Letters to Editor
When the K+ level reverted back to 5.0 meq/L, rewarming was started, and heart started beating but the rhythm was irregular. A shock of 10 joules was given, and the rhythm was restored to sinus rhythm. The patient was taken off‑pump on inotropes, injection adrenaline 0.03 mcg/kg/min, injection nitroglycerine 3 mcg/kg/ min and injection milrinone 0.5 mcg/kg/min. The BIS revealed a level of 45. The patient was extubated after the successful maintenance of haemodynamics and oxygenation parameters. The patient did not have any neurological impairment, and magnetic resonance imaging of the brain revealed a normal study. On enquiring, it was found that potassium chloride was inadvertently loaded in place of sodium bicarbonate as the new batch of potassium chloride ampoules were very similar to ampoules of sodium bicarbonate [Figure 1]. This case highlights the human error which resulted inadvertent loading of the wrong drug, which resulted in hyperkalaemia. Use of colour coded labels have resulted in a decrease in the drug errors (P = 0.04). [1] As per American Society for Testing and Materials International Standard D4774, nine classes of drugs commonly used in anaesthesia practice, had a standard background colour established for user‑applied syringe labels. For these drugs, colour of the container’s top, label border, and any other coloured area on the label, excluding the background, as required for maximum contrast, should correspond to the drugs classification.[2] It has been observed that human errors are often due to perceptual confusions. They distinguish information as per the expectation, although the information may not be what is expected.[3] It is a possible causal factor for drug errors comprising drugs with look‑alike labels and packing or look‑alike, sound‑alike (LASA) drug names.[4,5] Mechanism suggested for this confusion is that, when a person frequently handles many drugs, he becomes familiar with their colour coding scheme; but when he encounters a wrong drug with a LASA name, he follows his instinct and perceives the LASA drug as the envisioned drug. Due to the stress and frequent handling of drugs, medical professionals are susceptible to this perceptual bias.[5] Message is ‘read the label twice before you load the drug’.
Amitabh Kumar, Kapil Gupta, Manju Gupta1, Shyam Bhandari 1
786
Department of Anaesthesia, VMMC and Safdarjung Hospital, Department of Cardiothoracic and Vascular Surgery, VMMC and Safdarjung Hospital, New Delhi, India
Address for correspondence: Dr. Amitabh Kumar, Department of Anaesthesia, VMMC and Safdarjung Hospital, New Delhi ‑ 110 029, India. E‑mail: [email protected]
REFERENCES 1.
Fasting S, Gisvold SE. Adverse drug errors in anesthesia, and the impact of coloured syringe labels. Can J Anaesth 2000;47:1060‑7. 2. American Society for Testing and Materials. ASTM D4774‑06 Standard Specification for User Applied Drug Labels in Anesthesiology. Conshohocken, PA: ASTM International. Available from: http://www.astm.org/Standards/D4774.htm. 3. Shorrock ST. Errors of perception in air traffic control. Saf Sci 2007;45:890‑904. 4. Cohen MR, Kilo CM. High‑alert medications: Safeguarding against errors. In: Cohen MR, editor. Medication Errors. Vol. 5. Washington, DC: American Pharmaceutical Association; 1999. p. 1‑40. 5. Davis NM. Combating confirmation bias. Am J Nurs 1994;94:17. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.147189
Coiling of guide wire in the internal jugular vein during central venous catheter insertion: A rare complication Sir, Central venous catheters (CVC) are traditionally used for access in the intensive care unit setting and in burn patients for monitoring central venous pressure,[1] for total parenteral nutrition (TPN),[2] and for rapid volume replacement during shock. Much has been written regarding the complications of CVC.[3,4] The rate of major and minor CVC complications is up to 10%. These complications include arterial puncture, haematoma, pneumothorax, haemothorax, chylothorax, brachial plexus injury, arrhythmias, air embolism, catheter malposition, and catheter knotting. Gladwin et al. have reported that the incidence of axillary vein or right atrial catheter malposition is 14% during internal jugular venous catheterisation[5] whereas the overall rate of non‑infectious complications of Indian Journal of Anaesthesia | Vol. 58 | Issue 6 | Nov-Dec 2014
Letters to Editor
