Central Line: Advice on Making the Nick

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I'm always so scared to cut the damn wire that I sometimes realize I've made a nick unconnected to the actual puncture site. Any advice on making the nick?
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Angry Birds said:
I'm always so scared to cut the damn wire that I sometimes realize I've made a nick unconnected to the actual puncture site. Any advice on making the nick?
Click to expand...

I keep the guidewire in the needle and then make the nick on top of the metal needle. This provides protection to the guidewire and allows me the flexibility to make the nick large or deeper without having to worry about anything else. I then pull the needle out and introduce the dilator.
 
Scared to cut the wire? What are you using... a Claymore sword?


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Has anyone read a case report of losing a guidewire due to it being cut during CVL insertion?

Next time you have a spare kit try cutting the wire using the supplied scalpel. My guess is it takes multiple "sawing" motions or a single high velocity/tension "swipe" to cut the wire which hopefully you will not be doing during line placement.

FWIW I keep the blade oriented anteriorly, keep the tip of the 11 blade anterior to the wire, insert approx 3-4 mm, and increase the skin incision while withdrawing the scapel. Never had a problem.
 
I feel like that is hard to do (cut the wire). Regardless what I do is direct the sharp edge of the blade away from the wire with the point of the #11 blade touching skin right where the wire is going in. Never had an issue


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Keep the blade on top of the wire with the sharp end away from the wire. Don't cut along the skin but stab i.e. Just insert the blade deeper through the soft tissue rather than moving it across the skin. The shape of the blade will will create the required horizontal space.


Also try taking the blade and cutting the wire with it on a spare kit. If you can do it upload it here.


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I personally cut with the sharp edge pointing away and stab. It's definitely worth it to make a generous cut. Nothing worse then getting access and then having to start over because you kinked your guidewire attempting to dilate. I've seen it happen too many times.
 
I make the nick with the guidewire in the needle, and I slide the scalpel blade down the side of needle oriented perpendicularly... if that makes sense. The blade is in contact with the needle.
 
goodoldalky said:
I make the nick with the guidewire in the needle, and I slide the scalpel blade down the side of needle oriented perpendicularly... if that makes sense. The blade is in contact with the needle.
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Can you explain that a bit more? I understand the first part but not the perpendicular part. Thanks!
 
ucfknight407 said:
I personally cut with the sharp edge pointing away and stab. It's definitely worth it to make a generous cut. Nothing worse then getting access and then having to start over because you kinked your guidewire attempting to dilate. I've seen it happen too many times.
Click to expand...

But doesn't the sharp edge pointing away create the island to begin with ? I feel like now I'm going to point the sharp edge toward the wire, with the needle still there for protection and also with the knowledge that the guide wire won't cut anyways without a Claymore sword.
 
i dont know if uve ever tried to cut a wire, but its damn near impossible. i forget what we were doing exactly-- but we needed to cut one. needless to say it took 10 minutes and never got a clean cut.

Sent from my Pixel using Tapatalk
 
If you occasionally make nick's unconnected to the puncture hole, aside from passing blade along the steel needle another way is to put caudad traction (for an IJ) with your non-dominant hand index/middle finger while simultaneously using your thumb to bend the wire sort of in a mini arc. This turns your puncture hole into a more obvious defect that you then place the tip of your blade in (under the wire, I know, that sounds odd). Then just glide the blade along the underside of the wire. I direct my blade perpendicular to the course of the wire with cutting edge lateral but that's mainly just for potential scar/healing/cosmetic benefit.

And as I'm sure we're all aware, too big a nick at worst requires an extra suture or purse string, but too judicious a nick can turn into a bad time with a dilator really quickly.
 
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I load the dilator onto the guidewire and bring it to the skin surface and then make the nick.


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You've just put a needle into a blood vessel that may be only 3-5 mm wide at a depth of somewhere between 10-25 mm. Stab caudally with the blade oriented upward and running along the wire/needle/dilator (either on top or touching on the side) to a depth that has definitively gone through the skin (usually I'll stab parallel to wire until only back part of blade is visible above skin). If you find that you're whiffing on the stab it's usually because you're not retracting the soft-tissue cranially and you're hitting a skin fold that appears to be adjacent to wire but actually belongs to another zone of the neck entirely. I'll spread the fingers of my non-dominant hand proximally and distally from insertion site keeping them well away from the scalpel. Problem solved.
 
link2swim06 said:
You probably don't need a nick for IJs on most people. The line advances without much difficulty.
Click to expand...

