PERM-CATHETER
Received Nov 2, 2018 · Event occurred Oct 23, 2018
Report 8045964 · MDR key 8045964
Device
Product problems
- Material Split, Cut or Torn
Patient
17 YR
- Air Embolism
- Cardiac Arrest
- Death
- Loss of consciousness
- Loss Of Pulse
- Air Embolism
- Cardiac Arrest
- Death
- Loss of consciousness
- Loss Of Pulse
Narrative
Description of Event or Problem
PT HAS PERM-CATHETER VASCATH PLACED IN OPERATING ROOM ON (B)(6) 2018 WITHOUT COMPLICATIONS. PT RETURNED TO FLOOR. DURING THE EVENING HOURS, THE PT WAS FOUND PULSELESS. CATHETER TORN APART FOUND LAYING ON BEDSIDE TABLE. RESUSCITATION EFFORTS FAILED TO REVIVE PT. LEFT INTERNAL JUGULAR VEIN DOUBLE LUMEN PERMCATH DIALYSIS CATHETER PLACEMENT WITH ULTRASOUND AND FLUOROSCOPIC GUIDANCE. A (B)(6) WITH RENAL FAILURE DUE TO IGA NEPHROPATHY REQUIRING HEMODIALYSIS. THE CATHETER WAS SECURED TO THE SKIN OF THE EXIT SITE WITH 3-0 PDS SUTURE. MASTISOL AND STERI-STRIPS WERE APPLIED. A TEGADERM DRESSING WAS APPLIED TO THE CATHETER EXIT SITE. PROCEDURE COMPLETED BY 1615 ON (B)(6) 2018. NO EVIDENCE OF HEMO OR PNEUMOTHORAX. PT RETURNED TO ROOM. FAMILY OF THE PT LEFT PT ROOM DURING THE EVENING HOURS. NURSING CHECKS BEING PERFORMED AT 2330 AND PT DISCOVERED TO BE PALE AND UNRESPONSIVE. THE PROXIMAL END OF THE CATHETER WITH THE ARTERIAL AND VENOUS LINES WAS LYING ON THE BEDSIDE TABLE.