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Purpose: To report a potentially serious complication resulting from a faulty guide wire during central venous catheterization. Clinical features:We report breakage of a guide wire with potential severe implications for a 47-yr-old critical care patient. The tip of the J-wire became lodged in the internal jugular vein, and required fluoroscopic guidance for removal, which occurred without complication. Conclusion:Breakage of a guide wire during central venous catheter insertion has been very rarely reported. However, inherent faults in design or in the manufacturing process of the guide wire could lead to this rare complication. A simple bedside test is proposed to detect breakage in the core section of the guide wire. 5% and 19%. 2,3 Catheterization of the superior vena cava is usually carried out using the method described by Seldinger. 4,5 Under certain circumstances, breakage of the guide wire can occur with ensuing risk of foreign body embolism. This complication is extremely rare, with only a few case reports in the literature. 6 Our case demonstrates that guide wire breakage is not necessarily due to handling mistakes, but may also be attributed to inherent design flaws or manufacturing errors. Consent for reporting of personal health information was obtained in accordance with our local institutional guidelines. Objectif Case reportA 47-yr-old male intensive care patient (ASA III, body mass index 21) suffered from an infected large tissue defect on the right lower leg sustained in an accident ten days previously. The past medical history included Crohn's disease which was inactive at that time. His ongoing management required central venous pressure monitoring.A standard single-lumen central venous catheter set was used (Certofix®Mono, 16G, B. Braun, Melsungen, Germany). The enclosed standard steel needle was used for puncture of the right internal jugular vein. Despite free aspiration of blood, the first attempt to insert the J-shaped end of the guide wire failed. A second attempt using the straight end of the guide wire was also unsuccessful. For both attempts, the guide wire could only be advanced a few millimetres beyond the tip of the needle, indicated by a black indicator on the wire. The needle and the guide wire were then removed together, and a second puncture GENERAL ANESTHESIA

The influence of diabetic autonomic neuropathy upon the behavior of the circulatory system was investigated in 56 patients who had undergone ophthalmological surgery. A standardized test combination (variability in heart rate during deep breathing. Valsalva ratio, 30:15 ratio, change in blood pressure from lying to standing, sustained handgrip test) was used to study the patients' cardiovascular reflectory reactions. The patients were then divided into the following groups: Group I, non-diabetics. Group II, diabetics without autonomic neuropathy. Group III, diabetics with autonomic neuropathy. The anesthetic (induction by barbiturates and conduction by inhalation agents) and the surgical procedure (pars plana vitrectomy) were standardized and always identical. During anesthesia patients in group III experienced hypotensive reactions (systolic blood pressure below 90 mm Hg) significantly more often (72.2%) than patients in group I (25%). In order to achieve stability in blood pressure the patients of group III had to be given vasoactive drugs much more often (77.8%) than the patients of group I (12.5%) and those of group II (35.7%). We found a significant correlation between the degree of autonomic dysfunction and the largest drop in blood pressure under narcosis (r = -0.60, P less than 0.001). However, marked variability in heart rate and cardiac rhythm disorders during anesthesia were seen only in patients of groups I and II. These results prove the atypical hemodynamic behavior and especially the extreme instability in blood pressure in diabetic autonomic neuropathy under general anesthesia. Therefore we consider it to be very helpful to check the cardiovascular reflectory status of diabetics preoperatively.

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