Central Line Wire Patency

[pie944]

If you are placing a MAC line you always get the two "pops", what do people do if the wire doesn't move freely after the first pop? How about if it moves freely after the first 'pop', but not the second? People always say during lines you need to check wire patency, but no one ever seems to talk about what are the options if you lose that patency during the dilating process?

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[B-Bone]

i'm not sure quite what you mean. the word "patent" means open or unobstructed. The vessel needs to be patent to place a catheter. No idea what wire patency is.

If you can't move the wire, don't dilate. If you can't move the wire after you've dilated, don't place the catheter. The wire is probably bent and/or in the wrong place. You can always US the site with the wire in place to see where it goes (i.e. follow it down), but I would start over or move to the other side at that point.

I recall having problems like this when I first started placing lines. A few tips that have helped me avoid this problem are to poke everything (finder needle, steel needle, dilator) all at the same angle and never force anything. I see trainees and other inexperienced providers put the steel needle in at like 90 degrees to the skin. Then they go jam the dilator in and end up either (best case) pulling out a wire that looks like a cursive Q or (worse) shredding through the back wall of the vessel and causing badness.

If you never force anything (other than a little appropriate oomph to get the dilator through the muscle), you won't get bent/immobile wires. This is an experience thing.

 

[urge]

Make a big skin nick with the knife and your problems will go away. If you bend the wire you have to pull it out until you are on a straight part of the wire. Eventually you will pull the wire out if you keep bending and pulling. Have you had a wire get stuck after any pop, or is this a theoretical question?

 

[proman]

If you are placing a MAC line you always get the two "pops", what do people do if the wire doesn't move freely after the first pop? How about if it moves freely after the first 'pop', but not the second? People always say during lines you need to check wire patency, but no one ever seems to talk about what are the options if you lose that patency during the dilating process?

You shouldn't be checking for wire movement after the first pop. Once the wire is in, make your skin nick. If the nick is big enough the wire will move freely in the nick. Take the introducer, advance as a unit with the dilator while holding countertraction at the skin with your non-dominant hand. Feel first pop, don't bother checking for wire movement unless something feels strange. Second pop means the introducer is in the vessel, advance only a centimeter more then only advance the introducer, not the dilator.

I don't routinely check for wire movement after the first pop. If something doesn't feel right then I'll check. If the wire doesn't move freely at that point I would not advance the introducer, remove the introducer, leave the wire and reassess. Sometimes with the MAC you need to do a separate dilation before being able to place the MAC. There's nothing wrong with removing the wire, holding pressure and re-sticking. That beats a brachiocephalic vein injury and near certain death.

I recall having problems like this when I first started placing lines. A few tips that have helped me avoid this problem are to poke everything (finder needle, steel needle, dilator) all at the same angle and never force anything. I see trainees and other inexperienced providers put the steel needle in at like 90 degrees to the skin. Then they go jam the dilator in and end up either (best case) pulling out a wire that looks like a cursive Q or (worse) shredding through the back wall of the vessel and causing badness.

If you never force anything (other than a little appropriate oomph to get the dilator through the muscle), you won't get bent/immobile wires. This is an experience thing.

I go 90 degrees to the skin but then I use US for all my lines. Once in the vessel I'll lower the syringe to the ear lobe while aspirating. This ensures the tip of the needle isn't in the posterior wall of the vein and allows for easy placement of the wire. I think it's safer to go straight down at 90 degrees because you can't enter the chest that way.

Make a big skin nick with the knife and your problems will go away. If you bend the wire you have to pull it out until you are on a straight part of the wire. Eventually you will pull the wire out if you keep bending and pulling. Have you had a wire get stuck after any pop, or is this a theoretical question?

Eventually if you pull the wire hard enough it will unravel and be next to impossible to remove. It doesn't make much force. I would say never pull hard on the wire. Next time you can get your hands on a wire pull it apart. It doesn't take much force, especially if it's bent. If it doesn't come out easily remove the whole wire/catheter. FYI there is an issue with the Cook double lumen CVC where the wire is too big for the catheter. We had several wires separate when someone just pulled harder.

