Wire in Needle: A WIN for needle visualization! #FOAMed
After those last 3 microcasts I’m sure you’re all sticking needles in vessels under ultrasound guidance like crazy! As you should.
Why would you blindly stick a needle in the body unless you don’t really care where it goes? We’ve established that much.
Now, let’s take it to the next level. In this episode we demonstrate to you a new technique to increase needle visualization. To see all the evidence on this technique click here.
Ok, sorry, as you may have figured out, there is no evidence for this, but you’ve gotta admit, those were some cute cats. This podcast is definitely opinion, so do with it what you will. We’re just trying to share with you what we’re up to and what we think is cool.
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anyone tried this with peripheral IVs? good needle visualization is the crux for most of us, im sure, and i am more interested in tracking the needle than the flash. especially as i get a weak or delayed flash in many recent IVs- probably a combination of gel in the stylet and a long 20g catheter with a lot of flow attenuation.
i was thinking one way to do this with a PIV without going full sterile is use one of the common arrow a-line devices with the wire advanced to just before the bevel. I could go in and advance the cath off the stylet per normal, or could use seldinger, though in this case i would still need a second person to advice the wire that extra bit while maintaining US vision.
curious if anyone has experience or advice for us newbies.
Tony,
The first time I read and responded to this comment I misunderstood. Now I see that you were simply asking if anyone has experience with just using a-line kits for placing PIVs. The answer to that is “YES”. I know there are plenty of people who do this and like this. I’m not sure if they insert the wire to the tip like you mention, but that’s a great idea of they don’t. Personally I haven’t used the a-line kits for PIV, but I think I’m going to start now after this WIN episode.
Thanks,
Matt
p.s. – My prior response should be a lesson to all not to post on public forums while sleep deprived. Always take a day off from “posting” after night shifts.
Tony,
I’ve tried a few different wires in PIV needles, but they’ve been too big. Let me know if you come up with a good way to do this. I had the same idea that this would be great for PIV. The smaller needle in PIV makes needle visualization more difficult than during a central line.
I’m forwarding your comment on to Stone and Mallin to see if they’ve got a solution.
Matt
p.s. – working with Mallin on needle visualization study with pigs this weekend while visiting in SLC. We’ll send a tweet pic/vine or two. @ultrasoundpod
well, i won’t lie to you. i tried doing this today with a PIV phantom with the standard arrow a-line kits. i honestly coudlnt tell a difference. if i watch it in short or long axis and slide the wire in and out i can just barely tell. maybe the wire that fits into a stylet that fits into a 20g catheter is just too small to make much difference. if you add this to the fact that those arrow kits have a catheter on the small/short side for ultrasound IVs i don’t think ill repeat this experiment on the floors. ah well.
Oh well, good shot. It may not be a great option with PIV.
Tony,
My guess is that the plastic catheter from the Arrow kit is blunting the reverberation artifact that comes from the wire being inside the needle. Have you tried it with a smaller needle thats not wrapped in a plastic cath?
Mike
That’s a great point (I wish I was as smart as Mike)! Tony, we know from needles designed to be echogenic that this happens. Sometimes they put a coating on the echogenic needles and this has benefits, but it decreases the echogenicity of the needle.
Matt
p.s. – whichever Mike this is may want to identify themselves with a last name…..so we know whether to trust it or not.
Interesting point. It was not intuitive to me that the plastic sheath could change the echogenicity of a needle. It sounds like a spinal needle and a fine arterial line wire could allow me the best visualization while putting a fine peripheral IV in. However that still sounds unnecessarily complicated and I feel like I’d have to switch over to sterile technique (or perhaps at the very least sterile gloves) to feel good about it.
just to add one more (in vitro) data point:
a 22g BD spinal needle is similarly difficult to see in an ultrasound phantom as a 20g PIV catheter/stylet. putting the stylet in the spinal needle adds almost negligible increased echo except at the bevel of the stylet. however, putting a very fine procedure wire in the spinal needle adds a significant amount of echogenicity. all the annoyances of needing sterile technique and a third hand are still there though.
