Abstract 231: Patient, Operator, And Procedural Characteristics Of Guidewire Retention As A Complication Of Vascular Catheter Insertion

Abstract

Introduction: Guidewire retention after intravascular catheter insertion is considered a “never event.” Prior reports attribute this complication to various characteristics including uncooperative patients, operator inexperience, off-hour or emergent insertion, and underutilization of ultrasound guidance. In this descriptive analysis of consecutive events, we assessed the frequency of patient, operator, and procedural factors in guidewire retention. Methods: All consecutive incidents of guidewire retention across 10 hospitals within the Cleveland Clinic Health System in Ohio from August 2007 to October 2015 were prospectively identified and retrospectively analyzed. Data were manually obtained from the electronic medical records and reviewed for potential contributing factors for guidewire retention including patient, operator, and procedural characteristics. Results: A total of 24 guidewire retention events were identified. Overall, the median age was 74 years, 58% were males, and the median body mass index was 26.5 kg/m 2 . A total of 12 (50%) individuals were sedated during the procedure. Most incidents (10 [42%]) occurred in internal jugular venous access sites. The majority of cases (13 [54%]) were performed or supervised by an attending. Among all cases, 3 (12%) were performed by first-year trainees, 7 (29%) by residents, 3 (12%) by fellows, and 4 (17%) by certified nurse practitioners. Overall, 16 (67%) events occurred during regular working hours (8AM - 5PM). In total, 22 (92%) guidewires were inserted non-emergently, with 2 (8%) during a cardiac arrest. Ultrasound guidance was used in all but 1 case. Conclusion: Guidewire retention can occur even in the presence of optimal patient, operator, and procedural circumstances, highlighting the need for constant awareness of this risk. Efforts to eliminate this important complication will require attention to issues surrounding the technical performance of the procedure.