Incidents relating to arterial cannulation as identified in 7,525 reports submitted to the Australian incident monitoring study (AIMS-ICU)

Adverse events with arterial catheters in intensive care units: a scoping review

INTRODUCTION

The installation of an arterial line is one of the invasive procedures performed for hemodynamic monitoring and, even with its clear importance in intensive care, it is still an invasive procedure and liable to cause harms to the patients.

OBJECTIVE

To identify the adverse events associated with the use of arterial catheters in critically-ill patients in the world scientific production.

METHODOLOGY

The present scoping review was conducted according to the JBI methodology for scoping reviews. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was used for reporting. The research question was "Which adverse events related to the use of arterial catheters in patients admitted to intensive care are more evident in the literature?". Data collection took place in the following databases: LILACS; MEDLINE; EMBASE; CINAHL, EBSCOhost; and WEB OF SCIENCE.

RESULTS

Through the search strategies, 491 articles were found in the databases. After exclusion of duplicates, peer analysis of titles and abstracts, full reading and screening of lists of references, the final sample of studies included was 38 articles. The main harms cited by the publications were as follows: limb ischemia, thrombosis, hemorrhage, accidental removal, inadvertent connection of inadequate infusion solution, pseudoaneurysm and bloodstream infection.

CONCLUSIONS

It was evidenced that patients are subjected to risks of adverse events from the insertion moment to removal of the arterial catheter, focusing on the infusion solution used to fill the circuit, the type of securement and dressings chosen, as well as the Nursing care measures for the prevention of bloodstream infection.

Dressings and securement devices to prevent complications for peripheral arterial catheters

BACKGROUND

Peripheral arterial catheters (ACs) are used in anaesthesia and intensive care settings for blood sampling and monitoring. Despite their importance, ACs often fail, requiring reinsertion. Dressings and securement devices maintain AC function and prevent complications such as infection.

OBJECTIVES

To evaluate the effectiveness of peripheral AC dressing and securement devices to prevent failure and complications in hospitalised people.

SEARCH METHODS

We searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL Plus up to 16 May 2023. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform up to 16 May 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing different dressing and securement devices for the stabilisation of ACs in hospitalised people.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias using Cochrane's RoB 1 tool. We resolved disagreements by discussion, or by consulting a third review author when necessary. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included five RCTs with 1228 participants and 1228 ACs. All included studies had high risk of bias in one or more domains. We present the following four comparisons, with the remaining comparisons reported in the main review. Standard polyurethane (SPU) plus tissue adhesive (TA) compared with SPU: we are very uncertain whether use of SPU plus TA impacts rates of AC failure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.20 to 0.98; I² = 0%; 2 studies, 165 participants; very low-certainty evidence). Neither study (165 participants) reported catheter-related bloodstream infections (CRBSI), thus we are very uncertain whether SPU plus TA impacts on the incidence of CRBSI (very low-certainty evidence). It is very uncertain whether use of SPU plus TA impacts AC dislodgement risk (RR 0.54, 95% CI 0.03 to 9.62; I² = 44%; 2 studies, 165 participants; very low-certainty evidence). We are very uncertain whether use of SPU plus TA impacts AC occlusion rates (RR 1.20, 95% CI 0.37 to 3.91; I² = 3%; 2 studies, 165 participants; very low-certainty evidence). We are very uncertain whether use of SPU plus TA impacts rates of adverse events with few reported events across groups (RR 0.89, 95% CI 0.09 to 8.33; I² = 0%; 2 studies, 165 participants; very low-certainty evidence). Bordered polyurethane (BPU) compared to SPU: we are very uncertain whether use of BPU impacts rates of AC failure (RR 0.67, 95% CI 0.21 to 2.13; 1 study, 60 participants; very low-certainty evidence). BPU may make little or no difference to CRBSI compared to SPU (RR 3.05, 95% CI 0.12 to 74.45; I² = not applicable as 1 study (60 participants) reported 0 events; 2 studies, 572 participants; low-certainty evidence). BPU may make little or no difference to the risk of AC dislodgement compared with SPU (RR 0.75, 95% CI 0.17 to 3.22; I² = 0%; 2 studies, 572 participants; low-certainty evidence). BPU may make little or no difference to occlusion risk compared with SPU (RR 0.80, 95% CI 0.60 to 1.07; I² = 0%; 2 studies, 572 participants; low-certainty evidence). It is very uncertain whether BPU impacts on the risk of adverse events compared with SPU (RR 0.33, 95% CI 0.01 to 7.87; 1 study, 60 participants; very low-certainty evidence). SPU plus sutureless securement devices (SSD) compared to SPU: we are very uncertain whether SPU plus SSD impacts risk of AC failure compared with SPU (RR 0.78, 95% CI 0.40 to 1.52; I² = 0%; 2 studies, 157 participants; very low-certainty evidence). We are very uncertain if SPU plus SSD impacts CRBSI incidence rate with no events in both groups (2 studies, 157 participants; very low-certainty evidence). It is very uncertain whether SPU plus SSD impacts risk of dislodgement (RR 0.14, 95% CI 0.01 to 2.57; I² = not applicable as 1 study (96 participants) reported 0 events; 2 studies, 157 participants; very low-certainty evidence). It is very uncertain whether SPU plus SSD impacts risk of AC occlusion (RR 1.94, 95% CI 0.50 to 7.48; I² = 38%; 2 studies, 157 participants; very low-certainty evidence). We are very uncertain whether SPU plus SSD impacts on the risk of adverse events (RR 1.94, 95% CI 0.19 to 20.24; I² = not applicable as 1 study (96 participants) reported 0 events; 2 studies, 157 participants; very low-certainty evidence). Integrated securement dressings compared to SPU: integrated securement dressings may result in little or no difference in risk of AC failure compared with SPU (RR 1.96, 95% CI 0.80 to 4.84; 1 study, 105 participants; low-certainty evidence); may result in little or no difference in CRBSI incidence with no events reported (1 study, 105 participants; low-certainty evidence); may result in little or no difference in the risk of dislodgement (RR 0.33, 95% CI 0.04 to 3.04; 1 study, 105 participants; low-certainty evidence), may result in little or no difference in occlusion rates with no events reported (1 study, 105 participants; low-certainty evidence), and may result in little or no difference in the risk of adverse events (RR 0.35, 95% CI 0.01 to 8.45; 1 study, 105 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There is currently limited rigorous RCT evidence available about the relative clinical effectiveness of AC dressing and securement products. Limitations of current evidence include small sample size, infrequent events, and heterogeneous outcome measurements. We found no clear difference in the incidence of AC failure, CRBSI, or adverse events across AC dressing or securement products including SPU, BPU, SSD, TA, and integrated securement products. The limitations of current evidence means further rigorous RCTs are needed to reduce uncertainty around the use of dressing and securement devices for ACs.

