Approximately 5 million central venous catheters (CVCs) are placed in patients perioperatively in the United States every year.1 This procedure is associated with infectious, thrombotic, and mechanical complications that can negatively influence patient outcome and increase the cost of care.2 In recent years, effective strategies have been developed to prevent infectious3 and mechanical complications4,5 of CVC placement, but the problem of retained guidewires has not specifically been addressed. The incidence of guidewire retention is difficult to track, but one investigation estimated that this complication may occur at a rate of 1 case every few thousand catheter insertions.6 This result is consistent with the findings of Domino et al.,7 who in 2004 reviewed the data of the American Society of Anesthesiology Closed Claim Project, and reported that the most common complication associated with litigated, malpractice claims designated as central catheter injuries was “wire/catheter embolus.” Importantly, this complication was reported to be associated with substandard anesthesia care in 82% of the cases.
A current analysis of Closed Claims data reveals that, by decade, there has been a statistically significant increase in the proportion of claims related to central venous cannulation; 25 of these claims were attributed to retained wires/embolus, one of which resulted in death and another in a permanent disabling injury (personal communication, Karen L. Posner, PhD, University of Washington, Seattle, WA, 2011).
Several authors8–11 have previously focused their attention on risk factors for guidewire loss in patients undergoing central catheter placement in various settings, such as operating rooms, emergency departments, and intensive care units (ICUs). Operators’ inexperience, fatigue, and inattention, and inadequate supervision of trainees were suggested as predisposing factors. In aggregate, those studies support the notion that guidewire retention is a relevant patient safety issue. Despite the clinical significance and additional medical cost of these occurrences, no specific preventative strategies are recommended, even in the most current clinical guidelines.12–14
In a previous article, we discussed an approach based on Failure Mode and Effect Analysis to identify and address, in a training curriculum for residents, failure modes leading to CVC complications, including retained guidewire.15 This article focuses on clinical factors possibly related to guidewire retention after intraoperative CVC placement.
The goals of this report are (1) to highlight specific intraoperative situations recurring in retained guidewire cases; (2) to estimate the incidence of guidewire retention after central venous access in the operating room setting at a teaching institution; (3) to raise awareness of this complication; and (4) to suggest possible preventive measures based on a Failure Mode and Effect Analysis approach.
The Human Research Protection Office of Washington University in St. Louis approved the publication of this article, considering that this review of complicated clinical cases is clinical activity and does not constitute human subject research (patient permission was not obtained because personal identifiers are omitted from the report). All 4 cases of guidewire loss after intraoperative placement of a CVC reported at our institution since January 2006 are presented. These cases were classified as “sentinel events” and were investigated using root cause analyses by multidisciplinary teams involving representatives of Washington University in St. Louis School of Medicine and BarnesJewish Hospital.
Case 1 (2006)
A 51yearold man with interstitial pulmonary fibrosis underwent a right singlelung transplant. After induction of general anesthesia, a percutaneous introducer was placed in the right internal jugular vein (IJV) by a secondyear anesthesiology resident supervised by a cardiothoracic anesthesiologist. The anesthesia record documents that the pulmonary artery catheter could not be properly positioned because of presumed increased pulmonary artery pressures. It was then decided to place a percutaneous introducer in the left IJV. Again, the pulmonary artery catheter was unable to be directed into the pulmonary artery. According to the anesthetic record, sterile preparation of the target site, positive blood return, wire passage, introducer placement, and good venous blood flow were all documented for both right and left CVC placements. However, there was no documentation of either guidewire having been removed. The operative summary and anesthetic record showed the remainder of the procedure to be uneventful and the patient was transported to the ICU with his lungs mechanically ventilated. The first postoperative chest radiograph described a series of postoperative changes, but did not mention a retained guidewire. On the chest radiograph taken on postoperative day (POD) 2, a retained guidewire was detected (Fig. 1A). Vascular Interventional Radiology service was consulted and the guidewire was found to be lodged in subcutaneous tissue in the right neck. The guidewire was removed percutaneously without evidence of venous injury.
