title: Missed Central Venous Guide Wires: A Systematic Analysis of Published Case Reports.
abstract: OBJECTIVE
  The inadvertent loss of an entire guide wire during central venous catheterization can lead to serious patient harm and require additional investigations as well as retrieval procedures. We aimed to analyze globally published reports of lost wires during central venous catheterization to understand its possible etiology, presentation, treatment, and outcomes with an objective of finding solutions to make the procedure safer.
  
  
  METHODS
  MEDLINE, Scopus, and CINAHL, supplemented by scanning the reference lists of relevant publications.
  
  
  METHODS
  All reports describing an inadvertent intravascular loss of a complete guide wire during placement of central venous catheters published up to December 2014 were included. Reports exclusively describing the 1) retrieval method, 2) partially retained guide wires, and 3) entrapped guide wires during withdrawal were excluded.
  
  
  METHODS
  In each instance, we collected data about the method of the missed guide wire detection, the time interval between the procedure and detection, the supplementary investigations performed to confirm the diagnosis, and the risk factors associated with such events as well as the complications, the final outcome, and the wire retrieval methods used.
  
  
  RESULTS
  A systematic analysis of the accessed publications was performed.
  
  
  CONCLUSIONS
  Over the last decade, the number of reported instances of lost guide wires during central venous catheterization has increased rapidly. Unsupervised or improperly supervised insertions of the central catheters by trainees, distractions during insertions, and high workload are the main risk factors. A retained guide wire increases the risk and cost of additional diagnostic and therapeutic interventions, as well as imposing many minor-to-serious life-threatening complications. Continuing education along with simulator-based skill development, vigilant supervision, and a shared workload during out of hours working are likely to prevent such occurrences.
authors: 1Department of Anesthesiology and Critical Care, B.P. Koirala Institute of Health Sciences, Dharan, Nepal. 2Department of Anesthesiology, ESI-Post Graduate Institute of Medical Science & Research, Kolkata, India. 3Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
authors: Krishna
authors: K
authors: Pokharel
authors: Binay Kumar
authors: BK
authors: Biswas
authors: Mukesh
authors: M
authors: Tripathi
authors: Asish
authors: A
authors: Subedi
mesh_terms: D002405:Catheterization, Central Venous / Q000009:adverse effects*; D005547:Foreign Bodies / Q000453:epidemiology*; D006801:Humans