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Long-Term Central Venous Catheters: Issues for Care

Rita Wickham, MS, RN; Sandra Purl, MS, RN; and Diane Welker, MS, RN

From the College of Nursing and Section of Medical Oncology, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL; and Hurley Medical Center, Flint, MI.

Semin Oncol Nurs 1992;8,2(May):133-147.

INFECTION

[NOTE: The portion of this article on thrombus was covered in Meditheses 1994;1,2(Nov).]

Infection is a well-recognized complication of all types of catheters.26,39-41 Infections are potentially life-threatening, particularly in patients with neutrophil counts of <500 cells/mm, in those with rapidly declining neutropenia, or those with protracted neutropenia.42 Local infections, including exit site and port pocket, and tunnel infections can occur, as well as systemic infections from colonized thrombi or fibrin sle eves or from intraluminal or extraluminal catheter colonization.

Partly due to the increased use of central venous catheter over the past 10 years, the causative organisms identified in neutopenic and immuno-compromised cancer patients with bacteremia have changed dramatically over this period. Formerly, gram-negative aerobes from the gastrointestinal tract (i.e., Escherichia coli, Klebsiella, Pseudomonas aeruginosa) caused most infections. Today these cause 25% to 33% of infections, while gram-positive aerobes from the skin (i.e., Staphylococcus aureus, S. e pidermis, and streptococcus species) are implicated in more than 50% of all infections.43,44 Candida species are isolated 5% to 7% of the time. Coagulase-negative cocci, which are normal skin flora, have a high path ogenic potential when introduced through catheter insertion or other procedures that violate intact skin. These organisms are particularly difficult to eradicate because they can preferentially bind to catheter surfaces and some are capable of producing a slime-like glycocalyx that may resist antibiotics and host defense mechanisms.45,46

Risk Factors
Reported catheter-related infection rates vary greatly, from 2.7% to 60%.47 These differences are likely related to a number of interrelated factors including the immunocompetence of the patient, the number of catheter lumens or type of device placed, the development of extraluminal thrombosis, the patient's primary diagnosis, and the protocol of catheter care. Furthermore, there are differences in the manner in which catheter infection rates are reported. The most common meas ure is based on the number of infective episodes per 1,000 days of catheter use.

Neutropenia (<500 neutrophils/mm) predisposes all cancer patients, pediatric and adult, to infection. In one study of children, neutropenia was associated with 70% of catheter-related infections and 75% of noncatheter-related infections.< sup>48 Furthermore, 60% of patients whose catheters were inserted during neutropenic episodes developed subsequent septicemia. Uncontrolled bacteremia is considered to be a major contraindication to catheter insertion.39

Greater numbers of local and systemic infections occur in patients with multilumen catheters as compared with single lumen catheters.41,49,50 This difference may be related to usage, specifically to the incre ased number of manipulations of multilumen devices. A positive linear relationship exists between duration of catheter placement and infection.51 In one study, double lumen catheters became infected and were removed 135 days e arlier post placement compared to single lumen catheters.41 Although some investigators report lower infection rates with implanted ports than with external tunneled devices,40,52 one prospective trial has demonstrated no difference in incidence of infections.53

Extraluminal obstruction from mural thrombus, fibrin sleeve, or clot formation at the catheter tip is frequently associated with catheter-related infections.54-57 In a study by Press et al.,39 cath eter thrombosis was the primary prognostic factor for infections in tunneled catheters. This has led to studies evaluating the effect of very low dosages of anticoagulants on rates of catheter infections.