Epidemiology of adverse events in Intensive Medicine units

The severity of the critically ill patient, the practice of diagnostic procedures and invasive treatments, the high number of drugs administered, a high volume of data generated during the care of the critically ill patient along with a technical work environment, the stress and workload of work of professionals, are circumstances that favor the appearance of errors, turning Intensive Medicine Services into risk areas for adverse events to occur. Knowing their epidemiology is the first step to improve the safety of the care we provide to our patients, because it allows us to identify risk areas, analyze them and develop strategies to prevent the adverse events, or if this is not possible, be able to manage them. This article analyzes the main studies published to date on incidents related to safety in the field of critically ill patients.

Distal radial approach for arterial pressure monitoring with a long catheter provides safe and stable monitoring in the intensive care unit: A single-center retrospective study

BACKGROUND

To compare the distal radial artery approach (DRA) with a longer catheter to DRA with a shorter catheter in arterial catheter (AC) placement in the intensive care unit (ICU).

METHODS

This was a single-center retrospective cohort study of DRA with a long catheter (60 mm) for arterial catheterization in the ICU. DRA with a short catheter (25-30 mm) was used in the control group, and the groups were compared using multivariate regression analysis. The primary study endpoint was the incidence of unplanned AC removal. The secondary endpoint was the incidence of other inappropriate events, namely loss of arterial pressure waveforms, bleeding, catheter-related infection, pressure ulcer, and other complications associated with the AC.

RESULTS

In this study, the DRA with a long catheter was used in 50 patients. No unplanned AC removals or other inappropriate events occurred, and there were no complications associated with the DRA. The DRA procedural success rate was 100%. There was no significant difference in hemostasis times between the groups. Loss of arterial waveforms was an early predictor of unplanned AC removal.

CONCLUSIONS

The DRA with a long catheter provided stable monitoring and was associated with a low unplanned removal rate. This method has the advantages of fewer complications and shorter hemostasis time compared with the DRA with a short catheter, and may become a new AC option in the ICU.

Thenar Compartment Syndrome Related to Tightened Radial Arterial Line During Robotic Laparoscopic Surgery: A Case Report

We present a 54-year-old man who developed an unexpected thenar space compartment syndrome after robotic laparoscopic surgery, which was caused when the radial arterial pressure tubing was pulled too tightly around the base of the thumb while changing the surgical position. A conventional method of securing the tubing by looping it around the thumb appeared to be the primary cause. This complication went unnoticed during the surgery because the arm was tucked out of sight; there were no remarkable findings on monitoring. This case highlights the risks of looping tubing around the thumb, especially if continual inspection is not possible.

