Literature DB >> 28515615

The Tissue Dilator: A Victim or the Aggressor?

Prakash K Dubey1.   

Abstract

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Year:  2017        PMID: 28515615      PMCID: PMC5416799          DOI: 10.4103/ijccm.IJCCM_64_17

Source DB:  PubMed          Journal:  Indian J Crit Care Med        ISSN: 0972-5229


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Sir, The case report entitled “Bent guide wire of central venous catheter” by Raut et al. made for interesting reading.[1] We would like to make certain observations on this report. Bending or twisting of the guide wire is a known phenomenon during central venous catheterization and may lead to complications.[2] However, bending of the tissue dilator itself, which is made of a tougher material, is not commonly encountered during clinical practice. It appears from the accompanying diagram that the dilator along with the guide wire had bent almost 100° from the intended direction of insertion. Bending of the dilator to such an extent will require considerable force that is generally not applied during the procedure. This much resistance can only be produced against a bone and can be easily appreciated. A photograph showing the bend in the dilator would have helped in better appreciation of the incident. The skin, subcutaneous tissue, and the entry point in the vessel wall need to be dilated, and any insertion of the dilator beyond the vessel wall as depicted in the accompanying diagram should be avoided.[3] We believe that the insertion of tissue dilator at a more vertical angle than the guide wire was the triggering event in this case. Considerable force can be inadvertently applied during this step which can lead to not only kinking but also unraveling of the guide wire,[4] leading to serious consequences. However, this force is not sufficient enough to produce the bend in the dilator as described. When the dilator is advanced over the guide wire, it should move over a firmly held guide wire. The moment the dilator “hangs up” and moves the wire forward along with, one should get suspicious as at this point kinking may occur.[5] Avoidance of excessive force, inserting smallest bore that will allow the wire and inserting the smallest length to reach the vein are some of the suggestions made for safer use of dilators.[3]

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  5 in total

1.  Beware of the twisted guidewire.

Authors:  Prakash K Dubey
Journal:  J Clin Anesth       Date:  2008-02       Impact factor: 9.452

2.  Dilator-associated complications of central vein catheter insertion: possible mechanisms of injury and suggestions for prevention.

Authors:  J M Oropello; A B Leibowitz; A Manasia; R Del Guidice; E Benjamin
Journal:  J Cardiothorac Vasc Anesth       Date:  1996-08       Impact factor: 2.628

3.  Perforation of the great vessels during central venous line placement.

Authors:  J F Robinson; W A Robinson; A Cohn; K Garg; J D Armstrong
Journal:  Arch Intern Med       Date:  1995-06-12

4.  Kinking, unwinding and retrieval of the Seldinger guide wire.

Authors:  Prakash K Dubey
Journal:  J Anaesthesiol Clin Pharmacol       Date:  2014-10

5.  Bent Guide Wire of Central Venous Catheter.

Authors:  Monish S Raut; Priyanka Gupta; Sandeep Joshi; Arun Maheshwari
Journal:  Indian J Crit Care Med       Date:  2017-02
  5 in total

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