Another risk factor for infection may relate to the primary diagnosis and the medical indication for catheter placement. Some studies document a greater number of catheter-related infections in patients whose catheters are placed primarily for TPN or chem otherapy than in patients whose catheters are placed for antibiotic therapy.51,58 Higher rates of infection also occur in patients with hematologic malignancies.59 This is logical because patients who are being treated for cancer or receiving TPN are likely to have a longer duration of catheter placement and have other factors that increase risk for infection, such as placement of a multilumen device. Patients with the acquired im mune deficiency syndrome (AIDS) are also more likely to experience catheter-related infections than other patients.60,61

One risk factor that nurses may influence significantly is the manner in which catheter care in rendered. Policies and procedures should reflect the need for validated education relating to catheter care procedures and meticulous handling of these devices . Studies support the notion that when a catheter care team or nurse provide standardized, meticulous care, infection rates are significantly reduced, on average from about 25% to 33% to about 4%.62,63

Signs and Symptoms of Catheter-Related Infections
Signs and sympoms of cather-related infections, as well as bases for diagnosis and management, are summarized in Table 2.39,43,47,54,55,64-71 Erythema and pain occuring after time of no rmal healing (7 to 10 days) are the most consistent indicators of exit (Fig 2), port pocket (Fig 3), and tunnel (Fig 4) infections. However, these may be diminished or absent in neutropenic patients, particularly those with a neutrophil count of <100 mm/. 43 Exudate is also absent in local infections when there are few neutrophils to contribute to the inflammatory response. Sixty to eighty percent of fevers in the neutropenic patients are related to infection at some site, but fever is less specific in the nonneutropenic patients.43

Localized skin reactions ranging from erythematous rash to severe blistering may occur secondary to transparent dressings, plastic tape, cleansing solution, or ointment.66 These reactions, which may be confused with local infe ctions, are significent because they alter skin integrity and can cause loss of the catheter. Such complications can be minimized with the use of alternative cleansing and/or dressing techniques.65

Thrombus-related infection should be suspected when the patient has symptoms of infection as well as fibrin sleeve or mural thrombosis or in patients with persistent catheter-related bacteremia.54 Physical signs of thrombus fo rmation (e.g., enhanced venous pattern, swelling, etc. of the ipsilateral chest) may be suble or absent, so diagnostic procedures to document thrombosis or fibrin sleeve are indicated in addition to cultures.29,54

Diagnosis
Surveillance cultures have not proved helpful in defining patients who are likely to develop a catheter-related infection,72,73 thus intervention is reserved until infection is suspected. When the neutropenic patient has signs of systemic infection, cultures of all possible sites of infection (i.e., blood, wound, urine, catheter exit site, etc.) are drawn before beginning antibiotic therapy.

Table 2. Catheter-Related Infections

Site of InfectionSigns and Symptoms*Basis for DiagnosisManagementReference Source
Local
Exit/needleErythema(>1.0 cm <2.0 cm, tenderness

. Fever

. Induration and/or exudate around exit or Huber needle access site (depends on neutrophil count)

+ Positive exit/needle site culture

Clinical S&S

Exit/needle site culture

Local site care: frequency of skin care and dressing changes; alternative dressings; antimicro- bial ointment

Oral antibiotics: nonneutropenic patient, limited inflammation IV antibiotic s: neutropenic patient or progressive inflammation

Press et al.39
Gucalp43
Groeger et al.47
Bagnall-Reeb and Ruccione65
Jones66
Ulz et al.70
Port pocketErythema, swelling tenderness about port pocket

+ Positive exudate culture from port pocket

. Fever

Clinical S&S

Aspiration and culture port pocket exudate (by physician)

IV antibiotics through port if cannulated; through peripheral vein if port not cannulated

Consider port removal

Groeger et al.47
Moore67
TunnelErythema, tenderness and induration along SQ tract >2 cm from exit site

. Purulence/inflammation at exit site

. Positive culture from exit or insertion site

. Fever

Clinical S&S IV antibiotics

Consider catheter removal

Press et al.39
Hiemenz et al.64
Benezra et al.68
Systemic
(Septicemia) Thrombus-related 		+ S&S of SVC obstruction: neck-arm swelling; discomfort in neck, arm, chest or back; increased superficial venous pattern

Fever and chills

Clinical S&S

Radiographic procedures: e.g., venogram, ultrasound

Cathe ter and peripheral blood culture (5-10 times increase in colony forming units catheter v peripheral)

