LOSS OF THE GUIDE

WIRE:

IS IT MISHAP OR

BLUNDER ?

CASES REPORT STUDY.

4-12-2012

PROF.

HASSAN ALY OSMAN

PROFESSOR OF ANESTHESIA

AND SURGICAL INTENSIVE CARE.

FACULTY OF MEDICINE.

ALEXANDRIA UNIVERSITY.

4-12-2012

Introduction:

Percutaneous catheterization

of a central vein is a routine

daily technique during the

intensive care clinical

practice.

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 resectionof the rectum.

After surgery an anesthetist inthe first year of his traininginserted CV line via the rightinternal jugular vein.

He was not familiar with CVCor 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withdrawn.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.

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.

The consultant concentrated

to the anesthesia management,

while the trainee continued

with the CVC.

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 resectionof malignant colon and rectum.

During busy night shift, a thirdyear trainee cannulated leftpatient’s femoral vein forhemofiltration.

Information about life threatening problem of another

patient distracted him fromholding 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.o 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 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 !

o 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:

Radiological documentation

to detect the exact site.

Immediate heparinization if

not contraindicated.

Methods used to remove

the lost guide wire:

Gooseneck snare via the site

of cannulation using the

radiographic control.

Endovascular forceps.

Dormia basket.

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.