Episode #45 Perils, Pitfalls, and PIVs

May 18, 2021

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

Today, we return to the Rapid Response to Questions from our Readers Column for a review of safety concerns when using a Rapid Infusion Catheter. You can find the article here. https://www.apsf.org/article/perils-and-pitfalls-with-the-rapid-infusion-catheter-ric/

Some of the important considerations that may have led to the failure to remove the RIC dilator included the following:

  1. Anesthesia professional knowledge, skill, and experience with RIC placement
  2. Supervising anesthesiologist ability to intervene to ensure correct placement
  3. Lack of a warning label on the preloaded dilator with instructions to remove dilator prior to transfusion
  4. Ability to securely connect IV tubing to the dilator

We encourage you to stay vigilant during RIC placement.

The second Rapid Response that we review today comes from the October 2018 APSF Newsletter. It is “Burette Malpositioned Shut Off Valve Could Lead to Venous Air Embolism” by Duncan-Azadi and colleagues. You can find the article here. https://www.apsf.org/article/burette-malpositioned-shut-off-valve-could-lead-to-venous-air-embolism/

This is another time to stay vigilant in the OR and ensure that the burette remains in the upright vertical position so that the floating shut off valve continues to function properly.

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© 2021, The Anesthesia Patient Safety Foundation

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show. Obtaining appropriate IV access including the type, peripheral or central, location of the access site, number of peripheral IVs needed for the case, and size of desired IV catheter are all factors when it comes to being able to resuscitate patients and administer medications during surgery and anesthesia care. We hope you are ready for a thrilling show today because we are talking about perils and pitfalls of a certain type of IV catheter.

Before we dive into today’s episode, we’d like to recognize ICU Medical, a major corporate supporter of APSF. ICU Medical has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, ICU Medical – we wouldn’t be able to do all that we do without you!”

Today, we will be reviewing a Rapid Response to questions from our readers related to the Rapid Infusion Catheter or RIC line. To follow along with us, head over to APSF.org and click on the Newsletter heading. Third one down is Rapid Response. From here scroll down and click on the second page and our featured article is the second one down. It is called “ Perils and Pitfalls With the Rapid Infusion Catheter (RIC)” by McDaniel, Kiberenge, and Gould. This Rapid Response article first appeared in the February 2020 APSF Newsletter. Do you remember seeing this article in the Newsletter? Well, we are so excited to be reviewing it today.

The authors start with a summary and describe the use of the RIC line to quickly provide a large volume of intravenous fluids for resuscitation. Do you place RICs as part of your practice? This catheter in particular is a high-flow, low-resistance catheter which can be placed in a large peripheral vein after first placing a smaller IV and then placing a guidewire, followed by the catheter over the dilator. There is a risk for patient injury and loss of IV access if the RIC is not placed appropriately and carefully.

With that, let’s get into the article. The rapid infusion catheter is notable because prior to placing this catheter, a smaller peripheral IV catheter must be placed into a large peripheral IV. The RIC is a large bore catheter measuring 8.5Fr and the smaller peripheral IV is exchanged over a wire for the larger RIC line. The authors present a case where this type of catheter was placed for a patient undergoing liver transplantation. In the introduction, the authors write Dear Rapid Response, “This case illustrates once again how inexperience or unfamiliarity with invasive devices such as this ‘simple’ intravenous catheter has the potential for perioperative complications and significant patient injury.”