 

[pie944]

Sorry for not being clear, by patent I meant unobstructed, moves freely. I wasn't talking about difficulty dilating due to a skin tag/small nick/angle/etc.

Heart Transplant, did a R IJ where there was already a 7Fr Swan placed by the CCU team. Stuck distal to the swan insertion point, stick and flow was fine, wire met resistance the first two passes, didn't force, pulled back and rotated the guidewire J tip and passed without resistance. Dilated, felt fine, first pop wire moves freely, 2nd pop wire does not move(attendings have you check the wire after these steps). Attending had me advance the introducer. When I pulled back the dilator/wire as a unit the wire gave more resistance than normal and came out with a significant bend. The introducer had good flow, ended up being in the appropriate place.

 

[Idiopathic]

Sorry for not being clear, by patent I meant unobstructed, moves freely. I wasn't talking about difficulty dilating due to a skin tag/small nick/angle/etc.

Heart Transplant, did a R IJ where there was already a 7Fr Swan placed by the CCU team. Stuck distal to the swan insertion point, stick and flow was fine, wire met resistance the first two passes, didn't force, pulled back and rotated the guidewire J tip and passed without resistance. Dilated, felt fine, first pop wire moves freely, 2nd pop wire does not move(attendings have you check the wire after these steps). Attending had me advance the introducer. When I pulled back the dilator/wire as a unit the wire gave more resistance than normal and came out with a significant bend. The introducer had good flow, ended up being in the appropriate place.

it happens, sometimes you get lucky, sometimes you dont. Typically this means you have moved your dilator and your wire as one unit, rather than advancing the dilator over the wire, but even then it isnt perfect. the wire can get bent coming out as well, especially if you have any kind of angle in your approach. Im sure this was a challenging placement and sounds like you did just fine,.

 

[bullard]

Sorry for not being clear, by patent I meant unobstructed, moves freely. I wasn't talking about difficulty dilating due to a skin tag/small nick/angle/etc.

Heart Transplant, did a R IJ where there was already a 7Fr Swan placed by the CCU team. Stuck distal to the swan insertion point, stick and flow was fine, wire met resistance the first two passes, didn't force, pulled back and rotated the guidewire J tip and passed without resistance. Dilated, felt fine, first pop wire moves freely, 2nd pop wire does not move(attendings have you check the wire after these steps). Attending had me advance the introducer. When I pulled back the dilator/wire as a unit the wire gave more resistance than normal and came out with a significant bend. The introducer had good flow, ended up being in the appropriate place.

Sounds like a good opportunity to place a left subclavian line. 🙂

 

[proman]

Sorry for not being clear, by patent I meant unobstructed, moves freely. I wasn't talking about difficulty dilating due to a skin tag/small nick/angle/etc.

Heart Transplant, did a R IJ where there was already a 7Fr Swan placed by the CCU team. Stuck distal to the swan insertion point, stick and flow was fine, wire met resistance the first two passes, didn't force, pulled back and rotated the guidewire J tip and passed without resistance. Dilated, felt fine, first pop wire moves freely, 2nd pop wire does not move(attendings have you check the wire after these steps). Attending had me advance the introducer. When I pulled back the dilator/wire as a unit the wire gave more resistance than normal and came out with a significant bend. The introducer had good flow, ended up being in the appropriate place.

Sounds like a good opportunity to place a left subclavian line. 🙂

Yeah don't put a line in the same vessel that already has one. You'll never get it cleaned and you run the risk of nicking the existing catheter. I would have gone left IJ or femoral.

 

[pie944]

Yeah don't put a line in the same vessel that already has one. You'll never get it cleaned and you run the risk of nicking the existing catheter. I would have gone left IJ or femoral.

Left IJ was avoided due to her Biventricular ICD and this was going to be sternotomy * 4 so guidewires were placed in the femoral vessels prior to sternotomy.

 

[bullard]

Interesting. Just guidewires in the groin vessels. The times I've taken care of a third or fourth time sternotomy the surgeons actually cannulated femorally and went on bypass before sternotomy.

