Liability Related to Peripheral Venous and Arterial Catheterization: A Closed Claims Analysis

Factors associated with intraoperative intravenous catheter extravasation in children

Summary

This retrospective study aimed to determine the incidence of and factors associated with peripheral intravenous extravasation in paediatric patients in the intraoperative setting. We conducted a retrospective study of 56,777 patients who underwent general anaesthesia and had peripheral intravenous catheter placement at Cincinnati Children’s Hospital between 1 January 2015 and 1 January 2017. Data collected included age, American Society of Anesthesiologists Physical Status Classification, catheter site, number of cannulation attempts, ultrasound use for cannulation, surgery duration, and surgery class. Primary outcome was peripheral intravenous extravasation using an extravasation assessment tool. Some 64,814 peripheral venous catheters were placed in patients undergoing general anaesthesia. Significant extravasation was documented in 40 catheters with an estimated incidence of 1 in 1620 venous catheters (0.06%). Of those 40 catheters, 47.5% ( n = 19) were placed using ultrasound and 37.5% ( n = 15) required more than one cannulation attempt. In multivariable analysis, peripheral intravenous catheter extravasation was associated with American Society of Anesthesiologists Physical Status Classification (3, 4, 5) versus (1, 2) (odds ratio 2.42 (95% CI 1.08 to 5.41)), inpatient versus outpatient surgeries (odds ratio 2.99 (95% CI 1.31 to 6.81)), and intravenous catheters placed with ultrasound guidance (odds ratio 8.01 (95% CI 4.12 to 15.57)). Our study identified factors associated with intraoperative peripheral intravenous extravasation, and will help develop mitigation strategies to minimise harm to patients.

Thermal injury from forced-air warmer device precipitated by massive extravasation from peripheral venous cannula

Extravasation injury (EVI) is an iatrogenic complication of venous cannulation. Usually innocuous but occasionally it engenders sequelae. Its severity is determined by various physicochemical properties of infusate. A 50-year-old patient developed leg EVI from crystalloids infused through a pressurized digital infuser (PDI), likely from cannula tip displacement during positioning for craniotomy. We ignored checking gravity-aided free-fluids flow before switching on PDI. Following surgery, the patient had an edematous leg with bullae and epidermal peelings from severe extravasation and burns, respectively. Doppler revealed patent leg arteries. Therefore, EVI was conservatively managed, with complete recovery. Apparently, increased local tissue pressure from extravasation produced conditions of peripheral circulation sufficiency predisposing the leg to thermal injury from the forced-air warmer. On inspecting PDI postoperatively, its upper-pressure alarm limit was 300 mmHg, which prevented it from sounding alarm during extravasation.

Isolated Compartment Syndrome of the Hand After Intravenous Doxycycline Infiltration Injury

Isolated compartment syndrome of the hand, although uncommon, can lead to considerable functional deficits if not treated promptly. The most common etiologies are related to trauma, burns, or electric injuries; however, some cases have been reported after intravenous infiltration events, particularly rapid intravenous contrast injection. In this case report, we describe the development of compartment syndrome in the hand of a critically ill patient with COVID-19 pneumonia and sepsis 16 days after doxycycline infiltration injury. She presented with worsening pain, swelling, bullous eruption, and intrinsic minus hand posturing. Emergent surgical release of intrinsic hand compartments and evacuation of a hematoma resolved her symptoms and preserved hand function. Early recognition and surgical intervention of compartment syndrome of the hand after infiltration injury in medically complex patients will reduce morbidity in this patient population.

Purposeful Hourly Rounding to Decrease Peripheral Intravenous Infiltrations and Extravasations in Pediatrics

PURPOSE

Pediatric patients are at high risk for peripheral intravenous infiltrations and extravasations (PIVIE) resulting in patient harm. Structured hourly rounding has demonstrated to improve quality outcomes. The purpose of this quality improvement project was to implement structured hourly rounding to decrease the median rate of moderate PIVIE rates from 3.13 to 2.58 per thousand patient days over a 6-month time period in pediatric patients with infusing continuous IV fluids.

