Risks and Complications with Catheters and Catheter Removal (Nursing)

by Corey Hardin, BSN, RN, CCRN-CMC, CV-BC

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    00:01 Now we're going to be discussing pulmonary artery catheter risks and complications.

    00:06 I put these into three different groups for you.

    00:08 The first group is complications with assessing a central vein.

    00:13 You can have bleeding, a hematoma, arterial puncture, infection, pneumothorax, or hemothorax.

    00:21 Anytime we access a large vein, we can always have the risk of bleeding or hematoma.

    00:26 But how do we get arterial puncture? Well, remember, the artery and the vein run really close to each other, and sometimes they run on top of each other.

    00:34 So it does happen that we puncture the artery rather than the vein.

    00:39 Infection is a big risk for these patients.

    00:43 So make sure we take all precautions to reduce a central line infection.

    00:49 And then pneumothorax or hemothorax.

    00:51 So we're putting in a line but how do we affect the lungs? Well, sometimes we go into the subclavian vein, if we go a little bit lower into the pleural space by accident, then we can puncture that long and cause a pneumothorax and possible hemothorax.

    01:07 The second group I have is arrhythmias, you can cause atrial tachyarrhythmias, ventricular tachyarrhythmias, a right bundle branch block or a complete heart block.

    01:17 Though in my practice, I've never caused a right bundle branch block or complete heart block by a pulmonary artery catheter.

    01:23 I have caused patients to go into ventricular tachycardia.

    01:26 That's because the tip of the catheter when it goes into the right ventricle, irritates the wall and causes the patient to go into a ventricular tachycardia.

    01:36 You may see premature ventricular contractions happen.

    01:41 And that's okay, that just let you know you're in the right ventricle.

    01:44 You want to make sure that you start going into the pulmonary artery soon, don't let it sit there because you can cause a patient to have the attack.

    01:53 The third group we have are catheter-induced injuries.

    01:56 Those are myocardial perforations, valvular injuries, pulmonary rupture or infarction, thrombosis, or an embolism or even an air embolism.

    02:06 Now, how do we get myocardial perforation? Well, sometimes that right ventricle wall is called friable.

    02:12 After a heart attack, the tissue becomes really friable, which kind of looks like cook roast beef, and which you can shred it pretty easily.

    02:20 So if that tip of that catheter hits that wall hard enough, it can actually go through it and that's a medical emergency, we need to take that patient immediately to surgery to repair that.

    02:30 Valvular injuries happen, remember, when the balloon is inflated, and we try to take out the pulmonary artery catheter, we can actually involute the leaflets of the valves and cause them to rupture.

    02:40 Pulmonary rupture infarction happens when we inflate the balloon, which is in the pulmonary artery.

    02:46 If it's in a smaller branch, it can actually rupture that artery and cause serious risks and complications to the patient even death.

    02:53 So we want to be careful whether inflating that balloon.

    02:56 And then thrombosis and embolism can happen when a foreign object or when air goes through that pulmonary artery catheter into the lungs.

    03:04 So it acts like it's a pulmonary embolism just like a blood clot.

    03:08 So we need to be super cautious with what we're putting into this pulmonary artery catheter.

    03:14 Make sure there's no air in it, make sure we have no foreign objects, it's just saline.

    03:21 There's a rare complication which is thrombocytopenia which is caused because some of these pulmonary artery catheters are heparin-coated.

    03:28 So these patients who have a history of heparin-induced thrombocytopenia that can occur again with these, so we may need to make sure that they have no history of heparin-induced thrombocytopenia, or that the pulmonary artery catheter that you're using is not heparin-coated.

    03:43 Now let's discuss some potential errors that you can encounter with a pulmonary artery catheter.

    03:48 The first error is inaccurate measurements.

    03:51 This could be the numbers that you're seeing on the monitor are not accurate.

    03:55 This could be because the transducer is not in line with the phlebostatic axis or there could be bubbles in the pressure tubing causing it to have a dampened waveform.

    04:04 Why is this an error? Because when you're reading those, you think that those might be accurate, and you're titrating medications that offer those inaccurate measurements, so you're mismanaging the client.

    04:16 Our next potential error that we could have is misinterpretation of the data.

    04:20 The numbers that you're seeing are correct, but we're not understanding what they are telling us or what they mean.

    04:26 So this could also be mismanagement of the client.

