Rare but Fatal Complication of Umbilical Venous Catheterization

Nemri, Abdulrahman M. Al; Ignacio, Lena; Zamil, Fahad Al; Jarallah, Abdullah S. Al

doi:10.1111/j.1747-0803.2006.00031.x

Cited by 8 publications

(7 citation statements)

References 19 publications

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“…These incident reports were found to be the result of insufficient monitoring or inappropriate venous access devices—for example, peripheral intravenous route used for high‐osmolarity PN that should only be infused centrally. Extravasation injuries in infants due to PN have been recognized in several case reports and have also been highlighted by this study 15–18 . Incident reports related to the wrong dose being administered were frequently related to an error being made by healthcare staff, although they were difficult to categorize further because of insufficient information.…”

Section: Discussionmentioning

confidence: 61%

National evaluation of harm associated with patient safety incident reports related to the provision of parenteral nutrition to patients, using a national incident reporting system

2023

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BackgroundParenteral nutrition (PN)–related patient safety incidents have been associated with harm. Large‐scale studies are scarce, and little is known about contributory factors. This study evaluated PN‐related incident reports that described harm using a national database.Materials and MethodsA retrospective evaluation of incident reports involving PN in England and Wales reported to the National Reporting and Learning System between 2015 and 2020. We described frequency by degree of reported harm and incident characteristics. Content analysis was undertaken to understand contributory factors for reports related to moderate/severe harm or death.Results12,907 incident reports were identified. After screening, 2242 were evaluated; 1879 (83.8%) reported no harm, 309 (13.8%) low harm, 47 (0.02%) moderate harm, 4 (0.002%) severe harm, 3 (0.001%) deaths. The most reported age group, medication process, and error category were neonates (<28 days) (n = 570/1923, 29.6%), administration (n = 1126/2242, 50%), and omitted medication/ingredient (n = 291/2242, 13%), respectively. Content analysis of reports related to moderate/severe harm and death revealed patient age of <1 year, dependence on home PN (HPN), comorbidities, and staff errors as contributory factors.ConclusionsThis is the first evaluation of PN‐related incident reports in England and Wales to our knowledge. We demonstrated a low frequency of reports related to moderate or severe harm or death. More incidents were reported for neonates and during the administration processes. To reduce harm, systems/procedures that reduce errors in high‐risk patients (eg, neonates, patients receiving HPN) need to be established within organizations. Database limitations of voluntary reporting systems were recognized.

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Section: Discussionmentioning

confidence: 61%

National evaluation of harm associated with patient safety incident reports related to the provision of parenteral nutrition to patients, using a national incident reporting system

2023

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“…As duas localizações que atendem a esse critério são a aorta abdominal, logo acima da bifurcação das artérias ilíacas (localização baixa), e a aorta torácica, entre o ducto arterioso e o tronco celíaco (localização alta). O cateter umbilical venoso, após sua introdução, cursa pela veia umbilical, ramo esquerdo da veia porta e ducto venoso, entrando na veia cava inferior, onde deve ficar locado, próximo ao átrio direito [12,13,16,17].…”

Section: Cateterismo Umbilicalunclassified

“…Assim, o exame radiológico de tórax e abdome deve ser realizado logo após a realização do cateterismo, para confirmar a localização do cateter e, se necessário, orientar as condutas de recolocação ou remoção do mesmo [13][14][15].…”

Section: Introductionunclassified

Cateteres umbilicais em recém-nascidos: indicações, complicações e diagnóstico por imagem

