This pt had a 2.
7 french broviac placed in 2001.
It was used for infusion of medication.
The catheter was initially inserted into the saphenous vein which was then checked intra-operatively using fluoroscopy to confirm placement.
Seven months later, the pt required placement of a feeding tube, and it was felt the broviac was no longer needed.
The nurses had been able to infuse medicine through the broviac, but had not been able to draw from it.
The broviac was removed by left saphenous vein cut-down.
On 4/2002 the pt had a vcug [voiding cystourethrogram] to evaluate for reflux, and a fragment of the [broviac] catheter was noted to be in the inferior vena cava and left common iliac.
[the pt has experienced no sequela from this incident.
It is not known why the device was not examined when removed other than the physician may not have known it was broken until the fragment was found.
The life expectancy for this device and how long this catheter should remain in place are not known.
According to the facility's database, only one other report has been made regarding a broviac catheter breaking during removal.
It is not known if the catheter had actually broken prior to removal or upon removal.
The other devices within the same lot number have not been checked for signs of poor production.
It is not known if the labeling instructions or warnings for this device say anything specific about using it for the duration it was in use for in this situation.
The facility is not considering any procedural changes at this time based on this incident.
Staff do report they are able to draw blood from broviac catheters under normal circumstances.
The radiology report gives the exact location of the fragment as extending from the right upper quadant to the region of the left common iliac vein.
The tip of the fragment projects over the left mid portion of the sacroiliac joint.
It further states the fragment is approximately 11 cm in length and the proximal portion appears unchanged in comparison to a previous x-ray.
The catheter initially was inserted into the saphenous vein and it was checked intra-operatively using fluoroscopy.
It is not known what procedure was used to remove the fragment.
The fragment was not retained or given to the mfr at the time of removal although the facility is continuing to educate staff on the importance of saving such devices.
Device usage problem: device failed (e.
G.
Broke, couldn't get it to work or stopped working).
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