A Better Central Line Technique: Wire Through Catheter

July 11th, 2015
by reuben in _lecture, vascular access

Most of us were taught to place central lines using the wire through needle Seldinger technique, but using the introduction catheter instead of the needle makes successful wire insertion more likely and facilitates venous confirmation. A 7 minute screencast.

on vimeo

operating room video of wire through catheter technique. recommend viewing at 2x speed.

Update 1 Lee 2015 compares wire through needle and wire through catheter and shows that wire through needle is (slightly) better. The operators were anesthesiologists very experienced in central line insertion, which may account for their results. In the less controlled ED environment, with providers who don’t place a lot of lines (especially learners), the tendency of the needle to move before the wire can be transmitted may be more important. Also they did not confirm venous location in this study, which should be done whenever feasible and is greatly facilitated by the wire through catheter technique. Still, I’m aware of no data comparing the two techniques other than this (which appeared a few weeks after I posted the video), so though my success rate is definitely higher since I switched to wire through catheter, your mileage may vary.

Update 2  There are two advantages of the wire through needle (conventional approach): the needle is functionally slightly longer than the catheter, and the needle doesn’t kink. Neither of these advantages make a difference at the IJ site, and where I work almost all lines are IJ, so I didn’t mention this in the video. Based on feedback, I am surprised (and pleased) at how many non-IJ lines are being placed out there. If there is a lot of flesh in between the skin and the vein, for example at the femoral site in an obese person, the catheter can kink. This can be managed by keeping the pannus out of the way and keeping the skin taut throughout the procedure (flabby groin tissue can interfere with wire advancement as well, regardless of which technique you use to transmit the wire), but this requires an extra set of hands. At the subclavian site, the problem is not flesh but distance–sometimes you enter the vein relatively far away from where you enter the skin, and in this case the couple of millimeter difference between the wire and the catheter can be relevant. You can overcome this problem, in cases where you have to hub the catheter to get into the vein, by applying gentle continuous forward pressure on the hub until the wire is in the vein.

 

Back Top

Responses to “A Better Central Line Technique: Wire Through Catheter”

  1. Pingback:Episode 31 – Vasopressors | FOAMcast

  2. Great post- I will be doing a procedure lab tomorrow and I will try out your technique. For the subclavian approach- thinking out loud- couldn’t you consider doing a mini cut-down to make sure the catheter stays in the vein? The way I envision it- get a flash, don’t advance the catheter, make a small scalpel nick with the blade facing away from the catheter (large enough to for the hub of the angiocath), and use this to allow the hub of the catheter to be partially within the sub-q tissue and give you extra length. Probably an advanced technique that I wouldn’t trust an intern to do but perhaps one that would allow you to use this technique for subclavians? Or do you think it would be overkill?

    Great post

    Steve

  3. Great post! Will definitely give it a try. What I have done to skip some of those steps is remove the syringe altogether and just go with the needle. Since I am confirming that I am in the vein via ultrasound (using the in-plane technique), I don’t need to withdraw to confirm. I just thread the wire.

    Josh Guttman at
  4. Steve the mini-cutdown makes sense, I’d be interested to hear if it works. Josh – if you are awesome at ultrasound skipping the flash step avoids some (but not all) of the pitfalls I mention when using a needle to transmit the wire instead of a catheter. very slick.

  5. Pingback:LITFL Review 189

  6. one of the problems I have with the using the angiocath needle (as opposed to the seldinger needle) is that it seems I don’t always get the flash into the syringe, even with negative pressure. not sure if this is because there’s less of a seal between the needle and syringe, or there’s air leak around the angiocath, or just that the needle’s smaller. thoughts? [my comment, reposted from same comment on Matt Pirotte’s Central Line tips video on my site]

  7. seth – the angiocath needle is smaller bore than the seldinger needle, so you need to apply more negative force. but I have not had this problem – when the needle enters the vein, I can aspirate blood, albeit slower than with the wide bore seldinger needle. If you think you’re leaking air at the needle hub/syringe interface, tighten up the components?

Leave a Reply