LPN IV Series: Central Venous Catheters and Arterial Catheters

A central venous line, also known as a central venous catheter or a central venous access device (CVAD), is an intravenous (IV) catheter that has been inserted and positioned so the catheter tip is in the proximal one-third of the superior vena cave, the right atrium, or the inferior vena cava of the heart (Lockwood & Desai, 2019). Essentially, it is an indwelling device inserted into a larger and more central vein.

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).

Central venous catheters are usually placed in the internal jugular, femoral, or subclavian veins; these are the preferred sites for temporary placement (Berry, 2022). More information on each site will be discussed later in this course.

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 vesicants. They are very irritating and potentially damaging to small veins, and infiltration of these medications may cause extravasation. Formally, a vesicant is defined as an agent that is capable of causing tissue damage when it escapes from the intended vascular pathway into surrounding tissue (Gorski et al., 2021).

Many drugs can be considered vesicants and include the following.

Antiemetics:

• Hydroxyzine
• Promethazine

Cardiovascular agents/diuretics:

• Chlorothiazide
• Digoxin
• Dopamine
• Epinephrine
• Esmolol
• Mannitol >5%
• Phenylephrine
• Norepinephrine
• Tromethamine
• Vasopressin

Electrolytes and nutritional supplementations:

• Amino acid solutions ≥4.25%
• Arginine
• Calcium chloride
• Calcium gluconate 10%
• Dextrose >10%
• Sodium bicarbonate ≥8.4%
• Sodium chloride ≥3%
• Parenteral nutrition

Some chemotherapeutic agents are well-known vesicants and include the following:

• Actinomycin-D
• Dactinomycin
• Daunorubicin
• Doxorubicin
• Idarubicin
• Mechlorethamine
• Mitomycin-C
• Paclitaxel
• Vinblastine
• Vincristine
• Vinorelbine

Although this list is not all-inclusive, it does identify common vesicants.

Infiltration occurs when an IV catheter is dislodged from a vein, and IV fluid or medications infuse into the tissue.Extravasation is the infiltration of a vesicant and can cause irritation, pain, tissue necrosis, compartment syndrome, or even result in amputation (Brock & Cruz-Carreras, 2020; Chinn & Colella, 2017; David et al., 2020; Gorski et al.,2021; Masood et al., 2022).

Vasopressors are a type of drug, an adrenergic receptor agonist to be exact, that increases blood pressure, in part, by vasoconstriction. They essentially constrict or narrow blood vessels to increase high blood pressure. Vasopressors like dopamine, epinephrine, norepinephrine, and phenylephrine are primarily used to treat hypotension.

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).

Sometimes, obtaining IV access can be very challenging. At times, veins are just not visible or palpable, or if they are visible and palpable, they are in difficult places such as the wrist. Repeated attempts increase suffering and pain. Other times, patients are in an emergent situation and critical condition and need good access (Armenteros-Yeguas et al., 2017).

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). Normal CVP is 8 to 12 mm Hg.

CVP monitoring is used to measure a patient's response to fluid resuscitation and determine a patient's volume status (De Backer & Vincent, 2018; Hill & Smith, 2021; Mercolini et al., 2021; Rhodes et al., 2017; Tolson, 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).

A CVAD allows for the rapid administration of a large volume of IV fluid because it is inserted into a larger blood vessel than a peripheral IV (Somand and Ward, 2020). A CVAD may have multiple lumens.

Hemodialysis-central venous catheter insertion is commonly performed for patients with end-stage kidney disease. Hemodialysis uses a dialysis machine and a dialyzer to clean the blood. A hemodialysis-central venous catheter is used because it has a larger lumen, allowing for increased flow (Sohail et al., 2021). Though it is a standard procedure, many complications and adverse effects arise from the placement and procedure of a hemodialysis-central venous catheter.

Total parenteral nutrition (TPN) is often needed for patients who are malnourished; it often takes an extended length of time for renourishment. TPN solutions are hyperosmolar and should be administered through a CVAD (Alexander, 2020; David et al., 2020; Gorski et al., 2021). Peripheral parenteral nutrition solutions, which are less concentrated and have a relatively lower osmolarity, can be given through a peripheral IV (Berlana, 2022).

A temporary transvenous pacing wire can be inserted through a CVAD (Lockwood & Desai, 2019). The pacemaker ensures the heart beats regularly, not too slow or fast. It is temporary, unlike implanted pacemakers in the chest (Tjong et al., 2019).

A PICC is an IV catheter inserted into a peripheral vein. The catheter tip is positioned at the junction of the vena cava and the right atrium. A PICC is typically inserted into a vein in the upper arm, such as in the basilic, brachial, or cephalic vein. If necessary, the femoral vein can be used. Using ultrasound for inserting a PICC may reduce its failure due to an increased ratio of the catheter within the vessel (Berry, 2022; Gorski et al., 2021; Naik et al., 2022; Swaminathan et al., 2022; Yuen et al., 2022).

PICCs have several advantages: They can be inserted at the bedside, and compared to the other CVAD insertion sites, there are fewer insertion complications. They facilitate the transition of care, they are suitable for long-term (> 15 days) access, and they can be inserted by a vascular access nurse (Chopra et al., 2022; Gorski et al., 2021; Santos et al., 2020; Woller et al., 2016).

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).

Complications of PICCs include (but are not limited to) accidental withdrawal, catheter fracture, catheter migration, infection, thrombosis, hematoma, and occlusion (Bing et al., 2022; Chopra et al., 2022; Duwadi et al., 2018; Fohlen et al., 2022; Gorski et al., 2021; Smith et al., 2017; Vaughn et al., 2020; 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).

Non-tunneled catheters are very similar to tunneled catheters in their design and function; however, they are used very differently. A non-tunneled catheter goes directly into the vein and does not pass under the skin. There is an entry site but not an exit site.

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.

• Insertion – The insertion technique is a significant way tunneled and non-tunneled catheters differ. Non-tunneled catheters are inserted straight into the vein, without tunneling, while tunneled catheters pass under the skin and have both an entry and exit site (Clark et al., 2016).
• Design- Tunneled catheters have an extra cuff near the entry site that non-tunneled catheters do not have. The cuff helps to prevent microbes and bacteria from gathering around the entry site.
• Usage- Tunneled and non-tunneled catheters have different purposes and are used for different tasks. As discussed above, non-tunneled catheters are better used for standard IV therapy and for a short time. Tunneled catheters are inserted for long-term purposes such as chronic illnesses (Clark et al., 2016).
• Safety- Both types of catheters have different risks and safety levels. Even though tunneled catheters have a cuff to prevent the accumulation of microbes and bacteria, the insertion process is more complex, increasing the risk of infections and other complications.
• Duration- While non-tunneled catheters are not meant to be in place for long, tunneled catheters are designed to be in place for a minimum of a few weeks or even months, depending on their use (Mendu et al., 2017).

Implanted ports are often used for patients requiring long-term care. Implantable ports are placed subcutaneously under the skin and are made up of titanium or plastic portals with a silicone tube that self-seals and a flexible tube or catheter. Implanted ports are placed on the right or left side of the chest. The catheter on the port flows from the skin and is placed above the heart's right atrium, under the collarbone. Occasionally, ports may be implanted in the stomach to deliver the medication near the tumor. Port-a-Cath, PassPort, Medi-port, and Infusaport are other names for an implanted port. Even though the port is placed under the skin, there is a small bulge where the port is, and it can be felt under the skin (Zhou et al., 2022).

The port is a common choice for patients with cancer requiring extended or long-term treatment. Patients usually have an implanted port placed during surgery. After placement, checks are done to confirm the port is positioned correctly so that the port can be used immediately.

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).

Sometimes, catheters are impregnated or coated to prevent central line infections. It is commonly used in non-tunneled catheters that will be used for a short time or patients undergoing stem cell transplants. Commonly used agents include silver sulfadiazine, chlorhexidine, or rifampin (Lai et al., 2016a).

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).

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.

• Arrhythmias: Arrhythmias caused by CVAD placement rarely occur. They can occur during PICC placement and placement at other insertion sites, and asystole, atrial fibrillation, complete heart block, and ventricular tachycardia have been reported (Golamari et al., 2019). Nine dangerous arrhythmias that occurred during 12,388 CVAD insertions, an incidence of 0.07%, have been reported. Information on arrhythmias and CVAD insertion are scant.
• Arterial puncture: An arterial puncture has been reported to occur in up to 12% of CVAD insertions. Treatment options for this complication include immediate removal of the catheter and application of manual pressure or leaving it in place until another removal method can be used. An arterial puncture can cause serious complications, including (but not limited to) bleeding, dissection of the vessel, hemothorax, and pseudoaneurysm (Patel et al., 2021). Note: A pseudoaneurysm is a hematoma inside the wall of a blood vessel that has been injured by trauma – in the case of insertion, the catheter or the guidewire punctures the blood vessel.
• Hematoma: Hematoma formation has been reported to occur in 4.7% of CVAD placements, and a hematoma can cause compressive nerve injury (Gorski et al., 2021; Patel et al., 2021).
• Hemothorax: Hemothorax can occur during CVAD insertion, but it appears rare; this is when blood collects between the lungs and chest wall.
• Laceration: A blood vessel or right atrium laceration can occur during CVAD placement (Patel et al., 2021).
• Malposition: Researchers have retrospectively reviewed information on 2045 central venous catheter insertions. The authors defined catheter malposition as ". . . unintended placement of the catheter in a vessel other than the intended superior vena cava." There were 275 (13.4%) instances of catheter malposition.
• Nerve injury: Jugular and subclavian CVAD insertion can cause phrenic nerve injury, often causing trouble breathing (Gorski et al., 2021). Inserting a CVAD into the internal jugular vein can damage a sympathetic nerve, disrupt sympathetic outflow to a specific area, and cause Horner syndrome. Horner's syndrome is a rare complication of CVAD insertion that is characterized by facial anhidrosis (absence/lack of sweating), enophthalmos (eyes are sunken in), miosis (pupillary constriction), and drooping of the eyelids. Data on nerve injury is scant, but 1 case of nerve injury lasting > 72 hours in 9118 CVAD insertions in the internal jugular vein with an incidence of 0.01% has been reported.
• Pneumothorax and other pulmonary complications: Researchers have retrospectively reviewed information on 2045 central venous catheter insertions, and there were 14 (0.7%) occurrences of pneumothorax. Other pulmonary complications of CVAD insertion include air embolism (which can occur post-insertion), pneumomediastinum (air in the chest between the lungs), and tracheal injury (Patel et al., 2015).

CLABSIs are defined as the presence of bacteria that have originated from the catheter.

These four criteria define a CLABSI.

1. A laboratory-confirmed bloodstream infection
2. The patient has had a CVAD in place for > two days
3. The CVAD has been in place on the day of, or the day before, the first sign or symptoms
4. The infection cannot be attributed to another infection (Alotaibi et al., 2020)

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).

• Causes: A CVAD can become infected during the insertion and/or when it is in place (Gorski et al., 2021; Selby et al., 2021). Post-insertion contamination can occur during dressing changes; it can be caused by poor hand hygiene, the catheter hub and/or lumen can become contaminated during manipulation or routine use, and the catheter may become contaminated when a microorganism moves from another infection site to the CVAD (Gorski et al., 2021; Selby et al., 2021). Many CLABSIs are caused by a failure to correctly do CVAD maintenance care (Gorski et al., 2021; Lutwick et al., 2019; Selby et al., 2021).
• Risk factors: Risk factors for CLABSI are listed in Table 4.

• Biofilm: A biofilm is a microorganism that attaches to a surface and then forms a polymeric substance. The substance helps them attach to a surface, like a central venous catheter. By several complex mechanisms, biofilms protect the microorganism, prevent its eradication by the immune system, and decrease the effectiveness of antibiotics (Niemann et al., 2022; Selby et al., 2021). Biofilms are a well-known risk factor for CLABSI (Niemann et al., 2022). Bacterial colonization of a vascular catheter can happen very quickly, within 24 hours of insertion. A biofilm can form within 48 to 72 hours after a central venous catheter has been placed (Higgins et al., 2021).
• Signs and symptoms: Signs and symptoms of insertion site infection are obvious and include drainage, edema, erythema, fever, pain, and swelling. A diagnosis of CLABSI is considered when the patient has signs/symptoms of sepsis, and the diagnosis is confirmed by blood cultures, including cultures of the catheter tip (Gorski 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. A venous air embolism occurs when air enters the IV system due to a disruption/leak in its patency. Air enters the bloodstream and moves to the right ventricle, the lungs, and sometimes to the brain. An air embolism is potentially fatal (Abramson et al., 2020; Khaliq et al., 2018). Signs and symptoms of air embolism include (but are not limited to) altered mental status, coughing, dyspnea, hypotension, tachycardia, and wheezing (Gorski et al., 2021).

There are a few common diagnostic modalities used to diagnose an air embolism.

• An EKG can be done and usually shows strain on the right side of the heart, tachycardia, and T-wave changes.
• End-tidal carbon dioxide (ETCO2) may show a decrease in numbers, indicating an air embolism.
• Chest x-ray or CT scan may show enlargement in the pulmonary artery or trapped air in the artery.
• A transthoracic echocardiography may show trapped intra-cardiac air but is an intense procedure to be performed and often a last resort (McCarthy et al., 2017).

There are many interventions that providers may perform to alleviate an air embolism; they include:

• Hemodynamic support, including standard IV therapy, vasopressors, and inotropes (medications that tell the heart to contract with more/less power).
• High-flow, 100% oxygen; if necessary, hyperbaric oxygen may be used to decrease the partial pressure of nitrogen in the blood, thereby reducing the size of the air embolism.
• The patient should be placed in a left lateral decubitus position called Durant's maneuver. If the patient is hemodynamically unstable, the patient should be placed in the Trendelenburg position.
• An emergent cardiopulmonary bypass is warranted if the patient is unstable.
• CPR with high-quality chest compressions is necessary if the patient is in cardiovascular collapse or arrest (McCarthy et al., 2017).

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).

Pinch-off syndrome is a rare and potentially fatal complication caused by anatomic compression of the catheter (Caiazzo et al., 2022; Gorski et al., 2021; Lakshmi et al., 2022). It appears that it occurs most often with subclavian lines that have been in situ for a long duration (Caiazzo et al., 2022; Chuah et al., 2021). Signs and symptoms of the pinch-off syndrome include (but are not limited to) arrhythmias, cardiac perforation, cough, dyspnea, endocarditis (inflammation of the heart), and sepsis (Caiazzo et al., 2022; Chuah 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). Migration of a CVAD tip can be caused by coughing, a thrombosis, positive-pressure ventilation, physical activity like arm or neck movement, vomiting, or congestive heart failure (Gorski et al., 2021; Martinez and Puller, 2021).

