TO PROMOTE positive outcomes,clinicians caring for patients withcentral lines must monitor carefullyfor signs and symptoms of compli-cations. This article discusses poten-tial complications—catheter occlu-sion, bleeding and hematoma,catheter-tip migration, catheter rup-ture, phlebitis and associated pain,swelling and deep vein thrombosis(DVT), infection, and embolism. Italso provides assessment, preven-tion, and troubleshooting tips forcentral lines.

Catheter occlusionsA catheter occlusion occurs when ablockage prevents caregivers fromflushing the central line or aspirat-ing blood. An occlusion can bethrombotic or nonthrombotic (notcaused by a thrombus). About 40%to 50% of occlusions are nonthrom-botic and result from mechanical orpostural factors, medication precipi-tate, catheter malpositioning, or un-desirable catheter-tip location.

If you suspect your patient’scatheter is occluded, assess the en-tire infusion-delivery system for ob-

structions and kinks. Determine ifblood return is hampered by theposition of the patient’s arm or oth-er body part (when either lying orstanding). Evaluate the patient’smedication profile for drug incom-patibilities. Next, assess catheter patency: Does the catheter flusheasily, or only with difficulty? Doyou see a blood return? Finally,

havea quali-fied clini-cian assesscatheter-tip loca-tion from a recentX-ray, if available.

Mechanical occlusionsA mechanical occlusion can be ex-ternal or internal. External occlu-sions stem from a kink or clamp inthe portion of the catheter that’soutside the patient. Check whetherany clamps are activated, and lookfor sutures or a securement devicethat could be pinching the cathetertoo tightly. Then check for kinks inthe catheter. Finally, examine the I.V.tubing and pump for obstructions andmalfunctions.

Internal occlusions occur insidethe patient and are harder to assess.Causes include lodging of thecatheter tip against a vessel. If yoususpect an internal occlusion, con-sult the ordering physician or li-

Recognizing,preventing,

andtroubleshootingcentral-linecomplicationsBy Ann Earhart, MSN, RN, ACNS-BC, CRNI

Central lines canbe life-saving, but

adverse events can jeopardize

patient well-being.

18 American Nurse Today Volume 8, Number 11 www.AmericanNurseToday.com

LEARNING OBJECTIVES

1. Describe at least five complicationsassociated with central lines, alongwith their causes.

2. Discuss management of central-linecomplications.

3. Explain how to troubleshoot central-line patency problems.

The author and planners of this CNE activity havedisclosed no relevant financial relationships withany commercial companies pertaining to this activ-ity. See the last page of the article to learn how toearn CNE credit.

Expiration: 12/31/15

CNE1.6 contact

hours

www.AmericanNurseToday.com November 2013 American Nurse Today 19

censed independent practitioner,who will weigh the risks and bene-fits of keeping the catheter in placevs. replacing it.

Another cause of internal cathe -ter occlusion is pinch-off syndrome,in which the catheter passes throughthe areolar tissue of the space out-side the vessel lumen and becomescompressed between the clavicleand rib. As the patient raises andlowers the shoulder, repeated com-pression and shearing forces putpressure on the catheter. A morelateral catheter insertion allows thecatheter to travel within the sub -clavian vessel. Pinch-off syndromeis a serious complication requiringimmediate attention. It may occurwith acute, tunneled, and implantedlines placed via the subclavian vein.It doesn’t occur with peripherallyinserted central catheters (PICCs)because they’re inserted in the armand approach the superior vena cava from inside the vessel.

Postural occlusionsA postural occlusion affects catheterpatency or blood flow, dependingon patient or catheter position. Tofind out if patient positioning is af-fecting blood return, instruct the pa-tient to change positions by raisingand lowering the arm, or to take adeep breath or cough. If a positionchange helps obtain a blood return,consult with the physician on therisks and benefits of leaving thecatheter in place vs. removing it.

