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Sib peritonitis


									Access Complications
Sibylle Schmidt, R.N.
Euromed Clinic, D-90763 Fürth, Germany
phone +49-911-9714-641, fax +49-911-9714-642, e-mail:

Learning objectives
 To identify complications associated with parenteral and enteral access
 To list measures to be taken for the prevention of such complications
 To manage lumen occlusion of parenteral and enteral access devices
 To instruct nurses in state-of-the-art drug administration via an enteral tube


Malpuncture, Malposition and Embolism
Mechanical complications are rare and usually evident either during or shortly after the
insertion procedure [1]. The problems that may arise can be malpuncture (arterial puncture,
pneumothorax, hydrothorax), malposition and embolism (air, catheter, wire)[2-4]. Whereas
pneumothorax and arterial puncture can be immediately recognized, hydrothorax may occur
only several days after the insertion. Chest pain and shortness of breath are characteristic
symptoms of pneumo- and hydrothorax. In this situation a chest X-ray after injection of a
radiopaque contrast medium is needed. Either a wire catheter or a CT are useful in confirming
the diagnosis. Malpositioning can best be avoided by the use of intraoperative fluoroscopy.

Catheter Occlusion
Thrombotic catheter occlusion (CO) may be caused by intraluminal thrombi, mural thrombi,
fibrin sheaths or sleeves and fibrin tails [3]. Intraluminal thrombi can occur when the blood is
allowed to flow back into the catheter. Although the catheter surface properties do not have
an apparent pathogenetic role on thrombotic CO, the rigidity of the catheter material can have
a significant effect in producing an intraluminal CO. A slowly running drip or a restricted blood
aspiration are early signs of CO. A CO diagnosis is obvious when infusion or injection of fluid
is impossible [3].
For treatment of CO agents such as streptokinase, urokinase or tissue plasminogen activator
should be injected repeatedly [3]. Thrombotic occlusion can be prevented by a continuous
flow, i.e. by a pump. In order to prevent clotting, the catheter should be irrigated with a
heparin solution and not used for blood sampling.

Non-thrombotic CO can result from drug precipitation, nutrient incompatibilities and lipid
deposits [2]. Additional factors which may cause mechanical obstructions are: catheter tip
abutment against the vein wall, costoclavicular catheter compression and, when using ports,
displacement of the needle into the silicon membrane. The signs of non-thrombotic CO are
the same as those mentioned for thrombotic CO [1,2,4,5].
Depending on the cause of CO, a variety of strategies is needed for repair. In order to resolve
the lumen occlusion, injecting or rinsing the catheter system (with ascorbic acid, hydrochloric
acid, or ethanol) should be tried first (see Table 1).

  Table 1.   Treatment of Catheter Obstruction

  First-line procedures:
   Use a 10 ml syringe filled with saline solution
   Inject and draw intermittently

  Second-line procedures:
   Clamp the catheter, remove the cap and attach a 3-way stopcock to the catheter
   Attach a 10 ml syringe with e.g. urokinase to the direct line of the stopcock and an
     empty syringe to the side line
   Aspirate with the empty syringe while the direct line is closed
   Close the side line and open to the direct line. Due to the lower pressure the
     urokinase flows into the catheter
   Wait half an hour
   Procedure can be repeated several times
   When the catheter becomes patent, flush it throroughly with i.e. saline or heparin

Venous Thrombosis
Catheter-related venous thrombosis (VT) is a major problem and accounts for up to 40 % of
all upper extremity deep vein thromboses. Clinically, a central VT is suggested by the
presence of arm swelling, pain, subcutaneus collaterals and increased jugular venous
pressure. Ultrasound with doppler-mode and digital substraction angiography (DAS) are
standard methods for diagnosing a VT.
There is some controversy regarding the most appropriate treatment, but local and systemic
application of antithrombotic drugs have proven effective.

Catheter-related Infection / Sepsis
Infection of the exit site, pocket and tunnel infections as well as catheter-related blood stream
infection are frequent problems and cause a high morbidity in parenteral nutrition [6].
Diagnosis: Redness, sensitivity, tendernesss, induration, suppuration, fever, chills, rigors and
a severe disturbance of well-being indicate a systemic catheter-related infection, when other
sources of infection can be ruled out. Cultures of both the peripheral blood and isolates from
the catheter are necessary for a correct diagnosis [4,5,7-9].
Treatment and prevention: The decision to remove the catheter is made on an individual
basis and depends on the patient‘s status, the severity of the infection, the microorganism,
the immunocompetence and the need for any further venous access. Since removal of the
catheter can limit the number of possible access sites in the future, the catheter - whenever
possible - should be kept in situ. Preventive strategies during the insertion and maintenance
of the catheter can significantly reduce local and systemic infective complications [2,10].


In this section, based on personal experience only a few of the many possible complications
associated with enteral access have been selected [11].

Local Irritation
The most common problems are esophagitis, esophageal erosions and ulcer formation [10].
Such lesions can give rise to hemorrhage, particularly in the presence of strictures.
Nasopharyngeal discomfort very often results in a subsequent cessation of tube feeding.
Percutaneous tubes can cause irritation at the skin exit site due to movement and paraluminal
secretion. This can progress to bleeding, incrustation and proliferating granulation tissue.
High pressure of the internal or external retention device can lead to hemorrhage, ulceration,
necrosis and perforation of either the mucosal or the skin site.

Prevention and treatment: Fine-bore polyurethane or silicone nasogastric tubes are generally
well tolerated. Avoidance of local complications can be achieved by the appropriate care of
the enteral cutaneous stoma. A low pressure gradient between the retention devices causes
less complications than moderate or high pressure gradients. Granulation tissue can be
reduced by either trimming or cauterisation. Frequent cleaning, e.g. washing with water after
removal of the dressing helps to reduce the frequency of complications. The dressing should
be applied only to the thoroughly dried skin and tube. A wet dressing ( Ringer´s solution), if
changed frequently, will resolve local irritations within a few days. Apart from its documented
value during the insertion of a percutaneous gastrostomy (PEG) tube, a benefit of using
prophylactic antibiotics has not been established.

Aspiration pneumonia is considered to be the most dangerous infective complication in
enteral nutrition [12]. Therefore, patients most at risk, i.e. those who are hospitalized, sedated
or mentally disturbed need to be controlled meticuously. Early detection of aspiration can
avoid severe morbidity and lethal outcome. As clinical findings and chest X-ray are often
misleading, microbiological and chemical analyses of the tracheal secretion are needed to
establish the diagnosis. In case of motility disorders (reflux, late gastric emptying) jejunal
feeding should be considered.

Abscess and Peritonitis
Abscess formation at the exit site or along the tunnel of percutaneous tubes is suspected,
when pain, tenderness, edema, erythema, fever, induration or purulence are present.
Ultrasound examination, cultures or CT scan verify the diagnosis. If medical treatment is
ineffective or progression is seen, surgical measures have to be taken. Aseptic wound care
by the well instructed patient can reduce the rate of tube removal due to septic events.

Peritonitis is a rare complication, but should be searched for, when abdominal tenderness,
pain, systemic illness, signs of intestinal motility disorders or drainage of pus, enteric contents
or food from the tube site are present [11,12]. The tube feeding should be stopped and an
immediate examination carried out by a surgeon.

Tube Occlusion
If the formula diet does not flow through the tube, first check for kinking of the tube. Clogging
of the tube frequently occurs due to inappropriate care, the administration of crushed tablets
or inadequate rinsing after feeding (see Table 2)[13,14]. Among the techniques used to
desobliterate clogged tubes, rinsing with water, carbonated or enzymatic liquids, the use of
either guide wires or Fogarty catheters - applied repeatedly and in combination - will be
effective in the majority of cases (see Table 3). It must be stressed however, that the use of
guide wires or other potentially perforating devices must be performed under appropriate
imaging control. Otherwise, perforation due to guide wire deflection through a side hole of the
tube may occur. Patience is always more successful than rough treatment.