Case 2 (2006)
A 72 yearold woman with a contained splenic hemorrhage and left adrenal mass underwent a surgical abdominal exploration. After induction of general anesthesia, a right IJV catheter was placed by a secondyear anesthesiology resident supervised by an attending anesthesiologist. Documentation of placement of the CVC included skin preparation with chlorhexidine scrub, Trendelenburg positioning, wearing of sterile gloves and gown, use of a finder/seeker needle to locate the right IJV, guidewire insertion, and transduction of pressure to verify nonarterial catheter location. No documentation of the removal of the guidewire was noted on the anesthetic record. The patient’s intraoperative course was uneventful and the patient was transported to the ICU with her lungs mechanically ventilated. Chest radiographs revealed a retained guidewire on POD 1 (Fig. 1B). The retained guidewire was removed by an interventional radiologist and a new central venous cannula was placed.
Case 3 (2008)
A 70 yearold woman with idiopathic pulmonary fibrosis had a bilateral lung transplant. Because of poor peripheral venous access, after induction of general anesthesia, a percutaneous introducer venous cannula and a triplelumen CVC were placed in the right IJV (“double-stick” procedure). This was performed by a secondyear anesthesiology resident supervised by a cardiothoracic anesthesiologist. During CVC placement, there is documentation of 3 small doses of epinephrine being given, suggesting hemodynamic instability. Documentation of the placement of the central venous cannula included right IJV site sterile preparation, ultrasound visualization of the vein before venipuncture, use of fullbarrier sterile drape, and visualization of wire in the superior vena cava (by the attending anesthesiologist performing a transesophageal echocardiographic [TEE] examination). No documentation of the guidewire being removed was present on the anesthetic record. The remainder of the surgical procedure proceeded uneventfully and the patient was transported to the ICU with her lungs mechanically ventilated, with an “open” chest, and multiple packing sponges. Postoperative detection of the retained guidewire inside the multilumen catheter was noted on the initial chest radiograph (Fig. 1C). While the official reading of the film was pending, the nurse caring for the patient recognized the guidewire inside the catheter. The catheter with the contained guidewire was then removed at bedside by the intensivist on POD 1.
Case 4 (2009)
A 67 yearold woman with severe ischemic cardiomyopathy presented for scheduled placement of a left ventricular assist device. General anesthesia was induced, and documentation of administration of 4 doses of epinephrine suggested the patient’s hemodynamic instability. A percutaneous introducer and a multilumen central venous cannula were placed in the right IJV by a thirdyear anesthesiology resident and by a fourthyear medical student, both of whom were supervised by a cardiothoracic anesthesiologist. The attending anesthesiologist managed the patient’s hemodynamic status in addition to performing a TEE while the central venous cannulae were being inserted. During cannulation, 2 additional anesthesiology residents were at the head of the bed performing and observing the TEE examination along with the attending anesthesiologist. Documentation of the CVC placement per the anesthetic record includes the use of sterile technique, ultrasound vein visualization before skin preparation, use of a finder/seeker needle, use of the Seldinger technique, removal of guidewire, and good blood return from all catheter ports. The operation was complicated by an episode of ventricular fibrillation requiring direct current cardioversion twice, immediately after sternotomy. The remainder of the operative procedure was uneventful. The patient was transferred to the ICU with an “open” chest and multiple packing sponges. Multiple chest radiographs were obtained before and after definitive intraoperative wound closure. However, detection of the retained guidewire did not occur until POD 2 (Fig. 1D). The guidewire and the multilumen catheter, on that day, were removed at bedside by a cardiothoracic surgery fellow.
Additional information on these 4 cases is summarized in Table 1.
The improved success and the diminished complication rate of the “catheter over guidewire” technique for central venous cannulation were recognized in the late 1970s, and this method soon replaced the “catheter through needle” technique.16–18 Over the years, specific complications of the Seldinger technique included wire rupture, wire embolization, and perforation of vessels and heart.19–22 In 2005, The Joint Commission included “retention of objects after surgery and surgical procedures” in the list of reportable sentinel events.a As a result, a new patient safety tool with the capacity to capture guidewire retention became available.
The review of the 4 cases of retained guidewires after intraoperative placement of CVCs reported at our institution since 2006 suggests that urgent and complex surgical procedures in hemodynamically unstable patients may predispose them to this complication. In particular, 2 main factors may have contributed to guidewire retention.
First is the simultaneous presence of 2 guidewires on the field that likely confused providers in tracking and removing the wires from patients. In all of the reported cases, 2 CVC kits were opened and 2 guidewires were used. This was either because the initial attempts to thread the catheter had failed, requiring new equipment to complete the procedure (cases 1 and 2), or because of a planned doubleaccess of the vein (cases 3 and 4). Both failure of catheter placement on the first attempt and the need to place 2 lines in the same central vessel (“double-stick” procedure) are relatively common occurrences in the clinical setting of large academic institutions. Of further interest, in case 3, the resident first used the longer guidewire (60cm) of a triplelumen CVC kit for advancing a shorter 8F introducer. At that point, the resident was left with only the possibility of advancing the long triplelumen catheter over the short sheath introducer guidewire (45 cm), which remained hidden inside the catheter. The CVC was, then, not used intraoperatively, and the presence of the guidewire was only identified later in the ICU.
The second possible mechanism is inattention blindness. All procedures were performed shortly after anesthesia induction, in hemodynamically compromised patients, requiring continuous care to preserve vital functions. The attention of the attending physicians was directed from residents placing the CVC to maintaining patient hemodynamic stability. In cases 3 and 4, there is documentation of potent vasoactive drugs being given during placement of the CVC, suggesting that the patients were hemodynamically unstable. The attending physicians reported in the respective root cause analyses that when the patients became acutely unstable, their attention was diverted from residents’ activity, leading to inadequate supervision. In addition, the residents’ attention was also partially distracted from the ongoing procedure by monitor alarms after abnormal vital signs, and by the interactions with other team members. The resulting clinical errors, that may seem surprising in experienced and qualified providers, are actually well explained by cognitive psychology studies showing that demanding situations and interruptions cause forgetting of intentions, and difficulty in resuming suspended goals.23,24 We suggest that distraction of the clinicians and task interruptions resulted in unrecognized deviations from proper technique, which resulted in intravascular guidewire loss.
As other authors have already pointed out,10 there is often a delay in the recognition of lost guidewires that may add to patient risk. In all patients, a chest radiograph was taken shortly after the end of surgery, but the retained guidewires were not immediately detected by clinicians and radiologists in 3 of the 4 cases. Signaltonoise issues likely contributed to the error. First, the relatively low quality of a bedside chest radiograph obtained only in an anteroposterior projection decreases the signal created by the retained guidewire; second, there are numerous other wires and other opacities in patients tracheally intubated and with an instrumented chest (i.e., other vascular lines, electrocardiographic cables, and, in cases 3 and 4, with a packed, open chest) that increase the visual noise; finally, the very low frequency of retained guidewires after CVC placement likely led to detection and attribution errors.
Using billing data to provide an estimation of the number of CVCs placed in the operating room (Table 2), the estimated perioperative guidewire loss rate at our institution is 1:3291 procedures, similar to that reported by Bessoud et al.6 This is an alarmingly high rate of retained guidewires. It is possible that the use of billing data may have overestimated the incidence of this complication, because more catheters may have been placed than were billed. Incompletely documented CVCs are usually not billed, thus potentially resulting in an overestimate of the incidence of this complication.
This frequency was recorded in an academic tertiary/quaternary institution with a large number of trainees where complex procedures on severely ill patients are performed frequently. Institutions with a different mix of patients and procedures, and fewer (or no) trainees, may have a lower rate of such events. Still, we believe that our experience reflects the “real world” situation. If academic centers have similar rates, retained guidewire is a significant patient safety issue that calls for the adoption of specific preventative strategies. In this regard, it is of interest to review the structure and outcomes of the strategies implemented at our institution since 2006 in an effort to prevent similar adverse occurrences. In 2006, the first 2 cases of this series in conjunction with other similar complications from different clinical areas of our institution were identified, reviewed by the involved clinicians, and analyzed in multidisciplinary root cause analyses, as prescribed by The Joint Commission for sentinel events. Eventually, institutional preventative strategies based on a mandatory training for new hospital interns of all clinical specialties, and the adoption of a CVC checklist to guide and document every central catheter placement (see Supplemental Digital Content 1, http://links.lww.com/AA/A402) were devised and tested.
A full description of the development and implementation of the “New Intern Training” has been published.15 Briefly, a curriculum was designed that focuses on planning and execution skills for 3 identified safety priorities in central venous access procedures: (1) retained guidewires, which led to training on handling catheters and guidewires; (2) needlerelated mechanical complications (arterial puncture, pneumothorax), which prompted the development of an ultrasound training module; and (3) catheterassociated bloodstream infections, which were addressed through training on maximum sterile barriers.
In addition, the Department of Anesthesiology executed its own action plan that included the institution of a mandatory Central Venous Access Training Module for firstyear residents (Categorical 1) during their tutorial period centered on the same 3 clinical priorities, but also aiming at preparing residents for intraoperative tasks and working conditions (e.g., responsibility of anesthesia providers to guarantee both delivery of adequate anesthetic level for the patient, and maintenance of stable vital signs during the vascular access procedure; preparation of the sterile field that takes into consideration the location of the anesthesia machine, respiratory circuit, and monitors; and clarification of competencies and responsibilities of different operating room professionals, such as circulating nurses and anesthesia technicians, with regard to assisting anesthesia providers performing central venous access). It was also imperative that the removal of guidewires be documented in the anesthesia record after every central access procedure.
Notwithstanding these system changes introduced in 2006, 2 more cases of lost guidewire occurred, one in 2008 and another in 2009. Interestingly, the residents involved in these 2 latest cases had undergone the ad hoc training in the year preceding the event. These new occurrences suggest that either the training was inadequate, or that after 1 year, the information may no longer have been retained; alternatively, it may be that, as proposed by root cause analyses findings, difficult clinical situations may lead “middle career residents” and attendings to deviate from proper practices.
From these 2 additional occurrences, we also realized that the newly implemented documentation requirements were insufficient. Therefore, in 2009, after the adoption of an electronic medical record by our department, a dedicated popup window was designed to remind clinicians to document CVC placement details, including guidewire removal (Fig. 2). However, to illustrate that even this strategy based on electronic support is not entirely foolproof, it should be noted that in case 4, the guidewire removal was documented in the electronic record, but only 1 of the 2 wires used in the doublestick procedure had actually been removed. Based on this experience, we suggest that a systematic count of critical items should be performed and documented in the medical record, similar to the surgical instruments count. In all of the cases presented herein, there was no protocol in place to confirm the removal or the count of the guidewires at the end of the procedure. Even if counting is a tool with limited sensitivity and specificity, it may still be effective in capturing at least a significant fraction of such complications.25–27 In the future, it may be possible that new technologies such as radiofrequency detection may become available28 and prove their utility, but this is not currently the case for vascular guidewires.
In conclusion, we believe that future guidelines for CVC placement should address the possibility of guidewire loss and suggest measures that would help prevent this from occurring. There should be multiple mitigating interventions and they should be applied during multiple steps of the process.
The following represent actions that may contribute to reducing the retention of guidewires after CVC placement:
Raise trainees’ awareness of the failure modes that may lead to this complication and ensure that they have been trained to recognize errors before they cause harm. As an example of the approach we have implemented with good results in the training of new residents,14 we provide a short video clip (Video 1, see Supplemental Digital Content 2, http://links.lww.com/AA/A403). That training emphasizes that the primary error is advancing the guidewire too far into the vein, and that the guidewire should only be introduced up to the 20-cm mark at skin level. The video also illustrates how 2 additional errors must occur before the guidewire will no longer be retrieved easily. This training recognizes that errors will occur, but that procedures can be designed to minimize error frequency, decrease the severity of errors when they inevitably occur, and recognize errors before they cause irreversible harm.
Design the electronic medical record to drive clinicians’ attention toward important clinical factors (popup windows as reminders), and to promote proper clinical behaviors.29–31
The following represent measures that may result in early detection of retained guidewires:
Use of systematic counting procedures: all items at risk of being misplaced or lost should be counted at the end of the procedure with the assistance of team members not immediately involved in patient care.
Chest radiograph should be reviewed in the light of the possibility of this and other complications after CVC placement (retained guidewire, pneumothorax, vascular trauma, and malpositioned catheter).
Name: Andrea Vannucci, MD.
Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.
Attestation: Andrea Vannucci approved the final manuscript.
Name: Alicia Jeffcoat, MD.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Attestation: Alicia Jeffcoat approved the final manuscript.
Name: Catherine Ifune, MD.
Contribution: This author helped analyze the data and write the manuscript.
Attestation: Catherine Ifune approved the final manuscript.
Name: Christian Salinas, MD.
Contribution: This author helped write the manuscript and prepare the accompanying video.
Attestation: Christian Salinas approved the final manuscript.
Name: James R. Duncan, MD.
Contribution: This author helped analyze the data, write the manuscript, and prepare the online video.
Attestation: James R. Duncan approved the final manuscript.
Name: Michael Wall, MD.
Contribution: This author helped analyze the data and write the manuscript.
Attestation: Michael Wall approved the final manuscript.
This manuscript was handled by: Sorin J. Brull, MD, FCARCSI (Hon).
a The Joint Commission Sentinel Event Policy and Procedures. Available at: http://www.jointcommission.org/assets/1/6/2011_CAMH_SE.pdf. Accessed August 5, 2011
1. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348:1123–33
2. Kusminsky RE. Complications of central venous catheterization. J Am Coll Surg. 2007;204:681–96
3. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease catheterrelated bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–32
4. Wigmore TJ, Smythe JF, Hacking MB, Raobaikady R, MacCallum NS. Effect of the implementation of NICE guidelines for ultrasound guidance on the complication rates associated with central venous catheter placement in patients presenting for routine surgery in a tertiary referral centre. Br J Anaesth. 2007;99:662–5
5. Ortega R, Song M, Hansen CJ, Barash P. Videos in clinical medicine: ultrasoundguided internal jugular vein cannulation. N Engl J Med. 2010;362
6. Bessoud B, de Baere T, Kuoch V, Desruennes E, Cosset MF, Lassau N. Roche A. 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
7. Domino KB, Bowdle TA, Posner KL, Spitellie PH, Lee LA, Cheney FW. Injuries and liability related to central vascular catheters: a closed claims analysis. Anesthesiology. 2004;100:1411–8
