I've put in an IJ that met resistance early. Said screw it and threaded the catheter anyways. Post op c-xray: The catheter was turned acutely from IJ to the subclavian. Thank god it wasn't a cordis or a really long case. I haven't had one with resistance since, but I personally wouldn't thread it if I did. THere is always the possibility of partially thrombosed vein as well.
Correct. My experiences tell me never to thread a catheter over a guide wire which will not advance to at least 15 cm. You are just asking for trouble. At least the catheter is soft and will mst likely just curl up or not advance.
Over 10k central lines (?12-13K) and I've seen or had every complication published. Every one. Fortunately, they are rare and even rarer these days with U/S and prudence.
I've had more than dozen thrombosed or blocked veins over the past 5 years. Many are dialysis patients or others with medical conditions know to increase this incidence.
The frustrating part of this condition is the fact the IJ may be huge on U/S yet the wire won't advance very far.
As for placing a Cordis in a patient described by the OP it may end up one of two ways: the cords goes in fine and functions well or it ruptures the vein and the patient expires. If the latter happens to you be prepared to face the malpractice music.
Been on a CA 3 heart rotation. My last to central lines presented this. Site Rite, Stick, Good Flow, Guide wire goes in fine for 10cm(estimated) then meets resistance. Both times I have taken guide wire out, confirmed good venous flow with aspiration and ultrasound changed the needle angle to more shallow and tried to advance guide wire again with resistance at same spot.
The first time my attending had same problem, used a different type of guide wire and threaded the cordis. Second time another attending did another stick slightly more cephalad and had no issues.
After the second central line, my attending and I were talking and he told me that I should have tried to thread the cordis even though the guidewire met resistance at 10cm. He says it is just a GUIDE wire. You don't need to thread the thing 20cm like everyone does. Once you are in the vein you can thread the central line.
What do you all think?
I have a low threshold for going to another site when that happens. I will try one more time after getting resistance that I'm sure is distal to needle, then move on I assume something's thrombosed proximal.
I have had staff who push through resistance, but I'm not that bold yet.
My staff last night suggested having the patient turn their head TOWARDS the side of the subclavian we were working on when passing the wire. His opinion is, it's less likely to go up the ipsilateral IJ that way.
One of my pet peeves is people who put the wire in 'til only 1–2cm are sticking out. I tell my residents that past about 20cm, the risk/benefit ratio goes to infinity. Some people like to go to 30+ - I think they want to see ectopy to convince themselves they're in the right spot.
Correct. My experiences tell me never to thread a catheter over a guide wire which will not advance to at least 15 cm. You are just asking for trouble. At least the catheter is soft and will mst likely just curl up or not advance.
Over 10k central lines (?12-13K) and I've seen or had every complication published. Every one. Fortunately, they are rare and even rarer these days with U/S and prudence.
I've had more than dozen thrombosed or blocked veins over the past 5 years. Many are dialysis patients or others with medical conditions know to increase this incidence.
The frustrating part of this condition is the fact the IJ may be huge on U/S yet the wire won't advance very far.
As for placing a Cordis in a patient described by the OP it may end up one of two ways: the cords goes in fine and functions well or it ruptures the vein and the patient expires. If the latter happens to you be prepared to face the malpractice music.
Blade, have you ever seen tamponade from a line? It was reported in a recent study of U/S-guided SC lines, and that was a new one for me.
My staff last night suggested having the patient turn their head TOWARDS the side of the subclavian we were working on when passing the wire. His opinion is, it's less likely to go up the ipsilateral IJ that way.
I think there was some study from the 90s that showed that decreased the incidence of IJ cannulation. I just advance the wire to 20 cm. If you get resistance at 10cm you've probably gone down the subclavian. I'll pull back to 5 cm and rotate the wire so the J tip points the other direction. I wouldn't place an introducer if the wire only goes to 10 cm.
Just yesterday I placed a line that screwed the crap out of me. I usually have the TEE in before the line, I didn't yesterday because it wasn't ready. US guided stick with the Angiocath, tested with pressure tubing, saw the wire in short axis and long axis in the IJ fine. Tried to place the MAC but seemed that my skin nick wasn't big enough. At that point I'll frequently take the dilator out and do a separate dilation, that went easily. Placed the MAC easily, had some resistance taking the wire out, when I got it out it assumed a curled up configuration. Now I'm a bit worried. I aspirate on the lumens and get nothing. So I take the catheter out and hold pressure. Not a minute later the patient codes. I start CPR while the nurses call the cardiac surgeon and start prepping the patient. Thankfully he came back after <10 seconds. I think that's been the most terrified I've ever been. Patient was stable after, no vascular injury, only a small neck hematoma. I have no idea where that MAC went but I was very lucky yesterday.
