≥ 92% of participants will know how to care for a central or arterial line properly.
CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
≥ 92% of participants will know how to care for a central or arterial line properly.
This module will cover fundamental issues of a central line IV catheter and arterial line nursing care, like observing for and preventing complications.
After completion of this module, the participant will be able to:
Central venous lines and arterial catheters are commonly used in healthcare. They are often essential in critically and chronically ill patients; however, they can be used for acute situations. Compared with peripheral IV lines, the clinical indications for their use are more complex and, often, more serious. There are more complications, often more severe, associated with these devices, and the daily care of a patient with a central line or an arterial catheter is more involved.
Central venous catheters are commonly used medical devices. It has been estimated that in intensive care units (ICUs) in the United States (US) alone, there are 15 million days when a central venous catheter has been used, or the patient has had a central venous catheter in place (McConville & Patel, 2015). In the US, 5 million central line catheters are inserted annually (Sakuraya et al., 2022).
There are many indications for using a central venous catheter; many are patient and situation-specific. The more common indications for the use of a CVAD are listed in Table 1.
|Administration of irritants or vesicants|
|Inability to obtain peripheral IV access|
|Invasive hemodynamic monitoring|
|Long-term venous access|
|Rapid administration of IV fluids|
|Renal replacement therapy|
|Total parenteral nutrition|
|Transvenous pacemaker placement|
|(Manrique-Rodríguez et al., 2021; McConville & Patel, 2015)|
Many drugs are not able to be infused through a peripheral line. The pH and osmolarity (the concentration of a solution) of some drugs and the vasoconstricting effect of other drugs make them unsuitable for administration through a peripheral IV line. These types of drugs are classified as irritants or vesicants. They are very irritating and potentially damaging to small veins, and infiltration of these medications may cause extravasation.
|High-concentration dextrose solutions*|
|IV contrast solutions|
|Total parenteral nutrition*|
|Vasopressors- dopamine, epinephrine*|
|(Cho et al., 2019; Brock & Cruz- Carreras, 2020; David et al., 2020; Lawson et al., 2013; Manrique-Rodríguez, et al., 2021; Masood et al., 2022; Shrestha et al., 2020)|
Vasopressors can cause extravasation, and although these drugs can and have been safely administered through peripheral IVs, it is recommended that, when possible, vasopressors should be given through a CVAD (Alexander, 2020; Gorski et al., 2021; Lewis et al., 2019; Shrestha et al., 2020; Tian et al., 2020).
A CVAD, positioned so the catheter tip is in the superior vena cava near the right atrium, can be used to measure central venous pressure or CVP (Parenti et al., 2022; Shah & Louis, 2022).
CVP measures the pressure in the vena cava, providing a good approximation of mean right atrial pressure and an estimate of ventricular preload (De Backer & Vincent, 2018; Parenti et al., 2022; Shah & Louis, 2022).
CVP monitoring with a CVAD is invasive and time-consuming, and insertion and maintenance of a CVAD can cause serious complications (Parenti et al., 2022). In addition, some providers feel that CVP does not accurately predict response to fluid resuscitation and/or a patient's volume status and that it cannot and should not be used to guide treatment. Mercolini et al. (2021) wrote: "It is well known that CVP does not predict blood volume or fluid responsiveness." Other researchers have found that CVP measurement has many limitations that restrict its usefulness. Still, it is wiser to understand and consider these limitations rather than discard CVP monitoring completely. Clinicians and providers can decide if, how, and when to use CVP monitoring (Hill & Smith, 2021; Mercolini et al., 2021; Rhodes et al., 2017; Tolson, 2022).
Central IV catheters are recommended when long-term venous access is needed, but an exact duration of time that defines long-term has not been established. In many cases, long-term is associated with the medical condition for which CVAD access is needed, e.g., cystic fibrosis and chemotherapy (Gorski et al., 2021). Authoritative sources have defined the long-term use of a CVAD as > 14-15 days (Gorski et al., 2021; Woller et al., 2016).
Now that indications for CVADs have been discussed, it is time to review the types of different lines.