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.

Most patients with a central line-associated DVT are asymptomatic (Gorski et al., 2021; Citla Sridhar et al., 2020). Signs and symptoms of a CVAD-associated DVT include edema and/or pain in the chest, neck, or an extremity, erythema and/or numbness in an extremity, difficulty moving the extremities and/or the neck (Li & Lu, 2022; Gorski et al., 2021). Signs and symptoms of a pulmonary embolism include (but are not limited to) chest pain, diaphoresis (increased sweating), dyspnea, pleuritic pain, and tachycardia (Gorski et al., 2021).

A DVT is usually detected and diagnosed using duplex ultrasonography (Citla Sridhar et al., 2020). If a DVT is present and the CVAD is functional, and it is still needed, the current recommendations are to leave it in (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. Extravasation occurs when the IV medication is very irritating or a vesicant (Gorski et al., 2021). A vesicant is an agent capable of causing tissue damage when it escapes from the intended vascular pathway into surrounding tissue (Gorski et al., 2021). Drugs and other substances that are or can be vesicants include (but are not limited to) chemotherapy drugs, IV contrast media,  50% dextrose, TPN, and vasopressors, as discussed above (Cho et al., 2019; Brock & Cruz- Carreras, 2020; Lawson et al., 2013; Masood et al., 2022; Shrestha et al., 2020). Extravasation can cause irritation, pain, tissue necrosis, compartment syndrome (a painful condition from pressure in the muscles), amputation, sepsis, and death (Abdel al. et al., 2022;  Brock & Cruz-Carreras, 2020; Chinn & Colella, 2017; Masood et al., 2022). The signs and symptoms of extravasation can be delayed (Karius & Colvin, 2021).

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).

• Chemical occlusion: Chemical occlusion of a CVAD can be caused by precipitates of medications, such as crystals,  and/or components of TPN like calcium, phosphate, or lipids (Ast & Ast, 2014; Gorski et al., 2021; Ornowska et al., 2022).
• Mechanical occlusion: Mechanical occlusion of a CVAD can be external or internal (Ast & Ast, 2014). External occlusions can be in the IV tubing, the external part of the CVAD, or a filter, and they can be caused by the movement of a patient's head or neck (Ast & Ast, 2014; Gorski et al., 2021). Internal mechanical occlusion can be caused by a biofilm, kinks, catheter malposition, catheter migration, or pinch-off syndrome (Gorski et al., 2021; Ornowska et al., 2022).
• Thrombotic occlusion: A DVT is an example of a thrombotic occlusion. Symptoms include pain, swelling, redness, and numbness (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).

Phlebitis is an inflammation of the inner layers of a blood vessel (Lu et al., 2022). Phlebitis associated with a CVAD can be caused by chemical, infectious, and mechanical factors, patient-related factors, and rarely, post-infusion phlebitis (Gorski et al., 2021; Webster et al., 2015).

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).

• Chemical phlebitis: Chemical phlebitis can be caused by IV solutions with extremes of pH or osmolarity like dextrose solutions > 10% concentration, 3% sodium chloride, or by drugs like amiodarone (treats arrhythmias), chemotherapy drugs, potassium, and antibiotics like vancomycin (Gorski et al., 2021; Heng et al., 2020; Woods et al., 2022).
• Infectious phlebitis: Infectious phlebitis can be caused by contamination of the catheter and/or the insertion site (Gorski et al., 2021).
• Mechanical phlebitis: Mechanical phlebitis with vein irritation can be caused by a catheter that is too large in relation to the size of the blood vessel and the movement of the catheter after insertion (Gorski et al., 2021).
• Patient-related factors: Female patients, patients with diabetes, patients who are immunocompromised, and/or are ≥ age 60 have an increased risk for catheter-related phlebitis (Gorski et al., 2021).
• Post-infusion phlebitis: Post-infusion phlebitis occurs after an IV catheter has been removed (Gorski et al., 2021; Webster et al., 2015). Post-infusion phlebitis can be caused by any of the factors mentioned above, and the incidence of this complication has been reported to be from 0% to 23%. Post-infusion phlebitis can occur up to 48 hours after removing an IV catheter (Gorski et al., 2021). Webster et al. (2015) found that in the patient population they studied, 75% of the patients who developed post-infusion phlebitis did not have phlebitis when the catheter was removed.

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).

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). Standard Precautions, such as personal protective equipment like gloves and masks, should always be used during this assessment, especially hand hygiene and safe injection practices. Other infection control techniques like bloodborne and contact precautions should be used as needed. Sterile technique should be used for the parts of the assessment that require it. Each healthcare facility or organization will have a guideline for the frequency of this assessment.

