Two cases are described where catheters or wires were inserted and they did not end up where they were intended.  The figure, from the second case, shows the entangled wires removed from the dilated second guidewire site. (Image source: Anesthsia & Analgesia)

Two cases are described where catheters or wires were inserted and they did not end up where they were intended. The figure, from the second case, shows the entangled wires removed from the dilated second guidewire site. (Image source: Anesthsia & Analgesia)

Many have written about complications related to central line or Swan-Ganz catheter placement. This month’s issue of A&A Case Reports has three reports describing issues related to the catheters: two discussing placement and one examining removal. In the first case, Dr. Dirk J. Varelmann and Dr. Jan N. Hilberath, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, describe a flow-directed pulmonary artery catheter (PAC) that was looped in the pulmonary artery in the article titled “Misplacement of a Pulmonary Artery Catheter.” The patient had end-stage dilated cardiomyopathy and had an automatic implantable cardioverter defibrillator (AICD) for ventricular tachycardia. The patient was scheduled to undergo implantation of a left ventricular assist device. A PAC was placed through a 9F introducer sheath inserted through the right internal jugular vein. The central venous pressure (CVP) sensor of the pulmonary artery catheter showed a right ventricular pressure trace when it was advanced to 55 cm and a pulmonary artery pressure waveform when it was advanced to a depth of 65 cm. However, the pulmonary artery transducer consistently showed a normal CVP waveform. The providers initially thought that the transducers had been switched and were relabeled. A chest radiograph after the procedure showed that the catheter had looped, with the distal tip of the pulmonary artery catheter projected over the AICD coil in the superior vena cava, and the central venous orifice projected into the pulmonary artery. After reinsertion of the catheter, measurements were as expected.

In the second case, Dr. Yasunori Mishima, Department of Anesthesiology, Kurume University School of Medicine, Kurume, Japan, and colleagues, describe how two wires inserted into the right internal jugular vein became tangled in the article titled “A Significant Complication that Occurred During Insertion of Dual Guidewires into the Right Internal Jugular Vein for Central Venous Catheterization.” The patient had a ruptured thoracic aorta and was scheduled for emergency aortic arch replacement. After anesthesia induction, a 22-G venous catheter was inserted into the right internal jugular vein using ultrasound, and a guidewire (GW1) was inserted. Next, a 20-G venous catheter was inserted about 1 cm cranial to the first puncture site. Mild resistance was noted during catheter insertion, though there was backflow of venous blood. A second guidewire was inserted. After dilation, a catheter was inserted over the first guidewire. However, the first guidewire could not be removed after the catheter was passed. The catheter was removed, but even then the first guidewire could only be withdrawn to within 5 cm of the skin. It was then noted that the second guidewire could not be removed either. The puncture site of the second guidewire was dilated. Both first and second guidewires were removed through the second puncture site. It was noted that second guidewire had penetrated the first guidewire about 5 cm from its tip between the steel core and outer wire. You couldn’t do this if you tried!

Chest radiographs are routinely obtained after central venous catheter insertion in the ICU. The same is not typically done in the operating room. Perhaps that practice should change. Also, it’s difficult to show that outcome improves after pulmonary artery catheter insertion. At least in the operating room, doesn’t transesophageal echocardiography (TEE) provide the same information, if not more? Dr. Annemarie Thompson, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, notes in the accompanying editorial comment that TEE is also useful for visualizing catheters and wires and if it had been used, it could have helped guide the wires and catheters, precluding the complications described.