DESIGN AND METHODS

A pilot was conducted to hardwire hourly assessments for peripheral intravenous lines (PIV) in pediatric patients with continuous fluids utilizing a structured hourly rounding process. Bedside nurses utilized the P.A.T.H. model to assess pain management (P), assess PIVs for early PIVIE recognition (A), address things patient and family may need (T), and reduce the occurrence in hospital acquired conditions (H). Data was collected on unit nurse sensitive indicators and compliance to hourly rounding.

RESULTS

Structured hourly rounding using the P.A.T.H. model successfully hardwired hourly PIV assessments. The unit reduced their median moderate PIVIE rate to 1.83 per thousand patient days, an 41% improvement. The pilot also had positive unintended consequences of improved pain reassessment from 67% to 100%, increased patient satisfaction scores of 67% to 97% and reduced patient falls by 29%.

CONCLUSIONS

Structured hourly rounding using the P.A.T.H. model can positively hardwire hourly PIV assessments in pediatric patients.

PRACTICE IMPLICATIONS

Sustainability of hourly rounding requires leadership support and nursing commitment to impact quality metrics. Organizations should consider implementing focused hourly rounding to address PIVIEs.

Development of an Alarm Algorithm, With Nanotechnology Multimodal Sensor, to Predict Impending Infusion Failure and Improve Safety of Peripheral Intravenous Catheters in Neonates

BACKGROUND

Peripheral intravenous catheters connected to an infusion pump are necessary for the delivery of fluids, nutrition, and medications to hospitalized neonates but are not without complications. These adverse events contribute to hospital-acquired patient harm. An artificial intelligence theory called fuzzy logic may allow the use of appropriate variables to predict infusion failure.

PURPOSE

This innovative study aimed to develop an intravenous infusion nanotechnology monitoring system that would alert the nurse to impending peripheral intravenous infusion failure.

METHODS

An intravenous infusion nanotechnology monitoring system, using predictor variables of pressure, pH, and oxygen saturation used in a fuzzy logic alarm algorithm was developed to alert the nurse to impending peripheral intravenous infusion failure.

FINDINGS

The developed intravenous infusion nanotechnology monitoring system is composed of a peripheral intravenous catheter with nanotechnology multimodal sensor, an intravenous pump, a fuzzy logic algorithm, and alarm. For example, using this system, an elevated in-line pressure, a low pH, and a low venous oxygen level would generate an alarm for possible impending infusion failure.

IMPLICATIONS FOR PRACTICE

With further development, this technology may help nurses predict and prevent adverse outcomes from intravenous infusions. This work shows how nurses can be content experts and innovators of technology that they use to make clinical decisions.

IMPLICATIONS FOR RESEARCH

After regulatory approval, a randomized controlled trial may be performed to investigate whether interventions at the time of an alarm would result in fewer adverse outcomes and improve safety.

Utility of color flow Doppler ultrasound to identify peripheral intravenous catheter position in adult surgical patients

Objective:

To evaluate color flow Doppler flow ultrasound compared to standard clinical techniques, to detect the intravascular position of peripheral intravenous catheters in adult surgical patients.

Methods:

A prospective study was conducted in adult (>18 years old) patients scheduled to undergo elective surgery. Peripheral intravenous catheter position was evaluated with standard clinical techniques (free flow of fluid from a hanging bag, easy saline injection, and aspiration of blood), and with color flow Doppler ultrasound proximal to the insertion site to identify intravascular catheter position. Comparative test performance was carried out.

Results:

In total, 174 patients were enrolled. The venous catheter was deemed to be intravascular in 92.53% (n = 161) and 90.23% (n = 157) based on clinical evaluation and color flow Doppler, respectively (p = 0.206). Moderate to substantial agreement between the two approaches was found. Cohen’s kappa was 0.64 (95% CI 0.43–0.83). Specificity of clinical judgment to detect catheter extravascular position was only 58.82%, when the color flow Doppler technique was set as the gold standard. Free flow from a hanging bag method showed the best agreement with color flow Doppler to determine intravascular position of a catheter (p = 0.3173, kappa = 0.68), with sensitivity of 98.09% and specificity of 64.71%.