You're dilating over wire straight from needle puncture? Or are you just advancing catheter over wire sans dilating? This may work for something like a 7Fr at most but I think you're setting yourself up for a bad venous injury if you're using a dilator.

Seriously, the nick is not where potentially fatal IJ/inominate injuries originate from.
 
link2swim06 said:
You probably don't need a nick for IJs on most people. The line advances without much difficulty.
Click to expand...

I've kinked many a dilator trying to pass through skin. Doesn't even seem to be related to weight of patient and amount of skin - sometimes the scrawny older people have ****ing Kevlar surrounding their neck
 
engineeredout said:
I've kinked many a dilator trying to pass through skin. Doesn't even seem to be related to weight of patient and amount of skin - sometimes the scrawny older people have ****ing Kevlar surrounding their neck
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This. I've ruined so many dilators and kinked so many wires as a resident. Make a generous nick.
 
I usually nick over the needle. Solves the issue of worrying about cutting the wire.
 
engineeredout said:
I've kinked many a dilator trying to pass through skin. Doesn't even seem to be related to weight of patient and amount of skin - sometimes the scrawny older people have ****ing Kevlar surrounding their neck
Click to expand...

lol @ kevlar. I've seen the same thing with some old people, especially when trying to secure the line using sutures at the end. I'm like WTF this was supposed to be the easiest part.

Speaking of... any advice on the final securing part? Any tips in regard to style points as to securing the line at the end? (this question is open to all)
 
I make my skin suture, then backhand the needle through the hole on the catheter securement device rather than trying to find the hole with the pointy end. Protect the needle in the driver and hand tie. Try to do the whole thing without touching the needle with your fingers - I constantly have to remind my interns to stop grabbing at it with their fingers and sticking themselves, especially during codes when the patient's history is unknown and chest compressions are moving your equipment everywhere. During more elective lines, it's nice for the patient if you save a little lido for the suture sites - I find they often complain the most about those final sutures!

Bonus points for grabbing a suture removal kit before you start so you have a forceps to lift that rubbery old person or cirrhotic skin.
 
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TraumaLlamaMD said:
I make my skin suture, then backhand the needle through the hole on the catheter securement device rather than trying to find the hole with the pointy end. Protect the needle in the driver and hand tie. Try to do the whole thing without touching the needle with your fingers - I constantly have to remind my interns to stop grabbing at it with their fingers and sticking themselves, especially during codes when the patient's history is unknown and chest compressions are moving your equipment everywhere. During more elective lines, it's nice for the patient if you save a little lido for the suture sites - I find they often complain the most about those final sutures!

Bonus points for grabbing a suture removal kit before you start so you have a forceps to lift that rubbery old person or cirrhotic skin.
Click to expand...

I have long griped about the absence of forceps/pickups in the c-line kit.
 
When I do awake lines (much less common for me than for you EM guys) I make my wheal, then follow the needle to just above vessel and deposit in a track from there back as I withdraw (if US being used), and then do two quick skin wheals 45 degrees from the insertion site in each direction that should cover my suture passes. That may be slightly less perfect for lines like 7Fr tlc's with that annoying white rubber and blue plastic fixing device but in general it works. I tend to start my sutures 3/4 to 1 cm proximal instead of due lateral or directly beneath the eyelets so that the forces are pulling the line proximally.
 
Angry Birds said:
Speaking of... any advice on the final securing part? Any tips in regard to style points as to securing the line at the end? (this question is open to all)
Click to expand...
Dude, you're in the ED. Throw a Tegaderm over it so transport doesn't rip it out on the ride up the elevator and get them out of the department.

😉
 
Blade towards the wire. You aren't going to sever a guidewire with the scalpel unless you really f***** try.

Give it a shot in the SIM lab sometime. Not going to happen.
 
RustedFox said:
Pssstt... community places don't have SIM labs, rezzie.
Click to expand...

