Arterial trauma due to central venous catheter insertion: an analysis of incidents reported to the National Reporting and Learning System for England and Wales 2013-2023

IntroductionArterial trauma is a rare, but potentially life-threatening complication of central venous catheter insertion, with limited evidence to guide its prevention and management. We aimed to identify incidents from two national databases of incident reports to better characterise this complication and its consequences.MethodsWe extracted and analysed reports from the National Reporting and Learning System and the Strategic Executive Information System over a 10-year period, including incidents involving arterial insertion of a dilator or catheter. Arterial puncture by needle or guidewire was included if moderate or severe harm resulted.ResultsWe identified 241 arterial trauma incidents including diverse device types, settings and insertion techniques. Arterial trauma occurred despite the reassuring visual appearance of blood in 35 (15%) incidents and despite guidewire visualisation by ultrasound in 53 (22%) incidents. After catheter insertion, a chest radiograph was the most common method which failed to identify arterial cannulation in 20 (27%) cases of delayed recognition. Outcomes included 24 (10%) strokes and 10 (4%) deaths. After excluding femoral and peripherally-inserted catheters, stroke was associated with delayed diagnosis (RR 3.57, 95%CI 2.04-6.24) and arterial drug administration (RR 2.67, 95%CI 1.48-4.82). However, stroke (eight, 6%) and death (three, 2%) still occurred despite immediate recognition of arterial trauma, underscoring the dangers of arterial dilatation.DiscussionWhilst some incidents involved potential risk factors (e.g. operator inexperience, landmark technique, paediatric lines and emergent insertion) arterial trauma nevertheless occurs when experienced operators undertake seemingly routine procedures. Our findings complement previous research on serious harm from this complication and support the need for robust and objective pre-dilatation checks. It is essential that these findings inform the perception, discussion and mitigation of risk associated with central venous catheter insertion to prevent avoidable patient harm.