Central line- How far in should guidewire go?

[Sonny Crocket]

Been on a CA 3 heart rotation. My last to central lines presented this. Site Rite, Stick, Good Flow, Guide wire goes in fine for 10cm(estimated) then meets resistance. Both times I have taken guide wire out, confirmed good venous flow with aspiration and ultrasound changed the needle angle to more shallow and tried to advance guide wire again with resistance at same spot.

The first time my attending had same problem, used a different type of guide wire and threaded the cordis. Second time another attending did another stick slightly more cephalad and had no issues.

After the second central line, my attending and I were talking and he told me that I should have tried to thread the cordis even though the guidewire met resistance at 10cm. He says it is just a GUIDE wire. You don't need to thread the thing 20cm like everyone does. Once you are in the vein you can thread the central line.

What do you all think?

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[RxBoy]

What do you all think?

I've put in an IJ that met resistance early. Said screw it and threaded the catheter anyways. Post op c-xray: The catheter was turned acutely from IJ to the subclavian. Thank god it wasn't a cordis or a really long case. I haven't had one with resistance since, but I personally wouldn't thread it if I did. THere is always the possibility of partially thrombosed vein as well.

 

[BLADEMDA]

I've put in an IJ that met resistance early. Said screw it and threaded the catheter anyways. Post op c-xray: The catheter was turned acutely from IJ to the subclavian. Thank god it wasn't a cordis or a really long case. I haven't had one with resistance since, but I personally wouldn't thread it if I did. THere is always the possibility of partially thrombosed vein as well.

Correct. My experiences tell me never to thread a catheter over a guide wire which will not advance to at least 15 cm. You are just asking for trouble. At least the catheter is soft and will mst likely just curl up or not advance.

Over 10k central lines (?12-13K) and I've seen or had every complication published. Every one. Fortunately, they are rare and even rarer these days with U/S and prudence.

I've had more than dozen thrombosed or blocked veins over the past 5 years. Many are dialysis patients or others with medical conditions know to increase this incidence.

The frustrating part of this condition is the fact the IJ may be huge on U/S yet the wire won't advance very far.

As for placing a Cordis in a patient described by the OP it may end up one of two ways: the cords goes in fine and functions well or it ruptures the vein and the patient expires. If the latter happens to you be prepared to face the malpractice music.

 

[PMPMD]

Been on a CA 3 heart rotation. My last to central lines presented this. Site Rite, Stick, Good Flow, Guide wire goes in fine for 10cm(estimated) then meets resistance. Both times I have taken guide wire out, confirmed good venous flow with aspiration and ultrasound changed the needle angle to more shallow and tried to advance guide wire again with resistance at same spot.

The first time my attending had same problem, used a different type of guide wire and threaded the cordis. Second time another attending did another stick slightly more cephalad and had no issues.

After the second central line, my attending and I were talking and he told me that I should have tried to thread the cordis even though the guidewire met resistance at 10cm. He says it is just a GUIDE wire. You don't need to thread the thing 20cm like everyone does. Once you are in the vein you can thread the central line.

What do you all think?

I have a low threshold for going to another site when that happens. I will try one more time after getting resistance that I'm sure is distal to needle, then move on I assume something's thrombosed proximal.

I have had staff who push through resistance, but I'm not that bold yet.

My staff last night suggested having the patient turn their head TOWARDS the side of the subclavian we were working on when passing the wire. His opinion is, it's less likely to go up the ipsilateral IJ that way.

One of my pet peeves is people who put the wire in 'til only 1–2cm are sticking out. I tell my residents that past about 20cm, the risk/benefit ratio goes to infinity. Some people like to go to 30+ - I think they want to see ectopy to convince themselves they're in the right spot.

 

[PMPMD]

Correct. My experiences tell me never to thread a catheter over a guide wire which will not advance to at least 15 cm. You are just asking for trouble. At least the catheter is soft and will mst likely just curl up or not advance.

Over 10k central lines (?12-13K) and I've seen or had every complication published. Every one. Fortunately, they are rare and even rarer these days with U/S and prudence.

I've had more than dozen thrombosed or blocked veins over the past 5 years. Many are dialysis patients or others with medical conditions know to increase this incidence.

The frustrating part of this condition is the fact the IJ may be huge on U/S yet the wire won't advance very far.

As for placing a Cordis in a patient described by the OP it may end up one of two ways: the cords goes in fine and functions well or it ruptures the vein and the patient expires. If the latter happens to you be prepared to face the malpractice music.

Blade, have you ever seen tamponade from a line? It was reported in a recent study of U/S-guided SC lines, and that was a new one for me.

 

[proman]

My staff last night suggested having the patient turn their head TOWARDS the side of the subclavian we were working on when passing the wire. His opinion is, it's less likely to go up the ipsilateral IJ that way.

I think there was some study from the 90s that showed that decreased the incidence of IJ cannulation. I just advance the wire to 20 cm. If you get resistance at 10cm you've probably gone down the subclavian. I'll pull back to 5 cm and rotate the wire so the J tip points the other direction. I wouldn't place an introducer if the wire only goes to 10 cm.