Indications for the use of a PICC are listed in Table 3. These indications are called the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). These recommendations align with other sources (Duwadi et al., 2018; Fohlen et al., 2022; Gorski et al., 2021; Woller et al., 2016).
|Administration of irritants or vesicants|
|Delivering peripherally compatible solutions when the duration of therapy is ≥ 6 days|
|Delivering peripherally compatible solutions for patients in skilled nursing facilities (SNFs) when the duration of treatment is ≥ 15 days or when the patient will be moving from a hospital to an SNF|
|elivery of cyclical or episodic chemotherapy that can be administered through a peripheral vein in patients with active cancer, provided the proposed duration of such treatment is three or more months|
|Hemodynamic monitoring in a critically ill patient when monitoring will be needed for ≥ 15 days|
|Infusions for end-of-life or palliative care|
|Frequent phlebotomy in patients who have difficult/poor peripheral venous access, duration of stay ≥ 6 days|
|Intermittent infusions in patients who have difficult/poor peripheral venous access, duration of stay ≥ 6 days|
|Need for central venous access in a critically ill patient when access is needed for ≥ 15 day|
|(Woller et al., 2016)|
A central venous catheter can be inserted through the femoral, jugular, or subclavian vein (Berry, 2022). These catheters should be placed using ultrasound guidance (Gorski et al., 2021). These CVADs are sometimes referred to as non-tunneled central IV lines.
Insertion complications include carotid artery puncture when using the internal jugular vein, hematoma, hemothorax, and pneumothorax. Post-insertion complications include catheter occlusion, central line-associated bloodstream infection, and thrombosis (Berry, 2022; Gorski et al., 2021; McConville & Patel, 2015). (Note: Post-insertion complications will be discussed in a later section of the module).
The femoral, jugular, and subclavian insertion sites each have advantages and disadvantages in terms of insertion complications (Gorski et al., 2021). However, the differences - if there are any - between femoral, jugular, and subclavian insertion sites for the risk of complications after insertion are uncertain (McConville & Patel, 2015; Sakuraya et al., 2022). Gorski et al. (2021) noted that the femoral site is associated with a higher risk for infection, and the subclavian site has a higher risk for thrombosis. Sakuraya et al. (2022) performed a network meta-analysis of published literature. The authors found that the risk for catheter-related infections and mechanical complications, such as bleeding, hematoma, hemothorax, and pneumothorax, differed between insertion sites, but not always. For example, there were no significant differences between the sites for thrombotic complications. However, the literature they reviewed included PICC insertion and differences in study designs, and the patient populations that were studied complicated the analysis. The authors concluded: "based on the current literature, the most acceptable site for central venous catheterization is inconclusive, considering various complications in hospitalized patients"(Sakuraya et al., 2022).
Tunneled and non-tunneled central venous catheters are often used for acute and chronic hemodialysis. They are also used to treat patients who have acute kidney injury, patients who have been poisoned and need immediate removal of the drug, and for long-term venous access to deliver medications and TPN (Flick & Winters, 2022; Gorski et al. l., 2021; You & Oliver, 2022).
A tunneled central venous catheter has an access site; the catheter goes underneath the skin (an incision is made for this); the catheter incision travels down the vein, and the tip is positioned in the superior vena cava. Often, there is a cuff on the part of the catheter underneath the skin, which helps anchor the catheter. Some tunneled central venous catheters have an access site underneath the skin, accessed by needle puncture (Flick & Winters, 2022).
Like a tunneled catheter, non-tunneled ones are made up of a thin, long tubing that is open, allowing medications to go to the patient. Some non-tunneled catheters have single-lumens or multiple-lumens, allowing multiple solutions and medications to pass. Compared to tunneled catheters, non-tunneled catheters are easier to use (Clark et al., 2016).
Non-tunneled catheters are for temporary use, like standard IV therapy or checking labs. Non-tunneled catheters do not require incision and are usually used for two weeks or less (You & Oliver, 2022).
Though there are key similarities between these two types of catheters, significant differences must be noted.
There are single and double ports. Double ports look like two drums together.
Care providers stick a needle into the skin and through the port's septum to deliver medication. Blood can also be drawn from a port if necessary. After treatment is finished, ports can be easily removed (Machat et al., 2019).