We totally have a sim lab. Its called trying it with the left-over wire and bloody scalpel after I've finished putting in a CVL on my next shift. Will report back.

As far as random tips for securing it to the skin--
I teach to put the needle through the eyelets blunt side first, as mentioned above.
I teach not to tie the eyelet of the CVL directly to the skin / tight, instead to throw an air knot after a skin throw, THEN tie this to the CVL. Removes tension from the skin, decreasing pain/necrosis/infection risk. This is easier to see on a picture, check out page 19 of this handy PDF-- http://www.philippelefevre.com/downloads/cvc_insertion_guide.pdf
Granted for a code line I don't take the time to do this... 🙂
 
RustedFox said:
Pssstt... community places don't have SIM labs, rezzie.
Click to expand...
Not entirely true. Some do, some don't.

For the record, if their skin is soft, you can dilate without the skin nick. It's tough though. Try pushing it through someone with scleroderma. It's nearly impossible.

Another trick of trade I do is only dilate the skin. The vessel, even in the old patients, is usually soft enough to dilate with the CVL. Now, if it's all scarred down I'll used the dilator. But this really limits the bleeding you have if you don't dilate the vessel.

And yeah, I've never been able to cut the wire with a scalpel. Back in my vascular surgery days, we had an attending that would intentionally cut wires for procedures to remove the J tip. They used heavy wire cutters every time.
 
I agree. I can't imagine you could cut the wire with the scalpel, but I'm going to try next time I'm teaching a sim lab with lines.

Another random tip: If the line kit has the skin staples, use them to secure the line in place rather than suture. Much, much faster, and a much lower risk of sticking yourself and ending up in a needlestick protocol.
 
gamerEMdoc said:
I agree. I can't imagine you could cut the wire with the scalpel, but I'm going to try next time I'm teaching a sim lab with lines.

Another random tip: If the line kit has the skin staples, use them to secure the line in place rather than suture. Much, much faster, and a much lower risk of sticking yourself and ending up in a needlestick protocol.
Click to expand...

Just tried it yesterday with one of the lab kits. No way in heck you could ever accidentally cut the wire. I took that scalpel and barely put a dent in that thing and I was sawing it. There really is no circumstance I could see someone cutting it.
a) would take a heck of a lot of effort to cut it
b) you knick the skin while aiming down like a pen. It's a stab, not a slice.
 
Angry Birds said:
Can you explain that a bit more? I understand the first part but not the perpendicular part. Thanks!
Click to expand...

I will have the sharp edge pointing either left or right. It is neither toward nor away from the needle. I do it this way and keep the guidewire in the needle because this way I can slide the scalpel down the needle itself and ensure the nick is contiguous with where I am putting the line. I'm not concerned about cutting the guidewire, but I can't "slide" the scalpel down the guidewire.
 
I had the outer layer of a guide wire completely come apart on me. The thing is like a spring and nearly impossible to pull back out the needle once it starts unfurling. Only happened once and never again (don't ask me how). Looking at how it was built it would be impossible for a scalpel to cut through it
 
OK, so put in a central line today and it went much smoother taking the tips above in mind. I kept the needle in when making the cut, and I used a stabbing motion instead of a slicing motion. This made the difference and the line went smoother. Thanks ya'll!
 
Rendar5 said:
I had the outer layer of a guide wire completely come apart on me. The thing is like a spring and nearly impossible to pull back out the needle once it starts unfurling. Only happened once and never again (don't ask me how). Looking at how it was built it would be impossible for a scalpel to cut through it
Click to expand...

If you try to pull back a wire that you've put thru the sharp beveled needle without straightening the J tip first you can absolutely shred the wire. That would be my guess as what happened.
 
Robotic Wis-Hipple said:
If you try to pull back a wire that you've put thru the sharp beveled needle without straightening the J tip first you can absolutely shred the wire. That would be my guess as what happened.
Click to expand...
It can happen if you kink the wire anywhere and then try to pull it through something narrow, like the needle, the dilator, or the central line itself.
 
I pull the needle and cut around the wire.