Just yesterday I placed a line that screwed the crap out of me. I usually have the TEE in before the line, I didn't yesterday because it wasn't ready. US guided stick with the Angiocath, tested with pressure tubing, saw the wire in short axis and long axis in the IJ fine. Tried to place the MAC but seemed that my skin nick wasn't big enough. At that point I'll frequently take the dilator out and do a separate dilation, that went easily. Placed the MAC easily, had some resistance taking the wire out, when I got it out it assumed a curled up configuration. Now I'm a bit worried. I aspirate on the lumens and get nothing. So I take the catheter out and hold pressure. Not a minute later the patient codes. I start CPR while the nurses call the cardiac surgeon and start prepping the patient. Thankfully he came back after <10 seconds. I think that's been the most terrified I've ever been. Patient was stable after, no vascular injury, only a small neck hematoma. I have no idea where that MAC went but I was very lucky yesterday.

 

[periopdoc]

I am betting your cordis was along side the IJ with the wire exiting the tip of the dilator, bending 180 to run back up alongside the cordis and entering the IJ above where the tip of your cordis now lies then bending another 180 into the IJ. Your description exactly mirrors a complication I witnessed during fellowship. We left the line in and studied it.

I am curious if you would choose to remove the line if something like this happened again. I like the idea of defining where the line is if something goes awry. Obviously if I misplaced a line and the patient immediately coded, I would remove it, but it sounds like the patient coded after you removed the line.

I love having the TEE with the multiplane at 120ish and watching for that beautiful J in the right atrium.

IN RE the original question... I do not have nearly the experience of Blade, but I have only once placed a line when I could not FREELY advance and withdraw the wire at will or somehow visualize the wire distal to an explainable obstruction. It was an emergency and the guy had multiple pacer wires in the SVC. I assumed the resistance I was feeling was those and I got away with it.

One time I had resistance and I did a careful examination of the wire with U/S. It traversed the IJ and entered a small vein that joined the IJ and travelled inferiorly almost parallel to the IJ. Had I placed the cordis it would have torn said vein and I might have not noticed it until trying to explain the falling HCT later in the case. As it was I used real-time U/S to retrieve the wire to the junction, rotate it into the IJ, and advance into the correct lumen. The attending I was working with wasn't a huge U/S fan before this, but was pretty impressed and thought thatI should publish it.

Other times, I have had resistance only to find out that there is clot distal to my attempted insertion site.

I would recommend against placing a catheter if any unexplainable resistance is encountered.

I don't pay attention to the exact length of the wire anymore, I just know about how far I want it in. I go about 20-25cm and I would guess that I would feel uncomfortable at <15cm. If I was working with residents/ CRNAs/ AAs I would be a little more specific about having an exact number to shoot for so that we are on the same page.

I don't try for ectopy, but I am not unhappy when it occurs so my actual length may be closer to 30cm.

- pod

 

[B-Bone]

I once placed a cordis with similar resistance at about 15 cm. Placed a silastic catheter, drew back blood, transduced the silastic catheter which showed venous waveform. Couldn't see wire in TEE, but could see when I injected air bubbles through silastic catheter. Attending and I (i was a resident at the time) decided to place cordis. Afterwards, when placing PAC, met resistance at 15 cm repeatedly and eventually abandoned. While transducing cordis, still had venous waveform, drawing back blood, etc. We decided that wire and PAC were getting hung up on indwellingpacer wires. Did case (double valve with 2V CABG) and took pt to ICU. On post-op CXR, cordis was somehow going down RIJ and down right subclavian vein toward the arm. Don't ask me how the rigid catheter made this turn (it didn't really turn, it just seemed to have the venous anatomy jacked up around it), but by god that's what it did. To this day, I don't know how I did that without tearing up the dudes SVC and having him bleed to death. Since then, I will just switch sites if I run into wire that won't advance.

Except last week during a code in the ICU. I was there for airway, but intensivist couldn't get fem line in pulseless pt. They had that automatic chest compression device going. I did a blind RIJ triple lumen with the thing still going. Get in on first stick, but can't thread wire (either end) past 15 cm despite excellent blood return. I eventually just threaded it over the wire cuz this guy was going on 15 min compressions without IV access. He made it through the code (though died like 12 hours later). CXR showed my line at SVS/RA junction. I think the compression device was mechanically compressing the SVC so my wire wouldn't go any further. No way to prove it, but that's my theory.

 

[sevoflurane]

I think there was some study from the 90s that showed that decreased the incidence of IJ cannulation. I just advance the wire to 20 cm. If you get resistance at 10cm you've probably gone down the subclavian. I'll pull back to 5 cm and rotate the wire so the J tip points the other direction. I wouldn't place an introducer if the wire only goes to 10 cm.

