Agree but one thing I consistently saw when I was teaching junior residents as a senior was them not having the needle tip under the probe and instead having the middle of the shaft of the needle under the probe. You have to know where the needle tip is. Have to see the needle tip tenting the IJ before you penetrate the vessel.
Problem #2: after drawing back blood on the syringe, often people get excited and jiggle around the needle tip too much while trying to take off the syringe and inadvertently pull the tip out of the vessel before they can thread the guidewire in. This can also be avoided by using the angiocath to put in the catheter like an iv and then thread the guidewire through the catheter. This is what I do now, but I wish I would have done it all through training. Way better than guidewire through needle in my opinion.
If I can tell you anything, just be cautious when you are starting and do not dilate unless you are truly certain you are in the right place. Everyone will forgive you if they need to grab gloves to help you out but dilating the carotid is a mistake you don't want to make.
This is good advice. A few other things that come to mind:
- You have the pt in Trendelenburg and are using ultrasound, right? For that matter, you're trying IJ lines, right?
- Think about the geometry of what you're trying to do. If you're perpendicular to the vessel with your transducer (which is how I trained), and a given pt's IJ is (say) 2cm deep where you're going for it, you can't make your skin puncture right next to the transducer and expect to get a good picture unless you follow the needle with the transducer - which is kinda difficult. Likewise, especially steep needle angles will make it harder for you to get the wire in.
- Color of the blood you're getting does not reliably show where you are. On room air, oxygenated blood (especially after several decades of smoking) may look sorta-kinda venous. Conversely, on an FiO2 of 1.0, even venous blood can be pretty reddish. If you have access to a sterile loop of tubing (the good kits have one), it works well as a confirmatory step. I've seen even good residents hit the carotid, but this should help detect it. As okayplayer said, dilating the carotid is not a good idea.
- Free the angiocath from the needle before using it - move it just enough (to avoid catheter shear) to ensure it's not sticking. It's awfully frustrating to get the needle placed well, then goof things up trying to get the angiocath to advance.
- Likewise, get your guidewire ready (also freed up, with the tip of the wire loaded properly into its guide) before you get going.
- See a trend here? Take a moment at the beginning to get all your stuff ready, so that once you take the needle in your hand, you don't have to distract yourself with equipment.
- Remember where the IJ and carotid are when suturing, please.
That's all I can think of for now. Good luck!