Running head: CENTRAL VASCULAR ACCESS DEVICE COMPLICATIONS
Patient Risks Associated with Central Vascular Access Devices
Suzanne Cressell
West Shore Community College
Author Note
This research paper was written for NUR-245, IV therapy for
Professor Sue Warmuskerken, RN, MSN.
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Central Vascular Access Device Complications
The profession of nursing is dynamic. It is always advancing and changing. Even with
the many advances made in modern medicine today, the medical society continues to learn and
incorporate evidenced based practices (EBP) into nursing care, and appropriately, some nursing
practices that are deemed as unsafe or unsanitary by EBP would be cast off as bad practice. The
earliest intravenous (IV) therapy dates back to the mid sixteen hundreds and according to
workplacenurses.com (n.d.), in "1656 - Sr. Christopher Wren - used a quill and bladder; injected
opium into drops"(p.1). Human to human and animal to human blood transfusions were also
performed during the middle ages. However, it didn't take long for medical pioneers to learn that
transfusing blood from either human to human or animal to human was not always a viable
solution to life's ailments and could even cause death. Although the advancement of IV therapy
was attainable during this time, the knowledge of blood product compatibility or incompatibility
was not known. Moreover, due to the lack of the aforementioned knowledge, IV therapy
progression went stagnant. In these early years, the advancement of IV therapy would have been
a major milestone; however, the disappointment of the therapy failing to cure medical ailments
would set IV therapy back nearly two hundred and fifty plus years. It wasn't until the early
nineteen hundreds that IV therapy started to become more popular; however, at that time, it was
not maintained or administered via practicing nurses. It was a part of the physician's scope of
practice to administer IV therapy. Today, IV therapy is carried out primarily by nurses in a
variety of different medical settings. Although the advancement of many new IV access devices
made access easier for long term therapy, there were, and continue to be risks associated with
these devices if using EBP protocol is not followed. These devices are referred to as central
vascular access devices (CVAD) lines. Significant patient risks accompany the use of these
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devices, such as blood borne infections and IV infiltration/extravasation. These risks can be
drastically reduced by the nurse implementing EBP into accessing, flushing, and monitoring for
complications related to IV CVAD lines. While there are many risks associated with medication
administration through IV therapy sites, a top priority risk is preventing blood borne infections
and extravasation in patients with central vascular access devices. Today many patients have
implanted central lines, and blood borne infection continues to be a problem in the healthcare
setting when correct protocol is breached when accessing these devices.
Central vascular access devices appear to be an ideal way to administer medicines, fluids,
nutrients, and/or blood products as well as a way of drawing an individual's blood;
hence, infection prevention associated with the use of central vascular access devices or CVAD
is of paramount importance. If proper procedures and techniques are not adhered to, patients
could incur a prolonged hospital stay, and/or death; furthermore, the hospital could also be
subjected to increased costs. Most health care professionals would probably agree that
precautions do need to be taken when placing or accessing a CVAD so as to lower the risk of
central line infection, the methods and precautions currently being used do not appear to be
standardized; subsequently, there are several schools of thought on what methods should be
employed while accessing a patient’s CVAD. Furthermore, the importance that the hospital
places on the use of proper protocol has a huge impact on how the CVADs are accessed.
A CVAD is an important and highly useful device for the patient; these devices also help
the medical staff deliver many different types of solutions safely and effectively. There are
several important steps which should be adhered to in order to minimize the risks when placing a
patient's CVAD, and according to the Center for Disease Control’s website (2014):
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To prevent catheter-associated bloodstream infections doctors and nurses will:
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Choose a vein where the catheter can be safely inserted and where the
risk for infection is small.
•
Clean their hands with soap and water or an alcohol-based hand rub
before putting in the catheter.
•
Wear a mask, cap, sterile gown, and sterile gloves when putting in the catheter
to keep it sterile. The patient will be covered with a sterile sheet.
•
Clean the patient’s skin with an antiseptic cleanser before putting in the
catheter.
