Guidewires Left Behind

CHPSO is beginning to receive reports of retained surgical items. The goal is to understand better the causes and steps to reduce their incidence. Of the initial 20 reports, only two involved sponges or instruments; the rest were of miscellaneous items, some of which were left intentionally. For example, a micro-needle that fell into the incision may be left behind when the risks involved with attempted retrieval are judged to outweigh the risk of retention.

Several of the reports involved guidewires for central venous catheterization. In these cases, a central venous line was placed under emergent conditions, and it appears that the wire was not secured in one hand while the other advanced the catheter over the wire.

Retained intravascular guidewires are typically retrieved via a percutaneous intravascular procedure. Retrieval is important, as guidewires tend to migrate centrally and may provoke cardiac arrhythmias. Also, a retained guidewire can act as a microwave antenna during an MRI, creating unwanted local heating. If the guidewire is left in for a prolonged period, it may become fibrosed to the vessel wall or cardiac chamber and difficult to remove.

We do not know if the incidence of retained guidewires is changing. However, one recent patient safety initiative may have, as an unintended consequence, increased the risk of retained guidewires.

Efforts to reduce sepsis mortality include early placement of a central venous line to guide fluid therapy. Given the urgent need for central venous catheterization, more physicians are placing these lines than before. Some of the physicians may have less experience with the procedure and may be more prone to losing the guidewire when distracted or rushed by the urgency of the situation. We suggest that organizations with an early sepsis treatment program evaluate whether they need to include additional training or other support for less experienced physicians (e.g., an intra-procedure checklist) to address this potential risk. CHPSO also invites those with models for support of safer central venous catheterization to submit those for sharing with others.