Complications and troubleshooting

Insertion site should be inspected for signs of infection or phlebitis each time it is accessed or at least once daily (minimum) whilst an inpatient or at each home/clinic visit for patients receiving care at home or community (minimum once weekly).

Signs: generally feeling unwell, pyrexia or rigor, increasing early warning score (PEWS).

Action: Refer to medical team – catheter may be removed or infection may be treatable without device removal, depending on the patient’s clinical status and colonising organism.

Only take blood cultures from the VAD if it is thought to be the source of the infection. Document and report on Datix once infection is confirmed. Obtain blood cultures from each lumen of the VAD and discussion with medical staff if peripheral cultures should be required.  PVCs should be removed if there is any suspicion of infection.

Monitor PEWS, frequency will depend on patient’s clinical status – Consider Sepsis!

Exit site infection would be noted with tenderness/phlebitis at the exit site +/- exudate. Action: Obtain wound swab for culture and sensitivity. Redress exit site. If exudate present, increase frequency of dressing change. Refer to medical team, consider antibiotic therapy.

The inflammation of the intima layer of the vein. Signs of phlebitis include localised pain, redness and swelling.

There are three main types of phlebitis:

• Mechanical – Caused by venous catheter irritation to the lumen of the vein e.g. direct manipulation of PVC resulting in movement in the vein or large PVC in a small vein.
• Chemical – Caused by irritation from chemicals e.g. medications and chemotherapy.
• Infective – Usually bacterial and can present in a number of ways including discomfort, local site inflammation and systemic infection.

The inserted VAD moves from its intended position. VADs should be inspected on each use to monitor for signs of migration.

Action: DO NOT PUSH THE VAD BACK IN. Consider patency and position of tip of VAD. VAD may require to be removed and replaced.

Central VADs: A chest x-ray should be carried out to the review the position of the tip of the CVAD and reviewed by appropriate practitioner. The CVAD may require to be removed if not in an appropriate position.

The inadvertent leaking of a non-vesicant solution from its intended vascular pathway (vein) into the surrounding tissue. It is increasingly seen as a benign event as it generally does not lead to tissue necrosis; however, large volume of infiltrate can cause compression of nerves.

Action: Stop IV administration; remove VAD and re-site, if required. Document event and actions taken.

The inadvertent leaking of an irritant or vesicant solution from its intended vascular pathway (vein) into the surrounding tissue. A vesicant refers to any medicine or fluid with the potential to cause blisters, severe tissue injury or necrosis if it escapes from the intended venous pathway. The degree of injury may range from mild skin reaction to severe necrosis.

Action: Stop infusion immediately; leave VAD in situ initially; aspirate any fluid; NEVER FLUSH THE VAD.

Seek immediate advice from medical staff prior to removing VAD, who may advise administration of suitable neutralising agent. The VAD can then be removed and re-sited.

Subsequent management depends upon the medication involved and degree of damage.

Document event and actions taken. Report in Datix, ensuring the name of the medication is noted clearly.

For Systemic Anti-Cancer Therapies - refer to the West of Scotland Extravasation in Practice Policy, Guidance and Tools.

A VAD or one of its lumens is blocked by blood, medications or lipids. Repositioning of VAD integral clamps after every use will also prevent damage to the lumen.

Action: Check that there are no kinks in the catheter.

Ensure that clamps are open, move the clamp up/down the VAD then roll the previously clamped section between your fingers gently to ensure that the catheter walls are not ‘stuck’ together. 

Try altering the patient’s position or position of the arm. Replace needle free access device.

Peripheral devices - Remove VAD and re-site.

Central Devices - Flush catheter with IV 0.9% sodium chloride 2-3mls using a brisk push/pause flushing technique, check if blood can now be aspirated. If successful, flush with normal flushing procedure. If not successful consider Urokinase administration (requires a valid prescription).

This can be caused by material weakness or over manipulation of device on insertion. Using a syringe smaller than 10mls to flush also increases the risk of internal catheter fracture, further increasing the risk of infiltration or extravasation.

All VADs should be inspected for damage on removal. Any device that is removed and found to be fractured or incomplete, must be reported to the patient’s medical team for review and advice. Signs: Fluid/blood leaking

Action: Stop infusion. Using a plastic clamp, clamp the catheter just above the damaged area and as far away from the chest as possible, without delay to prevent possible air embolism. Cover the whole catheter with an occlusive dressing. A single lumen catheter may be able to be repaired. This should be discussed without delay with the team who inserted it e.g. NHSGGC. If unable to repair, the catheter should be removed as soon as possible to minimise risk of infections and air embolism. 

PICC external catheter fracture: In event of an external catheter fracture, PICCs should be removed immediately. 

A swelling of blood under the skin causing a hard, painful lump. There are various causes such as transfixation or transection of the vein; inadequate pressure to puncture site on removal of device and unsuccessful attempt at insertion of device.

Occurs when one or more air bubble(s) enter a vein or artery and block it. Correct techniques and good practice can minimise risks of air embolism occurring.

Signs of air embolism are:

• breathlessness
• chest pain
• hypotension
• cardiac arrest.

This can occur due to unclamped or open lumen or following the removal of a CVAD.

This would be indicated by swelling of leg or shoulder/neck/arm or face with or without pain, inflammation, distention of the neck veins/peripheral vessels.