Medication-precipitateocclusionsIf the I.V. bag contains multiplemedications, such as potassium, in-compatibility may occur in the tub-ing, causing precipitation. Infusionof parenteral nutrition, lipids,phenytoin, aminophylline, or potas-sium gluconate with other medica-tions promotes precipitate occlu-sions. The precipitate formsquickly, causing the line to becomesluggish and hard to flush.

If you suspect a catheter occlu-sion caused by precipitate, reviewthe patient’s medical record for pos-sible drug incompatibilities. Consultthe pharmacist, who may recom-mend a fibrinolytic or nonfibrinolyticagent. With a nonfibrinolytic agent,the goal is to increase precipitatesolubility by changing the pH in thecatheter lumen. For this procedure,first determine the catheter’s fill vol-ume. Fill volume varies from PICCsto ports, ranging from 0.3 to 0.5 mL.Larger catheters, such as dialysiscatheters, have larger fill volumes;the volume may be marked on theoutside of the catheter. Instill theproper amount so the medicationcontacts the precipitate, not the out-side of the catheter. To help preventmedication-precipitate occlusion,flush the catheter between eachmedication dose. (See Treatingmedication-precipitate occlusions.)

Thrombotic occlusionsMost catheter occlusions are throm-

botic, caused by changes in bloodflow, venous stasis, hypercoagula-bility, or trauma to the vessel wall.(See Types of thrombotic occlu-sions.) Thrombosis has been linkedto central-line–associated blood-stream infections (CLABSIs), somanaging a thrombotic occlusion iscrucial to prevent infection. Man-agement entails timely patency as-sessment and treatment.

If a catheter becomes partially oc-cluded or loses its blood return, afibrinolytic typically is ordered, to begiven according to manufacturer’sguidelines. Currently, alteplase is theonly fibrinolytic approved by theFood and Drug Administration (FDA)to treat thrombotic occlusions.

Bleeding and hematomasExpect minimal bleeding aftercatheter insertion. However, knowthat certain catheter types, insertiontechniques, and laboratory valuescan make patients more prone tobleeding. When assisting withcatheter insertion, control bleedingat the site before the final dressingis applied. If the insertion site con-tinues to bleed or ooze blood, ap-ply a sterile 2" x 2" gauze dressingunder the transparent dressing;change the dressing every 24 to 48hours. Follow your facility’s policyon caring for and maintaining agauze dressing.

If bleeding persists, consider us-ing a pressure dressing or wrap. Ifyour patient with a PICC has awrap applied around the arm, mon-itor extremities for color, motion,and sensation according to facilitypolicy. Document the time thepressure wrap was applied and thetime it was removed. Sensation lossand numbness have occurred whenpressure dressings were applied formore than 24 hours and the site,skin color, motion, and sensationweren’t checked.

If bleeding persists beyond 24 to48 hours after catheter insertion, as-sess for other possible causes. De-termine if bleeding could stem from

This table shows treatments for nonhemolytic catheter occlusions according to theprecipitate used, along with the recommended I.V. fluid to declot the occlusion. In-fuse only enough of the ordered fluid to fill the catheter, not for infusion into thebloodstream.

Precipitate Treatment (requires physician order)

Fat or lipid products 70% ethanol I.V.

Mineral 0.1-N hydrochloric acid I.V.

Acidic medications (pH below 5) 0.1-N hydrochloric acid I.V.

Base medications (pH above 9) Sodium bicarbonate or 0.1-N sodium hydroxide I.V.

Treating medication-precipitate occlusions

20 American Nurse Today Volume 8, Number 11 www.AmericanNurseToday.com

anticoagulant therapy, vigorousphysical activity, sutures, or coagu-lopathy. Be aware that patients withan elevated International Normal-ized Ratio or sutures that were acci-dentally placed through small ves-sels may continue to bleed, as smallpinholes within the catheter cancause oozing.

Continue to apply and changesterile gauze dressings every 24 to48 hours; to promote hemostasis,consider using such agents as anabsorbable gelatin sponge at the in-sertion site. Suture removal orcatheter removal or replacementmay be warranted to correct theproblem. Be sure to monitor the in-sertion site frequently and docu-ment findings.

