Case Reports – Maintenance

Disconnection / ports left open

Death of 29yr old living renal donor transplant recipient

Death – AAGBI alert

Severe cerebral air embolus

33yr female, 17 weeks pregnant. Child died at 4 months of age.

77yr male cerebral air embolus

62yr female death

32yr male disconnected CVC

66yr female collapsed from CVC ports being left open

62 yr male air embolus from disconnection

Death from sheath disconnection

81yr female death from CVC port being left open

Disconnection of CVC lead to stroke & later death. Over US$18million payment.

65yr male died post CVC disconnection

Pulmonary air embolism

Death post misconnection

38yr male air embolus from misconnection of CVC

Fatal air embolism from CVC misconnection

2yr old air embolism from misconnection

Cerebral air embolus from CVC misconnection


Other e.g. damage to central line

79yr male dies from cerebral air embolus after lacerating CVC while shaving

71 yr male – severe neurological impairment

52yr male lacerated CVC while shaving

72yr male lacerated CVC while shaving

62yr female air embolus post rupture of CVC

Air embolus from accidental laceration of CVC