R E V I E W S & A N A LY S E S Reducing Risk of Air Embolism Associated with Central Venous Access Devices Michelle Feil, MSN, RN INTRODUCTION the right side of the heart. In some cases, Patient Safety Analyst Intravascular air embolism is a prevent- this can create an air lock in one or more Pennsylvania Patient Safety Authority able hospital-acquired condition that can of the pulmonary arteries, obstructing result in serious harm, including death. pulmonary circulation and causing com- Intravascular air embolism was labeled a plete circulatory collapse. In general, the ABSTRACT serious reportable event by the National closer to the heart the air embolism is Quality Forum in 2002.1 In 2006, this introduced into the venous system, the Air embolism is a rare but potentially list was updated and adopted by the Cen- smaller the volume of air is required to be lethal complication of certain medical symptomatic. Apart from these effects, air and surgical procedures. Because air ters for Medicare and Medicaid Services (CMS) as part of the Inpatient Prospective embolisms, even when small, can cause embolism is a preventable hospital- tissue ischemia or inflammatory changes acquired condition that can result in Payment System, which became effective October 1, 2008, instituting nonpayment within blood vessels, leading to a host of serious harm, it has been labeled a seri- potentially lethal complications (e.g., sys- ous reportable event with nonpayment to hospitals in situations of patient harm due to occurrence of these serious report- temic inflammatory response syndrome, for harm by the Centers for Medicare pulmonary edema, myocardial and cere- and Medicaid Services. Between June able events.2 bral ischemia).5,6,7 2004 and December 2011, the Intravascular air embolism occurs when Pennsylvania Patient Safety Authority two conditions are met: (1) there is direct In contrast to venous air embolism, arterial received 74 reports related to air connection between a source of air and air embolism is very poorly tolerated, and the vascular system and (2) the pressure even a small amount of air can be lethal. embolism. The majority of confirmed or gradient favors the entry of this air into Of special concern, 25% of the general suspected air embolisms were attributed the bloodstream. This can occur through population is estimated to have a patent to central venous access devices. The active injection of air into the bloodstream foramen ovale (PFO), an opening between widespread use of these devices, along or through passive movement of air into the left and right atria that normally closes with a high mortality rate attributed to the bloodstream when the venous pressure at birth and is usually asymptomatic and air embolisms related to central venous is less than the prevailing atmospheric undetected.8 The presence of a PFO in the access devices, warrants special atten- pressure. Except in cases of trauma and setting of a venous air embolism is highly tion. Hospitals can decrease the risk for decompression sickness, most air embo- dangerous since there exists a pathway by air embolism by establishing policies lisms occur due to medical procedures, which the venous air embolism can quickly and procedures that contain specific including surgical procedures (especially pass into the arterial circulation and enter air embolism prevention protocols for those performed with the patient in the the cerebral circulation (causing a stroke) central venous access device insertion, upright position), intravascular catheteriza- or the coronary circulation (causing a myo- management, and removal. Other tion (such as through the use of central cardial infarction).5,6,7 measures to decrease risk include edu- cation and competency certification for venous access devices [CVADs]), radiologic The widespread use of CVADs, both staff and equipment safety controls. (Pa procedures (especially those using auto- within the hospital and community set- Patient Saf Advis 2012 Jun;9[2]:58-64.) matic contrast media injectors3,4), and the tings, warrants special attention due to use of air insufflation and positive pres- the risk for air embolism associated with sure ventilation.5,6 their use. The frequency of venous air The sequelae of air embolisms depend embolisms related to CVADs is estimated on the amount of air entering the blood- to range from 1 in 47 to 1 in 3,000.6,7 stream, the rate at which the air enters, While the frequency of this complication and the route of administration (venous may be low, mortality rates attributed versus arterial). The body can tolerate to venous air embolisms associated with small amounts of air introduced into the CVADs range from 23%9 to 50%.10 peripheral venous system at slow rates, often without symptoms. Small volumes AIR EMBOLISM REPORTS IN of air travel to the right side of the