 

[Idiopathic]

Sorry for not being clear, by patent I meant unobstructed, moves freely. I wasn't talking about difficulty dilating due to a skin tag/small nick/angle/etc.

Heart Transplant, did a R IJ where there was already a 7Fr Swan placed by the CCU team. Stuck distal to the swan insertion point, stick and flow was fine, wire met resistance the first two passes, didn't force, pulled back and rotated the guidewire J tip and passed without resistance. Dilated, felt fine, first pop wire moves freely, 2nd pop wire does not move(attendings have you check the wire after these steps). Attending had me advance the introducer. When I pulled back the dilator/wire as a unit the wire gave more resistance than normal and came out with a significant bend. The introducer had good flow, ended up being in the appropriate place.

why didnt you just take out the old swan, place the MAC and float a new swan. not criticizing, just curious if I am missing something

 

[pie944]

why didnt you just take out the old swan, place the MAC and float a new swan. not criticizing, just curious if I am missing something

Right side of the heart was massive, so a lot of times people here have you start to float the new PAC, get into the RV, pull out the old one, go the rest of the way. They're concerned that removing the old one and encountering difficulty with placement of the new PAC leaves you without anything. Although being in the RV doesn't guarantee you it will go where you want it to, I guess it's better odds.. Afterwards kept the 7Fr introducer in and just continued all the drips she was on prior to the OR.

 

[proman]

Right side of the heart was massive, so a lot of times people here have you start to float the new PAC, get into the RV, pull out the old one, go the rest of the way. They're concerned that removing the old one and encountering difficulty with placement of the new PAC leaves you without anything. Although being in the RV doesn't guarantee you it will go where you want it to, I guess it's better odds.. Afterwards kept the 7Fr introducer in and just continued all the drips she was on prior to the OR.

That's an f'ing disaster waiting to happen. The two PA-Cs can knot and be impossible to remove. Not the end of the world since you're doing a heart transplant but really non-sensical. In your case I would have stuck a line in the left IJ (presence of a device means nothing). Keep the current PA-C, withdraw when they dissect the heart out and refloat with the new heart. If you wanted a brand new PA-C for infection reasons, just put it in the left IJ introducer (I use MACs) but don't float it until the new heart is in. I do like oximetric CCO ones for transplants. But definitely don't place 2 PA-Cs at the same time.

 

[pie944]

That's an f'ing disaster waiting to happen. The two PA-Cs can knot and be impossible to remove. Not the end of the world since you're doing a heart transplant but really non-sensical. In your case I would have stuck a line in the left IJ (presence of a device means nothing). Keep the current PA-C, withdraw when they dissect the heart out and refloat with the new heart. If you wanted a brand new PA-C for infection reasons, just put it in the left IJ introducer (I use MACs) but don't float it until the new heart is in. I do like oximetric CCO ones for transplants. But definitely don't place 2 PA-Cs at the same time.

Why do people seem to avoid the left side then for that reason? Does it matter how recent the placement is?

New PA-C was for that reason.

 

[anbuitachi]

I came across this article that said first pop is prevertebral fascia. 2nd pop is vein. but isn't prevertebral fascia below the IJ? anyone remember? it's been a while

 

[Mman]

I came across this article that said first pop is prevertebral fascia. 2nd pop is vein. but isn't prevertebral fascia below the IJ? anyone remember? it's been a while

if your first pop is prevertebral fascia, your 2nd pop will be the dura

 

[vector2]

Right side of the heart was massive, so a lot of times people here have you start to float the new PAC, get into the RV, pull out the old one, go the rest of the way. They're concerned that removing the old one and encountering difficulty with placement of the new PAC leaves you without anything. Although being in the RV doesn't guarantee you it will go where you want it to, I guess it's better odds.. Afterwards kept the 7Fr introducer in and just continued all the drips she was on prior to the OR.

That is really, really dumb. Unless cards said the swan placement was so difficult that they had to use fluoro, I’m pulling the line and doing a fresh stick instead of leaving an icu pathogen colonized line in a soon to be immunosuppressed pt. Even if you couldn’t refloat a swan prepump, what new information are you really getting that you won’t have with TEE? We already know the heart sucks, the index/svo2 is low, and that they require inotropes. If for some reason I absolutely had to double stick the neck with a catheter already in place, I definitely would not stick distal to the insertion site of the existing catheter, but rather slightly lateral and proximal.