Just yesterday I placed a line that screwed the crap out of me. I usually have the TEE in before the line, I didn't yesterday because it wasn't ready. US guided stick with the Angiocath, tested with pressure tubing, saw the wire in short axis and long axis in the IJ fine. Tried to place the MAC but seemed that my skin nick wasn't big enough. At that point I'll frequently take the dilator out and do a separate dilation, that went easily. Placed the MAC easily, had some resistance taking the wire out, when I got it out it assumed a curled up configuration. Now I'm a bit worried. I aspirate on the lumens and get nothing. So I take the catheter out and hold pressure. Not a minute later the patient codes. I start CPR while the nurses call the cardiac surgeon and start prepping the patient. Thankfully he came back after <10 seconds. I think that's been the most terrified I've ever been. Patient was stable after, no vascular injury, only a small neck hematoma. I have no idea where that MAC went but I was very lucky yesterday.

Yeah... The code part is scary and I'd be searching for a reason. What happened during the code? Sats/bp/arrhythmia/etc...

I'd get an XRAY and would look for pulmonary parenchymal injury/ptx/hemiothorax/fluid collection. Those MACs have the potential to cause a lot of harm. Any pink-frothy edema like fluid out of the ETT during the case?

I'd prolly leave it in, alert the surgeon and take it out once the chest is open (if doing a heart)... under direct vision if possible. The surgeon can throw in some stitches if need be.

 

[Oggg]

I like seeing PVCs after running my wire almost all the way in. Knock on wood, I haven't seen any VT from this. Has anyone put a patient into VT or worse doing this?

 

[fakin' the funk]

Been on a CA 3 heart rotation. My last to central lines presented this. Site Rite, Stick, Good Flow, Guide wire goes in fine for 10cm(estimated) then meets resistance. Both times I have taken guide wire out, confirmed good venous flow with aspiration and ultrasound changed the needle angle to more shallow and tried to advance guide wire again with resistance at same spot.

If you are in the heart room using realtime U/S AND you have TEE you have two powerful tools to investigate WTF is going on when wacky line stuff happens.

With the ultrasound probe, you can interrogate the needle/wire interface as you're trying to advance, using long-axis views if need be, and see where exactly that needle tip is. Obviously this will only help you down to the level of the clavicle or maybe 1-2 caudad to it.

And if you think your wire is in far enough but are having trouble passing the catheter or aren't getting ectopy etc you can use the TEE to help guide you.

 

[RxBoy]

Blade, have you ever seen tamponade from a line? It was reported in a recent study of U/S-guided SC lines, and that was a new one for me.

At our hosptital, in the last 10 years we had at least 3 immediate deaths following line placement. One was a torn SVC after cordis placement, not sure the ultimate cause of death although it was within minutes. Second one was tension pneumo on someone with severe AS who coded and it was game over from there. Third one was with a swanz-ganz. Complete pulmonary artery rupture after balloon inflation intraop. DOn't know the details too much because it was before my time, but it was discussed in a line lecture we had last year. The attending with the pulm artery rupture didn't place swanz for some time, now he will place them only for the sickest patients and even then will NEVER reinflate after initial wedge.

Not to mention all the other deaths we probably had in the ICU from line sepsis.

Lines aren't benign procedures.

 

[RxBoy]

I think in next 20 years the swanz-ganz will be obsolete once a-line flowtrac's, continuous SvcO2 monitoring and TEEs become cheaper and more mainstream.

People will view the swan as ancient as the way we view repeated manual BP measuring or continuous esophageal stethoscopy.

 

[PMPMD]

At our hosptital, in the last 10 years we had at least 3 immediate deaths following line placement. One was a torn SVC after cordis placement, not sure the ultimate cause of death although it was within minutes. Second one was tension pneumo on someone with severe AS who coded and it was game over from there. Third one was with a swanz-ganz. Complete pulmonary artery rupture after balloon inflation intraop. DOn't know the details too much because it was before my time, but it was discussed in a line lecture we had last year. The attending with the pulm artery rupture didn't place swanz for some time, now he will place them only for the sickest patients and even then will NEVER reinflate after initial wedge.

Not to mention all the other deaths we probably had in the ICU from line sepsis.

Lines aren't benign procedures.

Seen one VT/VF death from a PAC. Pt was old/sick, and had no reserve: never got ROSC.

In the unit we often get to decipher the mysterious "line to nowhere" situations.

 

[jennyboo]

he told me that I should have tried to thread the cordis even though the guidewire met resistance at 10cm. He says it is just a GUIDE wire. You don't need to thread the thing 20cm like everyone does. Once you are in the vein you can thread the central line.

Hell no. I do not thread anything so big and stiff as a Cordis if the wire does not move back and forth freely. You would be asking for a complication.

I would consider threading a long angiocath (4 1/2", like a femoral a-line catheter) to confirm placement (it's small, 18 gauge and involves no dilation) -- and stop if it does not go freely without resistance. But I would NEVER push a cordis or the real central venous catheter against resistance. What you described above is a dangerous practice.

 

[proman]

I am curious if you would choose to remove the line if something like this happened again. I like the idea of defining where the line is if something goes awry. Obviously if I misplaced a line and the patient immediately coded, I would remove it, but it sounds like the patient coded after you removed the line.