I am betting your cordis was along side the IJ with the wire exiting the tip of the dilator, bending 180 to run back up alongside the cordis and entering the IJ above where the tip of your cordis now lies then bending another 180 into the IJ. Your description exactly mirrors a complication I witnessed during fellowship. We left the line in and studied it.
I am curious if you would choose to remove the line if something like this happened again. I like the idea of defining where the line is if something goes awry. Obviously if I misplaced a line and the patient immediately coded, I would remove it, but it sounds like the patient coded after you removed the line.
I love having the TEE with the multiplane at 120ish and watching for that beautiful J in the right atrium.
IN RE the original question... I do not have nearly the experience of Blade, but I have only once placed a line when I could not FREELY advance and withdraw the wire at will or somehow visualize the wire distal to an explainable obstruction. It was an emergency and the guy had multiple pacer wires in the SVC. I assumed the resistance I was feeling was those and I got away with it.
One time I had resistance and I did a careful examination of the wire with U/S. It traversed the IJ and entered a small vein that joined the IJ and travelled inferiorly almost parallel to the IJ. Had I placed the cordis it would have torn said vein and I might have not noticed it until trying to explain the falling HCT later in the case. As it was I used real-time U/S to retrieve the wire to the junction, rotate it into the IJ, and advance into the correct lumen. The attending I was working with wasn't a huge U/S fan before this, but was pretty impressed and thought thatI should publish it.
Other times, I have had resistance only to find out that there is clot distal to my attempted insertion site.
I would recommend against placing a catheter if any unexplainable resistance is encountered.
I don't pay attention to the exact length of the wire anymore, I just know about how far I want it in. I go about 20-25cm and I would guess that I would feel uncomfortable at <15cm. If I was working with residents/ CRNAs/ AAs I would be a little more specific about having an exact number to shoot for so that we are on the same page.
I don't try for ectopy, but I am not unhappy when it occurs so my actual length may be closer to 30cm.
- pod
I once placed a cordis with similar resistance at about 15 cm. Placed a silastic catheter, drew back blood, transduced the silastic catheter which showed venous waveform. Couldn't see wire in TEE, but could see when I injected air bubbles through silastic catheter. Attending and I (i was a resident at the time) decided to place cordis. Afterwards, when placing PAC, met resistance at 15 cm repeatedly and eventually abandoned. While transducing cordis, still had venous waveform, drawing back blood, etc. We decided that wire and PAC were getting hung up on indwellingpacer wires. Did case (double valve with 2V CABG) and took pt to ICU. On post-op CXR, cordis was somehow going down RIJ and down right subclavian vein toward the arm. Don't ask me how the rigid catheter made this turn (it didn't really turn, it just seemed to have the venous anatomy jacked up around it), but by god that's what it did. To this day, I don't know how I did that without tearing up the dudes SVC and having him bleed to death. Since then, I will just switch sites if I run into wire that won't advance.
Except last week during a code in the ICU. I was there for airway, but intensivist couldn't get fem line in pulseless pt. They had that automatic chest compression device going. I did a blind RIJ triple lumen with the thing still going. Get in on first stick, but can't thread wire (either end) past 15 cm despite excellent blood return. I eventually just threaded it over the wire cuz this guy was going on 15 min compressions without IV access. He made it through the code (though died like 12 hours later). CXR showed my line at SVS/RA junction. I think the compression device was mechanically compressing the SVC so my wire wouldn't go any further. No way to prove it, but that's my theory.
I think there was some study from the 90s that showed that decreased the incidence of IJ cannulation. I just advance the wire to 20 cm. If you get resistance at 10cm you've probably gone down the subclavian. I'll pull back to 5 cm and rotate the wire so the J tip points the other direction. I wouldn't place an introducer if the wire only goes to 10 cm.