heart PENNSYLVANIA and into pulmonary vasculature, where Between June 2004 and December 2011, the air is dissipated. With larger volumes Pennsylvania acute healthcare facilities and rapid infusion of air, pulmonary reported 74 air embolism events to the artery pressures rise, putting strain on Pennsylvania Patient Safety Authority: Page 58 Pennsylvania Patient Safety Advisory Vol. 9, No. 2—June 2012 ©2012 Pennsylvania Patient Safety Authority 41 confirmed events of air embolism, Figure 1. Air Embolism Reports to the Pennsylvania Patient Safety Authority, June 18 suspected events of air embolism (in 2004 to December 2011 which the patient was symptomatic in the presence of known risk factors for air embolism without radiographic confirma- 15 tion), and 15 events involving conditions (20%) in which the patient was placed at high risk of developing an air embolus (see Figure Confirmed cases of air embolism 1). Of the 59 events of confirmed or sus- pected air embolisms, 25 were reported as Suspected cases of air embolism Incidents in which no harm was caused to 41 18 Situations creating high potential the patient and 34 were reported as Seri- (56%) ous Events resulting in harm, including (24%) for air embolism seven cases of permanent harm and six deaths. Twenty-four of the 59 confirmed or MS12288 suspected air embolism event reports were associated with CVADs; the next most common associated clinical features were surgical procedures, intravascular proce- Figure 2. Confirmed and Suspected Air Embolism Reports to the Pennsylvania Patient Safety Authority, by Associated Clinical Feature, June 2004 through dures, and peripheral venous access devices December 2011 (see Figure 2). Despite the inclusion of air embolism as a serious reportable event for nonpayment by CMS, with presum- 3 ably increased attention to prevention, air (5%) embolism event reports to the Authority 14 Central venous access device have increased over time (see Figure 3). (24%) Examples of these reports include the 24 following: Surgical procedure (41%) An interventional radiology resident came to the floor and removed the Intravascular procedure catheter while the patient was sitting semirecumbent in a chair. A gauze Peripheral venous access device 18 dressing, combined with an occlusive (30%) dressing, was placed over the access MS12289 site. Not too long after that, another resident came in to visit the patient and noted [the patient] sitting in the chair, tachypneic and desaturated. caps, not clamped, lumen not covered vian central line. A follow-up chest The patient was moved to the ICU by thumb)]. The staff heard the air x-ray was obtained. Intravenous fluids [intensive care unit] with a possible sucking in and knew right away. The were administered through the central air embolism. patient was cared for immediately line. The patient was taken for a A patient came to interventional by being placed on his left side and CT [computed tomography] scan radiology for a tunneled catheter administering increased oxygen. of the head. During the CT scan, placement. During the procedure, The patient was transferred back to the physician was made aware by the patient got an air embolus. After the ICU with the ICU nurse and radiology that the central line was in talking to the physician, [it was physician. The patient was monitored the artery. The CT scan of the head determined that] the cause of the closely and needed no further showed intracranial air consistent embolism came from the catheter as treatments. with an air embolus. it was being passed into the patient A patient was admitted with a An infant was admitted to the ICU. due to the lack of [occlusion (e.g., no stroke. The physician placed a subcla- . . . She acutely developed bradycar- Vol. 9, No. 2—June 2012 Pennsylvania Patient Safety Advisory Page 59 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Figure 3. Air Embolism Reports to the Pennsylvania Patient Safety Authority, by resource with a summary of updated infor- Quarter, June 2004 to December 2011 mation and research on air embolisms and NUMBER their treatment and prevention.11 The Infu- OF REPORTS sion Nurses Society is also a resource for guidelines, policies, and procedures related 8 to CVAD care, including steps to prevent 7 and manage air embolisms.12,13 7 Insertion of Central Venous 6 Access Devices 5 — Take steps to increase central venous 5 pressure (CVP). Increasing CVP 4 4 4 4 4 4 decreases the pressure gradient that 4 would normally favor movement of 3 3 3 3 3 3 air into the bloodstream. CVP is 3 normally lower in all blood vessels 2 2 2 2 2 2 located above the level of the heart 2 and during inspiration. 