IV antibiotics

Consider thrombolytic or anticoagulant therapy
Consider surgical resection of thrombus and affected vein

Con sider catheter removal

Press et al.39
Rupar et al.54
Lewis et al.55
Verghese et al.69
Catheter Colonization Bacteremia or fungemia without catheter tract inflammation

Fever and chills

Clinical S&S

Catheter and peripheral blood culture (5-10 times increase in colony forming units catheter v peripheral)

Positive cathet er tip

Bacteremia - IV antibiotics

Fungemia - IV antifungal therapy

Consider catheter removal

7 Antibiotic lock

Press et al.39
Groeger et al.47< br> Hiemenz et al.64
Benezra et al.68
Schwartz et al.71
* denotes the presence or absence of a sign or symptom.

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Blood cultures should be drawn from each lumen and from a peripheral vein.42 All of the sample drawn from the catheter should be included for culture (no discard) if a catheter-related infection is suspected. If an exit infect ion is accompanied by purulent exudate, cultures and gram stain of the exudate are also obtained. If a port pocket infection is suspected, cannulation of the port should be avoided, if possible, because of the risk for tracking organisms into the systemic circulation.67 On the other hand, if the port is already cannulated, the needle should be left in place to obtain catheter cultures and infuse antibiotics.

A positive diagnosis of catheter sepsis exists when 15 or more colonies of an organism grow out in culture or if the colony count from the catheter is at least 10 times greater than cultures obtained from peripheral blood.40,68,72,73 However, quantitative cultures are not routinely performed in many centers and catheter infections that do not fit these strict criteria may occur.

Management of Local Infections
Although the management of infections is discussed under separate headings, it must be remembered that patients may simultaneously experience more than one type of catheter infection. Exit site infections in nonneutropenic patients often resolve with oral antibiotics and local site care, whereas those in neutropenic patients (<500/mm) often require IV antibiotics.39,64 Resolution of these infections usually occurs with normalization of neutrophil and white bl ood cell counts. In general, port pocket infections will respond to antibiotics, but isolation of S. aureus usually requires port removal.47

Management of Tunnel Infections
Tunnel infections, especially those caused by Pseudomonas species, are difficult to manage because they are commonly resistant to antibiotic therapy. Although a trial of IV antibiotics may be helpful, this is not usually successful unless accompani ed by catheter removal.68

Click on the graphic to view close-up.

Progressive exit site infection in a neutropenic patient. Note erythema and induration extend more than 2 cm from exit. Redness at neck is sunburn.
Port pocket infection: erythema and tenderness extending from incision across port pocket.
Tunnel infection: erythema and tenderness extending along tunnel.


Management of Systemic Infections
Guidelines for empiric antibiotic therapy for systemic catheter-related infections are based on the probable causative organisms, the susceptibility of microbes to antibiotics, and the underlying cause of neutropenia.42 Pendin g culture results, neutropenic patients may receive a broad spectrum beta-lactam and an aminoglycoside.47 Vancomycin may be added because of its effectiveness in eradicating gram-positive aerobes. Febrile nonneutropenic patien ts may be empirically treated with an antistaphylococcal penicillin (e.g., oxacillin) or vancomycin. Additional coverage to include aerobic gram-negative rods is based on the patient's clinical status, gram stain results, and other factors. Therapy is con tinued until neutropenia resolves and for a minimum of 7 days.42 Blood cultures should be obtained repeatedly to confirm antimicrobial response.

According to Hiemenz et al,64 unless antibiotics are sequentially infused through each catheter lumen, infections may not be eradicated. One in vitro study by Gaillard et al74 emphasizes the import ance of sterilizing the internal lumens. This study examined the effect of intermittent and continuous IV antibiotic therapy on catheters colonized with S. epidermis. The results showed that the internal lumen of colonized catheters can be steriliz ed with vancomycin (or another antibiotic to which the infecting organism is sensitive), but this is dependent on drug concentration and the length of time it remains in contact with the internal catheter surface. The investigators propose that locking a catheter with the antibiotic (5 mg/1 mL solution) for 2 hours will effectively penetrate the slime layer to kill all bacteria on the internal catheter surface, but this has not been confirmed in human studies.

