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Objective: To report the experience of a multiprofessional team on the management of an adverse event after the insertion of a peripherally inserted central catheter (PICC) because of the retention of the metallic guidewire. Method: An experience report concerning an occurrence at a general hospital in the city of Guarulhos, Sao Paulo, Brazil, in November 2015. Results: Description of the case of a 1-year-old infant, with hemophilia and neuropathy, who had its guidewire held after the insertion of a PICC 3F in the forearm without incidents, which made its removal impossible. Radioscopy revealed that the guidewire was curled up and had to be surgically removed. Conclusion: The surgical procedure was successful. There was no blood loss in the operating field. The infant recovered well, without any consequences detected because of the complication. The manufacturer was notified of the event. This case served as a learning experience for the multiprofessional team.

Enovelamento do fio guia em cateter central de inserção periférica (PICC): rara complicação.