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Publication Type: Safety Notice
Single or Multiple Incident: Single
Date: 8/12/2014 12:00:00 AM
Country: Australia

This alert discusses a patient safety incident involving a central venous access device (CVAD). A patient had sustained severe neurological damage post removal of a central venous access device due to an intravascular gas embolism. The removal of the device while the patient was sitting upright in a chair was believed to have been a contributory factor. Air embolism results from the introduction of air into the circulatory system. With patients in the sitting position, negative thoracic pressure will suck air into great veins. This can occur during insertion, manipulation or removal of a CVAD and cause sudden vascular collapse. Symptoms include cyanosis, hypotension, increased venous pressures, and rapid loss of consciousness. The alert provides recommendations for training requirements and procedures that must be followed for safe removal of a central venous access device as well as site specific requirements of staff and administration to ensure implementation and compliance with CVAD policy.

Additional Details

central venous access device (CVAD)

Removal of Central Venous Access Devices (CVAD)