Central Line Tips & Tricks: Part 5

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Harman Gill
I am a proud Indian by ethnicity and Sikh by religion who lives in the lovely upper valley here in New Hampshire. I love to host, cook and engage in health conversations and loud debates where decibels can be raised but respect is never lost! Talk to you soon!
Picture of Shyam Murali
Shyam Murali

Academic Chief Resident at Mercy St. Vincent Medical Center, pursuing a surgical critical care fellowship. His first steps into FOAMed started off with him learning something new each day and sharing it with MedTwitter. Days off include jamming on his saxophone, making EDM remixes, and spending quality time with his wife and puppy.

The video really talks about three main troubleshooting tips:  dilator won’t pass,  arrhythmias, arterial puncture/dilation.

  1. Dilator won’t pass: Try the following in sequence. Firstly make sure that you’re holding the dilator close to the level of the skin. Then make sure that you’re not burying your dilator in some redundant skin folds. If this happens then use your non-dominant hand to apply proximal tension to the skin around the mandible or proximal neck as you reattempt the simultaneous twisting and pushing forward motion with the dilator. Lastly, if both these tricks don’t work you may need to cut and elongate your incision with a scalpel.
  2. Arrhythmias: If you are advancing the guidewire and the monitor reads V.TACH – DONT PANIC! It means you have gone too far with your wire and you need to just retract your wire at least 5 cm.  PRO-MOVE:  If you are placing a left IJ and you experience this wide complex tachycardia then in a sense you know that your guidewire has made the appropriate turns to get to the RA / SVC Junction. Again, stay calm, don’t panic, and just withdraw your wire 5 centimeters.
  3. Arterial puncture/dilation:  yes, there is a difference!
    • Puncture: Remove needle or guidewire that has poked the artery and hold two-finger/point specific and continuous pressure for at least 10 minutes. Do not use this site again and make your team, patient aware,ness and document appropriately. 
  • Dilation: This is the dreaded and feared complication. Firstly familiarize yourself with what a central line in the artery looks like on chest x-ray/US … don’t know what this looks like… check it out in an upcoming post! If you are suspecting an arterial placement/ dilation of a central artery…don’t use the line.  You can draw blood off it to send a gas and check oxygen saturation.  DO NOT REMOVE IT & call for help (vascular surgeon)!

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