A closed claims analysis of injuries and liability related to central venous catheters was presented at the APSF/ASA booth during the October 2004 ASA meeting. The presentation was based on a paper which appeared in Anesthesiology in June 2004 by Domino, Cheney et al. Since 1988 the ASA Closed Claims Project has published evaluations of adverse anesthetic outcomes obtained from the closed files of US liability insurance companies. The adverse events occurred between 1970 and 2000 and reflect claims through 2002. The purpose of the review was to identify and describe patterns of injury and liability associated with central venous or pulmonary artery catheters.
Closed claim files contain source materials including medical records, depositions, peer and expert reviews, outcome reports, and so forth. A practicing anesthesiologist reviewer using standardized instructions extracts predefined information regarding the case and its outcome. All claims for injuries primarily resulting from a central catheter were analyzed. A primary damaging event involving a central catheter was identified by the on-site reviewer and confirmed by the Closed Claims Committee. The specific type of complication was next determined by 2 of the authors.
Complications were subdivided into use/maintenance or access related. Access versus use complications were assessed for 4 periods: 1978-1983, 1984-1988, 1989-1993, and 1994-1999. Ultimately a statistical comparison before and after 1989 was made. Patient injuries were evaluated for theoretical preventability. While closed claims analysis does not directly measure risk, it does provide an opportunity to evaluate liability and injuries over time as practice patterns change.
The catheters were inserted by an anesthesiologist alone or with a surgeon in 90% of claims. Sixty-eight percent of claims for complications associated with use involved nonanesthesia providers. Compared to all other claims, central catheter (CC) claims occurred in more ASA 3-4 patients and involved a higher proportion of patients who died. The proportion of claims judged to be associated with substandard care was 45%.
Seventy-five percent of the complications were related to wire/catheter embolus, cardiac tamponade, carotid artery encroachment, or hemo/pneumothorax. Wire and catheter emboli occurred with both insertion and removal and were associated with more substandard care (82%) than other CC claims. Cardiac tamponade was more often associated with use/maintenance than insertion, and 81% resulted in the patient’s death. In many claims the tamponade became symptomatic 1-5 days postoperatively. Thirty percent of the claims were in pediatric patients. In some cases an x-ray showing right atrial position of the catheter was obtained without subsequent adjustment by the anesthesiologist.
Carotid artery puncture/cannulation resulted in stroke, arterial surgery, and airway obstruction. Vessel recognition by ultrasound or transduction was not verified in any carotid artery case. Hemothorax occurred after subclavian and internal jugular cannulation resulting in a 93% death rate. Injuries to the subclavian vein/artery, innominate artery, and superior vena cava were seen. Pneumothorax had a lower proportion of death (15%) and frequently involved internal jugular cannulation. Pulmonary artery rupture involved a higher proportion of elderly women, was often not associated with cardiac surgery, and in all cases, resulted in death. The authors surmised that human factors were likely to be important in cases of wire/catheter embolus. They specifically observed an increased risk of cardiac tamponade in pediatric patients and stressed the importance of x-ray confirmation of catheter position after CC placement. Severe complications after cannulation of the carotid artery with even a 16 or 18 gauge cannulae were noted.
The proportion of claims for access injury increased and for use/maintenance decreased over the study decades. Almost half the CC claims were thought by the authors to be preventable. Techniques cited to possibly prevent injury included ultrasound guidance and pressure waveform monitoring during placement. Chest x-ray to detect wire/catheter fragments and confirm correct location was also suggested.
Thus the Closed Claims analysis presented at the Patient Safety Booth identified the types and severity of central catheter injuries resulting in claims over 3 decades. The analysis provides us with invaluable insight in an area of immense concern for anesthesiologists. The strength of the study lies in the conclusions regarding possible preventability and the resultant recommendations. We look forward to further efforts by the Closed Claims Study Group.
Dr. Christie is an Associate Professor of Anesthesiology at the University of South Florida’s College of Medicine. She also serves on the APSF Board of Directors.