Open central venous catheter port results in fatal air embolism

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…incident where a patient died following a clamp on a central venous catheter port being briefly left open, resulting in air embolisation…” The Royal College of Anaesthetists (2016).

The Royal College of Anaesthetists report “NHS Improvement have been alerted via the coroner’s court to an incident where a patient died following a clamp on a central venous catheter port being briefly left open, resulting in air embolisation and cerebral infarction. The coroner was particularly concerned that:

  • nursing staff were not aware of the risk of air embolisation when leaving a central venous catheter port uncapped and unclamped
  • they were unable to locate any literature or guidance regarding the risk of air entry if the clamp is left open during use of the catheter.”
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