Wire Gremlins

[Beeftenderloin]

Last week I placed a CVC with an attending I haven’t worked with before. 1 stick, wire threads easy, pick up US to confirm wire placement and promptly get reprimanded for letting go of the wire.

I understand the classic teaching is to NEVER let go of the wire otherwise magical wire gremlins will without failure pull the wire inside of the patient, resulting in embarrassing vascular surgery consults, M&M presentations and badness for patients. However, in practice, I and many others I’ve worked with let go of the wire all the time. I have never actually lost a wire but my understanding is that wires get lost when you lose control of or forget to pull out out the wire while dilating or threading your catheter, not wire gremlins.

Has anyone on here actually ever seen, experienced or heard of a wire getting “sucked in”? Would love to know if I’m being cavalier or reasonable.

---

Members don't see this ad.

 

[IMGASMD]

Classic teaching also tells me not to let go of the tube until it’s taped and secured.

If you have 20cm of wire, or 10cm of the epidural catheter hanging out.... it ain’t going anywhere.....

But if you are a first year, and who don’t have a “routine” down pat yet. I’d prefer you to have a handle on that wire.....

Edit: had an attending who was very green lost a wire. iR had to go retrieve it. Needless to say, he didn’t stay for long.

 

[MirrorTodd]

I'd say you're being reasonable. It certainly seems like those old school views are changing. I've actually had more than a few attendings tell me when I've been learning central lines to let go of the wire and don't worry about it getting sucked in. Honestly, the time when I've almost lost the wire is when the attending changed my process mid line and forced me to do it another way.

 

[deleted875186]

wore doesn’t go anywhere. When putting in a MAC line I frequently need to hold skin traction with one hand while advancing with the other, so I let go of the wire. Really, the saying should be never loose sight of your wire.

I still do announce to myself and everyone else in the room “wire removed” after the CVC goes in.

 

[deleted697127]

Ugh. Yea. They do get sucked in. You don’t get to make the rules for which corners you cut as a resident. If your attending wants you to do it a certain way, do it that way. It is fair game to ask him how he would control it. But yes, they absolutely do get sucked in.

 

[abolt18]

Ugh. Yea. They do get sucked in. You don’t get to make the rules for which corners you cut as a resident. If your attending wants you to do it a certain way, do it that way. It is fair game to ask him how he would control it. But yes, they absolutely do get sucked in.

If you leave a wire at 20cm at the skin. You're saying the wire can get pulled an additional 20-30cm into the body if your hand is not on it?

 

[coffeebythelake]

Agree you don't need to constantly hold the guidewire. Just Watch the guidewire, make sure it comes out the end of the central line or dilator and doesn't slide in as you are manipulating the line. Also good idea to give it a little wiggle as you are advancing your dilated or line to make sure it still moves freely

 

[MirrorTodd]

Ugh. Yea. They do get sucked in. You don’t get to make the rules for which corners you cut as a resident. If your attending wants you to do it a certain way, do it that way. It is fair game to ask him how he would control it. But yes, they absolutely do get sucked in.

Prelim google search did not yield any hard results of a guidewire getting "sucked in". Maybe you could provide some proof? Most of the info I found regarding retained guidewires, the people got distracted or had to use multiple kits and didn't keep count while inserting.

 

[deleted697127]

If you leave a wire at 20cm at the skin. You're saying the wire can get pulled an additional 20-30cm into the body if your hand is not on it?

Probably not. I think it more likely happens while pushing the catheter over the wire or shortly after while not holding on to the wire. But I’ve sat through this m and m. Seems like no one usually remembers what exactly happened. Give it a google. There are a zillion case reports of wires found on cxr days later. I know of 2 or 3 from residency. One where a port wouldn’t flush because it had a wire in it. It’s like doing surgery on the wrong side. Your attendings have a right to be picky about it.

