LOSS OF THE GUIDE WIRE: IS IT MISHAP OR BLUNDER ? CASES REPORT STUDY. 4-12-2012
PROF. HASSAN ALY OSMAN ANESTHESIA AND SURGICAL INTENSIVE CARE. FACULTY OF MEDICINE. ALEXANDRIA UNIVERSITY. PROFESSOR OF
4-12-2012
Introduction: ď ś Percutaneous catheterization
of a central vein is a routine daily technique during the intensive care clinical practice. ď ś
The general complications rate of CVC may be as high as 12 %.
The complications are mainly related to:
a. Anesthetist’s or Intensivist’s experience. b. Patient’s condition. c. The technique used. d. The central vein cannulated.
The seldlinger’s technique is frequently used for CVC.
Case I study. 63 years old female underwent
complicated anterior resection of the rectum.
After surgery an anesthetist in the first year of his training inserted CV line via the right internal jugular vein. He was not familiar with CVC or the seldinger technique and he was not supervised.
When he encountered resistance while advancing the guide wire, he became nervous, but he continued the catheter insertion. The catheter was accidently withdrawn. 2 nd cannulation trial was performed under supervision without any problems.
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The catheter tray was not checked for the guide wire after each procedures ! Half hour check x ray showed no problems.
One week later routine abdominal radiograph showed the guide wire at the right border of the spine. At that time, the 1st x ray was not available for comparison ! The guide wire was surgically removed by vascular exploration of the abdominal inferior vena cava under GA.
Case II study. 62 years old male was scheduled for elective vascular surgery. A consultant supervised first year trainee for CVC ( Rt.Int.J.) The surgeon started his job before completion of the CVC. The vein was identified and cannulated without problems.
Both the trainee and the supervising consultant were distracted from the cannulation procedures when the surgeon started his job. ď ś The consultant concentrated to the anesthesia management, while the trainee continued with the CVC. ď ś
While flushing the catheter, undue resistance was met, but this caused no suspicion. Postoperative x ray showed a guide wire extending from the inferior part of the vena cava to Rt.Int.J. Vein. The guide wire was removed using the Dormier basket.
Case III study. 68 years old male in septic shock & MOF after resection of malignant colon and rectum. During busy night shift, a third year trainee cannulated left patient’s femoral vein for hemofiltration. Information about life threatening problem of another patient distracted him from holding onto the guide wire.
He did not order the routine chest x ray !...he was busy ! The next morning he remembered no problems with the catheterization ! In a routine x ray, the guide wire was reported by the radiologist ! It was surgically removed.
Case IV study. An experienced physician passed cannula into the left Int.J.V of 43 years old man with subarachnoid hemorrhage using the seldenger’s technique for the first time. o He carried out the procedure without any supervision. o
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Routine x ray showed the the proximal one third of the guide wire within the catheter in the cannulated vein, while the two thirds were free in the blood stream !
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The guide wire could be held within the catheter using two clamps. Both were removed together by careful traction
Discussion 
Signs of guide loss: a. The guide wire missing. b. Resistance to injection especially to the distal lumen. c. Poor venous back flow from the distal lumen. d. Visible guide wire in the x ray.
Predisposing factors of the guide wire loss:
Inattention. Inexperienced operator. Inadequate supervision. Overtired staff.
Complications of the lost guide wire: Arrhythmia. Bleeding. Hemopricardium. Infection. Thrombosis and embolism.
Management of the lost guide wire: ďƒź Radiological documentation
to detect the exact site. ďƒź Immediate heparinization if
not contraindicated.
Methods used to remove the lost guide wire: ď ś
Gooseneck snare via the site of cannulation using the radiographic control.
Endovascular forceps. Dormia basket.
ď ś
Surgical exploration.
Conclusions. 1.Percutaneous CVC is routine technique requires: @. Supervision. @. Meticulous attention to its details. @. Training and skills. @. Avoid possible complications and ensure the safe management.
2. The loss of the guide wire is preventable complication. 3. During the CVC technique be sure that: @. The guide wire is visible at the proximal end before the advancement of the catheter. @. Always hold on the tip of the guide wire.
3. Always inspect the guide wire after complete removal at the end of the procedure. 4. The guide wire should be removed as soon as possible.