1 1 1 1 1 1 1 1 Place the patient in the 1 Trendelenburg position with MS12290 0 0 a downward tilt of 10 to 0 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 30 degrees during central line 2004 2005 2006 2007 2008 2009 2010 2011 placement.5,7,11,13 Avoid CVAD insertion during REPORTS BY QUARTER patient inspiration. Instruct the patient to hold his or her breath, dia, mottling, and hypotension. She The patient’s caregiver disconnected and perform a Valsalva maneu- required multiple rounds of medica- the patient’s IV line from the cen- ver if able.5,7,11 tions, including epinephrine, atropine, tral line so that the patient could Hydrate the patient to correct and sodium bicarbonate, as well ambulate into the bathroom. After hypovolemia prior to insertion as tracheal intubation and cardiac returning to bed, the patient coded. whenever possible.5,7,11,14 compressions. An echocardiogram After one minute of cardiopulmonary — Ensure all catheters and connections performed during the resuscitation resuscitation and oxygen bagging, the (especially in two-piece systems) are showed severely depressed myocardial patient began to respond. The patient intact and secure.5,7,11,13 function, no pericardial effusion, was also placed in Trendelenburg and — Occlude the catheter and/or needle and what appeared to be echo-bright turned for suspected air emboli. The hub.5,7,11,14 areas of the myocardium consistent patient was transferred to the ICU — Ensure that all self-sealing valves are with potential air embolus. Following for further observation. functioning properly.7,11 resuscitation, the infant returned to The 24 confirmed or suspected reports her previous cardiac baseline hemody- of air embolisms related to CVADs were Care and Maintenance of namics. The nurse caring for the child further analyzed by the Authority to iden- Central Venous Access Devices subsequently reported that approxi- tify associated factors (See Table). mately one-half hour before the event, — Ensure that all lumens are capped and/or clamped.5,11,14 he had changed the IV [intravenous] PREVENTION METHODS — Use Luer-lock connections for fluid administration tubing that was infusing into the patient’s umbilical Although uncommon, air embolism can needleless IV ports and self-sealing venous catheter. The nurse reported have serious adverse effects on patients and valves.11,12,13 that he had followed the hospital’s is largely preventable through the applica- — Use infusion pumps with air-in- nursing procedure for IV tion of evidence-based practices.1,2 Joint line sensors for all continuous tubing change. Commission Resources has published a infusions.11 Page 60 Pennsylvania Patient Safety Advisory Vol. 9, No. 2—June 2012 ©2012 Pennsylvania Patient Safety Authority Table. Reports to the Pennsylvania Patient Safety Authority of Confirmed or Suspected Air — Instruct the patient to hold his or Embolisms Related to Central Venous Access Devices, by Identified Associated Factors, her breath, and perform a Valsalva June 2004 through December 2011 maneuver as the last portion of the CONTRIBUTING FACTORS IDENTIFIED NUMBER catheter is removed; if unable to do Insertion so, time the removal during patient Venous catheter placed in artery 2 expiration.5,11,13,14,16,17 Injection of air 1 — Place pressure on the site until Line exchange with head elevated 1 hemostasis is achieved. One to five Lines not clamped or capped 1 minutes is suggested.11,13.16,17 No Valsalva maneuver 1 Not specified 3 — Apply a sterile occlusive dressing, Total 9 such as gauze impregnated with Care and Maintenance petroleum jelly and covered with Contrast media injector 1 a transparent film dressing. Leave Other injection of air 1 dressing in place for at least 24 Line not clamped or capped 1 hours. Change the dressing every 24 Line mishandled by unlicensed staff 1 hours until the exit site has healed. Total 4 (Plain gauze dressings have been Removal by Healthcare Provider associated with air passing through Head elevated during removal 6 a persistent catheter tract into the Not specified 3 bloodstream, resulting in air embo- Total 9 lisms, as have occlusive dressings Removal by Patient 1 No Cause Identified in Report 1 left in place for shorter periods of Total 24 time.)11,13,14,16,17 — Instruct the patient to remain lying flat for 30 minutes after removal of — Fully prime all infusion tubing, and on the central line. A break in the catheter.11,13,16,17 expel air from syringes prior to any the closed system, combined with injection or infusion.11,12 decreased CVP (due to movement TREATMENT FOR SUSPECTED AIR — Use an air-eliminating filter on to an upright position and deep EMBOLISM infusion tubing sets whenever inspiration), creates a high risk for A high degree of suspicion for air appropriate.11,13 air embolism.11 embolism should be maintained when — Remove air from infusion bags when — Teach patients and/or caregivers inserting, removing, or otherwise infusing fluids using inflatable pres- managing infusion therapy how to manipulating