Departure From Central Line Ritual
A man with a history of poorly controlled diabetes and pancreatic insufficiency was found unresponsive. Paramedics transported him to the emergency department, where a resident placed a right internal jugular line for access but was unable to confirm placement. The resident pulled the line, opened a second line insertion kit, started over, and confirmed placement with ultrasound. The patient went into cardiac arrest, and a chest radiograph noted a retained guidewire in the pulmonary artery. Dustin W. Ballard, MD, MBE; David R. Vinson, MD; and Dustin G. Mark, MD, all of Kaiser Permanente, apply the Haddon Matrix to an incident involving a retained guidewire after central venous catheterization to illustrate opportunities to avert a preventable error.
Departure From Central Line RitualCommentary by Dustin W. Ballard, MD, MBE; David R. Vinson, MD; and Dustin G. Mark, MD
A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alcohol and cocaine abuse was found unconscious by his neighbors. The patient had last been seen 2 days prior and complained of dizziness, thirst, and nausea. Emergency medical services found him unresponsive, with a Glasgow Coma Scale score of 3. He was intubated in the field. Upon arrival in the emergency department (ED), his pH was less than 6.8, carbon dioxide 37 mm Hg, oxygen 80 mm Hg, potassium 7.8 mEq/L, glucose 1400 mg/dL, lactate 11.2 mg/dL, and anion gap 42 mEq/L.
A right internal jugular line was placed for access. The resident who placed the line was relatively experienced in line placement but was unable to confirm placement with ultrasound. Instead he used manometry, which was not a part of the normal ED routine for line placement. He ultimately chose to pull the line. Just then, another trauma patient arrived, and the supervising attending physician left the room. The resident opened a second line insertion kit and restarted the process. Ultrasound was used to confirm correct placement. Upon flushing the line, it was noted that one of the ports was not working. The patient soon went into atrial tachycardia, which broke with adenosine. A chest radiograph was not obtained until later, after the patient went into ventricular fibrillation in the intensive care unit.
When the chest radiograph was finally completed, a retained wire was noted in the pulmonary artery. The interventional radiology team was consulted for wire removal. The retained wire likely caused a cardiac arrest, which required shocks, chest compressions, and cooling. After guidewire removal, the patient had no further episodes of arrhythmias, but experienced several other serious complications during a prolonged and stormy hospitalization.