Central venous thrombosis should be suspected in patients with bacteremia that persists beyond 72 hours.54 When thrombosis is present, optimal therapy may include catheter removal.39 Other clinicia ns have successfuly combined fibrinolytic and antimicrobial therapy to resolve thrombus-related infections.55,56,69 The patient must have adequate serum levels of antibiotics (confirmed by laboratory analysis ) before fibrinolytic therapy is initiated. This is crucial to prevent overwhelming septicemia as organisms are disseminated from the thrombus into the circulatory system.55

Another reason why symptoms may not resolve within 48 to 72 hours after the initiation of antibiotics is that the infectious agent is a fungus, gram-negative bacillus, or spore-forming organism.40,43 These infections usually r equire removal of the catheter for resolution of the infection.

The presence of fever in a cancer patient who has a catheter is not reason enough to remove the device. There is now sufficient evidence that in most instances causative organisms can be eradicated with antimicrobial therapy alone, thereby preserving the catheter.39,40,53,72,75 Recommendations for catheter removal vary and are specific to the situation (Table 3).39,40,42-44,54,< a href="#72">72,76

Preventative Strategies
Therapeutic strategies have been tried to improve resistance to catheter-related infection. One promising device is the VitaCuff (Vitaphore, San Carlos, CA), which is constructed of biodegradable collagen impregnated with silver ions. It is attached to a catheter before insertion and creates an additional physical as well as an antimicrobial barrier. Randomized controlled studies have confirmed that catheter colonization along the extraluminal surface occurs significantly less frequently with the VitaCuff than without it.77,78 Catheter-related bacteremias may be caused by intraluminal, as well as extraluminal colonization with subsequent dissemination into the circulation.79 Schwartz et al71 have suggested that locking t he catheter with a solution of vancomycin and heparin can decrease the incidence of intraluminal colonization and bacteremia in immunocompromised patients. Because no vancomycin was detectable in the peripheral blood of these patients, it was postulated t hat the development of vancomycin resistant organisms should not occur. Larger prospective trials are necessary to confirm that the benefit of locking catheters with such a solution outweighs the risk for development of antibiotic-resistant organisms.

Table 3. Indications for Catheter Removal in Patients With Catheter-Related Infections

  • Bacteremia and/or clinical symptoms persisting beyond 48-72 hours despite appropriate IV antibiotic therapy through the catheter.
  • Progressive exit site, insertion site, or subcutaneous tunnel infections (especially Pseudomonas infections).
  • Bacteremia due to certain Bacillus species or Corynebacterium species and fungemia due to Candida species.
  • Reproducible chills or hypotension following irrigation of the catheter (rule out heparin allergy).
  • Clinically unstable condition of the patient and/or development of hypotension due to sepsis.
  • Evidence of septic emboli or endocarditis.
  • Catheter is no longer functional or required for therapy.
Data from references 39, 40, 42-44, 54, 72, and 76.

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Although specific factors contributing to the prevention of infections have not been confirmed, prevention of exit infections may be within nursing's realm. The optimal dressing for exit sites is still controversial, as is the optimal frequency for dressi ng changes. One small study suggests that transparent dressings are associated with higher rates of infection in hospitalized patients than are occlusive gauze dressings.80 However, another randomized study of transparent, gau ze, or no dressings, found no statistically significant differences in infection rates of hospitalized adult oncology patients with any technique.81 Astute daily assessment by nurse or patient for signs and symptoms of exit in fection, and meticulous attention to the details of catheter site care appear to be the keys to minimize this risk.66,82 The Oncology Nursing Society has developed Access Device Guidelines (Module 1 - Cathete rs, Module 2 - Ports).83,84 These summarize current clinically and scientifically based recommendations and are useful in developing nursing education and policies for catheter care.

