ARGYLE UVC .35 FR/CH (1.2MM) X 25 CM)

Description of Event or Problem

NP CHANGING OUT MALPOSITIONED UVC. OLD CATHETER REMOVED, NEW CATHETER WOULD NOT PASS THROUGH LIVER TO IVC/ATRIAL JUNCTION. WAS RETRACTED TO LOW LYING AND SUTURED AS APPROX 3CM. NP WAS FLUSHING/DRAWING FROM LINE AND NOTICED AIR BUBBLES. NP ATTEMPTED TO REMOVE LINE AND CATHETER "SNAPPED" LEAVING APPROX. 3CM OF CATHETER IN BABY WITH END NOT VISIBLE AT CORD STUMP. NO BLOOD LOSS REPORTED, STAT BABYGRAM ORDERED AND SURGERY CONSULTED. RADIOGRAPH DEMONSTRATED CATHETER SEGMENT BELOW LIVER, BUT NOT IN CORD STUMP. BABY MADE NPO AND PIV X 2 PLACED. BABY AIR TRANSPORTED TO LEVINE CHILDREN'S HOSPITAL IN CHARLOTTE NC FOR PEDIATRIC INTERVENTIONAL SURGERY TO RETRIEVE RETAINED PIECE OF CATHETER. UVC PRODUCTS WITH SAME LOT NUMBER HAVE BEEN SEQUESTERED AND SET ASIDE.