Which is a normal finding on assessment of a clients peripherally inserted central catheter PICC )?

To promote positive outcomes, clinicians caring for patients with central lines must monitor carefully for signs and symptoms of complications. This article discusses potential complications—catheter occlusion, bleeding and hematoma, catheter-tip migration, catheter rupture, phlebitis and associated pain, swelling and deep vein thrombosis (DVT), infection, and embolism. It also provides assessment, prevention, and troubleshooting tips for central lines.

Catheter occlusions

A catheter occlusion occurs when a blockage prevents caregivers from flushing the central line or aspirating blood. An occlusion can be thrombotic or nonthrombotic (not caused by a thrombus). About 40% to 50% of occlusions are nonthrombotic and result from mechanical or postural factors, medication precipitate, catheter malpositioning, or undesirable catheter-tip location.

If you suspect your patient’s catheter is occluded, assess the entire infusion-delivery system for obstructions and kinks. Determine if blood return is hampered by the position of the patient’s arm or other body part (when either lying or standing). Evaluate the patient’s medication profile for drug incompatibilities. Next, assess catheterpatency: Does the catheter flush easily, or only with difficulty? Do you see a blood return? Finally,
have a qualified clinician assess catheter-tip location from a recent X-ray, if available.

Mechanical occlusions

A mechanical occlusion can be external or internal. External occlusions stem from a kink or clamp in the portion of the catheter that’s outside the patient. Check whether any clamps are activated, and look for sutures or a securement device that could be pinching the catheter too tightly. Then check for kinks in the catheter. Finally, examine the I.V. tubing and pump for obstructions and malfunctions.

Internal occlusions occur inside the patient and are harder to assess. Causes include lodging of the catheter tip against a vessel. If you suspect an internal occlusion, consult the ordering physician or licensed independent practitioner, who will weigh the risks and benefits of keeping the catheter in place vs. replacing it.

Another cause of internal cathe¬ter occlusion is pinch-off syndrome, in which the catheter passes through the areolar tissue of the space outside the vessel lumen and becomes compressed between the clavicle and rib. As the patient raises and lowers the shoulder, repeated compression and shearing forces put pressure on the catheter. A more lateral catheter insertion allows the catheter to travel within the sub¬clavian vessel. Pinch-off syndrome is a serious complication requiring immediate attention. It may occur with acute, tunneled, and implanted lines placed via the subclavian vein. It doesn’t occur with peripherally inserted central catheters (PICCs) because they’re inserted in the arm and approach the superior vena cava from inside the vessel.

Postural occlusions

A postural occlusion affects catheter patency or blood flow, depending on patient or catheter position. To find out if patient positioning is affecting blood return, instruct the patient to change positions by raising and lowering the arm, or to take a deep breath or cough. If a position change helps obtain a blood return, consult with the physician on the risks and benefits of leaving the catheter in place vs. removing it.

Medication-precipitate occlusions

If the I.V. bag contains multiple medications, such as potassium, incompatibility may occur in the tubing, causing precipitation. Infusion of parenteral nutrition, lipids, phenytoin, aminophylline, or potassium gluconate with other medications promotes precipitate occlusions. The precipitate forms quickly, causing the line to become sluggish and hard to flush.

If you suspect a catheter occlusion caused by precipitate, review the patient’s medical record for possible drug incompatibilities. Consult the pharmacist, who may recommend a fibrinolytic or nonfibrinolytic agent. With a nonfibrinolytic agent, the goal is to increase precipitate solubility by changing the pH in the catheter lumen. For this procedure, first determine the catheter’s fill volume. Fill volume varies from PICCs to ports, ranging from 0.3 to 0.5 mL. Larger catheters, such as dialysis catheters, have larger fill volumes; the volume may be marked on the outside of the catheter. Instill the proper amount so the medication contacts the precipitate, not the outside of the catheter. To help prevent medication-precipitate occlusion, flush the catheter between each medication dose. (See Treating medication-precipitate occlusions by clicking the PDf icon above.)

