Fio‐guia perdido – lições aprendidas

Abstract

Central venous catheter placement is a relatively common procedure in current practice, but it is not devoid of risks. Utmost care must be taken to follow a correct technique, and only appropriately trained and/or supervised medical professionals should perform this invasive act. One of the possible complications, completely avoidable by appropriate care, is the intravascular loss of the guide wire during insertion, which is a potentially serious complication. We describe one such case.

Loss of a Guidewire During Central Venous Catheter Insertion Into the Right Internal Jugular Vein

“…It particularly showcases the surgeon's quick thinking and interdisciplinary awareness by utilizing the N-Gage, a device from a different specialty, for successful guidewire retrieval. This decision, born from an acute understanding of the device's functionality across specialties, exemplifies the importance of a broad knowledge base and the ability to apply it inventively in critical situations [6,7] The incident reinforces the value of continuous multidisciplinary training and simulation to prepare for rare and unforeseen complications. Such preparation can enable medical professionals to act decisively and innovatively, ensuring patient safety when conventional tools and procedures are lacking.…”

“…The use of a detailed equipment checklist and conducting post-insertion imaging, such as chest and abdominal X-rays, are imperative practices. When reviewed collaboratively by the team, these tools serve as additional safeguards [ 6 , 7 ].…”

“…It particularly showcases the surgeon’s quick thinking and interdisciplinary awareness by utilizing the N-Gage, a device from a different specialty, for successful guidewire retrieval. This decision, born from an acute understanding of the device’s functionality across specialties, exemplifies the importance of a broad knowledge base and the ability to apply it inventively in critical situations [ 6 , 7 ]…”

Forgotten guidewire: A case report

“…Usually, final positioning of venous intravascular foreign bodies occurs in larger vessels, such as the innominate vein, superior/inferior vena cava, and pulmonary arteries, or in cardiac chambers, such as the right atrium and ventricle [ 8 ].…”