Coronial
QLDhospital

SG - Non-inquest findings

Deceased

SG

Demographics

68y, female

Date of death

2012-04-21

Finding date

2014-09-01

Cause of death

Haemorrhage secondary to right subclavian artery lacerations sustained during central venous catheter insertion

AI-generated summary

A 68-year-old woman died from massive blood loss following inadvertent puncture of the right subclavian artery during central venous line insertion. The anaesthetist used anatomical landmarks without ultrasound after an initial high approach failed. Upon recognising arterial puncture, appropriate escalation occurred with vascular surgery involvement and emergency surgical exploration and repair. However, the subclavian artery location prevented adequate manual pressure control. The patient arrested during neck exploration and despite sternotomy and vascular repair, died from hypovolemic shock and subsequent cardiac compromise. The expert review found the clinical decision-making appropriate throughout. Key learning: ultrasound-guided central line insertion is now best practice and reduces but does not eliminate arterial puncture risk; recognition and prompt escalation were exemplary; subclavian artery punctures cannot be managed by neck pressure alone and require immediate vascular surgery.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

anaesthesiageneral surgeryvascular surgerycardiothoracic surgerycardiology

Drugs involved

heparin

Clinical conditions

subclavian artery lacerationsubclavian vein lacerationhaemorrhagehypovolaemic shockcardiac arrestatrial fibrillationsystolic dysfunctionpulmonary hypertensionhaematoma

Procedures

central venous line insertionneck explorationsternotomysubclavian artery repairsubclavian vein repair

Contributing factors

  • Inadvertent puncture of right subclavian artery during central venous line insertion
  • Anatomical location of puncture (low in neck behind clavicle) preventing adequate manual pressure control
  • Massive blood loss estimated at 1360 mL intraoperatively plus 520 mL in neck drain
  • Cardiac arrest occurring during neck exploration
  • Hypovolemic shock and subsequent cardiac compromise from significant blood loss
  • Unavailability of ultrasound machine at time of procedure

Coroner's recommendations

  1. Refer findings to the Royal College of Anaesthetists for consideration of clinical learnings
  2. Review of current practice for inserting central lines including discussion with anaesthetist and vascular surgeon for management of inadvertent arterial puncture
  3. Increase availability of ultrasound machines for anaesthetists (four ultrasounds to be provided and purchased)
  4. Contemporaneous anaesthetic record documentation by anaesthetist throughout procedure and crisis management
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