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Managing complications of midlines and PICCs

GORSKI, LISA A. RN, APRN, BC, CRNI, MS; CZAPLEWSKI, LYNN M. RN, C, CRNI, OCN, BSN

I. V. ROUNDS
Free

OVERALL, the complication rate for midline catheters and peripherally inserted central catheters (PICCs) is low, but you still need to know how to deal with problems. Here we'll discuss how to prevent some common complications and intervene if problems occur.

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Warming up to phlebitis

An inflammation of the vein, phlebitis is characterized by redness, swelling, tenderness, and warmth along the catheterized vein and may have a mechanical, chemical, or infectious cause. Mechanical phlebitis usually occurs within the first week of catheter insertion and responds to warm compresses and arm elevation. Chemical phlebitis is triggered by the infusion of irritating I.V. drugs. Infectious phlebitis occurs when bacteria infect and damage the vein lining.

Prevention: Don't infuse irritating solutions through a midline catheter. Avoid placing the catheter in an area of flexion and secure the catheter to prevent migration. Perform hand hygiene and use aseptic technique when providing site care and administering therapy.

Interventions: Notify the prescriber. To treat mechanical phlebitis, apply warm compresses, elevate the arm, and give analgesics. Remove the catheter if signs and symptoms don't resolve or if phlebitis occurs after more than a week after catheter insertion.

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Catheter occlusion: Clearing the way

Partial or complete catheter occlusion limits or prevents blood aspiration, flushing, or administering solutions or drugs. Occlusions can be nonthrombotic (caused by drug precipitates or mechanical obstructions, for example) or thrombotic (caused by deposits of fibrin and blood components). Signs of an occlusion include inability to aspirate blood, resistance to flushing, sluggish infusion, and inability to flush or infuse fluid.

Prevention: Use the SASH (saline, administer drug, saline, heparin) technique to reduce the risk of infusate-related precipitates. Flush the catheter with at least 10 ml of 0.9% sodium chloride solution after blood withdrawal. Use a pulsing technique to flush the catheter. Consider using positive-pressure valves, which reduce the risk of blood reflux into the catheter tip.

Interventions: If you suspect thrombosis, notify the health care provider and administer an approved fibrinolytic agent, such as alteplase (Cathflo Activase) according to orders and your facility's protocol. For nonthrombotic occlusions, interventions depend on the suspected cause. Don't force an injection against resistance, which could cause an embolus or damage the catheter.

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Breaking up thrombosis

Signs and symptoms of catheter-related thrombosis include swelling in the arm, shoulder, or neck on the same side as catheter placement; increased arm circumference; and pain in the chest, jaw, or ear on the same side as catheter placement.

Prevention: Some patients may benefit from low-dose anticoagulant therapy. (For more information, see “Keeping Catheters Clear with Low-Dose Warfarin,” in the October issue of Nursing2004.)

Interventions: Notify the patient's health care provider of the signs and symptoms. Patients may be admitted to the hospital for therapy with fibrinolytic drugs and anticoagulants.

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Fighting infection

Catheter-related bacteremia is characterized by fever, chills, weakness, and malaise. A local infection is characterized by erythema, tenderness, induration, and purulent drainage at the insertion site.

Prevention: Maintain meticulous hand hygiene and use aseptic technique when providing site care and administering infusion therapy. If the patient self-administers I.V. care, teach him correct hand hygiene and aseptic technique. Teach the patient and his caregiver the signs and symptoms to report.

Interventions: Notify the patient's health care provider, obtain specimens for culture, and administer antibiotics as ordered. Treat a local infection with antibiotics as indicated.

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Put the brakes on migration

A change in the length of catheter extruding from the insertion site, change in the ability to withdraw blood, or certain patient complaints (such as palpitations or chest pain) may indicate catheter migration.

Prevention: Secure the catheter properly. Measure and document the length of catheter extruding from the site regularly.

Interventions: Notify the patient's health care provider and obtain an order for an X-ray to confirm catheter migration. The catheter may need to be replaced.

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Catheter fracture or embolism

Signs and symptoms of catheter fracture or embolism include a visible crack or hole in the catheter, leaking, cyanosis, hypotension, tachycardia, and change in level of consciousness.

Prevention: Use a 10-ml or larger syringe when flushing the catheter. Never flush against resistance; stop if you encounter resistance while attempting to remove a catheter. Never use scissors or other sharp objects near the catheter.

Interventions: Although some damaged catheters can be repaired, many can't and will have to be removed and replaced. If you suspect catheter embolism, place a tourniquet on the patient's upper arm to occlude venous flow (but not arterial flow) and activate emergency services.

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Air embolism emergencies

Your patient may have an air embolism if he has chest pain, shortness of breath, shoulder or low back pain, cyanosis, hypotension, tachycardia, or change in level of consciousness.

Prevention: Maintain a closed system. Clamp the catheter when changing the injection/access port. Remove air from the infusion system (syringes and tubing) before starting an infusion or giving a bolus dose.

Interventions: Place the patient on his left side with his head lower than his heart. Clamp the line to stop air from entering the system and activate emergency services.

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Dealing with a difficult removal

If you meet resistance when attempting to remove a catheter, stop the procedure and apply a sterile dressing. Never pull against resistance; this can cause the catheter to break or damage the vein wall. Use a warm compress to dilate the vein proximal to or at the insertion site. Consider using relaxation techniques; patient anxiety can contribute to venospasm, the most common cause of difficult catheter removal. Reattempt removal after interventions.

Lisa A. Gorski is a clinical nurse specialist for Covenant Home Health and Hospice in Milwaukee, Wis. Lynn M. Czaplewski is an I.V. specialist and staff educator for Medical Consultants, Inc., a physicians' oncology practice in Milwaukee. This article was adapted from Peripherally inserted central catheters and midline catheters for the homecare nurse, Journal of Infusion Nursing, L Gorski, L Czaplewski, November/December 2004.

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SELECTED REFERENCES

Infusion Nurses Society. Infusion nursing standards of practice. Journal of Intravenous Nursing. 23(6S), November/December 2000.
    O'Grady NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. 51(RR-10):1–29, August 9, 2002.
    © 2005 Lippincott Williams & Wilkins, Inc.