POST-INSERTION RELATED COMPLICATIONS

Infection
Infection is one of the most serious complications of CVC placement. Every year, CVCs cause 80,000 bloodstream infections in the U.S., leading to up to 28,000 deaths in intensive care unit patients. Each infection costs approximately $45,000, creating up to $2.3 billion in additional expenses every year (37).

Infections occur more commonly in the very young (‹1 year) or senior patients (›60 years) and in those who are immune-compromised. Other risks include patients who had inadequate procedural skin preparation, contamination of a catheter via poor hub disinfectant, unmaintained catheter lumens or poor post insertion maintenance (11). Infection is also greater in patients in a hyperthrombotic state, or patients with an accumulation of fibrin on their device.

Virtually all CVCs have biofilm. Biofilm originates from microflora on the patient's skin, healthcare workers or contaminated materials. These bacteria migrate to the catheter and can colonize the CVC within 24 hours of insertion. CVCs with a dwell time of at least 30 days are more likely to develop biofilm on the inner lumen of the catheter (38).

Catheters inserted into an internal jugular vein have usually been associated with a higher risk of infection than CVCs in the subclavian site (9) due to the difficulty maintaining an occlusive dressing at this particular site.

Symptoms of infection include:

• Fever and chills
• General malaise
• Tachycardia
• Hypotension
• Elevated white blood cell counts
• Erythema, pain and tenderness at the insertion site

Prevention/Management
As previously discussed, the IHI has established a care bundle, or grouping of evidence based best practices to be followed when inserting central venous catheters. Following these guidelines has proven to significantly reduce the risk of infection. The guidelines include:

• Hand hygiene
• Maximal barrier precautions
• Chlorhexidine for skin antisepsis
• Optimal catheter site selection with avoidance of femoral in adults
• Daily review of line necessity with removal as soon as no longer medically necessary (7,9).