Journal of Clinical Anesthesia (2015) 27, 406–410
Case Report
Case report of a guide wire loss and migration after central venous access☆ J. Van Doninck MD a,⁎, G. Maleux PhD b , S. Coppens MD c , L. Moke MD a a
Department of Orthopaedics, University Hospitals Leuven, Weligerveld 1, 3212, Pellenberg, Belgium Department of Interventional Radiology, University Hospitals Leuven, Weligerveld 1, 3212, Pellenberg, Belgium c Department of Anesthesiology, University Hospitals Leuven, Weligerveld 1, 3212, Pellenberg, Belgium b
Received 25 February 2015; revised 22 March 2015; accepted 16 April 2015
Keywords: Central venous catheter; Complication; Spinal surgery
Abstract We report a case of guide wire loss and migration after central venous access for spinal deformity surgery. Guide wire migration was noticed on a follow-up full spine x-ray 69 days postoperatively. Percutaneous retrieval was successfully performed using endovascular techniques. With this case report, we want to highlight the fact that one could miss other pathologies visible on these full spine x-rays when concentrating only on the measurement of spinopelvic parameters. © 2015 Elsevier Inc. All rights reserved.
1. Case A 53-year-old woman presented with a flat back deformity after multilevel spinal fusion and underwent a revision spinal decompression and posterior fusion from T11 to the sacrum. A Smith Petersen osteotomy and transforaminal lumbar interbody fusion were performed at the level L1-L2 as well as a pedicle subtraction osteotomy at the level L3 to correct the sagittal imbalance. After induction, a central venous catheter was placed via the right internal jugular vein by a resident in anesthesiology in the setting of a major training center, University Hospitals Leuven. The surgical procedure
☆
Disclosures: The authors have no conflicts of interest to disclose. ⁎ Corresponding author at: University Hospitals Leuven, Weligerveld 1, 3212 Pellenberg, Belgium. Tel.: + 32 16338801; fax: + 32 16338824. E-mail address: [email protected] (J. Van Doninck). http://dx.doi.org/10.1016/j.jclinane.2015.04.005 0952-8180/© 2015 Elsevier Inc. All rights reserved.
was uneventful. A postoperative chest x-ray was performed. A correct position of the catheter was confirmed, and pneumothorax was absent (Fig. 1). A few days postoperatively, the patient had a full spine x-ray of moderate quality. Positioning of spinal instrumentation and spinal deformity correction are classified as satisfactory. No abnormality was reported by the surgeon nor the radiologist (Fig. 2). The postoperative course was uneventful, and the patient was discharged at day 7. Nine weeks postoperative, the patient presents at the orthopedic outdoors clinic for first checkup. She is very satisfied with the improvement of her low back pain and only takes paracetamol. Full spine x-ray shows a correct position of the spinal instrumentation and a corrected sagittal balance with spinopelvic harmony. However, on the anteroposterior view, the surgeon marks a complete guide wire, lost from the central catheterization and migrated to the right lower extremity with one tip in the superior vena cava and the other end halfway the thigh (Figs. 3 and 4). Further x-rays of the right femur and right knee confirmed the presence of
Complication with central venous catheterization
407
Fig. 1 Chest x-ray after central venous catheterization with the catheter placed in the superior vena cava (white arrow) and the guide wire that is still in place (black arrow).
this guide wire. After informed consent, the intravascular foreign body was percutaneously removed via lasso technique (Amplatz goose neck; EV3, Plymouth, MN) under local anesthesia by our interventional radiologist (Fig. 5). The procedure was uneventful, and the patient is still doing fine (Fig. 6).
2. Discussion Thorough examination of all postoperative x-rays is vital not only to assess the surgical repair (evaluation spinal deformity, measurement of spinopelvic parameters, spinal deformity correction, and position of instrumentation) but also to rule out complications. In this case, both surgeon, anesthesiologist (resident and supervisor), and radiologist did not remark the guide wire at the initial x-rays. Often, the origin of this type of error can be situated in the psychologic field rather than in the field of medicine. Missing the guide wire on x-ray can be beyond an individual's conscious control due to a lack of attention or attention only on a specific focus as mentioned above [1]. Percutaneously catheterization of central veins is a routine procedure but has complications and pitfalls [2,3]. Guide wire loss is one of them and can cause thrombosis, embolism, perforation, cardiac arrhythmias, and sepsis [4]. In most cases, broken guide wires and fragments are found. Loss of a complete guide wire as we report is uncommon [4]. Some predisposing factors and signs of guide wire loss are described in the literature [5]. The wire should always be held at the tip to prevent passage into a vessel [5]. Safety measurements with a standard protocol including time out and sign out checklists as mentioned by the World Health Organization and also
Fig. 2 First postoperative full spine x-ray of moderate quality. The guide wire is visible but was initially not remarked.