Conclusion:

Color flow Doppler is a specific tool complementary to sensitive clinical indicators to detect peripheral venous catheter infiltration. The ability of color flow Doppler to accurately determine the position of a peripheral venous catheter depends on experience and familiarity with the tool by providers, who can master the technique with education and training.

Treatment of extravasation injuries in infants and young children: a scoping review and survey

BACKGROUND

Extravasation injuries are caused by unintended leakages of fluids or medicines from intravenous lines, but there is no consensus on the best treatment approaches.

OBJECTIVES

To identify which treatments may be best for treating extravasation injuries in infants and young children.

DESIGN

Scoping review and survey of practice.

POPULATION

Children aged < 18 years with extravasation injuries and NHS staff who treat children with extravasation injuries.

INTERVENTIONS

Any treatment for extravasation injury.

MAIN OUTCOME MEASURES

Wound healing time, infection, pain, scarring, functional impairment, requirement for surgery.

DATA SOURCES

Twelve database searches were carried out in February 2017 without date restrictions, including MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus and EMBASE (Excerpta Medica dataBASE).

METHODS

Scoping review - studies were screened in duplicate. Data were extracted by one researcher and checked by another. Studies were grouped by design, and then by intervention, with details summarised narratively and in tables. The survey questionnaire was distributed to NHS staff at neonatal units, paediatric intensive care units and principal oncology/haematology units. Summary results were presented narratively and in tables and figures.

RESULTS

The evidence identified in the scoping review mostly comprised small, retrospective, uncontrolled group studies or case reports. The studies covered a wide range of interventions including conservative management approaches, saline flush-out techniques (with or without prior hyaluronidase), hyaluronidase (without flush-out), artificial skin treatments, debridement and plastic surgery. Few studies graded injury severity and the results sections and outcomes reported in most studies were limited. There was heterogeneity across study populations in age, types of infusate, injury severity, location of injury and the time gaps between injury identification and subsequent treatment. Some of the better evidence related to studies of flush-out techniques. The NHS survey yielded 63 responses from hospital units across the UK. Results indicated that, although most units had a written protocol or guideline for treating extravasation injuries, only one-third of documents included a staging system for grading injury severity. In neonatal units, parenteral nutrition caused most extravasation injuries. In principal oncology/haematology units, most injuries were due to vesicant chemotherapies. The most frequently used interventions were elevation of the affected area and analgesics. Warm or cold compresses were rarely used. Saline flush-out treatments, either with or without hyaluronidase, were regularly used in about half of all neonatal units. Most responders thought a randomised controlled trial might be a viable future research design, though opinions varied greatly by setting.

LIMITATIONS

Paucity of good-quality studies.

CONCLUSIONS

There is uncertainty about which treatments are most promising, particularly with respect to treating earlier-stage injuries. Saline flush-out techniques and conservative management approaches are commonly used and may be suitable for evaluation in trials.

FUTURE WORK

Conventional randomised trials may be difficult to perform, although a randomised registry trial may be an appropriate alternative.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Surgical treatment of extravasation injuries: experience of the Hospital das Clínicas, Faculty of Medicine, University of São Paulo

OBJECTIVE

to report the experience of the Division of Plastic Surgery of the Hospital das Clínicas of the Medical School of the University of São Paulo in the treatment of cutaneous lesions due to accidental extravasation of drugs.

METHODS

we included patients with lesions due to extravasation of drugs over a period of 18 months. We retrospectively evaluated the following parameters: age, diagnoses during hospitalization and comorbidities, serum levels of albumin and hemoglobin, place of hospitalization, drug involved, anatomic segment affected, therapeutic management and death during hospitalization.

