This is a catastrophic injury/death case arising out of the improper positioning of a venous catheter (UVC) into the heart chamber (right atrium) of a hospitalized, preterm infant. The malpositioning of this UVC resulted in the device eroding through the heart wall. Because the UVC was being used to infuse total parenteral nutrition (TPN), the TPN began to flow into the pericardial sac (the lining surrounding the heart into which the heart beats). As TPN began to fill the pericardial sac (to cause a condition known as cardiac tamponade), the infants heartbeat drastically slowed to the point where no pulse measurement could be obtained. The infants cardiac depression lasted over one and one half hours and she suffered massive and irreversible brain damage.
As is well established in the medical literature, UVCs must be carefully placed and monitored in order to avoid complications resulting in serious injury and/or death. Positioning the tip of a UVC in the right atrium creates a substantial risk of a perforation of the heart wall as happened in this case.
Our investigation revealed that as of 1989, a full 10 years prior to the subject complication, the FDA had issued a bulletin warning of the danger of right atrium placement of UVCs that such placement posed the risk of perforation of the heart wall so as to cause serious injury and death. In addition, we developed proof that the hospitals own UVC protocol warned against right atrium placement of UVCs and the risk of heart wall perforation and catastrophic injuries.
To illustrate the mechanism of injury in this case, we worked with a prominent medical graphic company to produce a computer generated animation which illustrated: proper placement of a UVC, how perforation of the heart wall occurs as the result of improper positioning of a UVC, and the resulting brain damage that ultimately occurs. (Confidential settlement).