Invasive devices are commonly used in the hospital setting and are associated with infectious and noninfectious complications. As soon as the patient enters the hospital, he or she is evaluated for venous access need. In the vast majority of cases, venous access is seen as a necessity to provide care. In addition, patients who are critically ill or those with urinary retention may have a urinary catheter placed. Finally, those patients with respiratory failure may require support through mechanical ventilation. Patients with more severe illness are more likely to be exposed to invasive devices and therefore are at a greater risk for infectious complications. In addition, procedures performed in emergency situations may be less compliant with aseptic techniques.
Peripheral Venous Catheters
PVCs are the most commonly used catheter in the hospital setting, with up to 90 percent of patients having one during their stay. PVCs are associated with mechanical, chemical, and infectious complications. Mechanical complications include hematoma and infiltration. Phlebitis (inflammation of the vein) can also occur, either related to chemical irritation of the vein or secondary to infection. The occurrence of bacteremia in the presence of phlebitis and signs of sepsis is consistent with septic thrombophlebitis, a disease that is associated with significant morbidity and mortality. Multiple studies reported poor compliance with PVC care and serious events related to infectious complications. Although serious events related to PVC use occur less commonly than do those related to central venous catheters, over duration of use, the number of PVC complications becomes significant because of the high utilization.
Central Venous Catheters
CVCs are used in the hospital setting to provide patients with venous access and are more commonly used in the critically ill. Tunneled CVCs or implanted ports are used in patients who need long-term venous access and are usually placed in a sterile procedure area. Short-term CVCs are placed either by specialized teams, physicians, or physicians-in-training. Peripherally inserted central venous catheters (PICCs) are also considered CVCs, and are usually placed by specialized nursing teams or interventional radiology staff. CVCs are associated with mechanical and infectious complications. The mechanical complications include hematoma, deep venous thrombosis, and in some situations, pneumothorax. CLABSIs are linked to increased morbidity and mortality, and many of the infections are preventable if the process adheres to aseptic insertion and maintenance. Some CVCs have a higher complication risk than others. For example, a femoral CVC has a high risk of infection (especially in obese adults) and thrombosis, whereas a subclavian CVC has lower infection risk but poses an increased risk for pneumothorax. Our focus will be on short-term CVCs, including PICCs.
UCs are commonly placed in the hospital, particularly in the ED, ICU, and ORs. UCs may have mechanical and infectious complications. Mechanical complications include urethral trauma, hematuria, immobility, and fall risk. Infectious complications include asymptomatic bacteriuria, symptomatic CAUTI, and bacteremia related to CAUTI. Reducing UC-associated risk includes using the catheter only for an appropriate indication, and removing it promptly when no longer necessary. In addition, proper (aseptic) insertion technique and maintenance reduce the risk of introducing organisms into the UC closed system.
Endotracheal tubes are used to intubate patients with respiratory failure to provide mechanical ventilation. Contrary to UCs, the placement is rarely unnecessary; however, continued mechanical ventilation requires close evaluation to reduce the patient risk of developing VACs, including ventilator-associated pneumonia (VAP). A VAP results from aspiration of organisms into the lungs, leading to pneumonia. The risk of VAP increases with the duration of ventilation, and may be modified by other factors such as head-of-bed elevation and oral care. VAP is associated with significant morbidity and mortality.