CATHETER OCCLUSION

Catheter occlusions, in which blood cannot be drawn nor solutions infused, are most frequently caused by clotted blood. Precipitated TPN, drugs, or other IV solutions can also obstruct devices. Recognition of the probable cause is critical to appropriate intervention and salvage of a functional catheter. A catheter may become clotted in a relatively short time or infusion may become progressively sluggish over several days. Clotting can usually be prevented by maintaining positive pressure within the cath eter at all times and by vigorous flushing after aspirating blood.

By contrast, a precipitate causes catheter occlusion suddenly during a single infusion.85 TPN forms a calcium-phosphorus complex, and less frequently, incompatible drugs precipitate to cause occlusion. TPN is more likely to pr ecipitate if used several days after being prepared85 or when administered with lipids.86 All TPN bags should be examined and discarded if precipitate is evident, and the nurse must flush the cathe ter with at least 5 to 10 cc of a compatible IV solution between incompatible drugs to prevent precipitation.

Management of Clotted Catheters
If catheter occlusion has occurred, the nurse should attempt to identify the probable cause and proceed with appropriate management. If the probable cause is clotted blood, the device is locked with a small dose of a fibrinolytic agent (streptokinase or u rokinase). The dose of urokinase necessary to lyse a clot is not known, but is generally 5000 units in 1 cc. The mean time to catheter clearance with urokinase is 27.4 minutes87 so the agent should remain within the catheter f or at least 30 to 60 minutes. Instilling 1 mL of urokinase into each occluded lumen for a 4-hour dwell time, and then treating catheters that do not completely clear with continuous infusion of urokinase (200 U/kg per hour) for 24 hours has also been successful in restoring catheter patency.88 The longer dwell time may be advisable because the thrombolytic activity of urokinase and its byproducts continue for as long as 24 hours within a catheter.89 The agent is aspirated from the catheter when patency is restored if possible.

Newer agents are being investigated for their efficacy in restoring patency to clotted catheters. Although tissue plasminogen activator (t-PA) has been used to successfully clear five or six catheters that did not clear with urokinase,9 0 no large studies compare the efficacy and cost of these two agents.

The technique to instill the fibrinolytic agent (or agent to dissolve a precipitate) is critical. The nurse should first attempt to gently flush the catheter with normal saline. If resistance is met in a cannulated port, the nurse would recannulate it. Ne xt, the nurse aspirates any fluid remaining in the catheter before gently instilling the fibrinolytic or dissolving agent using a "to and fro" motion over a few minutes. A 3 or 5 cc syringe should be used because greater pressures can be generated with sm aller syringes, increasing the risk of inadvertent rupture of the catheter. Although the volume of an un-occluded catheter may be > 1 cc, the volume of an occluded catheter is unknown. Thus, the nurse must closely monitor the catheter for a sense of incre asing resistance while observing for signs of bulging or aneurysm formation, which require that no more agent be instilled into the catheter.

If the catheter does not clear in 2 or 3 instillations of urokinase, if a precipitate is evident, or if a solution that can precipitate was infusing, the nurse should consult with a pharmacist to determine whether there is a pharmacological agent to incre ase the solubility of the precipitate.

Management of Precipitated Catheters
Precipitated TPN or TPN plus lipids, as well as precipitates of etoposide, calcium salts plus sodium bicarbonate, and heparin plus incompatible antibiotic (e.g., amikacin) have been successfully cleared with instillations of 0.1 N hydrochloric acid (HCL), 85,86,91 whereas others have used another acidic agent (ammonium chloride) to dissolve precipitates formed by phenytoin, aminophylline, and calcium gluconate.70 It has also been proposed that a sol ution of 70% ethanol in water can clear catheters partially occluded by TPN and lipids.92

Drugs precipitate in the proximal lumen and clots form at the catheter tip but can involve a greater portion of the catheter, so the volume of clearing agent that can be instilled without causing catheter damage is variable.85 With precipitate formation, one would likely be able to initially instill a very small volume of dissolving agent (i.e., 0.2 cc over 2 minutes) until part of the precipitate has dissolved.