 

[DM27]

At the few places I've trained/worked we did double sticks in the IJ fairly frequently for transplants, but I don't think I would ever consider having two PA catheters in simultaneously when I am replacing one. I agree with the above poster that a PA catheter rarely adds significant value I can't get from the TEE anyways.

 

[T-burglar]

Why do people seem to avoid the left side then for that reason? Does it matter how recent the placement is?

People avoid the left sided veins on redo sternotomies because you can saw through the innominate . You can saw through that vessel on any sternotomy really, so right sided veins are best for any sternotomy, but its pretty unlikely on a first time sternotomy.

I would nearly always place a PAC for heart surgery. The information from the PA catheter is invaluable for ICU management and in the OR the information is complementary to the TEE. TEE is not a replacement for the PAC. PAC's are an excellent early warning system for ischemia, they are like cheating when it comes to valve assessment and both right and left sided diastology, and they clue you in to perfusion problems when the TEE looks deceptively fine. You learn a lot about the limitations of echocardiography by doing every pump case with a swan (and this is coming from the worlds biggest TEE fan).

As one example: acute MR post-CPB related to ischemia can appear as a VERY unimpressive color jet but when you look at the PA trace there are massive V-waves and high pulmonary pressures. The echo does not tell the whole story, just as the PAC does not tell the whole story, just as looking at the heart in the field does not tell the whole story.

 

[Drwine]

Since we started doing TAVR in it's infancy, my routine has been to do do "double barrel intubation" with ETT combined with TEE probe an inch behind. My platinum standard for line placement a couple of minutes later is the wire in the vena cava.

 

[vector2]

People avoid the left sided veins on redo sternotomies because you can saw through the innominate . You can saw through that vessel on any sternotomy really, so right sided veins are best for any sternotomy, but its pretty unlikely on a first time sternotomy.

I would nearly always place a PAC for heart surgery. The information from the PA catheter is invaluable for ICU management and in the OR the information is complementary to the TEE. TEE is not a replacement for the PAC. PAC's are an excellent early warning system for ischemia, they are like cheating when it comes to valve assessment and both right and left sided diastology, and they clue you in to perfusion problems when the TEE looks deceptively fine. You learn a lot about the limitations of echocardiography by doing every pump case with a swan (and this is coming from the worlds biggest TEE fan).

As one example: acute MR post-CPB related to ischemia can appear as a VERY unimpressive color jet but when you look at the PA trace there are massive V-waves and high pulmonary pressures. The echo does not tell the whole story, just as the PAC does not tell the whole story, just as looking at the heart in the field does not tell the whole story.

I’m at an institution that places continuous swans for every heart, and even though it’s 99.9% superfluous for preserved EF CABG, I don’t mind having one for most cases since I can get a quick, relatively error free svo2 and index immediately post pump and also eyeball the systemic to PA ratio. To play the devils advocate, I’d be interested in seeing the images of your non-echo significant but hemodynamically significant post pump MR. I’ve never seen ‘significant’ post pump MR (enough to cause V waves and pHTN) that didn’t have an obvious type I and/or type IIIb defect with associated color flow and pulmonary vein reversal.

 

[Psai]

People avoid the left sided veins on redo sternotomies because you can saw through the innominate . You can saw through that vessel on any sternotomy really, so right sided veins are best for any sternotomy, but its pretty unlikely on a first time sternotomy.

I would nearly always place a PAC for heart surgery. The information from the PA catheter is invaluable for ICU management and in the OR the information is complementary to the TEE. TEE is not a replacement for the PAC. PAC's are an excellent early warning system for ischemia, they are like cheating when it comes to valve assessment and both right and left sided diastology, and they clue you in to perfusion problems when the TEE looks deceptively fine. You learn a lot about the limitations of echocardiography by doing every pump case with a swan (and this is coming from the worlds biggest TEE fan).

