CPHON Central Line Care and Vascular Access 1 — Questions and Answers
Question 1: A child with a newly placed PICC line develops erythema, warmth, and tenderness along the arm vein pathway 48 hours after insertion. The nurse suspects:
- Phlebitis or thrombophlebitis of the accessed vein (Correct answer)
- Line-associated bloodstream infection (CLABSI)
- Air embolism
- Pneumothorax
Correct answer: Phlebitis or thrombophlebitis of the accessed vein
Erythema, warmth, and tenderness tracking along the vein indicate phlebitis or thrombophlebitis — inflammation of the vein wall, a known complication of peripherally inserted central catheters.
Phlebitis following PICC insertion occurs when the catheter causes irritation or trauma to the vein intima. Symptoms include erythema, pain, warmth, and swelling along the vein track. Mild phlebitis may be managed conservatively with warm compresses and anti-inflammatory medications; severe or progressive cases may require PICC removal. It is important to distinguish phlebitis from CLABSI — phlebitis does not typically cause systemic signs of infection (fever, elevated WBC) unless superinfected. The nurse should assess the site using a validated phlebitis scale and document findings.
Question 2: What is the first priority action when a nurse suspects a central line-associated bloodstream infection (CLABSI) in a pediatric oncology patient?
- Obtain blood cultures from the central line and a peripheral site before administering antibiotics (Correct answer)
- Remove the central line immediately
- Start empiric antibiotics immediately without cultures
- Apply topical antiseptic to the exit site
Correct answer: Obtain blood cultures from the central line and a peripheral site before administering antibiotics
Blood cultures must be drawn from both the central line and a peripheral site before antibiotics are administered to identify the organism, differentiate CLABSI from local infection, and optimize treatment.
When CLABSI is suspected, the nurse should immediately notify the provider and obtain paired blood cultures — simultaneously drawing one set from each lumen of the central line and one set from a peripheral venipuncture site. This pairing allows for differential time-to-positivity (DTP) analysis: if the central line culture turns positive ≥2 hours before the peripheral culture, this is diagnostic of CLABSI. Antibiotics should be started promptly after cultures are drawn, not before. Common organisms include coagulase-negative Staphylococcus, Staphylococcus aureus, gram-negative bacilli, and Candida species in immunocompromised patients.
Question 3: When flushing a Broviac/Hickman central venous catheter, which technique is most important for preventing catheter occlusion?
- Use a pulsatile (push-pause) technique with 10 mL normal saline and positive pressure clamping (Correct answer)
- Continuously inject at a constant slow rate
- Flush with heparinized saline using gravity flow only
- Use a 1 mL syringe to create maximum pressure
Correct answer: Use a pulsatile (push-pause) technique with 10 mL normal saline and positive pressure clamping
The pulsatile push-pause flushing technique creates turbulent flow inside the catheter lumen, dislodging fibrin deposits that can cause occlusion. Clamping during positive pressure prevents backflow of blood into the lumen.
The pulsatile (push-pause) flushing technique involves injecting the flush solution in a series of short, rapid pushes rather than a continuous slow injection. This creates turbulent, spiraling flow within the catheter lumen that physically dislodges protein deposits and fibrin that can adhere to the catheter wall and cause partial or complete occlusion. At least 10 mL of normal saline should be used (never <5 mL). Clamping the catheter during the last increment of the positive pressure flush (or using a positive-displacement connector) prevents blood backflow into the lumen at the tip, which is a major cause of thrombus formation and occlusion.
Question 4: A Mediport (implanted venous access port) is accessed with a non-coring Huber needle. When removing the Huber needle after completing an infusion, which step is essential?
- Maintain positive pressure on the syringe plunger while withdrawing the needle to prevent blood backflow into the port chamber (Correct answer)
- Clamp the extension tubing immediately before needle removal
- Flush with sterile water instead of normal saline for the final flush
- Leave the needle in place for 24 hours after access to minimize skin trauma
Correct answer: Maintain positive pressure on the syringe plunger while withdrawing the needle to prevent blood backflow into the port chamber
When de-accessing an implanted port, maintaining positive pressure (by keeping the plunger pressed forward) while withdrawing the Huber needle prevents blood from being aspirated back into the port septum and reservoir, which can cause clot formation.
When removing a Huber needle from an implanted port, the final flush (usually heparinized saline, 100 units/mL, 3–5 mL) is performed while simultaneously withdrawing the needle from the septum with positive pressure on the syringe plunger. This positive pressure prevents the elastic septum from drawing blood back into the port reservoir as the needle is withdrawn — a vacuum effect that could cause clot formation within the port and lead to inability to aspirate or infuse. After removing the needle, apply gentle pressure to the site until hemostasis is achieved.
Question 5: A nurse attempts to flush a tunneled central line and encounters resistance. The patient reports no discomfort and the line flushes partially but aspirates poorly. This presentation is most consistent with:
- Fibrin sheath or tip occlusion requiring alteplase (tPA) instillation (Correct answer)
- Line migration into the jugular vein
- Catheter rupture requiring emergency removal
- Air lock requiring vigorous flushing
Correct answer: Fibrin sheath or tip occlusion requiring alteplase (tPA) instillation
Partial resistance to flush with poor aspiration suggests a fibrin sheath or fibrin flap around the catheter tip — a common cause of 'withdrawal occlusion' that responds to alteplase instillation to dissolve the fibrin.
A fibrin sheath is a protein sleeve that forms around the catheter and can create a one-way valve effect at the tip: infusions push the sheath aside (allowing partial flushing) but aspiration causes the sheath to collapse against the catheter tip (preventing blood return). This is distinct from a complete mechanical occlusion. Treatment involves instilling alteplase (tPA) 2 mg/2 mL per lumen, dwelling for 30–120 minutes, then aspirating and discarding the dwell volume. The instillation may need to be repeated. If alteplase fails, catheter exchange over a guidewire or line replacement may be necessary.
Question 6: Which site assessment finding requires immediate removal of a peripheral IV catheter in a pediatric oncology patient receiving vesicant chemotherapy?
- Swelling, blanching, or pain at the infusion site indicating extravasation (Correct answer)
- Slight redness at the catheter insertion site without swelling
- Blood return not visible in the tubing
- IV rate running 10 mL/hr slower than prescribed
Correct answer: Swelling, blanching, or pain at the infusion site indicating extravasation
Swelling, blanching (skin pallor from vesicant infiltration into tissue), or pain at or around the IV site indicates extravasation of a vesicant — an oncologic emergency requiring immediate IV cessation and antidote administration.
Vesicant extravasation is a medical emergency in pediatric oncology. Vesicants (e.g., doxorubicin, vincristine, vinorelbine) cause severe tissue necrosis if they leak from the vein into surrounding tissues. Signs of extravasation include swelling/edema at the site, skin blanching or discoloration, pain or burning, or loss of blood return. Upon suspecting extravasation: STOP the infusion immediately, do NOT flush or remove the needle (aspirate residual drug), notify the provider, document the site, apply appropriate intervention (cold packs for anthracyclines, warm packs for vinca alkaloids), and administer antidotes (dexrazoxane for anthracyclines; hyaluronidase for vinca alkaloids).
CPHON Central Line Care and Vascular Access 1
A child with a newly placed PICC line develops erythema, warmth, and tenderness along the arm vein pathway 48 hours after insertion.
The nurse suspects: