Safety Notice: Air embolism following CVC port being left open

NHS Improvement have been alerted via the coroner’s court to an incident where a patient died following a clamp on a central venous catheter port being briefly left open, resulting in air embolisation and cerebral infarction. The coroner was particularly concerned that:

• nursing staff were not aware of the risk of air embolisation when leaving a central venous catheter port uncapped and unclamped
• they were unable to locate any literature or guidance regarding the risk of air entry if the clamp is left open during use of the catheter.

In relation to the specific concerns, NHS Improvement have been able to identify that appropriate guidance on this risk for nurses has been established. There are two key sources:

Royal College of Nursing (2010) Standards for infusion therapy Page 22: ‘Under no circumstances should devices be left with caps open or exposed.’

We understand that these standards are currently being updated but we anticipate this risk will continue to be emphasised when revised standards are published on the RCN website.

Critical Care Network/National Nurse Leads - National Competency Framework for Adult Critical Care Nurses Page 20 – ‘You must be able to demonstrate through discussion essential knowledge of (and its application to your supervised practice): Associated hazards and complications of central venous catheters and systems.’

An NRLS search earlier this year revealed that there were three incident reports of a patient suffering harm from their CVC line being left open.

The Safe Anaesthesia Liaison Group has therefore been asked to remind all colleagues that patients’ CVC lines should never be left unclamped and uncapped, and that any incidents of air entrainment as a result of leaving the line in this manner should be reported locally and to the NRLS.