Retrospective Observational Single-Center Study of Complications of Arterial Indwelling Catheters for Invasive Blood Pressure in Intensive Care Unit Patients

This study aimed to analyze the incidence of complications resulting from the use of an indwelling arterial catheter (IAC). We compared the characteristics of the patients with an IAC who developed complications with those who did not present any complications. The study included 1,869 patients with an IAC hospitalized in intensive care units (ICUs) between 2017 and 2018. Most patients were male (58.7%), in the seventh decade of life, and had systemic arterial hypertension. The most common site of IAC implantation was the radial artery. Fifty-four (2.88%) cases of complications related to an IAC were identified including bleeding, hematomas, and thrombosis. Female patients had a higher risk of complications (P = .030). Comorbidities such as arrhythmias (P < .001) and peripheral arterial disease (P = .041) also increased that risk. The use of vasoactive drugs (P = .001), hemodialysis (P = .001), and orotracheal intubation (OTI) (P = .001) was significantly associated with the occurrence of complications as well as length of stay in ICUs (P < .001) and IAC duration (P = .001). IACs are safe devices commonly used in ICUs, with an incidence of complications of 2.88%.

Clinical Validation of a Soft Wireless Continuous Blood Pressure Sensor During Surgery

We test a new wireless soft capacitance sensor (CAP) based on applanation tonometry at the radial and dorsalis pedis arteries against the gold standard, invasive arterial line (A-Line), for continuous beat to beat blood pressure (BP) measurements in the Operating Room during surgical procedures under anesthesia in 17 subjects with the mean age and body mass index (BMI) of 57. 35 ± 18.72 years and 27.36 ± 4.20 kg/m², respectively. We have identified several parameters to monitor in order to compare how well the CAP sensor tracks the entire hemodynamic waveform as compared to the A-Line. This includes waveform similarity, heart rate (HR), absolute systolic BP (SBP), diastolic BP (DBP), and temporal response to a vasopressor. Overall, the CAP sensor shows good correlations with A-Line with respect to hemodynamic shape (r > 0.89), HR (mean bias = 0.0006; SD = 0.17), absolute SBP, and DBP in a line of best fit (slope = 0.98 in SBP; 1.08 in DBP) and the mean bias derived from Bland-Altman method to be 1.92 (SD = 12.55) in SBP and 2.38 (SD = 12.19) in DBP across body habitus and age in OR patients under general anesthesia. While we do observe drifts in the system, we still obtain decent correlations with respect to the A-Line as evidenced by excellent linear fit and low mean bias across patients. When we post-process using a different calibration method to account for the drift, the mean bias and SD improve dramatically to −1.85 and 7.19 DBP as well as 1.43 and 7.43 SBP, respectively, indicating a promising potential for improvement when we integrate strategies to account for movement identified by our integrated accelerometer data.

Intra-arterial Foreign Body following Radial Artery Cannulation Requiring Microsurgical Removal: Case Report and Review of the Literature

We report the case of a pediatric patient who underwent intra-arterial exploration and removal of foreign body after an arterial catheter cannula inadvertently fractured during removal and a fragment remained within the radial artery. The fragment was visualized using fluoroscopy intraoperatively and was successfully removed from the common digital artery to the index finger where it had migrated. We present the case as a rare complication of an exceedingly common procedure with a timely response to avoid further complication.

Dressings and Securement Devices of Peripheral Arterial Catheters in Intensive Care Units and Operating Theaters: A Systematic Review

BACKGROUND

Hemodynamic monitoring, implemented by the placement of peripheral arterial catheters (PACs), is a characterizing aspect of the intensive care units. Peripheral arterial catheters can continually detect blood pressure and quickly conduct blood sampling. The use of PACs is generally considered safe, without serious complications. Currently, only 25% of the implanted catheters are actually subject to complications, including accidental removal, dislocation, occlusion, and infection. All of these complications arise from inadequate catheter stabilization at the level of the skin. This study aimed to summarize and describe the effectiveness and characteristics of dressings and securement devices for catheter stabilization.

METHODS

A systematic review of literature from the following databases was conducted: MEDLINE, CINAHL, Cochrane, EMBASE, and OvidSP. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to guide article selection and reporting.

RESULTS

Herein 626 articles were referred, with 5 directly related to the topic under discussion. We found 3 studies that describe PAC failure and 4 about dislodgement. We described 6 types of dressings or securement devices and classified them into 3 categories for classifying PAC dressings or securement devices. These were detected and grouped as adhesive tissues, sutureless devices, and transparent polyurethane dressings.

CONCLUSIONS

Current research indicates that transparent polyurethane dressings offer the most effective catheter stabilization, but adhesive tissues may constitute a valid alternative. However, there are limited high-quality studies about effective dressings and securement devices for PACs.

Outcome-based Clinical Indicators for Intensive Care Medicine

The clinical indicator is a tool used to monitor the quality of health care. Its use in the Intensive Care Unit (ICU) is desirable for many reasons: the maintenance of minimum standards, the development of best practice and the delivery of cost-effective health care. The utility of clinical indicators in ICU is limited by the lack of universal, robust, transparent, evidence-based and risk-adjusted measures of quality, and the difficulties in defining “quality care” and “good outcome”. Monitoring of adverse events, system descriptors, and resource indicators is valuable but they have a limited relationship to the quality of care. ICU mortality prediction models provide a global measure of quality and, despite their inherent deficiencies, remain one of the most robust and useful clinical indicators.