CVADs. Though often sure infusors.11 perform all steps necessary to prevent asymptomatic, the following are clini- — Fully prime contrast media injec- air embolism.11,12,13 cal signs of an air embolism: dyspnea, tors, and check for air prior to each tachypnea, decreased oxygen saturation, injection.11 Removal of Central Venous sense of impending doom, anxiety, agita- Access Devices tion, change in mental status, chest pain, — Trace lines, double-check all connec- tions, and take all steps necessary to — Place the patient in the Trendelen- tachycardia or bradycardia, hypotension, prevent tubing misconnections.11,13,15 burg position when possible. If pallor, and light-headedness. If the patient not possible, the supine position is is being monitored by capnography dur- — Inspect the insertion site, catheter, sufficient.5,11,14,16,17 ing the insertion, decreased or erratic and all connections regularly to — Position the catheter exit site (e.g., end tidal carbon dioxide can indicate assess for breaks or openings through neck, arm) at a height lower than the air embolism. Emergency management which air could enter the system.11,14 height of the patient’s heart.13 includes preventing the further entry of — Ensure the integrity of the central air, placing the patient in a left side-lying — Cover the exit site with gauze and line dressing surrounding the inser- position in Trendelenburg, and adminis- apply gentle pressure while remov- tion site.11 tering 100% oxygen. This position helps ing the catheter in a slow, constant — Use caution when moving or repo- motion.16,17 the air embolus to move toward the apex sitioning patients to prevent pulling of the right ventricle, away from the Vol. 9, No. 2—June 2012 Pennsylvania Patient Safety Advisory Page 61 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S pulmonary artery and right ventricular — Establish hospital policies and — Utilize equipment with safety fea- outflow tract. The administration of procedures that contain specific air tures that are designed to prevent oxygen supports the patient with cardio- embolism prevention protocols for air embolism (e.g., vascular access vascular instability or collapse and helps CVAD insertion, management, and catheters and caps with self-sealing or decrease the size of the embolus through removal.11,12 one-way valves, infusion pumps with its effects on the partial pressures of oxy- — Ensure practitioners inserting and air-in-line detection, infusion tubing gen and nitrogen within the blood, which removing CVADs have had adequate with in-line filters). 11,15 causes nitrogen to move from the embolus training and experience in perform- — Inform nonclinical staff, patients, into the bloodstream.5,7,11,16,17 ing the procedure.12,17,18 and family members that they must Withdrawing the air through the CVAD — Consider the use of a standardized ask a clinician to assist whenever a may be beneficial in some cases if it can insertion bundle kit or cart and stan- central line needs to be disconnected be done. Hemodynamic support should dardized removal kit. or reconnected.11 be provided with inotropic drugs and — Provide all nurses and other clinical fluid resuscitation to increase CVP. CONCLUSION staff handling CVADs with ongo- Cardiopulmonary resuscitation and/or ing training in proper line care, and Air embolism is an infrequent but intubation may be necessary. Chest com- assess staff for competence. Reassess potentially lethal complication of CVAD pressions may have the added benefit of competency annually. 17,18 utilization. The implementation of spe- helping to break up air emboli and move cific evidence-based prevention measures, — Consider establishing a vascular them away from the right ventricular along with risk reduction strategies, can access nurse team with 100% owner- outflow tract. Once stabilized, hyperbaric significantly decrease, or eliminate, this ship for placement, daily assessment, oxygen therapy can mitigate further effects Serious Event. and removal of nontunneled short- of air emboli and decrease their size.5,7,11 term central venous access catheters, ACKNOWLEDGEMENTS including peripherally inserted cen- H.T.M. Ritter III, BA, CBET, CCE, Pennsylvania RISK REDUCTION STRATEGIES tral venous catheter lines. 19 Patient Safety Authority, contributed to the topic Beyond the prevention measures taken by conception and initial literature review and data — Do not purchase nonintravenous acquisition for this article. Edward Finley, BS, individual clinicians, hospitals can take equipment that can be connected to Pennsylvania Patient Safety Authority, contributed the following measures to reduce the risk needleless IV ports.11,15 to the data collection and analysis. of CVAD-related air embolism: NOTES 1. National Quality Forum. Serious patientsafetyauthority.org/ADVISORIES/ 7. Mirski MA, Lele AV, Fitzsimmons L, reportable events in healthcare—2011 AdvisoryLibrary/2004/dec1(4)/Pages/ et al. Diagnosis and treatement of vas- update: a consensus report [online]. 