The CVAD insertion site should be routinely assessed for signs of infection and to ensure that the CVAD is securely attached. Signs and symptoms of insertion site infection are obvious, including drainage, edema, erythema, fever, pain, and swelling (Gorski et al., 2021).

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).

Sterile gauze is preferred if there is drainage at the insertion site or if the patient is sweating excessively (Gorski et al., 2021; Lutwick et al., 2019). For all other situations, a TSM is recommended as a transparent dressing allows for easy inspection of an insertion site, and TSMs may reduce the risk of CVAD dislodgement/removal (Gorski et al., 2021; Lutwick et al., 2019).

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).

A TSM dressing on a CVAD should be changed at least every seven days, and a TSM should be replaced immediately if it is loose or soiled or if blood, drainage, or moisture is underneath the TSM (Gorski 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

1. Disinfect the catheter access site before flushing (Gorski et al., 2021); this process is explained in the next section.
2. Use a 10 mL syringe or a 10 mL barrel syringe (which generates a lower pressure) to flush a CVAD (Gorski et al., 2021).
3. Aspirate before flushing (Gorski et al., 2021).
4. Flush the CVAD with 0.9% sodium chloride that is preservative-free (Gorski et al., 2021). If using a sodium chloride solution that has benzyl alcohol in it, do not use more than 30 mL in 24 hours. Do not use sterile water to flush a CVAD (Gorski et al., 2021).
5. It is recommended to use a pulse technique to flush a CVAD, i.e., a 1 mL bolus, a short pause, and then a repeat (Gorski et al., 2021). Studies have shown – but not proven – that this technique may decrease bacterial contamination in a CVAD lumen, remove solid deposits in the lumen, and decrease the accumulation of material that can obstruct the lumen (Ferroni et al., 2014; Gorski et al., 2021; Goossens, 2015). Clinical studies are needed to clarify the true effect of this technique.
6. Gorski et al. (2021) recommend flushing with a volume that is twice the volume of the internal volume of the catheter system, i.e., the catheter and add-on devices. Up to 10 mL may be needed for a CAVD.
7. Do not use force to flush a CVAD.
8. Blood can reflux back into the flushing syringe and push the plunger back. To prevent this, leave 0.5 to 1 mL of the flush solution in the syringe, or use a pre-filled syringe designed to prevent this (Gorski et al., 2021).
9. A central IV line should be flushed after infusion of medication; the frequency of CVAD flushing aside from that should be covered by a healthcare facility's protocol. Use enough flushing solution to remove all medication from the administration set and CVAD lumens (Gorski et al., 2021).

Disinfecting Access Ports

1. Access port disinfection should be done before every use.
2. Access port disinfection can be done actively or passively (Gorski et al., 2021; Helder et al., 2020; Voor In 't Holt et al., 2017; Rickard et al., 2021).
3. Active port disinfection can be done with 70% isopropyl alcohol, alcohol-based chlorhexidine, or povidone-iodine (Gorski et al., 2021; Rickard et al., 2021).
4. Passive disinfection is done by covering the access port with a cap or some type of cover containing a disinfectant, and the cap/covering is left on for a specific amount of time. Research indicates that passive disinfection can prevent CLABSI (Helder et al., 2020; Voor In 't Holt et al., 2017; Tejada et al., 2022).

Locking

1. Use heparin, 0.5 to 1 unit/10 mL, or 0.9% sodium chloride (Gorski et al., 2021).
2. Gorski et al. (2021) noted that there is no evidence that either solution is superior for muti-lumen, non-tunneled CVADs or PICCs, and the authors of a recent literature review wrote that they were uncertain whether intermittent locking with heparin results in fewer central venous catheter occlusions than intermittent locking with normal saline in adults. Low-certainty evidence suggests that heparin may have little or no effect on catheter patency duration. There was no evidence of differences in safety (central venous catheter-related bloodstream infections, mortality, or hemorrhage) (López-Briz et al., 2018).
3. Definitive answers regarding when and how often locking should be done, the optimal dwell time, what solution should be used (at times, a solution other than heparin or 0.9% sodium chloride may be used), and for whom locking should be done are not available (Gorski et al., 2021; Selby et al., 2021). Evidence shows that locking can prevent central line infections (Selby et al., 2021). Gorski et al., 2021 provided recommendations for some of these questions; follow the protocol of the health care facility/organization.

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. Korotkoff sounds are what medical personnel listen for when they are taking blood pressure, and it is the pulsatile circulatory sounds heard upon auscultation of the brachial artery (Ramakrishnan, 2016). In patients who are unstable and/or critically ill, there may be a need for more invasive techniques to monitor blood pressure. In this instance, arterial catheterization is warranted. More indications for arterial lines include:

• Frequent blood samples are needed
• Continuous beat-to-beat monitoring of blood pressure
• Administration of medications
• The need for an intra-aortic balloon pump

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:

• Normal- the shape of the waveform is from the closure of the aortic valve and the blood pressure (Foti et al., 2022).
• Over-damped- this is more loss of energy; it can be caused by air in the tubing, kinks or clots in the tubing, or narrowed pulse pressure (Lam et al., 2021).
• Under-damped- this can be caused by artifacts in the line, tachydysrhythmias (abnormal rhythm over 100 beats per minute), overestimation of systolic blood pressure, or underestimation of diastolic blood pressure (Foti et al., 2022).

