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Intravascular Access


Intravascular access is a means to administer fluids and medications and is a valuable tool for gathering hemodynamic information. The loss of “access” is a common reason for a phone call. This chapter provides orientation to various types of intravascular access, procedures to attain them, and common complications and problems. Some hospitals require informed consent before some of these procedures are performed; find out what the specific regulations are at your institution. Proprietary kits for intravascular line placement have specific instructions to follow for safe placement. The suggestions here do not attempt to supersede the written instructions supplied with each kit. Read the kit instructions, and follow the steps carefully. Perform procedures only if you are comfortable with them; enlist the help of more experienced personnel if you are unsure. Many hospitals have protocols for placing lines. Follow the protocols at your institution.

Loss of Line Function

Phone Call

Questions

  • 1.

    Why does a patient need intravascular access?

    • Reasons may range from hemodynamic monitoring by arterial or central venous lines, nutrition or medication delivery through central access, need for hemodialysis, or administration of medication or fluids through peripheral lines.

  • 2.

    Is the access still necessary?

    • Often, lines remain in place long after their usefulness is gone. There may be enteral routes or other options available for use. Even if you determine continued need for intravascular access, the patient may be stable enough to wait for intravenous (IV) line placement in the morning by the regular care team. Some hospitals have a policy that all inpatients need basic peripheral IV access.

  • 3.

    Are there immediate problems with the access?

    • These are discussed in the sections on the individual lines, but the question should be asked because some problems, such as severe bleeding or shortness of breath (SOB), may be life threatening.

  • 4.

    How long has the existing line been in place?

    • Long-term access lines such as long-arm or peripherally inserted central venous catheter (PICC) lines or Hickman-type catheters are designed to remain in for weeks to months but may have thrombotic or infectious complications. Other “medium-term” lines such as multilumen central venous access catheters or arterial lines may require removal and reinsertion with a clean line at intervals to minimize infectious risk.

  • 5.

    Are there any other symptoms?

  • 6.

    Are there any changes in vital signs?

Orders

  • 1.

    Have the means available to restart the access, if necessary. This may include peripheral IV trays or specific kits for arterial line or central venous access.

  • 2.

    Respond to any immediate problem such as bleeding or SOB as necessary.

Degree of Urgency

Loss of peripheral access is not an emergency unless a specific, important medication such as heparin is interrupted. If there is a significant change in vital signs or symptoms, the patient must be evaluated immediately.

Elevator Thoughts

What causes loss of IV access?

  • 1.

    Reevaluate the need for intravascular access.

  • 2.

    Think about the various options for vascular access.

    • There may be more than one approach that is appropriate in an individual patient.

  • 3.

    Causes of loss of function of a line are as follows:

    • a.

      Kinking of the line

    • b.

      Loose or disconnected line

    • c.

      IV pump failure

    • d.

      Intraluminal blockage

    • e.

      Thrombosis of the vessel

    • f.

      Thrombophlebitis

    • g.

      Misplacement of the line by initial insertion or migration

    • h.

      IV site infection

  • 4.

    Are there contraindications for placement of IV access?

    • a.

      Does the patient have chronic kidney disease (CKD) with potential need for dialysis access?

    • b.

      Does the patient have a surgical arteriovenous (AV) fistula?

Major Threat to Life

  • Loss of vital hemodynamic information

  • Interruption of important medication

  • Life-threatening complication after line placement, such as pneumothorax after central venous line placement, or arterial thrombosis of a peripheral limb associated with an arterial line

Surgical Chart Biopsy

  • What is infusion through the vascular access device?

  • Is the vascular access device being used for monitoring? If so, is that monitoring still necessary?

Bedside

Quick Look Test

If there is a specific complaint related to the line, such as SOB or pain, the patient may look distressed. A malfunctioning line usually does not produce symptoms. The patient may be distressed by the IV infusion pump alarms or by a leak in the IV tubing. The IV line also can infiltrate where the catheter becomes dislodged from the vein, infusing fluid into the surrounding tissues. This can be painful and the IV line needs to be removed.