I love having the TEE with the multiplane at 120ish and watching for that beautiful J in the right atrium.

- pod

I don't know what is the right thing to do. Obviously if you dilate the carotid you leave the catheter in. I just need to stick to have the TEE in because it is very reassuring to see the wire (maybe that's why I never get ectopy?) But there will be plenty of lines in the future in non-cardiac cases, so the echo probe isn't the 100% answer. When I did a short axis view of the RIJ after the code resolved, I saw what looked like a big flap that was bunched up. Maybe I just dissected the IJ. Afterwards, the was a definite neck hematoma.

Yeah... The code part is scary and I'd be searching for a reason. What happened during the code? Sats/bp/arrhythmia/etc...

I'd get an XRAY and would look for pulmonary parenchymal injury/ptx/hemiothorax/fluid collection. Those MACs have the potential to cause a lot of harm. Any pink-frothy edema like fluid out of the ETT during the case?

I'd prolly leave it in, alert the surgeon and take it out once the chest is open (if doing a heart)... under direct vision if possible. The surgeon can throw in some stitches if need be.

This guy was in a fib, rate controlled. The code was asystole, no EKG complexes, no BP. Literally 5 compressions got him back. Some have proposed it was the neck compression from hematoma/my hand as I held pressure. No drugs required, didn't even get registered in the anesthetic record. The patient showed absolutely no effects and the case proceeded as usual.

I think in next 20 years the swanz-ganz will be obsolete once a-line flowtrac's, continuous SvcO2 monitoring and TEEs become cheaper and more mainstream.

People will view the swan as ancient as the way we view repeated manual BP measuring or continuous esophageal stethoscopy.

The PA catheter is still the only way to measure pulmonary artery pressures. It still has a use, although it definitely won't be used as frequently (100% in my current practice).

 

[Hamhock]

Anyone checking under the sterile sheet with TTE for the wire when placing cordis introducers or larger lines into the SCV or IJ?

HH

 

[proman]

At our hosptital, in the last 10 years we had at least 3 immediate deaths following line placement. One was a torn SVC after cordis placement, not sure the ultimate cause of death although it was within minutes. Second one was tension pneumo on someone with severe AS who coded and it was game over from there. Third one was with a swanz-ganz. Complete pulmonary artery rupture after balloon inflation intraop. DOn't know the details too much because it was before my time, but it was discussed in a line lecture we had last year. The attending with the pulm artery rupture didn't place swanz for some time, now he will place them only for the sickest patients and even then will NEVER reinflate after initial wedge.

Not to mention all the other deaths we probably had in the ICU from line sepsis.

Lines aren't benign procedures.

I never wedge. PAOP is the only reason to wedge and PVR isn't really that important, even in liver transplants. My PACs sit either right before or right after the PA bifurcation.

 

[sevoflurane]

I never wedge. PAOP is the only reason to wedge and PVR isn't really that important, even in liver transplants. My PACs sit either right before or right after the PA bifurcation.

Agree. If you haven't hit PA by 50ish (60ish with left PACs)u r prolly coiled up somewhere.

Continuous PA reading is nice to have.

 

[BLADEMDA]

I think there was some study from the 90s that showed that decreased the incidence of IJ cannulation. I just advance the wire to 20 cm. If you get resistance at 10cm you've probably gone down the subclavian. I'll pull back to 5 cm and rotate the wire so the J tip points the other direction. I wouldn't place an introducer if the wire only goes to 10 cm.

Just yesterday I placed a line that screwed the crap out of me. I usually have the TEE in before the line, I didn't yesterday because it wasn't ready. US guided stick with the Angiocath, tested with pressure tubing, saw the wire in short axis and long axis in the IJ fine. Tried to place the MAC but seemed that my skin nick wasn't big enough. At that point I'll frequently take the dilator out and do a separate dilation, that went easily. Placed the MAC easily, had some resistance taking the wire out, when I got it out it assumed a curled up configuration. Now I'm a bit worried. I aspirate on the lumens and get nothing. So I take the catheter out and hold pressure. Not a minute later the patient codes. I start CPR while the nurses call the cardiac surgeon and start prepping the patient. Thankfully he came back after <10 seconds. I think that's been the most terrified I've ever been. Patient was stable after, no vascular injury, only a small neck hematoma. I have no idea where that MAC went but I was very lucky yesterday.

Yes. I had one that wasn't so lucky

 

[BLADEMDA]

I never wedge. PAOP is the only reason to wedge and PVR isn't really that important, even in liver transplants. My PACs sit either right before or right after the PA bifurcation.

Good advice. I've seen a PA rupture. It ain't pretty. You don't want one.

 

[BLADEMDA]

I like seeing PVCs after running my wire almost all the way in. Knock on wood, I haven't seen any VT from this. Has anyone put a patient into VT or worse doing this?

