Central line shenanigans

[la gringa]

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colleague of mine had a pt who needed a line recently. he was gone forever and the nurse came to get me multiple times to trouble shoot... bottom line, he tried THREE different sites (lt sc, then rt fem, then lt fem) and had the same issue:

- easily found vessel and fed wire
- dilator would NOT pass and tip was physically damaged
- wire was bent when removed

neither he nor i have ever seen such a thing... anyone seen this? any thoughts?

he ended up putting in an IO... nothing else to do at 3am when he and i are the only docs in the hospital who put in lines!!! (nurses and he couldn't get anything peripheral, upper GI bleed).

 

[EctopicFetus]

I have seen some patients whose vessels are so hard they will bend and damage the dilator but nothing like this.

I guess im kind of dumbfounded you had no success. Also if you were trying 3x lumen I would go cordis in the groin. The only other thing I can think of is is a saphenous cut down. Other than that the IO.

 

[jbar]

Maybe there was some weird pathology like scar tissue from previous lines. But when I've had the dilator not pass its usually a skin incision that is too small. People get too into making the cut deep and not making it long enough. I've also seen where the skin incision doesn't actually connect to the hole the wire is going through, so the dilator never "sees" the skin incision. The wire bending is telling me that they were forcing the wire against something, like trying to push the dilator through too small a skin incision. When the dilator doesn't pass easily rather than forcing I back out and make a bigger skin nick.

Now that's me talking off the cuff without knowing anything about the patient or the operator. If the same operator has that much trouble at multiple sites it makes me think there is a problem with their technique. But if you tell me this is an attending who has put in 100 central lines easily, then I'm not so sure what the problem was.

 

[la gringa]

yes attending a couple of yrs out... and the dilator was visibly damaged. skin incision looked adequate to me... i couldn't identify an operator error.

don't think the lady had prior central lines. was a bit fluffy which may have contributed to subclavian site issues... but both femorals???

 

[southerndoc]

Was he going through the vein or accidentally pulling the needle out/pushing it through the vein when he grabbed the wire? I've seen that (and even done it a few times). Get a flashback, go to grab the wire and somehow displace the needle from the vessel. That's why I put the guidewire on the field with me so I don't have to turn around to retrieve it.

The other thing is patient may have had clots (either acute or chronic) in their vessels.

 

[neusu]

Rather than just shove the dilator I turn it as I pass it, I find this helps it get through tough soft tissue.

 

[Groove]

colleague of mine had a pt who needed a line recently. he was gone forever and the nurse came to get me multiple times to trouble shoot... bottom line, he tried THREE different sites (lt sc, then rt fem, then lt fem) and had the same issue:

- easily found vessel and fed wire
- dilator would NOT pass and tip was physically damaged
- wire was bent when removed

neither he nor i have ever seen such a thing... anyone seen this? any thoughts?

he ended up putting in an IO... nothing else to do at 3am when he and i are the only docs in the hospital who put in lines!!! (nurses and he couldn't get anything peripheral, upper GI bleed).

Weird. I doubt it's operator error if he usually has no problems at all. Did he try US guided? I would almost be suspicious that there's some underlying pathology, sclerosed veins, scar tissue, clots, something... What I've been doing lately when I'm in a bind although usually it's reversed in that I'm trying to avoid doing a central line is to do a US guided PIV into a deep brachial, basilic or cephalic vein in the arm. You need at least a 1.8" angio so it doesn't infiltrate. I watched it on Youtube a few years ago and started doing them regularly after that. It works well but of course you need an US and can't exactly slam it in but I've gotten faster at doing them. That does sound odd though. Did you guys recently change kits or something? It wound be interesting to even watch the CVL on US and see exactly where the dilator is getting hung up though I doubt you guys had the time.

 

[Cerberus]

Weird. I doubt it's operator error if he usually has no problems at all. Did he try US guided? I would almost be suspicious that there's some underlying pathology, sclerosed veins, scar tissue, clots, something... What I've been doing lately when I'm in a bind although usually it's reversed in that I'm trying to avoid doing a central line is to do a US guided PIV into a deep brachial, basilic or cephalic vein in the arm. You need at least a 1.8" angio so it doesn't infiltrate. I watched it on Youtube a few years ago and started doing them regularly after that. It works well but of course you need an US and can't exactly slam it in but I've gotten faster at doing them. That does sound odd though. Did you guys recently change kits or something? It wound be interesting to even watch the CVL on US and see exactly where the dilator is getting hung up though I doubt you guys had the time.