Kido

Álvares

Mezzacappa

2015

Sci Med

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RESUMOObjetivos: Revisar os últimos dados de literatura acerca do cateterismo umbilical quanto a indicações, complicações e diagnóstico de sua localização através de exames de imagem. Métodos: Foram pesquisados artigos nas bases de dados PubMed, SciELO e LILACS, através dos seguintes descritores, assim como dos termos correspondentes em inglês: cateteres umbilicais; exame radiológico; ultrassonografia; recém-nascido; e cuidados intensivos neonatais. Foram incluídos também livros texto clássicos em literatura neonatal. Resultados: Foram selecionados 51 artigos, quatro livros texto e um manual versando sobre cateteres umbilicais venosos e arteriais em recém-nascidos. Revisamos indicações, novas técnicas de inserção, complicações associadas, fatores de risco e diagnóstico por imagem, com ênfase nas referências anatômicas utilizadas para o diagnóstico da posição da extremidade do cateter. Conclusões: O cateterismo umbilical representa um importante acesso à corrente sanguínea do recém-nascido e o diagnóstico por imagem desempenha um papel fundamental na avaliação correta do seu posicionamento, possibilitando, em caso de mau posicionamento, a conduta imediata para prevenção de complicações.DESCRITORES: cateteres; radiografia; ultrassonografia; recém-nascido; cuidados intensivos. ABSTRACT Aims:To review the latest literature on umbilical catheterization including its indications, complications, and diagnostic imaging for verification of catheter position. Methods: The PubMed, SciELO, and LILACS databases were searched using the following keywords and the corresponding terms in Portuguese: umbilical catheters; radiological examination; ultrasonography; newborn; and neonatal intensive care. Classic textbooks on neonatology were also reviewed. Results: A total of 51 articles, four classic textbooks, and one manual dealing with venous and arterial umbilical catheterization in neonates were selected. We reviewed the indications, new insertion techniques, complications, risk factors and, diagnostic imaging, with emphasis on the anatomic landmarks used for determination of catheter tip position. Conclusions: Umbilical catheterization is an important access to the bloodstream of the newborn, and diagnostic imaging plays a key role in the assessment of catheter tip position, thus enabling immediate management and preventing complications in cases of misplacement.

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“…In addition, umbilical catheter has been used for drawing blood samples, measuring venous blood pressure, and administering fluids, nutrition and medications, blood products, and exchange therapies in sick neonates (1). Use of umbilical catheters has several complications as reported by previous studies, such as thrombosis, embolization, hemorrhage, abscess, arrhythmias, effusions, portal hypertension, renal vein perforation, necrotizing enterocolitis and perforation of the colon, sepsis, cardiac tamponade, and ischemic injury of the extremities (1)(2)(3)(4)(5)(6).…”

Section: Introductionmentioning

confidence: 99%

Liver Hematoma Presented as Midgut Volvulus Due To Medical Error: A Case Report

et al. 2016

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Introduction: The use of an umbilical catheterization is a usual practice in neonatal units. The insertion of the catheter has potential complications. Case Presentation: Here, we report on our observation of a seven-day-old female newborn admitted for an abdominal distention and vomiting bile. Initially, diagnosis was midgut volvulus, for which an operation was performed. During the surgery, no intestinal malrotation, mesenteric defect or atresia was observed. Postoperative diagnosis was abdominal wall hematoma and rand ligament and ileus, as well as, sub-capsular liver hematoma. The patient had been hospitalized at birth at a neonatal intensive care unit (NICU). With the appearance of icterus on the first day of life, at the NICU tried to insert the umbilical catheter that had been filed. Conclusions:The complication found in the patient was the result of an aggressive act (the umbilical catheter insertion). This intervention should not be carried out unless there are clear indications, and if so, it should be done with much care.

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Rare but Fatal Complication of Umbilical Venous Catheterization

Cited by 8 publications

References 19 publications

National evaluation of harm associated with patient safety incident reports related to the provision of parenteral nutrition to patients, using a national incident reporting system

National evaluation of harm associated with patient safety incident reports related to the provision of parenteral nutrition to patients, using a national incident reporting system

Cateteres umbilicais em recém-nascidos: indicações, complicações e diagnóstico por imagem

Liver Hematoma Presented as Midgut Volvulus Due To Medical Error: A Case Report

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