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[gasattack3]

So, I'm putting in some large catheters for CRRT patients. Quintons in the SICU.

I've had 3 catheter kinks over the past couple years. As you may know, it can be a b.tch when that happens.

I've had it happen with an 8.5 F introducer to an IJ x2 and then today with a simple 7 F double lumen to a femoral vein.... It happened again with a 2 dilator Quinton set up but it was mild and I was still able to thread the catheter over the wire.

I've noticed that this happens when I need to dilate through a lot of SQ tissue, and the IJ's have both been with fatties. The double lumen to the femoral v. happened on a not-so-fatty, but still it was deeper than a regular IJ.

How can I avoid this?? Today, I had to ultimately pull out the guidewire and start fresh, with a new kit. The catheter simply would not pass.

The kinks are obviously coming from the dilator coming down at too obtuse an angle and once they kink you're screwed.

I realize it's my technique, but what can be done to alter this?? I'm open to any suggestions. Again, it's only happened a few times but it's a major hassle, especially given that you're putting these things into as sick of patients as we do.

What am I doing wrong?

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[Jay K]

The kinks are obviously coming from the dilator coming down at too obtuse an angle and once they kink you're screwed.

So that we are on the same page, I'm assuming you mean that the angle of needle entry and hence dilator are at a "closer to" perpendicular angle. You've identified this problem already. Given you have sufficient length of needle to enter at an acute angle (needle & aspirating syringe laid lower/closer to skin <45 degrees) and still penetrate the vessel, use ultrasound to evaluate the length of the scan-able portion of the vessel and enter as appropriate judging how much catheter you'll have in the vessel, given the angle of entry and given how much subcutaneous tissue you'll have to clear. Essentially your catheter will be the hypotenuse of the "triangle" since these catheters are fairly rigid and won't facilitate as much curve/bend as a regular CVL. Entering at a small acute angle will make for a straighter path and less bend to the dilator and catheter and subsequently less risk for kinking the catheter.

This works for me.

 

[gasattack3]

So that we are on the same page, I'm assuming you mean that the angle of needle entry and hence dilator are at a "closer to" perpendicular angle. You've identified this problem already. Given you have sufficient length of needle to enter at an acute angle (needle & aspirating syringe laid lower/closer to skin <45 degrees) and still penetrate the vessel, use ultrasound to evaluate the length of the scan-able portion of the vessel and enter as appropriate judging how much catheter you'll have in the vessel, given the angle of entry and given how much subcutaneous tissue you'll have to clear. Essentially your catheter will be the hypotenuse of the "triangle" since these catheters are fairly rigid and won't facilitate as much curve/bend as a regular CVL. Entering at a small acute angle will make for a straighter path and less bend to the dilator and catheter and subsequently less risk for kinking the catheter.

This works for me.

Yes, I think you are spot on. Thanks for the reinforcement. I think I've become too accustomed to diving too perpendicular to the skin so that I can see the needle with the US better. Heck, maybe I will be able to see it better the other way anyway.

I for sure need to modify my technique to a more "acute" ( per your <45 degrees) angle.

Thanks again. If anyone else has anything else to add, it's welcomed.

 

[aredoubleyou]

Yes, I think you are spot on. Thanks for the reinforcement. I think I've become too accustomed to diving too perpendicular to the skin so that I can see the needle with the US better. Heck, maybe I will be able to see it better the other way anyway.

I for sure need to modify my technique to a more "acute" ( per your <45 degrees) angle.

Thanks again. If anyone else has anything else to add, it's welcomed.

Enter the neck lower (nearer to the clavicle) than usual. Make a big cut with the knife. Dilate the track as flush to the skin as possible. When you place high IJs, the jaw is in the way, leading to greater angles. When there is a lot of resistance on dilation, its often a wire kink, especially with vas caths.

 

[seinfeld]

Don't push the dilator in. Corkscrew it.

 

[Robokor]

I find that withdrawing the guide-wire slightly when rotating the dilator into the tissue helps a lot in not getting caught in the ileo-femoral bend when doing femoral HDcaths (>24cm).

 

[deleted9493]

Practice with an in-plane approach using ultrasound.

Center the vessel using a short axis view, then turn your probe 90 degrees to get the long axis view. This view may give you a better sense of what you're actually doing with regard to angle of vessel entry.

https://carmenwiki.osu.edu/display/10337/Vascular+access

I'd echo the comments of the other posters--corkscrewing over the guidewire and ensuring thorough skin opening with your blade are hugely helpful, as well.