Annals ofBurns and Fire Disasters - vol. IX - n. 3 - September 1996

CENTRAL EMBOLIZATION BY A GUIDEWIRE IN A BURN PATIENT

Valero J.,(1) Barreiro J.,(1) S6ez E.(2) Vèzquez Gonzalez (3) Lòpez-Suso E.,(1) Martelo F.(1)

(1) Burns Unit, Plastic Surgery Service, Juan Canalejo Hospital, La Coruha, Spain
(2) Burns Unit, Anaesthesiology Service, Juan Canalejo Hospital
(3) Service of Cardiology, Juan Canalejo Hospital

SUMMARY. Few risks are involved in the replacement of central venous catheters when guidewires are used, but repeated practice, critical situations, and inexperience increase the possibilities of error. A case is described in which a burn patient suffered embolization of a guidewire during replacement of a central catheter. The situation was normalized percutaneously using radiographic control without affecting the patient's later evolution.

Introduction

The use of central venous catheters in burn patients is a widespread practice given the need for haemodynamic monitoring, the administration of vasoactive drugs and large volumes of liquids, and, occasionally, total parenteral nutrition. The risk of catheter infection in these patients is high, despite the observation of aseptic measures during implantation and manipulation of the catheter, and catheter replacement continues to be a routine practice. Replacing catheters using a guidewire reduces the complications arising out of implantation but the technique is not completely risk-free. In the case presented here, an entire guidewire was embolized in the venous system during replacement of a catheter through the internal jugular vein. This is an exceptional complication but it is possible that reports are not submitted because of their iatrogenic origin.

Case report

A 53-year-old male with a daily consumption of 40 cigarettes and more than 120 gm of ethanol who had suffered repeated bouts of convulsive crises and delirium tremens fell on to a low flame while in a state of severe alcoholic intoxication, suffering smoke inhalation and fullthickness burns in the buttocks, scrotum, legs, and hands, involving 12% TBSA. The patient was transferred to our Burns Unit where on admission, six hours after the accident occurred, he presented oliguria/anuria and smokeinhalation symptoms, i.e. profound perioral and perinasal burns, remains of soot in the oral cavity, and burned nasal vibrissae. A tube was inserted orotracheally and the right internal jugular vein was accessed with the introduction of a three-way catheter for perfusion. of lactated Ringer's solution, achieving haemodynamic stability and recovery of renal function. Decompressive incisions were effected on the hands and buttocks on admission, followed by fibre bronchoscoPy 24 hours post-admission which confirmed the airway damage. Over the next few days, the patient developed respiratory insufficiency and required mechanical ventilation. He also developed intolerance to enteral nutrition, and total parenteral nutrition was initiated. on the third day, the jugular catheter was changed using a guidewire, but during the replacement manoeuvre the guidewire was lost in the venous system. It was located radiologically and seen to extend from the right subelavian vein to the iliac fork (Fig. 1). The patient was immediately transferred to the haemodynamics ward where the guidewire was extracted percutaneously through the left femoral vein using a loop-type 8F catheter under radiological control ' On day 6 after admission, the burn area was slit and skin was grafted. It was necessary to amputate the left leg and the 2nd, 3rd and 4th fingers of the right hand.

Fig. 1 - Guidewire pointed by arrows in the RX thorax. Fig. 2 - Management of central venous catheter in a Burn Unit

Before surgery, the right femoral artery was accessed and the catheter located in the right internal jugular vein was replaced by another in the left internal jugular for the purpose of monitoring during surgery. The patient subsequently presented high fever and low blood pressure, leading to a diagnosis of pneumonia at the base of the left lung. The central venous catheter was replaced by a Swan-Ganz catheter, with haemodynamic support being initiated using vasoactive amines (dopamine, dobutamine, and norepinephrine). Samples of blood and urine and bronchial sweepings by telescopy and from the catheter tip were taken for cultures, and empirical antibiotic treatment was initiated with the association of ceftazidime and vancomycin. The bronchial sweepings were positive with growth of multiresistant Pseudomonas aeruginosa and the initial antibiotic treatment was replaced by imipinem and amikacin. Death ensued thirty days after admission due to multiple organ failure and sepsis.

In burns units as in other intensive care units, risk situations can arise out of human error. The patient in the case reported here required the insertion of several central venous catheters in order to administer vasoactive drugs, total parenteral nutrition and liquids and to monitor haemodynamic function and gasometric values.
The use of venous catheters is associated with numerous mechanical complications, e.g. unnoticed arterial puncture and catheterization,cervical bruising, haemothorax or pneumothorax, cardiac perforation due to inappropriate location of the central venous catheters, damage to the valve walls,' and arrhythmia, as also with infectious complications, e.g. infection of the catheter tip and related sepsis, suppurating thrombophlebitis, and endocarditis.
Although catheter change is not indicated in other groups -of patients unless there is evidence of related problems," it is routine practice in the case of burn patients. This practice is due to the high incidence of infection caused by the catheter and the presence of suppurating thrombophlebitis,11 to the difficulty of making an early diagnosis because of the almost invariable presence in extensively burned patients of a systemic inflammatory response syndrome, and to the frequent presence of other foci of infection, which makes diagnosis even more difficult. In the Burns Unit of the Juan Canalejo Hospital, in order to reduce the risk of puncturing, replacement of the catheter is carried out using a guidewire whenever there is a low degree of suspected infection and the tip of the extracted catheter is sent for microbiological analysis. If the semiquantitative culture is positive,` the replacement catheter is removed and a new venous access point is obtained through puncture in another site. Only in the case of severe limitations on venous access due to the presence of burns in the puncture area is a haemoculture technique applied through the suspected catheter, together with haemoculture of a blood sample taken from a peripheral vein.
Replacing catheters using guidewires is easy and cheap, and reduces the mechanical risks derived from punctures, without increasing risks of an infectious nature.',' Nonetheless, as shown by the case history reported here, the technique is not entirely risk-free. In addition to the possibility of losing the whole guidewire, one must also consider the embolization of fragments which may easily reach the pulmonary artery. The extraction of such fragments, even using radiographic control techniques, is difficult and occasionally thoracic surgery is required, although the risks deriving from the patient's general condition may necessitate postponement of the operation. Embolization of fragments is generally caused by unnoticed severing of the catheter during implantation, although this may also occur during withdrawal; embolization is also possible in central and peripheral catheters. Embolization of the entire guidewire is due to lack of practice in use of the technique or to situations of haemodynamic instability in a patient with poor alternative venous access, leading to errors caused by the need for rapid replacement of the catheter.
In conclusion, although replacement of a catheter using a guidewire reduces the risk factor, the procedure must be carried out by expert personnel and a separate venous access of good quality should be maintained, even if only temporarily, in order to avoid errors due to inexperience or to situations of stress in the medical staff performing the technique.

RESUME. La procédure du remplacement des cathéters veineux centraux ne présente pas de risques si l'on use des fils de guide, mais la répétition continue, les situations critiques, et l'inexpérience peuvent augmenter les possibilités d'erreur. Les Auteurs décrivent le cas d'un brûlé qui a souffert l'embolisation d'un fil de guide pendant le remplacement d'un cathéter central. La situation a été normalisée par voie percutanée en employant un contrôle radiographique, sans effets pour le décours successif du patient.

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