==== Front Indian J Crit Care MedIndian J Crit Care MedIJCCMIndian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine0972-52291998-359XMedknow Publications & Media Pvt Ltd India IJCCM-22-56110.4103/ijccm.IJCCM_93_18Letters to the EditorLoss of Guidewire Schummer Wolfram 121 Friedrich Schiller University Jena, Jena, Germany2 HELIOS Spital Überlingen, Überlingen, GermanyAddress for correspondence: Dr. Wolfram Schummer, HELIOS Spital Überlingen, Härlenweg 2, 88662 Überlingen, Germany. Friedrich Schiller University Jena, Jena, Germany. E-mail: wolfram.schummer@web.de7 2018 22 7 561 562 Copyright: © 2018 Indian Journal of Critical Care Medicine2018This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. ==== Body Sir, A male patient suffering from septic shock was referred to the university Intensive Care Unit from another hospital. Here, a triple-lumen central venous catheter (CVC) was placed, through the right internal jugular vein, using the Seldinger technique. All three ports were aspirated and flushed. The inlying right subclavian CVC was removed. The entire procedure was described as unproblematic, and a bedside chest X-ray was ordered [Figure 1]. Unfortunately, this was misinterpreted. Figure 1 Guidewire (arrow) on bedside chest X-ray, below level of central venous catheter tip As no source for the sepsis could be identified, a computed tomography scan was performed the next day. Surprisingly, hyperdense reflexes were observable in the right heart, most likely indicating a retained guidewire that had inadvertently not been pulled out during CVC placement [Figure 2]. Such inattention-related incidences can result in a variety of potentially life-threatening cardiovascular morbidities.[1] Accordingly, such lost guidewires should be removed as quickly as possible. Figure 2 Guidewire in the right heart (arrows indicate reflexes of guidewire) Interventional radiology is the recommended method.[2] In this case, the guidewire was caught by a gooseneck snare, passed through the femoral vein using radiographic control, and was removed along with the vascular sheath [Figures 3 and 4]. Figure 3 Aligning of guidewire (arrow) Figure 4 Gooseneck snare with extracted guidewire Fortunately, the incidence of lost guidewires is rare; however, in one study, it was calculated to be 0.05%.[3] TAKE HOME MESSAGES Not losing guidewires is of the utmost importance While performing central venous access, always hold onto the wire If the wire does get lost, it is important to handle the incident appropriately (i.e., identification on chest X-ray and removal by means of interventional radiology). The patient's wife consented to publication of this letter. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. ==== Refs REFERENCES 1 Schummer W Schummer C Gaser E Bartunek R Loss of the guide wire: Mishap or blunder? Br J Anaesth 2002 88 144 6 11881872 2 Egglin TK Dickey KW Rosenblatt M Pollak JS Retrieval of intravascular foreign bodies: Experience in 32 cases AJR Am J Roentgenol 1995 164 1259 64 7717243 3 Omar HR Sprenker C Karlnoski R Mangar D Miller J Camporesi EM The incidence of retained guidewires after central venous catheterization in a tertiary care center Am J Emerg Med 2013 31 1528 30