The Sequelae of Silence: Catheter Entrapment as a Preventable Morbidity Resulting from Communication Failure

Abstract

A 72-year-old male required reoperative mitral valve replacement surgery for culture negative endocarditis. Intraoperatively, a central venous catheter was placed without communication between the surgical and anesthesia teams. Despite a seemingly uneventful operative and post-operative course, prior to discharge, the catheter was unable to be removed and necessitated surgical removal. Bidirectional communication during cardiovascular surgery is key to achieving optimum outcomes. Fortunately, it often requires many errors to lead to unnecessary morbidity, however sometimes it takes but one.

Central line complications

“…[ 30 31 32 ] Additionally, lines can become entrapped by suture placement during cardiothoracic surgery. [ 33 ] To avoid this complication that requires reoperation for suture removal, free mobility of all lines should be tested at the conclusion of cardiovascular cases. In general, surgical removal in stable patients is often preferred in any type of catheter entrapment prior to the development of complications, especially if complications are the direct result of attempts at removal (such as catheter fragmentation, further distal embolization to harder to reach areas, such as the right ventricle or pulmonary arteries, or access site injuries).…”