RENAL ASSOCIATION
Patient Safety Project
January 2012
Insertion of haemodialysis catheters into arteries
The NPSA recently received an incident report describing a misplacement of a haemodialysis
catheter, in that the catheter was placed in artery not in a vein. A search of the NRLS identified
43 furthers similar reports, with 4 deaths possibly associated. They are also aware of other
types of central lines being inadvertently placed into an artery.
The NPSA review was discussed at their response meeting and it was suggested to share the
findings for information. The NPSA have agreed for this to be circulated to clinical directors for
their views on the basis that they respect confidentiality and don’t circulate the report more
widely.
Action
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The NPSA would be very grateful to receive advice on the prevention of these
incidents.
NICE guidelines (2002) recommend using ultrasound imaging for CVC insertion.
However, the NPSA has reports where this guidance has been followed but where the
line was still inserted into an artery.
Are there other clear actions that could be promoted to prevent misplacement of central
lines?
Are there any actions that might enable more timely detection of misplacement?
Please submit comments, solutions, and personal experience to:
Dr. Paul Rylance, Renal Association Patient Safety project lead by email to: paul.rylance@nhs.net
This is a draft document produced for internal NPSA processes and approved for sharing
with: Intensive Care Society and the Renal Network
Not for onward circulation without prior NPSA permission
NRLS analysis summary
Accidental insertion of vas cath into artery not vein (PSIMS 2011/014)
Trigger
Discussed on 1st November 2011:
Semi elective admission for VATs drainage of pleural effusion. Deteriorated post
op and needed to be readmitted to ITU . Vas cath inserted into right femoral vein
for haemofiltration . Further deterioration - PE suspected , patient
anticoagulated . Died despite best efforts to resuscitate . . Coroners PM
requested : this showed the vas cath in an artery not a vein - dissected iliac and
perforation 1.5 l blood in abdomen . Incident being investigated by [Staff Name]
as an SUI awaiting outcome . .
PS question
How many incidents were reported to the NRLS describing that a haemodialysis
catheter was inadvertently inserted into an artery?
Search
strategies
On the 14th November 2011, the NRLS was searched for incidents containing the
following terms in the free text description:
Vascath OR permacath OR (vas* Or perma AND cath*) AND arter
149 incidents were identified and all were reviewed.
Findings
In addition to the trigger incident, 43 reports were identified describing arterial
cannulation (n=29) and arterial puncture (n=14) of a haemodialysis catheter.
The catheters are placed in large veins and the insertion sites for the 43 relevant
incidents were as follows:
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Femoral vein/ groin (n=15)
Jugular vein/ neck (n=12)
Subclavian vein/ chest (n=5)
Unknown (n=11)
NICE guidelines (2002) recommend using ultrasound imaging for CVC insertion.
In most of the 43 relevant cases it remains unclear if ultrasound has been used
during catheter insertion (only three reports clearly state that it has and four
clearly state that it has not).
For jugular and subclavian lines, a chest X-ray should be performed to confirm
that the line is positioned inside the superior vena cava. Again, in most cases this
kind of information has not been provided in the incident reports.
The misplacement of the catheter was identified at different times and by
different methods. Some arterial punctures/ cannulation were discovered by staff
who noticed that the blood ‘looked arterial’ or that the flow was pulsating. In
other cases a chest x ray or blood gases were performed indicating misplacement.
In six cases arterial placement was only discovered after the removal of the line.
How was misplacement discovered?
Observations
Tests
After removal
Number of incidents
Realised immediately (during insertion)
1
Bleeding
1
Blood bright red/ looked arterial
5
Blood pulsating
4
Bruising noted
1
Groin pain
1
Leg noted to be pulseless
1
Respiratory distress / requiring CPR
2
Blood gases
2
x ray
6
Transducer/ scan
4
After removal
6
unknown
9
Total
43
The reported degree of harm for the relevant incidents is as follows:
Reported degree of harm
Number of reported
incidents
No harm
Low harm
Moderate harm
Severe harm
Death
TOTAL
16
9
13
5
43
None of the incidents were reported as resulting in death, however, on review it
appeared that four patients had died.
The incidents occurred in the following years:
2005 (4 incidents)
2006 (5 incidents)
2007 (6 incidents)
2008 (4 incidents)
2009 (6 incidents)
2010 (9 incidents)
2011 (9 incidents)
Other
information
According to Butterly DW and Schwab SJ (2000)1 the severity and likelihood of
insertion complications varies with the site of insertion.
Femoral: The complication rate is lowest in the femoral position, and
complications when they occur tend to be minor. The primary problem is
perforation of the femoral artery. Bleeding usually resolves with 10 to 15 minutes
1
http://cmbi.bjmu.edu.cn/uptodate/critical%20care/Fluid%20and%20electrolyte%20disorders/Acute%20hemodialysis%20vascul
ar%20access.htm
of direct digital compression.