EXTRAVASATION

Extravasation, the leakage of infusate from a vein into the subcutaneous space, is a relatively infrequent complication of central venous catheters. Extravasation of nonvesicant and vesicant agents can cause severe pain and irritation requiring catheter r emoval and extensive surgery (i.e., mastectomy).93,94 Other cases of documented extravasations of vesicants from catheters have fortunately resulted in only minor residual symptoms after catheter removal.94- 96

Signs and Symptoms of Extravasation
Extravasation can occur through several mechanisms, but will cause similar symptoms in the area of leakage. The most common symptom is the onset of pain, burning, or stinging in the chest, in the clavicular area, port pocket, or along the subcutaneous tun nel during or after infusion. Although discomfort may also occur with vein irritation, the onset of pain in these areas should always be assumed to be a result of the more serious event until proven otherwise. Swelling also occurs with infusion, but this may be subtle if small volumes are being infused. Erythema may be present during or develop after infusion.95,97

Causes of Extravasation
Extravasation most often results from needle dislodgement from ports, secondly from backtracking, and rarely from catheter damage and/or separation or malposition of the catheter tip.

Needle dislodgement. Needle dislodgement from ports can occur whether the patient is in the hospital or at home, and has been reported in 0% to 55% of patients.26,93,98-103 Factors that increase the ri sk of needle dislodgement include inadequate stabilization of the needle in the port, particularly during continuous infusions, and use of an incorrect type of needle. The needle should be taped across and in a chevron over the hub or wings before the dre ssing is applied, whether a gauze or transparent dressing is used. The correct length Huber needle will reach the bottom of the port without distorting the overlying skin, and yet not be so long that it is difficult to stabilize. Unsiliconized needles sho uld always be used, as they are less likely to slip out of the port septum.

Placement of the port over a mobile muscle (i.e., lateral pectoral) can, with arm and shoulder movement, cause a rocking motion against the needle leading to accidental decannulation. Thus ports should be implanted away from the shoulder.101 It is also difficult to cannulate a port and stabilize the needle when the port is beneath excessive adipose or breast tissue. Before surgery, female patients with excessive breast tissue should be evaluated with their brassieres on, and obese patients should be evaluated in the standing position to determine proper placement.102

Backtracking. Backtracking, which has been implicated in extravasations from tunneled catheters as well as from implanted ports, occurs when a partially occlusive thrombus forms at the catheter tip forcing infusate to flow back through the fibrin s leeve and out of the vein.26,94,96,103 Backtracking is more likely in catheters inserted by the percutaneous technique because the introducer makes a larger venipuncture than the catheter i tself and the vein is not ligated around the catheter.94

Catheter Damage or Separation. Catheter damage is rare but can occur during a difficult surgical placement, or secondarily to incorrect locking of a port and catheter. Both conditions would cause symptoms shortly after placement. The "pinch-off" sy ndrome can occur in devices inserted into the medial subclavian vein between the clavicle and first rib.26,95,104-108 The angle between these two bones is narrow in some persons, and friction from the weight of the body with sitting up and movement of the shoulder may cause a characteristic flattening of the catheter (Fig 5) that is visible on chest radiograph. Positional infusion problems that are worse when the patient is sitting and better when he or she l ies down or raises the arm may be the harbinger of the pinch-off syndrome. Repeated friction and stress can progress to catheter fracture and embolization of the distal portion to the right heart or pulmonary artery.105,106,108 Embolization may be asymptomatic or accompanied by cardiac arrhythmias, chest pain, or a swishing sound in the ipsilateral ear with catheter flushes.107,108 The signs and symptoms of extravasation will be detectable in the ipsilateral clavicular area.

