PC is a 22-year-old gentleman with a history of sickle cell crisis presented to ER for shortness of breath and eventually diagnosed sepsis and pneumonia. He was admitted. The plan was to receive a reverse blood transfusion, so they wished to do a venous catheter in the right IJ. General surgeon was asked to place this catheter bedside. During this ultrasound-guided attempt, Dr. perforated the subclavian artery. He immediately developed a large hematoma and was tachycardic. Rapid response was called and a stat chest x-ray revealed right-sided pleural effusion and large hemothorax. Chest tube was placed and was transferred to ICU. PC was then sent for a CTA chest which revealed a large hemothorax with heart and mediastinal shift to the left. Sight of bleeding appeared to be the anterior wall of this subclavian artery, just proximal to the IMA.
PC was emergently sent to a different hospital for higher level of care and vascular surgery. Found a very large hemopneumothorax that was not properly draining through the chest tube due to retained clots in the mediastinal space. The operative note states that there were multiple episodes of cardiac arrest due to exsanguination from the subclavian artery. The eventual surgical repair and thoracotomy for the evacuation of the pneumothorax was completed without any further complications. He did undergo the exchange transfusion and was managed in the ICU. He continued the antibiotic course and was eventually resolved of all symptoms and was discharged home.
The mother claims that he has had extensive psychological and emotional trauma as well as a very large scar to his chest and neck.
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Do you believe there might have been medical error?
This is a known complication of this procedure. The internal jugular vein can be accessed using a standard introducer needle with or without the aid of a seeker needle, angiocatheter over needle combination, or micropuncture kit There is a learning curve for central venous access procedures. Experienced operators enjoy greater success rates with fewer complications; among both experienced and inexperienced operators, an increased number of introducer needle passes correlates with increased complication rates, which are significantly higher after two to three unsuccessful passes. If three needle pass attempts have been made, the needle should be completely removed and the site reassessed, a new access site chosen, or assistance obtained from a more experienced clinician. Isolated arterial needle puncture is one of the most common complications of venous access but is typically uneventful if recognized. If the carotid artery is inadvertently punctured, withdraw the needle and apply pressure over the site for 5 to 10 minutes. Jugular venous access can be reattempted provided anatomic and ultrasound landmarks are not distorted by hematoma. No additional studies are generally required in the absence of findings to suspect ongoing arterial bleeding. By contrast, dilation and cannulation of the carotid artery is a more significant problem, as it is associated with vessel injury, thrombosis, major stroke, and hemorrhage. While smaller standard catheters pose lower risk, larger-bore catheters, such as dialysis catheters, are associated with higher rates of vascular complications. If carotid catheterization is confirmed, the catheter should be left in place and a vascular surgery consultation obtained immediately
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
A potential complication associated with central venous access is inadvertent needle puncture of an associated artery (eg, common femoral artery, carotid artery, innominate artery, subclavian artery, vertebral artery) instead of the targeted vein. Arterial puncture is noted to occur in about 5 percent of all central venous access procedures, with reported incidences ranging from 1 to 11 percent. It remains uncertain when and if coagulation defects should be corrected prior to elective central venous catheter placement. However, the consistent use of ultrasound during central venous access decreases the incidence of vascular complications. Inadvertent arterial puncture is typically reported to occur in less than 1 percent of access cases when ultrasound-guided access is used
What makes you a good expert for this case?
Lots of experience with these procedures and cases. I have reviewed this type of case and still perform these procedures. If everything was done correctly, this complication could still occur even in the best of hands
How often do you encounter cases similar to this one in your practice?
In our facility we see this type of injury unfortunately all to common. This is a residents run facility and we have a lot of learners and even though we teach the proper technique these complications can occur more than we would like to see
Do you believe there might have been medical error?
While accessing the internal jugular vein using ultrasound one should be able to visualize the passage of the guide wire clearly. Perforating the subclavian artery indicates an error in technique. I understand there being an arterial puncture but to have a perforation and significant hemothorax in the absence of a bleeding disorder suggests a larger opening and error in identification of structures.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is likely the procedure happened due to mistaken identification of anatomy. If the subclavian artery was punctured in an ultrasound guided neck catheter insertion, it usually suggests a misadventure Further it appears that the blood vessel was actually dilated rather than just punctured causing the severe bleeding.
What makes you a good expert for this case?
I am a pediatric surgeon who does venous access all the time on children.
How often do you encounter cases similar to this one in your practice?
5-10 times a month. We provide vascular access to children and adolescents year around at the children’s hospital.
Do you believe there might have been medical error?
This is a difficult case to evaluate. It is reported that an ultrasound was used which is the standard of care, but, if used properly (meaning that the U/S image shows the needle entering the IJ in real time), it is very unlikely that this complication could occur. Once the complication occurred, the patient seemed to have an appropriate evaluation, but I would never put someone in an ambulance with a mediastinal shift, although if he was hemodynamically normal and there were not capabilities in the hospital to handle the situation, then transferring may be appropriate. The patient needed massive resuscitation at the accepting facility and it is not clear from the record that a massive transfusion was done at the second hospital to help avoid the multiple cardiac arrests.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Sere my above response. I think that if used properly, an ultrasound guided placement in the right IJ would be standard of care, but it seems that is would be very unlikely to damage the subclavian artery with this approach if used correctly.
What makes you a good expert for this case?
I am board certified in general surgery and critical care. I have 18 years of post-residency experience at a busy verified level on trauma facility. I am the medical director of the acute care surgery section at our hospital.
How often do you encounter cases similar to this one in your practice?
We put in several central lines per week and do see patients with sickle cell anemia. I am very adept at placing central venous access in elective and urgent situations and also managing complications of their placement and use.
Do you believe there might have been medical error?
This is a known complication of CVC. Complication rate is of subclavian or common carotid artery puncture is 6-9% for internal jugular vein catheters. It would be interesting to know if this was only from the needle or was the artery dilated with the sequential dilators as well. If dilated that would be an error. Also I would like to know the timing and treatment of the bleeding…as in was the patient given TXA, platelets, if the patient has a large hemothorax with hemodynamic compromise and was not given massive transfusion protocol this could be an error. Placement or size of the chest tube could also be an error. Depending on the patients size manual compression of the artery could have slowed and or stopped the bleeding. If he was skinny and manual compression was not used this could be an error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This complication led to bleeding. There might be an error which led to continued bleeding and need for the thoracotomy.
What makes you a good expert for this case?
I’ve done at least 500 or more CVCs. I’ve punctured the subclavian artery myself and compressed the artery manually to stop the bleeding. I’ve put in at least 500 chest tubes and have done about 50 thoracotomies 10-20 emergent.
How often do you encounter cases similar to this one in your practice?
Not often but I’ve seen a handful.
Do you believe there might have been medical error?
The subclavian artery injury was directly resulted from this procedure. Other questions to consider: - Did the surgeon attempt IJ or subclavian? - How many attempts were made? - Did the surgeon dilate the artery after having placed the wire? Either way, this catastrophic injury is a direct result of the procedure.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The injury led to massive hemorrhage and hemorrhagic shock. The injury is directly related to the procedure. Here is what can be said about causation in this case: res ipsa loquitur
What makes you a good expert for this case?
I am a trauma/critical care surgeon and I perform this procedure regularly. I am dual board certified in general surgery and surgical critical care. I am the Trauma Medical Director and Department of Surgery Chair.
How often do you encounter cases similar to this one in your practice?
Central venous catheters is part of my daily practice.
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