Catheters can be impregnated or coated with antibiotics, antimicrobials, or antimycotics to decrease the accumulation and growth of bacteria, reducing catheter-related infections (Lai et al., 2016a).
A PICC or an internal jugular, femoral, or subclavian CVAD should be inserted using these basic principles.
Many complications can occur during CVAD insertion; fortunately, serious/dangerous complications like cardiac events seldom happen. The complications discussed here are familiar to most nurses, if not in the context of a CVAD insertion, then from their day-to-day clinical experience and the body of knowledge they have. The list presented here is not all-inclusive; some CVAD insertion complications are uncommon, and only a few cases have been documented. CVAD insertion complications can be minor, e.g., bleeding or nerve injury that quickly resolves, but dangerous arrhythmias, pneumothorax, and significant bleeding can occur.
The location of the CVAD tip should be checked immediately after insertion, and the tip position should be checked if a CVAD tip may have moved, i.e., the patient has been transported or there is excessive arm movement. Tip locations can be found using an x-ray, an electrocardiogram (ECG), or an ultrasound (Gorski et al., 2021; You et al., 2022).
A chest x-ray is sufficient for locating the CVAD tip (Gorski et al., 2021). However, the proper location of the tip, the cavoatrial junction, cannot be seen with an x-ray (Gorski et al., 2021). With this technique, CVAD tip location must be estimated using anatomical landmarks and measuring (Gorski et al., 2021).
Checking the CVAD tip position by ECG is done by connecting an ECG wire to the insertion guide wire. The CVAD tip position is determined by specific p-wave changes on the ECG. Using an ECG is superior to an x-ray. An installation of normal saline in the catheter lumen and an ECG can also be done (Gorski et al., 2021; Yu et al., 2022).
Ultrasound has been used successfully for checking CVAD tip location (Smith et al., 2017). However, Gorski et al. (2021) wrote: "The clinical applicability of this is currently limited by the small sample sizes used to demonstrate its efficacy . . . and its usefulness is limited by the knowledge, skill, and experience of the operator."
Post-insertion complications of CVADS will be covered in this section; monitoring for and preventing complications will be discussed later in the module. The complications discussed here are the ones that are common or most likely to occur.
CLABSIs are defined as the presence of bacteria that have originated from the catheter.
These four criteria define a CLABSI.
It has been estimated that each year in the US, in acute care settings, there are approximately 30,000 to 40,000 CLABSIs diagnosed. CLABSIs are associated with prolonged hospital stays and increased mortality (Alotaibi et al., 2020; Buetti et al., 2022; Huerta et al., 2018; Selby et al., 2021). The worldwide mortality rate from CLABSI has been reported to be up to 20% (Niemann et al., 2022).
|Body mass index > 40|
|Concurrent catheter placement|
|Prolonged duration of catheterization|
|Prolonged duration of hospitalization|
|Significant microbial colonization of the catheter hub|
|Substandard catheter care|
|(Buetti et al., 2022; Fisher et al., 2020; Niemann et al., 2022; Selby et al. 2021)|
Unless it is necessary to try and salvage the catheter, e.g., alternative IV access is absent or will be very difficult, CLABSI is typically managed by removing and replacing the catheter and with antibiotic therapy (Haddadin et al., 2022).
Air embolism is a very uncommon complication of CVAD placement, either during or after insertion.
There are a few common diagnostic modalities used to diagnose an air embolism.
There are many interventions that providers may perform to alleviate an air embolism; they include:
Catheter damage is uncommon, but a CVAD can fracture and form an embolism, and the external section of a CVAD can develop a crack or a hole (Gorski et al., 2021). A catheter can contribute to an embolism in several ways; it can become separated from the implanted port, a catheter can become fractured during a catheter exchange, or pinch-off syndrome can occur (Gorski et al., 2021).
A CVAD tip can migrate at any time after insertion. The tip can move to the mediastinum (the area between the lungs), the pericardium (the area around the heart), the pleura (thin layer covering lungs), and the trachea, causing thrombosis and serious complications like hemothorax and pericardial effusion (excess fluid around the heart).
