Respectful Insolence

I’m sure glad that wasn’t my complication

Via Kevin, MD, a picture of a complication I hope I never have:

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A description of the complication:

A 40-year-old man with Crohn’s disease underwent an uncomplicated operation involving lysis of adhesions that were causing intestinal obstruction. After surgery, a cardiologist inserted a central venous catheter through the left subclavian vein. No problems with catheterization were noted. Three weeks later, after discharge, mild pain and edema developed in the patient’s right lower leg. He was treated with antibiotics for 1 week, and his symptoms diminished. Six months after the operation, the patient presented with posterior cervical pain. A guide wire, presumably lost during the insertion of the central venous catheter, was protruding from the back of his neck (Panel A, arrow). A computed tomographic scan showed the fractured guide wire in the central venous system (Panel B, arrows). The wire protruding from the back of the neck was removed easily; however, it was difficult to remove the part of the wire involving the saphenous vein, and an open procedure with general anesthesia was required. The involved leg vein was thrombosed and occluded. At 1 year of follow-up, the patient was free of symptoms and signs.

This is one of the stranger complications of a central line that I’ve ever seen. Basically, the way a central line is inserted is by the Seldinger technique. In brief, a needle is introduced into the vein; a guidewire is threaded through the needle; the needle is removed; and the catheter is threaded over the wire into the vein, after which the wire is removed. Losing the guidewire is a potential technical complication, and when that happens it’s necessary to take the patient to angiography to find and retrieve the wire. However, I just don’t see how anyone who knows what he is doing can possibly fail to realize that he has lost the wire. It is possible for the wire to break, but this usually only happens after a very difficult insertion with lots of mucking about, and after such an insertion it is incumbent upon the surgeon to examine the wire after removing it and make sure the entire wire was retrieved. If there is any suspicion that the wire may have broken off (and, believe me, given the gentle curve into a “J” shape at the end of the wire, which is designed to make it less likely that the wire can perforate the vein as it’s threaded, it’s not hard to tell if the wire has broken), the appropriate X-rays (chest, abdominal, etc.) must be obtained to look for it.

It just goes to show that even relatively simple procedures can have serious complications, or, as I’ve said before, there’s no such thing as “minor” surgery. Central lines are no different.

Comments

  1. #1 Justin Moretti
    January 24, 2007

    Good God, am I ever glad I’m not putting those things in any more!

    But.. if it was lost in the subclavian vein, how the Hell did it ever come to protrude from the back of his NECK? And is that really the whole guidewire extending practically down from his neck to his pelvis?

    I was never the world’s best putter-inner of CVC lines, but this takes the cake…

  2. #2 Kiwiwriter
    January 24, 2007

    Crohn’s is no joke. My brother got it at age 13, and it caused endless agony for him and our family. It tore his guts apart and our family into pieces.

    14 years ago, he had 12 inches of intestine removed. The doctors said it looked like burned charcoal.

    The worst part of it was the brutish insensitivity my brother received from our magnificent educators at his schools. Not knowing Crohn’s from Strawberry Rash, they tried to make him do gym, ridiculed him for absences, and wouldn’t even give him an elevator pass. They marked him down as “worthless” and “lazy.”

    When my mother complained to the principal, he said a lot of Latin phrases. So she said two words. “Lawsuit” and “newspapers.”

    The principal said, “Hey, wait a minute.”

    He got his elevator pass. But he dropped out of high school anyway, to start college. He became a first vice president at Prudential, and is now an independent consultant.

  3. #3 Sid Schwab
    January 24, 2007

    Likewise, I find it unfathomable that a fractured wire wouldn’t be noticed at the time. I imagine the literature abounds with more stories: I once encountered a central feeding line and a Swan-Ganz catheter that had become literally knotted in the right ventricle. A very skillful radiologist undid the Gordian thing.

  4. #4 Nat
    January 24, 2007

    I wonder what time the central line was put in? My guess is about 3am.

    I also wonder about how long the Cardiologist had been awake? My guess longer than 20 hours or he had just been woken up from the on call room within the past 10 minutes.

  5. #5 Orac
    January 24, 2007

    I once encountered a central feeding line and a Swan-Ganz catheter that had become literally knotted in the right ventricle. A very skillful radiologist undid the Gordian thing.

    I’ve heard of cases where Swann-Ganz catheters got all knotted up in the ventricle, but I’ve never seen it happen.

  6. #6 jujuquisp
    January 25, 2007

    As an anesthesiologist who places these things all the time perioperatively, I find this complication hard to believe. Utter incompetence is the only thing that comes to my mind.

  7. #7 Crosius
    January 25, 2007

    And I thought it was unpleasant when the darn thing kept going up into my neck, instead of down towards my heart. There go my hackles – thanks for the memories.

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