Retention of central line guide wire.

Sir,

More than six decades ago, Seldinger introduced a novel technique of percutaneous vascular catheter placement.[1] This technique is considered easy and safe to achieve central venous access. However, the guide wire (GW), commonly called Seldinger's wire, has its own problems. We present a case where the GW was retained in the patient's body. The scenario in which this incident happened leads us to believe that the retention was a mishap rather than a blunder.

This case is about an 80-year-old patient, scheduled for radical hysterectomy. On the preoperative visit, she was found to be obese, having short stature, short neck, prominent upper loose incisors and poor veins chronic obstructive pulmonary disease, classified as American Society of Anesthesiologists III. Technical difficulties with anesthesia were anticipated. In the operating theater, while she was awake, lumbar epidural catheterization was done. Later intravenous (IV) induction was done. Although IV induction though was smooth, but hand ventilation via face mask and oral airway was difficult. Endotracheal intubation caused copious bleeding through the tube. Subsequently, she became hypotensive and hypoxic, which required IV administration of crystalloid fluid with phenylephrine, endo-bronchial suctioning, and ventilation with100% oxygen. She gradually improved. Simultaneously, she was positioned for the insertion of central venous catheter (CVC) through her neck. The first attempt failed and caused the distortion of the GW. Therefore, a second set of central line kit was opened. The right internal jugular was again punctured and the GW passed smoothly. The senior anesthetist (JSA) inserted the central line and simultaneously paid attention to the patient's physiological parameters. Concomitantly, he also supervised his junior. After the insertion of the central line, middle and proximal ports of the triple lumen line were aspirated for blood and then flushed with saline. When aspiration was attempted through the distal port, resistance was felt. After a few more unsuccessful attempts to withdraw the blood, we assumed the blockage was due to a blood clot. We decided not to use this port and the proximal end of this channel was labeled as “blocked.” The surgery, which took 4 hours, underwent without major problem. After the traumatic intubation, laryngeal edema was suspected. Therefore, the patient was send to the intensive care unit (ICU) for overnight ventilation. Chest radiograph was done on admission to the ICU, showed central line and no pneumothorax [Figure 1]. A week later, CVC was removed. Subsequent chest and abdominal radiograph revealed the retained GW, straight from the superior vena cava through right atrium and inferior vena cava, to the right femoral vein [Figure 2]. There was no sign or symptoms related to the retained GW. Next day, the interventional radiologist removed the GW from the right femoral vein.

Figure 1

Chest radiograph taken on admission to intensive care unit. This shows (1) radiolucent lumen of central venous catheter (CVC) visible at the neck (blue arrow). (2) Proximal end of retained guide wire in the CVC (red arrow). (3) Distal end of CVC (yellow arrow)

Figure 2

Plain abdominal radiograph. The retained guide wire is seen from the inferior vena cava (red arrow) up to the right femoral vein (blue arrow)

Central line insertion is a common intervention in the operating theater. Alone in USA, more than 5 million of central lines are inserted every year.[2] Retention of the GW is a rare complication. Its true incidence is not known, but it has been estimated at one per few thousands.[3] California department of public health statistic showed that one in every 10 retained foreign bodies after surgery was a retained GW.[4] Recently, Vannucci et al. in a special article, discussed the issue of retained GW after intraoperative placement of CVC.[5] Two main factors, which contributed to retention of GW in all 4 cases reported in this article were also present in our case. The first factor was “inattention.” Technical difficulties, which started from the beginning of this case caused anxiety and stress among the anesthesia team. There were many factors at the scene which diverted the operator's (JSA) attention away from the central line procedure. In attention, and not lack of care caused this complication. The operator, who was overwhelmed with various dimensions of the patient's care, continued the procedure and unknowingly pushed the GW along with CVC. Fatigue, which was also present in our case, has been recognized as a predisposing factor for leaving the foreign body in the patient.[6] The second common denominator was the use of 2 CVC kits were opened and 2 GW were used in all cases. From the patient's safety point of view, retained GW is an important issue. Therefore, measures to prevent and early diagnosis of this complication should be promulgated among those who perform CVC procedure.