Subclavian insertion complications are potentially more serious. Penetration or
cannulation of the subclavian artery can lead to haemothorax, in some cases
requiring a thoracotomy tube. The incidence of pneumothorax varies from less
than 1 percent to more than 10 percent of insertions, reflecting the skill and
experience of the physician. The risk of pneumothorax is greater from the left
than right side, since the pleura and dome of the lung are higher on the left.
Internal jugular insertions carry a higher likelihood of carotid artery
penetration, but a lower risk of pneumothorax (0.1 percent).
According to Bowdle (2010) the most common injury to arteries is related to
puncture or cannulation of the carotid artery. Puncturing the carotid artery with a
small needle occurs in about 6% of all procedures and, although undesirable,
does not generally produce any harm. However if the arterial puncture is not
recognized and a guidewire is placed into the artery and followed with a CVC or
a pulmonary artery catheter introducer sheath there is the possibility of a major
problem. Ultrasound and pressure waveform measurement are two commonly
used methods to reduce the chances of injury to the carotid artery.
Conclusions
Incidents relating to misplacement of central lines have previously been reviewed
and various scoping papers were discussed by the response group.
The purpose of this review was to see if there are any particular issues relating to
haemodialysis catheters which were not identified before. No further national
learning could be identified by looking at misplacement of these types of central
line separately.
Planned
action
Completed
by
For discussion with response group on 29th November 2011
Date
completed
25th November 2011
Dagmar Luettel, Clinical Reviewer
Examples from the free text descriptions:
Critically ill patient with multiple organ failure and coagulopathy transferred to theatres for
insertion of vas cath . Inadvertant placement of vas cath into carotid artery . Error recognised
and vas cath removed . Within hours , respiratory distress worsens resulting in fatal cardiac
arrest . Reported to HM Coroner . PM report states cause of death Ia " haemorrhage from
puncture of carotid artery " . .[reported as severe]
Vascath for CVVH inserted into the right femoral artery instead of right femoral vein . Had
been verified as suitable for use . Problems over morning with filter . Gas performed and error
noted . Vascath re sited and CVVH recommenced . Child in multi organ failure so both limbs
had no pedal pulse so this did not help in picking up the error . .[reported as severe]
Patient on CVVHF , 3L exchange . During handover blood in circuit appeared bright therefore
did a blood gas analysis from PiCCO arterial line followed by another analysis from CVVHF
circuit . Result showed sO2 97.5% , pO2 13.2kPa and a pCO2 7.56kPa . Informed medic who
asked for the vascath to be transduced , this returned a MAP of 65mmHg . CVVHF stopped and
blood flushed back to patient and systemic heparin infusion discontinued . Line currently
remains in situ , awaiting further review and instructions . .[reported as severe]
Senior Registrar inserted vascath into the femoral artery of sibling donor . Vascath insertion by
haematology SpR not performed under USS guidance . .[reported as moderate]
Dr Inserted right femoral vascath into femoral vein , Dr consultant Anaethetist asked myself to
remove the vascath because therapy not indicated in foreseeable future . on removing vascath ,
it became evident the line had been situated in artery and not the vein . Patient bleeding
perfusely , compression of artery required for 40 minutes . Additional fluid given to patient and
blood transfusion speeded up because patient became acutely hypo - tensive . ABG taken from
site to confirm arterial blood - when bleeding stoppped . . abg confirmed arterial sample . ( Ph
7.5 , Pco2 - 3.75 , P02 16.4 ) . . Dr informed , Dr M. Nil action taken from medical team .
.[reported as moderate]
Vascath was inserted by Consultant Anaesthetist into right subclavian . no cxr was requested ,
and he instructed the nurses to use the line immediately . CVVH started and connected by two
SSN . cardiovascularly patient very stable . 6 hours later i noticed that the circulating blood
was bright red . i took a gas and it was arterial blood , PaO2 13 and PaCO2 was 4 , sats 98% .
we transduced the vascath and the wave form was arterial . CVVH stopped immediately . CCP
and dr [Staff Name 1] informed immediately . new vascath inserted and CVVH changed . right
subclavian line labelled and nurses instructed not to remove it . .[reported as moderate]
Staff member was asked to place a vascath catheter for patient with obesity . Staff member used
acclies needle first . Staff member punctured accidentally the carotid artery instead of N17 vein
. Staff member realised just after the incident . Removed the catheter immediately , and applied
pressure for 20 minutes as the consultant on duty advised . Applied dressing on the site of
puncture , was clear when staff member left ITU . .[low harm]