An anesthesiologist inserted a
14-gauge peripheral intravenous (I.V.) catheter
into a patient’s left antecubital fossa in
preparation for coronary artery bypass graft surgery.
Induction was uneventful, and the patient’s
arms were tucked. One liter of fluid and approximately
1.5 liters of cell saver were given via the 14-gauge
I.V. After the four-hour procedure, the left arm
and hand were found to be dusky and tense. The surgeon
then performed an emergent fasciotomy. Despite the
fasciotomy, the patient lost the ability to produce
a strong grip. The case was settled with a payment
to the patient of $75,000. Was this preventable?
 omplications
secondary to peripheral I.V. and arterial line catheters
are a significant source of liability for anesthesiologists.
These liabilities ranged from frivolous to morbid
claims. The ASA Closed Claims Project database has
been invaluable in identifying important anesthetic
complications and mechanisms of injury.1,2
The Closed Claims Project database consists of a
standardized summary of data collected from 35 professional
liability carriers insuring approximately one-half
of practicing anesthesiologists in the United States.
Complications specifically due to peripheral catheters
were analyzed from the database from 1970 to 2001.
Currently 140 claims for injuries are related to
peripheral catheters (2.1 percent of 6,894 claims),
with 127 I.V. claims (91 percent) and 13 claims
related to arterial lines (9 percent).
Claims Related to Arterial Catheters (n = 13)
Arterial catheter claims involved radial (n = 7),
femoral (n = 5) and brachial (n = 1) arteries and
most frequently resulted from arterial thrombosis
(31 percent) and iliac artery puncture (31 percent)
[Table 1]. The claims associated with radial artery
cannulation involved a retained catheter or wire
(n = 2), radial nerve damage from multiple punctures
(n = 2), arterial occlusion and hand ischemia (n
= 2) (one in a smoker with severe peripheral vascular
disease and another in a patient with Raynaud’s
syndrome) and carpal tunnel syndrome from a hematoma
(n = 1). Of 13 arterial catheter claims, there were
two pediatric claims (15 percent). The largest payments
were the result of complications secondary to femoral
arterial lines. In one pediatric case, a clot developed
in the femoral artery, and the patient’s limb
required a subsequent amputation ($1.2 million).
In another femoral arterial line case, the right
iliac artery was lacerated secondary to the a-line
placement ($10 million). The patient later developed
hypotension postoperatively and eventually had a
cardiac arrest. The patient survived after surgical
intervention but suffered severe brain damage.
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Claims Related to I.V. Catheters (n =
127)
The most common I.V. complications included skin
slough or necrosis (28 percent) followed by swelling/inflammation/infection
(17 percent), nerve damage (17 percent) and fasciotomy
scars from compartment syndrome (16 percent) [Figure
1]. Burns due to heat compresses used to treat I.V.
infiltrations accounted for 3 percent of claims
[Figure 1].
Compartment Syndromes: Compartment
syndromes accounted for 22 percent of all I.V.-related
nerve damage cases. In addition, scars from fasciotomies
for treatment of compartment syndromes also accounted
for 16 percent of I.V. catheter claims. Many of
these claims related to compartment syndromes involved
cardiac cases in which the arms were tucked. Because
of this, the anesthesiologist could not visually
or tactilely monitor the peripheral I.V.
Skin Slough: The most common claim
related to I.V. catheters involved skin slough or
necrosis [Figure 1]. Of the reported drugs involved
with skin slough, the most commonly reported drugs
causing skin slough were thiopental (31 percent),
vasopressors (11 percent) and calcium chloride (9
percent).
Click
to enlarge image
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Figure 1: Intravenous
Catheter Complications (n=127)
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Patient and Case Characteristics
Claims for I.V. catheter complications were more
likely to involve patients with ASA Physical Status
scores of 3-5 compared to other claims (p<0.05).
No statistically significant difference was found
based on body habitus (obesity). I.V. catheter claims
had a higher proportion of cardiac surgery and a
lower proportion of emergency procedures than other
claims [p<0.05, Figure 2]. Claims for I.V. catheter
complications were more likely to involve temporary
nondisabling injury than other claims [p<0.05,
Figure 2].
Click
to enlarge image
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Figure 2: Intravenous
Catheter vs. Other Claims
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Monetary Compensation
Roughly 54 percent of all peripheral catheter claims
resulted in payment for injury. Monetary compensation
ranged from $275 to $10,050,000 (median $38,400) [Table
2]. Claims related to air embolism had the highest
median payment as well as a 100-percent payment-per-claim
[Table 2].
Click
to enlarge image
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Discussion
Complications secondary to I.V. catheters cause significant
injuries to patients and financial liability to practicing
anesthesiologists. Although limits inherent to the
Closed Claims Project exist,2,3
this analysis of peripheral catheter complications
has identified important mechanisms, demographics
and types of complications.
Skin slough cases had the highest percentage of I.V.
catheter claims. Thiopental was the most commonly
reported drug in skin slough claims. As the use of
thiopental as an induction agent declines, claims
related to skin slough may show a proportionate decrease.
Also an easily avoidable complication of thrombophlebitis/swelling
is burn injury due to heat compresses. Claims due
to air embolism had the highest median compensation
and a 100-percent rate of payment-per-claim. This
also is likely due to substandard care and the preventable
nature of air embolism. Several of these resulted
from air in the blood from the cell saver.
Because of arm tucking and the resulting inability
to monitor I.V. lines during cardiac cases, this group
represented the largest single case type. In the opening
vignette, the anesthesiologist was found liable in
that cardiac case. According to the claims file, there
were no reports of signs of an infiltrating I.V. other
than post facto visual and tactile inspection.
Although the anesthesia provider’s care was
found to be appropriate by peer review, the claim
nevertheless resulted in payment. There were other
cases of compartment syndrome in which there were
warning signs of infiltration such as a slowly dripping
I.V. Perhaps a low threshold to visually check the
arms when the I.V. is dripping slower than normal
is the best defense against I.V. infiltrations and
compartment syndromes.
There were surprisingly few claims for arterial catheters,
although some of the largest payments were due to
complications from femoral arterial cannulation. Our
findings of limited liability associated with radial
arterial cannulation is consistent with prospective
reports of the safety of radial artery cannulation.4
Although partial or complete radial artery occlusion
after decannulation occurred in a quarter of almost
1,700 patients, no ischemic damage to the hand or
disability occurred in any of the patients. In contrast,
liability associated with femoral lines may be greater.
Previous studies have shown the beneficial effect
of analysis of the Closed Claim Project database.1,2,3
Although it cannot be used for establishing cause-and-effect
relations,3
patterns of injury in this study of peripheral catheter
complications have identified important preventable
patient complications such as air embolism, burn injuries
due to heat compresses for infiltrations/thrombophlebitis
and compartment syndromes.
References:
1. Cheney FW, Posner K, Caplan RA, Ward RJ. Standard
of care and anesthesia liability. JAMA. 1989;
261:1599-1603.
2. Cheney FW. The
American Society of Anesthesiologists Closed Claims
Project. What have we learned, how has it affected
practice, and how will it affect practice in the future?
Anesthesiology. 1999; 91:552-556.
3. Lee L, et al. The Closed Claims Project: Has it
influenced anesthetic practice and outcome? Anesthesiol
Clin N Am. 2002; 20:485-501.
4. Slogoff S, Keats AS, Arlund C. On the safety of
radial artery cannulation. Anesthesiology.
1983; 59:42-47.
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Derek
W. Liau, M.D., is Resident Physician, Department
of Anesthesiology, University of Washington
School of Medicine, Seattle, Washington. |
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