Today we have a guest Pearl writer, our very own rising PGY2 Arjun Prabhu. He learned about an interesting complication while at a committee meeting and wanted to share:

You are getting set up for a femoral central line in resus and are thinking of the possible complications while you’re getting things together. You don’t have to worry about some of the cardiovascular complications of IJ or subclavian access, of course, so besides bleeding, infection, vascular injury, or very rarely venous air embolism, you aren’t thinking of any other major complications. You successfully enter the vein, but when you go to pass your guidewire, you have difficulty threading it. You struggle but eventually succeed in removing the wire, but when you do, it has unraveled. Is there another complication that you should be considering?

Recently, two cases of a fractured portion of the guidewire being retained inside the patient’s subcutaneous tissue have been reported. In both instances, the guidewire had been unraveled when removed.

While a literature search revealed only case reports on guidewire fracture and prevalence of this complication is unknown, shearing and breaking of the wire is thought to be due to pulling the wire back through the needle after it has passed the bevel.[1] In the rare instances in which the guidewire returns unraveled, ordering a post-procedure xray with instruction for radiology to look for a retained portion of guidewire is of low risk to the patient and could catch a serious complication, leading to a better outcome for your patient.

In the case described above, the 7.5 cm retained piece of guidewire was discovered on a KUB about 3 weeks after the incident and was thankfully removed without complication by IR.

[1] Khasawneh FA, Smalligan RD. Guidewire-Related Complications during Central Venous Catheter Placement: A Case Report and Review of the Literature. Case Reports in Critical Care. 2011;11:287261.

Thank you Arjun!

To deep dive into central lines and up your game, don’t miss Part 1 of the EMCrit Central Line Show and Central Line Microskills.