Just yesterday I placed a line that screwed the crap out of me. I usually have the TEE in before the line, I didn't yesterday because it wasn't ready. US guided stick with the Angiocath, tested with pressure tubing, saw the wire in short axis and long axis in the IJ fine. Tried to place the MAC but seemed that my skin nick wasn't big enough. At that point I'll frequently take the dilator out and do a separate dilation, that went easily. Placed the MAC easily, had some resistance taking the wire out, when I got it out it assumed a curled up configuration. Now I'm a bit worried. I aspirate on the lumens and get nothing. So I take the catheter out and hold pressure. Not a minute later the patient codes. I start CPR while the nurses call the cardiac surgeon and start prepping the patient. Thankfully he came back after <10 seconds. I think that's been the most terrified I've ever been. Patient was stable after, no vascular injury, only a small neck hematoma. I have no idea where that MAC went but I was very lucky yesterday.
Yeah... The code part is scary and I'd be searching for a reason. What happened during the code? Sats/bp/arrhythmia/etc...
I'd get an XRAY and would look for pulmonary parenchymal injury/ptx/hemiothorax/fluid collection. Those MACs have the potential to cause a lot of harm. Any pink-frothy edema like fluid out of the ETT during the case?
I'd prolly leave it in, alert the surgeon and take it out once the chest is open (if doing a heart)... under direct vision if possible. The surgeon can throw in some stitches if need be.
Blade, have you ever seen tamponade from a line? It was reported in a recent study of U/S-guided SC lines, and that was a new one for me.
At our hosptital, in the last 10 years we had at least 3 immediate deaths following line placement. One was a torn SVC after cordis placement, not sure the ultimate cause of death although it was within minutes. Second one was tension pneumo on someone with severe AS who coded and it was game over from there. Third one was with a swanz-ganz. Complete pulmonary artery rupture after balloon inflation intraop. DOn't know the details too much because it was before my time, but it was discussed in a line lecture we had last year. The attending with the pulm artery rupture didn't place swanz for some time, now he will place them only for the sickest patients and even then will NEVER reinflate after initial wedge.
Not to mention all the other deaths we probably had in the ICU from line sepsis.
Lines aren't benign procedures.
At our hosptital, in the last 10 years we had at least 3 immediate deaths following line placement. One was a torn SVC after cordis placement, not sure the ultimate cause of death although it was within minutes. Second one was tension pneumo on someone with severe AS who coded and it was game over from there. Third one was with a swanz-ganz. Complete pulmonary artery rupture after balloon inflation intraop. DOn't know the details too much because it was before my time, but it was discussed in a line lecture we had last year. The attending with the pulm artery rupture didn't place swanz for some time, now he will place them only for the sickest patients and even then will NEVER reinflate after initial wedge.
Not to mention all the other deaths we probably had in the ICU from line sepsis.
Lines aren't benign procedures.
Seen one VT/VF death from a PAC. Pt was old/sick, and had no reserve: never got ROSC.
In the unit we often get to decipher the mysterious "line to nowhere" situations.
I am curious if you would choose to remove the line if something like this happened again. I like the idea of defining where the line is if something goes awry. Obviously if I misplaced a line and the patient immediately coded, I would remove it, but it sounds like the patient coded after you removed the line.
I love having the TEE with the multiplane at 120ish and watching for that beautiful J in the right atrium.
- pod
I don't know what is the right thing to do. Obviously if you dilate the carotid you leave the catheter in. I just need to stick to have the TEE in because it is very reassuring to see the wire (maybe that's why I never get ectopy?) But there will be plenty of lines in the future in non-cardiac cases, so the echo probe isn't the 100% answer. When I did a short axis view of the RIJ after the code resolved, I saw what looked like a big flap that was bunched up. Maybe I just dissected the IJ. Afterwards, the was a definite neck hematoma.
Yeah... The code part is scary and I'd be searching for a reason. What happened during the code? Sats/bp/arrhythmia/etc...
I'd get an XRAY and would look for pulmonary parenchymal injury/ptx/hemiothorax/fluid collection. Those MACs have the potential to cause a lot of harm. Any pink-frothy edema like fluid out of the ETT during the case?
I'd prolly leave it in, alert the surgeon and take it out once the chest is open (if doing a heart)... under direct vision if possible. The surgeon can throw in some stitches if need be.
This guy was in a fib, rate controlled. The code was asystole, no EKG complexes, no BP. Literally 5 compressions got him back. Some have proposed it was the neck compression from hematoma/my hand as I held pressure. No drugs required, didn't even get registered in the anesthetic record. The patient showed absolutely no effects and the case proceeded as usual.
