TO THE EDITOR
Central line placement is a life-saving procedure commonly performed in the intensive care unit (ICU) for various indications, including intravenous fluid resuscitation, hemodynamic monitoring, vasopressor infusion, hemodialysis, and parenteral nutrition. Complications have occurred after central line placement, such as arrhythmia, pneumothorax, and vascular injury. We describe a case of iatrogenic guidewire retention in the inferior vena cava, show the chest x-ray finding, and identify preventive measures to avoid this complication. We emphasize that physicians must learn the abnormal chest x-ray of guidewire retention and interpret the chest x-ray after central line placement themselves to avoid a delayed diagnosis of guidewire retention.
CASE REPORT
A 92-year-old-woman was admitted to the ICU with a diagnosis of septic shock from urosepsis that occurred after outpatient lithotripsy and right ureteral stent placement. Physical examination was significant for high-grade temperature, hypotension, and tachycardia. Laboratory findings were significant for leukocytosis and serum lactate of 6 mmol/L. A right internal jugular vein central line was cannulated with the Seldinger technique (insertion of a catheter over a flexible J-point guidewire) for administration of vasopressors and intravenous fluid. A routine chest x-ray postprocedure was done (Figure 1). Upon chart review, we learned that the patient had been admitted to the ICU 2 months earlier with a similar diagnosis of a right ureteral stone complicated by acute pyelonephritis and septic shock requiring central line placement through the right femoral vein by an emergency department training physician at 3:00 am. Chest x-ray during that admission revealed a similar radiographic finding (Figure 2). The diagnosis of iatrogenic guidewire retention was established. The guidewire was successfully removed by interventional radiology under fluoroscopy without complication.
Chest x-ray postprocedure shows a metal-opaque structure with a J-point projecting toward the right lung apex extending distally into the abdomen, below the lower limits of the radiographic examination. The right neck central line tip projects at the superior vena cava.
An official reading from radiology reported as a catheter extends over the right neck, right paraspinal region into the right upper abdomen and out of the field of view, which misled the physicians who read the report without interpreting the actual image.
DISCUSSION
When reviewing the chest x-ray after central line placement, physicians must confirm the position of the line, the absence of pneumothorax, and potential iatrogenic guidewire retention. Guidewire retention from any site of cannulation could lead to a mortality rate up to 20%.1 Retention can occur when the physician does not hold the proximal end of the guidewire all the time during cannulation of the central line, and the wire is not properly removed from the venous lumen. Generally, guidewire retention is not recognized immediately after central line placement. The guidewire could be left in the circulation up to 17 months without symptoms.2 Factors contributing to guidewire retention include physician inexperience, inadequate supervision, a hastily performed procedure, and overworked house staff physicians.3 Completing a checklist postprocedure with the nursing staff is imperative to confirm that all the equipment is accounted for, including the appropriate disposal of the guidewire. The radiologist should notify the physician directly of abnormal findings. In addition, reviewing previous chest images is mandatory to determine if the complication occurred after the previous procedure as for this patient.
- © Academic Division of Ochsner Clinic Foundation 2017
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