Vascular Access Complications PDF

# Vascular Access Complications ## G. Catheter or Wire Embolus **The inadvertent loss of a catheter fragment, wire fragment or entire wire into a vein or artery; the catheter fragment or guide wire may lodge in the chambers of the heart or the vasculature of the lung** ### Causes * Shearing of c...

# Vascular Access Complications ## G. Catheter or Wire Embolus **The inadvertent loss of a catheter fragment, wire fragment or entire wire into a vein or artery; the catheter fragment or guide wire may lodge in the chambers of the heart or the vasculature of the lung** ### Causes * Shearing of catheter or guide wire by pulling/ withdrawing wire or catheter through a needle/Introducer against resistance * Improper readvancement or redirecting of needle overtop of already advanced wire or catheter * Operator error * Over-insertion/loss of control of the guide wire * Complete rupture of catheter internally due to excessively forceful flushing of catheter with small syringe without checking patency ### Prevention * Secure/hold distal end of the guide wire at all times until removed * If resistance is met during removal of a guidewire then remove needle and guidewire together * Ensure that the wire is intact at the end of the procedure; avoid CVAD in subclavian vein beneath clavicle (pinch off syndrome). Using ultrasound allows for a lateral insertion, thus avoiding pinch off * Gentle flushing against resistance * Ensure that only pressure injectable devices are being used for pressure injection * When placing a device in the subclavian vein, enter laterally (axillary vein) so device resides within the vein before passing through the costoclavicular space to diminish risk of breakage or kinking (a.k.a. "pinch off syndrome") * Pinch-Off Syndrome: Occurs when the catheter is compressed between the first rib and the clavicle, causing an intermittent mechanical occlusion for both infusion and withdrawal; approximately 40% of patients who exhibit signs of pinch off syndrome will experience catheter fracture and/or embolus * Verify the guidewire is out and intact at the end of the procedure. (Consider adding to insertion procedure checklist) * Verify and document the entire length of catheter at the time of removal by visually inspecting the tip or by comparing catheter length to that of the catheter at the time of insertion ### Symptoms * Catheter fracture may be asymptomatic, often identified incidentally on a routine chest film or recognized when the entire catheter is not retrieved at the time of removal * Symptoms may include dyspnea, anxiety, tachycardia, sudden pain at insertion site, or flank pain * Potential complications of leaving a catheter fragment or guide wire in-situ are thrombosis, infections such as septic thrombophlebitis, post-phlebotic syndrome, pulmonary embolism, arrhythmias, cardiac, and vascular damage ### Treatment * Notify licensed independent practitioner * Place patient on bed rest * Retrieval of the fragment or insertion of venous filter may be indicated * For peripherally inserted catheters with suspected or known catheter or wire embolus, apply tourniquet high in the axilla in attempt to retain fragment or embolus (apply toumiquet tightly enough to restrict venous blood flow but not arterial blood flow); radiographic studies and/or interventional radiology may be indicated ## H. Cardiac Arrhythmia **Aberrant heart rhythm** ### Causes * Catheter or wire annoying cardiac conduction. May occur post-insertion due to migration of catheter. ### Prevention * Ensure optimal tip position using tip location technology or chest radiography * Careful measurement and documentation of external anatomic landmarks * Adequate stabilization and proper dressing management * Daily assessment of VAD and patient condition making sure to regularly compare current external catheter length to that of external length at time of insertion/confirmation * Many patients with cardiac conditions or post-myocardial infarction (MI) are sensitive to wire and catheters. If arrhythmia occurs, consider left sided insertion where there is a bit more length to insert wire before reaching sensitive areas of the heart ### Symptoms * Palpitations * Rapid heart pounding * Irregular heart rhythm including: * Tachycardia * Premature Ventricular Contractions (PVCs) * Ventricular tachycardia ### Treatment * If catheter is tunneled or implanted, refer to Interventional Radiology * Retract any catheter that CXR has indicated is in the right atrium if arrhythmias are being experienced. * Evaluate patient's clinical status (medical condition, electrolytes, history of arrhythmia during facility course, etc.) and consider retracting the catheter ## I. Arterial Puncture **A needle puncture injury that pierces the arterial wall** ### Causes * Inadvertent arterial puncture during attempted access of an adjacent vein * Blind sticks * Operator inexperience * Patient movement ### Prevention * Use ultrasound (US) guidance for all CVAD insertions and US or other vein visualization technologies for difficult peripheral IV insertions ### Symptoms * Bright red, pulsatile blood return. Note: Pulsatile blood return may not appear in cases of hypotension or placement of catheter in extremities and blood color can be affected by blood oxygen levels and other clinical factors * Abrupt swelling/hematoma at puncture site * Pain, numbness, pallor, loss of pulse in affected extremity distal to puncture site ### Treatment * Promptly remove needle * Apply manual pressure until hemostasis achieved * Monitor the patient and site closely * Immediately escalate care if uncontrolled bleeding, pulses are faint or absent, pallor and/ or numbness continues