We could estimate from reports that at least one person dies every day from a central line related air embolus.
Unfortunately the true incidence may be magnitudes greater than this.
We welcome your comments and feedback.
For more information on how we may prevent this avoidable issue please read here.
How frequently do central line related air emboli deaths occur? (see here):
Even the most conservative estimates (5million CVCs per year in US, air embolus 0.1% of CVCs, and 23% mortality) indicate 1,150 deaths per year from this avoidable complication in the US alone.
Does education and experience help reduce the incidence? (see here)
Unfortunately studies suggest that those with greater experience may be less likely to follow appropriate procedures to minimise the risk of CVC related air embolus. Also the impact of education tends to wane rapidly with time.
If CVC related air embolus is so prevalent where are all the reports?
Below we’ve collated numerous case series and an overwhelming amount of case reports (insertion, maintenance, removal) which highlight the prevalence of this problem. Please note we have no access to error report databases (see here) – these cases represent only some of those available via the internet – we have little doubt there are multiple more.
As is the nature of adverse events in healthcare they tend to be dispersed in time and place. This often starves us of the impetus required to put effective system measures in place.
We’ll work tirelessly to present the data in a more readable format, however one may already start to appreciate the magnitude of this issue.
Please help us put a stop to these avoidable adverse events: (read here)
Thank you.
Estimates of Frequency:
1. How many central lines are inserted per year?
In US an estimated 6 million lines inserted per year and increasing.
5 million per year in US (NEJM 2003)
More than 5million per year in US. Approximately 8% of hospitalised patients.
As many as 5million CVCs per yr in US. 15% experience complications.
48% of ICU patients. 15million CVC days per year in US.
Estimated 200,000 CVCs per year in NHS (BMJ 2013)
2. What proportion of the central lines are complicated by air emboli?
Incidence may be as high as 0.8% (AAGBI)
0.13% of interventional radiology CVC manipulations
15 of 11,583 radiographically inserted central lines
(Gas embolism complicates 2.65 per 100,000 hospitalizations)
3. What proportion of the air emboli result in death?
Review of 24 cases – 50% died, of remainder 42% had permanent neurological injury
4 out of 10 cases resulted in death
Awareness, Experience & Education
Survey: Only 31% of nurses (whose job description included removal of central lines) reported using all the recommended procedures. (see here)
Nurses more aware than doctos of risks of air embolism on CVC removal (see here)
Air embolism entirely preventable complication, but not widely known among practitioners (see here)
Are we missing too many cases? (see here)
Nurse Survey. In overall group comparison, few differences were found between nurses and physicians in terms of patient positioning at CVC insertion or removal. Nurses were more likely than physicians to request air-occlusive dressings after CVC removal (19 of 53 [36%] vs. 12 of 140 [9%]; p < .001), but there was no difference between nurses and physicians in awareness of VAE as the reason for choosing one patient position or dressing over another (29% vs. 39%, respectively). Critical care nurses with <=2 years of experience more often placed the patient in the supine or the Trendelenburg position for CVC removal than nurses with >2 years of experience (71% vs. 26%; p = .03).
Although most physicians (127, 91%) chose the Trendelenburg position for CVC insertion, only 42 physicians (30%) reported concern for VAE. On CVC removal, only 36 physicians (26%) cited concern for VAE. Some physicians (13, 9%) reported elevating the head of the bed during CVC removal, possibly increasing the risk of VAE. Awareness of VAE or its prevention did not correlate with the level of physician training, experience, or specialty. After the educational intervention, concern for and awareness of proper methods of prevention of VAE improved (p < .001). At 6-month follow-up, reported use of the Trendelenburg position continued, but concern cited for VAE had returned to baseline. (see here)
Case Series
11 reports NPSA UK (2009 to 2011) all on removal of CVC 9 in sitting position
8 reported deaths 51 near miss events NSW CEC since April 2012
24 of 59 VAE reports due to CVAD – Pennsylvania 2004 to 2011
26 patients suffering cerebral air embolus
85 yr old – cerebral air embolism and death days later
2 cases reported by same practitioner
40yr female air embolus from femoral CVC insertion
72yr male dies post CVC insertion from cerbral air embolus
Air embolus diagnosed on echocardiogram
Echo diagnosis of air embolus with CVC inserted in upright position
Death from air embolus during subclavian venepuncture
66yr female IVC air embolus from femoral CVC
65yr male air emboli during CVC insertion
17yr female died, air embolus post CVC insertion
49yr male death from CVC related air embolus
67yr male air embolus from femoral CVC insertion
Case Reports – Maintenance
Disconnection / ports left open
Death of 29yr old living renal donor transplant recipient
33yr female, 17 weeks pregnant. Child died at 4 months of age.
77yr male cerebral air embolus
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
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
Case Reports – Removal
1. Patient not supine
Death
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
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
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
27yr male 30 mins post removal
73yr male air embolus post CVC removal by House Officer
2. Central line insertion site not sealed sufficiently
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
Please note we have only just started to collate this date. We have little doubt there are hundreds of other individual case reports in journals which are not included above. These reports only represent a fraction of the true number of cases. We will continue to update this list.
patientsafe 