Yes. I've had v tach and even got a fib once. Don't put the wire in all the way

 

[BLADEMDA]

I am betting your cordis was along side the IJ with the wire exiting the tip of the dilator, bending 180 to run back up alongside the cordis and entering the IJ above where the tip of your cordis now lies then bending another 180 into the IJ. Your description exactly mirrors a complication I witnessed during fellowship. We left the line in and studied it.

I am curious if you would choose to remove the line if something like this happened again. I like the idea of defining where the line is if something goes awry. Obviously if I misplaced a line and the patient immediately coded, I would remove it, but it sounds like the patient coded after you removed the line.

I love having the TEE with the multiplane at 120ish and watching for that beautiful J in the right atrium.

IN RE the original question... I do not have nearly the experience of Blade, but I have only once placed a line when I could not FREELY advance and withdraw the wire at will or somehow visualize the wire distal to an explainable obstruction. It was an emergency and the guy had multiple pacer wires in the SVC. I assumed the resistance I was feeling was those and I got away with it.

One time I had resistance and I did a careful examination of the wire with U/S. It traversed the IJ and entered a small vein that joined the IJ and travelled inferiorly almost parallel to the IJ. Had I placed the cordis it would have torn said vein and I might have not noticed it until trying to explain the falling HCT later in the case. As it was I used real-time U/S to retrieve the wire to the junction, rotate it into the IJ, and advance into the correct lumen. The attending I was working with wasn't a huge U/S fan before this, but was pretty impressed and thought thatI should publish it.

Other times, I have had resistance only to find out that there is clot distal to my attempted insertion site.

I would recommend against placing a catheter if any unexplainable resistance is encountered.

I don't pay attention to the exact length of the wire anymore, I just know about how far I want it in. I go about 20-25cm and I would guess that I would feel uncomfortable at <15cm. If I was working with residents/ CRNAs/ AAs I would be a little more specific about having an exact number to shoot for so that we are on the same page.

I don't try for ectopy, but I am not unhappy when it occurs so my actual length may be closer to 30cm.

- pod

If you put the line in the carotid pull it out. Contrary to what you may read the vascular surgeon doesn't like the line in the carotid. The funny part is when you need to get a CXR and the Radiologist calls to inform you that your line isn't properly placed. 😱

 

[BLADEMDA]

Blade, have you ever seen tamponade from a line? It was reported in a recent study of U/S-guided SC lines, and that was a new one for me.

My partner had a small cardiac tamponade from a central line placement. In the old days the wires were sharper (not as flexible) and the old guys sometimes placed the wire backwards (non flexible tip in first). The tamponade was self limiting and the problem resolved over the next 7 days.

 

[BLADEMDA]

With U/S and TEE combined with common sense I'm not sure the lawyers will be as understanding about line complications these days as they were 10-15 years ago.

 

[BLADEMDA]

Ignorance and lack of experience makes you bold. Real world experience which validates these complications are real and potentially devastating makes you more cautious and appreciative of the advances we have made with U/S and TEE.

I can place a line in 3-5 minutes 99 percent of the time. But, what about the other one percent? What happens to them if you aren't cautious or prudent?
For me that's over 100 patients in my career ( the one percent crowd)

No. I have not had 100 major complications. I'd say the number Is more like 8-10. But, I remember almost every one that went wrong and none of the 10,000 or more which went right.

The irony is I was braver after 500 central lines than after 10,000.

 

[OB1🤙]

I would consider threading a long angiocath (4 1/2", like a femoral a-line catheter) to confirm placement (it's small, 18 gauge and involves no dilation) -- and stop if it does not go freely without resistance. But I would NEVER push a cordis or the real central venous catheter against resistance. What you described above is a dangerous practice.

Agree. I like doing this. Seems like sometimes the guidewire gets stuck on pacer wires or the like, but is clearly distal to the needle. In that spot get out a long angiocath or fem a-line cath, get it over the wire, withdraw wire, and see what you can accomplish.

 

[BLADEMDA]

Hell no. I do not thread anything so big and stiff as a Cordis if the wire does not move back and forth freely. You would be asking for a complication.

I would consider threading a long angiocath (4 1/2", like a femoral a-line catheter) to confirm placement (it's small, 18 gauge and involves no dilation) -- and stop if it does not go freely without resistance. But I would NEVER push a cordis or the real central venous catheter against resistance. What you described above is a dangerous practice.

I'm sure it was a bunch of macho men. My hunch is women are more cautious as a group compared to men. However, perforating an internal jugular vein is no laughing matter.

 

[PMPMD]

One of my staff in residency told me about this case. He put a line in a pt for pelvic exent. Next day he gets called by rads that he left his wire in the pt. He said no way Turns out, during the case, urology came in to put in stents. But one guidewire went through renal parenchyma, renal vein, IVC to RA.

 

[CambieMD]

Correct. My experiences tell me never to thread a catheter over a guide wire which will not advance to at least 15 cm. You are just asking for trouble. At least the catheter is soft and will mst likely just curl up or not advance.

Over 10k central lines (?12-13K) and I've seen or had every complication published. Every one. Fortunately, they are rare and even rarer these days with U/S and prudence.