[Critically ill patient isolation: risk or protection?]

INTRODUCTION

Isolation precautions are an effective measure to prevent the spread of multi-resistant microorganisms (MMR). However, its implementation is complex and can increase some risks to the patient. The aim of this study is to determine whether the implementation of isolation precautions increase the risk of patient safety incidents (PSI) in critically ill patients.

MATERIAL AND METHODS

A retrospective observational study was conducted involving patients admitted to the ICU of a University Hospital, and that required isolation for more than 48h. Period of study: two years (from 2013/03/01 to 2015/03/31). Data source was the electronic medical record. The tools for evaluation were the Modular Review Form questionnaires (MRF1 and MRF2). An analysis was made of PSI and adverse events (AEs) during periods with and without isolation precautions, including the PSI type, severity, and preventability.

RESULTS

The study included a total of 76 patients, 74 of whom had at least one PSI. A total of 798 PSI were detected (511 during isolation period), 599 were a No harm incident (NHI) and 199 were adverse AEs. The most frequent PSIs were associated with medication (316) and patient health care (279). Most of them were moderately or highly preventable. The incidence of PSI during periods with and without isolation was 27.3 (SD 33.8) and 29 (39.6) per 100 patient-days, respectively.

CONCLUSIONS

PSIs in ICU are frequent, and the most of them are preventable. The adoption of isolation precautions does not constitute a risk factor for PSI. Improving patient safety culture is essential for an adequate prevention strategy.

Advanced Practice Organ Procurement Techniques: Insertion of Arterial Catheters

Placement of arterial catheters by organ procurement coordinators is becoming more common. Classroom and clinical training in this technique and provision of appropriate quality assurance and supportive policies/procedures by organ procurement programs will ensure the coordinators' success. This discussion reviews technical aspects of insertion of catheters into the radial, femoral, and axillary arteries, potential complications, and alternative noninvasive methods of measuring blood pressure.

A Narrative Review of Meaningful Use and Anesthesia Information Management Systems

The US federal government has enacted legislation for a federal incentive program for health care providers and hospitals to implement electronic health records. The primary goal of the Meaningful Use (MU) program is to drive adoption of electronic health records nationwide and set the stage to monitor and guide efforts to improve population health and outcomes. The MU program provides incentives for the adoption and use of electronic health record technology and, in some cases, penalties for hospitals or providers not using the technology. The MU program is administrated by the Department of Health and Human Services and is divided into 3 stages that include specific reporting and compliance metrics. The rationale is that increased use of electronic health records will improve the process of delivering care at the individual level by improving the communication and allow for tracking population health and quality improvement metrics at a national level in the long run. The goal of this narrative review is to describe the MU program as it applies to anesthesiologists in the United States. This narrative review will discuss how anesthesiologists can meet the eligible provider reporting criteria of MU by applying anesthesia information management systems (AIMS) in various contexts in the United States. Subsequently, AIMS will be described in the context of MU criteria. This narrative literature review also will evaluate the evidence supporting the electronic health record technology in the operating room, including AIMS, independent of certification requirements for the electronic health record technology under MU in the United States.

Arterial lines in the ICU: a call for rigorous controlled trials

The appropriate justification for using a diagnostic or therapeutic intervention is that it provides benefit to patients, society, or both. For decades, indwelling arterial catheters have been used very commonly in patients in the ICU, despite a complete absence of data addressing whether they confer any such benefits. Both of the main uses of arterial catheters, BP monitoring and blood sampling for laboratory testing, can be done without these invasive devices. Prominent among complications of arterial catheters are bloodstream infections and arterial thrombosis. To my knowledge, only a single observational study has assessed a patient-centered outcome related to arterial catheter use, and it found no evidence that they reduce hospital mortality in any patient subgroup. Given the potential dangers, widespread use, and uncertainty about consequences of arterial catheter use in ICUs, equipoise exists and randomized trials are needed. Multiple studies in different, well-characterized, patient subgroups are needed to clarify whether arterial catheters influence outcomes. These studies should assess the range of relevant outcomes, including mortality, medical resource use, patient comfort, complications, and costs.

Novel technologies can provide effective dressing and securement for peripheral arterial catheters: A pilot randomised controlled trial in the operating theatre and the intensive care unit

BACKGROUND

Peripheral arterial catheters are widely used in the care of intensive care patients for continuous blood pressure monitoring and blood sampling, yet failure - from dislodgement, accidental removal, and complications of phlebitis, pain, occlusion and infection - is common. While appropriate methods of dressing and securement are required to reduce these complications that cause failure, few studies have been conducted in this area.

OBJECTIVES

To determine initial effectiveness of one dressing and two securement methods versus usual care, in minimising failure in peripheral arterial catheters. Feasibility objectives were considered successful if 90/120 patients (75%) received the study intervention and protocol correctly, and had ease and satisfaction scores for the study dressing and securement devices of ≥ 7 on Numerical Rating Scale scores 1-10.