Airway and Vital Signs

There is generally no derangement in vital signs as a result of the nonfunction of the line, unless the medications delivered are responsible for altering cardiopulmonary physiology (such as inotropic agents). If thrombophlebitis is present, fever may be apparent.

Selective Physical Examination

VS: Repeat as necessary.
Line site: Inspect the line: Look for kinks and loose connections. Inspect the IV pump: Is it on and functioning correctly? Inspect the fluid: Is there fluid remaining in the IV bottle?
Skin: Is there redness, swelling, purulence, or clear fluid collection under the dressing?
Extrem: If the IV is in a peripheral site, look for swelling or discoloration of the limb; feel for distal pulses.

Additional tests:
  • 1.

    Chest x-ray (CXR): This is for evaluation of internal jugular (IJ) and subclavian central line tip placement. The tip should be at the superior vena cava (SVC). When looking at the CXR, the ideal line will have a tip near the lucency of the right main bronchus. Occasionally, after placement of a subclavian line, the tip can be found in the IJ vein. If out of place, the line must be repositioned. The CXR is also diagnostic when evaluating for pneumothorax after central line placement.

  • 2.

    Aspiration: Aspiration should be done in a sterile fashion. Wipe the connection with a small amount of iodine. Disconnect the IV tubing from the hub of the line, and immediately attach a 5- to 10-mL syringe to the hub. For a central line, wait for exhalation before detaching the IV tubing. Gently aspirate. Removal of a small-tip thrombus is usually sufficient to clear the line. Continue to aspirate until 3 to 5 mL of blood have been collected. Discard the blood and reconnect the line to the IV tubing. Replace a sterile dressing. Never flush the line because this might dislodge a larger clot propagating from the tip of the catheter into the vena cava and result in a pulmonary embolus.

Management

  • 1.

    If repositioning or aspiration of the line is unsuccessful in restoring function, another way of delivering medication is required. Ask a few basic questions:

    • a.

      Does the patient still need intravascular access?

    • b.

      Is the patient taking food or medication orally (PO)?

    • c.

      Can current medication be switched to PO or intramuscular (IM) administration?

    • d.

      Must the access be central access?

    • e.

      Is the patient on medication that requires central access, such as total parenteral nutrition (TPN), chemotherapy, inotropic drugs, or irritating medication such as amphotericin?

    • f.

      Are there other ports on an existing central catheter that are usable? If the site is clean, the line may be changed to a new one over a wire (Seldinger technique). If there is a problem with the site, such as erythema, the existing line must be removed regardless of the patency of the other lumens.

  • 2.

    A new site is required if the current skin site is red or purulent and the patient is febrile, or the line is clogged through the distal port (this also may dislodge a clot propagating from the tip of the catheter).

  • 3.

    Restart IV access, if required.

  • 4.

    If removal of the existing central line is required, remember to send the catheter tip for culture, if required; also hold pressure at the skin site after removal for 10 minutes (by the clock) to ensure adequate hemostasis.

Special Surgical Considerations

Occasionally, a surgical house staff member is called to remove a longer-term line such as a Hickman catheter. These differ from temporary central venous access in that a Dacron fiber cuff is present under the skin a short distance from the insertion site. The toughness of the adherence of the subcutaneous tissue to this cuff depends on the length of time during which the catheter has been in and on the healing properties of the patient. The removal of these lines is discussed later.

Bleeding From the Site

Phone Call

Questions

  • 1.

    Is this the only site of bleeding?

    • Blood oozing from more than one site may be evidence of coagulopathy.

  • 2.

    Is the line functional?

    • Did the patient undergo a surgical procedure, and if so, how long ago?

  • 3.

    Are there any other symptoms?

  • 4.

    Are there any changes in vital signs?

Orders

  • 1.

    Have the means available to restart the access, if necessary. This may include peripheral IV trays or specific kits for arterial line or central venous access.

  • 2.

    Respond to any immediate problems.