subclavian CVC placement is 5%.[6,7] Guide wires have been reported to cause arrhythmias, cardiac perforation, and tamponade.[8] Here, we report a case in which we encountered an unusual complication. The complication is not malpositioning of the CVC itself, but coiling of the guide wire used during CVC placement. A 35‑year‑old female patient of average build was admitted in our hospital with 70% burn injury. CVC placement was judged necessary for administering TPN 4 days after the burn injury. Her vital parameters were within normal limits and her prothrombin time and international normalised ratio were also within normal limits. The left internal jugular vein (IJV) was the only option available for cannulation. Consent was obtained from the patient for placing a CVC. We attached electrocardiogram, non‑invasive blood pressure, temperature and pulse oximetry monitors in the burn ward. A triple‑lumen catheter was chosen (BD Careflow®). Due aseptic precautions were taken and we planned to do the procedure by Seldinger technique. After proper positioning, we located the left IJV with a 22 Gauge needle by free aspiration of dark red blood after applying local anaesthesia with 1% lignocaine. Then, we inserted the introducer needle and after free aspiration of blood, we started to thread the guide wire through it. During threading of the guide wire, we experienced mild resistance and hence proceeded with the act. However, after about half the length of the guide wire was introduced, resistance was felt which stopped us from threading it further. We attempted extracting the guide wire for reinsertion. Unfortunately, the initial extraction attempt failed and about 12 cm of the guide wire length remained inside. Two additional attempts were made by two other operators, but these failed too and further attempts were abandoned fearing vessel injury. An emergency bedside chest X‑ray (anteroposterior view) was arranged, which revealed [Figure 1] that the guide wire was lying coiled about 3 cm distal to the puncture point. Clinical examination confirmed bilateral normal breath sounds, a normal respiratory rate and oxygen saturation of 98%. There was no subcutaneous emphysema and no evidence of haematoma, venous congestion, or limb ischaemia. We had no access to any interventional radiology procedure to extract the trapped guide wire and the decision was taken to arrange for emergency surgery Indian Journal of Anaesthesia | Vol. 58 | Issue 6 | Nov-Dec 2014
for removal of the same [Figure 2]. Fortunately, a peripheral venous line was patent and all investigation reports, necessary for surgery, were already available. The emergency surgery was commenced within 30 min under general anaesthesia. A 4 cm long incision was made 3 cm distal to our insertion point and the coiled guide wire was extracted from the left IJV after clamping it for a very short period. A venesection of the right long saphenous vein was also performed for reliable, large‑bore venous access since central venous access is difficult via the saphenous vein and no other site was available for attempting another central venous line. The operation lasted for about 30 min. The patient was reversed from anaesthesia uneventfully and was shifted back to the burn ward. Complications during the insertion of CVC can take place due to kinking or looping of the wire itself. Applying force to thread a guide wire through the introducer needle despite significant resistance is likely to cause such a problem.[9] Kinking of the guide wire can also result in misdirection of the dilator and perhaps insertion of the guide wire outside the vessel.[10] These complications may result from inexperience, the number of needle passes made, use of a relatively larger gauge needle than usual, severe dehydration, morbid obesity and coagulopathy. In our patient, the guide wire was not kinked outside the vessel, but got coiled inside the IJV just 3 cm distal to its insertion site, which may be regarded as a rare complication. The possible explanation may be a forceful threading of the guide wire through the introducer needle, though in actuality; we did not use undue force during threading of the guide wire. We also did not encounter undue resistance early which would have alerted us before so much of the guide wire got coiled.
Figure 1: Chest X-ray showing the coiled guide wire (arrow) 787
Letters to Editor Address for correspondence: Dr. Richeek Kumar Pal, Canning Subdivisional Hospital, South 24 Parganas, Canning, West Bengal, India. E‑mail: [email protected]
REFERENCES 1.
Figure 2: Guide wire in situ (arrow) prior to extraction by surgery
There are possibilities of coiling and kinking of the guide wire inside the vessel during insertion by Seldinger technique, in addition to the possibility of kinking outside the vessel. Since the complication can be serious, we recommend that force should not be used when even little resistance is encountered during threading of the guide wire and bedside chest X‑ray facility should be available to check for guide wire position if malpositioning is suspected.
ACKNOWLEDGEMENTS We would like to thank Col S Eapen, Head, Department of Anesthesiology and Critical Care, Lt Col Kiran S, Intensivist and ICU‑in‑Charge, and Major General B N B M Prasad, Commandant, Command Hospital (Eastern Command), Kolkata, India for their support and encouragement.
