrin sheathsheath ThrombosisThrombosis ThromboembolismThromboembolism

AirAir embolismembolism BleedingBleeding CardiacCardiac arrhythmiasarrhythmias PortPort erosionerosion throughthrough thethe skinskin CatheterCatheter migrationmigration IntoleranceIntolerance reactionreaction toto VADVAD

 CatheterCatheter rupture/Fracturerupture/Fracture  DeviceDevice rotationrotation
 CatheterCatheter
rupture/Fracturerupture/Fracture
 DeviceDevice rotationrotation

CentralCentral LineLine InfectionInfection

InsertionInsertion site:site: ReportableReportable signssigns andand symptomssymptoms

AnyAny rednessredness ((erythemaerythema)) Leaking,Leaking, bloody,bloody, oror purulentpurulent drainagedrainage TissueTissue inflammationinflammation oror indurationinduration TendernessTenderness toto palpationpalpation

 DoDo notnot accessaccess aa portport withwith aboveabove signssigns andand symptomssymptoms
 DoDo notnot accessaccess aa portport withwith aboveabove signssigns
andand symptomssymptoms

TroubleshootingTroubleshooting OcclusionsOcclusions

CompleteComplete cathetercatheter occlusionocclusion

InternalInternal thrombusthrombus DrugDrug precipitateprecipitate

InternalInternal thrombusthrombus DrugDrug precipitateprecipitate

WithdrawalWithdrawal occlusionocclusion

FibrinFibrin sheathsheath causescauses cacathetertheter toto actact likelike aa oneone--wayway valvevalve PinchPinch--offoff syndromesyndrome

causescauses caca thetertheter toto actact likelike aa oneone -- wayway valvevalve PinchPinch -- offoff syndromesyndrome

DoesDoes CVADCVAD flushflush freelyfreely andand havehave aa positivepositive bloodblood return?return? IfIf not:not:

   CheckCheck forfor kinkskinks inin externalexternal cathetercatheter oror tubingtubing CheckCheck



CheckCheck forfor kinkskinks inin externalexternal cathetercatheter oror tubingtubing
CheckCheck clampsclamps
ChangeChange needlelessneedleless connectorconnector oror implantedimplanted portport needleneedle
RepositionReposition patientpatient (on(on side,side, TrendelenburgTrendelenburg etcetc……),), askask patientpatient toto

cough,cough, raiseraise handshands aboveabove heahead,d, taketake deepdeep breath,breath, leanlean
forwardforward……justjust aboutabout anything!anything!
ConsiderConsider needneed forfor thrombolyticthrombolytic agentagent (t(t--PA)PA)


TroubleshootingTroubleshooting OcclusionsOcclusions

ObtainObtain orderorder forfor tt--PAPA instillationinstillation toto lumen(slumen(s)) ifif

flowflow isis sluggishsluggish oror bloodblood returnreturn isis absent.absent. IfIf tt--PAPA unsuccessfulunsuccessful afterafter secondsecond instillation,instillation, notifynotify providerprovider andand considerconsider repeatrepeat CXRCXR and/orand/or IRIR referralreferral forfor dyedye studystudy PreventionPrevention ofof occlusionocclusion isis key!key!

PushPush--pausepause oror pulsatilepulsatile flushflush techniquetechnique IncreasedIncreased salinesaline flushflush volumevolume afterafter bloodblood drawsdraws FlushFlush immediatelyimmediately afterafter infusionsinfusions oror bloodblood drawsdraws areare completedcompleted

 ReferRefer toto NursingNursing PoliciesPolicies andand ProceduresProcedures TroveTrove 0505--0303--0909

ReferRefer toto NursingNursing PoliciesPolicies andand ProceduresProcedures TroveTrove
0505--0303--0909

TissueTissue PlasminogenPlasminogen ActivatorActivator tt--PAPA ((AlteplaseAlteplase))

ReferRefer toto MGHMGH MedicationMedication ManualManual (see(see AlteplaseAlteplase))

ProviderProvider orderorder andand EMAREMAR documdocumentationentation required;required; separateseparate tt--PAPA

orderorder neededneeded forfor eacheach lumenlumen IVIV nursesnurses instillinstill tt--PAPA intointo PICCsPICCs;; tt--PAPA instillationinstillation toto allall otherother CVADsCVADs isis responsibilityresponsibility ofof unitunit RNRN Dosage:Dosage: (per(per lumen)lumen)

forfor patientspatients weighingweighing >> 30kg30kg (66lbs):(66lbs): 2mg/2ml2mg/2ml

forfor patientspatients weighingweighing << 30kg30kg (66lbs):(66lbs): 110%110% ofof internalinternal lumenlumen volumevolume ofof cathetercatheter (up(up toto 2mg)2mg) DiluentDiluent:: 2.2ml2.2ml sterilesterile waterwater withoutwithout preservativepreservative inin aa 10ml10ml syringesyringe DoDo NOTNOT clampclamp cathetercatheter whilewhile tt--PAPA isis instilledinstilled MinimumMinimum dwelldwell timetime ofof 3030 minutesminutes;; 6060 minutesminutes isis oftenoften requiredrequired

 FourFour hourhour tt--PAPA infusionsinfusions maymay bebe requiredrequired forfor significantsignificant

FourFour hourhour tt--PAPA infusionsinfusions maymay bebe requiredrequired forfor significantsignificant fibrinfibrin
sheathssheaths causingcausing withdrawalwithdrawal occlusionsocclusions