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.

• Palpation- The anatomical location of the arterial vessel should be confirmed before placement. Direct palpation of the arterial pulse assists with finding the proper location. After prepping and finding/verifying the location, the insertion may take place. The insertion angle will vary depending on the insertion, which means that some degrees may make the insertion process more difficult.
• The Allen Test- Before the insertion of a radial arterial catheter, an Allen Test is usually performed. The test ensures that the blood flow of the artery, especially the ulnar artery, is sufficient to avoid injury. To perform this test, both radial and ulnar arteries are occluded by manual palpation for around 15 seconds until the skin on the palm blanches. The patency is considered sufficient if the blanching resolves quickly after the ulnar arterial occlusion is released (Agarwal et al., 2020).
• Doppler Auditory Assistance- Auditory doppler devices can help determine the point of entry when accessing a needle, especially in patients with low blood pressure, and locating the pulse may be difficult (Aouad-Maroun et al., 2016).
• Ultrasound Guidance- Ultrasound guidance increases the success rate when placing an arterial line. It reduces the number of attempts, decreasing the risk of infection. Ultrasound guidance has an even higher success rate in infants and children. Also, using ultrasound may assist in finding the appropriate catheter size; this is important in pediatric patients and is now a standard of care (Cho et al., 2021).
• Seldinger Technique- A Seldinger Technique assists with gaining access to the arterial lumen using a guidewire. After the pulse is located, the artery is punctured with a needle. Once blood flow is detected, a guidewire is inserted into the needle hub to gain entry into the artery. Once advancement occurs, the needle can be removed. The opposite end of the guidewire is threaded into the distal end of the catheter until it is flush with the skin. The guidewire can be removed, and the tip of the guidewire should be checked for integrity, ensuring it is intact. The technique is best used when the artery runs deep into the extremity (Hsu et al., 2016).
• Catheter Over the Needle- A peripheral venous catheter can sometimes access more superficial arteries. After the artery is located, it is punctured with the over-the-needle device. After blood flow is found, the catheter is slid over the device before the needle is removed (Kim et al., 2021).
• Securing the Arterial Catheter- After placing the catheter, it must be secured. Securing the catheter prevents infection, dislodgement, and excessive motion that may interfere with monitoring results. Securing the catheter prevents the procedure from being repeated. Transparent adhesive dressings should be used so direct visualization is still possible. If the catheter is in the wrist, the hand should be extended slightly using a soft roll and a rigid board, allowing for fixation. The tubing should be looped around the thumb and secured to the forearm (Reynolds et al., 2018).

Contraindications to arterial cannulation include abnormal artery anatomy, localized infection, thrombosis, thromboangiitis obliterans, and active Raynaud's disease (Saugel et al., 2020). Note: Thromboangiitis obliterans, also known as Buerger's disease, is recurring inflammation and thrombosis of small blood vessels.

Absolute or strict contraindications for arterial cannulation include:

• Raynaud syndrome- this is where the smaller arteries constrict in response to cold temperatures. Blood supply becomes limited, and the patient may be numb and cool in affected areas (Temprano, 2016).
• Buerger disease
• Absent pulse where the artery is
• Poor perfusion of the limb 

Some relative contraindications include:

• Infection at the site of insertion
• Insufficient flow
• Partial to full-thickness burns near a potential insertion site
• Coagulopathy- a bleeding disorder that occurs when the blood is not clotting properly (Aynalem et al., 2021)
• Atherosclerosis (moderate or severe)- buildup in the arteries causing hardening (Libby et al., 2019)
• Vascular graft- this redirects blood flow to bypass a blockage (Hager & Burns, 2022)

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:

• Dislodgement
• Thrombosis
• Pain and swelling
• Hematoma
• Hemorrhage
• Embolization
• Pseudoaneurysm
• Infection
• Lack of blood flow in the limb
• Blood loss (Scheer et al., 2002)

Some complications specific to the radial artery include:

• Thrombotic complications
• Cerebral embolization
• Peripheral neuropathy (Scheer et al., 2002)

Some complications specific to the femoral artery include:

• Visceral injury of the abdomen
• Hematoma
• Arteriovenous fistula (Scheer et al., 2002)

Some complications specific to the brachial artery include:

• Nerve damage
• Embolization (Scheer et al., 2002)

There is also a high risk of thrombotic complications with the dorsalis pedis artery.