Richeek Kumar Pal, Baisakhi Laha, Sabyasachi Nandy1, Rajasree Biswas2 Department of Anesthesiology and Critical Care, Command Hospital (Eastern Command), 1 Department of anaesthesiology, Bangur Institute of Neurosciences, Kolkata, 2Department of Anesthesiology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
788
Sykes MK. Venous pressure as a clinical indication of adequacy of transfusion. Ann R Coll Surg Engl 1963;33:185‑97. 2. Dudrick SJ, Wilmore DW, Vars HM, Rhoads JE. Long‑term total parenteral nutrition with growth, development, and positive nitrogen balance. Surgery 1968;64:134‑42. 3. McGoon MD, Benedetto PW, Greene BM. Complications of percutaneous central venous catheterization: A report of two cases and review of the literature. Johns Hopkins Med J 1979;145:1‑6. 4. Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med 1986;146:259‑61. 5. Gladwin MT, Slonim A, Landucci DL, Gutierrez DC, Cunnion RE. Cannulation of the internal jugular vein: Is postprocedural chest radiography always necessary? Crit Care Med 1999;27:1819‑23. 6. Moosman DA. The anatomy of infraclavicular subclavian vein catheterization and its complications. Surg Gynecol Obstet 1973;136:71‑4. 7. Eerola R, Kaukinen L, Kaukinen S. Analysis of 13 800 subclavian vein catheterizations. Acta Anaesthesiol Scand 1985;29:193‑7. 8. Cavatorta F, Campisi S, Fiorini F. Fatal pericardial tamponade by a guide wire during jugular catheter insertion. Nephron 1998;79:352. 9. Khan KZ, Graham D, Ermenyi A, Pillay WR. Case report: Managing a knotted Seldinger wire in the subclavian vein during central venous cannulation. Can J Anaesth 2007;54:375‑9. 10. Schummer W, Schummer C, Fröber R. Internal jugular vein and anatomic relationship at the root of the neck. Anesth Analg 2003;96:1540. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.147190
Indian Journal of Anaesthesia | Vol. 58 | Issue 6 | Nov-Dec 2014
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
When the K+ level reverted back to 5.0 meq/L, rewarming was started, and heart started beating but the rhythm was irregular. A shock of 10 joules was given, and the rhythm was restored to sinus rhythm. The patient was taken off‑pump on inotropes, injection adrenaline 0.03 mcg/kg/min, injection nitroglycerine 3 mcg/kg/ min and injection milrinone 0.5 mcg/kg/min. The BIS revealed a level of 45. The patient was extubated after the successful maintenance of haemodynamics and oxygenation parameters. The patient did not have any neurological impairment, and magnetic resonance imaging of the brain revealed a normal study. On enquiring, it was found that potassium chloride was inadvertently loaded in place of sodium bicarbonate as the new batch of potassium chloride ampoules were very similar to ampoules of sodium bicarbonate [Figure 1]. This case highlights the human error which resulted inadvertent loading of the wrong drug, which resulted in hyperkalaemia. Use of colour coded labels have resulted in a decrease in the drug errors (P = 0.04). [1] As per American Society for Testing and Materials International Standard D4774, nine classes of drugs commonly used in anaesthesia practice, had a standard background colour established for user‑applied syringe labels. For these drugs, colour of the container’s top, label border, and any other coloured area on the label, excluding the background, as required for maximum contrast, should correspond to the drugs classification.[2] It has been observed that human errors are often due to perceptual confusions. They distinguish information as per the expectation, although the information may not be what is expected.[3] It is a possible causal factor for drug errors comprising drugs with look‑alike labels and packing or look‑alike, sound‑alike (LASA) drug names.[4,5] Mechanism suggested for this confusion is that, when a person frequently handles many drugs, he becomes familiar with their colour coding scheme; but when he encounters a wrong drug with a LASA name, he follows his instinct and perceives the LASA drug as the envisioned drug. Due to the stress and frequent handling of drugs, medical professionals are susceptible to this perceptual bias.[5] Message is ‘read the label twice before you load the drug’.