I've had more than dozen thrombosed or blocked veins over the past 5 years. Many are dialysis patients or others with medical conditions know to increase this incidence.

The frustrating part of this condition is the fact the IJ may be huge on U/S yet the wire won't advance very far.

As for placing a Cordis in a patient described by the OP it may end up one of two ways: the cords goes in fine and functions well or it ruptures the vein and the patient expires. If the latter happens to you be prepared to face the malpractice music.

A simple rule to follow in general is not to force anything that doesn't want to go. This applies to ETTs,needles, catheter and guide wires. How can you defend yourself if you cause a vascular injury.


Cambie

 

[sevoflurane]

One has to learn the difference between what a hard-calcified/tendenous platysma feels like and that which is not...

the not.... can get you in trouble.

As a rule.... check your wire patency at the beggining and half way through your dilation with a dilator... especially on a MAC (picture to the right).

That distal end can fu*% s*h*t up.

 

[joshmir]

you may have been trying to state this, but just in case, the pt may have gone asystolic from vagal tone from holding pressure causing a carotid massage

 

[periopdoc]

If you put the line in the carotid pull it out. Contrary to what you may read the vascular surgeon doesn't like the line in the carotid. The funny part is when you need to get a CXR and the Radiologist calls to inform you that your line isn't properly placed. 😱

The five different vascular surgeons that I have worked with in my life have uniformly stated that they want me to keep the line in the carotid if it is inadvertently placed there. Perhaps it is old dogma. I certainly don't know the vascular surgery literature. I would recommend checking with your surgeon before you pull it. I would consider 5000 of heparin too.

- pod

 

[proman]

you may have been trying to state this, but just in case, the pt may have gone asystolic from vagal tone from holding pressure causing a carotid massage

That's what I was trying to say. But does that happen in A Fib?

The five different vascular surgeons that I have worked with in my life have uniformly stated that they want me to keep the line in the carotid if it is inadvertently placed there. Perhaps it is old dogma. I certainly don't know the vascular surgery literature. I would recommend checking with your surgeon before you pull it. I would consider 5000 of heparin too.

- pod

I wouldn't pull a carotid catheter out. Anyone know what the recommendation is for a misplaced venous catheter? BTW, the patient did fine, was extubated <6 hours post op. Had typically old-man post CPB hypotension requiring norepi and some vasopressin but seems to be doing well.

 

[periopdoc]

That's what I was trying to say. But does that happen in A Fib?

Yes. There is vagal innervation of the AV node and is is conceivable that an increase in vagal tone from carotid massage could result in a reduction of AV nodal output and potentially cardiac arrest.

AV Nodal Physiology

Experimentally, vagally induced depression of AV nodal conduction can be produced by stimulation of the cervical vagi...

Recently, experimental and clinical studies used the utility of vagal nerve stimulation to selectively suppress AV nodal transmission during fast atrial rates (as in atrial fibrillation), providing a new tool for ventricular rate control and improved hemodynamics.

- pod

 

[BLADEMDA]

While Pulling the line out of the Carotid may have been acceptable 15-20 years ago the literature now recommends possible surgical exploration.

I am including the literature in the next few posts.

 

[BLADEMDA]

Management
While prevention of inadvertent arterial cannulation with large bore central venous catheters is paramount, an
approach to treating inadvertent arterial cannulation may be needed in rare circumstances. There have been no
guidelines in the literature for the treatment of accidental cannulation of arteries with large-bore catheters, but
two recently published case series document better outcomes with surgical or endovascular intervention when
compared with removal and compression (“pull/pressure”)9,37. Guilbert et al. recently published a proposed
algorithm for dealing with inadvertent arterial cannulation based on a review of cases from their own institutions
(summarized in Table 6 below) and a more extensive review of the literature37.
Management Complications
Catheter removal and compression Patient had massive stroke and died
Catheter removal and compression Arteriovenous fistula requiring surgical repair
Catheter removal and compression Left hemothorax requiring blood transfusion
Catheter removal and compression Pleural effusion, lung collapse, thoracic surgery to repair arterial
hole and lung decortication
Catheter removal and compression Hematoma and uncontrolled bleeding requiring open surgery to
repair jugular vein and carotid artery
Open surgical repair No complications
Open surgical repair No complications
Open surgical repair No complications
Open surgical repair No complications
Open surgical repair No complications
Open surgical repair No complications
Endovascular repair No complications
Endovascular repair No complications
Table 6: Summary of management and subsequent outcome in 13 cases of arterial cannulation
From Guilbert M-C, Elkouri S, Bracco D et al.:Arterial trauma during central venous catheter insertion: Case
series, review and proposed algorithm. J Vasc Surg 48:918-985, 2008
During their literature review, the group found that the “pull/pressure” method was associated with a large
incidence of serious complications (47%), including death, while the surgical or endovascular approach was
not (Figure 8A) Based on their own experience and this review of the literature, they proposed the
management algorithm in Figure 8B.
Figure 8(A): Complications from the “pull/pressure” technique of removing a large bore cannula in an artery were
significantly higher than surgical removal with direct repair of the artery or endovascular repair. (B): A proposed
algorithm for management of inadvertent cannulation of a cervical or thoracic artery with a large bore catheter during
attempted central venous catheter placement.
From Guilbert M-C, Elkouri S, Bracco D et al.:Arterial trauma during central venous catheter insertion: Case series, review
and proposed algorithm. J Vasc Surg 48:918-985, 2008.
A

