Arterial Line Flush Fluids Safety Investigation

Priscilla Lynch 

August 17, 2021

The Healthcare Safety Investigation Branch (HSIB) has launched an investigation that will look at the risks to critically ill patients when an incorrect infusion fluid is attached to an arterial line.

The use of an incorrect flush fluid can provide misleading results from the blood samples taken from an arterial line. In the event of glucose being mistaken for 0.9% sodium chloride, a patient’s blood test may suggest a high level of blood sugars. This can mislead a clinician who may initiate insulin treatment and could lead to unrecognised and dangerously low blood sugar levels.

Despite a large body of evidence and warnings over the last 13 years, events involving the wrong fluid used in conjunction with arterial lines continue to happen, the HSIB noted.

The HSIB was contacted by the Department of Health and Social Care and asked to consider this issue in response to a coroner’s investigation and the issuing of a prevention for future death notice.

The HSIB identified a patient safety incident involving a 66-year-old man, where the wrong flush fluid was used whilst he was being treated in an NHS trust’s critical care unit.

The patient had received treatment to drain his gallbladder and became very unwell with sepsis. He was admitted to a critical care unit with severely low blood pressure. An arterial line was inserted and the wrong fluid was attached; glucose was used instead of 0.9% sodium chloride.

The effect of the use of the wrong fluid was the contamination of blood tests taken from the site of the arterial line, which consequently misled clinicians to deliver insulin. The wrong fluid went unnoticed for approximately 16 hours, and the treatment of insulin reduced the patient’s blood sugar levels to below the recommended limit. The patient survived the event and no neurological harm was identified.

This article originally appeared on Univadis, part of the Medscape Professional Network.


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