Fig 5. The "pinch-off" syndrome occurs because the catheter, which is placed into the subclavian vein, becomes repeatedly compressed between the clavicle and first rib. (Reprinted with permission.105)

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Prevention of Extravasation
A thorough assessment should be completed before initiating any infusion. The catheter should be aspirated for blood return, although the absence of a blood return does not mean the catheter is not safe to use. However, sudden loss of blood return would r aise the nurse's concern. In addition, the inability to aspirate blood is variable and not uncommon in a significant number of catheters. The nurse must thus rely on several objective and subjective assessments to determine if it is safe to proceed with t he infusion.

The nurse closely observes the catheter tunnel or port pocket area for subtle swelling with the initial instillation of normal saline (NS) and asks the patient if they experience any discomfort or burning in the catheter area during this time. If any swel ling is noted the catheter/needle placement is investigated further. If discomfort occurs, the nurse then rapidly infuses 50 to 100 cc of NS while closely observing the chest wall for increasing swelling and eliciting for complaints of discomfort. If disc omfort continues with saline injection, the nurse delays the infusion and notifies the physician.

Observations for subjective and objective findings of extravasation continue during the infusion. There are no clear guidelines for the frequency of assessment of blood return, but the site should be checked at least as frequently as one would check a per ipheral IV (q 1 to 2 hours). Nursing judgement dictates that one checks more frequently (i.e., q 30 minutes or more often) if a vesicant agent or blood is infusing or if the patient is confused or restless. Although some clinicians focus on blood return t o assess catheter tip and needle placement, this should probably be routinely checked less frequently (e.g., q 4 to 8 hours) because of the possibility of increasing risk of infection and of clotting the catheter.

Management of Extravasation
The nurse promptly stops any infusion through a catheter for any subjective or objective indications of extravasation during infusion. Because symptoms of extravasation do not always occur with infusion, but may begin as long as a few days afterward, vagu e complaints of discomfort should not be ignored. Only nurses who understand the significance of extravasation of vesicant agents should administer these agents through catheters. There is no recommended procedure for management, but principles for periph eral vein extravasation can reasonably be applied to extravasation from a catheter (Table 4).26,109,110

Patient and family education are critical, especially if the patient will be receiving ambulatory continuous infusion of a vesicant agent. The patient must clearly understand that although the risk for extravasation can be minimized, it can never be elimi nated. Thus, the patient is taught to examine the needle site every 4 to 8 hours and to report any possible symptom of an extravasation immediately. Ambulatory infusion pumps with occlusion alarms should be used, and the patient should be provided with wr itten instructions of whom to call 24 hours a day if extravasation is suspected.

Table 4. Management of Extravasation From Central Venous Catheters

  • Stop the infusion as soon as extravasation is suspected.
  • Document the exact circumstances including the drug and amount extravasated if known, subjective and objective findings, and photograph if possible.
  • Notify the physician promptly.
  • Aspirate remaining drug from a tunneled catheter.
  • In the case of a port pocket extravasation aspirate remaining drug and leave the needle in place. If unable to aspirate vesicant from tubing, remove needle and with physician order insert 19 gauge needle SQ and aspirate extravasated solution.
  • Administer "antidote" per institutional policy and available literature.
  • Apply ice to the chest wall for 20 minutes qid; for vinca alkaloids apply moderate heat.
  • Follow patient closely by phone and return appointment, observing for worsening pain, erythema, induration and ulceration because symptoms may not become evident for several days.
  • Consult plastic surgeon for initial evaluation; intervention may include port removal if pain persists beyond 72 hours.

CATHETER MALPOSITION

Catheter tip malposition is limited to case reports. Although not synonymous with extravasation, the infusion of irritating or hypertonic solutions can cause painful phlebitis that may be mistaken for extravasation or may lead to thrombosis and subsequent backtracking.16,23,26 Malposition results from erroneous insertion of the catheter into a small tributary of the SVC, from migration of a correctly placed catheter into another vein or from perforation of the SVC or endocardi um by the catheter tip. Post-placement chest radiograph or fluoroscopy must include a lateral view to detect incorrect placement into small, low-flow tributary of the SVC (i.e., internal mammary, azygous, or left brachiocephalic). Precordial, sternal, or costochondral pain can occur with infusions into these small veins.111 Blood return may be obtained from malpositioned catheters, so blood return is not an absolute indicator of correct catheter tip location.