Just pulled up my procedure logs, and in 7 years I've placed 390 central lines. NONE have had a wire problem -- none were cut/sheared from the scalpel. I have, however, put lines in the azygous vein, brachial vein, internal jugular (subclavian to internal jugular), and a mammary vein in a patient with significant liver disease with esophageal and peripheral varices. Dropped a lung, but have never put one in the artery (thankfully). Never lost a guidewire. Always remember that central lines are not benign procedures, and you can get some interesting complications with them from time to time.
 
southerndoc said:
I pull the needle and cut around the wire.

Just pulled up my procedure logs, and in 7 years I've placed 390 central lines. NONE have had a wire problem -- none were cut/sheared from the scalpel. I have, however, put lines in the azygous vein, brachial vein, internal jugular (subclavian to internal jugular), and a mammary vein in a patient with significant liver disease with esophageal and peripheral varices. Dropped a lung, but have never put one in the artery (thankfully). Never lost a guidewire. Always remember that central lines are not benign procedures, and you can get some interesting complications with them from time to time.
Click to expand...

When you say you cut around the wire, how many stabs are we talking about ?
 
So a spin on this question. I find that the hardest part of a central line is keeping the damn needle steady while I feed the wire. I still think I could make a couple million making a better option for that wire. I am always fumbling to try and thread the damn thing and sometimes lose the vessel access especially in septic patients. Sometimes my gloves are sticky and sometimes the wire just has a hard time coming out of it's housing. I somehow just realized that my CVC kit comes with a needle with an angiocath. Moonlighting I decided to try this. I cannulated the vessel then slipped the angiocath into the vessel. I think I could have grabbed a cup of coffee and taken a deuce and still could have access to the vessel. It seems like I could have taken both hands off the angiocath and the worst that would happen is another 10cc of blood. Not sure why I haven't thought of this before but not sure if there are any drawbacks?

Also I have never been concerned about cutting the wire. Maybe I should be but I am not using a chainsaw for my nick.
 
You can let go of the needle as well.
Jedi level is being able to straighten the J-tip with one hand outside of the wire holster. I never use it, it's more of a pain than a help.
Also, you don't need to hub the wire. It needs to stick out as far as the triple lumen or you're going to be sitting there threading it back through the hole being all worried "it's going to slip in the patient" which I've never seen happen. I let go of the wire 100% of the time. It's not spaghetti that the heart is sucking in after all.

On edit: A poorly narrated video.
 
Last edited by a moderator:
I find that the angiocath over needle technique works very well. You can then do manometry off of the angiocath before threading the wire, probably the safest central line technique TBH.

With that said, when you do have issues with the angiocath it's usually because as you advance the catheter over the needle you inadvertently advance the needle and end up outside of the vessel (either thru and thru in a hypovolemic/small caliber vein or because you were more tangential than you wanted and you just sidewalled it), this happens more in spontaneously breathing patients or those with the aforementioned "tough Kevlar" skin.

And regarding the Jedi move of straightening the J wire with one hand and threading it out of the circular guidewire holder I'd imagine you guys end up placing lines without being fully gowned up occasionally and in that scenario you have to watch the distal half of the wire with the non-J tip end, it tends to bounce and sway and may come in contact with the underside of your arm.
 
EMDOC17 said:
So a spin on this question. I find that the hardest part of a central line is keeping the damn needle steady while I feed the wire. I still think I could make a couple million making a better option for that wire. I am always fumbling to try and thread the damn thing and sometimes lose the vessel access especially in septic patients. Sometimes my gloves are sticky and sometimes the wire just has a hard time coming out of it's housing. I somehow just realized that my CVC kit comes with a needle with an angiocath. Moonlighting I decided to try this. I cannulated the vessel then slipped the angiocath into the vessel. I think I could have grabbed a cup of coffee and taken a deuce and still could have access to the vessel. It seems like I could have taken both hands off the angiocath and the worst that would happen is another 10cc of blood. Not sure why I haven't thought of this before but not sure if there are any drawbacks?
Click to expand...

Explain, please!

Any videos of this? Hard to understand from text. 🙁
 
Angry Birds said:
When you say you cut around the wire, how many stabs are we talking about ?
Click to expand...

