By Chih-Hsin K. Liu, RN, MSN
Nurse-Consultant Center for Devices and Radiological Health
Food and Drug Administration Rockville, Md.
(Originally published November 1998)
A pulmonary artery catheter was inserted in a 37-year-old man admitted to the ICU with a gunshot wound. When the catheter was removed, the introducer was left in place for I.V. access. A short time later, air was noted in the introducer's side port. The patient's oxygen saturation decreased to 85%, his pulse rate increased to 140, his respiratory rate rose to 60, and he was short of breath and agitated. The diagnosis: air embolism.
What went wrong?
Percutaneous sheath introducers (PSIs) are used to insert pulmonary artery catheters; as a large-bore central venous access. PSIs are available as both one- piece and two-piece devices. Air embolisms are usually associated with two-piece PSIs, which have a detachable side port/hemostasis valve.
Air can enter a PSI at one of three points:
- at the connection between the side port and the I.V. tubing
- at the hemostasis valve if it doesn't seal after catheter removal
- at the side port/hemostasis valve adapter if it disconnects from the sheath hub (possible only with a two-piece PSI).
What precautions can you take?
- Make sure all connections are tight, including tubing connections, stopcocks and the PSI side port.
- Tape the tubing securely to the skin to prevent stress on the tubing and possible disconnection.
- Insert an obturator cap onto the hemostasis valve after catheter removal.
- When using a two-piece PSI, screw the side port/hemostasis valve adapter and the sheath hub together tightly; detachment is difficult to detect.
- If possible, use the one-piece design on agitated patients because the risk of disconnection is less.
- Teach patients Valsalva's maneu ver during catheter insertion and removal.
- Remove a PSI as soon as central venous access is no longer indicated.
- Apply petroleum gel gauze and a pressure dressing immediately after PSI removal
Although you need to support the adverse event-reporting policy of your health care facility, you may voluntarily report a medical device that doesn't perform as intended by calling MedWatch at 1-800-FDA-1088 (fax: 1-800-FDA-0178). The opinions and statements contained in this report are those of the author and may not reflect the views of the Department of Health and Human Services. Device Errors is coordinated by Chris Parmentier, RN.