WebM&M: Case Studies

An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics.  In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.  An hour into the operation, the anesthesiologist found her left calf to be warm and tense, presumably due to fluid extravasation from the IO line.  The IO line was removed, and the Orthopedic Surgery service was consulted intraoperatively due to concern for acute compartment syndrome.  Signs of compartment syndrome eventually resolved without any surgical intervention.  The commentary summarizes complications associated with IO lines, the importance of anticipating procedural complications, and methods to identify the signs and symptoms of acute compartment syndrome.

A woman with multiple myeloma required placement of a central venous catheter for apheresis. The outpatient oncologist intended to order a nontunneled catheter via computerized provider order entry but accidentally ordered a tunneled catheter. The interventional radiologist thought the order was unusual but didn't contact the oncologist. A tunneled catheter was placed without complications. When the patient presented for apheresis, providers recognized the wrong catheter had been placed, and the patient underwent an additional procedure.

Despite mechanical problems with the robotic arms during a robotic-assisted prostatectomy, the surgeon continued using the technology and completed the operation. Following the procedure, the patient developed serious bleeding requiring multiple blood transfusions, several additional surgeries, and a prolonged hospital stay.

Following a non-ST segment elevation myocardial infarction, a man was admitted to the hospital and placed on a telemetry monitor. As the monitor was constantly sounding with "low voltage" and "asystole" alerts and the patient was well each time clinicians checked, they silenced the alarms. The patient was found dead 4 hours later.

A 3-year-old boy hospitalized with anemia who was on chronic total parenteral nutrition was given an admixture with a level of sodium 10-fold higher than intended. Despite numerous warnings and checks along the way, the error still reached the patient.

Admitted with a congestive heart failure exacerbation, an elderly man acquired an infection around his peripheral IV site, accompanied by fever, chills, and back pain. Likely secondary to the infected peripheral IV catheter, the patient had developed methicillin-resistant Staphylococcus aureus bacteremia and an epidural abscess.

A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.

A premature infant had a PICC line placed for parenteral nutrition. During an attempt to remove it, the line broke. The infant had to be sent for surgical removal of the catheter and required an increased level of care, including ventilator support.

A code blue was called on a man admitted for chest pain, but the defibrillation pads placed on the patient were incompatible with the machine.

An intern increases a patient's warfarin dosage nightly based on subtherapeutic INR levels drawn each morning; after several days, the patient develops potentially life-threatening bleeding.

A central line placed incorrectly causes a patient to suffer permanent neurologic damage.

An infant codes due to pulmonary emboli after a central line flush.