I am a CA-1 and have put in maybe 8-10 RIJ central lines over the past 1.5 years. Not enough repetition for me to feel really comfortable yet. The main problem that I seem to be having is threading the guidewire. Usually no problems accessing the IJ (although I did have one accidental carotid puncture which we recognized). When I am threading the guidewire I usually get to a point maybe 8-10 cm into threading it where I meet resistance. Usually I pull back on the guidewire, attempt to turn it and readvance it. Often times the same issue with some resistance that I don't want to push through. Sometimes my attending will glove up and flip the guidewire so that instead of the curved end they will pass the other blunt end. It seems like this helps sometime. Any tips on what I am doing wrong here?
Thanks for the help. It is really bothering me that I am needing to get bailed out on my lines. I am headed to the ICU for a few months coming up and am going to have to put lines in unsupervised at night so I need to get this figured out.
do not get into the habit of doing that.
first thing i do when i cant thread the wire is remove the wire, hook the syringe back up, re-establish good flow, and then rotate the needle so that the bevel points in a different direction (90-180, whatever). that may redirect the wire away from the vessel wall
i feel that when people place US-guided IJ lines they forget which direction the vessel naturally goes and simply lock their eyes on whatever in on the screen. occasionally the needle is not as parallel to the vessel as it should be, and as a result (especially if its up against the wall), your wire will not thread easily. it is also not as easy to hold the needle perfectly still when reaching for the wire, etc. and if it moves in or out a little, that can be an issue.
one thing that helped me in training (which i still do) is to use the needle with the flexible catheter on it, thread that catheter off the needle, and then thread the wire through that - if it threads easily, it is in the vessel and the wire should go easily. this also allows you to have more control over the vessel, i think, and to hook up the CVP tubing for assessing venous flow, if you are into that.
the best advice is simply to learn the anatomy, realize things arent always where they are supposed to be, and dont be afraid to restick. you will learn eventually what resistance you can push through and what resistance you cant, but ill tell you from firsthand experience, a needle in the middle of a vessel (and parallel to the flow of that vessel) provides very little resistance to a wire, in the absence of clot or other anatomical problem.