13.aspx. cular air embolism. Anesthesiology 2007 2011 [cited 2012 Mar 8]. Available from 4. A word about air detection devices. PA Jan;106(1):164-77. Internet: http://www.qualityforum.org/ PSRS Patient Saf Advis [online] 2004 Dec 8. Cleveland Clinic. Patent foramen ovale Projects/s-z/Serious_Reportable_Events_ [cited 2012 Mar 8]. Available from Inter- [online]. 2010 Jan [cited 2012 Mar in_Healthcare_2010/Final_Report.aspx. net: http://patientsafetyauthority.org/ 14]. Available from Internet: http:// 2. Centers for Medicare and Medicaid ADVISORIES/AdvisoryLibrary/2004/ my.clevelandclinic.org/heart/disorders/ Services. Medicare program; listening dec1(4)/Pages/16.aspx. congenital/pfo.aspx. session on hospital-acquired conditions 5. O’Dowd LC, Kelley MA. Air embolism 9. Heckmann JG, Lang CJ, Kindler K, et in inpatient settings and hospital out- [online]. Up to Date 2000 Mar 2 [cited al. Neurologic manifestations of cerebral patient healthcare-associated conditions 2012 Mar 8]. Available from Internet: air embolism as a complication of central in outpatient settings. Fed Regist 2008 http://cmbi.bjmu.edu.cn/uptodate/ venous catheterization. Crit Care Med Oct 30;73(211):64618-9. Also available: critical%20care/embolic%20disease/ 2000 May;28(5):1621-5. https://www.cms.gov/HospitalAcqCond/ air%20embolism.htm. 10. Kashuk JL, Penn I. Air embolism after Downloads/1422_N_FEDERAL_ 6. Natal BL, Doty CI. Venous air embolism central venous catheterization. Surg Gyne- REGISTER_VERSION_PUB_10_30_ [online]. eMedicine 2009 Jul 27 [cited col Obstet 1984 Sept;159:249-52. 08_508.pdf. 2012 Mar 8]. Available from Internet: 11. Joint Commission Resources (JCR). Clini- 3. Venous air emboli and automatic con- http://emedicine.medscape.com/ cal care improvement strategies: preventing air trast media injectors. PA PSRS Patient article/761367-overview. embolism. Oak Brook (IL): JCR; 2010 Jul. Saf Advis [online] 2004 Dec [cited 2012 PDF e-book. Mar 8]. Available from Internet: http:// Page 62 Pennsylvania Patient Safety Advisory Vol. 9, No. 2—June 2012 ©2012 Pennsylvania Patient Safety Authority 12. Infusion Nurses Society (INS). Infusion 15. Tubing misconnections: making the 17. Ingram P, Sinclair L, Edwards T. The safe nursing standards of practice. Hagerstown connection to patient safety. Pa Patient removal of central venous catheters. Nurs (MD): INS; 2011. Saf Advis [online] 2010 Jun [cited 2012 Stand 2006 Aug 16-22;20(49):42-6. 13. Infusion-related complications. In: Infu- Mar 14]. Available from Internet: http:// 18. McGee DC, Gould MK. Preventing sion Nurses Society. Policies and procedures patientsafetyauthority.org/ADVISORIES/ complications of central venous cath- for infusion nursing, 4th ed. Hagerstown AdvisoryLibrary/2010/Jun7(2)/Pages/ eterization. N Engl J Med 2003 Mar (MD): Lippincott,Williams and Wilkins; 41.aspx. 20;348(12):1123-33. 2011:96-123. 16. Drewett SR. Central venous catheter re- 19. Rosenthal K. Targeting “never events.” 14. Brockmeyer J, Simon T, Seery J, et al. moval: procedures and rationale. Br J Nurs Nurs Manage 2008 Dec;39(12):35-8. Cerebral air embolism following removal 2000 Dec 8-2001 Jan 10;9(22):2304-15. of central venous catheter. Mil Med 2009 Aug;174(8):878-81. LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS — Recognize risk factors that contribute The following questions about this article may be useful for internal education and to air embolism. assessment. You may use the following examples or develop your own questions. — Recall the predominant contributing 1. Which of the following scenarios would not increase the risk for air embolus risk factors for air embolisms related formation? to central venous access devices a. Placement of a CVAD in a patient who is hyperventilating and unable to hold (CVADs), according to reports sub- his breath mitted to the Pennsylvania Patient b. Stopcock on CVAD left in open position and uncapped after blood sample Safety Authority. drawn from the line — Distinguish between circumstances c. Peripherally inserted central venous catheter (PICC) inserted in a patient with leading to CVAD-related air embo- hypertension and fluid overload status lism that create a high risk for harm d. Pressure applied to catheter exit site for five minutes after removal of central and those that create a low risk line, then dry sterile gauze dressing applied for harm. 2. Which of the following is the contributing risk factor associated with CVAD- — Identify strategies for prevention related air embolism that is most frequently reported to the Pennsylvania Patient and treatment of CVAD-related Safety Authority? air embolism. a. Removal of the central line while the patient’s head is