Talk Description
Victoria Tsang (a) ; Martin D Culwick (b); Victoria Eley (a,c).
a. Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women’s Hospital. Butterfield St, Herston 4006. Queensland, Australia.
b. Analyser, Australian and New Zealand Tripartite Anaesthesia Data Committee, Australian and New Zealand College of Anaesthetists, Melbourne, Australia
c. Faculty of Medicine, The University of Queensland. St Lucia 4067. Queensland, Australia.
ASA Number 1461
Introduction
Arterial lines are commonly inserted for intraoperative monitoring but are known to cause complications [1]. We aimed to identify and categorise the incidents related to arterial catheters reported to WebAIRS between 2009 and 2023.
Methods
Ethical approval was obtained (HREC/11/QRBW/311; HREC/12/NEPEAN/18; MEC/09/17/EXP). We searched 10,518 incidents reported to WebAIRS, applying the logical search terms (“arterial” OR “ art”( AND (“line” OR “catheter”). Incidents were included if they involved the insertion and presence of an arterial catheter, and there was a complication relating to the arterial line, the accuracy of arterial blood pressure readings, equipment or monitoring malfunction or human error related to the use of equipment. Incidents were excluded if the arterial line placement was not the reason for the reported incident, or if inadvertent arterial puncture occurred during venous cannulation.
Procedure characteristics (time of day, elective or emergency, ASA of the patient, seniority of the reporting clinician) were summarised. Incidents were categorised according to expert opinion and agreed on by the co-authors. Categories and subcategories were summarised as numbers (percent).
The severity and duration of patient complications were classified according to the definitions of the Agency for Healthcare Research and Quality Harm Scale [2]. Severity was classified as no harm, mild, moderate, severe or death and duration was defined as temporary, permanent or unknown.
Results
A total of 10,518 clinical incidents were reported between 2009 and October 2023, with 55 meeting our inclusion and exclusion criteria. Of the 55 incidents, 35 (64%) were elective cases and 45 (82%) were reported by FANZCA specialists.
Twenty-seven (49%) incidents were related to equipment failure, 17 (31%) involved compromised flow, 5 (9%) related to nerve injury, 2 (4%) were medication errors, 1 (2%) involved infection, 1 (2%) incident being inability to place arterial catheter, with 2 (4%) classified as “other injury”. The most common equipment problem was related to inappropriate transducer height resulting in inaccurate readings. Of the 17 incidents relating to compromised flow, all resulted in patient harm and the mechanisms were external compression (9, 53%), thrombosis (5,29%), occlusion by cannula (2, 12%) and arterial dissection (1, 6%). Clinical ischaemia was reported in 9 (53%) of the cases with compromised flow, while 3 (18%) of the 17 patients complained of pain post-operatively.
Twenty-six (47%) patients experienced mild harm, 10 (18%) experienced moderate harm, 2 (4%) experienced severe harm and there was one death reported, secondary to an air embolus. Of the 39 patients experiencing some level of harm, 34 (87%) were temporary, 2 (5%) were permanent and 3 (8%) unknown.
Discussion
The majority of incidents resulted in no harm or mild harm to the patient but we report one fatality associated with air entrainment and subsequent embolus. This review demonstrates some very common problems associated with arterial catheters, but also highlights some rare complications, with the aim of helping clinicians to improve clinical care.
References
1. Gregory Nuttall, Jennifer Burckhardt, Anita Hadley, Sarah Kane, Daryl Kor, Mary Shirk Marienau, Darrell R. Schroeder, Kathryn Handlogten, Gregory Wilson, William C. Oliver; Surgical and Patient Risk Factors for Severe Arterial Line Complications in Adults. Anesthesiology 2016; 124:590–597
2. Network of Patient Safety Databases Chartbook, 2021. Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Pub. No. 21-0050.