Air embolism is a relatively rare, life-threatening, and sometimes underappreciated complication associated with infusion therapy. Conditions that can result in an air embolism include the following:
* crack in the central venous access device (CVAD);
* disconnection between catheter connections, that is, between the catheter and intravenous (IV) administration set or between the injection/access cap and an unclamped CVAD;
* presence of a persistent catheter tract following CVAD removal;
* deep inspiration during CVAD insertion or removal; and
* inadvertent infusion of air in the IV administration set.
Prevention of air embolism is addressed within several of the INS Standards. The infusion nurse's knowledge and clinical expertise are vital to implementing appropriate nursing actions and carrying out clinical procedures. Standard 5: Clinical Competencies for infusion nurses includes the following in relation to reducing the risk of infusion-related complications:
* use of techniques to prevent catheter-related complications including, but not limited to, infection, phlebitis, occlusion, infiltration, and extravasation;
* initiation of appropriate actions in the event of adverse reactions and complications;
* provision of infusion therapy-related education that is culturally suitable and age-appropriate to peers, patients, and caregivers;
* monitoring for complications and adverse reactions to infusion therapy.1
Catheter removal is an important risk factor for air embolism, and the procedure must be undertaken carefully. The Practice Criteria under Standard 49: Catheter Removal state:
Caution should be used in the removal of a [peripherally inserted central catheter] PICC (or a nontunneled central catheter), including precautions to prevent air embolism. Digital pressure should be applied until hemostasis is achieved, then antiseptic ointment and a sterile occlusive dressing should be applied to the access site. If resistance is encountered when the catheter is being removed, the catheter should not be forcibly removed and the physician should be notified.1
The same statement is made for removal of tunneled catheters or implanted ports. However, the Standards specify:
Removal of a tunneled catheter or implanted port shall be considered a surgical procedure, or shall be performed by an advanced practice nurse with validated competency in accordance with the state's Nurse Practice Act, rules and regulations promulgated by the state's Board of Nursing, organizational policies and procedures, and practice guidelines.1
In a review of existing literature, including the INS Standards and case study reports, Peter and Saxman2 identified the best practices for preventing air embolism during the CVAD removal procedure, as follows:
* Position the patient in a supine position.
* Instruct the patient in Valsalva maneuver during the catheter removal process; if a Valsalva maneuver is contraindicated, have the patient exhale during the procedure.
* Slowly remove catheter and place immediate pressure to the exit site until hemostasis is achieved. The INS Policy and Procedure for catheter removal recommends a minimum of 30 seconds of pressure to the site.3
* Instruct the patient to perform Valsalva maneuver again and apply antiseptic ointment, a gauze dressing, and tape to the site.1,3
* Have the patient remain in the supine position for 30 minutes after catheter removal.3
* Leave dressing in place for 24 hours. Change dressing every 24 hours until exit site is healed.3
Additional practices to reduce the risk of air embolism include the following:
* Reducing the risk of infusion system disconnections;
* INS Standard 29: Add-on Devices and Junction Securement states, "All add-on devices shall be of Luer-Lok(TM) design"1;
* Frequent checking of administration set junctions, making sure that they are secure, especially before patients get out of bed;
* Ensuring that the catheter is clamped during IV administration and injection access/cap changes;
* Never using scissors near the venous access device, as this could result in accidental severing of the catheter. This is very important information to teach homecare patients as well. During my 20-some years as a home infusion nurse, there have been several incidents of severed catheters. INS Standard 24: Scissors states the following:
* 24.1 The use of scissors in the presence of vascular and nonvascular access devices shall be limited to suture removal.
* 24.2 Scissors shall not be used to remove vascular and nonvascular access device dressings, tape, or stabilization devices.1
Patient education is also critical in reducing the risk of air embolism, especially with home infusion patients. Laskey et al4 reported a case of air embolism in a pediatric patient when the mother inadvertently let an unprimed IV administration set flow by gravity into the patient, resulting in immediate respiratory and neurologic symptoms (the patient survived). INS Standard 11: Patient Education includes the following: "The nurse shall educate the patient, caregiver, or legally authorized representative relative to the prescribed infusion therapy and plan of care including, but not limited to, potential complications associated with treatment or therapy, and risks and benefits."1 It is important to teach patients or caregivers to properly prime tubing, to check connections frequently, to clamp the CVAD at appropriate times, and to avoid the use of sharp objects (such as scissors) near the catheter. In addition, should a crack, hole, or leaking in the catheter occur, clamps should be available to home infusion therapy patients and they should be taught how to immediately clamp the catheter close to the skin, above the damaged area of the catheter and to report the situation to the homecare provider immediately. Teaching about signs of potential complications and actions to take should be periodically reviewed with the patient and written information provided, as appropriate.
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