Misplaced Catheter Allegedly Causes Patient’s Hemorrhagic State and Eventual Death

Case Summary

This case involves a female patient with a past medical history of congestive heart failure and pulmonary fibrosis. The patient went to the hospital for severe shortness of breath evaluation.

Initially, the patient was in the intensive care unit. The patient then went to a step-down telemetry unit where the intensivist placed a triple lumen catheter using a femoral approach. The intensivist mistakenly placed the catheter via the artery instead of the vein. Allegedly, the intensivist did not immediately recognize the misplacement.

Days later upon patient improvement and preparation for discharge, the catheter was removed, which cause a hemorrhagic state. Due to the patient’s hematological anticoagulated state, she bled profusely and died due to complications.

Case Theory

The case here is clear in that the defendants were negligent in placing a triple lumen catheter into the femoral artery rather than the femoral vein. Furthermore, mismanagement continued after the identification of the medical error.

It is not extremely rare for a misplaced central line to happen. However, during a misplaced catheter event, the physician can correctly identify the error as not lying within the femoral vein. The physician can safely remove the misplaced central line using the proper medical protocol.

If the misplaced catheter is lying within or traversing large and incompressible arteries or veins, the physician should not remove it before considering what is likely to happen when removed.

A physician should seek advice and further imaging, typically in conjunction with interventional radiology or vascular surgery. When a misplaced central line catheter event occurs, the rule is “When in doubt, don’t take it out.”

Since no available identifying imaging was ordered in this case, the patient’s death could have likely been prevented had the standard of care been in place.

Questions for the Expert

• How is the arterial placement of femoral central venous catheter managed in a way that lessens the likelihood of complication?
• What is the standard of care with a misplaced femoral catheter?
• What testing and precautions should have taken place prior to the removal of the catheter?
• Does misplacement of the catheter, in this case, fall below the standard of care?

Expert Witness Involvement

Vascular Surgeon/Intensivist

In this case, a vascular surgeon can speak to the protocol and standard of care for proper line placement. This expert can also testify about the deviation from the standard of care. Additionally, a vascular surgeon can opine on the correct protocol for removal in the event of a misplaced line.