RESULTS

we followed-up 14 patients. The main drug involved was noradrenaline (21%). All patients underwent debridement of tissue necrosis. Three patients were submitted to flaps after preparation of the wound bed with negative pressure therapy, with good results. Seven patients had no definitive treatment of their lesions due to lack of clinical conditions.

CONCLUSION

in patients with favorable clinical conditions, the definitive treatment with flaps was adequate for cases of wounds due to extravasation of drugs in the subcutaneous tissue when there was exposure of noble structures.

Disabling Outcomes After Peripheral Vascular Catheter Insertion in a Newborn Patient: A Case of Medical Liability?

Patient: Female, newborn

Final Diagnosis: Loss of falange of the hand

Symptoms: Manual disability • Pain

Medication: Ampicilline

Clinical Procedure: Insert vascular catheter

Specialty: Forenscic Medicine

Vascular air embolism: A silent hazard to patient safety

PURPOSE

To narratively review published information on prevention, detection, pathophysiology, and appropriate treatment of vascular air embolism (VAE).

MATERIALS AND METHODS

MEDLINE, SCOPUS, Cochrane Central Register and Google Scholar databases were searched for data published through October 2016. The Manufacturer and User Facility Device Experience (MAUDE) database was queried for "air embolism" reports (years 2011-2016).

RESULTS

VAE may be introduced through disruption in the integrity of the venous circulation that occurs during insertion, maintenance, or removal of intravenous or central venous catheters. VAE impacts pulmonary circulation, respiratory and cardiac function, systemic inflammation and coagulation, often with serious or fatal consequences. When VAE enters arterial circulation, air emboli affect cerebral blood flow and the central nervous system. New medical devices remove air from intravenous infusions. Early recognition and treatment reduce the clinical sequelae of VAE. An organized team approach to treatment including clinical simulation can facilitate preparedness for VAE. The MAUDE database included 416 injuries and 95 fatalities from VAE. Data from the American Society of Anesthesiologists Closed Claims Project showed 100% of claims for VAE resulted in a median payment of $325,000.

CONCLUSIONS

VAE is an important and underappreciated complication of surgery, anesthesia and medical procedures.

Bedside Ultrasound: A Tool for Assessment of IV Functionality

Supplemental Digital Content is available in the text.

A Simple Diagnostic Test to Confirm Correct Placement of Dysfunctional Central Venous Catheters Before Chemotherapy in Children

BACKGROUND

In children undergoing intravenous chemotherapy, partial dysfunction of the central venous catheter (CVC) is common. Fluids can be infused into the catheter; however, blood cannot be aspirated. In those situations, chemotherapy is withheld and a catheter investigation is performed. Usually, a radiographic study with contrast media or therapy with thrombolytic drugs followed by rechecking for blood return is undertaken.

AIM

To evaluate if a previously described method using dilute sodium bicarbonate injection and the resultant rise in measured end-tidal carbon dioxide tracing can confirm correct intravascular placement of a dysfunctional CVC in children at the bedside.

PATIENTS

Cohort group of 22 children scheduled for chemotherapy with partial dysfunction of a CVC in a tertiary hematology-oncology care facility.

RESULTS

All children with a partial dysfunctional CVC that was proven to be intravascular after venogram or thrombolytic therapy had a distinct and predictable increase in end-tidal carbon dioxide response to injected bicarbonate.

CONCLUSION

Injection of 1 mL/kg (maximum 20 mL) of 4.2% dilute sodium bicarbonate is a quick, simple, bedside test allowing confirmation of intravascular location of dysfunctional CVC.

A functional test for the detection of infusion lines extravasation

Extravasation during intravenous (IV) infusion is a common secondary effect with potentially serious clinical consequences. The correct positioning of the needle in the vein may be difficult to confirm when no blood return is observed. In this paper, a novel method is proposed for the detection of extravasation during infusion therapy. A small volume of a sodium bicarbonate solution is administrated IV and, following its consecutive dissociation, an excess of carbon dioxide (CO2) is rapidly exhaled by the lungs. The analysis of the exhaled CO2 signal by a pattern recognition algorithm enables the robust detection of the CO2 excess release, thereby confirming the absence of extravasation. Initial results are presented for the application of the method on a group of 89 oncology patients.

