Description of Event or Problem · 0
DURING THE PUG PROCEDURE, THE USER ADVANCED THE PGW (PIGTAIL GUIDEWIRE) AND IBC (INTERNAL BALLOON CATHETER) AFTER COUPLING UNTIL EXITING FROM THE MOUTH. AFTER CUTTING THE PGW, THE PROCEDURALIST WAS UNABLE TO ADVANCE THE GUIDEWIRE ANY FURTHER DUE TO RESISTANCE. SIMILARLY, RESISTANCE WAS FELT WHEN ATTEMPTING TO REDUCE THE GUIDEWIRE AT THE ABDOMINAL END. A KUB WAS COMPLETED, WHICH SHOWED THAT THE GUIDEWIRE APPEARED TO BE TANGLED OR CAUGHT WITHIN THE ABDOMEN OF THE PATIENT. AFTER ADDITIONAL ATTEMPTS TO TROUBLESHOOT AND 2 HOURS OF ROLLING/MANIPULATING THE GUIDEWIRE FROM BOTH ENDS, THE GUIDEWIRE WAS ABLE TO BE REMOVED FROM THE PATIENT WITHOUT ADDITIONAL INTERVENTION. NO FURTHER COMPLICATIONS HAVE BEEN REPORTED. THE PATIENT RECEIVED A SUCCESSFUL PEG THE NEXT DAY, NO COMPLICATIONS REPORTED. NOTE: ALTHOUGH THIS CASE DID NOT REQUIRE MEDICAL OR SURGICAL INTERVENTION TO PREVENT LIFE-THREATENING ILLNESS OR INJURY OR PERMANENT/IRREVERSIBLE IMPAIRMENT TO A BODY STRUCTURE OR A BODY FUNCTION, IF THE TEAM HAD NOT DECIDED TO CONTINUE TO TRY TO DETANGLE THE GUIDEWIRE, OTHER INTERVENTIONS MAY HAVE BEEN PURSUED, LIKE ENDOSCOPY, AS MENTIONED IN THE CUSTOMER'S COMMUNICATION. IN COMPLAINTS OF SIMILAR GUIDEWIRE TANGLING EVENTS, INTERVENTIONS SUCH AS ENDOSCOPY OR LAPAROSCOPY HAVE BEEN UTILIZED TO IMAGE OR REMOVE THE GUIDEWIRE.