 

[deleted697127]

Prelim google search did not yield any hard results of a guidewire getting "sucked in". Maybe you could provide some proof? Most of the info I found regarding retained guidewires, the people got distracted or had to use multiple kits and didn't keep count while inserting.

I would assume the same way negative intrathoracic pressure can cause an air embolism? You may be right but i still think controlling the wire is a reasonable request.

 

[psychbender]

Probably not. I think it more likely happens while pushing the catheter over the wire or shortly after while not holding on to the wire. But I’ve sat through this m and m. Seems like no one usually remembers what exactly happened. Give it a google. There are a zillion case reports of wires found on cxr days later. I know of 2 or 3 from residency. One where a port wouldn’t flush because it had a wire in it. It’s like doing surgery on the wrong side. Your attendings have a right to be picky about it.

Those wires were not sucked in by some overwhelming negative pressure. They were advanced in by human hands, and left there, because the person placing the line did not realize they were advanced in. There's really not much mystery to it.

 

[deleted697535]

Ugh. Yea. They do get sucked in. You don’t get to make the rules for which corners you cut as a resident. If your attending wants you to do it a certain way, do it that way. It is fair game to ask him how he would control it. But yes, they absolutely do get sucked in.

.
How do Wires dont get sucked in on paralyzed head down patients? which is 99.99% of our customers?

they get pushed in by inattentive or careless hands that have left too little margin for error with a wire 1cm out of the skin or catheter...

 

[Hoya11]

Last week I placed a CVC with an attending I haven’t worked with before. 1 stick, wire threads easy, pick up US to confirm wire placement and promptly get reprimanded for letting go of the wire.

I understand the classic teaching is to NEVER let go of the wire otherwise magical wire gremlins will without failure pull the wire inside of the patient, resulting in embarrassing vascular surgery consults, M&M presentations and badness for patients. However, in practice, I and many others I’ve worked with let go of the wire all the time. I have never actually lost a wire but my understanding is that wires get lost when you lose control of or forget to pull out out the wire while dilating or threading your catheter, not wire gremlins.

Has anyone on here actually ever seen, experienced or heard of a wire getting “sucked in”? Would love to know if I’m being cavalier or reasonable.

I personally do not let go of the wire.. I guess just a habit but also because there is really no reason to..

You thread it in and you take the catheter out. You hold it in place while the catheter comes out.

You reach your other hand and get knife, make your nick, knife down, other hand grabs the TLC.

You feed the wire up into the TLC and you see it coming out the brown port.

You grab the end of the wire out of the brown port. You are always touching the wire.

If I were to leave the wire there I would make sure there is a good amount still sticking out.

 

[MirrorTodd]

I would assume the same way negative intrathoracic pressure can cause an air embolism? You may be right but i still think controlling the wire is a reasonable request.

I'd agree that it's reasonable too. But personally, I'm more worried about accidentally pulling the wire out than I am about it accidentally sliding in.

 

[deleted697535]

Probably not. I think it more likely happens while pushing the catheter over the wire or shortly after while not holding on to the wire. But I’ve sat through this m and m. Seems like no one usually remembers what exactly happened. Give it a google. There are a zillion case reports of wires found on cxr days later. I know of 2 or 3 from residency. One where a port wouldn’t flush because it had a wire in it. It’s like doing surgery on the wrong side. Your attendings have a right to be picky about it.

Im sorry but if an M and M case gets as far as ' a port wouldn’t flush because it had a wire in it', im out...
Whoever did this is so inexperienced or innattentive/stressed, they do not share the same profession.

Its like a junior mechanic being asked to never take his hands off the tires he is changing in case he loses one

Starting with a wire on your tray, and finishing with no wire on your tray has to raise some alarms or else you're a blind donkey

 

[patriot6]

I personally do not let go of the wire.. I guess just a habit but also because there is really no reason to..

You thread it in and you take the catheter out. You hold it in place while the catheter comes out.

You reach your other hand and get knife, make your nick, knife down, other hand grabs the TLC.

