Several examples of severe patient injury related to invasive devices are presented below. The following case studies illustrate the opportunities to reduce the risk and prevent complications related to the use of invasive devices.
Case 1
A 75-year-old man was admitted to the hospital with shortness of breath and bilateral leg swelling. He was diagnosed with congestive heart failure exacerbation. The PVC site was found to be swollen and tender on the third day of use. Purulence at the site was noted, and the PVC was removed. The patient was started on intravenous antibiotics, then switched to oral antibiotics, and eventually sent home. In the next few days, his right upper extremity became more swollen, tender to palpation, and erythematous. The patient was readmitted to the hospital and started on intravenous antibiotics again. His blood cultures grew methicillin- resistant Staphylococcus aureus (MRSA). His blood cultures continued to be positive for MRSA for more than 2 weeks, and a transesophageal echocardiogram showed vegetation on the aortic valve consistent with endocarditis. The patient cleared his bacteremia with antibiotics and was discharged home to finish his treatment.
A month later, the patient was readmitted because of several days of back pain and inability to get out of bed on the day of admission. The patient was evaluated and found to have an epidural abscess compressing his spinal cord and leading to paraplegia.
Summarizing this case, we found that the patient developed multiple complications related to his PVC infection. These included—
- Bacteremia and sepsis
- Septic thrombophlebitis
- Endocarditis
- Epidural abscess
- Paraplegia (inability to walk)
Ultimately, the patient underwent back surgery to decompress the pressure on the spinal cord caused by the abscess, and he was in the hospital for about 3 months to treat the infection and all other complications.
What led to these complications? Organisms colonizing the skin may have been introduced at the time of PVC placement or in maintenance of the catheter. The virulent organism caused a severe infection and irreversible injury to the patient.
Case 2
An 82-year-old woman was admitted to the cardiac intensive care unit for congestive heart failure. She had a UC placed and was started on diuretics. She appeared frail. Her physician and nurses felt that keeping the urinary catheter in place would make her more comfortable. On the fifth day after admission, the patient started complaining of chills. She was found to have a fever of 102 °F, and her blood pressure dropped to 90 systolic. Blood and urine cultures grew Escherichia coli. She was diagnosed with a CAUTI and associated septicemia and was treated with intravenous antibiotics for 5 additional days.
Summarizing this case, we found that the patient developed complications related to urinary catheter presence. These included—
- Bacteremia and sepsis
- CAUTI
- Prolonged hospital stay
What led to these complications? Organisms from the perineal area ascend into the bladder and may lead to symptomatic CAUTI. The risk increases with longer duration of UC use. Avoiding inappropriate use of the UC will reduce the risk.
Case 3
A 38-year-old man was admitted to the hospital because of a left leg infection. The patient had had a right internal jugular CVC placed on admission. He developed a high-grade fever, chills, sweats, and confusion 4 days after admission. Blood cultures grew Staphylococcus aureus, and the catheter tip grew the same organism. The patient was treated with intravenous vancomycin; infectious diseases and neurology consultations were obtained. The patient’s bacteremia persisted, and his repeat blood cultures continued to be positive for more than a week. An ultrasound of the internal jugular vein was also positive for thrombosis.
Summarizing this case, we found that the patient developed multiple complications related to the infection of his central venous catheter. These included—
- Bacteremia and sepsis
- Internal jugular vein thrombosis
This necessitated additional consultations by infectious disease and urology, placement of another invasive devise to administer intravenous antimicrobial therapy and ultimately resulted in a prolonged length of stay.
What led to all these complications? Organisms colonizing the skin when the CVC was placed were likely introduced at the time of placement.
How do we reduce the risk of a similar event happening? The use of proper insertion technique and maintenance can reduce the risk. The process should include all of the components needed to place a CVC in an aseptic manner.
Case 4
A 60-year-old man with chronic obstructive pulmonary disease was admitted to the hospital because of increased shortness of breath. In the ED, he was cyanotic and was intubated. The patient was admitted to the medical intensive care unit and was given intravenous steroids and respiratory treatments. He continued to be ventilator dependent and failed multiple weaning attempts. After 10 days of being on ventilator support, he had worsening of his oxygenation, and a chest radiograph showed a right lower lobe consolidation. His sputum culture grew Pseudomonas aeruginosa. A computed tomography scan of the chest showed a necrotizing pneumonia in the right lower lobe. The patient was treated with two antibiotics targeting Pseudomonas species, but continued to deteriorate and died a week later.
Summarizing this case, we found that the patient developed ventilator-associated pneumonia with the complication of death. This patient had low respiratory function reserve due to his underlying chronic lung disease. Potential interventions to reduce the risk of VAP include keeping the head of the bed elevated and practicing proper oral care.