I do deep PIVs with U/S guidance fairly regularly on patients with bad vasculature who I don't want to put a central line in (especially helpful in druggies with absolutely no access, who I need access for trauma scan and then plan on discharging). These lines usually don't last long though - they usually blow within 12 hrs.

 

[southerndoc]

Rather than just shove the dilator I turn it as I pass it, I find this helps it get through tough soft tissue.

I also do this and I've had great success with it.

Be careful reversing the guidewire if you bend it. I've heard of people doing this (instead of the coiled end going in first, reverse it so the straight end goes in). You can perforate the SVC by doing so.

 

[la gringa]

I also do this and I've had great success with it.

Be careful reversing the guidewire if you bend it. I've heard of people doing this (instead of the coiled end going in first, reverse it so the straight end goes in). You can perforate the SVC by doing so.

he did the turning, tried another puncture site along the same vessel... i'm suspecting as one mentioned above scar tissue or something else weird.

and i never use the non-J end unless it's a femoral... even then it's risky business if the wire won't pass easily.

 

[Stitch]

To me, when the wire bends then it's not where you thought it was, so sometimes I'll look on u/s to try and find it. I also agree with the above poster who pointed out that often the skin nick isn't big enough. I've seen damaged dilators (usually the end gets splayed and ruins the pointyness) from too small a nick or even just holding the dilator too far back while pushing it in. I try to hold it as close to the skin as possible.

 

[Arcan57]

To me, when the wire bends then it's not where you thought it was, so sometimes I'll look on u/s to try and find it. I also agree with the above poster who pointed out that often the skin nick isn't big enough. I've seen damaged dilators (usually the end gets splayed and ruins the pointyness) from too small a nick or even just holding the dilator too far back while pushing it in. I try to hold it as close to the skin as possible.

Also, if you don't withdrawal the wire when you are advancing the dilator it almost guarantees a kinked wire.

 

[ccfccp]

This may be a stupid thought, but where was he holding the dilator?

If you hold the dilator far back from the skin I've seen this happen a few times. If you're holding it basically at the skin and advancing a few millimeters at a time I've never seen that happen. Weird.

 

[Hamhock]

Also, if you don't withdrawal the wire when you are advancing the dilator it almost guarantees a kinked wire.

This.

Or a variation on this.

I suspect the hand that was advancing the dilator (especially if a cordis, which lots of EM folks put in less often and get a little aggitated with when difficulty arises) was also holding the wire. The hands have to be completely independent.

I see residents do this all the time.

Or insufficient cut in the skin as above.

Or too steep of an angle = not flattening out towards parallel with the skin.

HH

 

[docB]

I've seen this before although I'm usually able to get the catheter in despite the issue. I have suspected it might be due to creating a Z track style entry because you are retracting pannus, neck, etc. with the left hand for the stick and then you have to let go to hold the needle to feed the wire and the tissue slides back. It then gets held by the needle which is rigid until it's removed and then the wire winds up Zed since it's flexible.

I've got no data whatsoever on this. Just my thought. It would be a great resident project using flouro to see what's really going on.

 

[la gringa]

I've seen this before although I'm usually able to get the catheter in despite the issue. I have suspected it might be due to creating a Z track style entry because you are retracting pannus, neck, etc. with the left hand for the stick and then you have to let go to hold the needle to feed the wire and the tissue slides back. It then gets held by the needle which is rigid until it's removed and then the wire winds up Zed since it's flexible.

I've got no data whatsoever on this. Just my thought. It would be a great resident project using flouro to see what's really going on.

i think this is the most likely explanation... he wasn't too far back on the dilator but the lady was um, generous in the neck and groin. he did flatten out the angle - i have had to use this technique more than a few times to pass a dilator.

actually i did the subclavian stick b/c he was having trouble. a surgeon taught me a slight variation to get under the clavicle which has only failed me once. i didn't get hands-on involved in the fem sites.

thanks for the discussion... in the end, sounds like bad luck for my poor colleague (and me, since i stayed while he was stuck in there b/c he would have been single coverage and people kept coming in).

