Implanted venous access devices are essential for the long-term
care of many chronically ill patients. These patients may have poor
peripheral venous access due to the many venipunctures they have
previously suffered. When a patient’s long-term venous
access device cannot be easily aspirated or flushed, the Emergency
Physician must act quickly and intelligently to diagnose and correct
the malfunction without further damaging the device.
Indwelling central venous catheters allow access to the central
venous circulation from a peripheral site. This access to the central
circulation is via the end of a partially implanted catheter that protrudes
from the body or through the skin into a subcutaneous reservoir
of a fully implanted catheter.1,2 The proximal tip of the
central venous line may reside in either the superior vena cava
or in the right atrium.
Indwelling central venous access devices may malfunction for
a variety of reasons. The catheter tip may be lodged against the
wall of the blood vessel. The catheter may become obstructed by
an intraluminal or external clot. The catheter tubing may be obstructed
mechanically or by precipitated medications. Phenytoin and diazepam
cannot be given through silicone indwelling lines as they can crystallize
and permanently obstruct the catheter lumen.3 Calcium and
phosphate can form an insoluble precipitate within the catheter
lumen. Infused lipids can form waxy casts within the catheter lumen.
Any catheter that cannot be easily flushed or aspirated must
be investigated further. If peripheral venous access is readily
available, and the patient is not acutely ill due to catheter sepsis
or central venous thrombosis, catheter troubleshooting can be deferred
to the Primary Care Provider. The Emergency Physician will have
to correct the problem, if possible, if emergent or urgent access
to the device is needed.
Any device that is obviously displaced from the central circulation
is not salvageable and should not be used. Dislodging a clot or
septic thrombus from a catheter tip can lead to a fatal pulmonary embolism.
Catheter manipulation should be avoided if signs of sepsis or central
venous thrombosis are present.4 Unfortunately, such a diagnosis
is often possible only in retrospect. The use of indwelling dialysis
lines for other purposes is discouraged. Manipulation of a dialysis
line should only be undertaken in a true emergency or if the line
is malfunctioning and is needed for hemodialysis.
- Povidone iodine solution
- Sterile alcohol prep pads
- Thrombolytic agent
- Syringes, 5 mL and 10 mL
- 18 gauge needles
- Noncoring (Huber) needle
- 70% ethanol solution
- 0.1 N hydrochloric acid (HCl) solution
- Sterile saline
- Heparinized saline flush solution (100 U/mL)
- Sterile gauze squares
- Sterile gloves
The use of a specific thrombolytic agent is institution- and
physician-specific. Streptokinase, recombinant tissue plasminogen
activator (t-PA), and urokinase have all been successfully used
to dissolve a clot within a central venous catheter.3,5–9 Urokinase
and recombinant tissue plasminogen activator are most commonly used.
Streptokinase is ...