Pediatric emergency medicine trisk 4668 4668

Totally implanted systems are much less likely to clot than are tunneled catheters This situation is fortunate because irrigating the clot is more difficult to perform on a totally implanted system Specific agents may help dissolve precipitates or clots For waxy precipitates, 70% ethanol should be used For particulate precipitates, 0.1N hydrochloric acid (HCl) or 8.4% sodium bicarbonate should be used depending on the pH of the drugs/solutions infusing prior to the precipitate formation Fibrinolytic agents such as tPA (up to mg, dependent on catheter size) may dissolve a blood clot, and similar to HCl, may be used up to two times in 24 hours if necessary Ethanol should be used only one time per episode tPA infusions may be started at the suggestion of the surgical or interventional radiology consultants, who should be involved in the treatment plan if initial attempts are unsuccessful Air Embolism Failure to maintain a closed system during manipulation of indwelling venous catheters can result in embolism of air into the chambers of the heart Passage of the embolus to the systemic or pulmonary circulation can result in severe and irreversible tissue damage Air embolus can cause a patient to experience sudden onset of tachypnea, tachycardia, hypotension, or loss of consciousness Other diagnoses that should be considered in patients with these symptoms are pneumothorax, liberation of septic emboli, and direct cardiac insult If an air embolus is suspected, the patient should be placed in the left-sided Trendelenburg position and oxygen should be administered In addition, the indwelling catheter should be clamped and remain unused as other peripheral access is obtained Catheter Breakage The family members and physicians caring for the child with a tunneled catheter may have considered the nightmare of catheter breakage and subsequent exsanguination Although catheter breakage is a distinct possibility, most events occur during routine care rather than during playtime and therefore the blood loss is easily apparent and correctable A tunneled catheter can acquire a small hole from inadvertent needle puncture or even ordinary wear and tear Totally implanted catheters, in contrast, are less susceptible to local events or wear and tear However, trauma to the area can result in detachment of the proximal portion of the catheter from the implanted port Leakage of blood or fluid from the externalized portion of a tunneled catheter is easily noticed Externalized catheters must be immediately clamped proximal