You feed the wire up into the TLC and you see it coming out the brown port.

You grab the end of the wire out of the brown port. You are always touching the wire.

If I were to leave the wire there I would make sure there is a good amount still sticking out.

I keep my hand on the wire up until it's time to put the introducer in. Then, my left hand applies significant traction to the skin, while my right hand advances the introducer. I stop along the way to make sure the wire still moves freely. The wire isn't going anywhere.

 

[deleted697127]

Im sorry but if an M and M case gets as far as ' a port wouldn’t flush because it had a wire in it', im out...
Whoever did this is so inexperienced or innattentive/stressed, they do not share the same profession.

Its like a junior mechanic being asked to never take his hands off the tires he is changing in case he loses one

Starting with a wire on your tray, and finishing with no wire on your tray has to raise some alarms or else you're a blind donkey

Lol. yea agreed it was not the smartest but it’s medicine. Things happen. The resident got report before going to the or that the catheter wouldn’t flush and they looked at the CXR. It had been placed by the ICU and rounded on with more than one CXR with no one noticing including radiology.

 

[IMGASMD]

Lol. yea agreed it was not the smartest but it’s medicine. Things happen. The resident got report before going to the or that the catheter wouldn’t flush and they looked at the CXR. It had been placed by the ICU and rounded on with more than one CXR with no one noticing including radiology.

So at least 6 pairs of eyes had seen the films.
Icu intern, resident. Radiology resident/attending. Another set of radiology resident and attending?!

That’s not including the ICU team who supposedly round on cxr too?


W T F.

 

[Gator7]

For open heart I typically double stick and put in both wires first prior to the tlc or cordis. No realistic way to hold both wires the entire time and have never seen one get sucked in. The cases that have happened here are usually from Attendings known to be careless with the same story of “Idk what happened.” Same Attendings that put central lines in the carotid.

 

[GassYous]

I do the same as patriot6. I've done hundreds of central lines, have let go plenty of times and never had it get sucked in. But I have heard of wires getting left in and having to be retrieved although I don't know the exact details of what happened. I keep an eye on it like everyone else but don't lose my mind if I let go of it for a few seconds.

 

[chessknt]

Agree with above wire isn't going to magically get sucked in. I've put cvc in plenty of septic hypovolemic patients and wire still doesn't get sucked in.

That being said your attending is teaching technique and plenty of attendings have quirks so it's best to just roll with whatever then do what you want when you're done.

 

[nimbus]

When you double or triple stick a vessel to put in multiple lines, you have to let go of the wire and it does not get sucked in.

 

[deleted162650]

Just don’t feed your wire after midnight and you shouldn’t have any problems.

 

[sethco]

Amazingly, this actually happened at our flagship hospital to one of our Intensivists, where the guidewire for was sucked into the circulation from the IJ position. He put in the guidewire, turned to grab the skin knife/dilator, and the wire was gone. HOWEVER, big caveat, this patient was on ECMO which provided a vacuum-like effect. Other than that, I have never seen or heard of a guidewire being sucked into the body

 

[Iso4ane]

Amazingly, this actually happened at our flagship hospital to one of our Intensivists, where the guidewire for sucks into the circulation from the IJ position. He put in the guidewire, turned to grab the skin knife/dilator, and the wire was gone. HOWEVER, big caveat, this patient was on ECMO which provided a vacuum-like effect. Other than that, I have never seen or heard of a guidewire being sucked into the body

Yep, this is one of the few scenarios that I would think about having very close control of the wire. Another would we spontaneous Kussmauls Breathing.

 

[fakin' the funk]

- patient on positive pressure ventilation, not making respiratory efforts, high venous pressure (most OR pts) - no risk
- ICU or trauma pt who is crazy dry, breathing hard, not intubated, can't lay flat - yes you have to worry
- agree with others that far more likely is the chance of advancing wire too far or forgetting it

 

[Dexmetaketapropofol]

Total artificial heart is a Wire Gremlin don't forget

 

[Iso4ane]

Total artificial heart is a Wire Gremlin don't forget

That will just eat your wire and make the total artificial heart sick. Don’t feed wires to the Total Artificial Heart.