 

[Birdstrike]

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[omarsaleh66]

Sounds like there is alot of scar tissue, u are passing a dilator and kinking your wire so even though u have a good skin nick, u need to break up that skin real good with a hemostat. Break up the surrounding skin real good and then try passing your dilator. Also, u need to make sure your when u are advancing your dilator, your wire can move back and forth freely, if u feel resistance at all u need to stop because u are kinking your wire. We put in a ton of 13-14F dialysis catheters in Interventional radiology and lot of these people have scar tissue. I have the advantage of seeing the dilator and wire kinking under flouro, unfortunately u dont have that and you cant even see that with ultrasound. The best thing for me is making a good skin nick and then really make that skin lose and make a real good dermatotomy with hemostats. Trust me, u will have alot more ease placing central lines if u do this.

Also make sure your dilator is going the path of the vessel. You really have to pass it along the direction of the wire or the wire will kink.

 

[la gringa]

I've seen that where the wire passes but the dilator tip, which is pretty rigid gets caught up when trying to pass through the deeper facial layers. The harder you push the more of a mangled mess the tip becomes. Then it will never pass. Get a new kit, new dilator and push more gently (maybe)?

Was your ED coming to pieces while you're up doing floor work?

Who's the hospitalist/icu/PCP taking care of the patient?

Don't you have it in your hospital by-laws that ED physicians can only be called for floor Emergencies?

It's the "no good deed goes unpunished" provision.

In other words, if called to floor offering to "help out," quick easy favor will invariably turn into bizarre central line from hell.

this was an ED patient... this shop goes from 2 docs to 1 at 2am, right about when he was doing this line.

we do not go to the floor EVER at most of my shops... we do cover codes at 1 shop, but i rarely work there, and have yet to do a night there (most likely time to be called, obviously).

 

[jbar]

Also make sure your dilator is going the path of the vessel. You really have to pass it along the direction of the wire or the wire will kink.

This is a good point. A lot of people enter the vein with the finder needle at a fairly seep angle, like 45 degrees, and then only flatten out their needle if they hit resistance. I've seen some of my interns try to pass the dilator at this angle rather than flatting out the dilator as I advance it. It's good to think about what the tip is aiming at as well. With left IJs I aim for the left nipple, since that's about where the SVC is. Sometimes if you are off left or right the wire can make the turn but the dilator can't. You can also use the ultrasound moving down the neck from your insertion site to get a sense of the path of the IJ to help aim the dilator.

 

[Birdstrike]

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[la gringa]

Got it.

Do you ever go EJ?

Sometimes if you put the patient in trendelenburg, stand at the head if the bed and turn their head to the side, the external jugular will pop out even when every other peripheral vein on the body has been trashed. You can pop in a peripheral large bore IV in about 5 seconds that will pour way more fluid or blood that a triple lumen. I can't tell you how many times this saved me from having to get involved in central lines, IOs and the like.

i LOVE EJ's... this lady's were no good apparently (per my partner, his patient!). i can nearly always get one.

 

[Hamhock]

Sounds like there is alot of scar tissue, u are passing a dilator and kinking your wire so even though u have a good skin nick, u need to break up that skin real good with a hemostat. Break up the surrounding skin real good and then try passing your dilator. Also, u need to make sure your when u are advancing your dilator, your wire can move back and forth freely, if u feel resistance at all u need to stop because u are kinking your wire. We put in a ton of 13-14F dialysis catheters in Interventional radiology and lot of these people have scar tissue. I have the advantage of seeing the dilator and wire kinking under flouro, unfortunately u dont have that and you cant even see that with ultrasound. The best thing for me is making a good skin nick and then really make that skin lose and make a real good dermatotomy with hemostats. Trust me, u will have alot more ease placing central lines if u do this.

Also make sure your dilator is going the path of the vessel. You really have to pass it along the direction of the wire or the wire will kink.

Thanks for this post.

I have put in more than my fair share of central lines (as an EM doc) and feel like I have a pretty good handle on the procedure, potential complications, and "tricks" to get out around roadblocks during the procedure.

However, I have never considered blunt dissection with a hemostat (a "dermatotomy", as you call it). I can see how this would be useful for larger lines with a lot of potentially scarred "soft tissue" between the skin and vessel.

👍👍

HH