Accidental Catheter Removal in Critically Ill Patients: A
Introduction: The importance of accidental catheter removal (ACR) lies in the complications caused by the removal itself and by catheter reinsertion. To the best of our knowledge, no studies have analyzed accidental removal of various types of catheters in the intensive care unit (ICU). The objective of the present study was to analyze the incidence of ACR for all types of catheters in the ICU.
Methods: This was a prospective and observational study, conducted in a 24-bed medical/surgical ICU in a university hospital. We included all consecutive patients admitted to the ICU over 18 months (1 May 2000 to 31 October 2001). The incidences of ACR for all types of catheters (both per 100 catheters and per 100 catheter-days) were determined.
Results: A total of 988 patients were included. There were no significant differences in ACR incidence between the four central venous access sites (peripheral, jugular, subclavian and femoral) or between the four arterial access sites (radial, femoral, pedal and humeral). However, the incidence of ACR was higher for arterial than for central venous catheters (1.12/100 catheter-days versus 2.02/100 catheter-days; P < 0.001). The incidences of ACR/100 nonvascular catheter-days were as follows: endotracheal tube 0.79; nasogastric tube 4.48; urinary catheter 0.32; thoracic drain 0.56; abdominal drain 0.67; and intraventricular brain drain 0.66.
Conclusion: We found ACR incidences for central venous catheter, arterial catheter, endotracheal tube, nasogastric tube and urinary catheter that are similar to those reported in previous studies. We could not find studies that analyzed the ACR for thoracic, abdominal, intraventricular brain and cardiac surgical drains, but we believe that our rates are acceptable. To minimize ACR, it is necessary to monitor its incidence carefully and to implement preventive measures. In our view, according to establish quality standards, findings should be reported as ACR incidence per 100 catheters and per 100 catheter-days, for all types of catheters.

Use of catheters in critically ill patients is routine. In the European Prevalence of Infection in Intensive Care (EPIC) study, the following catheters were required in the management of critically ill patients: urinary catheter (75%), central venous catheter (64%), orotracheal tube (62%), arterial catheter (44%) and thoracic drain (14%). Use of catheters carries risks for complications such as nosocomial infection and accidental removal. Catheter-related infection has been studied extensively owing to the clinical and economic repercussions. However, accidental catheter removal (ACR) has received little attention. There are considerable data on ACR of orotracheal tubes, but few reports have been published on ACR of vascular catheters and nasogastric tubes, and scarcely any on other drainage types (urinary, thoracic, abdominal, intraventricular brain or cardiac surgical drain). Furthermore, to the best of our knowledge, no studies have analyzed accidental removal of various types of catheters in the intensive care unit (ICU). The importance of ACR lies in the potentially life-threatening complications that can result from the removal itself and from catheter reinsertion. Among the complications of accidental removal of vascular catheters per se are interruption to vital drug therapy (such as inotropes/vasopressors) or renal replacement therapy, and haemorrhagic shock. Unplanned endotracheal extubation has been associated with serious complications such as arrhythmias, haemodynamic instability, aspiration pneumonia and death. ACR of thoracic drains can result in pneumothorax and/or haemothorax. Following ACR of an abdominal drain, blood and purulent fluids can accumulate, ultimately resulting in development of sepsis.

Hydrocephalus is a possible outcome following ACR of a catheter being used for intraventricular brain drainage, and ACR of a cardiac surgical drain can result in cardiac tamponade. Complications arising from subclavian or jugular venous catheter reinsertion include pneumothorax and/or haemothorax. Endotracheal reintubation can lead to nosocomial pneumonia, and reinsertion of new drains can result in haemorrhage or nosocomial infection.

The objective of the present study was to determine the incidence of ACR for all catheter types used in the ICU and to report the data in a standardized and comparable way, with a view to establishing quality standards.