As one example: acute MR post-CPB related to ischemia can appear as a VERY unimpressive color jet but when you look at the PA trace there are massive V-waves and high pulmonary pressures. The echo does not tell the whole story, just as the PAC does not tell the whole story, just as looking at the heart in the field does not tell the whole story.

Maybe the high pulmonary pressures are from the heparin/protamine complexes or something else and not the MV?

 

[sigrhoillusion]

I had a situation a few days ago, where I was attempting an Ultrasound guided left subclavian TLC. Patient was s/p c3-7 lami/decompression. Used u/s to see vessel, got introducer in with good blod flow, threaded catheter easily, got good column test, attempted to thread wire but couldn't get it more than a few cms past the catheter. Took wire out and re-attempted with same results. I was going to attempt on right side, but surgeon and I decided since patient's pressures were adequate at the moment and was off pressors after the case, that they could hold off on central line, and if needed they could place it in ICU since patient was kept intubated and would be sedated. I could have done IJs, but that would have required taking off his cervical collar. Don't do subclavs often if ever, so not sure what the issue was with this one.

 

[Sugammadank]

I came across this article that said first pop is prevertebral fascia. 2nd pop is vein. but isn't prevertebral fascia below the IJ? anyone remember? it's been a while

Sorry for reviving an old thread but I can't find an answer to this...is the first pop deep cervical fascia? I've started supervising residents with central line placements, some of whom have never used a Cordis. So I've been telling them to feel for 2 pops but now realized that I can't name what the first pop is.

 

[PpfSuxTube]

Sorry for reviving an old thread but I can't find an answer to this...is the first pop deep cervical fascia? I've started supervising residents with central line placements, some of whom have never used a Cordis. So I've been telling them to feel for 2 pops but now realized that I can't name what the first pop is.

What does any of this mean?
Pops?


The best way of teaching very very junior residents like this is not teaching them at all on live patients. There's mannequins for this

If you have to teach them, then you have to scrub in with them when they're this junior sorry... It's just not safe at their level...

Words can't verbalise proprioception, and the feel of correct or incorrect placement...

Describing something in words as delicate and complex as the neck to a novice is like describing tits to a man with no hands...

You've no skin in the game

 

[gunnershow]

What does any of this mean?
Pops?


The best way of teaching very very junior residents like this is not teaching them at all on live patients. There's mannequins for this

If you have to teach them, then you have to scrub in with them when they're this junior sorry... It's just not safe at their level...

Words can't verbalise proprioception, and the feel of correct or incorrect placement...

Describing something in words as delicate and complex as the neck to a novice is like describing tits to a man with no hands...

You've no skin in the game

Mannequin doesn't have fascial layers lol. Only way to learn 14Fr MAC is by doing (under supervision).

 

[PpfSuxTube]

Mannequin doesn't have fascial layers lol. Only way to learn 14Fr MAC is by doing (under supervision).

Novices don't know what a fascial layer is or feels like.

Mannequins have simulated layers of resistance and most importantly not attached to a living person. They can at least get the mechanics of the advance down, and learn the kit, size of skin Nick needed etc, then can watch a few more, do a few more hand in hand with the staff man on low BMI young healthy ish.


No way someone who has never placed a 7 or 8fr introducer should do one solo on a living human being. I've seen every complication you could imagine from just such a situation incl death, SVC laceration, stroke, vertebral art dissection

You let a beginner put a 14fr neck line in under your supervision?

 

[Arch Guillotti]

You let a beginner put a 14fr neck line in under your supervision?

What's the big deal? We all have to learn somehow.

 

[Sugammadank]

What does any of this mean?
Pops?


The best way of teaching very very junior residents like this is not teaching them at all on live patients. There's mannequins for this

If you have to teach them, then you have to scrub in with them when they're this junior sorry... It's just not safe at their level...

Words can't verbalise proprioception, and the feel of correct or incorrect placement...

Describing something in words as delicate and complex as the neck to a novice is like describing tits to a man with no hands...

You've no skin in the game

I didn't think a simple question would trigger such an overreaction. How do you know I'm not scrubbed in when I'm teaching junior residents? Lots of assumptions and you didn't even bother to answer my question.