METHODS

In this single-site, four-arm, parallel, pilot randomised controlled trial, patients with arterial catheters, inserted in the operating theatre and admitted to the intensive care unit postoperatively, were randomly assigned to either one of the three treatment groups (bordered polyurethane dressing (n=30); a sutureless securement device (n=31); tissue adhesive (n=32)), or a control group (usual practice polyurethane dressing (not bordered) (n=30)).

RESULTS

One hundred and twenty-three patients completed the trial. The primary outcome of catheter failure was 2/32 (6.3%) for tissue adhesive, 4/30 (13.3%) for bordered polyurethane, 5/31 (16.1%) for the sutureless securement device, and 6/30 (20%) for the control usual care polyurethane. Feasibility criteria were fulfilled. Cost analysis suggested that tissue adhesive was the most cost effective.

CONCLUSIONS

The pilot trial showed that the novel technologies were at least as effective as the present method of a polyurethane dressing for dressing and securement of arterial catheters, and may be cost effective. The trial also provided evidence that a larger, multicentre trial would be feasible.

Description of a new non-injectable connector to reduce the complications of arterial blood sampling

Arterial cannulation is associated with complications including bacterial contamination, accidental intra-arterial injection and blood spillage. We performed a series of audits and experiments to gauge the potential for these, as well as assess the possible contribution of a new device, the Needle-Free Arterial Non-Injectable Connector (NIC), in reducing these risks. The NIC comprises a needle-free connector that prevents blood spillage and a one-way valve allowing aspiration only; once screwed onto the side port of a three-way tap, the device can only be removed with difficulty. We performed a clinical audit of arterial monitoring systems in our intensive care unit, which showed an incidence of bacterial colonisation of five in 86 (6%) three-way tap ports. We constructed a manikin simulation experiment of the management of acute bradycardia, in which trainee doctors were required to inject atropine intravenously. Ten of 15 (66%) doctors injected the drug into the three-way tap of the arterial monitoring system rather than into the intravenous cannula or the central venous catheter. In a laboratory study, we replicated the arterial blood sampling and flushing sequence from a three-way tap, with the syringes attached either directly to the three-way tap port or to a NIC attached to the port. The first (discard) syringe attached to the three-way tap was contaminated with bacteria. Bacterial growth was found in 17 of 20 (85%) downstream flushed samples (corresponding to the patient's circulation) when the three-way tap was accessed directly, compared to none of 20 accessed via the NIC (p < 0.0001). Growth was found on all of 20 (100%) ports accessed directly compared to none of 20 accessed via the NIC (p < 0.0001). The NIC effectively prevents bacteria from contaminating sampling lines. As its design also prevents accidental intra-arterial injection, we suggest that it can reduce complications of arterial monitoring.

Arterial waveform analysis

The bedside measurement of continuous arterial pressure values from waveform analysis has been routinely available via indwelling arterial catheterization for >50 years. Invasive blood pressure monitoring has been utilized in critically ill patients, in both the operating room and critical care units, to facilitate rapid diagnoses of cardiovascular insufficiency and monitor response to treatments aimed at correcting abnormalities before the consequences of either hypo- or hypertension are seen. Minimally invasive techniques to estimate cardiac output (CO) have gained increased appeal. This has led to the increased interest in arterial waveform analysis to provide this important information, as it is measured continuously in many operating rooms and intensive care units. Arterial waveform analysis also allows for the calculation of many so-called derived parameters intrinsically created by this pulse pressure profile. These include estimates of left ventricular stroke volume (SV), CO, vascular resistance, and during positive-pressure breathing, SV variation, and pulse pressure variation. This article focuses on the principles of arterial waveform analysis and their determinants, components of the arterial system, and arterial pulse contour. It will also address the advantage of measuring real-time CO by the arterial waveform and the benefits to measuring SV variation. Arterial waveform analysis has gained a large interest in the overall assessment and management of the critically ill and those at a risk of hemodynamic deterioration.

Cyanoacrylate tissue adhesives - effective securement technique for intravascular catheters: in vitro testing of safety and feasibility

Partial or complete dislodgement of intravascular catheters remains a significant problem in hospitals despite current securement methods. Cyanoacrylate tissue adhesives (TA) are used to close skin wounds as an alternative to sutures. These adhesives have high mechanical strength and can remain in situ for several days. This study investigated in vitro use of TAs in securing intravascular catheters (IVC). We compared two adhesives for interaction with IVC material, comparing skin glues with current securement methods in terms of their ability to prevent IVC dislodgement and inhibit microbial growth. Two TAs (Dermabond, Ethicon Inc. and Histoacryl, B. Braun) and three removal agents (Remove™, paraffin and acetone) were tested for interaction with IVC material by use of tensile testing. TAs were also compared against two polyurethane (standard and bordered) dressings (Tegaderm™ 1624 and 1633, 3M Australia Pty Ltd) and an external stabilisation device (Statlock, Bard Medical, Covington) against control (unsecured IVCs) for ability to prevent pull-out of 16 G peripheral IVCs from newborn fresh porcine skin. Agar media containing pH-sensitive dye was used to assess antimicrobial properties of TAs and polyurethane dressings to inhibit growth of Staphylococcus aureus and Staphylococcus epidermidis. Neither TA weakened the IVCs (P >0.05). Of removal agents, only acetone was associated with a significant decrease in IVC strength (P <0.05). Both TAs and Statlock significantly increased the pull-out force (P <0.01). TA was quick and easy to apply to IVCs, with no irritation or skin damage noted on removal and no bacterial colony growth under either TA.

