Letters to Editor

A pre-operative magnetic resonance angiography or an intraoperative Doppler is indispensable to avoid accidental injuries to the ICA during TSS as they indicate the potential vascular anomalies.[2] Hemorrhagic complications are also anticipated in patients with previous surgery, radiation therapy, bromocriptine therapy, tumor adhesion, invasive adenomas and sphenoidal sinus abnormalities.[1] A strict midline and vertical approach under televised fluoroscopy[3] and a careful dissection of the sphenoidal floor (when sellar floor erosion exists by tumor invasion or anatomical variations)[2] are essential surgical considerations in these cases. In spite of the precautions, injury to the ICA can occur rarely where immediate packing and tamponade insertion becomes imperative. If the carotid compression is effective then the bleeding reduces immediately. In our case, temporary manual carotid compression provided the benefits of reduced bleeding and also allowed the surgeon a clearer field to visualize the source for effective packing. Packing in a pool of blood without visualization of the rent has the hazard of the blood dissecting into the intracranial space, widening the rent of the cavernous carotid or damage deeper structures like hypothalamus. Brief occlusion of common carotid artery provokes a reduction in perfusion pressure in the ipsilateral circle of Willis wherein the magnitude of perfusion pressure drop is dictated by the adequacy of collateral circulation. Although the concerns regarding its adverse effects like reduced cerebral perfusion, atheromatous diseases and unruptured aneurysm existed and heterogeneity of the anatomy of circle of Willis is high[4] nevertheless, this exercise helped us to bail out of an exigent situation. Thus carotid compression for brief period can be a useful non-invasive maneuver in such situations which confers the advantages of buying time, reduced blood loss and improved view of the surgical field outweighing its drawbacks.

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K. K. Mukherjee, Rudrashish Haldar1, Hemant Bhagat2, Sukhen Samanta3 Departments of Neurosurgery, and 2Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, 1Department of Anesthesia, Gian Sagar Medical College, Banur, District Patiala, Punjab, 3Department of Anesthesia and Critical Care, All India Institute of Medical Sciences (JPNATC), New Delhi, India Address for correspondence: Dr. Rudrashish Haldar, Department of Anesthesia, Gian Sagar Medical College, Banur - 140 601, Patiala District, Punjab, India. E-mail: [email protected]

REFERENCES 1.

2.

3.

4.

Raymond J, Hardy J, Czepko R, Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment. AJNR Am J Neuroradiol 1997;18:655-65. Park YS, Jung JY, Ahn JY, Kim DJ, Kim SH. Emergency endovascular stent graft and coil placement for internal carotid artery injury during transsphenoidal surgery. Surg Neurol 2009;72:741-6. Hardy J, Wigser SM. Trans-sphenoidal surgery of pituitary fossa tumors with televised radiofluoroscopic control. J Neurosurg 1965;23:612-9. Alpers BJ, Berry RG, Paddison RM. Anatomical studies of the circle of Willis in normal brain. AMA Arch Neurol Psychiatry 1959;81:409-18. Access this article online Quick Response Code:

Website: www.saudija.org

DOI: 10.4103/1658-354X.136654

Retention of central line guide wire Sir, More than six decades ago, Seldinger introduced a novel technique of percutaneous vascular catheter placement.[1] This technique is considered easy and safe to achieve central venous access. However, the guide wire (GW), commonly called Seldinger’s wire, has its own problems. We present a case where the GW was retained in the patient’s body. The scenario in which this incident happened leads us to believe that the retention was a mishap rather than a blunder. Saudi Journal of Anesthesia

This case is about an 80-year-old patient, scheduled for radical hysterectomy. On the preoperative visit, she was found to be obese, having short stature, short neck, prominent upper loose incisors and poor veins chronic obstructive pulmonary disease, classified as American Society of Anesthesiologists III. Technical difficulties with anesthesia were anticipated. In the operating theater, while she was awake, lumbar epidural catheterization was done. Later intravenous (IV) induction was done. Although IV induction though was smooth, but hand ventilation via face Vol. 8, Issue 3, July-September 2014

