Patient, Operator, and Procedural Characteristics of Guidewire Retention as a Complication of Vascular Catheter Insertion

Abstract

OBJECTIVES: Guidewire retention after intravascular catheter insertion is considered a "never event. " Prior reports attribute this complication to various characteristics including uncooperative patients, operator inexperience, off-hour or emergent insertion, and underutilization of ultrasound guidance. In this descriptive analysis of consecutive events, we assessed the frequency of patient, operator, and procedural factors in guidewire retention. DESIGN:Pre-specified observational analysis as part of a quality improvement study of consecutive guidewire retention events across a multihospital health system from August 2007 to October 2015.

A Double Rarity: Lost intravascular Catheter Guidewire in Persistent Left Superior Vena Cava and Coronary Sinus - A Case Report

“…Guidewire loss is a very rare complication of central venous catheterization (CVC), typically considered a “never event”, but it still occurs at a frequency of 0.05%. 3 Complete loss of the guidewire is usually asymptomatic, as observed in this case, but can lead to fatal complications, such as cardiac tamponade, blood vessel perforation, and dysrhythmia. 8 The retained guidewire is usually detected during a procedure, but there have been cases where a diagnosis was discovered incidentally several months later during routine radiology diagnostics.…”

“…Despite improvements in institutional security protocols and standards, the use of anesthesia in uncooperative patients, and the implementation of ultrasound guidance, guidewire retention still occurs in the healthcare system. 3 Contrary to previous reports, the observational study by Kassis et al on 24 guidewire retention incidents found that most cases occurred in non-obese, non-coagulopathic patients during regular shift hours, in the jugular vein position, using ultrasound by attending physicians with preprocedural sedation in non-emergent settings. This suggests that despite improved security protocols and technological advancements in CVC placement, such as the use of ultrasound, human error remains a significant factor.…”

“…5 Although protocols like RaCeVa (Rapid Central Vein Assessment) and SIC (Safe Insertion of Centrally Inserted Central Catheters) have been proposed to enhance the efficacy and safety of central vein catheterization, guidewire loss remains a significant issue that has not been mitigated by the implementation of these new protocols. 3 , 6 , 7 …”

“… 2 Retention of the guidewire can cause dysrhythmia, vascular damage, thrombosis, embolism, and cardiac perforation with tamponade and death. 3 Although this complication is generally recognised intraoperatively, it can be discovered up to several months after the procedure. 4 In this paper, the authors present the first reported case of unrecognized loss of guidewire in the right atrium through the persistent left superior vena cava (PLSVC) and coronary sinus.…”