    04:30 Next, let's talk about some cues that you can recognize that may indicate we're having a complication.

    04:35 The first one involves your waveform.

    04:38 When you look at your PA waveform and it doesn't look like a PA waveform, it actually looks like an RV waveform, right ventricular waveform.

    04:46 Remember that waveform has the same systolic but the diastolic is really low and it really doesn't have a dicrotic notch.

    04:53 If you see that, what has happened as that PA catheter has gotten pulled out so the tip of it is now in the right ventricle, or when it was placed, it was right past a pulmonic valve and it has actually migrated back or slipped back into the right ventricle.

    05:09 This can cause PVCs, which would be another indication that it's in the right ventricle.

    05:14 If this happens, we need to contact a physician so they can float it further into the pulmonary artery and into the correct position.

    05:22 Our next cue is the PA waveform looks like it's stuck in wedge.

    05:26 So we look up and it looks like that wedge waveform, or even that CVP waveform, make sure your CVP and your PA is not switched on the monitor.

    05:35 And if that's not it, then you're stuck in wedge.

    05:37 This is actually an emergency because you're blocking blood flow going into the left side of the lungs.

    05:44 So what happens with that is the line get migrates further into the lungs.

    05:48 When we first place a pulmonary artery catheter, you'll have slack in that right ventricle.

    05:54 So really, the physician should pull it back 2-3 cm to reduce that slack so that it doesn't migrate farther into the pulmonary artery and cause a stuck in wedge waveform.

    06:06 If this happened, we have to immediately contact a physician for them to pull it back just a little bit so we get a PA waveform.

    06:14 Because remember, you're blocking blood flow so you may cause pulmonary infarction which is a serious condition for the patient.

    06:21 The last one is PA catheter does not wedge.

    06:24 So we inflate the balloon and we don't get a wedge waveform.

    06:27 This isn't an emergency.

    06:29 This just means that the catheter needs to be positioned correctly to get that wedge waveform.

    06:34 So if the physician just needs to come in and float it a little bit further until we do achieve a wedge waveform so we can get a pulmonary artery wedge pressure.

    06:44 The last issue that we may have with our waveforms is called an overwedged waveform, an overwedged waveform.

    06:52 This is where the PA catheter is too far distal in a very free very small branch of the pulmonary artery, and we inflate the balloon to the full 1 1/2 mLs.

    07:03 What happens is basically that puts so much pressure on that pulmonary artery that it actually bends the balloon around the tip of the catheter blocking the PA port.

    07:13 So then you just see 300 mm Hg which is from the pressure bag.

    07:19 What you'll see on the on the screen is that instead of it dropping down into a wedge waveform, you'll see it take off on the screen all the way up to 300.

    07:28 Kind of like if we were turning the stopcock off to the patient.

    07:31 This is also an emergency because if we leave it like this, we can call it pulmonary infarction or pulmonary rupture.

    07:39 All that needs to happen is to make sure that we pulled the air back and that we pull the PA catheter to a more proximal position in that pulmonary artery.

    07:48 So it's a bigger artery that rather than a really, really small branch of the artery.

    About the Lecture

    The lecture Risks and Complications with Catheters and Catheter Removal (Nursing) by Corey Hardin, BSN, RN, CCRN-CMC, CV-BC is from the course Hemodynamic Monitoring (Nursing).

    Included Quiz Questions

    1. “As veins and arteries can run close together or on top of each other, there is a risk of puncturing an artery when accessing a vein.”
    2. “Central venous access is preferable over peripheral venous access, as there is rarely bleeding with central venous access.”
    3. “Central venous access puts the client at risk for pneumothorax, but not hemothorax.”
    4. “Central venous access rarely results in infection, as the insertion sites are away from the client’s hands.”
    1. Myocardial perforation
    2. Pulmonary rupture
    3. Valvular injury
    4. Cardiomyopathy
    1. Ventricular tachyarrhythmia
    2. Right bundle branch block
    3. Complete heart block
    4. Atrial tachyarrhythmia
    5. Atrial fibrillation
    1. Thrombocytopenia
    2. Air embolism
    3. Pulmonary infarction
    4. Myocardial perforation

    Author of lecture Risks and Complications with Catheters and Catheter Removal (Nursing)

     Corey Hardin, BSN, RN, CCRN-CMC, CV-BC

    Corey Hardin, BSN, RN, CCRN-CMC, CV-BC

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