direct supervised bedside teaching [6] are mandatory to prevent this type of complication. Bedside teaching means automatically that there are minimum 2 clinicians (resident and supervisor) who can help each other not to forget a wire and communicate about the different steps during the procedure to stay alert. They can both check the postoperative chest x-ray. Finally, counting the equipment after the procedure as also stated in World Health Organization sign out guidelines can be of crucial importance to prevent errors. In this case, probably a combination of factors made that the wire was unnoticed
408
Fig. 3
J. Van Doninck et al.
Full spine x-ray after 69 days. The guide wire is seen very clearly in anteroposterior (a) and lateral (b) view (arrows show guide wire).
Fig. 4
a and b, The guide wire is migrated to the lower extremity.
Complication with central venous catheterization
Fig. 5
409
a to c, Endovascular removal of the guide wire with snare device.
and left in the patient. Removal of the foreign body is obligate even if the patient is asymptomatic because of possible life-threatening complications in the acute setting and on long term [4,7]. Attention has to be paid to the possible neo-intimalization of the wire with impossibility to remove the foreign body without damaging the vessel. One needs to choose between open surgical treatment and percutaneous endovascular wire retrieval. In the literature, percutaneous treatment seems to be more safe and effective as compared with open vascular surgery and is mentioned as treatment of choice [4,5,8-10]. Several procedures with various devices are possible, and no single technique is universally applicable to all intravascular foreign bodies [4,8,9]. The loop snare technique as performed in our case is the method of choice in most of cases because of its safety, feasibility, even relatively ease of use and high success with low complication rates and also its cost effectiveness [9,11,12].
3. Conclusion Although postoperative full spine x-rays are carefully examined with regard to the measurement of spinopelvic parameters in adult spinal deformity, one should be aware of other possible visible abnormalities. Central venous puncture is a frequently performed procedure. Loss of guide wire after catheter placement is an uncommon complication. It is a preventable problem provided that one always holds on to the tip of the wire during placement, and correct safety measurements and protocols are followed. Several complications are pending with a guide wire in situ. Therefore, extraction is mandatory in the acute setting but also when diagnosed later. Percutaneous retrieval with a snare device is the treatment of choice with high success rate and low complications. It is a quick and safe procedure if the radiologist is familiar with the technique.
410
J. Van Doninck et al.
Fig. 6
Full spine x-ray after removal of the guide wire in anteroposterior (a) and lateral (b) view.
References [1] Vincent C. Human error and systems thinking, in patient safety. 2nd ed. Chichester, UK: John Wiley & Sons, Ltd; 2010. [2] Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331(26):1735-8. [3] Mitchell SE, Clark RA. Complications of central venous catheterization. AJR Am J Roentgenol 1979;133(3):467-76. [4] Gulel O, Soylu K, Yuksel S, Keceligil HT, Akcay M. A forgotten guidewire causing intracardiac multiple thrombi with paradoxical and pulmonary embolism. Can J Cardiol 2013;29(6):751.e15-6. [5] Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: mishap or blunder? Br J Anaesth 2002;88(1):144-6. [6] Peters M, Ten Cat O. Bedside teaching in medical education : a literature review. Perspect Med Educ 2014;3(2):76-88.
[7] Savage C, Ozkan OS, Walser EM, Wang D, Zwischenberger JB. Percutaneous retrieval of chronic intravascular foreign bodies. Cardiovasc Intervent Radiol 2003;26(5):440-2. [8] Egglin TK, Dickey KW, Rosenblatt M, Pollak JS. Retrieval of intravascular foreign bodies: experience in 32 cases. AJR Am J Roentgenol 1995;164(5):1259-64. [9] Koseoglu K, Parildar M, Oran I, Memis A. Retrieval of intravascular foreign bodies with goose neck snare. Eur J Radiol 2004;49(3):281-5. [10] Dotter CT, Rösch J, Bilbao MK. Transluminal extraction of catheter and guide fragments from the heart and great vessels; 29 collected cases. Am J Roentgenol 1971;111(3):467-72. [11] Mallmann CV, Wolf KJ, Wacker FK. Retrieval of vascular foreign bodies using a self-made wire snare. Acta Radiol 2008;49(10):1124-8. [12] Cekirge S, Weiss JP, Foster RG, Neiman HL, McLean GK. Percutaneous retrieval of foreign bodies: experience with the nitinol goose neck snare. J Vasc Interv Radiol 1993;4(6):805-10.