 

[PpfSuxTube]

I didn't think a simple question would trigger such an overreaction. How do you know I'm not scrubbed in when I'm teaching junior residents? Lots of assumptions and you didn't even bother to answer my question.

I'm not going after you, I just never heard any of what you're describing before? I've never heard of pops in the neck...

So I can't answer your question. Sorry... Do you have any literature or book reference on that type of thing?

 

[CopaceticOne]

I'm not going after you, I just never heard any of what you're describing before? I've never heard of pops in the neck...

So I can't answer your question. Sorry... Do you have any literature or book reference on that type of thing?

I’ve heard it. That’s how it was described to me when I was learning. The “pop” isn’t a sound but rather the sudden relative loss of resistance while advancing the dilator / introducer.

 

[medicine2wallstreet]

Novices don't know what a fascial layer is or feels like.

Mannequins have simulated layers of resistance and most importantly not attached to a living person. They can at least get the mechanics of the advance down, and learn the kit, size of skin Nick needed etc, then can watch a few more, do a few more hand in hand with the staff man on low BMI young healthy ish.


No way someone who has never placed a 7 or 8fr introducer should do one solo on a living human being. I've seen every complication you could imagine from just such a situation incl death, SVC laceration, stroke, vertebral art dissection

You let a beginner put a 14fr neck line in under your supervision?

You sound like you suck to work with.

A resident under your supervision would graduate crippled and not technically ready to be an attending.

You are wrong.

 

[caligas]

You sound like you suck to work with.

A resident under your supervision would graduate crippled and not technically ready to be an attending.

You are wrong.

wut?

 

[Beeftenderloin]

Novices don't know what a fascial layer is or feels like.

Mannequins have simulated layers of resistance and most importantly not attached to a living person. They can at least get the mechanics of the advance down, and learn the kit, size of skin Nick needed etc, then can watch a few more, do a few more hand in hand with the staff man on low BMI young healthy ish.


No way someone who has never placed a 7 or 8fr introducer should do one solo on a living human being. I've seen every complication you could imagine from just such a situation incl death, SVC laceration, stroke, vertebral art dissection

You let a beginner put a 14fr neck line in under your supervision?

Many (most?) residency programs don’t have easy access to high fidelity task trainers as you describe. You learn on people. For many of the residents in my program the first CVC they ever placed was a cordis in the heart room.

So I can't answer your question. Sorry... Do you have any literature or book reference on that type of thing?

The description of feeling 2 pops with introducer placement was how it was taught in my residency and fellowship (different programs) and how I talk with my colleagues about the procedure at my job. I’ve never heard it described any other way.

I guess another way to describe would be 2 points of resistance followed by a loss of resistance as you advance the catheter through the layers of the neck into the vessel.

How was that phenomenon described to you as you learned ex and how do you describe it to learners or colleagues?

 

[DrN2O]

The "pop" is a change in tissue resistance. It's a good questions what the two pops/transition/gives are. I believe 1st is the platysma/superior layer of the deep cervical fascia, and 2nd is the deep cervical fascia between the SCM and the carotid sheath. But I'm no anatomist, so someone will correct me. Gone is the day of finding the triangle of SCM, so most just go right through the muscle. I suppose that there would be no "pop" if SCM is missed.

I think the mistake is making a superficial skin nick for beginners. The resistance is in the deeper tissue. It has to be big and deep enough for the white introducer sheath (not just the tip of the blue dilator).

Teaching novice on invasive procedures is hard. The language we use can be imprecise ("pop" vs. "give") and inconsistent (from teacher to teacher, e.g. hold/let go the wire). Scrubbing in to help certainly alleviates some anxiety for everyone, but the trainees need to learn by gaining gradual independence. I have never literally held someone's hand to dilate for introducer. I let them push, until one of us gets uncomfortable. After I put it in, realize usually they just needed push a little harder. The competent ones now know how to recalibrate the force they will use next time. Rinse, repeat.

 

[PpfSuxTube]

You sound like you suck to work with.

A resident under your supervision would graduate crippled and not technically ready to be an attending.

You are wrong.

Ha ha ha. Thanks