Sorry to disappoint Matt, but I think the WIN technique is a win. Stone will say something else I can go off on next month I’m sure. If not then, I am sure the Castlefest debate will be bloody.
Well Crap! I’m afraid the seething IVC anger/rage will cool down by the time Castlefest rolls around. I need a backup or two to ensure the Castlefestians get the blood they so crave…..
I hate to break it to you, Dawson, but Scott and I already worked out our IVC issues having agreed that fluid tolerance doesn’t equal fluid responsiveness, and let’s face it, the IVC is too boring to get this much hype. After a couple of group therapy sessions, some behavioral modification techniques, and an increase in our meds all that anger/rage seems like a distant memory.
Scott, we need to find something new to argue about. I’m open to suggestions…
http://www.ncbi.nlm.nih.gov/pubmed/23324885?dopt=AbstractPlus
really? positive predictive value, 62%? in <15 patients? i thought we moved on, bro…
Pretty sweet NPV of 100% for IVC though. And look at those SVV numbers…. dead sexy.
I’m surprised that Ao Velocities didn’t correlate though, seems intuitive that they should correlate with CI….. since they are virtually the same thing and all.
Scott,
I heard Stone say something about “Push-dose pressers are for wankers w/o US skills.”
just saying…..
We talked about your compulsive lying last week, Mike. Have you been keeping your fib journal like you promised?
Push dose pressors are a thing of beauty. Maybe we could argue about how we like to mix them? I’m a fan of 1mg of epi in 1liter of NS for an easy 1mcg/ml solution (also happens to work with 1 vial [10mg] of phenylephrine in 1liter NS for a 10mcg/ml solution). This way you can add 1 “bottle” of either to a liter of NS and end up with a solution you could draw into a 10cc syringe and push 5 or 10cc. Picked this up from a former resident and it seems like a simple way to not have to deal with math in the heat of a push dose pressor moment.
Stone,
Don’t bash that SHOCK paper. The lead author, Lanspa, is the author of our fluid responsiveness chapter in “Introduction to Bedside Ultrasound”. Wow, I feel better after getting that commercial in.
Not bashing the paper. Just bashing the IVC in comparison to SVV.
I’ll help you understand the need for two thresholds and a gray zone for the interpretation of tests at Castlefest. I’ll speak very slowly.
happy now , Matt
I am so excited. You should do that.
Nothing like discussing test thresholds and the gray zone of interpretation of tests to really jazz up a crowd.
Christmas is coming in April this year, Dawson
I like the idea of the wire in needle technique but find it clunky to hold the wire whilst needling.
My preference is to use the cannula in the kit (without syringe) and visualise the puncture of the vein (in-plane) and the cannula sliding off the needle into the vein. Then put down US to take out needle and insert wire into cannula, then put ultrasound back onto to visualise wire coming out of cannula in vein.
The cannula is, however, more difficult to visualise on the ultrasound than the needle, particularly with more vertical approach to deeper veins.
I tried this last shift on a femoral central line and it was just perfect! For the jugular however I often struggle with the very short necks of some of my patients, which makes it hard to find a spot to stick the needle in once the us probe is in place … so I often just look where to go, mark the spot and stick it in. Any suggestions?
Justin
re: wire in a needle
I love the idea but do wonder…
What happens if the patient takes a very large breath (say, as if to sneeze) just at the moment you have successfully cannulated the IJ (with needle hub not only open to atmospheric pressure but un-occludable due to wire hanging halfway out)?
Would say it’s the same thing that happens if the patient takes a deep breath as you’re wiring the vessel w a traditional technique. Not much air getting in around the wire, and obviously maintaining control of the wire is a priority as with all things Seldinger.
You know…that works for me.
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