Central Line Related Air Embolism – Applying Human Factors to the Design of Safe Systems

You are at a cardiac arrest on the ward.  The nurse informs you the patient rapidly deteriorated when their fluids were disconnected from their central line.  That is when you notice the central line lumens have been left open to air.  You are suspicious of an air embolus, which is confirmed on admission to ICU, and despite resuscitative attempts the patient dies two days later.  … Continue reading Central Line Related Air Embolism – Applying Human Factors to the Design of Safe Systems

Equipment

Air can enter central lines accidentally left open to air in a matter of seconds causing intractable cardiac arrest. There have been numerous case reports of deaths from this mechanism – all are avoidable. (See the CEC – Clinical Focus Report Central Venous Access Devices and Air Embolism) We do not need central lines or vascular attachments that open to air. We could effectively eliminate this … Continue reading Equipment

Centralised Central Line Management Training

The Clinical Excellence Commission along with NSW Agency for Clinical Innovation and Health Education Training Institute  have developed an excellent centralised training resource. Many cases occur because of accidental line disconnections (this problem can be engineered out – see here). Many other cases occur when central lines are removed with patients sitting upright – staff should ensure patients are lying flat or slightly head down … Continue reading Centralised Central Line Management Training

Vascular Access Decision Tree

50% of central lines are inappropriate. Approximately 20% cause morbidity and mortality from acute events, air emboli, and blood stream infections. Perhaps it’s better to infuse dilute amiodarone through forearm cannulae with risk of thrombophlebitis, than endure the real but poorly documented risk of central/PICC line insertion. Read this review article on extravasation injuries in adults. It’s difficult for us to make well informed decisions. … Continue reading Vascular Access Decision Tree

Central Lines Are Removed Supine

The majority of central line related air emboli reported in NSW occurred during line removal. In most cases the patient being sat up was seen as a major contributing factor. See: Central Line Related Air Emboli An effective awareness campaign could be extremely useful in focussing staff on an important message: CENTRAL LINES ARE REMOVED SUPINE We’re creating a brief animation clearly explaining why the supine … Continue reading Central Lines Are Removed Supine

Central Line Management Form

One universal form for central line documentation will allow strong data generation to review equipment and processes. Despite the nurse indicating that there had been a verbal request for the removal of the patient’s central line, there was no written documentation that this should take place, and no clear indication why…. We encourage all hospitals and staff in NSW to use the: Central Line Insertion … Continue reading Central Line Management Form

Sticky post

Central Line Related Air Emboli

You attend a cardiac arrest on the ward. The nurse, who was ambulating the patient after their fluids were disconnected, informs you the patient had rapidly deteriorated. That is when you notice the central line lumens had been left open to air. Your suspicions of air embolus are supported on echocardiography, however despite resuscitative attempts the patient dies in ICU two days later. The unfortunate … Continue reading Central Line Related Air Emboli