I think in next 20 years the swanz-ganz will be obsolete once a-line flowtrac's, continuous SvcO2 monitoring and TEEs become cheaper and more mainstream.
People will view the swan as ancient as the way we view repeated manual BP measuring or continuous esophageal stethoscopy.
The PA catheter is still the only way to measure pulmonary artery pressures. It still has a use, although it definitely won't be used as frequently (100% in my current practice).
At our hosptital, in the last 10 years we had at least 3 immediate deaths following line placement. One was a torn SVC after cordis placement, not sure the ultimate cause of death although it was within minutes. Second one was tension pneumo on someone with severe AS who coded and it was game over from there. Third one was with a swanz-ganz. Complete pulmonary artery rupture after balloon inflation intraop. DOn't know the details too much because it was before my time, but it was discussed in a line lecture we had last year. The attending with the pulm artery rupture didn't place swanz for some time, now he will place them only for the sickest patients and even then will NEVER reinflate after initial wedge.
Not to mention all the other deaths we probably had in the ICU from line sepsis.
Lines aren't benign procedures.
I never wedge. PAOP is the only reason to wedge and PVR isn't really that important, even in liver transplants. My PACs sit either right before or right after the PA bifurcation.
I think there was some study from the 90s that showed that decreased the incidence of IJ cannulation. I just advance the wire to 20 cm. If you get resistance at 10cm you've probably gone down the subclavian. I'll pull back to 5 cm and rotate the wire so the J tip points the other direction. I wouldn't place an introducer if the wire only goes to 10 cm.
Just yesterday I placed a line that screwed the crap out of me. I usually have the TEE in before the line, I didn't yesterday because it wasn't ready. US guided stick with the Angiocath, tested with pressure tubing, saw the wire in short axis and long axis in the IJ fine. Tried to place the MAC but seemed that my skin nick wasn't big enough. At that point I'll frequently take the dilator out and do a separate dilation, that went easily. Placed the MAC easily, had some resistance taking the wire out, when I got it out it assumed a curled up configuration. Now I'm a bit worried. I aspirate on the lumens and get nothing. So I take the catheter out and hold pressure. Not a minute later the patient codes. I start CPR while the nurses call the cardiac surgeon and start prepping the patient. Thankfully he came back after <10 seconds. I think that's been the most terrified I've ever been. Patient was stable after, no vascular injury, only a small neck hematoma. I have no idea where that MAC went but I was very lucky yesterday.
Yes. I had one that wasn't so lucky
I am betting your cordis was along side the IJ with the wire exiting the tip of the dilator, bending 180 to run back up alongside the cordis and entering the IJ above where the tip of your cordis now lies then bending another 180 into the IJ. Your description exactly mirrors a complication I witnessed during fellowship. We left the line in and studied it.
I am curious if you would choose to remove the line if something like this happened again. I like the idea of defining where the line is if something goes awry. Obviously if I misplaced a line and the patient immediately coded, I would remove it, but it sounds like the patient coded after you removed the line.
I love having the TEE with the multiplane at 120ish and watching for that beautiful J in the right atrium.
IN RE the original question... I do not have nearly the experience of Blade, but I have only once placed a line when I could not FREELY advance and withdraw the wire at will or somehow visualize the wire distal to an explainable obstruction. It was an emergency and the guy had multiple pacer wires in the SVC. I assumed the resistance I was feeling was those and I got away with it.
One time I had resistance and I did a careful examination of the wire with U/S. It traversed the IJ and entered a small vein that joined the IJ and travelled inferiorly almost parallel to the IJ. Had I placed the cordis it would have torn said vein and I might have not noticed it until trying to explain the falling HCT later in the case. As it was I used real-time U/S to retrieve the wire to the junction, rotate it into the IJ, and advance into the correct lumen. The attending I was working with wasn't a huge U/S fan before this, but was pretty impressed and thought thatI should publish it.
Other times, I have had resistance only to find out that there is clot distal to my attempted insertion site.
I would recommend against placing a catheter if any unexplainable resistance is encountered.
I don't pay attention to the exact length of the wire anymore, I just know about how far I want it in. I go about 20-25cm and I would guess that I would feel uncomfortable at <15cm. If I was working with residents/ CRNAs/ AAs I would be a little more specific about having an exact number to shoot for so that we are on the same page.
I don't try for ectopy, but I am not unhappy when it occurs so my actual length may be closer to 30cm.