 

[mdawarre]

Amazingly, this actually happened at our flagship hospital to one of our Intensivists, where the guidewire for was sucked into the circulation from the IJ position. He put in the guidewire, turned to grab the skin knife/dilator, and the wire was gone. HOWEVER, big caveat, this patient was on ECMO which provided a vacuum-like effect. Other than that, I have never seen or heard of a guidewire being sucked into the body

Almost happened to me as a PGY2 doing an IJ. Pt was very sick, on CRRT. The wire just felt weird to me, like there was traction on it. It was also hard as hell to stick the IJ. It was tiny.

 

[Hoya11]

I keep my hand on the wire up until it's time to put the introducer in. Then, my left hand applies significant traction to the skin, while my right hand advances the introducer. I stop along the way to make sure the wire still moves freely. The wire isn't going anywhere.

i hold the wire tip with my right hand and advance the introducer over the wire with my left. i dont apply any skin traction, just make a big enough nick

 

[vector2]

I’ve let go of the wire routinely for the last 5-6 yrs and have never had an issue.

 

[BobBarker]

I did a IJ on a total artificial heart as an intern. I didn’t advance the wire very far and definitely held onto it.

 

[abolt18]

Probably not. I think it more likely happens while pushing the catheter over the wire or shortly after while not holding on to the wire. But I’ve sat through this m and m. Seems like no one usually remembers what exactly happened. Give it a google. There are a zillion case reports of wires found on cxr days later. I know of 2 or 3 from residency. One where a port wouldn’t flush because it had a wire in it. It’s like doing surgery on the wrong side. Your attendings have a right to be picky about it.

See, to me these are different things. Taking your hand off the wire and letting it lie on the patient's neck while you're not manipulating it is FINE (like when double-sticking as described elsewhere on this thread). Taking your hand off the wire while you're threading something over it like the dilator or catheter is NOT FINE.

This also is a general rule. When you have a mechanical device inside the venous system that is a vacuum, which could literally pull the wire in, then rules change and I would hear and support an argument that you should NEVER take your hand off that wire.

 

[chocomorsel]

See, to me these are different things. Taking your hand off the wire and letting it lie on the patient's neck while you're not manipulating it is FINE (like when double-sticking as described elsewhere on this thread). Taking your hand off the wire while you're threading something over it like the dilator or catheter is NOT FINE.

This also is a general rule. When you have a mechanical device inside the venous system that is a vacuum, which could literally pull the wire in, then rules change and I would hear and support an argument that you should NEVER take your hand off that wire.

You need two hands to put a dilator over the wire. Are people pushing in the dilator with just a tiny bit of wire sticking out the other end?
Once the dilator is in and wire is sticking out on the other side, it should not slide into the patient is you have plenty of it sticking out.

 

[Hork Bajir]

Keeping control of the wire is important. However, keeping control of the wire doesn’t necessarily mean never letting go of the wire. In patients undergoing PPV (provided they are not in reverse T-berg) the risk of the wire getting sucked in is zero. As mentioned above, a spontaneously breathing patient is slightly higher risk; patients on MCS are a whole different ball game (both for risk of wire loss and for air entrainment).

If you need to keep the end of the wire pinned down (for neurosis, attending preference, or any other reason) and want to use two hands for dilation (one hand holds traction and the other advances the dilator with intermittent checks to ensure the wire still moves freely), consider looping the wire around and using a large tegaderm to pin down the end of the wire somewhere on the sterile field. Typically not necessary, but gets the job done. I do this when I’m double sticking the neck and one of the wires is longer/stiffer, in order to hold the wire out of my way for the second stick while preventing contamination of the end

 

[Planktonmd]

Last week I placed a CVC with an attending I haven’t worked with before. 1 stick, wire threads easy, pick up US to confirm wire placement and promptly get reprimanded for letting go of the wire.

