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Chapter 39

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 ...

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