Increasing nurse competence in peripheral intravenous therapy

Infiltration and phlebitis are common complications associated with peripherally inserted vascular (PIV) therapy. This performance improvement plan included a pretest, a competency-based training module, and a posttest to determine whether nursing knowledge of infiltration and phlebitis improved. The postintervention data revealed a 50% reduction in infiltration and phlebitis. Annual education requirements combined with competency skills for assessing PIV catheter sites will provide nursing staff with the knowledge and tools to change current practice.

Management of extravasation injuries: a focused evaluation of noncytotoxic medications

Extravasations are common manifestations of iatrogenic injury that occur in patients requiring intravenous delivery of known vesicants. These injuries can contribute substantially to patient morbidity, cost of therapy, and length of stay. Many different mechanisms are behind the tissue damage during extravasation injuries. In general, extravasations consist of four different subtypes of tissue injury: vasoconstriction, osmotic, pH related, and cytotoxic. Recognition of high-risk patients, appropriate cannulation technique, and monitoring of higher risk materials remain the standard of care for the prevention of extravasation injury. Prompt interdisciplinary action is often necessary for the treatment of extravasation injuries. Knowledge of the mechanism of extravasation-induced tissue injury, agents for reversal, and appropriate nonpharmacologic treatment methods is essential. The best therapeutic agent for treatment of vasopressor extravasation is intradermal phentolamine. Topical vasodilators and intradermal terbutaline may provide relief. Intradermal hyaluronidase has been effective for hyperosmotic extravasations, although its use largely depends on the risk of tissue injury and the severity of extravasation. Among the hyperosmotic agents, calcium extravasation is distinctive because it may present as an acute tissue injury or may possess delayed clinical manifestations. Extravasation of acidic or basic materials can produce significant tissue damage. Phenytoin is the prototypical basic drug that causes a clinical manifestation known as purple glove syndrome (PGS). This syndrome is largely managed through preventive and conservative treatment measures. Promethazine is acidic and can cause a devastating extravasation, particularly if administered inadvertently through the arteriolar route. Systemic heparin therapy remains the accepted treatment option for intraarteriolar administration of promethazine. Overall, the evidence for managing extravasations due to noncytotoxic medications is nonexistent or limited to case reports. More research is needed to improve knowledge of patient risk, prompt recognition of the extravasation, and time course for tissue injury, and to develop prevention and treatment strategies for extravasation injuries.

Peripheral intravenous catheter infiltration: anesthesia providers do not adhere to their own ideas of best practice

STUDY OBJECTIVE

To survey anesthesia providers for their opinion on "best practice" in perioperative peripheral intravenous catheter (PIV) management, and to determine if they follow those opinions.

DESIGN

Survey instrument.

SETTING

Academic medical center.

SUBJECTS

266 United States (U.S.) anesthesia provider respondents (attending anesthesiologists, anesthesiology residents, anesthesia assistants, certified registered nurse-anesthetists and student registered nurse-anesthetists).

MEASUREMENTS

Between May 2009 and October 2010 a national survey was distributed to individuals who provide intraoperative anesthesia care to patients. Results were gathered via the SurveyMonkey database.

MAIN RESULTS

266 anesthesia providers from across the U.S. took part in the survey. The majority (70%) had less than 5 years' experience. Nearly 90% of respondents cared for a patient with an intravenous catheter infiltration at some point during their training; 7% of these patients required medical intervention. Intravenous assessment and documentation practices showed great variability. Management and documentation of PIVs was more aggressive and vigilant when respondents were asked about "best practice" than about actual management.

CONCLUSION

There is no commonly accepted standard for management and documentation of PIVs in the operating room. From our survey, what providers think is "best practice" in the management and documentation of PIVs is not what is being done.

