Two Cases of Femoral Single Lumen Catheter Breakage Inside the Vein – Learning Points For All Of Us By Dr. Kulwant Singh
Case 1 –
49 years old male was taken up for dialysis, after informed consent and under strict aseptic precautions femoral single lumen catheter was inserted in right femoral vein. When the technician tried to attach the catheter with the tubing, its distal outer end (hub) broke down and there was bleeding. So hurriedly he tried to stop the bleeding with gauge and planned to remove this catheter. During removal, it further broke down with its tip remaining inside. Though the patient was vitally stable but it was a panic situation for him and attendants. We explained the family about the complication, documented it and referred patient to nearby cardiology unit, advising patient not to move or bend (flex) his leg.
Cardiologist scanned the patient under fluoroscopy and to our luck it was stuck at site of insertion only. It was removed by vascular surgeon by local dissection only. (Picture 1 and 2 ). Patient was discharged after 1 day.
Case 2 –
54 years old male, in nearby hospital was taken up for dialysis in same manner as above. He had some blood leak near insertion site, so technician while trying to inspect it found that there is crack in catheter. There was again break of tip end while he tried to remove it. He further tried to negotiate to get hold of end with forceps but all in vain and patient was finally referred for retrieval. When cardiologist scanned the patient, the tip end had already migrated up to common iliac vein. Cardiologist finally took it out through the snare from the femoral vein in cathlab. After keeping patient under observation for one day, he was discharged.
The above two events were taken seriously and were informed to the appropriate authorities of the concerned hospital. Inspection team found that the flexibility of the batch of the catheter was not as per standards; catheter was very brittle and was breaking like matchstick (picture 3). Though on both occasions new catheter was used, was this an effect of storage (changing weather) or sterilization technique at manufacturer end is not clear.
Learning points for Nephrologists and Technicians – What can we do from our end?
- Complications are part and parcel of every medical profession but always take prior informed consent. Most of the times we are in hurry of starting the dialysis as our patients are having hyperkalemia or fluid overload, but forgetting the basics can cost us a lot.
- Always explain the complication to patient/attendants and document it in your records, what happened, and what you did at that moment. Also when you refer a patient to some center give proper referral slip and never forget to document vitals when he left your center.
- Now from this case particularly, we learnt that before inserting these rigid single lumen catheters, always CHECK their flexibility. They are generally flexible so that even you can bend them without breaking or cracking. If you have any suspicion that it is on brittle side, don’t take a chance.
- Don’t panic, stay calm. Don’t negotiate the area much, by attempting so we are further pushing the end inside. Try to immobilize the patient on that dialysis bed only and advise him/her not to bend/flex the leg. Venous flow is slow and upward, broken tip generally doesn’t go much higher and cardiologists can easily remove it from vein or even heart through snare.
Picture 1 (As below)– White colored tip seen embedded in femoral vein wall
Picture 2 (As below)–Retrieved catheter tip
Picture 3 (As below) – New Catheter Packet which was checked by inspection team showing multiple pieces of brittle catheter
Dr. Kulwant Singh is currently working as Consultant Nephrologist and Renal Transplant Physician with Shalby Hospitals, Mohali and Grecian Hospital, Mohali, Punjab. After doing his MBBS from Smt NHL Medical College, Ahmedabad and MD Medicine from Saurashtra University, Rajkot (MP Shah Mecical college Jamnagar), he completed his DNB Nephrology from one of the oldest and prestigious Hospitals of India – Sir Ganga Ram Hospital, New Delhi, where he was trained in both basic and critical care nephrology, temporary and permanent vascular access creation, hemodialysis, peritoneal dialysis and extensive training in managing kidney transplant patients. He was awarded a Gold medal at national level in Nephrology for year 2013.