31 results for “central arterial line insertion”
68y · Female·Haemorrhage secondary to right subclavian artery lacerations sustained during ce…
…d 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 hig…
74y · Female·Complications of carotid artery injury from central line insertion in the settin…
…old woman with metastatic colon cancer, died from complications of carotid artery injury sustained during central venous catheter (CVC) insertion as part of a Whipple procedure and hemicolectomy. The CVC was inadvertent…
66y · Female·retroperitoneal haemorrhage due to anticoagulation following right cerebrovascul…
…year-old woman died from retroperitoneal haemorrhage following anticoagulation for stroke caused by intra-arterial central venous catheter placement. The catheter was mistakenly inserted into the right carotid artery ins…
63y · Male·Right cerebral infarction caused by infusion of medication via central venous li…
…spiratory depression, hypernatremia and alcohol withdrawal requiring benzodiazepines and BiPap support. A central venous line was inserted for medication access prior to transfer to ICU. The line was inadvertently place…
62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…
… poor outcomes: late recognition of blood loss, delay in activating massive transfusion protocol, loss of central line preventing vasopressor administration, inadequate team communication, and suboptimal fluid resuscita…
38y · Male·Urosepsis
John Miklosowa, a 38-year-old man with Down syndrome and severe intellectual disability, died from urosepsis after rapid deterioration at his residential facility on 28 March 2009. He had a permanent suprapubic catheter …
39y · Male·Hypoxic/Ischaemic Encephalopathy due to Cerebral Arterial Gas Embolism
…dday but the device remained in place for 6+ hours while Phillip sat out of bed with family visitors. An IV line disconnected from the Multi Flow Extension Set, allowing air entry into the CVAD. Critical failures include…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
… illness and acute kidney injury); delayed and sub-optimal antibiotic dosing and timing; failure to place arterial line for continuous blood pressure monitoring; and critically, failure to admit to ICU despite severe sep…
48y · Male·sepsis and renal failure due to perforated gastric ulcer
A 48-year-old man with hepatitis C and schizo-affective disorder presented to West Coast District Hospital on 20 October 2014 with severe abdominal pain radiating to the right shoulder tip, generalised tenderness, and a …
30y · Male·Acute pneumonia and multi-organ failure, due to or as a consequence of traumatic…
Faysal Ishak Ahmed, a 30-year-old Sudanese refugee, died from traumatic brain injury sustained in a fall down stairs at Manus Island Regional Processing Centre on 22 December 2016. He collapsed and fell while alone, like…
49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…
Deborah Burgen died from intra-abdominal haemorrhage complicated by septic shock following delayed emergency surgery for bowel obstruction. She attended the emergency department six times over eleven days with identical …
57y · Male·Multiple Organ Failure and Intra-Abdominal Haemorrhage following Cholecystectomy
A 57-year-old man with multiple comorbidities (obesity, diabetes, hypertension, COAD, sleep apnoea) underwent elective laparoscopic cholecystectomy at a regional hospital. The procedure was converted to open due to dense…
74y · Male·Intra-abdominal haemorrhage complicating elective umbilical hernia repair
A 74-year-old man with significant cardiac history (atrial fibrillation, dilated cardiomyopathy, pacemaker) underwent elective umbilical hernia repair. Intraoperatively, unexpected ascites was discovered and partially dr…
19y · Female·Meningococcal septicaemia
Emma McGrath, a 19-year-old nursing student, died from meningococcal septicaemia caused by the W strain after presenting to the ED with a 12-hour history of vomiting, diarrhoea, abdominal pain and fever. The atypical pre…
41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…
A 41-year-old man with acute posterior circulation stroke was misdiagnosed as encephalitis despite normal lumbar puncture findings. The critical failure was Dr R.'s failure to diagnose stroke on 7 September and arrange u…
69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…
A 69-year-old woman died of septic shock following bile leak complications after laparoscopic cholecystectomy. Critical failures included: (1) inappropriate transfer to low-dependency unit on post-op day 1 despite consul…
43y · Male·Multi-organ failure with coagulopathy secondary to acute exacerbation of chronic…
A 43-year-old man with a colloid cyst of the third ventricle presenting with progressive headache was admitted for planned endoscopic surgery. Surgery was delayed from Friday to Monday due to unavailability of specialist…
82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…
Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…
53y · Female·multiple organ failure as a result of septic shock
Pauline Kessell, aged 53, died from septic shock caused by overwhelming sepsis following endoscopic pyeloscopy with…
77y · Female·Complications following a recent fracture and surgical repair of the right hip i…
…eveloped rapidly preoperatively and remained painful. The case illustrates that elderly patients with borderline organ reserve require close monitoring, lower threshold for infection suspicion, and protocolized periopera…
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