•
Clean their hands, wear gloves, and clean the catheter opening with an
antiseptic solution before using the catheter to draw blood or give
medications. Healthcare providers also clean their hands and wear gloves
when changing the bandage that covers the area where the catheter enters the
skin.
•
Decide every day if the patient still needs to have the catheter. The catheter
will be removed as soon as it is no longer needed.
•
Carefully handle medications and fluids that are given through the catheter
(p.1).
It should be noted that patients will have their CVADs placed by surgeons or nurses; however, it
will be primarily up to the nurses to follow the methods and procedures for accessing these
devices that have been put into place by the hospitals where they are practicing. Accessing a
central line can happen multiple times during a patient’s stay in the hospital, and there are
several methods or “best practices” that are currently being used to access a patient’s CVADs.
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Some institutions have implemented the use of “care bundles” in order to reduce the occurrence
of blood borne infections related to central vascular access devices. These care bundles consist
of the multiple best evidenced based practice guidelines which are aimed at reducing the number
of catheter based infections within the hospital or home setting. According to Whited and Lowe
(2013) in an article written for the Clinical Journal of Oncology Nursing at one hospital:
The bundles included using carts with all supplies for central line insertions, using a
checklist during insertion, stopping procedures if any guidelines have been violated,
daily assessment and documentation of the need for having a central line, daily inspection
of the insertion site, site care as needed and every seven days, hand hygiene before
handling the IV system and for 15 seconds before each use, and scrubbing the infusion
hub with alcohol . . . . Education on central lines and CLABSI prevention is an easy but
effective way to reduce the incidence of CLABSI (p.23).
The use of care bundles listed by the Center for Disease Control (CDC) and practiced at hospitals
throughout the country appear to be effective ways to reduce or eliminate CLABSIs; however,
CLABSIs still occur and patients are still subjected to infections. So why are these infections
still occurring?
Some of the infections could be due in part to the failure of staff to properly follow the
steps that have been put into place by the hospital administration. It could be argued that the
difficulty of a procedure has a great deal of impact on how well employees adhere to the steps
within that procedure. There are an ever increasing number of steps being implemented by the
CDC, hospitals, and other health care organizations when it comes to medical procedures, but are
those steps that are meant to lessen infections and help patients, actually hurting the patients?
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When a task becomes cumbersome, some employees fail to adhere to it. While many employees
follow proper protocol, some hospital administrations do not emphasize the importance of
upholding standards. The climate in an organization can help to influence the manner in which
an individual does his or her job; subsequently, the hospital staff that places importance on
accessing CVADs may discover a lower rate of infections among the patient population. On the
other end of the spectrum, the hospital staff that does not emphasize the importance of using
strict infection control protocol established through EBP, might find an increase in the number of
CVAD infections occurring in that facility. Using care bundles, best EBP, and aseptic technique
can drastically reduce the risk for infection; nevertheless, if infection does occur it is the nurse’s
job to identify the signs and symptoms quickly so treatment can begin, without delay.
Unless these central vascular access device infections are completely eradicated from the
health care setting, nurses and patients together need to be acquainted with the early signs and
symptoms of this life threatening, catheter based infection. If an infection has infiltrated the line,
the patient may have an elevated temperature, increased heart rate (HR), purulent drainage,
warmth, or inflammation accompanied by redness at the catheter site. Assessment around the
catheter insertion site for swelling is important, swelling can cause a blockage; consequently, the
lymph fluid is unable to drain properly. If any of these symptoms occur, it is imperative to
obtain two blood cultures from the CVAD immediately. These patients can advance quickly
from infection to sepsis to septic shock and possibly death if the infection goes unnoticed. Once
cultures are obtained, a broad spectrum antibiotic should be administered as prescribed as soon
as possible. If a culture and sensitivity test comes back positive, then, at that time, a targeted
antibiotic would be administered to target the organism responsible. If the patient has a
temperature, it can be treated and controlled with Tylenol as prescribed. These types of
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infections can be reduced with proper education and standard safety precautions. Nurses need to
be vigilant in following the best EBP to ensure every patient's safety. Cutting corners and not
taking proper precautions in preventing these types of infections from occurring will be putting
these vulnerable patient populations in dire jeopardy. Infection of a central vascular access
device is a serious complication, and two equally threatening complications, extravasation and
infiltration, can arise under entirely different set of circumstances associated with the use of a
central vascular access devices.