elevated b. Inadvertent placement of the venous catheter in an artery c. Injection of air using contrast media injectors d. Accidental removal of the central line by the patient 3. Complete the following sentence: Air embolism associated with the presence of a patent foramen ovale (PFO) is highly dangerous . a. in neonates only b. in 10% of adults who have confirmed PFOs c. only in patients with symptomatic PFOs that have been unable to be closed surgically d. because it allows air to move from the venous system into the arterial circula- tion, where it can cause a stroke or myocardial infarction 4. Which of the following conditions for CVAD-related air embolism formation car- ries the highest risk of harm? a. 5 mL syringe of air injected into a peripheral intravenous (IV) line over 10 minutes b. 5 mL of air injected into a CVAD over one minute c. 5 mL of air injected into a CVAD by rapid IV push d. 5 mL of air from unprimed IV tubing infused into a PICC line over five minutes Vol. 9, No. 2—June 2012 Pennsylvania Patient Safety Advisory Page 63 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S SELF-ASSESSMENT QUESTIONS (CONTINUED) 5. All of the following are risk reduction strategies that a hospital can take to reduce the incidence of CVAD-related air embolism EXCEPT: a. Require training and annual competency evaluation for all nurses and physi- cians who perform central line removal. b. Mandate an evaluation by biomedical engineering when considering the pur- chase of any new nonintravenous medical equipment to ensure that it cannot be connected to intravenous lines or needleless IV ports. c. Instruct patients and families to disconnect themselves from their IV lines when ambulating to the bathroom in order to minimize tripping hazards. d. Consider establishing a vascular access nurse team with ownership for central line placement, daily assessment, and removal. An elderly patient with Alzheimer’s disease has been admitted with a urinary tract infection and is being cared for on a medical-telemetry unit where he has been receiving IV antibiotics through a right upper arm double-lumen PICC line. The patient has been placed on constant observation with a sitter at the bedside due to his delirium and wandering behaviors. The patient has a pat- tern of becoming agitated in the evenings after his wife leaves for the day. At 7 p.m., the sitter calls the nurse into the room because the patient is more agitated than usual and is getting out of bed and pulling on his IV lines. When the nurse assesses the patient, she discovers that the patient has been incontinent and is standing next to the bed yelling, “They are trying to kill me!” He has ripped his infusion tubing, the PICC line dressing is off, and the line is out approximately 10 cm. His heart rate is 110 bpm, with a blood pressure of 88/50 mmHg, respiratory rate of 22 breaths per minute, and pulse oxygenation of 90%. 6. In the above scenario, which combination of assessment findings is MOST sugges- tive of air embolism? a. Change in mental status, incontinence, and hypoxia b. Tachycardia, hypotension, and agitation c. Tachycardia, dyspnea, incontinence, and multiple potential points of entry for air into the bloodstream d. Tachypnea, tachycardia, hypotension, change in mental status, and multiple potential points of entry for air into the bloodstream 7. Which of the following BEST describes the appropriate immediate actions to be taken in this scenario? a. Notify the rapid response team, speak to the patient in a reassuring manner, and attempt to get the patient to lie down on his left side, putting the bed in the Trendelenburg position and applying 100% oxygen via a nonrebreather mask while waiting for the team to arrive. b. Call security to help get the patient back in bed and apply four-point limb restraints, administer Haldol that has been prescribed as needed for agitation, and place the bed in the Trendelenburg position while applying 100% oxygen. c. Ask the sitter to help reassure the patient while assisting him back to bed in a left side-lying position, putting the bed in the Trendelenburg position and applying 100% oxygen. At the same time, delegate another staff member to notify the rapid response team and the physician responsible for the patient, continue to reassure the patient while applying an occlusive dressing to the PICC insertion site, and clamp all lines. d. Assist the patient back to bed, administer Haldol as ordered for agitation, and call the vascular access nurse to come assess the PICC line. Page 64 Pennsylvania Patient Safety Advisory Vol. 9, No. 2—June 2012 ©2012 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 9, No. 2—June 2012. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2012 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. 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