Placing central line, difficulty passing wire fully

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PpfSuxTube said:
It sound to me that this is the problem the 2019 op was having...

Now you need to be really careful here and know exactly what you're doing/seeing/treating.

You can always see an ijv valve on USs. If you can't it may be something else and as others have alluded to. Never ever ever dilate an ijv unless you're sure you're in. You can kill someone with an ijv laceration

Int jugular valve is common enough, around 10% of ppl have one iirc and can cause some trouble getting the wire down...

Often just using the straight end of the wire gets thru this obstruction. The nurses have a 'slippy wire' some times that works. Idk what it's called honestly, I stopped using it cause it's too cumbersome and long

Puncturing lower in the neck with the IV type catheter over needle, that comes in the kit can get thru the valve.
Very rarely you just can't get thru it at all, that happens me maybe 1 every 6 months, so then I just go to alternate sites.

About once or twice a year I'll have to use left ijv or subclavian

You must keep very high levels of suspicion if the wires not going down. These are very high stakes, I've seen ppl die from this type of situation where the wire isn't in the vein at all, thru and thru or knuckled up
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Can you clarify what you mean by knuckled up? Curling back on itself if the J gets caught up on something?
 
WheezyBaby said:
Can you clarify what you mean by knuckled up? Curling back on itself if the J gets caught up on something?
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Hard to describe in words alone. It happens with either too small a skin nick or very thick skin/musculature... what happens is the dilator pushes the wire @ a wierd angle and doesn't slide along the wire rather it kinks the wire and causes a knuckling effect that subsequently prevents the dilator from advancing into the vein.

Very annoying

Its funny but the skin nick is a skill in and of itself. Too big and 50k heparin it can bleed like stink, too small and these issues occur, especially with the big cannula for robotic stuff...
 
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PpfSuxTube said:
Hard to describe in words alone. It happens with either too small a skin nick or very thick skin/musculature... what happens is the dilator pushes the wire @ a wierd angle and doesn't slide along the wire rather it kinks the wire and causes a knuckling effect that subsequently prevents the dilator from advancing into the vein.

Very annoying
Click to expand...

Thanks, I know what you're referring to. I've had a different issue i thought you might be referring to. Had a toddler where just advancing the J I think the vessel narrowed at some point near the clavicle where it was catching and would double back on itself. There was also a valve but was past the valve. Ultimately just a couple attempts at rewiring got it to pass but should have just got a micropuncture kit, quite sure the wire in that would've passed easily
 
caligas said:
Sounds good but you do know that’s where the lung is?
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lol yes I do and that's why I take a super steep approach to enter the vessel directly under the US probe and than walk the needle into the vessel. All under complete needle visualization.
 
nimbus said:
No problems visualizing the wire distally when you do that? Can you see the valve when you pierce it with the needle?
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I, almost always, am able to visualize a valve obstructing the path of the wire if it exists, you just have to scan distal enough. Granted, I place most central lines in the cardiac room so TEE is always present to visualize the wire in the RA as well. We use the same approach in our robotic hearts, we use 18 or 20 Fr SVC cannulas for CPB.
 
PpfSuxTube said:
Hard to describe in words alone. It happens with either too small a skin nick or very thick skin/musculature... what happens is the dilator pushes the wire @ a wierd angle and doesn't slide along the wire rather it kinks the wire and causes a knuckling effect that subsequently prevents the dilator from advancing into the vein.

Very annoying

Its funny but the skin nick is a skill in and of itself. Too big and 50k heparin it can bleed like stink, too small and these issues occur, especially with the big cannula for robotic stuff...
Click to expand...

I find the blade orientation, angle, depth, and correct size nick for a Mac line to be one of the hardest things for residents to grasp.

I've lost count of the number of times the nick was too long but not deep enough or was deep enough but they weren't right on the wire so there's a skin bridge.
 
caligas said:
Sounds good but you do know that’s where the lung is?
Click to expand...

There's a couple papers about doing an IJ in-plane with U/S essentially on the clavicle in a similar position to where you place it for a supraclavicular block. However, instead of visualizing the SCA you visualize where the IJ meets the SCV.

 
OK, someone explain this one to me. We use an introducer needle get it into the vein, good return of dark non-pulsatile blood. Wire meets resistance at around 10 to 15 cm. So we remove needle and slide the angiocath from the central line kit over the wire that is partially in, and it goes easily. We pull the wire out completely, then put same wire down angiocath and it goes like butter. Place introducer and swan, normal waveforms.

