Dilating issues with central line

[beavis]

Hello all,

QUESTION - I've had a run of central lines lately where the dilator will not advance. It gets jammed/kinked just subQ, without getting to the actual vessel. The wire will bend and the dilator tip will get frayed. I've done ~1000 central lines, and I never really had this issue until the past few months.

What am I doing wrong??

Thought I could get multiple opinions from the crowd here!

Thanks!

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[deleted126335]

Most likely ineffective nick with the blade.


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[Wiscoblue]

Make a good cut with the blade. Once the tip is frayed you just have to open a new kit

 

[Jimmy Chitwood]

I concur with the above. Almost definitely making an ineffective nick before dilating. It is harder than you think to dilate skin.

 

[pjl]

Hello all,

QUESTION - I've had a run of central lines lately where the dilator will not advance. It gets jammed/kinked just subQ, without getting to the actual vessel. The wire will bend and the dilator tip will get frayed. I've done ~1000 central lines, and I never really had this issue until the past few months.

What am I doing wrong??

Thought I could get multiple opinions from the crowd here!

Thanks!

Which line type?

 

[BobBarker]

Put some traction on the skin and rotate the dilator as you push it in.

 

[drmwvr]

After 1000 lines, guessing you know how to nick the skin... had a similar problem with the arrow MAC dilator. They were frayed at the tip if not imperforate right out of the kit. Sent tracking numbers etc. thru appropriate channels. Never found out what the issue was, but haven't seen the problem recently.

 

[Doctor4Life1769]

Make sure the skin is properly cut without leaving an area of skin not cut that interferes with dilator.

 

[Noyac]

Everyone here is on the mark. It is a 99% chance that the skin nick is your issue. But nobody is telling you their nick technique. Here's mine which I am sure is the same as most everyone here.
Wire is in and I load the dilator over the wire.
Advance to just above the skin and grab the knife
Place tip directly adjacent to the wire ( if you leave a small tag of skin btw the wire and your cut it will be difficult,t to advance the dilator)
Stab the knife at least half way into the skin making what seems to be a larger than necessary incision. Yes it bleeds. But you are ready to advance the dilator immediately.
Advance the dilator half way, it is unnecessary to advance the entire length of the dilator.
Pull back and occlude the skin nick with a finger while removing the dilator and loading the catheter.

I assume you are referring to the IJ location. If using the SC location then bury the scaple and the dilator.

 

[Planktonmd]

A common reason for that problem is attempting to advance the dilator through the body of the SCM muscle which means you are cannulating the IJ too low in the neck.
Go a little bit higher.

 

[2ndyear]

A common reason for that problem is attempting to advance the dilator through the body of the SCM muscle which means you are cannulating the IJ too low in the neck.
Go a little bit higher.

I've noticed since ultrasound I always end up lower than I'd like. I have to consciously force myself to move more cephalad. It's easy to forgo surface landmarks and focus on the picture.

 

[pjl]

If you truly have done a thousand lines you know what to do and most likely you either changed technique, or your equipment is different.

The reason I asked the line type is that we had a batch of the 9 fr double lumen introducers that had a bit of a wrinkle on the tip. Those just didnt dilate right and had to be trashed.

For the learners:
For skin nicks, I use the blade up to the blue part for the 9 french, 1/2 blade for standard triple lumen or quad lumen. Blade always facing away from the carotid, back of blade scraping on the wire so there is no skin bridge.
Just like the others, I immediately put my left hand finger on the incision right after the blade exits. Then proceed.

 

[beavis]

I really appreciate all of the advice!

Skin knick was my first thought, but I have always been generous. The first few times it happened I made sure that there was no skin tag between the knick and the wire. Standard double-lumen/triple-lumen kits -- can't blame it on the equipment. Dilators don't appear frayed prior to insertion.

I think Plankton might be on the right track -- I'll make a conscious effort to look at landmarks first, then US (and to avoid the SCM).

The only other issue I could think of is that I did a peds fellowship doing central lines through supple-baby-skin, and I did not do many adult lines during that time. My current gig includes more adult lines than peds.

Either way, I was getting so damn frustrated with the fraying dilators and bending wires that I wanted the ask for advice from everyone's pooled experience. Thanks again for your time!

 

[Impromptu]

I know this isn't what you wanted to talk about, but in the nicest possible way, I am questioning the 1000 central lines number for a resident or even a new attending. In my mind I commonly overestimated the number of procedures I had done, which is why I am so grateful that I was in the habit of recording all of them in residency and have continued doing this as an attending. Now in my ever expanding document I can use Ctrl-F and find out how many of any procedure I have done.

But maybe I am projecting my own numbers onto you. If you have really dont about 1000 CVCs, then congratulations. That is quite an accomplishment.

As others have said, the skin nick is the most likely cause for difficulty dilating. I place my blade directly on my wire (sharp side away from wire) and follow it in with what always looks like too deep of a cut. You want to do it with just 1 cut, as I don't think multiple cuts will give much benefit.

I like to make sure that my wire is freely movable during the insertion so that I don't use it as a wire cutter on the vessel. But worrying about that I was at first too timid with the force I was using trying to dilate. With experience I have learned an appropriate amount of force to use in different people.

 

[Arch Guillotti]

I know this isn't what you wanted to talk about, but in the nicest possible way, I am questioning the 1000 central lines number for a resident or even a new attending. In my mind I commonly overestimated the number of procedures I had done, which is why I am so grateful that I was in the habit of recording all of them in residency and have continued doing this as an attending. Now in my ever expanding document I can use Ctrl-F and find out how many of any procedure I have done.

1000 lines is nothing. Blade has done at least 20,000 - none of which have taken over 5 minutes, all the while running 4 rooms etc etc etc

 

[fakin' the funk]

1000 lines is nothing. Blade has done at least 20,000 - none of which have taken over 5 minutes, all the while running 4 rooms etc etc etc

The key to his success is doing the lines one-handed while the other hand is used to post abstracts on SDN.

 

[deleted171991]

The key to his success is doing the lines one-handed while the other hand is used to post abstracts on SDN.

Not to mention the third.

 

[Planktonmd]

1000 lines is nothing. Blade has done at least 20,000 - none of which have taken over 5 minutes, all the while running 4 rooms etc etc etc

I think the number is now in the Millions!