©2015 Elsevier
Case Report
Case report of a guide wire loss and migration after central venous access☆ J. Van Doninck MD a,⁎, G. Maleux PhD b , S. Coppens MD c , L. Moke MD a a
Department of Orthopaedics, University Hospitals Leuven, Weligerveld 1, 3212, Pellenberg, Belgium Department of Interventional Radiology, University Hospitals Leuven, Weligerveld 1, 3212, Pellenberg, Belgium c Department of Anesthesiology, University Hospitals Leuven, Weligerveld 1, 3212, Pellenberg, Belgium b
Received 25 February 2015; revised 22 March 2015; accepted 16 April 2015
Keywords: Central venous catheter; Complication; Spinal surgery
Abstract We report a case of guide wire loss and migration after central venous access for spinal deformity surgery. Guide wire migration was noticed on a follow-up full spine x-ray 69 days postoperatively. Percutaneous retrieval was successfully performed using endovascular techniques. With this case report, we want to highlight the fact that one could miss other pathologies visible on these full spine x-rays when concentrating only on the measurement of spinopelvic parameters. © 2015 Elsevier Inc. All rights reserved.
1. Case A 53-year-old woman presented with a flat back deformity after multilevel spinal fusion and underwent a revision spinal decompression and posterior fusion from T11 to the sacrum. A Smith Petersen osteotomy and transforaminal lumbar interbody fusion were performed at the level L1-L2 as well as a pedicle subtraction osteotomy at the level L3 to correct the sagittal imbalance. After induction, a central venous catheter was placed via the right internal jugular vein by a resident in anesthesiology in the setting of a major training center, University Hospitals Leuven. The surgical procedure
☆
Disclosures: The authors have no conflicts of interest to disclose. ⁎ Corresponding author at: University Hospitals Leuven, Weligerveld 1, 3212 Pellenberg, Belgium. Tel.: + 32 16338801; fax: + 32 16338824. E-mail address: [email protected] (J. Van Doninck). http://dx.doi.org/10.1016/j.jclinane.2015.04.005 0952-8180/© 2015 Elsevier Inc. All rights reserved.
was uneventful. A postoperative chest x-ray was performed. A correct position of the catheter was confirmed, and pneumothorax was absent (Fig. 1). A few days postoperatively, the patient had a full spine x-ray of moderate quality. Positioning of spinal instrumentation and spinal deformity correction are classified as satisfactory. No abnormality was reported by the surgeon nor the radiologist (Fig. 2). The postoperative course was uneventful, and the patient was discharged at day 7. Nine weeks postoperative, the patient presents at the orthopedic outdoors clinic for first checkup. She is very satisfied with the improvement of her low back pain and only takes paracetamol. Full spine x-ray shows a correct position of the spinal instrumentation and a corrected sagittal balance with spinopelvic harmony. However, on the anteroposterior view, the surgeon marks a complete guide wire, lost from the central catheterization and migrated to the right lower extremity with one tip in the superior vena cava and the other end halfway the thigh (Figs. 3 and 4). Further x-rays of the right femur and right knee confirmed the presence of
Complication with central venous catheterization
407
Fig. 1 Chest x-ray after central venous catheterization with the catheter placed in the superior vena cava (white arrow) and the guide wire that is still in place (black arrow).
this guide wire. After informed consent, the intravascular foreign body was percutaneously removed via lasso technique (Amplatz goose neck; EV3, Plymouth, MN) under local anesthesia by our interventional radiologist (Fig. 5). The procedure was uneventful, and the patient is still doing fine (Fig. 6).
2. Discussion Thorough examination of all postoperative x-rays is vital not only to assess the surgical repair (evaluation spinal deformity, measurement of spinopelvic parameters, spinal deformity correction, and position of instrumentation) but also to rule out complications. In this case, both surgeon, anesthesiologist (resident and supervisor), and radiologist did not remark the guide wire at the initial x-rays. Often, the origin of this type of error can be situated in the psychologic field rather than in the field of medicine. Missing the guide wire on x-ray can be beyond an individual's conscious control due to a lack of attention or attention only on a specific focus as mentioned above [1]. Percutaneously catheterization of central veins is a routine procedure but has complications and pitfalls [2,3]. Guide wire loss is one of them and can cause thrombosis, embolism, perforation, cardiac arrhythmias, and sepsis [4]. In most cases, broken guide wires and fragments are found. Loss of a complete guide wire as we report is uncommon [4]. Some predisposing factors and signs of guide wire loss are described in the literature [5]. The wire should always be held at the tip to prevent passage into a vessel [5]. Safety measurements with a standard protocol including time out and sign out checklists as mentioned by the World Health Organization and also
Fig. 2 First postoperative full spine x-ray of moderate quality. The guide wire is visible but was initially not remarked.
