Percutaneous Retrieval of a Lost Guidewire That Caused Cardiac Tamponade

Pérez-Díez, Diego; Salgado‐Fernández, Jorge; Vázquez-González, Nicolás; Calviño-Santos, Ramón; Vázquez‐Rodríguez, José Manuel; Aldama-López, Guillermo; García-Barreiro, Juan Javier; Castro‐Beiras, Alfonso

doi:10.1161/circulationaha.107.689000

Cited by 27 publications

(26 citation statements)

References 2 publications

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“…Most of these cases were not recognized immediately after catheter insertion nor after the post insertion control chest X-ray (CXR). Only a repeat CXR or a new sign or symptom (cardiac tamponade [6], sustained abdominal pain in our case) alarmed for this complication. This means that we are not thinking of this complication because it is not familiar to us.…”

Section: Discussionmentioning

confidence: 84%

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Abdominal pain due to a lost guidewire: a case report

Taslimi

Safari

Kazemeini

et al. 2009

Cases J

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A lost guidewire is a hazardous, yet completely preventable, and rare complication associated with central venous catheter insertion. Here, we report a case of a lost guidewire in a patient presented with persistent abdominal pain. The guidewire was retrieved completely during a surgical operation after the diagnosis had been confirmed by radiologic studies. Following some tips during insertion of a central venous catheter will help to prevent this mortal complication or at least, in rapid diagnosis of its loss. Interventional radiologic techniques are now readily used to retrieve a lost guidewire.

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Section: Discussionmentioning

confidence: 84%

“…There are some reports of forgotten guidewire in the literature [2,4-6]. Most of these cases were not recognized immediately after catheter insertion nor after the post insertion control chest X-ray (CXR).…”

Section: Discussionmentioning

confidence: 99%

Abdominal pain due to a lost guidewire: a case report

Taslimi

Safari

Kazemeini

et al. 2009

Cases J

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“…In one extreme example a guidewire remained hidden inside a 53-year-old man without clinical manifestations for 14 years [9]. In other cases, significant harm can occur, and much earlier, for example due to guidewire fracture [10,11]. Equally, whilst the risk of serious harm from a retained guidewire may be moderately low, if too many of such events occur the risk of reputation loss and even a risk to the operating license of a hospital Trust may outweigh the risk of patient harm.…”

Section: Issues Surrounding Retained Guidewiresmentioning

confidence: 99%

“…However, they can fail to identify the wires on post-operative radiographs even though they are clearly visible [11,15,16]. Unfortunately, it is not unusual for central line patients to be simultaneously equipped with devices like nasogastric tube, surgical drainage catheters and telemetry wires, and this myriad of radio-opaque materials may further distract the radiologist from noticing the presence of a guidewire.…”

Section: Human Factors Issues Previously Attributed To Guidewire Lossmentioning

confidence: 99%

Guidewire retention following central venous catheterisation: A human factors and safe design investigation

Horberry

Teng

Ward

et al. 2014

International Journal of Risk &Amp; Safety in Medicine

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BACKGROUND: Central Venous Catheterisation (CVC) has occasionally been associated with cases of retained guidewires in patients after surgery. In theory, this is a completely avoidable complication; however, as with any human procedure, operator error leading to guidewires being occasionally retained cannot be fully eliminated. OBJECTIVE: The work described here investigated the issue in an attempt to better understand it both from an operator and a systems perspective, and to ultimately recommend appropriate safe design solutions that reduce guidewire retention errors. METHODS: Nine distinct methods were used: observations of the procedure, a literature review, interviewing CVC end-users, task analysis construction, CVC procedural audits, two human reliability assessments, usability heuristics and a comprehensive solution survey with CVC end-users. RESULTS: The three solutions that operators rated most highly, in terms of both practicality and effectiveness, were: making trainees better aware of the potential guidewire complications and strongly emphasising guidewire removal in CVC training, actively checking that the guidewire is present in the waste tray for disposal, and standardising purchase of central line sets so that differences that may affect chances of guidewire loss is minimised. CONCLUSIONS: Further work to eliminate/engineer out the possibility of guidewires being retained is proposed.

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“…11 Retrieval is usually done by interventional radiology using gooseneck snares, endovascular retrieval forceps or Dormia baskets; surgical removal is also reported. After the occurrence of this complication, we made some changes in the dialysis catheter insertion protocol.…”

Section: Case Reportmentioning

confidence: 99%