Catheter-tip migrationIf the catheter loses its blood re-turn, suspect catheter-tip migration.The tip may migrate out of the su-perior vena cava at any time due tocatheter- or patient-related factors.Some catheters are made of stiffermaterials (such as the nontunneleddialysis catheter), whereas PICCsare more flexible and more likelyto migrate. Power injection, powerflushing, push-pause flushing meth-ods, vomiting episodes, and suc-tioning also can cause the cathetertip to migrate in and out of the su-perior vena cava.

Signs and symptoms of catheter-

tip migration include changes incatheter patency or loss of bloodreturn; discomfort in the upper arm,shoulder, jaw, chest, or ear duringinfusions; and an external catheterlength that differs from the lengthat the time of insertion. For exam-ple, if the external length of a PICCwas 1 cm at insertion but is now 20cm, assume the PICC is no longerin the superior vena cava. This alsocan happen with a central line inthe chest: If the line was inserted inthe subclavian vessel with 1 cm ex-posed externally but 3 cm are ex-posed on day 5, suspect it’s nolonger lodged in the vessel. (SeeAssessing for catheter malposition.)

Catheter rupturePressure generated during catheterflushing can’t be measured accu-rately. A small syringe size (lessthan 3 mL) may cause higher pres-sures within the catheter. With par-tial or complete occlusions, higherpressures occur within the catheter.Excessive pressure on the syringeplunger also can cause unmanage-able pressure within the catheter,leading to rupture.

If you encounter resistance whenflushing the catheter, stop flushingand try to determine the cause.Don’t keep flushing against resist-ance, as this may lead to catheterembolus or leakage.

If the catheter breaks during

flushing, the healthcare team mustconsider whether to repair or re-place it. Points to consider includethe following:• How much longer will central-line

therapy continue? Catheter repairmay be more appropriate if thera-py will continue for a few days,whereas replacement is more ap-propriate for longer-term therapy.

• Are vessels available for a newinsertion? Did the inserting clini-cian note that the catheter wasinserted with much difficulty?Does the patient have a historyof multiple catheter insertions?

• Is the catheter appropriate forexchange? Is there a chance ofcontamination or infection withthis catheter or insertion site?

• Is repair feasible based on vari-ables of catheter damage andexposure? What are the possiblerisks of contamination and in-fection?

• What are the manufacturer’s rec-ommendations? Many cathetersdon’t come with repair kits. De-pending on leakage or breakagelocation, repair may be impossi-ble—for instance, with a double-lumen catheter that’s leaking be-low the bifurcation.

• If the catheter is visibly rupturedon the outside, is there a possi-bility it has ruptured on the in-side? This can be determined on-ly by X-ray or dye study.If catheter repair is appropriate

and a healthcare provider writes anorder for it, an infusion or vascularexpert should repair it followingthe manufacturer’s guidelines andusing aseptic technique, with modi-fication equipment supplied by themanufacturer.

Phlebitis and related painAnother complication of a centralline is phlebitis (vein inflammation)with related pain. Although mostcommon with a PICC, it can occurwith any central line. Phlebitis caus-es erythema, pain, or swellingalong the path of the vein in which

Types of thrombotic occlusionsFour types of thrombotic occlusions can occur—intraluminal, mural, fibrin sheath,and fibrin tail.

Intraluminal thrombi account for 5% to 25% of thrombotic occlusions. They formwithin the central line and can be partial or complete. Left untreated, a partialthrombus may progress to a complete thrombus. Poor flushing technique afterblood withdrawal promotes this type of thrombus.

Mural thrombi result from vessel trauma or previous vessel injury. Fibrin from thevessel-wall injury binds to cover the catheter surface. Frequent cannulation at-tempts and rigid catheters increase the risk of a mural thrombus.