What manner of sorcery has occurred here?

(I can only figure that the wire is curling or folding and is barely into the vein and the angiocath somehow straightens it out)
 
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caligas said:
OK, someone explain this one to me. We use an introducer needle get it into the vein, good return of dark non-pulsatile blood. Wire meets resistance at around 10 to 15 cm. So we remove needle and slide the angiocath from the central line kit over the wire that is partially in, and it goes easily. We pull the wire out completely, then put same wire down angiocath and it goes like butter. Place introducer and swan, normal waveforms.

What manner of sorcery has occurred here?

(I can only figure that the wire is curling or folding and is barely into the vein and the angiocath somehow straightens it out)
Click to expand...

I'm assuming no look with ultrasound before pulling the wire? The case where I saw a wire double on itself it was very apparent on US
 
i like to look at the needle tip in the short axis view to make sure needle tip is in the bulleye of the vein. The vessel feels pretty crunchy when the wire is not centered. If it is off center, I just redirect the needle tip under direct vision into the bullseye and wire will usually pass smoothly...
Sometimes, I have the nurse Adduct the right arm and pull the arm if the wire is fussy.
Dialysis patients are difficult sticks....They have this issue but its usually from stenosis. vascular guys have this problem every day but they have fluoro....I watch those guys shoot dye under fluro, balloon the vessel and sneak the wire past these areas in the lab. I tell them i am going to consult you for the next Swan i need in a dialysis patient and they laugh. Glad I don't have their job.
 
caligas said:
OK, someone explain this one to me. We use an introducer needle get it into the vein, good return of dark non-pulsatile blood. Wire meets resistance at around 10 to 15 cm. So we remove needle and slide the angiocath from the central line kit over the wire that is partially in, and it goes easily. We pull the wire out completely, then put same wire down angiocath and it goes like butter. Place introducer and swan, normal waveforms.

What manner of sorcery has occurred here?

(I can only figure that the wire is curling or folding and is barely into the vein and the angiocath somehow straightens it out)
Click to expand...
Sounds like your wire hit the int jugular valve and got turned back.
 
caligas said:
OK, someone explain this one to me. We use an introducer needle get it into the vein, good return of dark non-pulsatile blood. Wire meets resistance at around 10 to 15 cm. So we remove needle and slide the angiocath from the central line kit over the wire that is partially in, and it goes easily. We pull the wire out completely, then put same wire down angiocath and it goes like butter. Place introducer and swan, normal waveforms.

What manner of sorcery has occurred here?

(I can only figure that the wire is curling or folding and is barely into the vein and the angiocath somehow straightens it out)
Click to expand...

Were you in my ICU last week? Ha.

I was helping get a trauma patient lined up and had same thing. Regular needle wire would not pass. My buddy came over and said to try exactly what you did, use the angiocath and rewire. Worked immediately. He said he's found that the angiocath sometimes allows the wire to enter at a slightly different angle (his guess) and allows passage.

Who the hell knows.
 
Shimmy8 said:
Were you in my ICU last week? Ha.

I was helping get a trauma patient lined up and had same thing. Regular needle wire would not pass. My buddy came over and said to try exactly what you did, use the angiocath and rewire. Worked immediately. He said he's found that the angiocath sometimes allows the wire to enter at a slightly different angle (his guess) and allows passage.

Who the hell knows.
Click to expand...
Ha, no this was in the OR. Very interesting though.
 
okayplayer said:
I do angiocath over needle to access the IJ every time. Surprised more folks don’t do this as their initial approach.
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Agree.

This is my preferred approach, especially when teaching newbie residents. Prevents me from being overly frustrated with the drifting / moving hand holding the needle when they shift their attention to getting the wire and trying to advance it through.
 
CopaceticOne said:
Agree.

