Fatal iatrogenic cardiac tamponade due to central venous catheterization

Autores da FMUP

• Teresa Maria Salgado De Magalhães

  Autor

• Ricardo Jorge Dinis Oliveira

  Autor

Participantes de fora da FMUP

• Valente Aguiar, MS
• de Carvalho, ER

Unidades de investigação

• Ciências da Saúde Pública e Forenses, e Educação Médica

• Laboratório Associado RISE- Rede de Investigação em Saúde

  

  Investigador

  Fernando Carlos De Landér Schmitt

• RISE-Health

  

  Investigador

  Fernando Carlos De Landér Schmitt

Abstract

Fatal adverse events caused by any health professional as consequence of malpractice are uncommon. In this work, the authors report a fatal cardiac tamponade associated with a peripherally inserted central catheter (PICC) by the right jugular vein that perforated the right atrium of the heart. The diagnosis of cardiac tamponade was not detected in hospital during the intrapericardial infusion of total parenteral nutrition and was only registered during the autopsy. The postmortem examination showed a milky liquid inside the pericardial cavity compatible with the total parenteral nutrition administered. The catheter in its migration in the cardiac chambers, mechanically perforated the inner wall of the endocardium between the trabeculae carneae, continued its course between the myocardial fibers until it was externalized. In conclusion, cardiac tamponade, although it is an extremely rare medical complication, has a high risk of fatality specially if peripheral rather than central veins were cannulated.

Keywords

• Central catheterization; Forensic autopsy; Cardiac perforation and tamponade; Cardiogenic shock; Iatrogenic damage