direct supervised bedside teaching [6] are mandatory to prevent this type of complication. Bedside teaching means automatically that there are minimum 2 clinicians (resident and supervisor) who can help each other not to forget a wire and communicate about the different steps during the procedure to stay alert. They can both check the postoperative chest x-ray. Finally, counting the equipment after the procedure as also stated in World Health Organization sign out guidelines can be of crucial importance to prevent errors. In this case, probably a combination of factors made that the wire was unnoticed
408
Fig. 3
J. Van Doninck et al.
Full spine x-ray after 69 days. The guide wire is seen very clearly in anteroposterior (a) and lateral (b) view (arrows show guide wire).
Fig. 4
a and b, The guide wire is migrated to the lower extremity.
Complication with central venous catheterization
Fig. 5
409
a to c, Endovascular removal of the guide wire with snare device.
and left in the patient. Removal of the foreign body is obligate even if the patient is asymptomatic because of possible life-threatening complications in the acute setting and on long term [4,7]. Attention has to be paid to the possible neo-intimalization of the wire with impossibility to remove the foreign body without damaging the vessel. One needs to choose between open surgical treatment and percutaneous endovascular wire retrieval. In the literature, percutaneous treatment seems to be more safe and effective as compared with open vascular surgery and is mentioned as treatment of choice [4,5,8-10]. Several procedures with various devices are possible, and no single technique is universally applicable to all intravascular foreign bodies [4,8,9]. The loop snare technique as performed in our case is the method of choice in most of cases because of its safety, feasibility, even relatively ease of use and high success with low complication rates and also its cost effectiveness [9,11,12].
3. Conclusion Although postoperative full spine x-rays are carefully examined with regard to the measurement of spinopelvic parameters in adult spinal deformity, one should be aware of other possible visible abnormalities. Central venous puncture is a frequently performed procedure. Loss of guide wire after catheter placement is an uncommon complication. It is a preventable problem provided that one always holds on to the tip of the wire during placement, and correct safety measurements and protocols are followed. Several complications are pending with a guide wire in situ. Therefore, extraction is mandatory in the acute setting but also when diagnosed later. Percutaneous retrieval with a snare device is the treatment of choice with high success rate and low complications. It is a quick and safe procedure if the radiologist is familiar with the technique.
410
J. Van Doninck et al.
Fig. 6
Full spine x-ray after removal of the guide wire in anteroposterior (a) and lateral (b) view.
References [1] Vincent C. Human error and systems thinking, in patient safety. 2nd ed. Chichester, UK: John Wiley & Sons, Ltd; 2010. [2] Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331(26):1735-8. [3] Mitchell SE, Clark RA. Complications of central venous catheterization. AJR Am J Roentgenol 1979;133(3):467-76. [4] Gulel O, Soylu K, Yuksel S, Keceligil HT, Akcay M. A forgotten guidewire causing intracardiac multiple thrombi with paradoxical and pulmonary embolism. Can J Cardiol 2013;29(6):751.e15-6. [5] Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: mishap or blunder? Br J Anaesth 2002;88(1):144-6. [6] Peters M, Ten Cat O. Bedside teaching in medical education : a literature review. Perspect Med Educ 2014;3(2):76-88.
[7] Savage C, Ozkan OS, Walser EM, Wang D, Zwischenberger JB. Percutaneous retrieval of chronic intravascular foreign bodies. Cardiovasc Intervent Radiol 2003;26(5):440-2. [8] Egglin TK, Dickey KW, Rosenblatt M, Pollak JS. Retrieval of intravascular foreign bodies: experience in 32 cases. AJR Am J Roentgenol 1995;164(5):1259-64. [9] Koseoglu K, Parildar M, Oran I, Memis A. Retrieval of intravascular foreign bodies with goose neck snare. Eur J Radiol 2004;49(3):281-5. [10] Dotter CT, Rösch J, Bilbao MK. Transluminal extraction of catheter and guide fragments from the heart and great vessels; 29 collected cases. Am J Roentgenol 1971;111(3):467-72. [11] Mallmann CV, Wolf KJ, Wacker FK. Retrieval of vascular foreign bodies using a self-made wire snare. Acta Radiol 2008;49(10):1124-8. [12] Cekirge S, Weiss JP, Foster RG, Neiman HL, McLean GK. Percutaneous retrieval of foreign bodies: experience with the nitinol goose neck snare. J Vasc Interv Radiol 1993;4(6):805-10.
©2015 Elsevier
