Modeling the Effects of the Locked Pack Procedure to Prevent Guidewire Retention in a Clinical Setting

We read with interest the study by Mariyaselvam et al.¹  regarding the use of a locked pack (which required a guidewire to be inserted and lifted to open) to prevent guidewire retention after completion of central venous catheter insertion, and we commend them for their effort and this novel technique. The introduction of a locked pack will stimulate the search for a missed guidewire and, hence, its subsequent retrieval (if still inside the catheter). This will definitely reduce the occurrence of these rare events if the cause is retention of the whole guidewire, specifically due to operator distraction. From our experience of retained guidewires at our institution, a larger percentage of these incidents were due to other technical causes, such as breakage or inability to retract the guidewire.

In a retrospective study performed by our group, we reviewed 12,887 central venous catheter insertions over a 26-month period from 2011 to 2013.²  Of those insertions, eight involved guidewire retention. Of those eight cases, only two (25%) were caused by operator distraction. Five (63%) were due to retained fragment after guidewire breakage, and one case (12.5%) was due to inability to retract the guidewire because of impingement. Using our study data where the guidewire retention incidence was 1:1,611, we attempted to model the effects of the locked pack technique. If we remove two of the eight cases where guidewire retention was due to operator distraction, this yields a new incidence of guidewire retention: 1:2,148. Using a one-tailed z-ratio analysis, we can determine if this new ratio is significantly less. This new incidence rate is not significantly less than our initial rate of 1:1,611 (z = 0.204, P = 0.421).

Since our initial review, we have implemented an intense safety education program, and now immediate electronic confirmation of guidewire removal is required in patient charts. After reading the Mariyaselvam et al. manuscript, we reevaluated the incidence of retained guidewire through retrospective analysis of central venous catheter placements over a 26-month period from 2015 to 2017, and found three new instances of guidewire retention out of 7,558 insertions, yielding an incidence rate of 1:2,519. While this is still not a significant reduction (z = 0.319, P = 0.374), it is comparable to the reductions seen in our model implementation of the locked pack.

The authors declare no competing interests.