Letters to Editor Page | 444

mask and oral airway was difficult. Endotracheal intubation caused copious bleeding through the tube. Subsequently, she became hypotensive and hypoxic, which required IV administration of crystalloid fluid with phenylephrine, endobronchial suctioning, and ventilation with100% oxygen. She gradually improved. Simultaneously, she was positioned for the insertion of central venous catheter (CVC) through her neck. The first attempt failed and caused the distortion of the GW. Therefore, a second set of central line kit was opened. The right internal jugular was again punctured and the GW passed smoothly. The senior anesthetist (JSA) inserted the central line and simultaneously paid attention to the patient’s physiological parameters. Concomitantly, he also supervised his junior. After the insertion of the central line, middle and proximal ports of the triple lumen line were aspirated for blood and then flushed with saline. When aspiration was attempted through the distal port, resistance was felt. After a few more unsuccessful attempts to withdraw the blood, we assumed the blockage was due to a blood clot. We decided not to use this port and the proximal end of this channel was labeled as “blocked.” The surgery, which took 4 hours, underwent without major problem. After the traumatic intubation, laryngeal edema was suspected. Therefore, the patient was send to the intensive care unit (ICU) for overnight ventilation. Chest radiograph was done on admission to the ICU, showed central line and no pneumothorax [Figure 1]. A week later, CVC was removed. Subsequent chest and abdominal radiograph revealed the retained GW, straight from the superior vena cava through right atrium and inferior vena cava, to the right femoral vein [Figure 2]. There was no sign or symptoms related to the retained GW. Next day, the interventional radiologist removed the GW from the right femoral vein. Central line insertion is a common intervention in the operating theater. Alone in USA, more than 5 million of central lines are inserted every year.[2] Retention of the GW is a rare complication. Its true incidence is not known, but it has been estimated at one per few thousands.[3] California department of public health statistic showed that one in every 10 retained foreign bodies after surgery was a retained GW. [4] Recently, Vannucci et al. in a special article, discussed the issue of retained GW after intraoperative placement of CVC.[5] Two main factors, which contributed to retention of GW in all 4 cases reported in this article were also present in our case. The first factor was “inattention.” Technical difficulties, which started from the beginning of this case caused anxiety and stress among the anesthesia team. There were many factors at the scene which diverted the operator’s (JSA) attention away from the central line procedure. In attention, and not lack of care caused this complication. The operator, who was overwhelmed with various dimensions of the patient’s care, continued the procedure and unknowingly Vol. 8, Issue 3, July-September 2014

Figure 1: Chest radiograph taken on admission to intensive care unit. This shows (1) radiolucent lumen of central venous catheter (CVC) visible at the neck (blue arrow). (2) Proximal end of retained guide wire in the CVC (red arrow). (3) Distal end of CVC (yellow arrow)

Figure 2: Plain abdominal radiograph. The retained guide wire is seen from the inferior vena cava (red arrow) up to the right femoral vein (blue arrow)

pushed the GW along with CVC. Fatigue, which was also present in our case, has been recognized as a predisposing factor for leaving the foreign body in the patient.[6] The second common denominator was the use of 2 CVC kits were opened and 2 GW were used in all cases. From the patient’s safety point of view, retained GW is an important issue. Therefore, measures to prevent and early diagnosis of this complication should be promulgated among those who perform CVC procedure. Jamil S. Anwari, Sohail Imran Department of Anesthesia, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia Address for correspondence: Dr. Jamil S. Anwari, C-151, Prince Sultan Military Medical City, P.O. Box: 7897, Riyadh 11159, Saudi Arabia. E-mail: [email protected]

Saudi Journal of Anesthesia

Letters to Editor Page | 445

REFERENCES 1.

2. 3.

4.

Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol 1953;39:368-76. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33. Bessoud B, de Baere T, Kuoch V, Desruennes E, Cosset MF, Lassau N, et al. Experience at a single institution with endovascular treatment of mechanical complications caused by implanted central venous access devices in pediatric and adult patients. AJR Am J Roentgenol 2003;180:527-32. Song Y, Messerlian AK, Matevosian R. A potentially hazardous complication during central venous catheterization: Lost guidewire retained in the patient. J Clin Anesth 2012;24: 221-6.

5.

6.

Vannucci A, Jeffcoat A, Ifune C, Salinas C, Duncan JR, Wall M. Special article: Retained guidewires after intraoperative placement of central venous catheters. Anesth Analg 2013;117:102-8. Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: Mishap or blunder? Br J Anaesth 2002;88:144-6. Access this article online Quick Response Code:

Website: www.saudija.org

DOI: 10.4103/1658-354X.136655

Yet another way to clear water drops from ETCO2 sampling line Sir, It is very common to see the alarm in monitor, “sample line obstruction” especially in prolonged surgeries. It is always wise to check for a kinking of sampling line first and solve other common problem like obstruction due to water droplets. There are different ways to overcome such problem viz, using auxillary oxygen[1] or compressed air to clean sampling line, prophylactically putting HME filters.[2] The most common thing anesthesiologist does is changing the sampling line. Many a times additional sampling line is not available. In such situation cleaning the sampling line is done by using auxiliary oxygen supply with added disadvantage of diluting anesthetic gases. Even though this method is effective, many anesthesia workstations are not having facility of auxiliary oxygen supply. In such condition, this method will help to clear water droplets. In this method, the angle connector with side port is attached to common gas outlet as shown in Figure 1. The proximal end of sampling line is connected to side port simultaneously obstructing the open end of angle connector. The switch is turned from circle system to the open system. The fresh gas flow is increased to a total of 6-7 L/min to clear water droplets. Once cleared, the proximal end of sampling line is attached to ETCO2 module; by switching the knob to circle system the fresh gas flow is reduced to initial setting. This method helps during head and neck surgeries also where the Saudi Journal of Anesthesia

Figure 1: Attachment of angle connector and sampling line to common gas outlet

distal end of sampling line is not approachable. One should not forget to switch back to the circle system at the end of cleaning sampling line. Sampling line can be cleaned using this method effectively at the end of the case by oxygen flush instead of fresh gas flow. Akshaya N. Shetti Department of Anesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India Address for correspondence: Dr. Akshaya N. Shetti, Department of Anesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India. E-mail: [email protected]

Vol. 8, Issue 3, July-September 2014

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