Missing the guidewire: an avoidable complication
© Omar et al. 2010
Received: 18 March 2010
Accepted: 25 September 2010
Published: 25 September 2010
Central venous catheterization is an imperative tool in the critically ill patient to administer fluids, medications and for monitoring the central venous pressure. This procedure is associated with a variety of complications, some of which can be life threatening. In this brief report, we are addressing one of the rare complications of central venous catheterization which is missing the guidewire. We also described several precautions to avoid this complication as well as modifications in the guidewire to prevent its escape.
Central venous catheterization is an imperative tool for many critically ill patients whether to administer fluids, drugs or measure the venous pressures. The complication rate of this procedure maybe as high as 12%  In this report we are addressing one of the rare complications following central venous catheterization which is missing the guidewire. Although this complication has been rarely reported, we assume that this is underestimated due to medicolegal reasons. Usually the loss of a complete guide-wire passes uncomplicated; however complications might arise due to embolization from fragmentation of the guidewire or from a thrombus formed over the guidewire. Other possible complications include vascular injury and cardiac arrhythmias. Interventional radiology is the method of choice for wire removal using either a gooseneck  snare or a Dormier basket 
'Physician tips to avoid this complication
1. A quiet environment is required to minimize distraction to the operator.
2. Ensure adequate length of the guidewire outside the patient sufficiently exceeding the length of the catheter and the dilator.
3. The tip of the guidewire should be kept in hand of the operator or assistant at all times throughout the procedure.
4. Make sure that the guidewire is visible at its proximal end before advancing the catheter or dilator.
5. After the guidewire is inserted, and the dilation is done, clamp a hemostat to the proximal end, to secure it stays outside the body.
6. Ensure the presence of the guidewire in the set after completing the procedure.
7. Post insertion X-ray should be immediately performed and read by the line inserter, as often a second reader might not notice, and/or the inserted catheter might obscure the vision of the wire.
We suggest the following techniques to avoid this complication
Demonstrating the distance between the skin puncture site and cavo-atrial junction in various central venous catheterization approaches.
Right Internal Jugular Vein to Atrio-caval Junction
Right Subclavian Vein to Atrio-caval Junction
Left Internal Jugular Vein to Atrio-caval Junction
Left Subclavian Vein to Atrio-caval Junction
Written informed consent was obtained from the patient's next of kin for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal
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