Thrombotic occlusion of the cannulated artery- this is the most common complication, regardless of the insertion site. However, the most common sites where this occurs are the radial and dorsalis pedis arteries. In fact, occlusion occurs in up to 20% of radial artery lines compared to 2% in femoral artery lines. Thrombosis is also possible when the catheter is removed. The most significant risk factor for thrombosis upon catheter removal is the size of the catheter lumen; the bigger it is, the more likely a thrombus may form. A hematoma increases the likelihood of a thrombus developing (Onal et al., 2015).

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. If ischemia is diagnosed, removal of the catheter will decrease the risk of complications. However, if ischemia is still ongoing after catheter removal, the following can be considered:

• Thrombolysis is a procedure or medication used to break up blood clots. Medication can be taken to prevent clots from forming (Ucar, 2019).
• Anticoagulation- medications called blood thinners that prevent the formation of blood clots (Frappé et al., 2020).
• Surgical bypass- this is done to improve blood flow through the veins; many different types of bypass can be done (Schmidt-RioValle et al., 2020).
• Embolectomy is a minimally invasive procedure to remove a blood clot (Onal et al., 2015).

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. 

Arterial lines can be a source of infection and sepsis. The risk for infection increases after the arterial line is in for longer than 96 hours.

Arterial lines can contribute to embolization when flushing the arterial line. Risk factors that increase the potential for embolisms include:

• Frequent flushing
• Smaller patients
• Injection sites, such as brachial or radial sites
• Position air travels toward the head when the patient sits upright (Scheer et al., 2002)

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:

1. Insertion site care.
2. Blood sampling.

• Insertion site care: Observe the insertion site and monitor the patient for signs and symptoms of infection, ischemia of the hand, and phlebitis (Plowright & Sumnall, 2022). Unlike CVADs, local and systemic infections are uncommon complications of radial artery catheters (Scheer et al., 2002). The basic dressing for a radial artery catheter is 1) a primary dressing to protect the site from contamination and 2) a securement dressing to prevent catheter movement (Gorski et al., 2021; Larsen et al., 2021). The securement dressing can be an adhesive dressing, an integrated securement device (a combination of a primary and securement dressing), a tissue adhesive, or a medical-grade glue (Gorski et al., 2021). Research studies, to date, have not shown that one type of dressing is superior in preventing infection, catheter dislodgement, occlusion, and other complications (Larsen et al., 2021; Reynolds et al., 2015).
• Blood sampling: Arterial catheters are used for obtaining blood samples, and this must be done correctly to prevent a clot in the catheter and to ensure that there is no infusion solution in the sample (Plowright & Sumnall, 2022; Sprint Working Party et al., 2014). The recommended solution for maintaining arterial line patency is 0.9% sodium chloride (Patel et al., 2021; Sprint Working Party et al., 2014). There are documented cases of a glucose-containing solution being used. However, measured blood glucose is incorrectly high, insulin is being given, and patients are suffering significant harm and death (Patel et al., 2021; Sprint Working Party et al., 2014). Obtaining an uncontaminated blood sample from an arterial catheter can be done by 1) withdrawing and discarding a volume of blood from the system (three to five times the amount of dead space in the system, or 2) using the closed system method. These processes occur by removing the dead space volume from a distal port to the sampling port (Patel et al., 2021; Plowright & Sumnall, 2022). Patel et al. (2021) noted that removing five times the dead space volume may not remove enough glucose to measure blood glucose accurately, and the authors recommended using the closed system method. To prepare for the blood sampling procedure, hand hygiene should occur first. The equipment should be gathered, and the tray should be disinfected and decontaminated. A non-touch technique should be used to prepare equipment, such as the labels on the blood samples. Patient identification should be checked with two patient identifiers. Remember to follow the facility's policies and protocols. Verbal consent should be obtained after fully explaining the process to the patient. The patient should be in a comfortable position. The insertion site, equipment, and tubing should be checked for abnormalities. If an infusion is running, it should be clamped and paused until after the sample is collected (Leslie et al., 2013).

Blood cultures should be taken from the lumens as per orders. The rubber stopper on the blood culture bottles should be disinfected. A non-touch technique should be used, and disinfection should be done with 2% chlorhexidine and 70% isopropyl alcohol swab for a minimum of 15 seconds. It should be allowed to air dry. The needleless connector should be replaced. The catheter hub should be disinfected with 2% chlorhexidine and 70% isopropyl alcohol for 30 seconds and allowed to air dry fully. The needleless connector should be reattached and repeated for each lumen. A 20 mL syringe (for adults) and 10 mL (for pediatrics) should be connected to the needleless connector on the catheter to take blood samples. The clamp, if present, should be opened, and blood should be withdrawn. The syringe with blood should be attached to the sterile blood transfer device. A non-touch technique should be used to attach and fill the aerobic bottle; the anaerobic bottle comes next. If using a syringe, an empty one should be connected to the needleless connector. The clamp should be opened, and around 10 mL of blood should be withdrawn and discarded. If blood cultures were taken first, discarding any blood would be unnecessary (Leslie et al., 2013).