DVT is a well-described complication of PICCs and other types of CVADs (Bing et al., 2022; Duwadi et al., 2018; Gorski et al., 2021; Grau et al., 2017; Sakuraya et al., 2022; Citla Sridhar et al., 2020; Swaminathan et al., 2022; Yuen et al., 2022). The incidence of central line-associated DVT varies, depending on the patient population and other factors. It has been estimated that 10% of all DVTs in adults and 50% to 80% of all DVTs in children are associated with a central line catheter (Citla Sridhar et al., 2020).
The vascular endothelium (the inner cellular lining of veins, arteries, and capillaries) prevents blood clotting and platelet adhesion (Citla Sridhar et al., 2020; Wang et al., 2018). Central venous access placement disrupts these functions. By blocking contact of blood with the endothelium, a CVAD changes the structural integrity of the endothelium and becomes a risk factor for DVT formation (Citla Sridhar et al., 2020; Wang et al., 2018).
The risk factors for central line-related DVTs are listed in Table 5. The risk factors are patient-related, insertion-related, and catheter-related.
|Age: Increased age is associated with increased risk|
|Pre-existing Conditions: Cancer (especially metastatic), catheter infection, chemotherapy, critical illness, hypercoagulability (acquired or hereditary), WBC < 12,000, radiotherapy treatment to the thorax, systemic infection|
|Insertion site, femoral, internal jugular, subclavian: The data indicate no significant difference in DVT risk between these sites|
|Insertion site, PICC: The data is conflicting and inconclusive as to whether a PICC line has an increased risk of DVT compared to the three other insertion sites|
|Number of insertion attempts: The data is conflicting|
|The catheter tip location is misplaced|
|Catheter to vein ratio: Higher ratio, higher risk|
|Duration of placement: Data is unclear if the duration of time increases the risk|
|A multi-lumen catheter|
|Presence of another catheter|
|(Gorski et al., 2021; Citla Sridhar et al., 2020; Sakuraya et al., 2022; Puri et al., 2022; White et al, 2018; Sharp et al., 2015)|
Most patients with a central line-associated DVT are asymptomatic (Gorski et al., 2021; Citla Sridhar et al., 2020).
Infiltration occurs when the IV catheter dislodges from the vein, and IV fluid infuses into the surrounding tissue. Signs and symptoms of infiltration include swelling in and around the area. Infiltration usually does not cause significant pain, but infiltration of certain medications, like chemotherapy drugs, can cause serious tissue damage (Brock & Cruz-Carreras, 2020; Masood et al., 2022).
Extravasation is an infiltration; the IV catheter dislodges from the vein, and IV fluid moves into the tissue. The difference between infiltration and extravasation is the type of IV fluid and the consequences.
Occlusion of a CVAD is common; it has been estimated that as many as 25% of patients with CVADs develop an occlusion (Ast & Ast, 2014).
Occlusion of a CVAD can be usefully divided into 1) chemical occlusion, 2) mechanical occlusion, and 3) thrombotic occlusion (Gorski et al., 2021; Ornowska et al., 2022).
Signs and symptoms of CVAD occlusion, in general, include the inability to aspirate blood, a slow/sluggish blood return when aspirating, slow/poor infusion rate, inability to infuse, infusion pump alarms, and leaks and/or swelling at the insertion site (Gorski et al., 2021).
There is little current information about the risk for and incidence of phlebitis and femoral, jugular, and subclavian CVADs. Lu et al. (2022) found that the reported rate of phlebitis in PICCS was 0.6% to 9.7%. Most published information on catheter-related phlebitis concerns peripheral IVs (Gorski et al., 2021).
Signs and symptoms of phlebitis include erythema, induration, pain, redness, swelling, and a palpable venous cord (Gorski et al., 2021; Webster et al., 2015). Gorski et al. (2021) recommend using a phlebitis assessment scale and observable data to rate the severity of an IV catheter-related phlebitis. Several phlebitis assessment scales are available, e.g., the Venous Infusion Phlebitis (VIP) scale. However, it is unclear if they are valid assessment scales or how good their inter-observer/rate reliability is (Gallant & Schultz, 2006; Gorski et al., 2021).
Nursing care for a patient who has a CVAD involves:
The fifth one has been covered in the "Complications of Central Venous Access Devices" section.
