We wish to report an unusual failure of a central line, with obvious safety implications. A four-lumen central line (ARROW â g+ard â BluePlus, Teleflex Incorporated, Limerick, PA, USA) was inserted into the right internal jugular vein (using a standard Seldinger technique without incident) for intraoperative use. All ports aspirated blood and were flushed without any problems, and the line was sutured in place. During the course of the operation, some blood was noted on the patient's pillow, which was initially assumed to be from the catheter insertion site. Close examination revealed that one of the four lumens had become separated from the catheter hub ( Fig. 1), allowing retrograde bleeding from the internal jugular vein. There was no apparent traction on the catheter, and later examination showed no sign of damage or trauma to the hub or the lumen tubing.In this case, the patient was not harmed. A large blood clot formed where the leak had occurred, but was not associated with any haemodynamic instability. Anaesthesia was safely maintained, in spite of remifentanil extrusion through the affected lumen. However, disconnection of the lumen had the potential for harmful consequences, including haemorrhage, air embolism, infection or failure to deliver intravenous anaesthesia or vasoactive drugs. Visible haemorrhage onto the pillow provided a warning in this case, but might not always be apparent, for example during interhospital transport.It may be prudent to employ a gentle tug-test when checking a central line to ensure that each of the lumens is satisfactory secured to the hub.We are unaware of any similar incidents. Alongside the in-hospital incident reporting system, this event has been reported to both the Medicines and Healthcare products Regulatory Agency (MHRA) and the manufacturers.
A replyDr Patterson has informed Arrow of the unfortunate incident at the Aberdeen Royal Infirmary. We are currently investigating the root cause of this incident to understand fully the issue and reason for failure, although this work is not yet complete. However, the failure described is a very rare occurrence, reported in 0.00006% of the several million Arrow catheters used worldwide each year. Regardless, given the critical nature of how our products are used, Arrow will consider additional process improvements that can be made, in addition to the many manufacturing and design improvements made over the past 35 years. In this particular case, we applaud the staff at the hospital, who quickly identified early warning signs and quickly Figure 1 Central venous cather hub, showing disconnection and open lumen.Anaesthesia