If there is a slow blood return or no blood return at all, reposition the patient and ask them to take a deep breath and hold it or cough. For CVADs that are locked with sodium chloride 0.9%, the catheter should be flushed with 10-20 mL of sodium chloride 0.9% using a pulsatile action. After, try to aspirate blood. If still no blood return, consult with providers of care (Leslie et al., 2013).

A transparent dressing should be used for both central and arterial lines. They allow for daily visualization to look for signs of infection. Transparent dressings also protect the insertion site by enabling some moisture to be drawn away. A device should be used to secure the line in place for lines that are not sutured. For lines that are oozing blood, secure the line with a gauze dressing and tape. Bulky dressings should be avoided as they delay the detection of serious bleeding. Tape or dressings should not be wrapped around the arterial line insertion site circumferentially as they can affect circulation (Reynolds et al., 2018).

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.

Routine monitoring and assessment should occur at the start of every shift and every four hours afterward. The right solution should be confirmed, as well as adequate volume and pressure. A decreased pressure increases the risk of clotting (Nguyen & Bora, 2022).

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.

• Hand hygiene and infection control should be followed before, during, and after the procedure. Equipment, such as an eye shield and non-sterile gloves for blood sampling, should be laid out in an accessible position.
• Two patient identifiers should be used to confirm patient identification.
• A vascular or provider consult may also be necessary (Kabra et al., 2015).
• Coagulation tests should be performed to check platelets, INR, and PTT. If platelets are <50,000 or INR is >1.5, orders should be reviewed with a care provider. If the patient takes any coagulation medications, such as antiplatelet agents or anticoagulants, orders should also be reviewed with a physician. It is possible that platelets or plasma may be administered to reduce the risk of bleeding. After removal, additional site pressure may be warranted.
• The bedside should be prepared, and the patient should be assessed. The provider should use a bedside stool to keep them in an optimal position for pressure application while reducing strain on the back. Direct pressure should be applied to stop central or arterial venous catheter bleeding. The patient may be unable to lay flat during the procedure or while pressure is applied. Assistance may be needed for positioning, pressure, or blood cultures. A sedative and analgesic may be ordered and administered if the patient is uncooperative or restless. Inadequate pressure or contamination may occur if the patient is restless due to pain or improper positioning (Kabra et al., 2015).
• The tray at the bedside should be prepared. Hand hygiene should be performed, and the central line dressing tray should be opened. Non-sterile gowns, gloves, masks, and face shields should be worn. Sterile scissors should be used for the suture line. Chlorhexidine may be necessary for device removal. Sterile petroleum gel should be applied to the center of a gauze square. Petroleum gel creates a barrier to prevent air and possibly bacteria from entering the catheter tract. However, this gel can make hemostasis challenging; care should be taken to ensure the petroleum gel does not enter the catheter tract and bloodstream before clotting.
• The old dressing should be removed and discarded while wearing non-sterile gloves. A swab stick may be necessary to help loosen the dressing. The site should be cleansed with chlorhexidine and allowed to dry for at least two minutes (Kabra et al., 2015).
• The catheter should be removed. The head of the bed should be lowered, and the patient should be placed in the Trendelenburg position if possible. Dry gauze should be placed over the insertion site for ease of removal. If resistance is met, a provider of care or physician should be notified. The patient should be asked to hold their breath during the removal. The catheter should be pulled in a slow, steady motion. Direct and immediate pressure should be applied at the site for at least five minutes. Assess for bleeding and inspect the catheter to ensure it is intact. If damaged, the physician or provider of care should be notified. If warranted, the tip should be sent off for cultures (Burnham et al., 2018).
• If the catheter is broken, direct pressure above the insertion site should be applied to stop blood flow. The patient should be positioned on their left side with their head down, and the physician or provider of care should be notified immediately. If the fractured catheter piece can be felt, additional pressure may be necessary to prevent the piece from moving.
• Hemostasis is essential after an arterial line removal. Firm pressure should be held for a minimum of five minutes beyond the point when homeostasis has occurred. If oozing is seen, reapply pressure for another five minutes, minimum. The only way to ensure bleeding stops is direct and adequate pressure. Without hemostasis, hematomas can form, resulting in occlusion. Distal circulation should be checked.
• After the bleeding has stopped, a transparent dressing should be applied. A transparent dressing allows the site to be seen without changing the dressing frequency, increasing the chance of bacteria and infections. Pressure dressings should not be used as they will not stop a vascular bleed and will only delay the detection of a bleed or problem. A lack of direct and adequate pressure will increase the risk of hematoma formation.
• After catheter removal and the bleeding has stopped, limit movement of the extremity for at least one hour. The limb should be checked often for bleeding; every five minutes for the first 30 minutes, then every thirty minutes for two hours, then hourly for four hours. If bleeding reoccurs, apply pressure. The distal portion of the extremity should also be assessed for circulation at the same time.
• Ask the patient if they are experiencing any numbness or tingling. Take blood pressure in the other arm for a while (Kabra et al., 2015).
• The procedure should be documented, as well as follow-up assessments.