A fibrin sheath occurs in up to 47% of patients with central lines. It forms when afibrin layer adheres to the catheter’s external surface. Unless treated, it canprogress to cause catheter malfunction or a mural thrombus.

A fibrin tail forms when the catheter tip moves against the wall of the vein and fibrin adheres to the end of the catheter. The tail acts as a one-way valve, allowingfluid infusion but preventing blood aspiration. It can progress to a total occlusionunless treated.

www.AmericanNurseToday.com November 2013 American Nurse Today 21

the catheter is lodged. The condi-tion is classified as chemical, me-chanical, or bacterial.

Chemical phlebitisChemical phlebitis is an inflamma-tory response of the vein intima tothe infusates or catheter materialused for access. (See Chemicalphlebitis effects.) It’s associated withperipheral I.V. lines but may occurwith a central line if the catheter tipmigrates from its central location inthe superior vena cava. Other caus-es include extended catheter dwelltime, administration of irritatingmedications or solutions, improper-ly mixed medications, rapidly in-fused medications or solutions, orparticulate matter.

Mechanical phlebitisMechanical phlebitis is associatedwith catheter movement that irri-tates the vein intima. Early-stagemechanical phlebitis stems frommechanical irritation of the venousendothelium. It usually occurs sev-eral inches proximal to the inser-tion site. Signs and symptoms in-clude tenderness, erythema, andedema. The most common causesof mechanical phlebitis are large-bore catheters and inadequatecatheter securement.

Treatment entails application oflow-degree heat from a continuous,controlled source. Continue apply-ing heat until all signs and symp-toms resolve, which usually occurswithin 72 hours after treatment be-gins. If they don’t resolve, discon-

tinue catheter use. The healthcareteam should consider an ultrasoundstudy to rule out DVT. (Patientswith prior DVT and surgery lastinglonger than 1 hour are at increasedrisk for catheter-related DVT.) If ul-trasound reveals DVT, consult theordering clinician about treatmentoptions, which include anticoagu-lants given either with the catheterin place or after its removal.

Bacterial phlebitisBacterial phlebitis is an inflammationof the vein intima associated withbacterial infection. The least com-mon type of phlebitis, it is more se-rious because it pre-disposes the patientto systemic complica-tions. Contributingfactors include:• poor hand hy-

giene by health-care providers

• failure to checkequipment forcompromised integrity

• poor aseptic tech-nique duringcatheter site or sys-tem preparation

• poor cap or hubdisinfection beforeobtaining catheteraccess

• poor insertiontechnique

• inadequate orbreached dressing

• infrequent site ob-

servation and failure to assessadequately for complications

• preexisting patient condition orinfection.Keep in mind that wearing gloves

doesn’t eliminate the need to washyour hands before and after patientcontact. Use a hand sanitizer orwash your hands for 10 to 15 sec-onds with soap and running water.

InfectionHealthcare-acquired infections(HAIs) are infections that arise 48hours after admission, within 3 daysafter discharge, or within 30 daysafter surgery. The Centers for Medi -care & Medicaid Services has identi-fied conditions that can be prevent-ed by prudent and reasonable care,deeming them “never” events; it nolonger reimburses for their care.Vascular catheter-associated infec-tions and air embolism are two“never” events.

More than 80% of HAIs are asso-ciated with central lines and otherdevices. The catheter site and hubare the most important sources ofbacteria and fungi leading to

Assessing for catheter malpositionAlthough not done routinely, taking daily external measurements of a central linein a patient’s chest can help you assess for catheter malpositioning. Here’s how:• Evaluate blood return before and after you administer each dose of I.V. medica-

tion, or at least once during your shift if you don’t administer medicationsthrough the central line. If you don’t see a blood return, suspect catheter occlu-sion or malpositioning.

• Assess how much of the catheter is exposed externally. If more is exposed thanyou think should be, check to be sure. Review your facility’s policies for measur-ing external catheter length.

