loss of the guide wire
DESCRIPTION
loss of the guide wireTRANSCRIPT
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LOSS OF THE GUIDE
WIRE:
IS IT MISHAP OR
BLUNDER ?
CASES REPORT STUDY.
4-12-2012
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PROF.
HASSAN ALY OSMAN
PROFESSOR OF ANESTHESIA
AND SURGICAL INTENSIVE CARE.
FACULTY OF MEDICINE.
ALEXANDRIA UNIVERSITY.
4-12-2012
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Introduction:
Percutaneous catheterization
of a central vein is a routine
daily technique during the
intensive care clinical
practice.
The general complications
rate of CVC may be as high as
12 %.
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The complications are mainly
related to:
a. Anesthetist’s or Intensivist’s
experience.
b. Patient’s condition.
c. The technique used.
d. The central vein cannulated.
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The seldlinger’s technique
is frequently used for CVC.
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Case I study. 63 years old female underwent
complicated anterior resectionof the rectum.
After surgery an anesthetist inthe first year of his traininginserted CV line via the rightinternal jugular vein.
He was not familiar with CVCor the seldinger technique and he was not supervised.
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When he encountered
resistance while advancing the
guide wire, he became nervous,
but he continued the catheter
insertion.
The catheter was accidently
withdrawn.
2 nd cannulation trial was
performed under supervision
without any problems.
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The catheter tray
was not checked for
the guide wire after
each procedures !
Half hour check x ray
showed no problems.
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One week later routine
abdominal radiograph showed
the guide wire at the right
border of the spine.
At that time, the 1st x ray was
not available for comparison !
The guide wire was surgically
removed by vascular
exploration of the abdominal
inferior vena cava under GA.
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Case II study.
62 years old male was scheduled
for elective vascular surgery.
A consultant supervised first
year trainee for CVC ( Rt.Int.J.)
The surgeon started his job
before completion of the CVC.
The vein was identified and
cannulated without problems.
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Both the trainee and the
supervising consultant
were distracted from
the cannulation procedures
when the surgeon started his
job.
The consultant concentrated
to the anesthesia management,
while the trainee continued
with the CVC.
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While flushing the catheter,
undue resistance was met,
but this caused no suspicion.
Postoperative x ray showed a
guide wire extending from the
inferior part of the vena cava
to Rt.Int.J. Vein.
The guide wire was removed
using the Dormier basket.
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Case III study. 68 years old male in septic
shock & MOF after resectionof malignant colon and rectum.
During busy night shift, a thirdyear trainee cannulated leftpatient’s femoral vein forhemofiltration.
Information about life threatening problem of another
patient distracted him fromholding onto the guide wire.
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He did not order the routine
chest x ray !...he was busy !
The next morning he
remembered no problems
with the catheterization !
In a routine x ray, the guide
wire was reported by the
radiologist ! It was surgically
removed.
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Case IV study.o An experienced physician
passed cannula into the left
Int.J.V of 43 years old man with
subarachnoid hemorrhage using
the seldenger’s technique for
the first time.
o He carried out the procedure
without any supervision.
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o Routine x ray showed the
the proximal one third of the
guide wire within the catheter
in the cannulated vein, while
the two thirds were free in the
blood stream !
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o The guide wire could be held
within the catheter using two
clamps. Both were removed
together by careful traction
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Discussion Signs of guide loss:
a. The guide wire missing.
b. Resistance to injection
especially to the distal
lumen.
c. Poor venous back flow from
the distal lumen.
d. Visible guide wire in the
x ray.
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Predisposing factors of the
guide wire loss:
Inattention.
Inexperienced operator.
Inadequate supervision.
Overtired staff.
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Complications of the lost guide
wire:
Arrhythmia.
Bleeding.
Hemopricardium.
Infection.
Thrombosis and embolism.
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Management of the lost
guide wire:
Radiological documentation
to detect the exact site.
Immediate heparinization if
not contraindicated.
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Methods used to remove
the lost guide wire:
Gooseneck snare via the site
of cannulation using the
radiographic control.
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Endovascular forceps.
Dormia basket.
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Surgical exploration.
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Conclusions.
1.Percutaneous CVC is routine
technique requires:
@. Supervision.
@. Meticulous attention to its
details.
@. Training and skills.
@. Avoid possible complications
and ensure the safe
management.
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2. The loss of the guide wire is
preventable complication.
3. During the CVC technique be
sure that:
@. The guide wire is visible
at the proximal end before
the advancement of the
catheter.
@. Always hold on the tip of the
guide wire.
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3. Always inspect the guide wire
after complete removal
at the end of the procedure.
4. The guide wire should be
removed as soon as possible.
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