Monday, July 14, 2014

After several years of chemotherapy, my late friend Monique Doyle Spencer's veins had deteriorated to the point that it was very hard for nurses to insert IV lines.  The most painful moments for her would occur when someone would try multiple times to insert a line.  She noticed that, if they didn't succeed the first or second time, the process would just get worse and worse as they tried harder and harder.  The psychology of the moment was that the person would "anchor" into a certain approach, and the nurse's well intentioned efforts would fall to failure as frustration and anxiety grew--for both parties.

I mentioned this story to my colleague Bijan Teja, a second year surgical resident, who has seen the same phenomenon occur with regard to central line insertions by doctors.  He sent the following note:

Please see attached two papers that have shown that the complication rates increase dramatically with more than two failed attempts at central venous line placement. The recommendation is to stop after two or three tries, and usually try a different site, a different operator, or both.

The first paper from the New England Journal of Medicine in 1994 studied 821 patients requiring central venous catheter placement, and found "if only one needle pass was attempted, the failure rate was 1.6 percent, as compared with 10.2 percent for two passes and 43.2 percent for three or more passes." The authors also noted that the rate of complications rose dramatically from 4.3 percent with one pass to 24.0 percent with more than two passes. "The strongest predictor of a complication was a failed catheterization attempt."

Given the increased likelihood of failure and the markedly increased risk of a complication when more than two needle passes were attempted by the same physician, we believe that more than two attempts by the same physician should be discouraged, particularly when catheterization is elective. We found that when one physician failed to place the catheter, the success rate for an attempt by a second physician (whose degree of experience was similar to that of the first) with one or two needle passes was similar to the success rate for the cohort as a whole on the first attempt. The complication rate was also similar.

The second paper from the journal Surgery in 1998 studied 1435 children requiring central venous line placement and found that two or more attempts at placing the catheter was associated with a 5.4 fold increase in complications compared to insertion on the first attempt.  For those of you attending physicians who are ready to jump to the conclusion that success was a matter of experience, please note that that the paper concludes: "We found no increase in complications associated when catheters were placed by interns or residents."

These studies and Monique's experience demonstrate again that the expertise and good intentions of doctors and nurses can fall to our immutable cognitive and psychological characteristics.  I hope clinicians can learn that it is no sign of weakness to say to a colleague, "Would you mind taking over? I'm stuck here and need a short break."


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