Case 1: “Cardiac arrest leading to ECPR. Called from break to a very hypotensive child - report that child had had some desats. Saline and suction was done and had finished when child became hypotensive. APLS started with defib attached - paced not a shockable rhythm. ECLS call out and surgeon to open chest. Drugs initially given via RIJ and at some point I asked for a 200cm line to be attached to make it easier with chest opening. It became apparent after a period of time the low glucose was not rising and the heparin had little effect. I said out loud that this is unusual and this prompted the drugs nurse to look at the line. She clearly identified there may be a problem. I asked them to stop using the 200cm line and give drugs direct into the RIJ. When finished and drapes remove, 200cm line in bed and all lumens with bungs or infusions. The child was on 0.3 adrenaline throughout. The child missed receiving bicarb calcium fluid blood due to this.”

Case 2: “Alerted by emergency buzzer to cubicle. On attendance patient under-going CPR (shortly after ROSC therefore discontinued). Nurse explained that syringe driver containing norad had alerted her that the line was occluded and then the patient instantaneously lost BP then output. Medic attended immediately and administered noradrenaline whilst awaiting defib, immediate significant improvement of BP. On further investigation it was found that the norad had been running on the purple line of the Kimel line (previously known to have had issues with occlusions with other patients)”

Case 3: “Whilst procedure being carried out, Vascular consultant noticed that patient's right arm was swollen on further examination it looked as if the cannula had tissued and arm looked mottled and oedematous.”

These cases highlight the need for vigilance with all lines. The reporters in case 2 imply a recurring problem, but do not say whether they reported it to the MHRA; this would be the correct thing to do, at yellowcard.mhra.gov.uk.