Thrombotic occlusions

Most catheter occlusions are thrombotic, caused by changes in blood flow, venous stasis, hypercoagulability, or trauma to the vessel wall. (See Types of thrombotic occlusions by clicking the PDF icon above.) Thrombosis has been linked to central-line–associated bloodstream infections (CLABSIs), so managing a thrombotic occlusion is crucial to prevent infection. Management entails timely patency assessment and treatment.

If a catheter becomes partially occluded or loses its blood return, a fibrinolytic typically is ordered, to be given according to manufacturer’s guidelines. Currently, alteplase is the only fibrinolytic approved by the Food and Drug Administration (FDA) to treat thrombotic occlusions.

Bleeding and hematomas

Expect minimal bleeding after catheter insertion. However, know that certain catheter types, insertion techniques, and laboratory values can make patients more prone to bleeding. When assisting with catheter insertion, control bleeding at the site before the final dressing is applied. If the insertion site continues to bleed or ooze blood, apply a sterile 2″ x 2″ gauze dressing under the transparent dressing; change the dressing every 24 to 48 hours. Follow your facility’s policy on caring for and maintaining a gauze dressing.

If bleeding persists, consider using a pressure dressing or wrap. If your patient with a PICC has a wrap applied around the arm, monitor extremities for color, motion, and sensation according to facility policy. Document the time the pressure wrap was applied and the time it was removed. Sensation loss and numbness have occurred when pressure dressings were applied for more than 24 hours and the site, skin color, motion, and sensation weren’t checked.

If bleeding persists beyond 24 to 48 hours after catheter insertion, assess for other possible causes. Determine if bleeding could stem from anticoagulant therapy, vigorous physical activity, sutures, or coagulopathy. Be aware that patients with an elevated International Normalized Ratio or sutures that were accidentally placed through small vessels may continue to bleed, as small pinholes within the catheter can cause oozing.

Continue to apply and change sterile gauze dressings every 24 to 48 hours; to promote hemostasis, consider using such agents as an absorbable gelatin sponge at the insertion site. Suture removal or catheter removal or replacement may be warranted to correct the problem. Be sure to monitor the insertion site frequently and document findings.

Catheter-tip migration

If the catheter loses its blood return, suspect catheter-tip migration. The tip may migrate out of the superior vena cava at any time due to catheter- or patient-related factors. Some catheters are made of stiffer materials (such as the nontunneled dialysis catheter), whereas PICCs are more flexible and more likely to migrate. Power injection, power flushing, push-pause flushing methods, vomiting episodes, and suctioning also can cause the catheter tip to migrate in and out of the superior vena cava.

Signs and symptoms of catheter-tip migration include changes in catheter patency or loss of blood return; discomfort in the upper arm, shoulder, jaw, chest, or ear during infusions; and an external catheter length that differs from the length at the time of insertion. For example, if the external length of a PICC was 1 cm at insertion but is now 20 cm, assume the PICC is no longer in the superior vena cava. This also can happen with a central line in the chest: If the line was inserted in the subclavian vessel with 1 cm exposed externally but 3 cm are exposed on day 5, suspect it’s no longer lodged in the vessel. (See Assessing for catheter malposition by clicking the PDF icon above.)

Catheter rupture

Pressure generated during catheter flushing can’t be measured accurately. A small syringe size (less than 3 mL) may cause higher pressures within the catheter. With partial or complete occlusions, higher pressures occur within the catheter. Excessive pressure on the syringe plunger also can cause unmanageable pressure within the catheter, leading to rupture.

If you encounter resistance when flushing the catheter, stop flushing and try to determine the cause. Don’t keep flushing against resistance, as this may lead to catheter embolus or leakage.

If the catheter breaks during flushing, the healthcare team must consider whether to repair or replace it. Points to consider include the following:

• How much longer will central-line therapy continue? Catheter repair may be more appropriate if therapy will continue for a few days, whereas replacement is more appropriate for longer-term therapy.
• Are vessels available for a new insertion? Did the inserting clinician note that the catheter was inserted with much difficulty? Does the patient have a history of multiple catheter insertions?
• Is the catheter appropriate for exchange? Is there a chance of contamination or infection with this catheter or insertion site?
• Is repair feasible based on variables of catheter damage and exposure? What are the possible risks of contamination and infection?
• What are the manufacturer’s recommendations? Many catheters don’t come with repair kits. Depending on leakage or breakage location, repair may be impossible—for instance, with a double-lumen catheter that’s leaking below the bifurcation.
• If the catheter is visibly ruptured on the outside, is there a possibility it has ruptured on the inside? This can be determined only by X-ray or dye study.

If catheter repair is appropriate and a healthcare provider writes an order for it, an infusion or vascular expert should repair it following the manufacturer’s guidelines and using aseptic technique, with modification equipment supplied by the manufacturer.

Phlebitis and related pain

Another complication of a central line is phlebitis (vein inflammation) with related pain. Although most common with a PICC, it can occur with any central line. Phlebitis causes erythema, pain, or swelling along the path of the vein in which the catheter is lodged. The condition is classified as chemical, mechanical, or bacterial.

Chemical phlebitis

Chemical phlebitis is an inflammatory response of the vein intima to the infusates or catheter material used for access. (See Chemical phlebitis effects by clicking the PDF icon above.) It’s associated with peripheral I.V. lines but may occur with a central line if the catheter tip migrates from its central location in the superior vena cava. Other causes include extended catheter dwell time, administration of irritating medications or solutions, improperly mixed medications, rapidly infused medications or solutions, or particulate matter.

Mechanical phlebitis

Mechanical phlebitis is associated with catheter movement that irritates the vein intima. Early-stage mechanical phlebitis stems from mechanical irritation of the venous endothelium. It usually occurs several inches proximal to the insertion site. Signs and symptoms include tenderness, erythema, and edema. The most common causes of mechanical phlebitis are large-bore catheters and inadequate catheter securement.

Treatment entails application of low-degree heat from a continuous, controlled source. Continue applying heat until all signs and symptoms resolve, which usually occurs within 72 hours after treatment begins. If they don’t resolve, discontinue catheter use. The healthcare team should consider an ultrasound study to rule out DVT. (Patients with prior DVT and surgery lasting longer than 1 hour are at increased risk for catheter-related DVT.) If ultrasound reveals DVT, consult the ordering clinician about treatment options, which include anticoagulants given either with the catheter in place or after its removal.

Bacterial phlebitis

Bacterial phlebitis is an inflammation of the vein intima associated with bacterial infection. The least common type of phlebitis, it is more serious because it predisposes the patient to systemic complications. Contributing factors include:

• poor hand hygiene by healthcare providers
• failure to check equipment for compromised integrity
• poor aseptic technique during catheter site or system preparation
• poor cap or hub disinfection before obtaining catheter access
• poor insertion technique
• inadequate or breached dressing
• infrequent site observation and failure to assess adequately for complications
• preexisting patient condition or infection.

Keep in mind that wearing gloves doesn’t eliminate the need to wash your hands before and after patient contact. Use a hand sanitizer or wash your hands for 10 to 15 seconds with soap and running water.

Infection

Healthcare-acquired infections (HAIs) are infections that arise 48 hours after admission, within 3 days after discharge, or within 30 days after surgery. The Centers for Medi¬care & Medicaid Services has identified conditions that can be prevented by prudent and reasonable care, deeming them “never” events; it no longer reimburses for their care. Vascular catheter-associated infections and air embolism are two “never” events.

More than 80% of HAIs are associated with central lines and other devices. The catheter site and hub are the most important sources of bacteria and fungi leading to catheter colonization and resultant CLABSIs. With short-term catheters (those indwelling less than 14 days), the insertion site is the major contamination source. Bacteria on the patient’s skin migrate along the external surface of the catheter; bacterial colonization of the surface leads to formation of biofilm, in which microbes are nested in a protective matrix of extracellular bacterial polymer.