 

[BLADEMDA]

POD,

While you are technically correct in your approach to a large bore catheter in the artery the vascular surgeons here told me they would just pull it out.
Of course, they are wrong:



Interestingly, a survey of vascular surgeons presented with a hypothetical case of an 8.5Fr catheter in a
carotid artery, found that the respondents saw this complication 1-5 times per year and half would simply
pull the catheter and apply pressure. However, when vascular surgeons were shown the data from the
study by Guilbert et al., most of them changed their management to the surgical or endovascular
approach as judged by pre- and post-test questions (Figure 9).

 

[BLADEMDA]

Several of the specific findings of the Guilbert et al. study are worth noting:
1. Arterial cannulation can occur despite the use of ultrasound guidance.
2. The low internal jugular approach can injure the subclavian or innominate arteries or even the aorta.
Arterial injury below the sternoclavicular joint cannot be repaired through a cervical approach.
Clinical suspicion of an intrathoracic injury should prompt imaging to locate the site of injury and plan
surgical or endovascular treatment (see Figure 6 for an example of endovascular treatment).
3. Prolonged arterial cannulation can result in thrombus formation and stroke.
4. A normal carotid duplex exam following removal of a catheter from the carotid does not rule out the
possibility of a stroke. Because of this, postponing elective surgery has been recommended to avoid
unrecognized stroke in an anesthetized patient.
5. False aneurysms or arteriovenous fistulas can occur late following the pull/pressure technique, so
close follow-up is needed.

 

[BLADEMDA]

http://miradorbiomedical.com/wp-content/uploads/2011/01/Review_ArterialCannulation_Bowdle_FINAL.pdf


If anyone can assist me in posting the graph from the above reference it would be appreciated.

 

[BLADEMDA]

A4. The American Society of Anesthesiologists included the following statement in their 2010 Practice
Guidelines for Central Venous Access (Draft),“Case reports of adult patients with arterial puncture by a
large bore catheter/vessel dilator during attempted central venous catheterization report severe
complications (e.g., cerebral infarction, arteriovenous fistula, hemothorax) following immediate catheter
removal; no such complications were reported for adult patients whose catheters were left in place before
surgical consultation and repair16,17. The consultants and ASA members agree that, when unintended
cannulation of an arterial vessel with a large bore catheter occurs, the catheter should be left in place and
a general or vascular surgeon should be consulted.”
1. Ezaru, C.S., Mangione, M.P., Oravitz, T.M., Ibinson, J.W. & Bjerke, R.J. Eliminating arterial injury during central venous
catheterization using manometry. Anesth Analg 109, 130-4 (2009).
2. Kusminsky, R.E. Complications of central venous catheterization. J Am Coll Surg 204, 681-96 (2007).
3. Cayne, N.S. et al. Experience and technique for the endovascular management of iatrogenic subclavian artery injury. Ann Vasc Surg
24, 44-7.
4. Pikwer, A. et al. Management of inadvertent arterial catheterisation associated with central venous access procedures. Eur J Vasc
Endovasc Surg 38, 707-14 (2009).
5. Wicky, S. et al. Life-threatening vascular complications after central venous catheter placement. Eur Radiol 12, 901-7 (2002).
6. Kron, I.L., Joob, A.W., Lake, C.L. & Nolan, S.P. Arch vessel injury during pulmonary artery catheter placement. Ann Thorac Surg 39,
223-4 (1985).
7. Mansfield, P.F., Hohn, D.C., Fornage, B.D., Gregurich, M.A. & Ota, D.M. Complications and failures of subclavian-vein
catheterization. N Engl J Med 331, 1735-8 (1994).
8. Milling, T.J., Jr. et al. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous
cannulation: the Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Crit Care Med 33, 1764-9 (2005).
9. Chapman, G.A., Johnson, D. & Bodenham, A.R. Visualisation of needle position using ultrasonography. Anaesthesia 61, 148-58
(2006).
10. Blaivas, M. Video analysis of accidental arterial cannulation with dynamic ultrasound guidance for central venous access. J
Ultrasound Med 28, 1239-44 (2009).
11. Thompson, C. & Barrows, T. Carotid arterial cannulation: removing the risk with ultrasound? Can J Anaesth 56, 471-2 (2009).
12. Parsons, A.J. & Alfa, J. Carotid dissection: a complication of internal jugular vein cannulation with the use of ultrasound. Anesth
Analg 109, 135-6 (2009).
13. Adachi, Y.U. & Sato, S. Four cases of inadvertent arterial cannulation despite of ultrasound guidance. Am J Emerg Med 28, 533.
14. Bailey, P.L., Glance, L.G., Eaton, M.P., Parshall, B. & McIntosh, S. A survey of the use of ultrasound during central venous
catheterization. Anesth Analg 104, 491-7 (2007).
15. Jobes, D.R., Schwartz, A.J., Greenhow, D.E., Stephenson, L.W. & Ellison, N. Safer jugular vein cannulation: recognition of arterial
puncture and preferential use of the external jugular route. Anesthesiology 59, 353-5 (1983).
16. Guilbert, M.C. et al. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. J Vasc Surg
48, 918-25; discussion 925 (2008).
17. Shah, P.M., Babu, S.C., Goyal, A., Mateo, R.B. & Madden, R.E. Arterial misplacement of large-caliber cannulas during jugular vein
catheterization: case for surgical management. J Am Coll Surg 198, 939-44 (2004).

