Emergency Management of the Hi-Tech Patient in Acute and Critical Care

Table 5.2 Procedure for accessing an implanted central venous catheter.

Catheter breakage can occur for a variety of reasons, including inadvertent cutting during a dressing change, a patient pulling away during an attempt to access the line, snagging of the externalized portion of a CVC during daily activities or play, or blunt‐force injury during contact sports or accident. Any fluid or blood reported by the patient or witnessed in the ED should be treated as a catheter break. Visualization of the catheter's Dacron cuff outside the chest wall should be treated similarly. To prevent infection, air embolus, or bleeding, broken externalized lines should be immediately clamped with nontoothed forceps proximal to the site of breakage and the damaged portion of the line should be cleaned with povidone‐iodine and covered with sterile dressing. While repair kits specific to each type of CVC are available in many centers, they should be deployed only by those with expertise in their use – usually in consultation with an institutional IV team or interventional radiology. Less commonly, externalized CVCs can fracture proximal to their point of exit in the chest. In these cases, it is critical to apply pressure to the catheter's entrance to the vein and not to the chest wall exit site itself. A chest radiograph should be performed to determine the location of the proximal line fragment. Rarely, fractured catheter fragments are discovered in the pulmonary circulation, from which they must be removed by interventional radiology – usually via a femoral approach. Trauma or patient manipulation may dislodge an implanted port from its subcutaneous pocket in the chest wall. For this reason, practitioners should always check the stability of the port reservoir before attempting to access it with a needle. If port dislodgement is suspected, obtain a chest radiograph to interrogate the integrity of the implanted system. If dislodgement is confirmed by an X‐ray, immediately discontinue any infusions running through the port and notify the interventional radiology or surgery department of the need for catheter replacement.

CVC occlusion is brought to the attention of ED providers either when patients complain of their catheter not working in the outpatient setting, or when ED’s attempts to instill fluid or draw back blood from a CVC are unsuccessful. CVCs are considered to be partially occluded if fluid can be instilled in them, but blood cannot be drawn back. A CVC is fully occluded if neither fluid instillation nor blood aspiration can be completed successfully. If occlusion is suspected, the first step should be to obtain a chest radiograph to determine the position and integrity of the catheter tubing. Catheter occlusion occurs for a variety of reasons, from formation of medication precipitates within the lumen of the line to development of fibrin sheaths and/or thrombus either within or surrounding the catheter tubing. If a small clot is suspected within the lumen of the CVC, the ED practitioner can attempt to aspirate it from the line with a 10 cc syringe that is half‐filled with saline. This technique is rarely successful in removing clots from implanted CVCs, as the small caliber of the noncoring needle used to access the catheter reservoir makes clot aspiration extremely difficult. If clot aspiration is unsuccessful, lysis of the occlusion can be attempted with a variety of lytic agents, depending on the nature of the blockage (e.g. clot vs. waxy precipitate vs. particulate matter). Practitioners should refer to their institution's guidelines for management of CVC occlusion for details on the use of each lytic agent. In centers where catheter fibrinolysis is not within the usual scope of practice of the ED nurses or providers, lytic maneuvers can also be attempted in consultation with an institutional IV team or with interventional radiology. Because it is possible for fibrin sheaths and large thrombi to embolize into the central venous circulation, it is critical that ED providers be able to recognize the signs and symptoms of pulmonary embolus – tachycardia, tachypnea, chest pain, and hypoxemia – and have a high index of suspicion for catheter‐related thromboembolus if a patient exhibits these symptoms. Indwelling CVCs also bring with them an increased risk of catheter‐associated deep‐ or central‐vein thrombosis. Patients with PICC‐associated thrombosis may demonstrate unilateral limb pain and swelling on the side of catheter insertion. Patients with central venous thrombosis associated with either an externalized CVC (Broviac, Hickman) or an implanted port may demonstrate signs and symptoms of SVC syndrome, including edema of the face, neck, or chest and neurologic changes. Both deep and central venous thrombosis are usually indications for removal of the catheter and initiation of anticoagulation.

While rare, air embolism is a potentially fatal complication of CVCs with which ED practitioners must be familiar. A patient with CVC‐associated air embolism may demonstrate acute‐onset chest pain, dyspnea, hypotension, tachycardia, dizziness, and anxiety. Because such patients may progress to loss of consciousness and cardiac arrest, ED providers suspecting air embolus must act quickly to prevent further air entry into the CVC circuit. Externalized catheters should be clamped immediately, and the patient should be placed in Trendelenburg in the left lateral decubitus position to trap any air bubbles in the right ventricle. Patients with suspected air embolus should be put on 100% supplemental oxygen, and alternate IV access should be obtained as quickly as possible. To prevent air emboli, patients, their care providers, and all ED personnel must keep the externalized portion of any indwelling CVC clamped whenever the line is not actively in use. Finally, because the proximal tip of most CVCs terminates at the SVC‐RA junction, it is important to note that fracture or migration of an indwelling line can lead to other rare intrathoracic complications, including cardiac arrhythmia, cardiac tamponade, or – more commonly during catheter placement – pneumothorax or hemothorax. Patients presenting with these complications are unlikely to implicate the CVC in their chief complaint, so it is incumbent upon the ED provider to have a high index of suspicion in screening for them.