With long-term catheters (those indwelling more than 14 days), the major infection source is intraluminal colonization. Organisms may be introduced if the catheter hub goes unscrubbed, if the catheter is manipulated, or if poor flushing technique is used. Organisms migrate from the hub toward the catheter tip and then to the patient. Biofilm develops, with organisms remaining nested in the biofilm or detaching to float freely in and outside the lumen.

Signs and symptoms of infection can be specific or vague. Redness or swelling may occur at the insertion site. Nonspecific indications include fever, chills, and hypotension.

CLABSIs may warrant central-line withdrawal. Treatment depends on the specific organism present, extent of illness, signs and symptoms, catheter type used, duration of anticipated need for venous access, and presence of alternative venous access.

Embolism

An embolism may involve the catheter itself, fibrin, or air entry.

Catheter embolisms

A catheter embolism occurs with catheter rupture and may result from using too much pressure when flushing the line. If the catheter doesn’t flush easily, never try to force it. Assess it for mechanical or fibrin occlusions.

Other causes include power-injecting a nonpower-injectable central line. (The FDA has posted guidelines on power injection and events of catheter breakage. Visit www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDeviceSafety/ucm070193.htm.) Other causes of catheter embolism include migration and catheter breakage from internal and external causes. To prevent these problems, always secure the catheter adequately, avoid pulling or tuggingon it, and follow recommendations for its removal when it’s no longer needed.

Fibrin embolisms

A fibrin embolism occurs when fibrin breaks off from the catheter during flushing. Signs and symptoms depend on where the clot travels. This type of embolism must be treated immediately, but can be hard to detect due to the resources needed (such as computed tomography and angiography). The best way to prevent a fibrin embolism is to assess the catheter every shift and provide proper care and maintenance.

Air embolisms

An air embolism can arise during catheter insertion, maintenance, or removal. Be sure to minimize air entry during insertion by positioning the patient and equipment properly. Air can enter the patient accidentally through loose caps and non-Luer Lock—type devices and syringes. When caring for a central line, make sure all air is removed from syringes, all syringes and devices are the Luer Lock type, and all caps are applied securely to the central line.

Air embolism also can occur during central line removal. To decrease this risk, use techniques that prevent air from entering the insertion site after catheter removal. For removal, position the patient flat or in a slight Trendelenburg position to increase intrathoracic pressure. Have the patient hold the breath or breathe out. For a patient on a ventilator, check the manufacturer’s guidelines on whether to remove the catheter on inspiration or expiration. Many of the new ventilator settings provide pressure on expiration for catheter removal.

Applying a dressing on the catheter insertion or exit site also helps prevent air embolism. On catheter removal, apply an occlusive dressing to seal the site; this prevents small amounts of air from tracking down the insertion site to the vessel. An occlusive dressing includes an antiseptic ointment or petrolatum gauze placed under a gauze dressing. (Gauze dressings by themselves aren’t occlusive.) Some clinicians place a transparent dressing atop the gauze dressing. However, be aware that transparent dressings are semipermeable and breathable—not occlusive. Finally, keep the patient flat in bed for 30 minutes after catheter removal and monitor for signs and symptoms of embolism: shortness of breath; chest pain; cough; wheezing; skin that’s cool, clammy, or bluish; rapid or irregular heartbeat; weak pulse; and lightheadedness or fainting. If these occur, turn the patient onto the left side, call the rapid response team (if available at your facility), apply oxygen, notify the physician, and start basic life support if necessary.

Toward better outcomes

With the basic information in this article, you can help prevent, recognize, and troubleshoot central-line complications. Also be sure to consult your facility’s policy and procedures; all healthcare facilities should use current guidelines recommended by national organizations, research, and evidence-based practice. Your expanded knowledge base and use of evidence-based policy and procedures can help you optimize patient outcomes.

Click here for a complete list of references and here for an algorithm for troubleshooting central lines.

Ann Earhart is a vascular and infusion clinical nurse specialist at Banner Good Samaritan Medical Center in Phoenix, Arizona.

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