INSERTION-RELATED COMPLICATIONS

Bleeding/Hemorrhage
(continued)

Prevention/Management Several steps may be taken to prevent excessive bleeding. Avoid trauma to the vein by inserting the introducer gently but firmly. Be cautious during the skin nick to avoid nicking the vessel; also, do not perform a larger than necessary skin nick.

If excessive bleeding is an issue, verify the bleeding is not a result of arterial puncture. Apply manual pressure to insertion site. Reinforce dressing (a heavy pressure dressing should be used for the first 24 hours). If necessary, a hemostatic dressing may be used (11).


Inability to Advance Introducer/Dilator Sheath

The inability to advance the introducer may occur if the skin nick is too small, the vein is deep, there is poor skin turgor or there is a perforation on the back wall of the vein. Difficulty advancing the sheath may be because the guidewire is not properly located and the sheath is about to perforate a major intrathoracic vein. If difficulty is encountered recheck position by removing the wire and reconfirming blood flow. Patients who have previously had CVCs inserted may have scar tissue that may make threading a dilator difficult.

Symptoms include:

• Sheath is difficult to advance
• Sheath/dilator kinks upon attempted advancement
• Patient reports pain when the sheath is introduced

Prevention/Management
Avoid this complication by performing a skin nick if necessary. Maintain firm and steady pressure with a twisting motion in the same angle and course as the spring-wire. If difficulty advancing occurs, consider removing the sheath and wire simultaneously as the wire may have bent back on itself and check that the outer introducer sheath remains smooth (11).