The infusion system should be routinely assessed (Gorski et al., 2021). This assessment should include the solutions and solution containers, the infusion pump/infusion device, the IV tubing, IV connections, the insertion site dressing, and the insertion site (Gorski et al., 2021).
The CVAD insertion site should be routinely assessed for signs of infection and to ensure that the CVAD is securely attached.
A secure attachment of a CVAD prevents the CVAD from moving and from accidental removal. The attachment of the CVAD should be assessed each time the insertion site is assessed for infection (Gorski et al., 2021). Each healthcare facility/organization will have its own guideline for the frequency of this assessment.
A CVAD can be dressed in a chlorhexidine-impregnated dressing, sterile gauze, or a transparent semipermeable membrane called a TSM (Gorski et al., 2021; Lutwick et al., 2019; Selby et al., 2021).
Chlorhexidine-impregnated CVAD dressings may decrease the risk of insertion site infection compared to other dressings (Lutwick et al., 2010; Selby et al., 2021). A chlorhexidine-impregnated dressing should be used if the patient is ≥ 18 years of age and they have a non-tunneled CVAD or if other techniques for preventing a CLABSI have not worked (Gorski et al., 2021).
A sterile gauze dressing should be changed at least every two days, and a sterile gauze dressing should be changed if it is damp, loose, or soiled (Gorski et al., 2021; Lutwick et al., 2019; Selby et al., 2021).
Gorski et al. (2021) recommend cleaning the skin around the CVAD insertion site and the area that the dressing will cover with alcohol-based chlorhexidine solution (Gorski et al., 2021). Compared with povidone-iodine, an alcohol-based chlorhexidine solution may or may not reduce bacterial growth in the area and reduce the incidence of CLABSI (Bakir et al., 2021; Lai et al., 2016b; Lin et al., 2022). Povidone-iodine or 70% isopropyl alcohol can be used if needed (Gorski et al., 2021).
Do not routinely apply an antimicrobial ointment to the CVAD insertion site (Gorski et al., 2021; Lutwick et al., 2019).
Each healthcare facility/organization will have its guideline for the frequency of CVAD dressing changes.
Flushing and locking are essential for the prevention of CVAD occlusion and CLABSI. Flushing cleans the CVAD; locking ensures that it remains patent between uses and helps to prevent CLABSI (Gorski et al., 2021; Selby et al., 2021).
Flushing: Routine and Post-Medication Administration
Disinfecting Access Ports
Central Line-Associated Bloodstream Infections (CLABSIs)
Catheter migration: Nursing care may not prevent catheter migration. However, it is important to know the relatively benign signs and symptoms of catheter migration, like poor flow and no blood return, and the serious signs of catheter migration, like arrhythmias and pneumothorax (Gorski et al., 2021).
DVT: Know the risk factors for DVT and know that a CVAD-associated DVT is clinically silent in most cases. Administer anticoagulation therapy, if prescribed, as this is the primary treatment (Stevens et al. 2021).
Infiltration/extravasation: Knowing the signs, symptoms, and risk factors of infiltration and extravasation can prevent an air embolism.
Occlusion: Preventing an occlusion requires a nurse to know and to correctly use flushing and locking techniques (Gorski et al., 2021).
There are specific policies and protocols for central line removal, and they differ for each facility.
Arterial catheters are used for short-term hemodynamic monitoring and when frequent blood gas analysis and blood sampling are needed; these are the primary uses of an arterial catheter (Berry, 2022; Gorski et al., 2021; Kaufmann et al., 2020). Invasive blood pressure measuring with an arterial catheter is recommended for and used most often for the treatment of 1) high-risk surgical patients, in selected cases, 2) critically ill patients, and 3) patients who are in shock (Gelb et al., 2018; Gorski et al., 2021; Kaufmann et al., 2020; Lakhal et al., 2018; Meidert et al., 2021; Saugel et al. 2020; See, 2022).
Most hospitalized patients can have non-invasive monitoring of their blood pressure by auscultation.
Advances in design and use now allow arterial lines to monitor and calculate stroke volume and cardiac output. They can also monitor the response to fluid therapy when the patient is hypovolemic (Gelb et al., 2018; Gorski et al., 2021; Kaufmann et al., 2020; Lakhal et al., 2018; Meidert et al., 2021; Saugel et al. 2020; See, 2022).
