Complications of Peripheral Venous Access Devices: Prevention, Detection, and Recovery Strategies

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Abstract

Most hospitalized patients have placement of a peripheral venous access device, either a short peripheral catheter or a peripherally inserted central catheter. Compared with central venous catheters that are not peripherally inserted, the other 2 types are generally perceived by health care providers as safer and less complicated to manage, and less emphasis is placed on the prevention and management of complications. Expertise of nurses in inserting, managing, and removing these devices may reduce the likelihood of complications, and increased recognition of complications associated with use of the devices is important to ensure continued improvements in the safety, quality, and efficiency of health care. Complications associated with short peripheral catheters and peripherally inserted central catheters include tourniquet retention, tubing and catheter misconnections, phlebitis, air embolism, device fragment embolization, and inadvertent discharge with a retained peripheral venous access device. Integration of prevention, detection, and recovery strategies into personal nursing practice promotes the quality and safety of health care delivery.

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Bloodstream Infection Associated With Short Peripheral Catheters

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Monitoring for catheter-associated bloodstream infection, system-level prevention efforts, and research and published guidelines overwhelmingly focus on central venous access devices.5,6 However, as Hadaway5 notes, the Centers for Medicare and Medicaid Services disallows payment for any “vascular catheter-associated infections,” including infections associated with short peripheral catheters (SPCs), both local and systemic.

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The incidence of local soft tissue infection related to SPC placement is not well defined,27 and discussions about SPC-associated infection are complicated by overlapping and conflicting definitions of phlebitis and local soft tissue infection. SPC-associated bloodstream infection is rare: 0.1% of SPCs placed, or 0.5 per 1000 catheter days.28 By comparison, the rate of bloodstream infection associated with peripherally inserted central catheters among hospitalized patients is estimated to be 6%, or 2.16 per 1000 catheter days (similar to the reported rates for central venous catheters).29

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Bloodstream infection associated with an SPC is a potentially life-threatening complication. In one case,30 a patient died after an SPC inserted in the emergency department “went unnoticed for 5 days.” Phlebitis and infection developed, directly resulting in the patient's death. In another case,2 a patient had a well-functioning SPC that had been placed 96 hours earlier. He had no signs or symptoms of inflammation. Discharge was (at that time) anticipated for the next day, and placement of a new SPC was likely to be difficult, so the interdisciplinary team opted to keep the first SPC in place. During the next 24 to 48 hours, the site became erythemic. The SPC was promptly removed, but bacteremia due to methicillin-resistant Staphylococcus aureus developed followed by an epidural abscess that required 6 weeks of intravenous antibiotics. The infections were directly attributed to phlebitis at the SPC site.

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Nurses should be aware that, although uncommon, SPC-associated bloodstream infection can occur. Although the connection between local inflammation and infection is poorly understood, early recognition of phlebitis, prompt removal of the related device, and ongoing monitoring of the inflamed access site after removal of the device may reduce the harm of SPC-associated bloodstream infections. These infections are preventable; selection of the optimal device and site for insertion; proper site preparation and insertion; and use, management, and removal of SPCs (evaluated and reinforced through ongoing competency verification) reduce the incidence of these serious events.31

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Clinical Scenarios Resulting in Air Embolism

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Air embolism associated with peripheral vascular access devices (PVADs) is a rare but potentially deadly complication. Prompt recognition and immediate action can reduce the likelihood of patient harm; however, providers may not detect an air embolism because of to the nonspecific signs and symptoms and an underappreciation of the clinical scenarios that may lead to this potentially life-threatening complication.16 Clinical scenarios relevant to acute and critical care settings include the following:

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Administration Through Intravenous Access Devices

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Inadvertent intravenous administration of an air bolus, often delivered through an air-containing syringe or unprimed infusion tubing, is the most common mechanism for air embolism.16,49 Both of these sources may result in an embolism large enough to cause cerebral ischemia and infarction.

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Tubing Misconnection

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Infusion of air (and other medical gases) has been reported in instances in which oxygen (or air) tubing or an air-filled enteral syringe is inadvertently attached to a VAD.10,11,16,39–41 Misconnection events are discussed in the text.

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Catheter or Hub Damage

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Compared with short peripheral catheters, peripherally inserted central catheters (PICCs) are particularly susceptible to external hub and catheter fracture.16 PICC barotrauma can be caused by excessive pressure generated by use of syringes smaller than 10 mL, by use of an unsanctioned power injector, or by flushing a PICC against resistance.17 Twisting, kinking, cutting, or clamping of catheters and hubs can result in mechanical damage. The age of a device and storage conditions can also contribute to potential for fracture. In one case, 2 consecutively placed PICCs fractured shortly after placement. The devices, although not past the expiration date for use, were “hard and brittle.” Investigation revealed that the PICCs had been exposed to ultraviolet light while in storage and had degraded before use.51

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Entrainment of Air Bubbles in Infused Material

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Infusion of small bubbles may occur during continuous intravenous administration.16,49 Infusion devices are designed to permit no more than 1 mL of air during a 15-minute period, but according to the Food and Drug Administration,51 this standard “does not represent a universally safe level of air infusion,” and the clinical impact of cumulative infusions of small air bubbles is poorly defined. When entrained air is visually noticeable, continued infusion of air should be prevented, regardless of the presence or absence of alarms from the infusion device. Of note, patient positioning and attempts to aspirate the air do not ameliorate the consequences of air embolism related to the entrainment of particularly small (micro) bubbles.47

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After Removal of a VAD

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Although occurrence of an air embolism during or after VAD removal is most commonly associated with central venous catheters, embolism can also occur in association with removal of PVADs.16 PICCs and large-bore short peripheral catheters inserted above the heart (eg, in the external jugular vein) provide adequate ingress for a clinically significant amount of air; and the standard techniques for removal of a central venous catheter should be used for these devices. Two primary mechanisms for air embolism related to removal of VADs are improper removal technique (eg, not placing the patient in the Trendelenburg position) and not placing (and maintaining) a truly occlusive dressing on the access site after the device is removed. After a catheter is removed, a tract providing a pathway for air can persist for up to 24 hours. This tract may provide ingress of air in response to the pressure gradient caused (or exacerbated) by reduced intrathoracic pressure (inhalation) or hypovolemia. Occluding the catheter tract during catheter removal and for at least 24 hours afterward and using appropriate dressing materials can markedly reduce the likelihood of an air embolism after device removal. Removal of central venous catheters (including PICCs) and similar devices (eg, short peripheral catheters placed in the external jugular vein) is a procedure with potential for serious complications, and providers should have appropriate training and ongoing verification of competency in removal.17

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