FibrinFibrin SheathSheath

Retrieved 9/25/09 from http://www.imedicine.com/search_results.asp? start=21#Multimediamedia Catheter thrombosis in
Retrieved 9/25/09 from
http://www.imedicine.com/search_results.asp?
start=21#Multimediamedia
Catheter thrombosis in subclavian vein
Retrieved from www.IV-therapy.net 10/6/09

PinchPinch--offoff SyndromeSyndrome

 CompressionCompression ofof thethe cathetercatheter betweenbetween thethe firstfirst ribrib andand thethe
 CompressionCompression ofof thethe
cathetercatheter betweenbetween thethe
firstfirst ribrib andand thethe
clavicleclavicle
 CanCan leadlead toto
intermittentintermittent
compressioncompression oror
cathetercatheter fracturefracture
UsedUsed withwith permissionpermission fromfrom OlivierOlivier
Wenker,Wenker, MD,MD, MBA,MBA, DEAADEAA RetrevedRetreved
12/29/0912/29/09
file://file://www.uam.eswww.uam.es/
/journals/ija/vol4n2//
/journals/ija/vol4n2/
q&a14.htmq&a14.htm

PinchPinch--offoff SyndromeSyndrome

SignsSigns ofof PinchPinch--off:off:

   WithdrawalWithdrawal OcclusionOcclusion ResistanceResistance toto infusioninfusion ofof



WithdrawalWithdrawal OcclusionOcclusion
ResistanceResistance toto infusioninfusion ofof
fluidsfluids
PatientPatient positionposition changeschanges
areare requiredrequired toto
infuse/withdrawinfuse/withdraw fromfrom portport
(e.g.(e.g. raiseraise arm,arm,
trendelenburgtrendelenburg))

RetrievedRetrieved withwith permissionpermission 12/23/0912/23/09
http://www.bardaccess.chttp://www.bardaccess.com/pdfs/ifus/0720656om/pdfs/ifus/0720656--
 FollowFollow diligentlydiligently
secondarysecondary toto riskrisk ofof
cathetercatheter fracture/shearingfracture/shearing
5565120_Brevia_IFU_web.pdf5565120_Brevia_IFU_web.pdf

MiscellaneousMiscellaneous

InformationInformation

RelatedRelated toto peripheralperipheral andand centralcentral IVIV accessaccess

Information Information Related Related to to peripheral peripheral and and central central IV IV access access

FiltersFilters

AirAir--eliminatingeliminating :: 0.20.2 micronmicron TPNTPN :: 1.21.2 micronmicron (exception:(exception: pedipedi usesuses aa 0.20.2 micronmicron filter)filter) BloodBlood products:products: 170170 micronmicron filterfilter onon bloodblood setset tubingtubing MannitolMannitol:: 1.21.2 micronmicron

micron filter filter on on blood blood set set tubing tubing   Mannitol Mannitol :

PatentPatent ForamenForamen OvaleOvale (PFO)(PFO) FiltersFilters

PFO:PFO: openingopening betweenbetween rightright andand leftleft atriaatria AirAir--eliminatingeliminating filterfilter 0.20.2 micronmicron SomeSome medicationsmedications shouldshould NOTNOT bebe filtered;filtered; ex.ex.-- amphotericinamphotericin NOTNOT forfor useuse withwith bloodblood transfusionstransfusions CheckCheck primingpriming volumevolume ShouldShould bebe changedchanged everyevery 9696 hourshours PlacedPlaced closestclosest toto insertioninsertion sitesite;; i.e.,i.e., onon devicedevice

Placed ‘ ‘ closest closest to to insertion insertion site site ’ ’ ; ; i.e.,

ReferencesReferences

BardBard AccessAccess SystemsSystems--PortsPorts-- MRIMRI ImplantedImplanted PortsPorts CopyrightsCopyrights 20052005 C.R.C.R. BardBard IncInc http://www.bardamless.com/porthttp://www.bardamless.com/port--mrimri--port.phpport.php BardBard AccessAccess SystemsSystems--PortsPorts-- MRIMRI ImplantedImplanted PortsPorts CopyrightsCopyrights 20052005 C.R.C.R. BardBard IncInc http://www.bardamless.com/porthttp://www.bardamless.com/port--mrimri--port.phpport.php Cope,Cope, D.,D., EzzoneEzzone,, S.,S., HagleHagle,, M.,M., MmlorkindaleMmlorkindale,, D.,D., Moran,Moran, A.,A., SanoshySanoshy,, J.,J., WinkelmanWinkelman,, l.,l., andand CampCamp--Sorrell,Sorrell, D.D. (editor)(2004)(editor)(2004) AccessAccess DeviceDevice Guidelines:Guidelines: RecommendationsRecommendations forfor NursingNursing PracticePractice andand Education,Education, 22 ndnd ed.ed. Pittsburgh:Pittsburgh:

OncologyOncology NursingNursing Society.Society.
OncologyOncology NursingNursing Society.Society.

PLEASEPLEASE NOTENOTE

AllAll informationinformation providedprovided isis subjectsubject toto reviewreview andand revision.revision. PleasePlease continuecontinue toto referrefer toto MGHMGH PoliciesPolicies andand ProceduresProcedures inin TroveTrove asas youryour primaryprimary resourceresource

Policies and and Procedures Procedures in in Trove Trove as as your your primary primary resource