Medicine Surgery

I’m sure glad that wasn’t my complication

Via Kevin, MD, a picture of a complication I hope I never have:

Central line complication

A description of the complication:

A 40-year-old man with Crohn’s disease underwent an uncomplicated operation involving lysis of adhesions that were causing intestinal obstruction. After surgery, a cardiologist inserted a central venous catheter through the left subclavian vein. No problems with catheterization were noted. Three weeks later, after discharge, mild pain and edema developed in the patient’s right lower leg. He was treated with antibiotics for 1 week, and his symptoms diminished. Six months after the operation, the patient presented with posterior cervical pain. A guide wire, presumably lost during the insertion of the central venous catheter, was protruding from the back of his neck (Panel A, arrow). A computed tomographic scan showed the fractured guide wire in the central venous system (Panel B, arrows). The wire protruding from the back of the neck was removed easily; however, it was difficult to remove the part of the wire involving the saphenous vein, and an open procedure with general anesthesia was required. The involved leg vein was thrombosed and occluded. At 1 year of follow-up, the patient was free of symptoms and signs.

This is one of the stranger complications of a central line that I’ve ever seen. Basically, the way a central line is inserted is by the Seldinger technique. In brief, a needle is introduced into the vein; a guidewire is threaded through the needle; the needle is removed; and the catheter is threaded over the wire into the vein, after which the wire is removed. Losing the guidewire is a potential technical complication, and when that happens it’s necessary to take the patient to angiography to find and retrieve the wire. However, I just don’t see how anyone who knows what he is doing can possibly fail to realize that he has lost the wire. It is possible for the wire to break, but this usually only happens after a very difficult insertion with lots of mucking about, and after such an insertion it is incumbent upon the surgeon to examine the wire after removing it and make sure the entire wire was retrieved. If there is any suspicion that the wire may have broken off (and, believe me, given the gentle curve into a “J” shape at the end of the wire, which is designed to make it less likely that the wire can perforate the vein as it’s threaded, it’s not hard to tell if the wire has broken), the appropriate X-rays (chest, abdominal, etc.) must be obtained to look for it.

It just goes to show that even relatively simple procedures can have serious complications, or, as I’ve said before, there’s no such thing as “minor” surgery. Central lines are no different.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

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