Venous air embolism leading to cardiac arrest in an infant with cyanotic congenital heart disease

Gas emboli, including venous and arterial, are a rare but important complication of pediatric cardiac surgery. They have the potential to have devastating consequences and require prompt recognition and treatment. We present a case of gas embolism occurring in the immediate postoperative period in an infant with cyanotic congenital heart disease after palliative cardiac surgery resulting in cardiopulmonary arrest. The embolism was diagnosed by visualization of air within the vessel creating an airlock and occluding pulmonary blood flow.

Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by patients and providers

BACKGROUND

Mandatory and voluntary reporting of adverse events is common in health care organizations but a more accurate understanding of the extent of patient injury may be obtained if additional sources are used. Patients in Sweden may file a claim for economic compensation from the national insurance system if they believe they have sustained an injury. The extent and pattern of reporting of serious adverse events in a mandatory national reporting system was compared with the reporting of adverse events on the basis of patient claims.

METHODS

Regional sentinel event reports were compared with malpractice claims data between 1996 and 2003. A sample consisting of 113 patients with deaths or serious injuries was selected from the malpractice claims data source. The medical records of these patients were reviewed by three chief medical officers.

RESULTS

Of the deaths or injuries associated with the 113 patients-25 deaths, 37 with more than 30% disability, and 51 with 16/o-30% disability-23 (20%) had been reported by chief medical officers to the National Board of Health and Welfare as sentinel events. Most adverse events were found in orthopedic surgery, and orthopedic injuries had more serious consequences. None of the patient injuries caused by infections were reported as sentinel events. Individual errors were more frequent in cases reported as sentinel events.

CONCLUSIONS

Adverse events causing severe harm are underreported to a great extent in Sweden despite the existence of a mandatory reporting system; physicians often consider them to be complications. Health care organizations should consider using a portfolio of tools-including incident reporting, medical record review, and analysis of patient claims-to gain a comprehensive picture of adverse events.

Bring Out Your Data

Recent healthcare legislation, financial pressures, and regulatory oversight have increased the need to create improved mechanisms for performance measurement, quality management tracking, and outcomes-based research. The Anesthesia Quality Institute (AQI) has established the National Anesthesia Clinical Outcomes Registry (NACOR) to support these requirements for a wide-range of customers including individual anesthesiologists, anesthesia practices, hospitals, and credentialing agencies. Concurrently, the availability of increased digital sources of healthcare data make it possible to capture massive quantities of data in a more efficient and cost-effective manner than ever before. With NACOR, AQI has established a user-friendly, automated process to effectively and efficiently collect a wide-range of anesthesia-related data directly from anesthesia practices. This review will examine the issues guiding the evolution of NACOR as well as some potential pitfalls in its growth and usage.

Study of placing a second intravenous line in trauma

OBJECTIVE

We evaluated the benefit of emergency medical services providers' placing a second intravenous (IV) line in the prehospital trauma setting. Our hypothesis was that the placement of a second IV catheter in trauma does not result in an improvement in heart rate, blood pressure, rehospitalizaton rate, or 30-day mortality.

METHODS

A retrospective chart review of 320 trauma patients in a one-year period was conducted at our level I trauma center. All trauma patients who had vascular access obtained prehospitally were included.

RESULTS

Patients with two IV lines received an average of 348.4 mL more fluid (95% confidence interval [CI]: 235.6, 461.1; p < 0.0001). No change in heart rate, pulse oximetry, Glasgow Coma Scale score, systolic blood pressure, rehospitalization rate, or 30-day mortality was noted. These effects persisted for patients who were initially tachycardic (heart rate 3.92 bpm; 95% CI ?3.01, 10.82; p = 0.27) or hypotensive (blood pressure 22.00 mmHg; 95% CI ?4.17, 48.16; p = 0.10).

CONCLUSIONS

Redundant prehospital IV lines provided no noticeable benefit in physiologic support for trauma patients. When controlling for confounding variables, no significant outcome difference was noted, even in the hypotensive patients. The traditional approach for establishment of a secondary IV line in prehospital trauma patients should not be followed in a dogmatic fashion.