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| LETTERS TO EDITOR |
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| Year : 2021 | Volume
: 22
| Issue : 2 | Page : 192-193 |
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A migrated guidewire of a hemodialysis catheter in a COVID-19 patient
Sarfaraz Ahmad1, Shagufta Naaz1, Neeraj Kumar2, Amarjeet Kumar2
1 Department of Anesthesiology, AIIMS, Patna, Bihar, India
2 Department of Trauma and Emergency, AIIMS, Patna, Bihar, India
| Date of Submission | 23-Mar-2021 |
| Date of Decision | 28-Apr-2021 |
| Date of Acceptance | 02-May-2021 |
| Date of Web Publication | 29-Sep-2021 |
Correspondence Address:
Dr. Shagufta Naaz
Department of Anesthesiology, AIIMS, Phulwari Sharif, Patna - 801 507, Bihar
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/TheIAForum.TheIAForum_44_21
How to cite this article:
Ahmad S, Naaz S, Kumar N, Kumar A. A migrated guidewire of a hemodialysis catheter in a COVID-19 patient. Indian Anaesth Forum 2021;22:192-3 |
Sir,
One of the most challenging comorbidities associated with COVID-19 patients is chronic kidney disease (CKD). We often have to perform dialysis, and a catheter is placed to obtain vascular access. A rare but not unusual complication is the lost guidewire during dialysis catheter placement.[1],[2],[3] Wearing a PPE kit during such procedures increases discomfort and may contribute to such complications.
Here, we report a case of the migrated guidewire in a 48-year-old female who presented to our intensive care unit to manage severe acute respiratory distress syndrome associated with COVID-19 infection and having CKD stage III. The patient was intubated and on a mechanical ventilator. Left side femoral vein cannulation was performed under ultrasonography guidance for dialysis. Unfortunately, during insertion, the guidewire slipped from the hand and could not be withdrawn after the hemodialysis catheter insertion. It migrated inside the body. It happened because of the poor visibility as there was fogging in the goggles of the PPE. The diagnosis of lost guidewire was confirmed with serial radiological studies [Figure 1]. The guidewire's distal end was at the inferior vena cava and proximal end at the femoral vein near the inguinal ligament. The cardiothoracic and vascular surgery (CTVS) surgeon anticipated that the guidewire was stuck at the site and was not likely to migrate further. We performed the right-sided femoral vein cannulation, and dialysis was done urgently with the guidewire in situ, given very high urea and creatinine levels. The migrated guidewire was removed subsequently by giving incision on the left femoral vein at the bedside by the CTVS surgeon under local anesthesia. Thromboembolism of vessels was ruled out using color Doppler. The patient was already on prophylactic anticoagulant therapy as per the protocol of the institute for COVID-19 patients with severe disease. She was being administered unfractionated heparin 5000 units subcutaneously twice daily due to deranged renal function. Further course was uneventful.
The migration of guidewire, although usually asymptomatic, may cause arrhythmias, damage of vessels, and thrombosis. The usual attribute for a lost guidewire is operator inexperience, inattention, inadequate supervision, and overworked staff and doctor. The guidewire loss sign comprises a missing guidewire, resistance to insertion, poor venous blood backflow, and x-ray film detection.
Some practical preventable measures taken are to hold the guidewire's proximal end with a needle holder until the guidewire is removed from the vessel. The guidewire should never be forced when any resistance is encountered. We should always look for the integrity of the guidewire after its removal to rule out any breakage. Keeping the possibility of guidewire migration in mind, we should try not to introduce >18 cm, taking it as the upper limit of safe guidewire insertion in an adult patient.
Furthermore, excessive sweating (100%), fogging of goggles, spectacles, or face shields (88%), suffocation (83%), fatigue (75%), and headache due to prolonged use (28%) are common problems associated with using PPE kits.[4] In India, being a country with hot and humid conditions, the problem is even more daunting. Some improvement in materials (that cause less heat stress) and designs of PPE kit (to cause less fogging) is required so that it is comfortable for the physicians to carry out various procedures and the safety of patients is not compromised. Policies regarding PPE use are scheduling longer breaks, increasing the chance to hydrate, and a cool environment may help.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Taslimi R, Safari S, Kazemeini A, Aminian A, Joneidi E, Larti F. Abdominal pain due to a lost guidewire: A case report. Cases J 2009;2:6680.  |
| 2. | Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: Mishap or blunder? Br J Anaesth 2002;88:144-6. |
| 3. | Abuhasna S, Abdallah D, Ur Rahman M. The forgotten guide wire: A rare complication of hemodialysis catheter insertion. J Clin Imaging Sci 2011;1:40. [ PUBMED] [Full text] |
| 4. | Agarwal A, Agarwal S, Motiani P. Difficulties encountered while using PPE kits and how to overcome them: An Indian perspective. Cureus 2020;12:e11652. |
[Figure 1]
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