 

[BLADEMDA]

Case 5 (HD). A 65-year-old man in our burn unit
underwent central line cannulation of the right subclavian
artery with a triple lumen 7F catheter. The injury was
recognized immediately, the catheter was left in place, and
vascular surgery consultation sought. The patient was
transported to the angiography suite. A guiding catheter
was inserted in the subclavian artery by transfemoral approach.
The central line was exchanged over a 7F introducer,
which was then removed after which a collagenbased
vascular closure device was deployed to ensure
hemostasis. Angiographic image acquisition after deployment
of the sealing device did not show active bleeding
therefore no further endovascular treatment was needed.
The patient made an uneventful recovery.

 

[BLADEMDA]

Any line over 7F in size needs Surgical exploration or an Interventional Radiology Stud to bail you out.

 

[periopdoc]

Which graph do you want? That article was written by the guy that was my Chief of Cardiac Anesthesia at U. Washington. Great dude.

- pod

 

[BLADEMDA]

Which graph do you want? That article was written by the guy that was my Chief of Cardiac Anesthesia at U. Washington. Great dude.

- pod

Figure 9. Did you ever see a surgical exploration of the carotid due to a Central line insertion while at UW? How about Interventional Radiology?

I'm sumprised your former Cardiac Chief didn't get you a copy of that outstanding review article he wrote.

 

[periopdoc]

While I haven't seen this particular version of the data (if I am correct it was published after I concluded my fellowship) I have seen the data in several different forms (presentations, 1-on-1 discussions etc). When I say I am not up to date on the data, I mean that I do not read vascular surgery journals and they may have new recommendations with which I am not familiar. I am very familiar with the anesthesia literature and recommendations, as you might expect from a fellow of Dr. Bowdle's.

I did not sit in on any of the surgical explorations that occurred while at UW. We did have IR come into the OR on a couple of occasions where there were central line mishaps and I had the opportunity to observe. In both cases it was determined that and vascular damage was too inconsequential to require repair of any sort.

- pod

 

[Bostonredsox]

Been on a CA 3 heart rotation. My last to central lines presented this. Site Rite, Stick, Good Flow, Guide wire goes in fine for 10cm(estimated) then meets resistance. Both times I have taken guide wire out, confirmed good venous flow with aspiration and ultrasound changed the needle angle to more shallow and tried to advance guide wire again with resistance at same spot.

The first time my attending had same problem, used a different type of guide wire and threaded the cordis. Second time another attending did another stick slightly more cephalad and had no issues.

After the second central line, my attending and I were talking and he told me that I should have tried to thread the cordis even though the guidewire met resistance at 10cm. He says it is just a GUIDE wire. You don't need to thread the thing 20cm like everyone does. Once you are in the vein you can thread the central line.

What do you all think?

So I have put in about 30-35 central lines or so thus far as an intern and am by no means an expert but I figured I would throw in my 2 cents from what I have picked up along the way with my IJs (25 of my 30 have been US guided IJ). In general, If I cant get my guidwire in completely, meaning with less than 15cm of wire hanging out from the neck, assuming no ectopy and an average height patient on the right side of the neck, then I retract my wire, put the syringe back on and draw blood again. If I get blood still then I try and rethread. If I still cant thread fully, and it will usually hang up in the same spot, then I just restick. In general, the needle is just up against the vessel wall or something ******ed like that. I have yet to come across an IJ I couldnt get after a second stick other than one, and that one wa sa dialysis patient who had had several line sbefore and was scarred as *$)%. When I am supervising fellow interns or teaching med students I tell them all, if after two attempts to pass the wire your hung up, restick. Just my two cents. Another thought is to just stivk your probe back over the neck and find your wire to make sure it looks good in the vessel, then track the probe down to see if you can see shadow signifying obstruction. I dont do this because well our US blows its an outdated model from the ED which doesnt even show your needle as you cannulate you have to rely on skin-tenting to know your in the right spot. 🙁 And for what it's worth I am an IM resident not an anesthesiologist so I have no IJ experience without US seeing as if they need a line quicker than then the 8 minutes or so it takes me with an US in the neck than Im sticking them in the groin. Bottom line I just restick if I cant put the wire in all the way after two tries. I never thread over a wire thats not all the way in. Cheers.