Sir,
Central venous cannulation is often a necessity for patients in intensive care units or in patients with difficult peripheral access. Loss of the guidewire is a serious and potentially life-threatening complication with reports of fatalities in up to 20% of cases, when the complete guide wire is lost.[1]
A 2-year 3-month-old female child presented to our institute with chief complaints of poor weight gain, abdominal discomfort, and decrease in appetite. Chest X-ray of the patient showed a radio-dense wire extending into inferior vena cava (IVC) and right atrium [Figure 1]. Patient had a history of hospital admission at the age of 8 months for jaundice. Peripherally inserted central catheter (PICC) was inserted at that hospital in right femoral vein due to difficult peripheral venous cannulation. PICC line was kept for 12 days and later it was removed. Later on, patient presented to our institute with above mentioned complaints. Computerised tomography (CT) scan showed evidence of a linear radio-dense wire extending from infrarenal IVC into the right ventricle. Its tip was seen in the superior vena cava suggestive of foreign material [Figure 1b]. Transthoracic echocardiography showed a hyperechoic mobile structure of size 20 × 10 mm (possibly a vegetation) in the right atrium having attachment to the superior vena cava and IVC with to-and-fro movement across tricuspid valve and near total occlusion of IVC by hyperechoic structure till mid abdomen level [Video 1]. Moderate to severe tricuspid regurgitation (TR) was seen on transthoracic echocardiography. Surgical removal of PICC guidewire was planned. Complete blood count, serum electrolytes, coagulation profile, liver, and kidney function tests were done preoperatively. Preoperative electrocardiogram showed sinus tachycardia and nonspecific ST-T wave changes. The open surgical repair was planned under hypothermic cardiopulmonary bypass
Figure 1.
(a) Chest X-.Ray PA view showing a radio dense wire extending into inferior vena cava and right atrium. (b) Computerised tomography scan showing evidence of a linear Ra: Right atrium dense wire extending from infrarenal IVC, extending into right ventricle and the tip is seen in superior vena cava suggesting foreign material. (c) Guidewire with vegetation. (d) Right atrium opened with blocked IVC. IVC: Inferior vena cava
Patient was induced with general anaesthesia and endotracheal intubation carried out after injecting fentanyl 5 μg/kg, midazolam 0.1 mg/kg, and vecuronium 0.1 mg/kg. Five lead electrocardiogram, invasive arterial blood pressure, central venous pressure, temperature, end tidal carbon dioxide, pulse oximetry, and urine output were monitored intraoperatively. Cardiopulmonary bypass (CPB) was established after cannulating ascending aorta and right atrium. Total circulatory arrest was initiated. Right atrium was opened and removal of guidewire with vegetation from right atrial wall and tricuspid valve leaflet were done [Figure 1c and 1d]. Tricuspid valve was checked for tricuspid regurgitation and anteroseptal commissuroplasty was done. Post repair, moderate to severe tricuspid regurgitation was present. CPB was instituted again, and tricuspid valve was repaired. After complete rewarming, patient was weaned off CPB uneventfully. 180 ml of packed red blood cells was transfused intraoperatively. Total duration of surgery was four hours. Patient was shifted to paediatric intensive care unit and was extubated on second postoperative day.
Complications pertaining to the retained guide wire include complete loss of wire, injury to the vessel from the wire, fracture of the wire, and bleeding.[1-5] Patients undergoing foreign body removal pose a challenge for the anaesthesiologist as there can be risk of arrhythmia, bleeding causing haemodynamic instability, prolonged aortic cross clamp time, and postbypass myocardial dysfunction. Percutaneous retrieval was not possible in this case due to the extent of guide wire with associated vegetation and risk of its embolisation. Therefore, decision was made for surgical plan to remove guide wire under cardiopulmonary bypass. This case highlights the importance of formulating a plan for the anaesthetic management of patients undergoing guidewire removal and preparedness for postoperative management.
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