Light Can Wreak Havoc on CVCs
MedSun: Newsletter #3, April 2006

By Roberta Sullivan, RN, BSN, MPH

A Central Venous Catheter (CVC) was successfully placed in an infant through the femoral vein. Less than 24 hours later, the catheter had broken, and a portion of it remained inside the infant’s vascular system. After it was removed, a second CVC was inserted. Within minutes, it also broke for no apparent reason. The patient required additional intervention to retrieve the second catheter segment, which was also hard and brittle.

What went wrong?
The hospital stored these products, which come in transparent wrap, in a carousel inventory control system with a clear front panel, which exposed them to ultraviolet (UV) light. The catheters were made of polyethylene, which is susceptible to degradation by UV light over time. Both catheters were close to their labels’ expiration dates but weren’t yet outdated.

What precautions can you take? Use these guidelines to store and use medical devices safely:

•Follow labeling recommendations that specify cool, dark, and dry places for storage.
•Consider using opaque double wrapping to protect products from light exposure.
•Routinely check expiration dates before using any medical device.
•Closely examine all devices before use; if any fail your inspection, notify your facility’s biomedical services or engineering department.
•Return devices involved in adverse events or malfunctions to your facility’s biomedical services or engineering department, which will check them before returning them to the manufacturer. These steps can help to determine what went wrong and prevent future problems.
•Follow your facility’s policies and procedures for reporting incidents.

Roberta Sullivan is on the Social and Scientific Systems, Inc. staff.


MedSun Newsletters are available at www.fda.gov/cdrh/medsun