Sorry, you need to enable JavaScript to visit this website.
Skip to main content
Morbidity and Mortality Conferences
Displaying 1 - 10 of 84
Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest
Gary Raff, MD, and Brian Goudy, MD ,  

This case involves a 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) who underwent implantation of a central venous catheter with a subcutaneous port. The anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. In the post-anesthesia care unit, the patient’s arterial blood pressure started fluctuating and she developed cardiac arrest. A “code blue” was called and the child was successfully resuscitated after insertion of a thoracostomy drainage (chest) tube. Unfortunately, the surgeon damaged an intercostal artery when he inserted the chest tube emergently, which caused further bleeding and two additional episodes of PEA arrest. This commentary addresses the importance of mitigating risk during procedures, balancing education of proceduralist trainees with risk to the patient, and prompt review of diagnostic studies by qualified individuals to identify serious complications.

Subscribe to Morbidity and Mortality Conferences