This is my preferred approach, especially when teaching newbie residents. Prevents me from being overly frustrated with the drifting / moving hand holding the needle when they shift their attention to getting the wire and trying to advance it through.
Click to expand...
It’s way easier to get the wire with the angiocath. Honestly I feel like we mix the blind technique when we are doing it with ultrasound. Most residents are somewhat capable of doing arterial lines which are tiny compared to the IJ. I don’t even hold negative pressure on the syringe. I just do it as an ultrasound guided IV and follow my needle tip into the vessel then thread off the angiocath. Works perfectly.
 
james775 said:
It’s way easier to get the wire with the angiocath. Honestly I feel like we mix the blind technique when we are doing it with ultrasound. Most residents are somewhat capable of doing arterial lines which are tiny compared to the IJ. I don’t even hold negative pressure on the syringe. I just do it as an ultrasound guided IV and follow my needle tip into the vessel then thread off the angiocath. Works perfectly.
Click to expand...

Lol I do EXACTLY this. I started having residents do the same.

Can't count how many times I saw a resident screw it up (myself included) because as soon as they got a flash of blood, their attending would insist they immediately drop the ultrasound, THEN drop the angle of the needle/syringe, THEN try, unsuccessfully, to advance the catheter. That blind repositioning of the needle was like instant sabotage so many times. It's stupid. You have the ultrasound in your hand... USE IT to guide the needle through the entire process.
 
okayplayer said:
I do angiocath over needle to access the IJ every time. Surprised more folks don’t do this as their initial approach.
Click to expand...
Exactly this, I don’t know why anyone uses the introducer, what advantages does it have vs an angiocath? You have to keep the needle in position as you’re getting the wire, putting in an angio, confirming blood return is much easier.
I do mine in plane, not 0 degrees aligned with the vein but rather about 60, watch the angio and wire both go in. A military guy showed me this and I’ve seen a few wires go into an accessory vein in the dialysis crowd
 
Maverikk said:
Exactly this, I don’t know why anyone uses the introducer, what advantages does it have vs an angiocath? You have to keep the needle in position as you’re getting the wire, putting in an angio, confirming blood return is much easier.
I do mine in plane, not 0 degrees aligned with the vein but rather about 60, watch the angio and wire both go in. A military guy showed me this and I’ve seen a few wires go into an accessory vein in the dialysis crowd
Click to expand...
Because when you do a couple hundred a year or more, you don't need the angiocath basically ever, and the introducer needle comes preloaded on the syringe in the kit... so it's a few seconds faster, less effort for the same result.

I dont know what the angle thing is you mention. Lots of people try to recreate the wheel with ijv cannulation but the honest truth is short axis straight in with the regular needle works just fine 99.9%
 
Maverikk said:
Exactly this, I don’t know why anyone uses the introducer, what advantages does it have vs an angiocath? You have to keep the needle in position as you’re getting the wire, putting in an angio, confirming blood return is much easier.
I do mine in plane, not 0 degrees aligned with the vein but rather about 60, watch the angio and wire both go in. A military guy showed me this and I’ve seen a few wires go into an accessory vein in the dialysis crowd
Click to expand...
Try hooking the wire-holder with your pinky or ring finger in your dominant hand and simultaneously holding the metal needle and syringe barrel in the same hand with the fingers you normally use to puncture and aspirate.

There, you don’t have to search for your wire after getting your flash and screwing off the syringe
 
T-burglar said:
Try hooking the wire-holder with your pinky or ring finger in your dominant hand and simultaneously holding the metal needle and syringe barrel in the same hand with the fingers you normally use to puncture and aspirate.

There, you don’t have to search for your wire after getting your flash and screwing off the syringe
Click to expand...
Or anchor your left hand holding the introducer needle onto something, most often the patients mandible.

Also use your uss dynamically to identify the needle tip and advance it inferiorly in such a fashion that it's well into the ijv and also away from the posterior wall.

That's a far better technique that can also be used with the angiocath.

This way you're sure you're dead centre of the vein
 
That’s what I do, all out of plane imaging, position the needle tip in the center of the vein before dropping the ultrasound.

I still hold the wire and needle-syringe with the same hand simultaneously
 
CopaceticOne said:
Agree.

This is my preferred approach, especially when teaching newbie residents. Prevents me from being overly frustrated with the drifting / moving hand holding the needle when they shift their attention to getting the wire and trying to advance it through.
Click to expand...
Angiocath method is routine at certain places. I don't think it's any easier than the thin-walled needle, because it adds at least two more steps where the newbies can lose the access. #1: separating the angiocath from the needle. #2: advancing the angiocath into the vein. #1b people like to pre-separate the angiocath from needle, this just makes any withdraw and redirect more difficult. I think the teaching is: big vein, angiocath; small vein, straight needle; hard anatomy: micropuncture kit.
 