Amitabh Kumar, Kapil Gupta, Manju Gupta1, Shyam Bhandari 1
786
Department of Anaesthesia, VMMC and Safdarjung Hospital, Department of Cardiothoracic and Vascular Surgery, VMMC and Safdarjung Hospital, New Delhi, India
Address for correspondence: Dr. Amitabh Kumar, Department of Anaesthesia, VMMC and Safdarjung Hospital, New Delhi ‑ 110 029, India. E‑mail: [email protected]
REFERENCES 1.
Fasting S, Gisvold SE. Adverse drug errors in anesthesia, and the impact of coloured syringe labels. Can J Anaesth 2000;47:1060‑7. 2. American Society for Testing and Materials. ASTM D4774‑06 Standard Specification for User Applied Drug Labels in Anesthesiology. Conshohocken, PA: ASTM International. Available from: http://www.astm.org/Standards/D4774.htm. 3. Shorrock ST. Errors of perception in air traffic control. Saf Sci 2007;45:890‑904. 4. Cohen MR, Kilo CM. High‑alert medications: Safeguarding against errors. In: Cohen MR, editor. Medication Errors. Vol. 5. Washington, DC: American Pharmaceutical Association; 1999. p. 1‑40. 5. Davis NM. Combating confirmation bias. Am J Nurs 1994;94:17. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.147189
Coiling of guide wire in the internal jugular vein during central venous catheter insertion: A rare complication Sir, Central venous catheters (CVC) are traditionally used for access in the intensive care unit setting and in burn patients for monitoring central venous pressure,[1] for total parenteral nutrition (TPN),[2] and for rapid volume replacement during shock. Much has been written regarding the complications of CVC.[3,4] The rate of major and minor CVC complications is up to 10%. These complications include arterial puncture, haematoma, pneumothorax, haemothorax, chylothorax, brachial plexus injury, arrhythmias, air embolism, catheter malposition, and catheter knotting. Gladwin et al. have reported that the incidence of axillary vein or right atrial catheter malposition is 14% during internal jugular venous catheterisation[5] whereas the overall rate of non‑infectious complications of Indian Journal of Anaesthesia | Vol. 58 | Issue 6 | Nov-Dec 2014
Letters to Editor
subclavian CVC placement is 5%.[6,7] Guide wires have been reported to cause arrhythmias, cardiac perforation, and tamponade.[8] Here, we report a case in which we encountered an unusual complication. The complication is not malpositioning of the CVC itself, but coiling of the guide wire used during CVC placement. A 35‑year‑old female patient of average build was admitted in our hospital with 70% burn injury. CVC placement was judged necessary for administering TPN 4 days after the burn injury. Her vital parameters were within normal limits and her prothrombin time and international normalised ratio were also within normal limits. The left internal jugular vein (IJV) was the only option available for cannulation. Consent was obtained from the patient for placing a CVC. We attached electrocardiogram, non‑invasive blood pressure, temperature and pulse oximetry monitors in the burn ward. A triple‑lumen catheter was chosen (BD Careflow®). Due aseptic precautions were taken and we planned to do the procedure by Seldinger technique. After proper positioning, we located the left IJV with a 22 Gauge needle by free aspiration of dark red blood after applying local anaesthesia with 1% lignocaine. Then, we inserted the introducer needle and after free aspiration of blood, we started to thread the guide wire through it. During threading of the guide wire, we experienced mild resistance and hence proceeded with the act. However, after about half the length of the guide wire was introduced, resistance was felt which stopped us from threading it further. We attempted extracting the guide wire for reinsertion. Unfortunately, the initial extraction attempt failed and about 12 cm of the guide wire length remained inside. Two additional attempts were made by two other operators, but these failed too and further attempts were abandoned fearing vessel injury. An emergency bedside chest X‑ray (anteroposterior view) was arranged, which revealed [Figure 1] that the guide wire was lying coiled about 3 cm distal to the puncture point. Clinical examination confirmed bilateral normal breath sounds, a normal respiratory rate and oxygen saturation of 98%. There was no subcutaneous emphysema and no evidence of haematoma, venous congestion, or limb ischaemia. We had no access to any interventional radiology procedure to extract the trapped guide wire and the decision was taken to arrange for emergency surgery Indian Journal of Anaesthesia | Vol. 58 | Issue 6 | Nov-Dec 2014
for removal of the same [Figure 2]. Fortunately, a peripheral venous line was patent and all investigation reports, necessary for surgery, were already available. The emergency surgery was commenced within 30 min under general anaesthesia. A 4 cm long incision was made 3 cm distal to our insertion point and the coiled guide wire was extracted from the left IJV after clamping it for a very short period. A venesection of the right long saphenous vein was also performed for reliable, large‑bore venous access since central venous access is difficult via the saphenous vein and no other site was available for attempting another central venous line. The operation lasted for about 30 min. The patient was reversed from anaesthesia uneventfully and was shifted back to the burn ward. Complications during the insertion of CVC can take place due to kinking or looping of the wire itself. Applying force to thread a guide wire through the introducer needle despite significant resistance is likely to cause such a problem.[9] Kinking of the guide wire can also result in misdirection of the dilator and perhaps insertion of the guide wire outside the vessel.[10] These complications may result from inexperience, the number of needle passes made, use of a relatively larger gauge needle than usual, severe dehydration, morbid obesity and coagulopathy. In our patient, the guide wire was not kinked outside the vessel, but got coiled inside the IJV just 3 cm distal to its insertion site, which may be regarded as a rare complication. The possible explanation may be a forceful threading of the guide wire through the introducer needle, though in actuality; we did not use undue force during threading of the guide wire. We also did not encounter undue resistance early which would have alerted us before so much of the guide wire got coiled.
