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Prevent Dangerous Hemodialysis Catheter Disconnections

BY SHIRLEY A. ZEIGLER, RN, CRNP, MSN

(Article reprinted from Nursing2007, Volume 37, Number 3, p. 70.)

TEN MINUTES AFTER a patient began receiving a hemodialysis treatment, his venous blood line separated from the catheter. Shortly after the venous blood line was clamped, the patient complained of shortness of breath. His respirations were labored at a rate of 28 to 32 breaths/minute. He was immediately placed on his left side in Trendelenburg’s position, started on 10 liters/minute of oxygen by face mask, and transported to the hospital. Despite these measures, he died of an air embolism.

What went wrong?

An implanted or nonimplanted hemodialysis catheter can be used as a “bridge” device until the patient’s arteriovenous graft or native fistula is ready to be used. If the hemodialysis catheter inadvertently separates from the venous blood line, the patient can suffer an air
embolism or quickly lose a large amount of blood.

When a catheter separates, the hemodialysis machine’s alarm doesn’t always go off. Its venous pressure monitor triggers an alarm when the venous blood line falls below the limit set by the user.

A patient can lose 200 to 250 mL/minute of blood when a catheter separates. The rate of blood loss varies depending on the rate at which the blood is being pumped through the hemodialysis machine.

The Food and Drug Administration (FDA) has received adverse event reports describing hemodialysis catheters that have separated, leaked, cracked, torn, or broken, leading to infection, air embolism, blood loss, additional surgery, or death.

What precautions can you take?

Follow these steps to reduce the chances of hemodialysis catheters separating and to lessen the harm if they do separate:

• Know and follow your facility’s policies and procedures for managing catheters and blood line tubings used for hemodialysis.
• Read the manufacturer’s instructions carefully before initiating treatment. Use and care for the catheter according to the manufacturer’s device labeling.
• Inspect equipment for damage before initiating hemodialysis.
• During hemodialysis, monitor catheters and arterial and venous blood line tubing for cracks, tears, and breaks of the catheter hub or luer connection. Remember, alarms may not sound if a catheter separates from the venous blood line.
• Use luer connections or tape with hemodialysis catheters and tubing as specified by your facility protocols.
• Use the indicated vascular access site only for hemodialysis.
• Make sure the catheter site remains visible during treatment. For example, remove sheets and blankets if necessary.
• When a hemodialysis catheter separates from the blood line tubing or the integrity of the catheter is compromised in any other way, ollow your facility’s policy for preventing air embolism and infection, including clamping the line immediately.
• If a catheter separates, monitor the patient for signs and symptoms of hypovolemia and air embolism: shortness of breath, chest pain, altered level of consciousness, agitation, tachycardia, tachypnea, and hypotension. Then intervene if required.
• Fill out your facility’s adverse event report. If faulty equipment was involved, also report it to your facility’s biomedical engineering department.

Report adverse events to the FDA by calling MedWatch at 1-800-FDA-1088.

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 contacting MedWatch at 1-800-FDA-1088 (fax: 1-800-FDA-0178) or online at http://www.fda.gov/medwatch/how.htm. The opinions and statements in this report are those of the author and may not reflect the views of the Department of Health and Human Services. Beverly Albrecht Gallauresi, RN, BS, MPH, who coordinates Device Safety, is a nurse-consultant at the Center for Devices and Radiological Health at the Food and Drug Administration in Rockville, Md.

Shirley A. Zeigler is a nurse-consultant at the Center for Devices and Radiological Health.

Updated March 29, 2007