Medical error and decision making: Learning from the past and present in intensive care

BACKGROUND

Human error occurs in every occupation. Medical errors may result in a near miss or an actual injury to a patient that has nothing to do with the underlying medical condition. Intensive care has one of the highest incidences of medical error and patient injury in any specialty medical area; thought to be related to the rapidly changing patient status and complex diagnoses and treatments.

PURPOSE

The aims of this paper are to: (1) outline the definition, classifications and aetiology of medical error; (2) summarise key findings from the literature with a specific focus on errors arising from intensive care areas; and (3) conclude with an outline of approaches for analysing clinical information to determine adverse events and inform practice change in intensive care.

DATA SOURCE

Database searches of articles and textbooks using keywords: medical error, patient safety, decision making and intensive care. Sociology and psychology literature cited therein.

FINDINGS

Critically ill patients require numerous medications, multiple infusions and procedures. Although medical errors are often detected by clinicians at the bedside, organisational processes and systems may contribute to the problem. A systems approach is thought to provide greater insight into the contributory factors and potential solutions to avoid preventable adverse events.

CONCLUSION

It is recommended that a variety of clinical information and research techniques are used as a priority to prevent hospital acquired injuries and address patient safety concerns in intensive care.

A Retrospective Study to Determine Whether accessing Frequency Affects the Incidence of Microbial Colonisation in Peripheral Arterial Catheters

Peripheral arterial catheters are used for the continuous monitoring of blood pressure and repeated blood sampling in critically ill patients, but can be a source of catheter-related bloodstream infection. A common assumption is that the more frequently an arterial catheter is accessed, the greater the likelihood of contamination and colonisation to occur. We sought to determine whether the accessing frequency has an influence on the rate of colonisation in a peripheral arterial catheter.

A retrospective, unmatched, nested case control study was conducted in our intensive care unit. The intensive care unit charts of 96 arterial catheters from 83 patients were examined to measure the number of times each respective arterial catheter was accessed. Multivariate Cox proportional hazards regression was used to compare the rate of accessing of arterial catheters and account for varying arterial catheter in situ duration. Arterial catheters which had a high access rate of 8.1 or more times/day (five colonised of 32 patients: hazards ratio 1.69, 95% confidence interval 0.52 to 5.49; P=0.77), or a medium access rate of 6.7 to 8.0 times/day (six colonised of 32 patients: hazards ratio, 1.35, 95% confidence interval, 0.37 to 4.92: P=0.65) were not significantly more colonised when compared to arterial catheters which had a low access rate of 0 to 6.6 times/day (six colonised of 32 patients), adjusted for arterial catheter insertion site and place in hospital where the arterial catheter insertion was performed.

We were unable to demonstrate that the accessing frequency of an arterial catheter was a major predisposing factor for the likelihood of colonisation. Other mechanisms other than hub colonisation should be investigated further.

Complications associated with arterial catheterization in children

OBJECTIVES

To examine the prevalence of and risk factors associated with arterial catheterization complications in a large pediatric patient population in an effort to generate hypotheses for future prospective study of arterial catheter placement.

DESIGN

Retrospective cohort study.

SETTING

Patients discharged between January 1, 2000, and March 31, 2005, from 33 children's hospitals belonging to the Child Health Corporation of America.

PATIENTS

Patients were 10,394 children identified from the Pediatric Health Information System database. Inclusion criteria included age 1 month to 18 yrs, admitted to a pediatric intensive care unit, received an arterial catheter for monitoring, and hospitalized for >or=1 day following catheter placement.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We assessed complications as defined by ICD-9 coding associated with arterial catheterization, including thrombosis, embolism, and infection. Complications were reported in 10.3% (1,072) of patients, most frequently infection/inflammation (61.8%), complication of vascular device not otherwise specified (14.9%), mechanical complications (14.1%), and embolic or thrombotic issues (7.5%). Independent predictors of complications associated with arterial catheterization were age (compared with 1-4 months) of 5-11 months (odds ratio [OR] 1.5; 95% confidence interval [CI] 1.25-1.82) or 1-2 yrs (OR 1.39; 95% CI 1.09-1.78), insertion of catheters after the first hospital day and need for cardiac surgery (OR 1.31; 95% CI 1.03-1.68), bone marrow transplantation (OR 1.79; 95% CI 1.19-2.70), and dialysis (OR 1.36; 95% CI 1.05-1.77). There was no association of arterial catheter complications with patient gender, Medicaid status, or presence of coagulopathy or shock.

