Missed Guide Wire in Inferior Vena Cava after Central Venous Cannulation.

Sir,

We report an interesting clinical report of missed guide wire during central venous cannulation in the right internal jugular vein (IJV). A 79-year-old female patient, known case of chronic obstructed pulmonary disease on irregular treatment presented in Emergency Department with shortness of breath, giddiness, and history of acute gastroenteritis since last 2 days. On examination, she was dehydrated, dyspneic, and hypotensive. Blood gas analysis (ABG) revealed arterial pCO2 of 102 mmHg. The patient was intubated in view of Type II respiratory failure and kept on mechanical ventilation support after resuscitation. Fluid administration was advised according to central venous pressure guidance. Junior Resident (1st year) on duty attempted to put central line via right IJV. Unfortunately, resident has forgotten to pull the guide wire while threading central venous catheter in to the vein as he rushed to attend a serious emergency case admitted meanwhile in Intensive Care Unit. In chest X-ray [Figure 1], following procedure missed guide wire diagnosed in situ in the IJV descending to the right femoral vein. Subsequently, patient's relatives were counseled and consented to shift the patient in cardiac cath lab for its retrieval under fluoroscopy guidance. Retrieval was done by snaring the end of guide wire in the right femoral vein under local anesthesia with the help of snare uneventfully.[1]

Figure 1

Chest X-ray image showing central venous catheter in right internal jugular vein (green arrow) and guidewire within inferior vena cava descending to right femoral vein (red arrows).

Migration of the guidewire inside the major vessel is an uncommon and serious complication of central venous line placement.[2] In this report, the guidewire has migrated up to inferior vena cava through right IJV along with venous blood flow. Authors wish to highlights through this incident, the importance of supervision via senior resident or consultant with following standard step by step protocol for central line cannulation, and avoid performing multitask during the procedure. However, using a J-tip style guidewire is a much safer practice, not to insert the guidewire beyond that required length of 20 cm as the distance between skin puncture site and cavo-atrial junction via various approaches is between 16 and 21 cm.[3] Furthermore, withdrawing the guidewire until the proximal end comes out of the catheter port and holding the guidewire during the dilatation step and during the catheter insertion would ensure additional safety against accidental migration of guidewire within major vessels. Recent American Society of Anesthesiologists guidelines for central venous access issued a standard work and safety (bundle) checklist before, during, and after central line insertion to avoid such untoward complications.[4]

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