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.
Air Embolism and Other Rare Complications
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.
Further Reading
1 1 Campbell, P.M. (1996). Troubleshooting central venous catheters in the emergency department. J. Emerg. Nurs. 22 (5): 416–419; quiz 419‐421.
2 2 Carde, P., Cosset‐Delaigue, M.F., Laplanche, A., and Chareau, I. (1989). Classical external indwelling central venous catheter versus totally implanted venous access systems for chemotherapy administration: a randomized trial in 100 patients with solid tumors. Eur. J. Cancer Clin. Oncol. 25 (6): 939–944.
3 3 Castagnola, E., Molinari, A.C., Giacchino, M. et al. (2007). Incidence of catheter‐related infections within 30 days from insertion of Hickman‐Broviac catheters. Pediatr. Blood Cancer 48 (1): 35–38.
4 4 Cesaro, S., Corro, R., Pelosin, A. et al. (2004). A prospective survey on incidence and outcome of Broviac/Hickman catheter‐related complications in pediatric patients affected by hematological and oncological diseases. Ann. Hematol. 83 (3): 183–188.
5 5 Chopra, V., Fallouh, N., McGuirk, H. et al. (2015). Patterns, risk factors and treatment associated with PICC‐DVT in hospitalized adults: a nested case–control study. Thromb. Res. 135 (5): 829–834.
6 6 Chopra, V., Ratz, D., Kuhn, L. et al. (2014). PICC‐associated bloodstream infections: prevalence, patterns, and predictors. Am. J. Med. 127 (4): 319–328.
7 7 Chow, L.M., Friedman, J.N., Macarthur, C. et al. (2003). Peripherally inserted central catheter (PICC) fracture and embolization in the pediatric population. J. Pediatr. 142 (2): 141–144.
8 8 Christianson, D. (1994). Caring for a patient who has an implanted venous port. Am. J. Nurs. 94 (11): 40–44.
9 9 Coles, C.E., Whitear, W.P., and Le Vay, J.H. (1998). Spontaneous fracture and embolization of a central venous catheter: prevention and early detection. Clin. Oncol. (R. Coll. Radiol.) 10 (6): 412–414.
10 10 Debets, J.M., Wils, J.A., and Schlangen, J.T. (1995). A rare complication of implanted central‐venous access devices: catheter fracture and embolization. Support. Care Cancer 3 (6): 432–434.
11 11 Duggan, C. (1995). Central venous catheters in the emergency department: access, utilization, and problem solving. Pediatr. Emerg. Care 11 (5): 322.
12 12 Dyer, B.J., Weiman, M.G., and Ludwig, S. (1995). Central venous catheters in the emergency department: access, utilization, and problem solving. Pediatr. Emerg. Care 11 (2): 112–117.
13 13 Greene, M.T., Flanders, S.A., Woller, S.C. et al. (2015). The association between PICC use and venous thromboembolism in upper and lower extremities. Am. J. Med. 128 (9): 986–993.e1.
14 14 Hendrickson, M.L. (1993). How to access an implanted port. Nursing 23 (1): 50–53.
15 15 Hogan, M.J., Coley, B.D., Shiels, W.E. 2nd et al. (1998). Recurrent deep venous thrombosis complicating PICC line placement in two patients with cystic fibrosis and activated protein C‐resistance. Pediatr. Radiol. 28 (7): 552–553.
16 16 Johansson, E., Hammarskjold, F., Lundberg, D., and Arnlind, M.H. (2013). Advantages and disadvantages of peripherally inserted central venous catheters (PICC) compared to other central venous lines: a systematic review of the literature. Acta Oncol. 52 (5): 886–892.
17 17 Kao, C.L. and Chang, J.P. (2002). Catheter fracture and embolization from an implanted venous access device. J. Emerg. Med. 22 (1): 95–96.
18 18 Larouere, E. (1999). Deaccessing an implanted port. Nursing 29 (6): 60–61.
19 19 Larouere, E. (1999). The art of accessing an implanted port. Nursing 29 (5): 56–58.
20 20 Wesley, J.R. (1992). Permanent central venous access devices. Semin. Pediatr. Surg. 1 (3): 188–201.
21 21 Yi, X.L., Chen, J., Li, J. et al. (2014). Risk factors associated with PICC‐related upper extremity venous thrombosis in cancer patients. J. Clin. Nurs. 23 (5–6): 837–843.
22 22 Yukisawa, S., Fujiwara, Y., Yamamoto, Y. et al. (2010). Upper‐extremity deep vein thrombosis related to central venous port systems implanted in cancer patients. Br. J. Radiol. 83 (994): 850–853.
23 23 Zochios, V., Umar, I., Simpson, N., and Jones, N. (2014). Peripherally inserted central catheter (PICC)‐related thrombosis in critically ill patients. J. Vasc. Access 15 (5): 329–337.
6 Vascular Access for Hemodialysis
Sarah Fesnak1,2, Xenia Morgan3, and Kimberly Windt3
1 Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
2 Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
3 Hemodialysis Unit, Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
Introduction
Hemodialysis is a procedure to regulate fluid status and remove waste products and/or toxic substances from a patient's blood. Vascular access allows a patient's blood to be circulated extracorporeally through a dialysis machine, where it filters past a semipermeable membrane in contact with a washing solution (diasylate). Fluid and solutes are removed via diffusion, osmosis, and convection. Hemodialysis is one of three forms of renal replacement therapy (the others are peritoneal dialysis and renal transplant) available to patients with advanced renal failure. Patients may require hemodialysis on