CRNI Managing Infusion Complications 2 — Questions and Answers

Question 1: A patient with a central venous catheter suddenly develops unilateral facial and arm swelling. What complication should the nurse suspect?

Allergic reaction to the catheter material
Superior vena cava syndrome from catheter-related thrombosis (Correct answer)
Pneumothorax
Catheter migration

Correct answer: Superior vena cava syndrome from catheter-related thrombosis

Unilateral facial and arm swelling suggests catheter-related deep vein thrombosis with obstruction of venous return, potentially progressing to SVC syndrome.

Catheter-related upper extremity deep vein thrombosis can obstruct venous return, causing unilateral swelling of the face, neck, and arm on the affected side. If the thrombus extends or the SVC is compromised, it can progress to SVC syndrome with bilateral facial swelling, distended neck and chest wall veins, dyspnea, and headache worse when bending forward. This is a medical emergency. The CRNI should immediately notify the provider, position the patient with the head of bed elevated, and anticipate diagnostic imaging (CT venography or duplex ultrasound). Treatment includes anticoagulation and potentially thrombolytic therapy. Catheter removal is considered based on clinical stability and ongoing need.

Question 2: What is the FIRST action when infiltration of a non-vesicant solution is suspected?

Apply a warm compress to the area
Stop the infusion and disconnect the IV tubing (Correct answer)
Aspirate residual fluid from the catheter
Elevate the extremity and continue monitoring

Correct answer: Stop the infusion and disconnect the IV tubing

The first priority is to stop the infusion to prevent further fluid accumulation in the surrounding tissue, then disconnect and assess the site.

When infiltration of a non-vesicant solution is suspected, the immediate action is to stop the infusion and disconnect the IV tubing from the catheter. This prevents further fluid accumulation in the interstitial tissue. Assessment should include: estimating the volume infiltrated, measuring the circumference compared to the opposite extremity, grading the infiltration (INS Infiltration Scale I-IV), and noting skin temperature, color, and the patient's pain level. For non-vesicant infiltration, treatment includes elevating the affected extremity and applying warm or cold compresses depending on the solution. A new IV must be started in a different extremity. Thorough documentation is essential.

Question 3: Which sign differentiates mechanical phlebitis from chemical phlebitis?

Mechanical phlebitis presents with fever
Mechanical phlebitis typically occurs within 24-48 hours of insertion and relates to catheter size and movement (Correct answer)
Chemical phlebitis shows purulent drainage
There is no clinical difference between them

Correct answer: Mechanical phlebitis typically occurs within 24-48 hours of insertion and relates to catheter size and movement

Mechanical phlebitis develops early (24-48 hours) from physical irritation of the vein by the catheter, while chemical phlebitis relates to the pH, osmolality, or composition of the infusate.

Mechanical phlebitis results from physical trauma to the vein intima by the catheter itself - caused by catheter gauge too large for the vein, catheter movement (inadequate stabilization), or insertion technique. It typically appears within 24-48 hours of catheter placement. Chemical phlebitis results from irritation by the infusate and relates to solution pH (less than 5 or greater than 9), high osmolality, or specific drug properties. It may appear hours to days after starting the offending infusion. Both present with erythema, pain, warmth, and a palpable venous cord along the vein, but understanding the cause directs the intervention: catheter stabilization or replacement for mechanical, and route/solution modification for chemical phlebitis.

Question 4: A patient with a PICC line reports inability to flush the catheter. After repositioning the arm, flushing is successful. What is the likely cause?

Complete catheter occlusion
Positional occlusion from catheter tip against the vessel wall (Correct answer)
Catheter fracture
Fibrin sheath formation

Correct answer: Positional occlusion from catheter tip against the vessel wall

Positional occlusion occurs when the catheter tip rests against the vessel wall, blocking flow in certain positions but resolving with repositioning.

Positional occlusion (also called withdrawal occlusion or persistent withdrawal occlusion) occurs when the catheter tip abuts the vessel wall, creating a ball-valve effect that impedes flow in certain positions. It resolves with patient repositioning (arm abduction, deep breath, position change). While not immediately dangerous, it indicates the catheter tip may be malpositioned - potentially in a smaller vessel, too far into the right atrium, or resting against the SVC wall. The CRNI should: document the positional nature, report to the provider, anticipate a chest X-ray to verify tip position, and differentiate from thrombotic occlusion (which does not resolve with repositioning) or fibrin sheath (which allows infusion but prevents aspiration).

Question 5: What is the appropriate intervention for a suspected air embolism during central line tubing change?

Elevate the head of bed and administer oxygen
Place the patient in left lateral Trendelenburg position and administer 100% oxygen (Correct answer)
Position the patient supine and call a code
Have the patient perform Valsalva maneuver and continue the tubing change

Correct answer: Place the patient in left lateral Trendelenburg position and administer 100% oxygen

Left lateral Trendelenburg position traps air in the right atrium apex, preventing it from entering the pulmonary vasculature, while 100% oxygen helps absorb the air.

Air embolism during central line manipulation is a life-threatening emergency. The left lateral Trendelenburg (Durant's maneuver) position places the right atrium as the highest point in the heart, trapping the air bubble in the right atrial apex and preventing it from entering the pulmonary vasculature where it could cause cardiovascular collapse. Immediate actions include: clamp the catheter, place the patient in left lateral Trendelenburg, administer 100% oxygen (nitrogen washout helps absorb the air bubble), and call for emergency assistance. Prevention during tubing changes includes: having the patient perform Valsalva or timing the change during expiration, using Luer-lock connections, and priming all tubing completely before connection.

Question 6: A patient receiving total parenteral nutrition through a CVC develops sudden fever, tachycardia, and hypotension. Blood glucose is 45 mg/dL. What complication should be suspected?

Refeeding syndrome
Catheter-related bloodstream infection with hypoglycemia from sepsis (Correct answer)
Simple hypoglycemia from insulin excess
TPN fluid overload

Correct answer: Catheter-related bloodstream infection with hypoglycemia from sepsis

Sudden fever, tachycardia, and hypotension during TPN administration suggest CRBSI, with hypoglycemia resulting from sepsis-induced glucose consumption and possible TPN interruption.

This presentation suggests CRBSI in a patient receiving TPN. The high dextrose content of TPN creates an ideal growth medium for bacteria and fungi (particularly Candida species). Sepsis causes increased glucose utilization by inflammatory cells and tissues, potentially leading to hypoglycemia - especially if TPN flow was disrupted or discontinued. The CRNI should: stop the TPN infusion through the suspected line, maintain IV access with dextrose-containing fluid (to prevent rebound hypoglycemia), obtain paired blood cultures (peripheral and catheter), initiate continuous glucose monitoring, administer IV dextrose for hypoglycemia, and anticipate broad-spectrum antibiotic and antifungal therapy. The TPN catheter lumen may need to be replaced.

CRNI Managing Infusion Complications 2

A patient with a central venous catheter suddenly develops unilateral facial and arm swelling.
What complication should the nurse suspect?