The human error: delayed diagnosis of intravascular loss of guidewires for central venous catheterization

Auweiler, Marion; Kampe, Sandra; Zähringer, M.; Buzello, Shariah; Spiegel, T. von; Buzello, W.; Hekmat, Khosro

doi:10.1016/j.jclinane.2004.11.007

Cited by 31 publications

(34 citation statements)

References 8 publications

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“…1 However, a retained guidewire may remain undiagnosed for months to years at a time, 4 and the morbidity and mortality appear to coincide with delayed removal of these foreign objects. 5 Accordingly, removal of retained guidewires immediately after recognition is critical to mitigating complications.…”

Section: Discussionmentioning

confidence: 99%

“…However, there are several instances of guidewire intravascular embolization without the proceduralists' knowledge. 5 In these cases, diagnosis frequently depends upon radiographic evidence. Yet, immediate postoperative chest radiography may be limited by poor image quality, patient positioning, as well as radiographic distractors such as electrocardiac cables within the imaging field.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Positioning Artifact Causing Retained Foreign Object Appearance in a Radiograph of a Venous Catheter

Abcejo

Smith²,

Hebl³

2015

A & A Case Reports

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In preparation for an abdominal tumor debulking procedure, a patient had a right internal jugular central venous catheter (CVC) inserted. A radiologist interpreted a postoperative chest radiograph as containing a 7-cm foreign body in the distal lumen of the CVC. After removal, dissection of the CVC revealed a polyurethane plug in the distal lumen. The manufacturer (Arrow®) states that the synthetic plug is part of standard CVC construction that may produce a radiopaque signal with specific patient positioning during radiography. This report is intended to raise awareness of the potential for this radiographic finding and prevent the unnecessary removal of clinically indicated CVCs.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Positioning Artifact Causing Retained Foreign Object Appearance in a Radiograph of a Venous Catheter

Abcejo

Smith²,

Hebl³

2015

A & A Case Reports

View full text Add to dashboard Cite

show abstract

“…A complete guidewire may not necessarily produce any symptoms and it may remain unnoticed for long, so the diagnosis of a retained foreign body is commonly delayed 14. Only a repeat control chest x-ray or a new sign or symptom (such as cardiac tamponade, abdominal pain) alarmed for this complication 15.…”

Section: Discussionmentioning

confidence: 99%

A delayed diagnosis of a retained guidewire during central venous catheterisation: a case report and review of the literature

Gündüz¹,

Vatan²,

Ösken³

et al. 2012

BMJ Case Reports

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SummaryCentral venous catheterisation allows delivery of medications, intravenous fluids, parenteral nutrition, haemodialysis and monitoring of haemodynamic variables. Various complications may occur during and after the procedure. However, the complete guidewire retention has rarely been reported. In this report, we have presented a complete guidewire retention as a result of inadvertent catheter insertion. After 17 months of the first operation performed upon the diagnosis of Fournier's gangrene, the patient was admitted to the cardiology polyclinic with a recurrent chest pain. Echocardiography showed a wire-shaped foreign body within the right part of the heart, and a fluoroscopic examination showed a guidewire reaching from the superior vena cava to the right external iliac vein. In retrospect, the wire was already visible on the postoperative chest x-rays and CT taken while the patient was still in intensive care unit, but its presence was overlooked at that time. The guidewire was retrieved completely during a surgery. BACKGROUND

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“…The loss of a guidewire occurs very rarely during central venous catheterization (CVC) [4][5][6] . The guidewire may remain unnoticed in the vessel for a long time and may not induce specific symptoms 6) .…”

Section: Introductionmentioning

confidence: 99%

“…The guidewire may remain unnoticed in the vessel for a long time and may not induce specific symptoms 6) . However, it may cause vascular injury, cardiac injury, arrhythmia, or chronic venous thrombosis 7) .…”

Section: Introductionmentioning

confidence: 99%

Recurrent Chylothorax Caused by a Retained Guidewire in a Central Vein: A Case Report

Jeon

Kim

Hwang

et al. 2017

Ann Geriatr Med Res

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The loss of a guidewire occurs very rarely during central venous catheterization (CVC). Guidewire loss can lead to serious mechanical, thrombotic, and infectious complications. A 74-year-old woman was admitted to our institution with dyspnea. Chest computed tomography revealed a guidewire that had remained in a central vein for 3 years, and the patient had extensive central venous thrombosis and a chylothorax. The guidewire and venous thrombus could not be removed because of high perioperative risk due to adhesions and chronic atrophic changes of the intravascular layer. The chylothorax was resistant to conservative treatment. Therefore, the patient was subjected to thoracic duct ligation and embolization. Subsequently, the chylothorax disappeared and the patient was discharged. Physicians should be especially aware of the adverse effects caused by a remnant guidewire and the need for simple chest radiography after CVC.

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The human error: delayed diagnosis of intravascular loss of guidewires for central venous catheterization

Cited by 31 publications

References 8 publications

Positioning Artifact Causing Retained Foreign Object Appearance in a Radiograph of a Venous Catheter

Positioning Artifact Causing Retained Foreign Object Appearance in a Radiograph of a Venous Catheter

A delayed diagnosis of a retained guidewire during central venous catheterisation: a case report and review of the literature

Recurrent Chylothorax Caused by a Retained Guidewire in a Central Vein: A Case Report

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