1

EMDOC17 said:
So a spin on this question. I find that the hardest part of a central line is keeping the damn needle steady while I feed the wire. I still think I could make a couple million making a better option for that wire. I am always fumbling to try and thread the damn thing and sometimes lose the vessel access especially in septic patients. Sometimes my gloves are sticky and sometimes the wire just has a hard time coming out of it's housing. I somehow just realized that my CVC kit comes with a needle with an angiocath. Moonlighting I decided to try this. I cannulated the vessel then slipped the angiocath into the vessel. I think I could have grabbed a cup of coffee and taken a deuce and still could have access to the vessel. It seems like I could have taken both hands off the angiocath and the worst that would happen is another 10cc of blood. Not sure why I haven't thought of this before but not sure if there are any drawbacks?
Click to expand...

Watch EMCrit's central line microskills: http://emcrit.org/wee/central-line-micro-skills-deliberate-practice/
 
shoal007 said:
i dont know if uve ever tried to cut a wire, but its damn near impossible. i forget what we were doing exactly-- but we needed to cut one. needless to say it took 10 minutes and never got a clean cut.

Sent from my Pixel using Tapatalk
Click to expand...
e30ftw said:
Has anyone read a case report of losing a guidewire due to it being cut during CVL insertion?

Next time you have a spare kit try cutting the wire using the supplied scalpel. My guess is it takes multiple "sawing" motions or a single high velocity/tension "swipe" to cut the wire which hopefully you will not be doing during line placement.

FWIW I keep the blade oriented anteriorly, keep the tip of the 11 blade anterior to the wire, insert approx 3-4 mm, and increase the skin incision while withdrawing the scapel. Never had a problem.
Click to expand...

Haha my old senior resident actually DID cut the wire when he was an intern. We are still not sure how he did it, but I have him, the program director, the attending, and the old cheif resident of surgery all on record admitting this is totally possible and required emergent surgery
 
Janders said:
We totally have a sim lab. Its called trying it with the left-over wire and bloody scalpel after I've finished putting in a CVL on my next shift. Will report back.

As far as random tips for securing it to the skin--
I teach to put the needle through the eyelets blunt side first, as mentioned above.
I teach not to tie the eyelet of the CVL directly to the skin / tight, instead to throw an air knot after a skin throw, THEN tie this to the CVL. Removes tension from the skin, decreasing pain/necrosis/infection risk. This is easier to see on a picture, check out page 19 of this handy PDF-- http://www.philippelefevre.com/downloads/cvc_insertion_guide.pdf
Granted for a code line I don't take the time to do this... 🙂
Click to expand...

One of the intensivists at my hospital will use the dialater as a spacer for the sutures for that exact reason.
 
EMDOC17 said:
So a spin on this question. I find that the hardest part of a central line is keeping the damn needle steady while I feed the wire. I still think I could make a couple million making a better option for that wire. I am always fumbling to try and thread the damn thing and sometimes lose the vessel access especially in septic patients. Sometimes my gloves are sticky and sometimes the wire just has a hard time coming out of it's housing. I somehow just realized that my CVC kit comes with a needle with an angiocath. Moonlighting I decided to try this. I cannulated the vessel then slipped the angiocath into the vessel. I think I could have grabbed a cup of coffee and taken a deuce and still could have access to the vessel. It seems like I could have taken both hands off the angiocath and the worst that would happen is another 10cc of blood. Not sure why I haven't thought of this before but not sure if there are any drawbacks?

Also I have never been concerned about cutting the wire. Maybe I should be but I am not using a chainsaw for my nick.
Click to expand...


Bolded for the win. I have said to myself at least 100 times (without exaggeration) - this needle/syringe combo and guidewire are far too big and unwieldy for 99.5% of patients. Its not like we're putting IJ lines into Andre the giant every day. If you're putting in a femoral line in a fatty boom-bahh, then yeah - you need a bigger dagger.
 
DocEspana said:
Haha my old senior resident actually DID cut the wire when he was an intern. We are still not sure how he did it, but I have him, the program director, the attending, and the old cheif resident of surgery all on record admitting this is totally possible and required emergent surgery
Click to expand...

He must be in the special zone.

maxresdefault.jpg
 
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