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

Median claim for VAE US$ 325,000, 100% payment. 2007 range $25,800 to $4,120,00

Average cost $66,000 per air embolism event in US 2006

Additional burden Euro 56,670 per case

6 patients suffering neurological injury related to CVC management

6 CVC related air emboli AIMS database

6 cases related to CVC removal

10 cases (4 deaths) air embolus on removal of dialysis catheter

2 fatal CVC related cerebral air emboli & literature review

5 cases of CVC related air emboli in lung transplant recipients

15 cases one institution radiology dept in 5 years

Several cases of air embolus related to central lines in NPSA

9 reports NPSA patient deterioration from CVC removed upright

19 cases of CVC air embolus, 7 fatal

3 reports of harm from CVC being left open to air

8 cases of air embolism from central line removal

2 cases of homonymous hemianopia from CVC related cerbral air emboli

Venous air emboli related to removal of CVCs