Infiltration occurs when there is a leak at a peripheral IV site; similarly, extravasation is a
complication in which IV fluids are leaked from a CVAD into surrounding tissue. There is only
a slight difference between the two terms. Infiltration occurs as a result of a non-vesicant
solution leaking into surrounding tissue from a peripheral IV site; whereas, extravasation occurs
when a vesicant leaks from a central catheter into the surrounding tissue. For the purpose of this
paper, a vesicant can be defined as any IV solution that has potential for tissue damage when
leaked from a central line into the surrounding tissue. According to Al-Benna, O'Boyle, and
Holley from the Department of Plastic, Reconstructive and Burns Surgery of Nottingham
University Hospitals (2013):
Soft tissue damage following extravasation may be due to a number of factors related
to the physicochemical properties of the drug or infusate. The following agents have
been known to cause extravasation injuries, but the lists are by no means definitive.
(....) It is now well documented that a number of physicochemical factors influence,
and usually increase, the extravasation risk of individual drugs as follows:
Ability to bind directly to DNA,
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Ability to kill replicating cells,
Ability to cause tissue or vascular dilatation,
pH outside the range 5.5–8.5,
Osmolarity greater than plasma (>290mosmol/L),
Formulation compounds such as alcohol, polyethylene glycol (p.2).
Some commonly seen vesicants in the medical setting include medications, such as,
chemotherapy agents and antibiotics. Medications that destroy the cell are considered toxic,
posing the risk for cell death in the event of extravasation. The toxic properties of a vesicant
solution can lead to tissue death, ulceration, compartment syndrome and chronic pain.
Ulceration of the surrounding tissue may pretense a serious risk for further infection
complications, and if the extravasation is severe enough, the potential need for reconstruction
surgery with engraftment exists. The extent of tissue damage that possibly will or will not occur
is directly related to the amount of the extravasation (leakage amount), the chemical properties
(chemical makeup) of the vesicant, and the concentration (potency) of the administered
medication.
It would seem that infiltration and extravasation risk factors are obvious; however, the
different variables mentioned previously make every patient and every situation potentially
present with a different set of circumstances. As registered nurses Phillips and Gorski (2014)
point out, risk factors for infiltration and extravasation include:
Needle dislodgment/ improper needle access with implanted vascular access ports, deeply
placed ports, catheter attached to an implanted port that separates or fractures internally,
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catheter migration and subsequent malposition into the tissue, loss of catheter integrity
(e.g., hole/crack in the catheter) (p. 552).
The potential of the aforementioned risk factors affecting the general patient population is
considerably high due to the presence of IV sites in nearly all hospitalized patients. Although not
all patients will have a CVAD device or PIV (peripheral intravenous) device, it is still imperative
for the nurse to be able to identify complications of infiltration and extravasation in patients with
either access site.
A number of signs and symptoms can be outwardly evident such as increased or varying
pain, inflammation or pooling under the skin, cool to the touch, and inflammation accompanied
by a reddened area at the site; nevertheless, other complications are not so easily seen. The
insertion site is often the first and only observation made by the nurse. While determining or
assessing whether extravasation has occurred during administration of a vesicant, it is equally
important to check other sites for possible signs of extravasation. As Hadaway, RN, C, CRNI,
MEd (2002) noted in an article she wrote on infiltration:
Think not only about where the catheter enters the vein, but also the about where the
medication enters the vein. Assess the entire catheter and adjacent structures, including,
for example, the vein entry site, the catheter tip location, and the venous pathway in
between those two points. (p.38)
Without proper monitoring and timely treatment, extravasation can become a serious crisis for
the patient. With this knowledge, the nurse will be able to actively monitor and assess for signs
of extravasation to prevent further injury to the patient.