CONCLUSIONS

Complications associated with arterial catheterization are common in critically ill children. Significantly, we were unable to account for the potential confounding effect of central venous catheterization in this study secondary to limitations of ICD-9 coding. This study serves as a hypothesis-generating report of a large pediatric sample and suggests the need to carefully assess arterial catheter-associated complications in a prospective study independent of central venous catheters.

Prospective study of peripheral arterial catheter infection and comparison with concurrently sited central venous catheters

OBJECTIVE

Peripheral arterial catheters are perceived as having low infective potential compared with other catheters and may be overlooked as a cause of catheter-related bloodstream infection. We aimed to measure colonization and rates of catheter-related bloodstream infection in arterial catheters, to investigate risk factors for arterial catheter colonization, and to compare arterial catheter infection rates with those in concurrently sited and managed central venous catheters.

DESIGN

Prospective 24-month cohort study.

SETTING

Eight-bed combined general intensive care and high-dependency unit of a 350-bed Australian teaching hospital.

PATIENTS

Three hundred twenty-one arterial catheters in 252 adult and pediatric patients were observed for 1,082 catheter days, and 618 central venous catheters in 410 patients were observed for 4,040 catheter days. All catheters were inserted in, or presented to, the intensive care unit. Both arterial catheters and central venous catheters were inserted by trained personnel under aseptic conditions, and management was standardized.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The incidence per 1,000 (95% confidence interval) catheter days of colonization (> or = 15 colonies) and catheter-related bloodstream infection was 15.7 (9.5-25.9) and 0.92 (0.13-6.44) for arterial catheters and 16.8 (13.3-21.3) and 2.23 (1.12-4.44) for central venous catheters. Arterial catheter colonization was not significantly different than that in central venous catheters (hazard ratio, 1.17; 95% confidence interval, 0.41-3.36; p = .77). Arterial catheter colonization increased with dwell time and was similar to central venous catheters over time. Femoral arterial catheters were colonized more often than radial arterial catheters (hazard ratio, 5.08; 95% confidence interval, 0.85, 30.3; p = .075), and colonization was significantly higher when the catheter was inserted in the operating theater or emergency department (hazard ratio, 4.45; 95% confidence interval, 1.42-13.9; p = .01) compared with the intensive care unit.

CONCLUSIONS

The incidence of catheter-related bloodstream infection from arterial catheters was low. However, both arterial catheter colonization and rates of catheter-related bloodstream infection were similar to those in concurrently sited and identically managed central venous catheters. By inference, the arterial catheter should be accorded the same degree of importance as the central venous catheter as a potential source of sepsis.

The anaesthesiologist in the intensive care unit

PURPOSE OF REVIEW

This review focuses on recent knowledge in areas of anaesthesia expertise which are indispensable to intensive care unit management, including airway management, vascular access, regional analgesia and the treatment of status asthmaticus and status epilepticus.

RECENT FINDINGS

Etomidate as the sole agent for intubation in the intensive care unit has a 90% success rate, while in a prehospital setting, the addition of succinylcholine to etomidate results in a 99% success rate. In determining successful intubation, capnography and laryngoscopic/fibreoptic visualization are superior to auscultation, while auscultation is as effective as the self-inflating bulb or transillumination with the lightwand. The dorsalis pedis artery is an effective alternative to radial artery cannulation, while arterial cannulation itself can result in major adverse effects if complications arise. Ultrasound guidance in the placement of central catheters results in an improved insertion success rate. Internal jugular and subclavian lines have similar risk of haemothorax or pneumothorax, while subclavian lines are associated with the lowest incidence of infection. Midazolam, thiopentone and propofol have all been found to be efficacious in terminating refractory status epilepticus, with thiopentone resulting in a lower incidence of breakthrough seizures or treatment failure but an increased incidence of hypotension. Inhalational anaesthesia using isoflurane or desflurane has also been found to be successful in refractory status epilepticus. In the management of status asthmaticus, limiting minute volume while tolerating hypercapnia and acidosis as well as the use of inhalational anesthesia have proven effective strategies in a number of refractory cases.

SUMMARY

The anaesthesiologist's unique knowledge and skills are ideally suited to the practical management of patients in a critical care setting as well as in the treatment of the critical phases of many illnesses.

[Adverse events in Intensive Medicine. Managing risk]

Health care interventions entail a risk of adverse events (AE), that may cause lesions, incapacities and even death in the patients. Given the complexity of the care of the critical patient, the Critical Care Services are a high risk setting for the appearance of AE in these patients, many of them avoidable. Several studies show the influence of organizational factors focused on the system in the reduction of care risk and on the result of the critical patients. The voluntary and anonymous registry and reporting systems make it possible to identify a significant percentage of these incidents, analyze the factors related (that contribute or limit), establish preventive strategies, permitting management of risk, and potentially reduce the appearance and consequences of avoidable AE with all this. Initiatives such as the ICU Safety Reporting System (ICUSRS), that use a web database as registry system and includes contributions from different sites, favor the safety and risk culture, essential in the improvement of health quality of critical patients.

