Sarah NorthfieldClinical Nurse (Research)

Registered Nurse (Medical Oncology Unit)

Cancer Care Services, RBWH

Fracture, Dislodgement, Migration & Localised Infection – the complications of life with

a CVAD

This presentation is independently prepared and reflects no commercial entity nor promotes particular products unless these are supported by

research data.

Disclosures

Learning Objectives

• To perform a comprehensive CVAD assessment

• To identify and manage CVAD complications -fracture, migration, accidental dislodgement and localised infection

• To practically apply CVAD assessment and troubleshooting techniques during an interactive session

What is a CVAD Fracture/Rupture?When there is an incomplete break in the wall of the catheter and can occur at any place along the CVAD

(INS 2011)

Tunnelled CVAD fracture

ManagementFor an external rupture: 1) Clamp the portion of the catheter between the site of damage and

chest wall 2) Notify treating team for management 3) Depending on the location, external ruptures can be repaired by

trained personnelOR

If irreparable, the device will need to be removed.4) Document steps taken in progress notes

For a suspected internal rupture: 1) Stop the infusion 2) Notify treating team for management, such as dye studies to

diagnose the potential rupture3) If rupture is confirmed, remove device4) Document steps taken in progress notes

Subclavian vein insertion with catheter pinched

between clavicle and first rib

What are the signs & symptoms?

For a suspected internal embolus:

1) place the patient on left side in Trendelenburg position and apply oxygen

2) Contact treating team for management

3) A chest x-ray is required to confirm catheter fragmentation and location.

4) Document steps taken in progress notes

* If PICC breaks during removal, immediately tourniquet the arm, monitor vital signs and arrange a medical review.

Management

And do you want to know what the crazy

thing is?!

The movement of the internal catheter tip from the desired end location (with or without the external length changing).

Signs and Symptoms • a change in functional capacity of the device

inability to inject fluid Inability to aspirate

• cardiac arrhythmias • Patient complains of ear gurgling• increased external catheter length • local pain or swelling• difficulty or inability to swallow• neurological abnormalities • dyspnoea

What is Catheter Migration?

1) discontinue all infusions and secure device

2) notify the treating team – call medical emergency if meets criteria

venographic studies to verify tip location

radiological intervention to reposition tip

flexible catheters, such as PICCs, can be repositioned with rapid flushing of the catheter.

N.B: this technique must be approached with caution

3) Document steps taken in progress notes

Catheter Migration - Management

Accidental Dislodgement

1) Place gauze over the exit site and apply pressure until bleeding has ceased

2) Apply gauze and transparent semi-permeable dressing to site

3) Check catheter tip is intact (or if trimmed PICC measure and compare to insertion notes)

4) Notify treating medical team

5) Assess for venous air embolism and take nursing actions if signs are noted

6) Document steps taken in progress notes

Accidental Dislodgement - Management

Infection can occur at catheter exit site, along the catheter tunnel or in the Portacath pocket.

Localised Infection

Signs & Symptoms

1) swab and culture infected site

2) Cleanse site with 2% Chlorhexidine Gluconate v/v 70% Isopropyl Alcohol and apply dressing appropriate to clinical situation

3) administer intravenous or oral antibiotics as prescribed

4) Document steps taken in progress notes

Localised Infection -Management

First line of defence against infection & dislodgement….

Evidence-based preventative strategies: • Perform comprehensive CVAD assessment at least once each shift• Decontaminate the insertion site with a single-use application of 2%

chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) (Epic 3 2014)

• Use a sterile, transparent, semi-permeable polyurethane dressing to cover the intravascular insertion site.

changed every 7 days, or sooner, if they are no longer intact or if moisture collects under the dressing (Epic 3 2014)

• Evidence that chlorhexidine-impregnated dressings in adult patients with a central venous catheter as a strategy to reduce catheter-related bloodstream infection (CRBSI) (Epic 3 2014)

• PICC should be secured at all times via dedicated fixing device (EviQ 2016)• use aseptic non-touch technique when providing CVAD care (ASAP 2013)• Hand must be decontaminated, pre and post CVAD care (Epic 3 2014)

GOOD CVAD MANAGEMENT!

ReferencesInfusion Nurses Society. 2011. "Infusion Nursing Standards of Practice." Journal of Infusion Nursing 34 (Supplement)(1S):S1-S109.

Loveday, H. P., J. A. Wilson, R. J. Pratt, et al. 2014. "epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England." J Hosp Infect 86 Suppl1:S1-70.

EviQ Cancer Treatments Online. (2016). Supporting Document – Central Venous Access Device. Retrieved from http://www.eviq.org.au

Association for Safe Aseptic Practice (ASAP). (2013). Aseptic Non Touch Technique, ANTT. Available at: http://www.the-antt.org/