Facility policies and procedures should be adhered to. Some kits include everything needed for this procedure. Depending on the facility and policies, a Heparin 500ml bag with a pressure bag at 300mmHg is often used. An ICU monitor shows the numbers being monitored. Transducer kits should be calibrated and ready to go; the transducer should be level with the patient when the patient is flat to ensure correct readings. The monitoring device should be set to zero while the transducer hub is leveled (Saugel et al., 2020).
A wave test should also be performed as it shows a baseline arterial line waveform. Waveforms may be:
Ensure the tubing is not kinked. Do not force the flush if the tubing or line does not flush. Forcing the flush could cause a thrombosis to dislodge and can be fatal for the patient (Nguyen & Bora, 2022).
Arterial catheters are usually placed in the radial artery (Chandrashekarappa et al., 2018; Hanrahan et al., 2022; Kumar & Geube, 2021; Saugel et al., 2020; Vidovich, 2018). Radial artery cannulation is technically easy; there is usually good collateral circulation if there is an occlusion of the radial artery, and complications are very uncommon (Hanrahan et al., 2022; Nuttall et al., 2016). The brachial, femoral, and ulnar arteries and other sites can also be used (Kumar & Geube, 2021; Saugel et al., 2020; Singh et al., 2017; Vidovich, 2018).
There are specific procedures that should be followed for placement and technique.
Contraindications to arterial cannulation include abnormal artery anatomy, localized infection, thrombosis, thromboangiitis obliterans, and active Raynaud's disease (Saugel et al., 2020). Note:
Complications of radial arterial cannulation include (but are not limited to) accidental removal, hematoma, infection, ischemia caused by an embolism of thrombosis, dissection of the radial artery intima, nerve damage, occlusion, and arterial spasm (Berry, 2022; Imbrìaco et al., 2022; Nuttall et al., 2016; Scheer et al., 2002).
Post insertion, the most common complication of radial artery catheters is temporary occlusion of the artery, occurring in 1.5% to 35% of patients (Scheer et al., 2002). Temporary occlusion of the radial artery rarely causes serious complications, and permanent occlusion is rare (Scheer et al., 2002). Gleich et al. (2021) did a retrospective review of 5142 arterial cannulations (3395 radial artery cannulations), and the rate of major complications was 0.2%, and there were no complications with the radial artery cannulations.
Some common complications that can affect any insertion site include:
Some complications specific to the femoral artery include:
Some complications specific to the brachial artery include:
There is also a high risk of thrombotic complications with the dorsalis pedis artery.
A thrombosis is more likely in female patients, those with an abnormal cardiac output, and those with a catheter in for longer than a few days.
Ischemia can occur for many reasons; many incidences can be corrected easily, but some require surgical interventions.
Arterial lines can contribute to blood loss. From blood draws to samples, it is not uncommon to lose up to 30 ml a day; the longer the catheter is in, the more blood loss that is seen.
Radial artery cannulation is a commonly performed procedure, and there is a lot of published literature on insertion techniques and complications (Imbrìaco et al., 2022). Much less information is available about maintaining the radial arterial line, which is the nurse's primary responsibility. Despite the frequent use of radial arterial lines, little practice evidence exists in the literature about the nursing management of radial arterial lines.
The primary nursing care responsibilities for radial artery catheter care that are covered here are:
Blood cultures should be taken from the lumens as per orders. The rubber stopper on the blood culture bottles should be disinfected.
Allergies should be checked before dressing changes, as some patients are allergic to specific dressing types and cleaning solutions. Contact dermatitis can occur if the chlorhexidine solution is not allowed enough time to dry. A chlorhexidine gel pad has been shown to reduce the chances of an infection within the line.
Transparent dressings should be changed every seven days or as needed. If dressings feel "boggy" or are very swollen, they should be changed. Often, they need to be changed every two days due to sweating and poor skin integrity. Gauze dressings should be changed daily and as needed. Any tape and gauze on the dressings should be changed daily. It should also be changed if it is loose or not occlusive (Reynolds et al., 2018).