Disclosing errors and adverse events in the intensive care unit*

OBJECTIVE

To review the issue of disclosing errors in care and adverse events that have caused harm to patients in critical care.

DESIGN

Review the scope of the problem, the definitions of errors and adverse events, and the benefits and problems of disclosing errors and adverse events and provide an approach by which to have these difficult discussions.

SETTING

Medical center.

PATIENTS

Critically ill patients and their families.

INTERVENTIONS

Applying a systematic framework for disclosing errors and adverse events to affected patients and their families.

MEASUREMENTS AND MAIN RESULTS

Several national organizations mandate that physicians discuss errors in care and adverse events that have caused harm with affected patients, but failure to do so is a common problem in critical care as surveys of intensivists indicate that, although most believe that errors should be disclosed, few routinely do so. The likelihood of an adverse event is increased in intensive care units because of the nature of critical care. Not all errors or adverse events require disclosure. There are ethical, financial, legal, systems, and personal benefits to disclosing errors, and disclosure discussions should address common patient concerns.

CONCLUSIONS

Failure to disclose errors and adverse events in critical care is an important and common problem. There are numerous reasons why errors and adverse events should be disclosed, and use of a standard framework for doing so will facilitate the process.

Review of the Australian incident monitoring system

BACKGROUND

A survey was conducted to assess the benefits and limitations of the Australian Incident Monitoring System (AIMS) as a programme to improve patient safety.

METHODS

A 12-point questionnaire was sent to 12 current users of AIMS in November 2002.

RESULTS

The AIMS provides a consistent system of coding, trending and monitoring of incident data. It promotes a patient safety culture and an awareness of system error. Other benefits include the building of teamwork and the implementation of strategies to reduce the prevalence and severity of incidents. The majority of respondents (83%) reported that AIMS investigations resulted in significant changes to equipment usage, medication prescribing or administration, clinical protocols, training programmes and falls risk assessment tools. Although 75% of users reported improvements in patient outcomes, these were difficult to measure. A major limitation of AIMS was the low rate of incident reporting by medical staff. Voluntary reporting systems did not capture all incident data and the information was often too generic for root cause analysis. There were difficulties benchmarking data and concerns were raised regarding the ownership of information. The programme requires ongoing resources to implement change strategies and to maintain incident reporting levels. On a scale of 1 (poor rating) to 10 (excellent rating) the mean benefit rating was 7.6.

CONCLUSION

The Australian Incident Monitoring System is beneficial as a component of a clinical risk management strategy. Usefulness could be improved by increased participation by medical staff. The level of resources required should not be underestimated if the programme is to demonstrate improvements to patient outcomes. More recent versions of AIMS promise improved capabilities and will require similar evaluation.

[Assessment of the efficacy of the implementation of an arterial cannulation protocol as quality assurance method]

AIM

Arterial cannulation is a usual technique in intensive care. With this study, we aim to assess the efficacy of the implementation of an arterial cannulation protocol.

MATERIAL AND METHOD

The study was performed in several phases: a first cross-sectional cut-off to assess the technique performed and the incidence of complications, without knowledge of the study by the staff involved. There was a second phase of development and explanation to the unit staff of a protocol performed based on the results obtained and the available evidence. The third phase was of reevaluation of the results after the implementation of the protocol by a new cross-sectional cut-off without knowledge of the staff.

RESULTS

In phase 1, a total of 100 arterial cannulations were studied, obtaining the existence of a large amount of catheters not fixed by suture (44%) and a significant percentage of cases of accidental withdrawal (15%) as fundamental results. The protocol was implemented to solve these problems. It stressed the suture of all the cannalized catheters. Data on 80 patients and 133 catheters have now been gathered. The percentage of catheters that were sutured according to the protocol indication was 98%, significantly greater than phase 1 (p< 0.0001). The number of catheters whose withdrawal reason was accident removal was also significantly inferior (4%; p = 0.002).

CONCLUSIONS

The implementation of an arterial cannulation protocol with a high rate of follow-up by the nursing staff has achieved a reduction in the incidence of iatrogenies due to the technique.

Apparent hyperkalaemia from blood sampled from an arterial cannula

Blood samples were obtained from a radial artery cannula in a 60-yr-old man during coronary artery surgery. Serum potassium concentrations of 9.3, 8.4, and 7.4 mmol litre(-1) were obtained. A simultaneous venous blood sample gave a serum potassium concentration of 4.4 mmol litre(-1). The ECG was unchanged. After the arterial cannula was repositioned, subsequent blood samples gave expected ranges of serum potassium concentration. We suggest that the initial arterial cannula position caused a high shear rate in the blood when samples were withdrawn, causing haemolysis and hyperkalaemia.