I understand the classic teaching is to NEVER let go of the wire otherwise magical wire gremlins will without failure pull the wire inside of the patient, resulting in embarrassing vascular surgery consults, M&M presentations and badness for patients. However, in practice, I and many others I’ve worked with let go of the wire all the time. I have never actually lost a wire but my understanding is that wires get lost when you lose control of or forget to pull out out the wire while dilating or threading your catheter, not wire gremlins.

Has anyone on here actually ever seen, experienced or heard of a wire getting “sucked in”? Would love to know if I’m being cavalier or reasonable.

I have been doing this business for along time, placed countless central lines, let go of the wire every single time, never had a problem!

 

[jw3600]

I have been doing this business for along time, placed countless central lines, let go of the wire every single time, never had a problem!

Help an EM colleague understand what double sticking the neck is? Is this venous access AND arterial access for bypass or something?

Edit: Google surprisingly helpful. You guys routinely double cannulate the IJ?

 

[Planktonmd]

Help an EM colleague understand what double sticking the neck is? Is this venous access AND arterial access for bypass or something?

Edit: Google surprisingly helpful. You guys routinely double cannulate the IJ?

It's a good idea if you need to place a PA catheter and need another line for fluids.

 

[GassYous]

It's a good idea if you need to place a PA catheter and need another line for fluids.

We use a 9 fr that does both

 

[abolt18]

Help an EM colleague understand what double sticking the neck is? Is this venous access AND arterial access for bypass or something?

Edit: Google surprisingly helpful. You guys routinely double cannulate the IJ?

Only time I really double sick usually is for liver transplants and sometimes heart transplants/LVADs in redo chests. In those cases, one line is a 9Fr MAC introducer that we thread a PAC through and the other is a 13Fr Hog (that's what we call it, but it's a dialysis line). It attaches both its lumens very nicely to a rapid infusion system (RIS).

 

[vector2]

An Arrow MAC introducer is a 14 fr (4.7 mm) external diameter catheter. It's got a 9 fr introducer port and the 12g side port.

Another important point is that the 12g (white port) has a faster flow rate than the 9 fr introducer port if you have a swan or a SLIC going through the introducer.

 

[Beeftenderloin]

An Arrow MAC introducer is a 14 fr (4.7 mm) external diameter catheter. It's got a 9 fr introducer port and the 12g side port.

View attachment 325519

Another important point is that the 12g (white port) has a faster flow rate than the 9 fr introducer port if you have a swan or a SLIC going through the introducer.

The 9fr lumen is still a bit faster than the 12g lumen, even with an 8fr catheter inside it. Though your point is well made. Putting any kind of catheter through the introducer will drastically reduce the flow rate.

 

[GassYous]

I like the ric in the ac for livers

 

[vector2]

The 9fr lumen is still a bit faster than the 12g lumen, even with an 8fr catheter inside it. Though your point is well made. Putting any kind of catheter through the introducer will drastically reduce the flow rate.View attachment 325527

They should work on more consistent advertising. I've also tested it n = a few with the Belmont and the 12g is definitely faster under pressure when a swan is present.

 

[Iso4ane]

View attachment 325519

Another important point is that the 12g (white port) has a faster flow rate than the 9 fr introducer port if you have a swan or a SLIC going through the introducer.

The 9fr lumen is still a bit faster than the 12g lumen, even with an 8fr catheter inside it. Though your point is well made. Putting any kind of catheter through the introducer will drastically reduce the flow rate.View attachment 325527

Our packaging shows that brown is always faster than white, regardless of the presence of a swan/dlic too, but in practice I find the White port is faster when a Swan/DLIC is in place.

EDIT: The values we have are similar to these