And now it is time to reveal the perils of the RIC in the following case presentation of a 47 year-old man with atrial fibrillation and hepatocellular carcinoma who presented to the OR for a deceased donor liver transplant. The patient tolerated induction of general anesthesia and intubation. Then, an 8.5Fr Rapid Infusion Catheter was placed in order to provide large volume resuscitation during the case. The authors reveal that the RIC was placed with the standard insertion technique with a 20g PIV catheter placed in the right antecubital brachial vein, through which the RIC guidewire was placed. Then the RIC vein dilator 8.5Fr catheter assembly was advanced over the wire and into the vein. In order to confirm of correct placement of the RIC, IV tubing was connected to the dilator hub to transduce the vascular pressure and venous placement was confirmed. After this, the anesthesia professional did not remove the dilator (which is the appropriate next step) and instead connected the Rapid Infusion System directly to the RIC dilator. The authors include pictures of the standard RIC setup and the inappropriate connection between the RIC dilator and the infusion system. I encourage you to check it and I will include a link to the article in the show notes as well. After connecting to the rapid infusion system, IV fluids were administered at rates up to 400ml/min and there were no high-pressure alarms from the rapid infusion system. During the procedure, repeat assessment of the RIC and the patient’s extremity revealed no swelling, edema, or other signs of extravasation. However, during transport to the ICU after the long surgery, the right arm with the RIC was edematous due to infiltration as a result of the RIC dilator. In the ICU, the RIC was removed and the dilator was visualized to be remaining in place within the 8.5Fr catheter.

So, what happened in this case? Placement of the RIC occurs with the dilator within the catheter over the wire. After placement, the next two steps are very important to follow. First, the wire must be removed. Second, the dilator must be removed from the RIC catheter and in this case the anesthesia professional did not remove the catheter. As a result, the RIC plus catheter remained in place and in use for the duration of the case incorrectly. The authors reveal the results from their root cause analysis with 4 contributing factors that included:

  1. a lack of operator knowledge, skill, and experience with RIC insertion,
  2. the supervising anesthesiologist was distracted by two concurrent invasive procedures,
  3. the preloaded dilator on the RIC was devoid of any label warning it must be removed prior to transfusion, and
  4. the ability to successfully connect intravenous tubing to the dilator itself.

While the perils were significant with the case, the patient did not have any permanent vascular or arm injury, but the potential was there especially since the dilator was attached to a rapid infusion system which is able to deliver high volume IV fluids from a positive pressure infusion pump. There is a call to action for medical centers and anesthesia department directors and OR medical directors to make sure that there is appropriate education for anesthesia professionals and trainees and OR staff for any new or for infrequently used devices in the clinical area.

This is something that we have talked about before on this podcast during Episode #29. I hope that you have already listened to it, but if not, I encourage you to go check it out. For that show, Bob Thiele from the APSF Committee on Technology highlighted the important relationship between anesthesia patient safety and technology and we reviewed the article from the Winter 2013 APSF Newsletter, “Training Anesthesia Professionals to Use Advanced Medical Technology.” Many of the recommendations from the 2013 article have been incorporated into anesthesia training as well as training for OR staff. It is important that we continue to do so with any and every new medical technology especially given our increasing complex patients, procedures, and busy clinical schedules.

Let’s take a look at the reply from the Teleflex medical director, Chris Davlantes. I am going to read it now.

“On behalf of Teleflex, I would like to thank you and the Anesthesia Patient Safety Foundation (APSF) for forwarding a letter, which you recently received from a physician describing an erroneous use of the Arrow® RIC® Rapid Infusion Catheter Exchange Set. The concern raised by the clinician was that the sheath/dilator assembly was left in the patient (without removing the dilator) and then connected to a rapid infusion system. This adverse event has been forwarded to the appropriate department within Teleflex and will go through the usual complaint management/risk evaluation process. In the meantime, we are committed to patient safety—as are you and the >122,000 anesthesia providers who will be receiving your publication—and we can only reinforce to clinicians the importance of using the device as instructed in the Instructions For Use documents.

Thank you to Davlantes and Teleflex. The complaint management and risk evaluation process is an important step for improving patient safety.

We have time for one more Rapid Response today. We are sticking with the IV theme, but we are heading back to the October 2018 APSF Newsletter. To follow along with us click back on the Newsletter heading, 4th one down is Newsletter archives. Then, scroll down and click on the October 2018 Newsletter. From here, scroll down until you see the Rapid Response column on the left and our featured article is the first one. It is “Burette Malpositioned Shut Off Valve Could Lead to Venous Air Embolism” by Duncan-Azadi and colleagues. I will include a link in the show notes as well and I encourage you to check out the article for photos of the Burette for a visual representation.

The authors start by describing the scope of the problem and it is a big threat to patient safety since venous air embolism is a life-threatening emergency. The literature reveals that air embolism is very rare from peripheral IV infusions and this is especially true for pediatric patients, but this is not the time to let down our guard due to the risk for significant morbidity and mortality. This is a case of a 150ml Burette that was malpositioned and could have led to a venous air embolism in a pediatric patient. At that time, this patient safety threat had not been reported in the literature.

So, we need to take a closer look at the burette. At the author’s institution, the 150ml burettes are used for pediatric patients younger than 9 years old and attached to normal saline/lactated ringer’s solution 500mls collapsible bags. The next part of this case is significant since a shortage of the 500ml bags so 1000ml bags needed to be used instead. The 1000ml bags are larger which meant that the burette hung at an angle leading to the malpositioned shut-off valve. If all the fluid in the burette was infused to the patient and the vent was left open, air could have entered the venous circulation with the help of the Venturi effect resulting in a venous air embolism. If the burette vent is closed, air cannot reach the patient. The good news is that the vent was closed and no venous air embolism occurred.

Further discussion by the authors highlights the significance of a venous air embolism since the National Quality Forum describes venous air embolism as a “never event” and the Joint Commission includes this complication as a “sentinel event.” This is a known and preventable complication from peripheral IV fluids that may occur due to inadequately primed tubing, failure to use an air detection alarm on an IV infusion pump, and manipulation of peripheral IVs. Don’t forget that patients with congenital heart disease including a patent foramen ovale and right to left shunt are at risk for a paradoxical air embolus if air enters the venous circulation. One step to minimize this risk is to use a micron filter at the distal end of the peripheral IV tubing, but keep in mind that these filters increase the resistance to flow and may even prevent gravity infusion through smaller IV catheters. Other strategies to reduce the risk of venous air embolism include air detection devices, careful de-airing, and inline air removal devices.

If a 150ml burette must be used with a 1000ml bag of crystalloid, anesthesia professionals must pay close attention to the positioning of the burette since the shut-off valve only works with the burette is hanging straight to the floor. With the larger bag of fluid, correct position of the burette can be obtained by hanging the burette at a lower level with the use of a rubber band or similar device. This allows the shut-off valve to function appropriately. In addition, you may want to consider using a micron air filter if you are unable to ensure that the burette remains in the correct position for the duration of its use.

Thank you to the authors for submitting this Rapid Response case report to highlight this important patient safety concern and strategies to help keep patients safe while using the burette.

JW Beard, the medical director for ICU Medical submitted a reply for this rapid response. He reminds us that the burette has a floating shut-off valve that floats on the surface of the fluid in the burette and then rests on the floor of the burette and occludes the tubing outlet when the fluid is empty as long as the burette remains in an upright, vertical position. When the burette is not in a vertical position, the floating shut-off valve may not rest on the floor of the burette to occlude the tubing outlet. The company also completed a review of the product and the labeling and directions for use including consideration of a new recommendation the product should only be used in the vertical position to ensure correct function of the shut off valve. Other investigations include alternative shut off valve designs, proximal tubing length between the IV bag and the burette and the addition of air-eliminating filters. Beard also provides an alternative method for fluid administration for patients at risk for air embolism by using an infusion pump with an air trap and an air-in-line detector. This has the added benefit for accurate delivery of specific IV fluid volumes, air detection, and use with needle-free injection ports, air filters, and burettes.

Thank you to Beard and ICU Medical for your thoughtful replay to this Rapid Response in 2018.

Spoiler alert!! We will be hearing more from JW Beard in a future show so I hope that you will continue to listen!!

If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. If you have not done so already, we hope that you will rate us and leave a review on iTunes or where ever you get your podcasts and feel free to share this podcast with your friends and colleagues and anyone that you know who is interested in anesthesia patient safety.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2021, The Anesthesia Patient Safety Foundation