Unusual but completely avoidable complication during central venous catheterization.

Central venous catheterization is generally a safe procedure, but several complications such as pneumothorax, arrhythmias, arterial puncture, infection, and thrombosis are known to occur even in the experienced hands. Complications related to guide wire are very rare and mostly relate to the expertise of operating person. We hereby report a rare but completely avoidable complication, that is, complete loss of the guide wire into the subclavian vein which was successfully retrieved by surgery.

INTRODUCTION

Central venous catheterization (CVC) is commonly used for monitoring of central venous pressure (CVP), fluid administration, drug infusions, parenteral nutrition and for aspiration of air emboli but it also carries numerous complications. The complication rate for CVC varies from institution to institution and mainly depends on their level of training and experience of treating doctor. Mainly three routes have been used for CVC, that is, internal jugular vein (IJV), subclavian vein, and femoral vein but the subclavian approach is preferred due to its consistent landmarks, lower potential for infection or arterial injury and increased patient comfort. Clinical reporting regarding the intravascular loss of guide wire through subclavian approach is very sparse. Most of these complications are iatrogenic and hence preventable. Hence, here we share our experience and suggest various precautions to avoid such a rare but dangerous complication.

CASE REPORT

A 54-year-old male with a diagnosis of perforation peritonitis with chronic renal failure and coronary artery disease was brought to the emergency department. Due to his poor peripheral venous access and for CVP guided fluid therapy, the plan was made to get the central venous access. After ensuring appropriate coagulation status, the right subclavian vein was chosen for catheterization. A seven French percutaneous 15 cm length triple lumen catheter was used by Seldinger technique. Under all aseptic precautions, the vein was cannulated with introducer needle in first attempt by a resident doctor in the absence of expert supervision and assistance. Following this guidewire was introduced through the needle without any resistance (length of guide wire introduced inside vein was not noticed). During threading of catheter over the guide wire, patiently made a sudden jerky movement which distracted the trainee doctor. To prevent patient movement, he tried to hold the patient's right shoulder with one hand and started putting the catheter with wire inside the subclavian vein without holding guide wire tip as such. This lead to loss of guide wire inside the catheter inadvertently but on gently pulling out the catheter, no part of the guide wire was found outside puncture site. Immediately call made to senior doctors for this mishap. Urgently chest X-ray was obtained which showed the proximal tip of the guide wire in a subclavian vein near the junction with IJV [Figure 1]. Although patient remained stable throughout this period, the plan was made to remove the guide wire by surgery. Patient was explored under general anesthesia through a transverse incision in the right supraclavicular fossa. Meticulous dissection was carried out to expose right subclavian vein and tip of the guide wire was felt in subclavian vein with a finger. A small venotomy about1 cm made proximal to the junction with IJV, through which guide wire retrieved and the incision closed with 6-0 proline. Following this primary procedure, that is, an exploratory laparotomy was performed without any complication. The postoperative period was uneventful, and patient discharged on 7th day.

Figure 1

Chest X-ray - showing complete loss of guide wire inside vein with arrow pointing tip in subclavian vein

DISCUSSION

Placement of a central venous catheter is a common procedure associated with an overall complication rate of 12–15% but in inexperienced hands without expert guidance this rate increases several times.[12] So before doing CVC, a good knowledge about the procedure and related complications, adequate operating skills and expert guidance are required in order to minimize adverse effects. Normally Seldinger technique is used for central venous cannulation which was originally used to cannulate vessel for the radiographic procedure.[3] Clinical literature regarding the loss of guide wire and complication caused by it is very limited due to medicolegal issues and iatrogenic origin. A complete guide wire loss may remain unnoticed due to the absence of any symptoms as like in our case, but such a foreign body can cause arrhythmia, thrombosis, embolism and vascular damage.[45] So lost guide wire should be removed as quickly as possible. Cardiac tamponade occurring 3 years after a guide wire loss as a late complication has also highlighted the importance of wire extraction as soon as a diagnosis is made.[6] Several risk factors like lack of attention and knowledge, inexperienced operator, inadequate guidance and introduction of the excessive length of guide wire have been attributed to loss of guide wire during cannulation.[78]

In our case, lack of detailed preprocedure knowledge with less hand experience of trainee doctor, patient movement leading distraction of trainee doctor, absence of expert supervision and lack of assistance are probable risk factors for this complication. As the resident doctor has not paid attention to introduced length of the guide wire, the excessive introduction of the guide wire can be an additional factor for its loss also. Many reasons stand behind this faulty practice of excessive introduction of guide wire including not knowing its dangerous implications, fear of losing vascular access, use of a circular advancer, and concerns over contamination of the proximal end of the wire especially in under trainee doctor.[9] To prevent this rare complication using Seldinger technique, the following preventive measures must be taken:

Always consider guide wire as delicate and fragile instrument with structural weakness and inspect the wire for any defects before insertion

Guidewire should be held from tip all the time during the procedure to prevent accidental slipping in or out of the vessel[7]

Procedure should preferably be performed under sedation with local anesthesia if patient's clinical condition favorable

Procedure should be performed under the guidance/supervision of an expert person with the help of expert assistant especially for under trainee doctor

Proper monitoring especially electrocardiography monitor to get arrhythmia alarm indicating the introduction of the excessive length of guide wire inside vein should be used during this procedure

The guide wire should not be pushed too far inside the vein. In most of the cases, 18 cm should be considered as the upper limit of guide wire insertion[9]

Before advancing catheter over the guide wire, we must be sure that wire is visible and held at the proximal end. Always railroad the catheter over the guide wire into vein

At the end of procedure always check for guide wire in procedure tray and routine postinsertion chest radiograph to rule out any complication.

CONCLUSION

Before placing a central vein catheter make sure that under trainee doctor should have a thorough foreknowledge of the procedure with its complications and procedure should be carried out under supervision with adequate assistance. We must stop the practice of “See one, Do one and Teach one.” The loss of the guide wire is completely preventable complication provided we emphasize on holding the guide wire tip all the time by other hand.