1Klinik für Neurologie, Universitätsklinikum Eppendorf, Hamburg, 2Klinik für Anästhesiologie und Intensivtherapie, Friedrich-Schiller Universität Jena, Jena and 3Institut für Diagnostische und Interventionelle Radiologie, Friedrich-Schiller Universität Jena, Jena, Germany*Corresponding author. Present address: Klinik für Anästhesiologie und Intensivtherapie, Friedrich-Schiller Universität Jena, Bachstrasse 18, D-07743 Jena, Germany
Accepted for publication: August 27, 2001
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Abstract |
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Br J Anaesth 2002; 88: 1446
Keywords: equipment, catheter, central venous; complications
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Introduction |
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Case 1 |
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Case 2 |
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Case 3 |
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Case 4 |
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Discussion |
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inattention (all cases);
inexperienced operatoreither in method (i.e. Seldinger technique) or actually central venous cannulation per se (Cases 1, 2 and 4);
inadequate supervision of trainees (Cases 1, 2 and 4);
overtired staff (Case 3).
The signs of guide wire loss include:
the guide wire is missing;
resistance to injection via the distal lumen;
poor venous backflow from the distal lumen;
guide wire visible on a radiograph.
Consequences of guide wire loss include embolism from fragments of catheters or guide wires which can be fatal in up to 20%,9 but no data exist on lost guide wires. In contrast to such emboli, the loss of a complete guide wire usually does not cause symptoms. In general, the guide wire is found by chance on a radiograph and has not been missed previously. There are no data on the complications of lost guide wires, but such a foreign body could cause arrhythmias, vascular damage, thrombosis and embolism. Guide wires should be removed as quickly and completely as possible.10
Interventional radiology is the method of choice. With modern devices a lost catheter, guide wire fragment, or entire guide wire should be able to be removed in most cases.11 During the intervention the patient should be heparinized.12 Usually the foreign body (e.g. the guide wire) is caught by a gooseneck snare passed via the femoral vein using radiographic control.11 The use of endovascular forceps or a Dormier basket increases the risk of endovascular trauma.12 If the foreign body is captured, it is usually necessary to remove it along with the vascular sheath. If the vascular sheath is twice the size of the lost catheter or the lost guide wire it may be possible to withdraw the foreign body through it.12 If heparinization is contraindicated, extraction should be attempted by careful surgical exploration.
Each single step of central venous cannulation can cause serious complications. These complications should be understood by the operator and continuous attention during the procedure is vital. With the Seldinger technique, the following precautions should be taken.
Inspect the wire for defects before insertion.
Consider a guide wire to be a delicate and fragile instrument.
When resistance to insertion is met, remove and inspect the wire for damage, reposition the introducer so that no resistance to its passage is felt.
Particular caution should be used when attempting central catheter placement in patients who are predisposed to thrombosis or have had repeated catheterizations of a particular vessel.
If multiple manipulations are needed, reinspect the wire and replace it if necessary.
Pass catheter over wire into the vein.
Make sure that the wire is visible at the proximal end, before the catheter is advanced.
The catheter should be railroaded over the guide wire into the vein, holding the wire, and not pushing catheter and wire together into the vein.
Always inspect the wire for complete removal at the end of the procedure [13].
Hold onto the wire at all times until removal from the vessel.
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Conclusion |
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References |
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