• Make sure the catheter is secured by sutures or a securement device.• Verify periodic X-rays to reconfirm catheter-tip location when the external

catheter length changes or when two doses of fibrinolytics fail to declot thecatheter.

Chemical phlebitis effects

This image shows redness on the right subclavian area ofthe patient’s chest. The patient had an implanted port; tub-ing leading to the port ruptured and then separated fromthe housing after injection with contrast. The nurse admin-istered a vesicant chemotherapy agent through the port,observing that it flushed well without blood return. The pa-tient said the port didn’t always give a blood return andcomplained of burning in the chest when the vesicant wasadministered. The vesicant leaked out of the tubing and in-to the subclavian vein, causing chemical phlebitis.

22 American Nurse Today Volume 8, Number 11 www.AmericanNurseToday.com

catheter colonization and resultantCLABSIs. With short-term catheters(those indwelling less than 14days), the insertion site is the majorcontamination source. Bacteria onthe patient’s skin migrate along theexternal surface of the catheter;bacterial colonization of the surfaceleads to formation of biofilm, inwhich microbes are nested in aprotective matrix of extracellularbacterial polymer.

With long-term catheters (thoseindwelling more than 14 days), themajor infection source is intraluminalcolonization. Organisms may be in-troduced if the catheter hub goes un-scrubbed, if the catheter is manipu-lated, or if poor flushing technique isused. Organisms migrate from thehub toward the catheter tip and thento the patient. Biofilm develops, withorganisms remaining nested in thebiofilm or detaching to float freely inand outside the lumen.

Signs and symptoms of infectioncan be specific or vague. Rednessor swelling may occur at the inser-tion site. Nonspecific indications in-clude fever, chills, and hypotension.

CLABSIs may warrant central-linewithdrawal. Treatment depends onthe specific organism present, extentof illness, signs and symptoms,catheter type used, duration of antici-pated need for venous access, andpresence of alternative venous access.

EmbolismAn embolism may involve thecatheter itself, fibrin, or air entry.

Catheter embolismsA catheter embolism occurs withcatheter rupture and may result fromusing too much pressure whenflushing the line. If the catheterdoesn’t flush easily, never try toforce it. Assess it for mechanical orfibrin occlusions.

Other causes include power-injecting a nonpower-injectablecentral line. (The FDA has postedguidelines on power injection andevents of catheter breakage. Visit

www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDeviceSafety/ucm070193.htm.)Other causes of catheter embolisminclude migration and catheterbreakage from internal and externalcauses. To prevent these problems,always secure the catheter ade-quately, avoid pulling or tugging on it, and follow recommendationsfor its removal when it’s no longerneeded.

Fibrin embolismsA fibrin embolism occurs when fib-rin breaks off from the catheter dur-ing flushing. Signs and symptomsdepend on where the clot travels.This type of embolism must be treat-ed immediately, but can be hard todetect due to the resources needed(such as computed tomography andangiography). The best way to pre-vent a fibrin embolism is to assessthe catheter every shift and provideproper care and maintenance.

Air embolismsAn air embolism can arise duringcatheter insertion, maintenance, orremoval. Be sure to minimize airentry during insertion by position-ing the patient and equipmentproperly. Air can enter the patientaccidentally through loose caps andnon-Luer Lock—type devices andsyringes. When caring for a centralline, make sure all air is removedfrom syringes, all syringes and de-vices are the Luer Lock type, andall caps are applied securely to thecentral line.

Air embolism also can occur dur-ing central line removal. To de-crease this risk, use techniques thatprevent air from entering the inser-tion site after catheter removal. Forremoval, position the patient flat orin a slight Trendelenburg positionto increase intrathoracic pressure.Have the patient hold the breath orbreathe out. For a patient on a ven-tilator, check the manufacturer’sguidelines on whether to removethe catheter on inspiration or expi-

ration. Many of the new ventilatorsettings provide pressure on expira-tion for catheter removal.

