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Handle complications with invasive lines
Be honest: Are you entirely comfortable caring for a patient with an invasive line? If your answer is no, you could be putting a patient’s life in danger, says Reneé Semonin Holleran, RN, PhD, CEN, CCRN, CFRN, clinical manager of the ED at University of Utah Hospital and Clinics in Salt Lake City.
"There is the potential for life-threatening complications such as sepsis or loss of a line if you do not know how to use it properly," she warns.
You’ll be seeing increasing numbers of patients with short peripheral catheters, midline catheters, peripherally inserted central catheters, tunneled catheters, and implanted ports, predicts Lynn Hadaway, RNC, CRNI, a Milner, GA-based consultant providing continuing education in infusion therapy and vascular access.
"More patients are being seen in the ED with long-term central venous catheters already in place," she says. "These are patients living with these catheters for months or even years due to a variety of illnesses."
Observe strict aseptic technique, and follow your ED’s policy as to when and how dressings should be changed, says Holleran. "Always instruct patients on the importance of keeping their lines clean," she adds.
Be ready for complications
Many serious catheter-related complications can present in the ED, says Hadaway. "When these complications cannot be managed by the patient’s home care nurse, or the patient is being seen in an ambulatory setting [and the patient needs assistance when the facility is closed], the only alternative is to go to the local ED for management," she says.
As an ED nurse, you must have a good understanding of the type of catheter and know where the tip originally was located, says Hadaway. In addition, you should know current recommendations for proper management of each type of complication, she adds.
"For instance, fever alone in a patient with mild or moderate severity of illness should not have the catheter immediately removed," says Hadaway. "Cultures taken from the catheter and a peripheral venipuncture are needed to determine if the catheter is the cause of the fever."
Here are three complications you may see in your ED, with recommendations for appropriate interventions:
Catheter-related bloodstream infection and vein thrombosis are the most prevalent complications seen in EDs, says Hadaway.
"Management depends upon the type of catheter and the patient’s condition," she advises.
For instance, a local infection at the insertion site, a tunnel or port pocket infection requires immediate catheter removal, says Hadaway, pointing to current guidelines from the Alexandria, VA-based Infectious Disease Society of America.1 (To access the free guidelines, go to www.journals.uchicago.edu/IDSA/guidelines. Scroll down to "Guidelines for the Management of Intravascular Catheter-Related Infections" and click on "Full Text.") If elevated body temperature is present without other signs or symptoms of bloodstream infection, blood cultures are drawn from the suspected catheter and a peripheral vein, says Hadaway.
"There is really no consensus of opinion about the best method for treatment," says Hadaway. Options include radiological procedures for catheter-directed thrombolysis, infusion of a thrombolytic agent through the present catheter, and systemic anticoagulation with heparin, she points out.
This is a rare complication that could occur when catheters are broken or the tubing or injection cap has become separated from the catheter hub, says Hadaway.
"This problem demands immediate attention," she underscores. "If it occurs outside the ED, the patient may not even make it to the ED for treatment."
Air emboli occur during catheter insertion, during tubing and injection cap changes, when accidental damage occurs to the external catheter, and when removing the catheter, she explains.
"Air emboli can occur when any central venous catheter is inserted in the ED, where catheters are frequently inserted into the subclavian or jugular veins," says Hadaway. "These sites carry the highest risk of air emboli."
There also are reports in the literature about catheter hubs falling off or becoming separated from the catheter and the patient arriving in the ED with an air emboli, notes Hadaway.2
This situation can occur if the ED nurse changes the tubing or injection cap attached to the catheter while the patient is still in the ED, she adds. "The patient should be lying flat and instructed to perform a Valsalva maneuver during this change," says Hadaway. "If there is a clamp on the catheter, it also should be closed."
The immediate action is to place the patient on his or her left side with the head down, she says. "This is an attempt to keep the air in the lower part of the right ventricle and away from the pulmonary artery," she explains. "Oxygen is started, and the other steps are based on signs and symptoms."
For more information about caring for patients with invasive lines, contact: