Central venous catheterization was a common technology in clinical anesthesia and rescue. Guide wire fracture and retention was a very rare and severe complication in central venous catheterization.1 Here, we reported a case that guide wire was broken and remained in the body in internal jugular vein puncture process in an 8-year-old boy.
This boy with a weight of 25 kg was admitted to hospital for bilateral lower limbs sore pain, malformations, and hemorrhage with activity restriction for 2 hours caused by traffic accident. The diagnosis was skin avulsion of double lower limbs, fracture with dislocation of the right femur and acetabulum, chest contusion, and hemorrhagic shock. Debridement and hemostasis, incision for reduction, and fixation of femoral fracture were to be performed. When the boy entered the operation room, he had general development, without head and facial trauma and bruises, sleepiness, pale, and cold clammy limbs. His heart rate was 150 beats/min as shown by the Philips MP70 ECG monitor. The right brachial artery blood pressure was 55/30 mmHg, SpO2 was 88%, and breathing was 35 times/min. Mask oxygen inhalation was performed, midazolam of 0.02 mg/kg, etomidate of 0.3 mg/kg, fentanyl of 3.5 μg/kg, and rocuronium of 0.9 mg/kg were administered intravenously, and intratracheal intubation (ID=6.0) was facilitated. In view of the critical condition of the patient, central venous line placement was determined and a pediatric pack (5 Fr two-lumen pediatric central venous catheter, Arrow International, Reading, USA) was selected. In Trendelenburg position, the right internal jugular vein (level of cricoid cartilage) was chosen to insert the puncture needle (20 Ga), with dark red blood in resorption and without blood squirting in the injector. It was difficult to place or pull out the J type guide wire, and it was found that the J head was twisted slightly. After further confirmation of the puncture needle in internal jugular vein clinically, it was tried to place J head guide wire again, but there was resistance with neither advance nor retreat. So we decided to withdraw the guide wire and found that the puncture needle could be withdrawn smoothly while the guide wire could not be pulled out. To make the guide wire be withdrawn from skin, we tried slightly to pull the wire with resistance and found the guide wire stretched with fine tinsel. There was a metal complex of about 2-3 cm observed using a C-arm fluoroscope, with the distance of about 3.5 cm from the skin puncture point (Figures 1 and 2). After we reported to a senior anesthesiologist, he attempted to pull out the fractured guide wire without success at first, and the thin metal wire was broken when he attempted secondly. After discussion, we decided to operate and remove the metal under direct vision, during which, the residual part was found to be embedded in the deep sternocleidomastoid between C5-6 parapophysises, beside vertebral artery, and not in internal jugular vein. After removal of residual broken wire (Figure 3), central venous catheter was placed again under direct vision. After surgery, the boy was sent to ICU for 3 days and endotracheal extubation was performed 12 hours later. Then he continued to recover and discharged smoothly.
It is common that the process of internal jugular vein puncture is not smooth, which mostly could be resolved by adjustments clinically. In this case, guide wire was broken and remained in the body, which was confirmed by C-arm fluoroscope. The broken guide wire was cut off and removed under direct vision successfully. Analysis of causes and lessons are as follows: (1) Children have small veins, thin vein walls, and loosen surrounding tissues; such anatomical factors including internal jugular vein inside or outside of carotid artery not fully developed may increase the difficulty of the catheterization. In this case, the puncture needle was in the vein but the guide wire was not placed smoothly. J head may be bunted in the vascular sidewall initially, there was resistance while J head of the guide wire was pulled in or out the puncture needle for several times, and this action resulted in the slope of the puncture needle cutting the guide wire directly and stripping the thin wire from the guide wire. During the operation, the residual part was found to be embedded in the deep sternocleidomastoid between C5-6 parapophysises, beside vertebral artery, and not in internal jugular vein or internal carotid artery. It could be speculated that the guide wire went through the vessel wall in catheterization, and that J head remained outside the vein because of elastic recoil after fracture. Of course, it could not be excluded that the residual part was attempted to be pulled out through the thin metal wire causing the overall shift.
This fracture was reported to mainly occur in the advancing and withdrawing of the needle, because these related operations mostly likely produce large shearing force.2 These operations have the following risks: (a) if the thin wire broken and the residual part remained in the vessel, it may flow into the heart and lung with blood flow, resulting in arrhythmia, pulmonary embolism, or even threatening of life; 3 (b) the residual part could pierce internal jugular vein or (and) the internal carotid artery in the traction, resulting in massive bleeding or arteriovenous fistula formation; (c) the residual part could injure brachial plexus in the traction;4 (d) Subsequent processing difficulty will increase if the needle was pulled from its original position. In this case, the puncture needle was pulled back smoothly, but there was resistance when the guide wire was placed; operation incision found that the residual part was embedded in the deep sternocleidomastoid between C5-6 parapophysises, beside vertebral artery. The reason may be that the needle remained in the blood vessel wall in the puncture and skidded off the vessel wall in the guide wire placement process, because there was no apparent breakdown in the vascular wall under direct vision that pulling operation caused a shift; (e) it cannot be pulled out blindly while its true location was unknown, so as not to damage adjacent blood vessels and nerve tissues, especially large power vein involving the vertebral artery.5 Although those above situations did not occur during operation in this case, we must draw the corresponding lessons from the experience of this accident. (2) Anatomical landmarks must be paid attention in the puncture process, all possibilities must be considered if the guide wire placement is not smooth. Guide wire should not be placed repeatedly and replaced while it is twisted. When puncture fail or the guide wire is placed with difficulty, guidance of ultrasound or X-ray fluoroscopy should preferably be adopted to analyze the situation. (3) The integrity of guide wire should be examined before puncture. If fracture occurs and only a fine metal wire connects, the best way is to remove under direct vision, and the methods with minimally invasive surgery like pulling and expanding skin along the steel wire rarely work. (4) When the child was to be performed with internal jugular vein or subclavian vein puncture with emergency, the puncture should be performed in the guidance of ultrasound or X ray fluoroscopy if possible.
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3. Karakaya D, Baris S, Güldogus F, Incesu L, Sarihasan B, Tür A. Brachial plexus injury during subclavian vein catheterization for hemodialysis. J Clin Anesth 2000; 12: 220-223.
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5. Monsuez JJ, Dourd MC, Martin-Bouyer Y. Catheter fragments embolization. Angiology 1997; 48: 117-120.