This Signal is about the risk of air embolism when removing central lines.
A sample report extract reads:
“... I was called urgently to the ward as the patient had apparently turned blue, and collapsed whilst [the central line] was being removed... A cardiac arrest call was instigated just before I arrived. The patient was blue, unconscious and on 15L O2. I asked the sister what had happened. A staff nurse had removed it and soon afterwards the patient had lost consciousness and turned blue. I asked her what position the patient was in and she said sitting bolt upright.”
A search of incidents reported to the National Reporting and Learning System (NRLS) between June 2009 and June 2011 found eleven reports describing that patients suddenly deteriorated following intentional removal of a central line. Patients involved in these incidents became breathless, confused, unconscious or sustained a cardiac arrest.
In almost all reports it was stated that staff did not follow correct procedures and removed the catheter whilst the patient was sitting up. However, clinical guidelines, e.g. the Guidelines on the insertion and management of central venous access devices in adults (2007) from the British Committee for Standard in Haematology, recommend that the patient should lie down to avoid the potentially fatal complication of air embolus.
There were also 25 incidents describing the accidental removal of central lines. In some cases the line was not secured correctly and some incidents occurred when the patient was turned or mobilised.
NHS organisations should ensure that:
· Staff are aware of complications associated with removal of central lines and the precautions to prevent air embolus;
· removal of central lines is only undertaken by trained and experienced staff;
· local policies include techniques for securing and removing central lines; and
· extra care is provided when turning or mobilising a patient with a central line.
We would like to hear from you - please contact us with your initiatives to reduce risks in these areas.
Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA