Document Detail

Guide-wire fragment embolisation in paediatric peripherally inserted central catheters.
MedLine Citation:
PMID:  22409691     Owner:  NLM     Status:  MEDLINE    
OBJECTIVE: To report guide-wire fragment embolisation of paediatric peripherally inserted central catheter (PICC) devices and explore the safety profile of four commonly used devices.
DESIGN, SETTING AND PARTICIPANTS: Clinical incidents involving paediatric PICC devices in Queensland public hospitals were reviewed. A PICC user-experience survey was conducted at five public hospitals with 32 clinicians. A device design evaluation was undertaken, and magnetic resonance imaging (MRI) safety was tested by a simulation study.
MAIN OUTCOME MEASURES: Embolisation events; technical mistakes, multiple attempts and breakages during insertion; willingness to use the device; failure modes and risk priority rating; movement and/or temperature change on exposure to MRI.
RESULTS: Six clinical incidents of silent guide-wire embolisation, and four near misses were identified; all were associated with one type of device. The survey found that this device had a reported broken-wire embolisation rate of 0.9/100 insertions with no events in other devices; two of the four devices had a higher all-cause embolisation rate (3.3/100 insertions v 0.4/100 insertions) and lower clinician acceptance (68%-71% v 91%-100%). All devices had 6-17 identified failure modes; the two devices that allowed removal of a guide wire through a septum had the highest overall risk rating. Guide-wire exposure to MRI was rated a potential safety risk due to movement.
CONCLUSIONS: There is marked variation in the safety profile of 3 Fr PICC devices in clinical use, and safety performance can be linked to design factors. Pre-MRI screening of all children who have previously had a PICC device inserted is recommended. We advocate a decision-making model for evaluation of device safety.
Joel M Dulhunty; Andreas Suhrbier; Graeme A Macaulay; Jennifer C Brett; Alexa V A van Straaten; Ian M Brereton; Jillann F Farmer
Publication Detail:
Type:  Comparative Study; Journal Article    
Journal Detail:
Title:  The Medical journal of Australia     Volume:  196     ISSN:  1326-5377     ISO Abbreviation:  Med. J. Aust.     Publication Date:  2012 Mar 
Date Detail:
Created Date:  2012-03-13     Completed Date:  2012-05-02     Revised Date:  2012-05-17    
Medline Journal Info:
Nlm Unique ID:  0400714     Medline TA:  Med J Aust     Country:  Australia    
Other Details:
Languages:  eng     Pagination:  250-5     Citation Subset:  IM    
Patient Safety and Quality Improvement Service, Queensland Health, Brisbane, QLD.
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MeSH Terms
Catheterization, Central Venous / adverse effects,  instrumentation*
Catheterization, Peripheral / adverse effects,  instrumentation*
Child, Preschool
Cluster Analysis
Cohort Studies
Equipment Design
Equipment Safety
Retrospective Studies
Risk Assessment
Upper Extremity Deep Vein Thrombosis / epidemiology*,  etiology*
Erratum In:
Med J Aust. 2012 Mar 19;196(5):316

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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