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The best prevention for this serious complication is education. Education of not only the
nurse on proper IV administration and IV maintenance, but educating the patient as well, will
help in identifying the risks and early signs of extravasation. It is the responsibility of the nurse
to know what kind of medication solutions will be given intravenously and if those medications
pose a risk for extravasation to the patient. In the event a patient needs any vesicant medications,
it may be necessary to use a CVAD and not a PIV site. Vesicant material is best given through a
CVAD due to the larger vein in which it is placed, therefore reducing the risks; however, the risk
still exists for extravasation occurrence. The central catheter should be checked by the nurse per
shift or as required to make sure it is stable and will not be pulled from the vein. Security of the
device is accomplished with an intact, secure, and sterile dressing and a stabilization device. In
addition, care needs to be exercised when accessing an implanted port, it is necessary to make
sure the length of the needle is appropriate for the depth of the port. If the needle is too short to
access the port completely and properly, extravasation could occur near the port. Finally,
checking the central line for patency with normal saline is essential in the prevention of
infiltration/extravasation. If patency of the CVAD cannot be established, it should be
investigated before IV therapy begins.
In the event extravasation has occurred, with either a vesicant or non-vesicant medication
in a central vascular device or PIV site, some standard protocols should be followed. As
produced in a concept map found in the article Extravasation Injuries in Adults by Al- Benna et
al. (2013), "the infusion should immediately be stopped, the medication should be aspirated
from the line, and the physician should be notified" (p.5). The actual amount of tissue death will
determine the extent of the interventions needed. This could be as simple as stopping the
infusion or as complex as reconstruction surgery in the event of major ulceration with tissue
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death. Extravasation can be a serious and potentially image altering complication due to IV
therapy. Education must be a top priority in facilities across the nation for nurses and patients
alike in order to prevent and recognize the symptoms of extravasation.
With the passing of several hundred years, medical advances have made delivering
medicines, fluids, nutrients, and/or blood products via intravenous therapy easier and more
efficient. Nevertheless, even with the major advancements in medicine, the risk for
complications still exist today. Infection and extravasation are complications that can arise in
patients with central vascular access devices (CVAD). Infection can quickly become a serious
complication and possibly produce a fatal outcome if proper technique and protocol procedures
using evidenced based practice (EBP) are not followed. Education of the staff nurses on use of
aseptic technique while accessing the device and the nurse being able to recognize the early
symptoms are diminishing these health care acquired infections (HCAI). The education of the
patient is also important because the patient should be able to identify the signs and symptoms of
infection that may occur from the use of the device. Likewise, extravasation also poses a
significant risk for the patient with a central line. Ulceration and cell tissue death can occur if
extravasation is left unmonitored or untreated. Nurses must be attentive to the monitoring of the
central vascular access device site for signs of extravasation. Frequent monitoring must be
performed when delivering a vesicant solution through the device. It would be assumed that the
above mentioned complications could easily be prevented by using the best evidenced practice;
however, these life threatening complications are still not eradicated in the healthcare setting.
With the continuing advancements in medicine, providing ongoing education that supports "best
practice" must be a top priority to protect the patient population.
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References
Al- Benna, S., O'Boyle, C., and Holley, J.(2013) Extravasation Injuries in Adults. SRN
Dermotology 1-8. CINAHL Complete, EBSCOhost
Center for Disease Control Infection.Central Line-Associated Bloodstream
Infection (CLABSI) (2014). Retrieved from http://www.cdc.gov/hai/bsi/bsi.html
Gorski, L., & Phillips, L.(2014). Complications of infusion therapy. Manual of I.V.
Theurapeutics: Evidenced Based Practice for Infusion Therapy. Philadelphia, PA:
F.A.Davis Company (pp. 551-552)
Hadaway, L. (2002). I.V. infiltration: not just a peripheral problem. Nursing, 32(8), 36-43
IV history (n.d.) Retrieved from http://workplacenurses.com
Whited, A., & Lowe, J. M. (2013). Central Line-Associated Bloodstream Infection: Not Just an
Intensive Care Unit Problem. Clinical Journal Of Oncology Nursing, 17(1), 21-24.