Case Reports – Removal

1. Patient not supine


16yr female – CVC removal in preparation for discharge

50yr male – CVC removed in preparation for discharge

53yr male – Dialysis catheter removed, US$10million settlement

Father of 3 – death on catheter removal, US$8.2million settlement

23yr female – US$6million settlement

18yr male death post CVC removal

Death on removal of CVC, patient sat up

65yr male, severe cerebral air embolus ultimately causing death

Lethal pulmonary air embolus on removal of dialysis catheter

Death 8 days post op from CVC removal

Lethal case of air embolus from dialysis catheter removal upright

43yr male death post CVC removal

Male – stroke and death over 2 months later from CVC removal upright

Female (mother) death from CVC removal in upright position

Death from removal of double lumen catheter in upright position

36yr male died post CVC removal

73yr male died post removal of double lumen dialysis catheter

44yr male, Liver Transplant, death post CVC removal

18yr male, Liver Transplant, death post CVC removal

Female, death post removal of CVC

68yr female death post CVC removal

83yr male death post CVC removal in upright position


Neurological Impairment

Acute decompensation, CVC removed by resident – review by Dr Peter Pronovost

57yr female minimal long term injury

Female – severe neurological injury, US$3.85million settlement

35yr – central line removed by 1st yr resident, severe injury, US$5.75 million

54yr female – severe neurological injury, US$3.8million settlement

Collapse and acute hemiplegia

95yr female, permanent neurological impairment

54yr male air embolus and neurological deficit post PA catheter removal

50yr female massive cerebral air embolus and severe neurological injury

Young male air embolus post CVC removal

20yr male – treated with hyperbaric oxygen therapy

43yr male cerebral air embolus from CVC removal

Air bubbles on echocardiography post CVC removal

89yr female post CVC removal

76yr male stroke from air embolus post CVC removal

23yr male coronary air embolism and MI

57yr female cerebral air embolism post removal of CVC



No residual deficit

52yr male 8 days post op

60yr male

27yr male 30 mins post removal

73yr male air embolus post CVC removal by House Officer


2. Central line insertion site not sealed sufficiently

Death of 84yr old

51yr old, cerebral air embolism, site not sealed appropriately

49 female stroke post CVC removal

65yr male air embolus post air embolus removal

Near fatal embolism, fibrin sheath as portal of air entry

76yr male air embolus via residual tract