- pod
If you put the line in the carotid pull it out. Contrary to what you may read the vascular surgeon doesn't like the line in the carotid. The funny part is when you need to get a CXR and the Radiologist calls to inform you that your line isn't properly placed.
????
Correct. My experiences tell me never to thread a catheter over a guide wire which will not advance to at least 15 cm. You are just asking for trouble. At least the catheter is soft and will mst likely just curl up or not advance.
Over 10k central lines (?12-13K) and I've seen or had every complication published. Every one. Fortunately, they are rare and even rarer these days with U/S and prudence.
I've had more than dozen thrombosed or blocked veins over the past 5 years. Many are dialysis patients or others with medical conditions know to increase this incidence.
The frustrating part of this condition is the fact the IJ may be huge on U/S yet the wire won't advance very far.
As for placing a Cordis in a patient described by the OP it may end up one of two ways: the cords goes in fine and functions well or it ruptures the vein and the patient expires. If the latter happens to you be prepared to face the malpractice music.
A simple rule to follow in general is not to force anything that doesn't want to go. This applies to ETTs,needles, catheter and guide wires. How can you defend yourself if you cause a vascular injury.
Cambie
Management
While prevention of inadvertent arterial cannulation with large bore central venous catheters is paramount, an
approach to treating inadvertent arterial cannulation may be needed in rare circumstances.
There have been no
guidelines in the literature for the treatment of accidental cannulation of arteries with large-bore catheters, but
two recently published case series document better outcomes with surgical or endovascular intervention when
compared with removal and compression (“pull/pressure”)9,37. Guilbert et al. recently published a proposed
algorithm for dealing with inadvertent arterial cannulation based on a review of cases from their own institutions
(summarized in Table 6 below) and a more extensive review of the literature37.
Management Complications
Catheter removal and compression Patient had massive stroke and died
Catheter removal and compression Arteriovenous fistula requiring surgical repair
Catheter removal and compression Left hemothorax requiring blood transfusion
Catheter removal and compression Pleural effusion, lung collapse, thoracic surgery to repair arterial
hole and lung decortication
Catheter removal and compression Hematoma and uncontrolled bleeding requiring open surgery to
repair jugular vein and carotid artery
Open surgical repair No complications
Open surgical repair No complications
Open surgical repair No complications
Open surgical repair No complications
Open surgical repair No complications
Open surgical repair No complications
Endovascular repair No complications
Endovascular repair No complications
Table 6: Summary of management and subsequent outcome in 13 cases of arterial cannulation
From Guilbert M-C, Elkouri S, Bracco D et al.:Arterial trauma during central venous catheter insertion: Case
series, review and proposed algorithm. J Vasc Surg 48:918-985,
During their literature review, the group found that the “pull/pressure” method was associated with a large
incidence of serious complications (47%), including death, while the surgical or endovascular approach was
not (Figure 8A) Based on their own experience and this review of the literature, they proposed the
management algorithm in Figure 8B.
Figure 8(A): Complications from the “pull/pressure” technique of removing a large bore cannula in an artery were
significantly higher than surgical removal with direct repair of the artery or endovascular repair. (B): A proposed
algorithm for management of inadvertent cannulation of a cervical or thoracic artery with a large bore catheter during
attempted central venous catheter placement.
From Guilbert M-C, Elkouri S, Bracco D et al.:Arterial trauma during central venous catheter insertion: Case series, review
and proposed algorithm. J Vasc Surg 48:918-985, .
A
A4. The American Society of Anesthesiologists included the following statement in their Practice
Guidelines for Central Venous Access (Draft),“Case reports of adult patients with arterial puncture by a
large bore catheter/vessel dilator during attempted central venous catheterization report severe
complications (e.g., cerebral infarction, arteriovenous fistula, hemothorax) following immediate catheter
removal;
no such complications were reported for adult patients whose catheters were left in place before
surgical consultation and repair16,17. The consultants and ASA members agree that,
when unintended
cannulation of an arterial vessel with a large bore catheter occurs, the catheter should be left in place and
a general or vascular surgeon should be consulted.”
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catheterization using manometry. Anesth Analg 109, 130-4 ().
2. Kusminsky, R.E. Complications of central venous catheterization. J Am Coll Surg 204, 681-96 ().
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().
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Ultrasound Med 28, -44 ().
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Analg 109, 135-6 ().
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catheterization. Anesth Analg 104, 491-7 ().
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