Catheter tip migration into the jugular system, which rarely occurs, is similarly problematic. The patient may be asymptomatic or experience withdrawal or total catheter occlusion, pain with infusion, and audible catheter flushes in the ipsilateral ear.26,96,112-114 If the patient experiences pain or burning with infusion and incorrect catheter tip location is confirmed, the catheter must be repositioned before infusions of irritating, caustic, or hyperosmoti c fluids. If the patient is not symptomatic, the physician may elect to not reposition the device.

Patients with silastic and polyurethane catheters may experience perforation of the SVC or endocardium, causing pseudoaneurysm, mediastinal widening, pleural and pericardial effusions, and cardiac tamponade.115-118 This poten tially fatal complication usually occurs within 3 weeks after placement and is accompanied by the sudden onset of chest pain and shortness of breath. Although risk factors are not well defined, this complication is most often related to cannulation of the left subclavian vein because catheters introduced from the left must turn at a right angle into the SVC, causing the tip to curve. Chest radiograph shows this curving of the catheter tip on one or more views, which is thought to represent buckling of the tip into the venous intima.115,119 Alternatively, if the catheter tip is close to the vein wall rather than in the center of the vein, chemical injury from infusing solutions may damage the intima or act synergistically with mechanical injury to erode through the vein wall.120 Should symptoms of a malposition occur, the nurse immediately stops the infusion, notifies the physician, and initiates other emergency measures as needed.

OTHER NURSING CONSIDERATIONS

Patients and families bear a great responsibility in detecting early symptoms of problems because many patients are treated in the outpatient setting. Therefore, nurses must provide them with clear and specific instructions including what symptoms to repo rt. Patients must also know which health care team member(s) to contact for assistance with problems and home care management. Catheters are frequently placed in outpatient surgery or during a short hospital stay, so teaching is accelerated and more inten se. Consistency in the teaching methods between the hospital, the outpatient setting, and home care is necessary to avoid confusing the patient and family.

The ability to minimize and accurately recognize catheter-related problems requires adequate education of nurses and physicians because their inexperience has been documented to be the factor most frequently related to catheter complications.121 The development of standards of care and of expertise in staff are important components to successfully prevent catheter-related complications. Nursing research is needed to provide support for nursing practice, as tradition commonly provides the rationale for current practice.

Documentation is critical for providing information regarding the circumstances of complications and interventions implemented to manage them. Use of a catheter flowsheet, as described by Mikos and Finn,122 provides an effect ive means of documenting assessment and routine care as well as for retrieving data for quality assurance. Quality assurance activities are a systematic way to identify clinically relevant catheter-related problems and appropriate management solutions. On e example is the Vascular Access Device Committee at the Johns Hopkins Oncology Center (Baltimore, MD). The implementation of this multidisciplinary group has established the responsibilities and accountability of the various members and identified key fa ctors for specific complications and groups at high risk. This has resulted in a decreased number of catheter-related problems in this institution.123

The need for multidisciplinary collaboration extends beyond the institutional level. One group that has enhanced collaboration is the National Association of Vascular Access Networks (NAVAN) (telephone: 415-327-9430). Finally, the Food and Drug Administra tion has convened a group of nurse and physician experts along with catheter manufacturers and representatives from several government agencies to investigate problems and complications resulting from central venous catheter use.1< /a> This group will ultimately develop educational materials such as videotapes for physicians and nurses. They have made several initial recommendations relating to catheter placement and care, as well as for the education of physicians and nurses. In ad dition, significant issues and concerns related to catheters have been identified. Continued multidisciplinary efforts are crucial, for our growing awareness relating to the problems as well as the benefits of long-term central venous catheters is the vit al step in maximizing the use of these devices.

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REFERENCES

  1. Collins JL: Central venous catheter complications. Oncol Nurs Forum 18:819-820, 1991 (letter)
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