Central line cardiac tamponade


Intravenous news: Leagle.com report “Shortly after Jamia Hoard was born at Roper Hospital in Charleston, South Carolina on March 30, 2002, she developed respiratory distress and was transferred from the Level 1 newborn nursery to the Level 2 nursery. Jamia’s treating physician was Marshall Goldstein, M.D., a board-certified neonatologist. Dr. Goldstein determined it was necessary for Jamia to have a peripheral intravenous line (IV) for infusion of medications and fluids and for withdrawal of blood for testing. After nurses were unable to place the IV, Dr. Goldstein ordered pediatric nurse practitioner Karen Johnson to insert an umbilical vein catheter (UVC).

A chest X-ray was taken prior to insertion of the UVC. Johnson initially advanced the UVC to a depth of 11 to 13 centimeters. Because the UVC was not drawing blood, Johnson inserted it deeper into Jamia’s chest. A second X-ray was made to confirm whether the UVC was placed properly. When Johnson read the second X-ray, she did not observe a problem with the UVC placement. The X-rays were sent to the radiology department for review by a radiologist.

The next morning, the on-call radiologist, Robert Smith, M.D., read Jamia’s X-rays. Dr. Smith’s written report stated: “An umbilical vein catheter has been placed. The tip terminates high within the right atrium. There are persistent bilateral coarse infiltrates essentially unchanged compared with the prior exam. No pneumothorax is seen.” At 10:34 a.m., Dr. Smith sent the X-rays and his report to the nursery.

When Dr. Goldstein made rounds that afternoon at 2:00 p.m., he examined Jamia, reviewed her lab results and X-rays, and read Dr. Smith’s radiology report. Following this examination, Dr. Goldstein wrote a note in Jamia’s chart in which he stated the UVC was placed “in approximately right atrium.”

At approximately 4:00 a.m. the next day, April 1, Jamia went into cardiac arrest. The nursing staff called Dr. Goldstein, who instructed staff to pull the UVC back and to transfer Jamia immediately to the Level 3 nursery at the Medical University of South Carolina (MUSC). At MUSC, neonatologists determined Jamia was experiencing “cardiac tamponade,” a potentially fatal syndrome.”

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