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June 2002
Volume 66 |
Number 6
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| Central Line Complications
From the ASA Closed Claims Project: An Update |
T. Andrew Bowdle, M.D., Ph.D.
We previously reported on central line complications from the
ASA Closed Claims Project in 1996 from a database of 3,533 claims
of all types.1 There were 48 claims related to
central venous or pulmonary artery catheters, including 20 fatalities.
Seventy-five percent of the fatalities were due to cardiac tamponade
or vascular injury. We have now undertaken re-evaluation of central
line complications from the ASA Closed Claims Project, from a
database of 5,475 claims of all types, including 75 claims related
to central lines. Analysis of the claims reported since 1996 reveals
some interesting differences from the previous analysis.
In this most recent analysis, we have divided the claims into
two groups, those with clinical events occurring prior to 1990
and those occurring in 1990 or later [Table
1]. The set with event dates prior to 1990 corresponds very
closely, although not precisely, to the claims that we reported
on in 1996. (There is a lag time between the clinical event and
the legal process that ultimately results in a closed claim.)
A few cases have been added as the closed claims database has
been refined, and a few cases have been excluded because the central
line complication was due to the actions of someone other than
the anesthesiologist, usually the surgeon.
In the analysis of closed claims with clinical events prior to
1990 (essentially our 1996 report), three classes of complications
of central lines were most important: perforation of the heart
with pericardial tamponade (10 out of 49 claims), catheter or
wire embolism (10 out of 49 claims) and injury to veins or arteries
other than the pulmonary artery (16 out of 49 claims). These complications
accounted for 17 out of the 23 deaths.
Interestingly, the closed claims for central line complications
with event dates of 1990 and later have a somewhat different distribution
compared to those with event dates preceding 1990 [Figure
1]. Cardiac tamponade accounts for only two of 26 claims and
catheter or wire embolism for zero out of 26. Unfortunately, injury
to veins or arteries other than the pulmonary artery resulting
in hemothorax, hydrothorax or injury to the carotid or subclavian
arteries continues to be a major problem. Sixteen of 26 cases,
including seven fatalities, were accounted for by this class of
complication. As in the analysis from 1996, the inadvertent placement
of a large-bore catheter or an introducer sheath into an artery
instead of a vein was a prominent cause of morbidity and mortality.
Several methods have been used to distinguish vein from artery,
including the subjective evaluation of the pressure of blood spurting
from the needle, the color of the blood, assessment of blood gases,
deliberate stimulation of arrhythmias by the guidewire and transduction
of a pressure waveform. Some of these methods have major drawbacks.
The subjective evaluation of the pressure of blood spurting from
the needle depends upon the size of the needle, the pressure in
the vessel and perhaps even the position of the needle bevel in
the vessel. The color of the blood depends upon the ambient lighting
and the characteristics of the syringe and the oxygen saturation.
A high FiO2 may make venous blood appear very much like arterial
blood, and conversely, hypoxemia may make arterial blood appear
venous. Blood gases may be helpful but are relatively impractical
because of the time required to receive the result. The onset
of arrhythmia with advancement of the guidewire into the heart
is indirect evidence of venous placement but carries the hypothetical
risk of inducing a potentially harmful arrhythmia or even of perforating
the heart with the guidewire. By contrast, transduction of a pressure
waveform safely and instantaneously identifies the vessel as artery
or vein; only very rarely will there be any ambiguity in the recognition
of arterial and venous waveforms.
Jobes et al. performed a retrospective review of 1,021 cases
of internal jugular cannulation and found 43 cases of arterial
puncture, five of which were unrecognized by blood flow and color
criteria, resulting in inadvertent placement of 8.5 French introducer
sheaths in the carotid arteries. One patient suffered a hemothorax
and died.2 Subsequently they performed a prospective
study of 1,284 patients using transduction of the pressure waveform
to positively identify the vein.2 Arterial puncture
was unsuspected in 10 patients until it was detected by inspection
of the pressure waveform. Consequently there were no inadvertent
arterial cannulations.
Compact, portable two-dimensional (2D) ultrasound devices also
have proven useful in locating central veins and distinguishing
them from arteries.3,4 A recent
report from the Agency for Healthcare Research and Quality reviewed
the clinical evidence related to the use of ultrasound for placement
of central lines and concluded that ultrasound improved catheter
insertion success rate, reduced the number of venipuncture attempts
and reduced the number of complications.5
2D ultrasound is particularly useful when the internal jugular
vein cannot be located easily and quickly using standard anatomical
landmarks. However, consideration should be given to transducing
a waveform even when the 2D ultrasound is used to identify the
vein because the needle, which is nearly parallel to the ultrasound
beam, is often not clearly seen in the ultrasound image.
Analysis of complications of central lines from the ASA Closed
Claims Project confirms that the placement and use of central
lines are associated with the possibility of serious morbidity
or mortality. Fortunately, many of these complications may be
preventable by positively identifying the vessel as a vein prior
to inserting a wire or large-bore catheter. As in 1996, the author
recommends examination of the pressure waveform as the most convenient
and reliable method for distinguishing the vein and artery. 2D
ultrasound devices also may be useful aids to locating the vessels
and may help to reduce complications, especially in cases where
locating the vein is difficult.
References:
1. Bowdle TA. Central line complications from
the ASA Closed Claims Project. ASA Newsl. 1996; 60(6):22-25.
2. Jobes DR, Schwartz AJ, Greenhow DE, et al.
Safer jugular vein cannulation: Recognition of arterial puncture
and preferential use of the external jugular route. Anesthesiology.
1983; 59:353-355.
3. Troianos CA, Jobes DR, Ellison N. Ultrasound-guided
cannulation of the internal jugular vein. A prospective, randomized
study. Anesth Analg. 1991; 72:823-826.
4. Randolph AG, Cook DJ, Gonzales CA, Pribble
CG. Ultrasound guidance for placement of central venous catheters:
A meta-analysis of the literature. Crit Care Med. 1996; 24:2053-2058.
5. Rothschild JM. Ultrasound guidance of central
vein catheterization. Evidence Report/Technology Assessment, No.
43. Making Health Care Safer. A Critical Analysis of Patient Safety
Practices. Agency for Healthcare Research and Quality Publication
No. 01-E058. 2001; 245-253. < www.ahrq.gov/clinic/ptsafety/
>.
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T.
Andrew Bowdle, M.D., Ph.D., is Professor of Anesthesiology
and Pharmaceutics (Adjunct) and Chief, Division of Cardiothoracic
Anesthesiology, University of Washington, Seattle, Washington. |
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