Description of Event or Problem · 1
THERE HAVE BEEN 3 INCIDENTS (IN 1 PT) OF CATHETER MALFUNCTION. THE RESIDENT WENT TO THE TRAUMA BAY TO INSERT A TRIPLE LUMEN BOLT SYSTEM INTO THE PT TO MONITOR ICP, PBTO2 AND BTEMP. THE PROCEDURE WENT WITHOUT A HITCH... DURA OPENED, PTO2 AND BTEMP PROBES WERE PASSED EASILY. THEN THE L-CATHETER WAS ZEROED AND WAS PASSED INTO THE BOLT SYSTEM. A WAVE FORM DID APPEAR HOWEVER, WHEN THE RESIDENT TIGHTENED THE ICP CAP, THE ICP SHOT UP TO THE 300'S (WITH NO WAVE) AND 3 RED LINES APPEARED WHERE THE ICP NUMBER SHOULD READ ON THE CAMINO. THE RESIDENT LOOSENED AND PULLED THE CATHETER OUT AND TRIED AGAIN WITH THE SAME RESULT. A SECOND L-CATHETER WAS THEN OBTAINED AND THE PROCEDURE ATTEMPTED A THIRD TIME. THE SAME RESULT OCCURRED. THIS TIME, HOWEVER, THE RED LINES DISAPPEARED AND A MESSAGE APPEARED... "NOT CONNECTED... CANNOT READ." A THIRD CATHETER WAS OBTAINED AND THE PROCEDURE ATTEMPTED FOR THE FOURTH TIME. THIS TIME THE L-CATHETER PLACEMENT WAS SUCCESSFUL; THE ICP WAVE FORM WAS GOOD AND WAS <20. LAST NIGHT (2 DAYS AFTER THE FOURTH CATHETER WAS PLACED) THIS PT'S ICP BEGAN TO TREND UPWARD. WHEN THE ICP WAS SUSTAINED ABOVE 20 THE PT WENT FOR A HEAD CT. THE CT SHOWED NO INCREASE IN SWELLING AND AN EVOLVING STROKE. IT WAS NOTED AFTER THE CT SCAN THAT THE ICP READING WAS 40-50 WITHOUT A WAVE FORM. MULTIPLE INTERVENTIONS WERE PERFORMED INCLUDING SEDATION AND MANNITOL. WHEN THE TREATING TEAM WAS STILL UNABLE TO CONTROL THE ICP THE DECISION WAS MADE TO PLACE A VENTRICULOSTOMY QUESTIONING THE VALIDITY OF THE L-CATHETER. THE OPENING PRESSURE OF THE VENTRIC WAS 9 (L-CATHETER READING WAS STILL 40-5-). DURING THE TIME OF INCREASED ICP READING FROM THE L-CATHETER, PBTO2 DID TREND DOWNWARD SOMEWHAT THOUGH NEVER APPEARED BELOW 20. CO WILL SAVE ALL THE L-CATHETERS SO THE PT TO MONITOR ICP, PBTO2 AND BTEMP. THE PROCEDURE WENT WITHOUT A HITCH... DURA OPENED, PBTO2 AND BTEMP PROBES WERE PASSED EASILY. THEN THE L-CATHETER WAS ZEROED AND WAS PASSED INTO THE BOLT SYSTEM. A WAVE FORM DID APPEAR HOWEVER, WHEN THE RESIDENT TIGHTENED THE ICP CAP, THE ICP SHOT UP TO THE 300'S (WITH NO WAVE) AND 3 RED LINED APPEARED WHERE THE ICP NUMBER SHOULD READ IN THE CAMINO. THE RESIDENT LOOSENED AND PULLED THE CATHETER OUT AND TRIED AGAIN WITH THE SAME RESULT. A SECOND L-CATHETER WAS THEN OBTAINED AND THE PROCEDURE ATTEMPTED A THIRD TIME. THE SAME RESULT OCCURRED. THIS TIME, HOWEVER, THE RED LINES DISAPPEARED AND A MESSAGE APPEARED... SAYING SOMETHING LIKE "NOT CONNECTED... CANNOT READ." A THIRD CATHETER WAS OBTAINED AND THE PROCEDURE ATTEMPTED FOR THE FOURTH TIME. THIS TIME THE L-CATHETER PLACEMENT WAS SUCCESSFUL; THE ICP WAVE WAS GOOD AND WAS <20. LAST NIGHT (2 DAYS AFTER THE FOURTH L-CATHETER WAS PLACED) THIS PT'S ICP BEGAN TO TREND UPWARD. WHEN THE ICP WAS SUSTAINED ABOVE 20 THE PT WENT FOR A HEAD CT. (THE CT SHOWED IN SWELLING AND AN EVOLVING STROKE). IT WAS NOTED AFTER THE CT SCAN THAT THE ICP READING WAS 40-50 WITHOUT A WAVE FORM. MULTIPLE INTERVENTIONS WERE PERFORMED INCLUDING SEDATION AND MANNITOL. WHEN THE TEAM WAS STILL UNABLE TO CONTROL THE ICP THE DECISION WAS MADE TO PLACE A VENTRICULOSTOMY QUESTIONING THE VALIDITY OF THE L-CATHETER. THE OPENING PRESSURE OF THE VENTRIC WAS 9 (L-CATHETER READING WAS STILL 40-50). DURING THE TIME OF INCREASED ICP READING FROM THE L-CATETHER, PBTO2 DID TREND DOWNWARD SOMEWHAT THOUGH NEVER BELOW 20.