8. Thomas J, SinclairSmith B, Bloomfield D, Davachi A. Nonsurgical retrieval of a broken segment of steel spring guide from the right atrium and inferior vena cava. Circulation. 1964;30:106–8
9. Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: mishap or blunder? Br J Anaesth. 2002;88:144–6
10. Auweiler M, Kampe S, Zahringer M, Buzello S, von Spiegel T, Buzello W, Hekmat K. The human error: delayed diagnosis of intravascular loss of guidewires for central venous catheterization. J Clin Anesth. 2005;17:562–4
11. Lum TE, Fairbanks RJ, Pennington EC, Zwemer FL. Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography. Acad Emerg Med. 2005;12:658–62
12. Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M. ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr. 2009;28:365–77
13. Bishop L, Dougherty L, Bodenham A, Mansi J, Crowe P, Kibbler C, Shannon M, Treleaven J. Guidelines on the insertion and management of central venous access devices in adults. Int J Lab Hematol. 2007;29:261–78
14. Rupp SM, Apfelbaum JL, Blitt C, Caplan RA, Connis RT, Domino KB, Fleisher LA, Grant S, Mark JB, Morray JP, Nickinovich DG, Tung A. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2012;116:539–73
15. Duncan JR, Henderson K, Street M, Richmond A, Klingensmith M, Beta E, Vannucci A, Murray D. Creating and evaluating a datadriven curriculum for central venous catheter placement. J Grad Med Educ. 2010;2:389–97
16. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography: a new technique. Acta Radiol. 1953;39:368–76
17. Blitt CD, Wright WA, Petty WC, Webster TA. Central venous catheterization via the external jugular vein: a technique employing the JWIRE. JAMA. 1974;229:817–8
18. Belani KG, Buckley JJ, Gordon JR, Castaneda W. Percutaneous cervical central venous line placement: a comparison of the internal and external jugular vein routes. Anesth Analg. 1980;59:40–4
19. Doering RB, Stemmer EA, Connolly JE. Complications of indwelling venous catheters, with particular reference to catheter embolus. Am J Surg. 1967;114:259–66
20. Ross AM. Polyethylene emboli: how many more? Chest. 1970;57:307–8
21. Bernhardt LC, Wegner GP, Mendenhall JT. Intravenous catheter embolization to the pulmonary artery. Chest. 1970;57:329–32
22. Tan PL, Gibson M. Central venous catheters: the role of radiology. Clin Radiol. 2006;61:13–22
23. Li SY, Blandford A, Cairns P, Young RM. The effect of interruptions on postcompletion and other procedural errors: an account based on the activationbased goal memory model. xp Psychol Appl. 2008;14:314–28
24. Einstein GO, McDaniel MA, Williford CL, Pagan JL, Dismukes RK. Forgetting of intentions in demanding situations is rapid. Exp Psychol Appl. 2003;9:147–62
25. Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207:80–7
26. Egorova NN, Moskowitz A, Gelijns A, Weinberg A, Curty J, RabinFastman B, Kaplan H, Cooper M, Fowler D, Emond JC, Greco G. Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg. 2008;247:13–8
27. Lincourt AE, Harrell A, Cristiano J, Sechrist C, Kercher K, Heniford BT. Retained foreign bodies after surgery. J Surg Res. 2007;138:170–4
28. Rogers A, Jones E, Oleynikov D. Radio frequency identification (RFID) applied to surgical sponges. Surg Endosc. 2007;21:1235–7
29. Nair BG, Newman SF, Peterson GN, Wu WY, Schwid HA. Feedback mechanisms including realtime electronic alerts to achieve near 100% timely prophylactic antibiotic administration in surgical cases. Anesth Analg. 2010;111:1293–300
30. Wax DB, Beilin Y, Levin M, Chadha N, Krol M, Reich DL. The effect of an interactive visual reminder in an anesthesia information management system on timeliness of prophylactic antibiotic administration. Anesth Analg. 2007;104:1462–6
31. Schwann NM, Bretz KA, Eid S, Burger T, Fry D, Ackler F, Evans P, Romancheck D, Beck M, Ardire AJ, Lukens H, McLoughlin TM. Pointofcare electronic prompts: an effective means of increasing compliance, demonstrating quality, and improving outcome. Anesth Analg. 2011;113:869–76
32. Newcombe RG. Twosided confidence intervals for the single proportion: comparison of seven methods. Stat Med. 1998;17:857–72