Abstract
A patient bled from a Vascath when returning from a computed tomographic scan, resulting in a massive haemorrhage, cardiac arrest and severe hypoxic brain injury. The patient died nine days after the incident. Whilst the Coroner’s ruling was that the incident had not significantly contributed to the death, and indeed commended the report and subsequent actions, she has asked me to distribute these to the wider intensive care community.
This unfortunate incident highlights areas of improvement that are not unique to our Trust concerning the use of vascular access lines for computed tomography (CT), transfer of a critically ill patient and implementation of the Massive Haemorrhage Protocol (MHP) within hospital.
The investigation actions focused on the following:
Decision making relating to use of the Vascath to administer CT contrast Transfer of the patient between intensive care unit (ICU) and CT Activation of the MHP
The patient was a 77-year-old gentleman receiving treatment for mantle cell lymphoma. He was in multi-organ failure. An abdominal computed tomographic scan, with contrast, was performed to rule out bowel ischaemia as the patient had developed severe hyperlactataemia.
The patient was transferred with a competent ST4 anaesthetic trainee (completed his transfer competencies and had been on a transfer course), an ICU nurse and a porter.
Decision making relating to use of the Vascath.
The Vascath was used at the discretion of the anaesthetist, based on his experience.
Since the incident, we have an ICU policy regarding use of intravenous lines for connection and disconnection to CT contrast lines, based on flow rates through catheters and reduced risk of extravasation with high pressure.
In order of preference, the lines we now use are:
Peripheral cannula of 20 G or larger. Haemofiltration catheter Largest lumen on the central line
All Vascaths now have clear link bungs (one way valve bungs) attached to their lumens. The CT contrast line can be connected to this bung, obviating the need to remove the bung. These bungs need to be removed for haemofiltration.
Only a member of the ICU team can connect or disconnect the contrast line to central lines including Vascaths. The ICU team is responsible for ensuring the lumen is patent and safe to use. The responsibility for giving the drug remains with the radiographer.
These points are all now documented in the haemofiltration guidelines, transfer guidelines and radiographers’ guidelines.
Transfer of the patient between ICU and CT.
We have updated the transfer guidelines. The important new additions above the Intensive Care Society and Association of Anaesthetists of Great Britain and Ireland guidelines include safety checklists prior to leaving the unit and prior to return from an area of safety to ICU. The checklist includes recommendations specifically related to the incident.
Activation of the Major Haemorrhage Protocol
In stressful situations, miscommunication occurs. In this incident, the MHP was activated incorrectly.
There has been in-depth review of the MHP. Actions now include:
One method of MHP activation and a clear pathway Introduction of Haemosafe fridges with O negative or group specific blood available immediately in a number of locations within the hospital, including the ICU. Massive haemorrhage simulation training of all new doctors and all nursing staff
The family of the deceased patient showed great kindness and dignity throughout the investigation and court proceedings. Along with the Coroner, they wanted actions to be taken to help prevent this type of incident happening again. The family have fully consented to the publication of case details.
Serious incidents occur in all of our units. Critical Care Networks are showing some interest in sharing serious incident information, but we need to pool ideas so that our systems become more robust.
Consent
Written consent for the inclusion of clinical information in this letter was gained from the patient’s next of kin who also requested that the patient’s name not be withheld. Anyone seeking further information about the patient should contact the editorial office.