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La cateterizacion venosa central (CVC) debe ser realizada por profesionales medicos capacitados y/o supervisados en caso de inexperiencia, siguiendo estrictos protocolos de actuacion para prevenir incidentes. La incidencia de complicaciones es de hasta un 15%, algunas potencialmente mortales; estas pueden ser dificiles de evitar, mientras que otras se producen por errores humanos y por lo tanto son susceptibles de intervencion y totalmente evitables. Presentamos el caso de una canalizacion de una via central con perdida de alambre-guia de manera inadvertida, descubierta de forma accidental en estudio de imagen por evolucion torpida en postoperatorio, asi como la propuesta de un checklist para su prevencion. ABSTRACT Central venous catheterisation (CVC) must be must be conducted by professionals who have appropriate knowledge and/or monitored if they´ re not skilled enough, according with strict guidelines in order to prevent incidents. The incidence of complications is up to 15%, some of them potentially fatal; these may be difficult to avoid, while others are due to human failure and therefore amenable to intervention and completely avoidables. A case report of unoticed canalisation of a central line losing the guidewire is presented; discovered by accident in an image test due to torpid postoperatory evolution, as well as the proposal of a checklist to its prevention.

Pérdida inadvertida de un alambre-guía durante canalización de una vía venosa central.