Cordis Help

[Myostatin]

Question about cordis placement. Last time I placed a 9 fr cordis in the IJ, the catheter kinked and when I would try and draw back I got lots of air bubbles / poor flow. I found it odd because I had no problems accesing the IJ or placing the line, everything went smoothly. Changing the catheter over a wire didn't help the situation and I had to stop and put it in on the other side. Anyone have tips for preventing this from happening? Thnx

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[huktonfonix]

Im sure you checked but the first question always has to be, "Are you sure you are in the IJ?". After that, its possible that the cordis is up against the wall of the vein or at a branch point and flow may improve based on the pts volume status. There shouldn't be too many places that a 9 Fr cordis can actually kink from an IJ route.

 

[gasnewby]

If you aspirate air, you're usually in the pleural space or intrapleural. Hope you checked a cxr before switching sides.

 

[Noyac]

How in the world do you kink a cordis. You used the dilator I assume and that thing is hard to kink just in your hands. Maybe you shouldn't be putting these things in people.

 

[camkiss]

We have had this happen several times in our institution. The catheter is definitely in the vein, but when you aspirate you get air. We hypothesise that the valve on the white insertion port of the catheter is incompetent, and thus letting air in. We have wired through them, replaced with another catheter, and it worked fine. It is scary when you see air bubbles, though. This seems to happen in hypovolemic patients.

 

[Myostatin]

Noyac,

you're a friggin idiot. The dialator is firm but the cordis itself is flexibile and could potentially kink... do a net search. Sounds like you've never seen one let alone put one in, unless of course you're in the habit of leaving dialators in your patients. God help us if you're running cases in the OR.

Yes I was in the IJ, as I said insertion was uncomplicated... and no there was no pneumo. Camkiss's explanation makes sense, perhaps that's what happened.​

 

[urge]

brup

 

[Noyac]

Noyac,

you're a friggin idiot. The dialator is firm but the cordis itself is flexibile and could potentially kink... do a net search. Sounds like you've never seen one let alone put one in, unless of course you're in the habit of leaving dialators in your patients. God help us if you're running cases in the OR.

Yes I was in the IJ, as I said insertion was uncomplicated... and no there was no pneumo. Camkiss's explanation makes sense, perhaps that's what happened.​

OK Einstein, maybe I deserved that.

But would you please explain to me how you are kinking your catheters.​

 

[coprolalia]

Whatever actually happened, I would just like to reiterate the point about switching sides before getting a chest xray, especially when you aspirate air. Muy peligroso. No lungs = no respirations = no patient. Fellow residents, don't make a habit of doing this.

-copro

 

[Planktonmd]

Noyac,

you're a friggin idiot. The dialator is firm but the cordis itself is flexibile and could potentially kink... do a net search. Sounds like you've never seen one let alone put one in, unless of course you're in the habit of leaving dialators in your patients. God help us if you're running cases in the OR.

Yes I was in the IJ, as I said insertion was uncomplicated... and no there was no pneumo. Camkiss's explanation makes sense, perhaps that's what happened.​

You said that you changed the catheter and still had the same problem,
So it can't be an incompetent valve.​

 

[Myostatin]

Alright.... let me clarify. Yes, I did get a cxr before switching sides and there was no pneumo. Accesing the IJ was not a problem - introducer + dialator advanced smoothy. Once the cordis was all the way in and the dialator out I got good venous flow back with no air - initially. When I repositioned to suture the line in, I noticed that it was a kink at the hilt of the cordis, i.e. the indwelling portion of the cordis didn't align with the external portion, which resulted in a steep angle. I tried to aspirate back, and while there was flow, it wasn't as free as before, and I suspect that because of the resistance to flow, air bubbles were getting in from the top port, or that perhaps there was a small air leak from a small hole in the external portion of the catheter. Again, its not like I was aspirating back signficant air, there were just small bubbles and increased resistance to flow back. I think that somehow the angle I inserted at was incorrect, but I'm not sure why, as I used the standard landmark, i.e. apex of the angle between the heads of the SCM and had no problem finding the IJ. So Im not sure what I did wrong, and yes, I'm absolutely sure I wasn't in the lung.... thnx for your help.

 

[Myostatin]

... looking back point taken that the correct thing to do would have been to stop and get a cxr immediately rather than trying to change over a guidewire under the assumption that there was a problem with the catheter, but the bottom line is that the catheter worked fine intially, and I wasn't in the lung. Somehow even after changing over a guidewire there was a significant angle between the internal and external portions of the catheter at the hilt, and the flow back was not free, so I'm not sure what exactly I did wrong in placing it in the firstplace that the trajectory of it wasn't correect.

 

[blackjack]

I had kinking with a RIJ cordis once with a thick-necked dude when I retracted the skin as I inserted the cordis. After insertion and suturing (and 3/4 of the way thru the CABG), the damn cordis bent from the weight of the neck flubber. Had to change it to a SC at the end of the case.

 

[UTSouthwestern]

Chances are you went through part of the muscular belly of the SCM. When you straighten the head, the muscle can contract/bundle around the portion of the cordis that remains imbedded. A quick way to test this hypothesis is to turn the patient's head back to the left (or lift the blubber) and see if flow is thus restored.

Also, if you are seeing air with a fully implanted cordis consider the following:

You have a put a major league cut/skin nick into the skin, sq fat, and unfortunately the vein and you are now entraining air into the vein as you suck back. Easily confirmed by pinching the skin at the insertion point and aspirating to see if air continues to entrain.

You have an incompetent dilator/PAC valve and are entraining air at that point. Put the sterile blue cordis cap on (it should be air tight) and again check for air aspiration. If the air stops and you indeed have an incompetent PAC/dilator valve, you can continue to use the cordis as a volume device, but you cannot remove that sterile blue cap for a secondary central line, PAC, paceport, or slick catheter or else you risk entraining air especially in the hypovolemic patient or patient in a head up position.

Unfortunately, if you reach this last possibility, you likely have penetrated the pleural cavity, unless you have somehow managed to get the cordis into the vein and rip through it and superficial tissues and now have the tip of your cordis sticking distally through skin (in which case you need lasik).


The only rec I would have to avoid kinking of the cordis is to start as medially as possible so that your placement path dives under the muscle and has no possibility of penetrating muscle (i.e. anterior approach as opposed to middle or posterior approach).