  Table 2. Prevention of Tube Clogging - Correct Administration of Drugs
   Before and after each application rinse with water
   Do not administer fruit juice or acidic liquids by tube
   Try to apply drugs as a dissolved solution
   Dilute viscous and hyperosmolar liquids with water
   If crushing the tablets is allowed, use a pestle and mortar
   Give the powdered tablets as a dissolved solution
   The contents of capsules should be dissolved in water
   Never mix drugs with the formula diet

  Table 3. Desobliterate the Clogged Tube
   To remove the clog, attach a 10 ml syringe filled with water to the tube
   Gently draw back the plunger to remove the blockage. Instillate water
   If obstruction persists, use 2 ml syringe to instill a liquid to lyze the clog (e.g. coke,
     enzymes) into the tube, wait half an hour
   The tube may also be milked with the fingers
   Procedures should be repeated several times, if necessary
Further Reading
1. Dempsey DT. Complications of parenteral and enteral nutrition. In: Torosian MH (ed). Nutrition for the hospitalized
    patient: Science and principles of practice. New York: Marcel-Dekker, 1995, 353-379
2. Bean E. Catheter access and complications. Part I: Access and non-septic complications. In: Haffejee and Salamis
    (eds.) Handbook of Clinical Nutrition. 1990: 5-21
3. Haire WD, Herbst L. Use of alteplase (t -PA) for the management of thrombotic catheter dysfunction: Guidelines from
    consensus conference of the national association of vascular access networks (NAVAN). Nutr Clin Pract 2000; 15: 265-
4. Maroulis J, Kalfarentzos F. Complications of parenteral nutrition at the end of the century. Clin Nutr 2000; 19: 295-304
5. Flowers JF, Ryan JA, Gough JA. Catheter-related complications of total parenteral nutrition. In: Fischer JE (ed.) Total
    Parenteral Nutrition. 2nd ed. Boston: Little Brown, 1991: 25-46
6. Symmonds B. Catheter access and complications. Part III: Nursing management of catheters, peripheral lines and
    administration systems. In: Haffejee and Salamis (eds.). Handbook of Clinical Nutrition 1990: 35-41
7. Bower RH. Home parenteral nutrition. In: Fischer JE (ed.) Total Parenteral Nutrition. 2nd ed. Boston: Little Brown, 1991:
8. Haffejee AA, Beau E, Singh B. Catheter access and complications. Part II: Catheter related sepsis. In: Haffejee and
    Salamis (eds.). Handbook of Clinical Nutrition 1990: 23-33
9. Karim A. Farr BM. Central venous catheter-related infections: A review. Nutrition 1996; 12: 208-213
10. Steinhaus EP, Alexander HR. Vascular access techniques. In: Torosian MH (ed). Nutrition for the hospitalized patient:
    Science and principles of practice. New York: Marcel-Dekker, 1995: 307-327
11. Gossner L, Ludwig L, Hahn, EG, Ell C. Risiken der perkutanen endoskopischen Gastrostomie. Dtsch Med WSchrift
    1995; 120: 1768-1772
12. Silk DBA, Payne-James JJ. Complications of enteral nutrition. In: Rombeau JL, Caldwell M (eds). Enteral and tube
    feeding. Philadelphia: WB Saunders, 1990: 510-531
13. Auringer M, Krecke H. Sind Retardarzneiformen (zer-)teilbar? Krankenhauspharmazie 1996; 17: 1996 478-483
14. Probst W. Arzneimitteltherapie bei Patienten mit Ernährungssonde. PZ Prisma 1997; 1: 31-41

Further reading
   Baker SS. Enteral nutrition in Pediatrics. In: Rombeau JL, Rolandelli RH (eds). Enteral and Tube Feeding. Philadelphia:
    WB Saunders, 1997: 349-367
   Kirby DF, De Legge MH. Enteral nutrition and the neurologic diseases. In: Rombeau JL, Rolandelli RH. (eds.) Enteral
    and tube feeding. Philadelphia: WB Saunders, 1997: 287-299

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