  • 3.

    Have the nurses hold pressure on actively bleeding sites until you arrive.

Degree of Urgency

If there is a significant change in vital signs or symptoms, the patient must be evaluated immediately.

Elevator Thoughts

What causes bleeding from an IV site?

  • 1.

    A new site will ooze slightly but should stop within several hours.

  • 2.

    Coagulopathy, causing bleeding, may result from the following:

    • a.

      Medications including heparin, warfarin, streptokinase, and tissue plasminogen activator (t-PA).

    • b.

      Platelet dysfunction from thrombocytopenia or nonsteroidal antiinflammatory drugs (NSAIDs).

    • c.

      Clotting factor deficiency, dilutional coagulopathy, disseminated intravascular coagulation (DIC).

Major Threat to Life

  • Soft-tissue swelling; subcutaneous blood can exert pressure on surrounding structures; depending on the site of the line, the hematoma can displace lung (with a subclavian line), trachea (with an IJ line), or compress on the femoral nerves causing pain (with a femoral line or femoral access)

    • Loss of vital hemodynamic information

    • Interruption of important medication

    • Life-threatening complication, such as pneumothorax after central venous line placement, or arterial thrombosis of a peripheral limb associated with an arterial line.

Surgical Chart Biopsy

  • What are the trends in vital signs? Has the patient become increasing tachycardic, suggesting anemia?

  • What are the most recent coagulation studies?

  • When was the line placed?

Bedside

Quick Look Test

Minor bleeding is not associated with discomfort. If the bleeding is because of impending sepsis, the patient may appear ill.

Airway and Vital Signs

If the line is in the IJ site, pay special attention to the patient’s airway. Is the patient breathing well? If a significant amount of blood is lost, pulse rate may be elevated and blood pressure (BP) may drop.

Management

  • 1.

    Inspect the wound.

    • Remove the dressing and clean around the site. Try to identify a specific site of oozing, although this often is not possible.

    • If it is the femoral access site, be sure to check distal pulses. Note that a retroperitoneal hematoma resulting from a femoral access will not reveal much on physical examination although a computed tomography (CT) with IV contrast could be helpful.

  • 2.

    If no specific site can be identified, apply pressure (with a gloved hand) at the site for 20 minutes (by the clock). If this is the femoral access site, as used by interventional radiology or vascular surgery, be sure to hold pressure proximal to the site of oozing on the skin to hold pressure on the actual access site of the vessel.

  • 3.

    Recheck the site being careful not to dislodge any clot that may have formed; if bleeding continues, hold pressure for another 20 minutes.

  • 4.

    If bleeding continues, consider evaluation of the patient for coagulopathy.

    • See Chapter 26 for evaluation and treatment of bleeding disorders.

  • 5.

    Bleeding may compromise the function of the line, and if this is the case, consider replacement of the line but at another site.

Purulence at the Site

Phone Call

Questions

  • 1.

    Is the patient febrile?

  • 2.

    Are there other signs of infection?

  • 3.

    Is the line functional?

  • 4.

    Did the patient undergo a surgical procedure, and if so, how long ago?

  • 5.

    Are there any other symptoms?

  • 6.

    Are there any changes in vital signs?

Orders

  • 1.

    Have the means available to restart the access, if necessary. This may include peripheral IV trays or specific kits for arterial line or central venous access.

  • 2.

    Respond to any immediate problems.

Degree of Urgency

If there is a significant change in vital signs or symptoms, the patient must be evaluated immediately.

Elevator Thoughts

What causes purulence at an IV site?

  • 1.

    Local site infection

  • 2.

    Suppurative thrombophlebitis

  • 3.

    Line sepsis

Major Threat to Life

  • Sepsis

  • Suppurative thrombophlebitis

Surgical Chart Biopsy

  • Check for new fever, tachycardia, or hypotension.

  • Review the fluid balance. Has the patient been voiding?

  • Are there recent blood cultures? What is growing out of the culture?

  • Is the patient already on antibiotics?

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