Rewiring peripheral cannula

[deleted697535]

Had an horrific case yest that had me thinking all night.

Back home we had a lovely kit for the level 1 infusor that involved using a seldinger technique on a special stubby cannula that would go thru a standard 22g.

We don't have that in my place now.

Can I use the wire out of an art line to somehow replicate the same process and turn a 22g into a 14 or 16?

Anyone ever diy a trick like that?

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[deleted59964]

RIC Line

We have these

 

[sigrhoillusion]

Had an horrific case yest that had me thinking all night.

Back home we had a lovely kit for the level 1 infusor that involved using a seldinger technique on a special stubby cannula that would go thru a standard 22g.

We don't have that in my place now.

Can I use the wire out of an art line to somehow replicate the same process and turn a 22g into a 14 or 16?

Anyone ever diy a trick like that?

What was the case? Did you have access to the neck or groin?

As mentioned above a kit like above is nice. A-line wire (not sure what the smallest gauge they can go through, but I'm pretty sure at least a 20g... forget if 22g.

 

[vector2]

Minimum rewire gauge is 20g for arrow ric kits. I tried rewiring a 20g to a 16g once....it didn't go well. Even with a small nick, I found that our standard piv cannulas were too flimsy to thread over small wires without some kind of dilator/obturator.

 

[sigrhoillusion]

Ultrasound as well...

Again would like to know what the case was, and patient details (ESRD? PVD? Multiple bypasses?)

 

[ScarfTheVerb]

I've tried and failed a couple times to wire in an IV. I think the a line and RIC work so well because they have a tapered tip that slides through the skin well and into the vessel. Our standard IV cannula just get hung up on the skin or tear the vein in my experience.

 

[Orin]

Can I use the wire out of an art line to somehow replicate the same process and turn a 22g into a 14 or 16?

I've done it with a wire but primarily for when I'm using a long IV catheter to get into a deep vein with ultrasound guidance. Get it in, get flash, get wire, seldinger over the IV. All the above caveats are true. The difficult part of converting an existing 22g would be that your vein may only accommodate a 22g. Then you have to deal with a skin nick that is already healed up a bit, weird angles, etc.

If you're in a bind, IO it?

 

[deleted697535]

I'd prefer not to talk about the case.

So is there any 'diy' option that might be feasible using regular available equipment?
How about if I took the wire from an art line , put it thru an existing 20 guage and used the dilator from a cvp line, then tried to use a 14 guages or 16 guage?

 

[deleted162650]

dilator from a cvp line, then tried to use a 14 guages or 16 guage?

I would think the blunt edge of the IV cannula would get hung up when you try to thread it since the difference in diameter of the wire and the ID of the IV is so big. That's why the RICs have the tapered introducer stylet like a Cordis. If you're gonna use items out of a central line kit, you're probably better off just trying to thread the central line catheter itself over the wire since it has a tapered tip.

 

[AdmiralChz]

I'd prefer not to talk about the case.

So is there any 'diy' option that might be feasible using regular available equipment?
How about if I took the wire from an art line , put it thru an existing 20 guage and used the dilator from a cvp line, then tried to use a 14 guages or 16 guage?

You're using a lot of equipment (opening both a-line and CVL kits, high $$$) for such a poor risk:benefit ratio here and only getting a single peripheral out of it. Ultrasound is so much simpler and straightforward to use. I think you'd be better with a new stick in most instances that I can consider rather than attempting a re-wire. As others have said, if it's a true pediatric emergency then consider IO access if IV isn't available.

 

[AdmiralChz]

I placed a couple long-arm CVPs during residency and the kit involved a dilator for the basilic vein... interestingly when I google it all the citations are from prior to 1990. I think there's a reason so few people use them now...

 

[Robotic Wis-Hipple]

Micropuncture kit comes with a wire that would go down a 22ga and catheter that's more tapered sort of like a dilator, then you could wire that I guess and then place a 4Fr or 5Fr sheath that your interventional labs would have.

But I'm with the others, US-ing a more central vessel is both more rational and likely less expensive, time consuming, and likely less risky.

 

[deleted697535]

So the problem was mutliple multiple failed attempts peripherally, a clamped ivc and aorta, a cspine collar, and tpa. We had 3 working 20 guages on the remaining veins. I snuck a 16g into the ej thru the collar

I would've loved an easy way to convert one of the 20s into a 14

 

[nimbus]

So the problem was mutliple multiple failed attempts peripherally, a clamped ivc and aorta, a cspine collar, and tpa. We had 3 working 20 guages on the remaining veins. I snuck a 16g into the ej thru the collar

I would've loved an easy way to convert one of the 20s into a 14

Tough situation. I would take the collar off, leave the head midline, and stick the IJ with US guidance. If you need volume resuscitation, good IV access trumps potential C spine injury.

Another thing to consider is US guided brachial vein catheter....you can get a big 14gx6" single lumen in using seldinger if there's a nice vein. But a cordis in the IJ would be my first choice.

 

[sigrhoillusion]

Tough situation. I would take the collar off, leave the head midline, and stick the IJ with US guidance. If you need volume resuscitation, good IV access trumps potential C spine injury.

Another thing to consider is US guided brachial vein catheter....you can get a big 14gx6" single lumen in using seldinger if there's a nice vein. But a cordis in the IJ would be my first choice.

What he said. IV access. Hopefully don't need too much neck movement for IJ. If they are hypovolemic and hypotensive the ischemia to the brain will probably result in similar neurologic issues as the possible c-spine issue...

 

[deleted9493]

As others have pointed out, the issue in upsizing is doing so without adequate dilation/guidance. Sure, you can put a wire into a 20g angiocath smoothly but try to push a 14g over said wire and it will hang up/kink on the proximal portion of the vein, or tissue even before you get that far. You need a dilator that's tight to the wire and will carry the intended catheter past the barrier of the proximal vein (a dilator that is actually through the lumen of the final catheter...i.e. pass the dilator and catheter in unison, remove the dilator)...as is done with cordis kits or RIC lines.

 

[dchz]

Micropuncture kit comes with a wire that would go down a 22ga and catheter that's more tapered sort of like a dilator, then you could wire that I guess and then place a 4Fr or 5Fr sheath that your interventional labs would have.

But I'm with the others, US-ing a more central vessel is both more rational and likely less expensive, time consuming, and likely less risky.

I have an attending that would guide a 14g over the 5Fr or 16g over 4Fr and ultrasound guide it in.

 

[Laryngophed]

I'd prefer not to talk about the case.

So is there any 'diy' option that might be feasible using regular available equipment?
How about if I took the wire from an art line , put it thru an existing 20 guage and used the dilator from a cvp line, then tried to use a 14 guages or 16 guage?

At this point, if I open the central line kit, the patient is getting 16cmof plastic or a 9Fr. Hole in one of the IJs with inline held and I'm moving on with the day.

All that said, I tried to do the "DIY RIC" once and I ran into the problem everyone has hit on. My upsized catheter hung up at skin (fixed with skin nick) and vein. Like noted, you need something with a taper on it.

 

[Ronin786]

Subclavian is always another option. Sure TPA sucks and you can't hold pressure, but you're so deep into it at this point take whatever you can get.

 

[fakin' the funk]

Yes, agree with the others on the pitfall of "DIY RIC."

I tried to upsize a 20g PIV in the AC to something bigger (we had these great 14g 2" catheters). Wire, nick, thread fail (*doink*), thread fail, bigger nick, significant bleeding, pressure held x5 minutes, significant bleeding, tourniquet on upper arm while plastics/micro fellow was called to investigate the extent of vascular injury (minor). Learn from my mistake please.