Figure 1: Chest X-ray showing the coiled guide wire (arrow) 787
Letters to Editor Address for correspondence: Dr. Richeek Kumar Pal, Canning Subdivisional Hospital, South 24 Parganas, Canning, West Bengal, India. E‑mail: [email protected]
REFERENCES 1.
Figure 2: Guide wire in situ (arrow) prior to extraction by surgery
There are possibilities of coiling and kinking of the guide wire inside the vessel during insertion by Seldinger technique, in addition to the possibility of kinking outside the vessel. Since the complication can be serious, we recommend that force should not be used when even little resistance is encountered during threading of the guide wire and bedside chest X‑ray facility should be available to check for guide wire position if malpositioning is suspected.
ACKNOWLEDGEMENTS We would like to thank Col S Eapen, Head, Department of Anesthesiology and Critical Care, Lt Col Kiran S, Intensivist and ICU‑in‑Charge, and Major General B N B M Prasad, Commandant, Command Hospital (Eastern Command), Kolkata, India for their support and encouragement.
Richeek Kumar Pal, Baisakhi Laha, Sabyasachi Nandy1, Rajasree Biswas2 Department of Anesthesiology and Critical Care, Command Hospital (Eastern Command), 1 Department of anaesthesiology, Bangur Institute of Neurosciences, Kolkata, 2Department of Anesthesiology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
788
Sykes MK. Venous pressure as a clinical indication of adequacy of transfusion. Ann R Coll Surg Engl 1963;33:185‑97. 2. Dudrick SJ, Wilmore DW, Vars HM, Rhoads JE. Long‑term total parenteral nutrition with growth, development, and positive nitrogen balance. Surgery 1968;64:134‑42. 3. McGoon MD, Benedetto PW, Greene BM. Complications of percutaneous central venous catheterization: A report of two cases and review of the literature. Johns Hopkins Med J 1979;145:1‑6. 4. Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med 1986;146:259‑61. 5. Gladwin MT, Slonim A, Landucci DL, Gutierrez DC, Cunnion RE. Cannulation of the internal jugular vein: Is postprocedural chest radiography always necessary? Crit Care Med 1999;27:1819‑23. 6. Moosman DA. The anatomy of infraclavicular subclavian vein catheterization and its complications. Surg Gynecol Obstet 1973;136:71‑4. 7. Eerola R, Kaukinen L, Kaukinen S. Analysis of 13 800 subclavian vein catheterizations. Acta Anaesthesiol Scand 1985;29:193‑7. 8. Cavatorta F, Campisi S, Fiorini F. Fatal pericardial tamponade by a guide wire during jugular catheter insertion. Nephron 1998;79:352. 9. Khan KZ, Graham D, Ermenyi A, Pillay WR. Case report: Managing a knotted Seldinger wire in the subclavian vein during central venous cannulation. Can J Anaesth 2007;54:375‑9. 10. Schummer W, Schummer C, Fröber R. Internal jugular vein and anatomic relationship at the root of the neck. Anesth Analg 2003;96:1540. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.147190
Indian Journal of Anaesthesia | Vol. 58 | Issue 6 | Nov-Dec 2014
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
