Delayed events

Air embolism

The need to insert percutaneous central venous catheters with the patient in a 20° to 30° head-down Trendelenburg tilt to prevent this problem is well established, yet episodes continue to be reported because this principal has been ignored. It is vital to remember that accidental disconnection or any defect in the infusion system will create a 'cardio-atmospheric fistula' and air can and will enter rapidly causing cardiovascular collapse, hemiplegia, coma, or death.

Bacterial colonization

Venous access systems can only be kept sterile if a meticulous insertion technique is followed by disciplined maintenance from the nursing staff. Hopefully, in the future, the use of stopcocks or valve side-ports will steadily be eliminated since these increase the risk of bacterial contamination. The role of bacterial adherence to catheter hub plastics and subsequent colonization of the devices is under constant investigation. Recently, the development of antibiotic-impregnated silicone central venous catheters has been achieved and introduced into clinical practice with favorable early results ( Raad.etal 199.7). Care must be taken to exclude patients with known hypersensitivity to the antibiotic. The value of a specialist nurse or team to care for venous access systems has been emphasized and fully reviewed.

If catheter-related sepsis is suspected, early involvement of the microbiology team is mandatory. The appropriate specimens and swabs should be taken; any tunnel track should be examined, and serum expressed and sent for culture. Samples from the infusate, tubing, and bag should be cultured. Recently, the value of using a new endoluminal brush method for in situ diagnosis of catheter-related sepsis has been shown to be of great clinical value ( Kite etal: 1997). Auscultation of the heart for new murmurs should be performed and the fundi examined for evidence of endophthalmitis or emboli. An echocardiogram should also be performed to exclude valvular vegetations. A comprehensive review of complications associated with intravenous access devices has been published ( Whitman 1996).

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