Infusion-Related Complications
Central Vascular Access Device Occlusion
Policy
The nurse will address preventive measures, identify signs and symptoms of, and promptly intervene when central vascular access device (CVAD) occlusion is suspected.
A thorough assessment of the patient and the CVAD for the potential cause of an occlusion will be performed, and the appropriate intervention will be performed to restore catheter patency.
Catheter clearance agents, such as precipitate-clearing or thrombolytic (declotting) agents, are used only with CVADs.
Prevention
Use a positive-pressure flushing technique with negative-pressure needleless connectors to prevent the reflux of blood into the catheter tip
Flush visible blood from CVAD
Flush after blood draws
Flush between medication/solution administration (see Flushing and Locking) to prevent precipitate formation from mixing of incompatible infusâtes
Change filters on a routine basis
Ensure all clamps are open before initiating infusion
Assessment
Assess for signs of partial or complete occlusion, including:
Sluggish infusion or flushing
Lack of brisk blood return
Increasing occlusion alarms on an electronic infusion device (EID)
Complete inability to infuse or flush (complete occlusion)
Assess and attempt to identify potential causes of occlusion
Mechanical:
External: tight suture, clamped catheter, kinked tubing, obstructed filter, nonfunctioning needleless connector
Internal: catheter malposition, kinked catheter, pinch-off syndrome
Nonthrombotic: lipid buildup from 3-in-1 parenteral nutrition admixtures, drug precipitate
Thrombotic: most common, due to fibrin buildup, blood clots within or around catheter (eg, intraluminal occlusion or fibrin sheath/tail)
Identify appropriate catheter-clearance agent (precipitate-clearing or declotting agent).
Assess patient for any contraindications to use a selected catheterclearance agent
Intervention
Follow single-syringe method or stopcock method for complete occlusions as these are instillation methods that use a negativepressure approach
Follow direct instillation method for partial or nonthrombotic occlusions when CVAD can still be flushed but blood aspiration is not possible or flow is sluggish
Use a volume of the precipitate-clearing or declotting agent based on the manufacturer’s directions for use or in an amount approximating the internal lumen volume of the CVAD and any add-on devices
Check the CVAD manufacturer’s directions for use when considering instillation of alcohol solutions such as ethanol, as they may damage catheters made of some types of polyurethane
Single Syringe Method: Use with Complete Occlusions
Perform hand hygiene.
Gather supplies.
Gloves, nonsterile
Antiseptic solution
10-mL syringe with precipitate-clearing or declotting agent
10-mL syringe preservative-free 0.9% sodium chloride (USP)
Needleless connector
Tape
Explain procedure to patient.
Don gloves.
Disinfect needleless connector with antiseptic solution; allow to dry completely.
Clamp CVAD, if appropriate.
Attach syringe with precipitate-clearing or declotting agent to needleless connector.
Unclamp CVAD and while holding syringe vertically, gently pull plunger back to approximately 8-mL mark.
While maintaining syringe in vertical position, slowly release the plunger. Make sure the solution is in the end of the syringe nearest the CVAD. Do not apply pressure to plunger. Clamp CVAD.
Leave syringe in place and secure with tape. Label syringe “Do not use—declotting” with date, time, and nurse’s initials.
Allow solution to dwell according to manufacturer’s directions for use.
After appropriate dwell time, unclamp CVAD and attempt to aspirate blood.
A free-flowing blood return indicates patency
If patency is reestablished, withdraw a total of 4-5 mL of blood, clamp CVAD, and remove and discard syringe
Repeat procedure if patency is not achieved
Notify LIP if unable to achieve patency
Attach 10-mL syringe of preservative-free 0.9% sodium chloride (USP), unclamp, and flush CVAD (see Flushing and Locking).
Resume ordered therapy or lock catheter as appropriate.
Dispose of used supplies in appropriate receptacles.
Remove gloves.
Perform hand hygiene.
Document procedure and outcome in patient’s permanent medical record.
Stopcock Method: Use with Complete Occlusions
Perform hand hygiene.
Gather supplies.
Gloves, nonsterile
Antiseptic solution
3-way stopcock
10-mL syringe, sterile
10-mL syringe with precipitate-clearing or declotting agent
10-mL syringe, preservative-free 0.9% sodium chloride (USP)
Needleless connector(s)
Explain procedure to patient.
Don gloves.
Disinfect junction of CVAD and needleless connector with antiseptic solution; allow to dry completely.
Clamp catheter.
Remove needleless connector and attach sterile stopcock, turned off from the patient to the CVAD hub.
Attach empty 10-mL syringe to 1 port of stopcock.
Attach 10-mL syringe of precipitate-clearing or declotting solution to remaining stopcock port.
Open stopcock port connected to empty syringe.
Pull plunger back on empty syringe to approximately 8-mL mark while maintaining plunger position; close port, creating negative pressure within catheter lumen.
Open stopcock connected to syringe with precipitate-clearing or declotting agent, allowing solution to enter into CVAD.
Procedure steps 9-11 may need to be repeated until solution is pulled into CVAD
Secure device to patient and label “Do not use—declotting” with date, time, and nurse’s initials.
May opt to remove stopcock and syringes and replace with sterile needleless connectors during dwell time
Allow solution to dwell according to manufacturer’s directions for use.
After appropriate dwell time, disinfect needleless connector with antiseptic solution; allow to dry completely.
Attach empty 10-mL syringe and attempt to aspirate blood.
A free-flowing blood return indicates patency
If patency is reestablished, withdraw a total of 4-5 mL of blood, clamp CVAD, and remove and discard syringe
Repeat procedure if patency is not achieved
Notify LIP if unable to achieve patency
Attach 10-mL syringe of preservative-free 0.9% sodium chloride (USP), unclamp, and flush CVAD (see Flushing and Locking).
