1. CASE REPORT
Dr. Claudia Dulea

2. History
82 yrs old male :Laparotomy, ?Appendicectomy
 PMH: HTN,NIDM (diet control),
Diverticulosis,Ostheoarthritis
Allergies:NKDA
Reg med:
atenolol,lansoprazole,simvastatin,
indapamid
Examination: SR, no chest pain, no IHD, no SOB,
chest clear,BP:120/65,HR-90,O2 sat.94% r a
Airway: Mallampati II
Bloods:Hb.10,8,Na:138,K:3.1,(had replacement on
the ward)U:8,3,Creat:91,Plts:286,INR:1,3,WCC
17.1,CRP:27
Glucose:7.4,CXR and AXR-N

3. Pre-assessment

4. General Anaesthetic
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Slow iv induction-Propofol,
Tube size 8,grade 1 view
Med. during procedure:
fentanyl:150mcg,rocuronium 40+10
mg,morphine:4+2mg,amoxycillin:1
g,gentamicin
160mg,metronidazole :
500mg,dexa,ondansentron,paraceta
mol
Patient stable during procedure.

5. General anaesthetic

6. 
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Operation was more extensive than
expected :Laparotomy became Right
Hemicolectomy,for ascending colon
tumor, HDU bed booked and surgeons
asked for CVC line for TPN.
Half way trough the procedure discussed
with consultant oncall, told happy to do
case and CVC line by myself, as patient
stable and planned to ask Reg to do post
TAP blocks.

7. Description
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As soon as procedure finished, patient
maintained under anaesthetic for TAP
blocks and CVC insertion, which were
done in the same time.
Table head tilt, and Right side of the neck
exposed
Went scrubbing while ODA prepared
everything for CVC insertion and TAP
blocks

8. CVC insertion
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Seldinger technique, aseptic, used GGHM, skin
desinfectionx2,sterile drape applied, catheter and
guide wire checked, IJV identified with
ultrasound, needle with syringe inserted under
direct vision ,blood on aspiration, guide wire
passed trough, syringe removed, dilator passed
over guide wire, skin cut, dilatation achieved,
dilator out and catheter inserted over guide wire
and inadvertently guide wire pushed into
circulation, realized immediately procedure
stopped and everyone present (Reg and ODA)
informed.
Started to chase the wire everywhere including
with ultrasound inside the patient…
Patient monitored continuously ,no signs of
arrhythmias

9. CVC insertion
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Xray called in and guide wire identified into
femoral vein.
Consultant oncall informed
Advice from Vascular surgeon: safe over night
,guide wire to be fished in the morning by
interventional radiologist or to be transferred to
St George”s for vascular retrieval.
Surgeon informed
Vascular Reg on call in St George”s contacted for
advice: happy with plan ,nothing to be done over
night, atbx and anticoagulation.
Patient stable all this time, as being monitored
continuously

11. CVC insertion

12. CVC insertion
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TAP blocks finished to perform, under ultrasound.
Patient extubated awake, transferred to
recovery.
Observations continued to be stable, comfortable,
but patient slightly confused after anaesthesia,
and after half an hour transferred to HDU for
close monitoring over night.
I checked patient every hour: stable, still mild
confused, up till morning.
Critical incident form filled in.
Everything documented into notes
Plan to tell patient and NOK morning and arrange
guide wire retrieval

13. Observations

14. Morning
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Next morning discussed with a Anaesthetic
Consultant, and patient care was transferred to
her care
Patient and NOK informed
Unable wire retrieval at our hospital, patient to be
transferred to St. George”s with an anaesthetist
and referral letter
Arterial line inserted for monitoring during
transfer
Vasc Reg expecting patient
Patient stable and comfortable during transfer

15. Retrieval
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Guide wire still into femoral vein
Interventional radiologist:11 TR right IJV inserted,
guide wire fished out, pressure dressing applied,
no events, no further management plans.
Patient transferred back to our hospital for
recovery post laparotomy.
Surgeons not requested another CVC as pt
tolerated oral fluid intake day 2 post op
Patient remained in HDU for 3 more days, then
transferred on the ward, where made full
recovery, being discharged 10 days post op with
OPA in 1 month time.

16. Reflection
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What could I have done different?
-Everything…Be more careful
…Never be too confident
… Never do the case by myself
Reflected on my technique…over and over again…
Next 10 CVC done under direct supervision
Feedback: nothing wrong with my technique but
need more focusing when doing any kind of
procedure
Seen internet case reports and thought about a
plan trying to prevent happening again:
Discussed with Educational Supervisor
Discussed with College Tutor

17. Reflection
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Plan:
1)Present the case at Clinical Governance Meeting
-discussed with Consultants in charge of
teaching…
2)every August power point presentation of CVC
insertion
3)Video about CVC insertion under ultrasound+
prevent or deal with complications
4)?make CVC insertion part of Basic
Competencies?
5)Start using in theatre of a standard form (like in
ICU), where the box of verbal confirmation of
wire out has to be ticked

18. Reflection
I know a lot of people will judge, maybe I
will have done the same: How can you
loose a 35 cm wire?
 Answer :EASY…few seconds of not
focusing and disappears…
 Main Lesson
“ NEVER LET GO OF THE WIRE”
I have learned my lesson now but with what
sacrifice?
Learn from my mistake…keep hold of wire
at all time
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