Central lines are essential for the care of many patients, however we estimate at least one patient dies worldwide every day from central line related air emboli (see here).
All of these cases are avoidable.
They tend to occur from:
1. Accidental line disconnections
2. During line removal if patients are sat upright
3. On insertion of larger lines (e.g. Tunnelled Vas Caths) with patients breathing spontaneously, generating negative intrathoracic pressure.
1. Central lines and their attachments do not need to open to air. We should ensure that only vascular access devices and attachments with moulded valves are used. In Australia the TGA have approved use of the Kimal Altius Central Lines – we look forward to trialling these soon.
2. We have created an awareness video animation focussed on removing central lines supine. This was available for release in December 2016. We are awaiting approval from the CEC NSW to release the video to the wider public.
3. We have liased with several central line dressing manufacturers to develop dressings with the phrase ‘Remove Central Lines Supine”To avoid air emboli‘ imprinted on them as a point of care message to staff.
4. According to the MAGIC guidelines approximately 50% of central line insertions are inappropriate.
Minimise the risk of avoidable central line related air emboli in your hospital.
You attend a cardiac arrest on the ward. The nurse, who was ambulating the patient after their fluids were disconnected, informs you the patient had rapidly deteriorated. That is when you notice the central line lumens had been left open to air. Your suspicions of air embolus are supported on echocardiography, however despite resuscitative attempts the patient dies in ICU two days later. The unfortunate nurse involved subsequently quits nursing altogether.
We estimate from worldwide reports there is at least one death every day from a central line air embolus – all cases are avoidable. (see here)
Awareness about this issue is poor, and solutions so far implemented have had limited effect. We need to appreciate the complexity of our work environments and apply human factors engineering if we are to prevent these iatrogenic complications.
The power is in your hands to make a difference. Review and implement these 5 effective solutions:
2. Vascular Access Decision Tree
3. Centralised Education and Training
4. Awareness Campaign
5. Central Line Management Form
See: Central Line Related Air Embolism – Applying Human Factors to the Design of Safe Systems