Lines and insertion sites should be inspected daily. Lines should be maintained as long as no issues arise. Inserting a new line increases the risk of infection. Lines should only be changed when there is redness or infection.
Safety measures should be taken when caring for patients with an arterial line.
Arterial lines are effective, but they are not without risk. Infection, hemorrhage, trauma, and ischemia are possible. Swelling and impaired circulation may indicate ischemia due to occlusion from a hematoma or thrombus. Bleeding can occur if the lumen or cap is accidentally bumped. Bleeding can happen quickly and be extensive. Significant blood loss is possible if the assessment is not performed routinely. Assess for crepitus, as it can indicate infection or air. An aseptic technique should be used, primarily when the line is handled.
Flushing should be done thoroughly after blood sampling. Adequate pressure and volume should always be maintained to prevent thrombosis (Nguyen & Bora, 2022).
If the line is blocked, do not try to force it. Any clots should be aspirated first and then flushed. Flushing a clot can cause ischemia and even a heart attack.
A normal saline flush should be used every shift; accidental use of 5% dextrose can cause altered glucose levels.
The site should be assessed for redness, pain, swelling, or discharge. The dressing should be evaluated for bogginess and changed when warranted.
The extremity should be assessed for circulation, color, and swelling. Blanching should be observed when flushing.
Keep dressings exposed to quickly determine if bleeding or problems are present. Arterial line alarms should be kept on to detect instability or dislodgement.
Determine if there are any issues, such as position, and report concerns or issues to providers. The need for an arterial line should be reviewed daily, depending on the patient's circumstances and diagnosis. If the line is placed during an emergent situation, the need should be reassessed after the patient is stable.
Both central venous and arterial lines are necessary if the patient is unstable and extensive care is required. However, the line should be removed as soon as possible to decrease the chances of infection (Nguyen & Bora, 2022).
Removal of an arterial line requires strict adherence to a facility's policies and procedures. The removal order should be confirmed. The removal steps for an arterial line are very similar to the removal of a CVAD.
A fifty-two-year-old male has been admitted to an ICU. He had been diagnosed with acute respiratory distress caused by COVID-19 infection, and elective intubation and mechanical ventilation were needed. In the first week of admission, the patient's pulmonary status neither deteriorated nor improved, and the providers did not feel that attempting to wean him from the ventilator was safe. On day two, a feeding tube was inserted, and enteral nutrition was begun.
On day eight of his ICU stay, the patient, who was still mechanically ventilated, developed sepsis and became hypotensive. His systolic blood pressures were consistently < 80 mm Hg, the mean arterial pressures were abnormally low, and the serum lactate, at one point, was 16 mg/dL (normal 18 mg/dL). Despite vigorous fluid resuscitation, the patient's hemodynamic state did not improve. His BUN and creatinine rose from normal values to 29 mg/dL and 1.9 mg/dl, respectively. Given these complications, the continued need for mechanical ventilation, and the likelihood that the patient might need long-term central venous access, it was decided to insert a central IV line in the external jugular vein. Infusion of norepinephrine infusion and phenylephrine were started, empiric antibiotic therapy was started, and plans were made to begin TPN. Daily chlorhexidine gluconate baths were started, the central line insertion site was covered with chlorhexidine-impregnated dressings, and a 1:1 nurse-patient ratio was used whenever possible. Within 24 hours, his blood pressure improved there was an improvement in the clinical signs of sepsis.
One day later, the phenylephrine infusion was tapered down and then discontinued. The next day the norepinephrine infusion was tapered down and discontinued. Still, the nurse noticed redness and swelling around the catheter insertion site, and the patient – who had been afebrile for 48 hours – had a temperature of 101.3°F. CLABSI was suspected (as opposed to recurrence of sepsis) because the patient was afebrile, hemodynamically stable, and perfusing well, e.g., with good urine output and good peripheral circulation. There were good alternatives for IV access, the central line was removed, and the tip was cultured. Empiric antibiotic therapy was started, two peripheral IV lines were inserted, and enteral nutrition was restarted.
Analysis: The indications for placement of a CVAD were clear; the patient needed vasopressor infusions and TPN, and there was a lack of reliable venous access. The appropriate CVAD care was given – chlorhexidine gluconate baths, chlorhexidine-impregnated dressings for the CVAD insertion, 1:1 nurse-patient ratio – but despite this, a CLABSI developed. Because the patient was hemodynamically stable and there was evidence that the sepsis was resolving, the CVAD line was removed.
Central venous and arterial lines are often necessary components of medical care. Central venous lines are usually indicated for administering irritants, vesicants, or vasopressors. Sometimes a central venous line is necessary for long-term access, renal replacement therapy, rapid administration of fluids, invasive hemodynamic monitoring, or the inability to obtain other IV access.
The first type of central venous access device is a PICC line. The IV catheter is inserted into a peripheral line, usually in the upper arm. PICC lines are commonly inserted for patients needing long-term access, such as chemotherapy. Though effective, complications of PICC lines include occlusion, hematomas, and infection. The next type includes tunneled and non-tunneled catheters. Though they are similar in design and function, they are used for different purposes. A tunneled catheter has both an entry site and an exit site, which are used for longer purposes. Non-tunneled catheters are for temporary use, like standard IV therapy or labs. Non-tunneled catheters do not require an incision and are usually used for two weeks or less. Totally implantable ports are also used for long-term purposes. Impregnated and coated catheters, coated with antibiotics, antimicrobials, or antimycotics, exist to decrease the accumulation and growth of bacteria and reduce catheter-related infections.
No matter which type of catheter is implanted, specific steps must be taken to complete the process properly. A CVAD with the smallest catheter and least amount of lumens should be used; these choices help to limit complications. An ultrasound should be used to insert a CVAD to reduce complications. Some common complications associated with CVAD include arrhythmias, arterial puncture, hematomas, hemothorax, lacerations, malposition, nerve injury, and pulmonary complications. Those are complications associated with insertion; there are post-insertion complications that should also be looked for. The most common type of post-insertion complication is a CLABSI. It can occur due to poor hand hygiene of the person inserting the catheter or contamination after insertion. Another complication is an air embolism, which occurs when air leaks into the bloodstream. Air embolisms can be diagnosed with an EKG, x-ray, CT scan, or, if needed, transthoracic echocardiography. Patients with air embolisms require immediate interventions such as hemodynamic support, oxygen, supportive positioning, and, worst-case scenario, CPR.
During insertion, damage is possible, which may result in catheter migration. A CVAD tip can migrate at any time after insertion. Other serious complications include a DVT, which can consist of symptoms of edema and/or pain in the chest, neck, or an extremity, erythema and/or numbness in an extremity, and difficulty moving the extremities and/or the neck. It can progress to a pulmonary embolism, evidenced by chest pain, diaphoresis, dyspnea, pleuritic pain, and tachycardia.
There are specific complications related to the catheter, including infiltration, extravasation, phlebitis, and occlusion. Both infiltration and extravasation result when fluid leaks into the surrounding tissue. Excavation occurs with vesicants and can result in increased harm, such as necrosis and tissue loss. Phlebitis results in inflammation of the vessel and can be grouped into different diagnoses, such as chemical or mechanical phlebitis. Occlusion results when something blocks the line and can also be divided into different diagnosis categories, such as chemical or mechanical occlusion.
Nursing care is pertinent, no matter if the patient has a CVAD or arterial line. Specific nursing care tasks include 1) assessment of the infusion system, 2) assessment of the insertion site, 3) dressing changes, 4) flushing and locking, and 5) observing for complications. The infusion system and the assessment site deserve routine monitoring and assessment for complications. Dressing changes should be performed as scheduled, such as every seven days, or as needed, such as when the dressing feels "boggy." Flushing, locking, and disinfecting ports require special steps and approaches.
Nursing care also means that complications should be prevented at all costs. Each complication requires different steps to prevent them. Central line infections require adequate hygiene and disinfection, and air embolisms require maintaining the integrity of the infusion system.
Central venous and arterial lines should be removed as soon as possible. Removal of catheters requires specific steps to ensure the catheter remains intact and the procedure goes smoothly. Orders should always be checked, and the facility's policies and procedures should always be followed. There are pros and cons related to the insertion and use of these devices; it depends on the patient and their situation. Regardless, safety measures must be followed.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.