Resume ordered therapy or lock catheter as appropriate.
Dispose of used supplies in appropriate receptacles.
Remove gloves.
Perform hand hygiene.
Document procedure and outcome in patient’s permanent medical record.
Direct Instillation Method: Use with Partial Thrombotic or Nonthrombotic Occlusions
Perform hand hygiene.
Gather supplies.
Gloves, nonsterile
Antiseptic solution
10-mL syringe
10-mL syringe with precipitate-clearing or declotting agent
10-mL syringe of preservative-free 0.9% sodium chloride (USP)
Needleless connector
Explain procedure to patient.
Don gloves.
Disinfect needleless connector with antiseptic solution; allow to dry completely.
Attach syringe with precipitate-clearing or declotting solution.
Unclamp CVAD, if appropriate, and slowly inject precipitate-clearing or declotting agent. Do not force solution into CVAD.
Clamp CVAD. Label CVAD “Do not use — declotting” with date, time, and nurse’s initials.
Allow solution to dwell according to the manufacturer’s directions for use.
After appropriate dwell time, disinfect needleless connector with antiseptic solution; allow to dry completely.
Attach empty 10-mL syringe and attempt to aspirate blood.
A free-flowing blood return indicates patency
If patency is reestablished, withdraw a total of 4-5 mL of blood, clamp CVAD, and remove and discard syringe
Repeat procedure if patency is not achieved
Notify LIP if unable to achieve patency
Attach 10-mL syringe of preservative-free 0.9% sodium chloride (USP), unclamp, and flush CVAD (see Flushing and Locking).
Resume ordered therapy or lock catheter as appropriate.
Dispose of used supplies in appropriate receptacles.
Remove gloves.
Perform hand hygiene.
Document procedure and outcome in patient’s permanent medical record.
Agents for CVAD Clearance of a Drug Precipitate | ||||||||||
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Bibliography
Baskin JI, Pui CH, Reiss U, et al. Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet. 2009;374:159-169.
Gorski L, Perucca R, Hunter M. Central venous access devices: care, maintenance, and potential complications. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:495-515.
McKnight S. Nurse’s guide to understanding and treating thrombotic occlusion of central venous access devices. Medsurg Nurs. 2004;13(6):377-382.
Phillips LD. Manual of I.V. Therapeutics: Evidence-Based Practice for Infusion Therapy. 5th ed. Philadelphia, PA: FA Davis; 2010:593-620.
Vascular Access Device-Related Infection
Policy
The nurse will address preventive measures, identify signs and symptoms of, and promptly intervene when vascular access device (VAD)-related infection is suspected.
Risk factors for infection and catheter-associated bloodstream infection include:
Inadequate skin antisepsis prior to VAD insertion
Multiple manipulations of infusion delivery system
Patient age, condition, acuity
Presence of secondary infection
Education and skill level of clinician
Inadequate VAD insertion technique
Inadequate care and maintenance practices
Prevention
Perform hand hygiene prior to placing and before providing any VAD-related interventions
Use maximal sterile barrier precautions during central vascular access device (CVAD) insertion
Choose the optimal CVAD site for placement; the subclavian vein is the preferred site for nontunneled catheters
Use chlorhexidine for skin antisepsis prior to CVAD insertion; it is the preferred skin antiseptic
Perform skin antisepsis prior to peripheral catheter insertion using an antiseptic solution
Disinfect needleless connectors prior to access
Maintain aseptic technique during all infusion therapy administrations and VAD care
Change administration set and any add-on devices at recommended intervals
Minimize use of add-on devices
Remove VAD when no longer needed
Teach patients/caregivers who will self-manage their VAD/infusions: hand hygiene, aseptic technique, disinfection of needleless connectors
Assessment
Identify signs and symptoms of exit site infection:
Tenderness
Erythema within 2 cm of catheter-skin junction
Induration within 2 cm of catheter-skin junction
Purulence at exit site
Identify signs and symptoms of port-pocket or tunnel-tract infection:
Erythema
Necrosis of skin over reservoir of implanted port
Tenderness
Induration
Purulent exudate from needle access site
Purulent exudate from subcutaneous port pocket
Identify signs and symptoms of infection in the tract of a tunneled catheter:
Erythema
Tenderness
Induration in tissues overlying catheter and greater than 2 cm from catheter exit site
Identify signs and symptoms of catheter-related bloodstream infection:
Acute onset of fever, chills, and hypotensim
No other apparent source of infection but the catheter
Intervention
If signs and symptoms of exit site infection are present:
Notify licensed independent practitioner (LIP) of signs and symptoms
Obtain culture of purulent exudate
Apply topical ointment to affected area
Apply warm, moist compresses
Initiate oral or parenteral anti-infective therapy
If signs and symptoms of port-pocket or tunnel-tract infection are present:
Notify LIP of signs and symptoms
Anticipate removal of device
If signs and symptoms of catheter-related bloodstream infection are present:
Notify LIP immediately
Obtain blood cultures from device and from a separate peripheral vascular access site, as ordered (see Culturing for Infusion-Related Infections)
Culture infusate if there is possibility of infusion-related contamination
Initiate parenteral anti-infective therapy as ordered
If unsuccessful in treating suspected infusion-related infection, VAD may need to be removed
Additional interventions
Monitor patient including ongoing assessment of VAD site, vital signs, review of laboratory findings, and response to interventions
Perform site care and maintenance if catheter is not removed
Replace administration sets and solution containers per organizational policy
Document in patient’s permanent medical record:
Observations and patient assessment
LIP notification
Interventions taken and outcome
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