DrN2O said:
Angiocath method is routine at certain places. I don't think it's any easier than the thin-walled needle, because it adds at least two more steps where the newbies can lose the access. #1: separating the angiocath from the needle. #2: advancing the angiocath into the vein. #1b people like to pre-separate the angiocath from needle, this just makes any withdraw and redirect more difficult. I think the teaching is: big vein, angiocath; small vein, straight needle; hard anatomy: micropuncture kit.
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I don't disagree with what is bolded above.

To clarify - The issue with I see very often with newbies is that they try to only use the Raulerson syringe in the kits we have. (It was painful to watch during my time in the MICU.)

But hard anatomy is not something I typically have a true newbie attempt. That may make me a jerk attending, but I've see too many sequela of shenanigans to ignore the impact that inexperience can have with already challenging access.
 
DrN2O said:
Angiocath method is routine at certain places. I don't think it's any easier than the thin-walled needle, because it adds at least two more steps where the newbies can lose the access. #1: separating the angiocath from the needle. #2: advancing the angiocath into the vein. #1b people like to pre-separate the angiocath from needle, this just makes any withdraw and redirect more difficult. I think the teaching is: big vein, angiocath; small vein, straight needle; hard anatomy: micropuncture kit.
Click to expand...
You can make it even simpler and just give the resident a long 18 gauge IV. If a resident is unable to do an ultrasound guided IV into a massive vessel like the IJ they probably shouldn’t be putting a steel needle into the neck.
 
james775 said:
You can make it even simpler and just give the resident a long 18 gauge IV. If a resident is unable to do an ultrasound guided IV into a massive vessel like the IJ they probably shouldn’t be putting a steel needle into the neck.
Click to expand...

How is this appreciably different than just using the angiocath from the kit? You walk it in under US guidance the same way.
 
Beeftenderloin said:
How is this appreciably different than just using the angiocath from the kit? You walk it in under US guidance the same way.
Click to expand...

It’s the same but a commenter mentioned that residents were having trouble threading and unscrewing syringe for angiocath in kit. If you stick the angiocath without syringe attached it will bleed back on you. IV will keep it in the chamber.
 
james775 said:
You can make it even simpler and just give the resident a long 18 gauge IV. If a resident is unable to do an ultrasound guided IV into a massive vessel like the IJ they probably shouldn’t be putting a steel needle into the neck.
Click to expand...
Yeah but if you make them start it like a regular IV you have to put a tourniquet around the neck and that upsets the nurses and leads to incident reports.
 
I use the bare needle in the kit, no angiocath. Ultrasound out of plane. Blood back, tip viewed in lumen, drop probe, brace needle on neck/mandible with left hand, wire in. Verify with ultrasound that the wire is in the vein before dilating, scanning down the neck as far as I can, and print that image for billing.

If I have any doubt at all that the wire isn't in the IJ and only the IJ, I put the angiocath in over the wire to transduce before dilating. Maybe once or twice per year I do that.

When I was a fellow we'd put the TEE probe in right after intubation and park it in a modified bicaval view and watch for the wire. I may go back to doing it that way. Logistically it's a little difficult to do that since the echo machine would be where my line tray sits.


When I was teaching residents I'd either visualize the wire on TEE before dilating, or make them transduce every time. Very different risk profile when a trainee is holding the probe and needle.

I once had one make a skin nick by sinking the entire 11 blade to the hilt. It bled like you'd imagine it would and I was afraid the carotid got opened. Held pressure and called vascular surgery over, who determined that nope you just but a really really big hole in the IJ. I was always super super conservative with trainees.

My practice is a little different now that it's just me.
 
james775 said:
You can make it even simpler and just give the resident a long 18 gauge IV. If a resident is unable to do an ultrasound guided IV into a massive vessel like the IJ they probably shouldn’t be putting a steel needle into the neck.
Click to expand...
This is a very interesting idea. But this removes one thing that I'm trying to teach the trainees which is the feel of blood return when they enter the vein. It's already hard enough to unglue their eyes from the ultrasound screen even when they have already (unknowingly) back-walled the vein because they didn't track the needle tip.

I personally have switched to oblique approach to the RIJ based on some radiology paper. It lets me visualize the needle in-plane and keep the carotid in view at the same time. But that's a bit more cognitive load for the residents.
 
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