An earlier post for AA2day described cases of guidewires inadvertently left in patients. In a case report titled “Inadvertent Intrathecal Placement of a Pulmonary Artery Catheter Introducer,” which was published in this month’s issue of Anesthesia & Analgesia, Dr. Marcel Vercauteren, Department of Anesthesiology, University Hospital Antwerp, Edegem, Belgium, and co-authors describe a patient who, during anesthesia for intended coronary artery bypass grafting, underwent insertion of a large bore intrajugular vein catheter that inadvertently traveled into the intrathecal space.
Whether the needle placed before insertion of the guidewire might have punctured the intrathecal space, the guidewire or needle might have penetrated the jugular vein, a vertebral vein was cannulated followed by penetration of the vessel wall, the guidewire might have traveled posterior to the carotid artery, penetrating the prevertebral fascia and scalenus anterior muscle to enter the intervertebral foramen of C6 to 7, or a false passage might have occurred is unclear. Though the majority of complications that occur after attempted cannulation of a central venous catheter are caused by inexperience, this was not the case in this report. Most complications also are seen when multiple attempts at cannulation placement are required and for this patient, the authors did indeed attempt placement three times.
The authors did not use ultrasound imaging to assist in catheter placement, though it is unclear whether or not the event would have occurred if ultrasound had been used. Clear fluid was obtained when the catheter was aspirated. The catheter was then removed and anesthesia was discontinued. A lumbar drain was inserted to monitor CSF pressure and the presence of blood. Initially the patient did have minor paresthesias in the right hand that resolved 4 days after the event. One month later, the patient was readmitted for the surgery that was initially intended. The multidetector computed tomography scan shows a dramatic image. Though unusual, others have also described the same complication.
So, why do we present this here? First, as noted in a previous post, never events can happen to anyone who is practicing anesthesia specifically and medicine more generally. Second, this event was fascinating and we felt it would also be interesting for you, the reader.