Applying a dressing on thecatheter insertion or exit site alsohelps prevent air embolism. Oncatheter removal, apply an occlusivedressing to seal the site; this pre-vents small amounts of air fromtracking down the insertion site tothe vessel. An occlusive dressing in-cludes an antiseptic ointment orpetrolatum gauze placed under agauze dressing. (Gauze dressings bythemselves aren’t occlusive.) Someclinicians place a transparent dress-ing atop the gauze dressing. How-ever, be aware that transparentdressings are semipermeable andbreathable—not occlusive. Finally,keep the patient flat in bed for 30minutes after catheter removal andmonitor for signs and symptoms ofembolism: shortness of breath; chestpain; cough; wheezing; skin that’scool, clammy, or bluish; rapid or ir-regular heartbeat; weak pulse; andlightheadedness or fainting. If theseoccur, turn the patient onto the leftside, call the rapid response team (ifavailable at your facility), apply oxy-gen, notify the physician, and startbasic life support if necessary.

Toward better outcomesWith the basic information in thisarticle, you can help prevent, rec-ognize, and troubleshoot central-line complications. Also be sure toconsult your facility’s policy andprocedures; all healthcare facilitiesshould use current guidelines rec-ommended by national organiza-tions, research, and evidence-basedpractice. Your expanded knowledgebase and use of evidence-basedpolicy and procedures can helpyou optimize patient outcomes. O

Visit www.AmericanNurseToday.com/Ar chives.aspx for a list of selected references and an al-gorithm for troubleshooting central lines.

Ann Earhart is a vascular and infusion clinical nursespecialist at Banner Good Samaritan Medical Centerin Phoenix, Arizona.

www.AmericanNurseToday.com November 2013 American Nurse Today 23

Please mark the correct answer online.

1. The blood return on your patient’s centralline decreases when he lies down. You find nokinks in the tubing. What’s the most likely causeof this problem?

a. Catheter ruptureb. Hematomac. Medication-precipitate occlusiond. Catheter occlusion

2. Which of the following complications is mostlikely to cause a central line to become sluggish?

a. Catheter ruptureb. Hematomac. Medication-precipitate occlusiond. Catheter occlusion

3. The site of your patient’s central line is oozingblood. What is an appropriate action to take?

a. Apply a sterile gauze dressing under atransparent dressing.

b. Apply a transparent dressing under a sterilegauze dressing.

c. Change the dressing every 12 hours.d. Change the dressing every 72 hours.

4. Which statement about catheter migration iscorrect?

a. Peripherally inserted central catheters (PICCs)are more flexible than other central cathetersand are more likely to migrate.

b. PICCs are less flexible than other centralcatheters and are less likely to migrate.

c. PICCs are more flexible than other centralcatheters and are less likely to migrate.

d. PICCs are less flexible than other centralcatheters and are more likely to migrate.

5. Your patient states she has jaw and eardiscomfort during infusions of antibiotics. Hersymptoms may indicate:

a. thrombotic occlusion.b. mechanical phlebitis.c. catheter-tip migration.d. catheter rupture.

6. A possible cause of chemical phlebitis is: a. short catheter dwell time. b. extended catheter dwell time.c. slowly infused medications.d. catheter tip in the superior vena cava.

7. Which statement about mechanical phlebitisis correct?

a. Signs and symptoms usually resolve less than24 hours after treatment begins.

b. Signs and symptoms usually resolve about 1week after treatment begins.

c. Mechanical phlebitis is treated by applicationof low-degree heat.

d. Mechanical phlebitis is treated by applicationof high-degree heat.

8. Your patient develops an infection 3 weeksafter a central line was placed. What is the mostlikely source of the infection?

a. External catheter colonizationb. Microbes in an intracellular bacterial polymerc. Insertion-site infectiond. Intraluminal colonization

9. To prevent an air embolism, what actionshould you take during removal of a central line?

a. Ask the patient to hold his or her breath.b. Ask the patient to breathe in.c. Place the patient in an upright position.d. Place the patient in a reverse Trendelenburgposition.

