Journal of Patient Safety & Quality Improvement

Journal of Patient Safety & Quality Improvement

The Hidden Cost of a Routine Procedure: Point-of-Care Ultrasound-Guided Retrieval of a Retained Peripheral Intravenous Cannula Fragment: A Case Report

Document Type : Case Report

Authors
Karupothu Rani 1
Elandevan Gunasekaran 2
Harish Damu 1
Showry Abraham 2
1 Department of Anesthesiology, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India.
2 Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India
10.22038/psj.2026.97037.1540
Abstract
Background:
Peripheral intravenous (PIV) cannulation is one of the most frequently performed invasive procedures in clinical practice and is generally considered safe. However, catheter fracture with intravascular retention is a rare but potentially serious complication that may result in thrombosis, embolization, vascular injury, infection, and the need for invasive intervention if not promptly recognized. Point-of-care ultrasonography (POCUS) has emerged as a rapid, readily available bedside imaging modality for the localization of retained intravascular foreign bodies and facilitates minimally invasive retrieval.

Case Presentation:
A 60-year-old man was admitted following a road traffic accident with a fracture of the tibia requiring orthopaedic management. During removal of a peripheral intravenous cannula inserted into the left forearm, resistance was encountered, and inspection of the catheter revealed absence of the distal tip, raising suspicion of catheter fracture with intravascular retention. Immediate bedside POCUS using a high-frequency linear-array transducer accurately localized the retained catheter fragment within a superficial forearm vein. Following ultrasound-guided skin marking, the fragment was successfully retrieved through a small targeted incision under local anaesthesia. The procedure was performed without fluoroscopy, computed tomography, angiography, or extensive surgical exploration.

Results:
Point-of-care ultrasonography enabled rapid bedside localization and successful minimally invasive retrieval of the retained catheter fragment with minimal tissue dissection. No intraoperative or postoperative complications occurred. The patient recovered uneventfully, with no evidence of thrombosis, infection, neurovascular compromise, or fragment migration during follow-up.

Conclusions:
Retained peripheral intravenous catheter fragments represent an uncommon but clinically significant patient safety event. Immediate point-of-care ultrasonography enables rapid diagnosis, precise localization, and minimally invasive bedside retrieval while reducing the need for advanced imaging or extensive surgical exploration. Early recognition combined with multidisciplinary management can prevent migration-related complications, improve patient outcomes, and reduce healthcare costs.
Keywords
Peripheral intravenous cannula
Retained catheter fragment
Point-of-care ultrasound
Intravascular foreign body
Ultrasound-guided retrieval
Patient safety
Subjects
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Journal of Patient Safety & Quality Improvement
Volume 14, Issue 4
Autumn 2026
Pages 259-266