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Back To Vidyya Sample Content From CIRS


Two cases with endotracheal bleeding after Swan-Ganz catheter use


The CIRS system encourages anesthesiologist from around the world to visit the CIRS Web site and fill out their anonymous critical report questionnaire. The report is designed to statistically weight the information to facilitate record keeping that will watch for trends such as poor procedure or faulty equipment. On the feedback page, practitioners can write in and give their comments to a colleague's case without fearing the repercussions that might accompany identification. CIRS is an excellent start on the road to eliminating medical errors.

Below is sample content from the sight. It is in no way an endorsement from Vidyya on best practice issues, rather it is provided as an educational resource. Visit the CIRS® sight for more information at www.medana.unibas.ch/eng/CIRS/CIRS.htm.

We hope you enjoy the sample content.

Two cases with endotracheal bleeding after Swan-Ganz catheter use

CASE 1:

This is the short description of the incident:

The patient was in for mitral valve replacement because of severe mitral regurgitation. Monitoring with Swan Ganz PA-catheter. At the end of cardiopulmonary bypass suddenly blood in the endotracheal tube. Because of normal hemodynamics no evidence for left heart failure. No major hemorrhage. Spontaneus resolving of bleeding. Chest X-ray after the procedure showed a patchy sign in the right middle segment of the lung. A post-operative angiogram confirmed the hypothesis of a lesion of the pulmonary artery tree. The SG-catheter was unblocked and situated in the wedge-position during bypass.  

 

Short description of the management of incident:

Since the bleeding stopped by itself, no further action was required.

 

Outcome : Prolonged hospitalization.

 


CASE 2:

This is the short description of the incident:

Patient with severe mitral regurgitation and aortic stenosis scheduled for valve replacement of both valves. Monitoring with SG pulmonary artery catheter. After cannulation of the right atrium for cardio-pulmonary bypass it was no longer possible to manipulate the SG-catheter, because the upper canula of the cpb-pump was so tightly fitted in the right atrium. Consequently, the catheter remained in this position for the whole bypass-period. After restitution of spontaneous circulation, suddenly blood appeared in the endotracheal tube. The chest X-ray after the operation showed a small, light shadow at the tip of the catheter, suggesting a pseudo-aneurysm of the pulmonary artery.

 

This is the description of the management:

Since the bleeding stopped spontaneously, a pulmonary angiogram was performed 7 days later, showing no aneurysm.

 

The outcome of this incident was prolonged hospitalization.

 

See the recommendations out of the literature.



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Editor: Susan K. Boyer, RN
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