10. Which of the following should you do afterremoval of a patient’s central line?

a. Apply a gauze dressing and a transparentdressing.

b. Apply an antiseptic ointment or petrolatumgauze under a gauze dressing.

c. Keep the patient flat for 1 hour. d. Keep the patient flat for 15 minutes.

11. Which type of thrombotic occlusion occurs inup to 47% of patients with central lines?

a. Intraluminal thrombusb. Mural thrombusc. Fibrin sheathd. Fibrin tail

12. Which type of thrombotic occlusion occurswhen the catheter tip moves against the wall ofthe vein and fibrin adheres to the end of thecatheter?

a. Intraluminal thrombusb. Mural thrombusc. Fibrin sheathd. Fibrin tail

13. Which statement about how to assess forcatheter malposition is not correct?

a. Assess how much of the catheter is exposedexternally.

b. Evaluate blood return every 48 hours. c. Make sure the catheter is secured by suturesor a securement device.

d. Verify periodic X-rays to reconfirm catheter-tiplocation.

14. What is an appropriate treatment forprecipitate from fat or lipid products?

a. 70% ethanol I.V.b. 0.1-N hydrochloric acid I.V.c. Sodium bicarbonated. 0.5-N sodium hydroxide I.V.

15. You suspect a nonthrombotic occlusion inyour patient’s central line, but you find noproblem with the equipment. An appropriatenext step is to:

a. mix Cathflo and instill into the catheter;repeat in 1 hour.

b. assess the catheter length outside the bodyand compare it with baseline.

c. discuss removal of the catheter with thepatient’s physician.

d. obtain an order for a dye study to assessfurther.

16. What is an appropriate treatment for athrombotic occlusion?

a. Sodium bicarbonateb. 70% ethanolc. Alteplase d. Corticosteroid

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PURPOSE/GOAL

To provide nurses with information on complications of centrallines, including their causes, management, and prevention.

LEARNING OBJECTIVES

1. Describe at least five complications associated with centrallines, along with their causes.2. Discuss management of central-line complications.3. Explain how to troubleshoot central-line patency problems.

CNE: 1.6 contact hours

CNE

Central-line problems: Troubleshooting flowchart

© Ann Earhart, RN, ACNS-BC, CRNI. 2012.

Signs of occlusion:Sluggish or no blood return,

difficulty flushing

Nonthromboticocclusion suspected

Assess equipment:• Check catheter and tubing for kink-

ing and closed clamps.• Ensure I.V. pump is working prop-

erly.• Check sutures for tightness.• Verify needle placement for im-

planted ports.

Problemsolved

Problem not solved:Continue assessment

Assess patient:• Have patient raise and lower arms,

sit up and lie down, take a deepbreath, and cough.

• Look for edema, erythema, pain, ordilated vessels.

• Assess amount of catheter outsidebody compared with baseline.

Problemsolved

Administer alteplase as ordered:• Mix 2.2 mL sterile water into 2 mg

Cathflo®. Instill into each lumenwithout a blood return. Each lumenreceives the entire 2-mg dose.

• Check for blood return after 2hours.

Rule out precipitates or lipidresidue:• Check for potential drug-drug or

drug-solution incompatibilities.Assess for thrombotic occlusion:• Determine adequacy of withdrawal

and infusion.• Assess for partial or total occlusion.

Catheter tip central:Continue assessment

Check last X-ray fortip placement

Problemsolved

Problem not solved:• Administer 2nd dose of Cathflo®

2 mg.• Check blood return after 2 hours.

Problem not solved:Discuss catheter recommendationswith physician:• Repeat X-ray if more than 24 hours

since last chest X-ray.• Prepare patient for dye study to

evaluate catheter function.• Remove catheter.• Replace catheter.

Catheter tip not central:Stop infusion. Consult physicianon whether to use currentcatheter or remove or replace it.

No X-ray: Consult physician.Consider X-ray to determine tipplacement before proceeding.

Use this algorithm to guide assessment and management of central-line occlusions.