UMBILI-CATH

Description of Event or Problem

THE NEW FOOTPRINT'S DUAL LUMEN 3.5FR UMBILICAL VENOUS CATHETER BROKE UNDER NO SPECIFIC CAUSATION WHERE THE TWO LUMENS COME TOGETHER AT LINE. THE PATIENT WAS AN EXTREMELY PREMATURE INFANT ON TPN (TOTAL PARENTERAL NUTRITION) AND TWO PRESSORS (DOPAMINE AND NOREPI). THE BEDSIDE RN AND PRACTITIONER WERE PRESENT WHEN IT OCCURRED. A 26GA PIV (PERIPHERAL INTRAVENOUS) WAS EMERGENTLY PLACED IN THE LEFT ARM AND THE FLUIDS WERE TRANSFERRED TO THE PIV UNTIL PHARMACY COULD RE-MIX CONCENTRATIONS FOR PIV. THE REMAINDER OF THE UVC (UMBILICAL VENOUS CATHETER) LINE WAS PULLED, AND PRESSURE HELD. PVAT WAS ALSO IMMEDIATELY NOTIFIED FOR AN URGENT PICC (PERIPHERALLY INSERTED CENTRAL CATHETER) AND MOTHER WAS UPDATED BY PHONE. THE PATIENT EXPERIENCED BRIEF HYPOTENSION AND THE NEED FOR AN EARLY PICC.