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LETTERS TO EDITOR
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 190-191
 

Ultrasound-guided dilation of central venous catheter track to prevent dilator-related injury


Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India

Date of Submission16-Mar-2021
Date of Decision08-Apr-2021
Date of Acceptance02-May-2021
Date of Web Publication29-Sep-2021

Correspondence Address:
Dr. Hariprasad Ramalingam
Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_39_21

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How to cite this article:
Ramalingam H, Roy S, Sharma A, Kothari N, Goyal S. Ultrasound-guided dilation of central venous catheter track to prevent dilator-related injury. Indian Anaesth Forum 2021;22:190-1

How to cite this URL:
Ramalingam H, Roy S, Sharma A, Kothari N, Goyal S. Ultrasound-guided dilation of central venous catheter track to prevent dilator-related injury. Indian Anaesth Forum [serial online] 2021 [cited 2021 Dec 7];22:190-1. Available from: http://www.theiaforum.org/text.asp?2021/22/2/190/326975




Sir,

While placing a central venous catheter (CVC), complications such as inadvertent arterial puncture, hematoma formation, massive hemothorax, or pneumothorax can occur. Even with the use of ultrasound (US), complications can happen when the operator inserts the dilator blindly to dilate the track for the subsequent insertion of the CVC.[1] It is not uncommon for residents to insert the dilator to its full length.[2] There have been reports of mechanical trauma related to the dilator that leads to false track formation and a blood vessel or cardiac chamber's perforation, resulting in devastating intrathoracic bleeding.[3] The complications that are attributed to dilator insertion is under-reported, and the exact incidence is not known. However, there are no guidelines practiced to reduce dilator-related complications.[4]

In a patient with buccal mucosa carcinoma scheduled for wide local excision and modified radical neck dissection, CVC was inserted in the subclavian vein after general anesthesia. The needle was inserted in-plane under real-time US guidance, and the intravenous position of the guidewire was confirmed with US seen as a shiny hyperechoic shadow [Figure 1]. Instead of passing the dilator blind as is the norm, it was passed over the guidewire while being visualized using the US. As the dilator is threaded over the guidewire, the hyperechoic shadow of the guidewire disappears, and the dilator appears as a hypoechoic shadow between two linear hyperechoic lines (Barrel sign) [Figure 2]. The point where the hyperechoic lines disappear is the site where the tip of the dilator is present. Then, it was removed, and a smooth 7 Fr triple lumen catheter was threaded over the guidewire. The dilation of the tract is an indispensable step since the 7 Fr catheter cannot be introduced over the guidewire in the absence of a well-defined track. The dilatation of the track under real-time US guidance while visualizing the dilator's tip may help prevent dilator-related complications. As most of the stiff dilator is made of polyvinyl chloride (synthetic fiber), echogenic shadow will be generated as it passes into the tissues.[5]
Figure 1: The shiny hyperechoic shadow of the guidewire in the subclavian vein

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Figure 2: Conversion of the hyperechoic shadow by the hypoechoic shadow of the dilator (Barrel sign)

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The use of real-time US for dilating the track may help in preventing dilator-related injuries. However, large-size randomized trials and further studies are required to prove the efficacy of passing the dilator under US guidance to prevent dilator-related complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the guardian has given his/her consent for images and other clinical information to be reported in the journal. The guardian understands that name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Powell H, Beechey AP. Internal jugular catheterisation. Case report of a potentially fatal hazard. Anaesthesia 1990;45:458-9.  Back to cited text no. 1
    
2.
Oropello JM, Leibowitz AB, Manasia A, Del Guidice R, Benjamin E. Dilator-associated complications of central vein catheter insertion: Possible mechanisms of injury and suggestions for prevention. J Cardiothorac Vasc Anesth 1996;10:634-7.  Back to cited text no. 2
    
3.
Collier PE. Prevention and treatment of dilator injuries during central venous catheter placement. J Vasc Surg Venous Lymphat Disord 2019;7:789-92.  Back to cited text no. 3
    
4.
Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 2020;132:8-43 doi: https://doi.org/10.1097/ALN.0000000000002864.  Back to cited text no. 4
    
5.
Pepley DF, Sonntag CC, Prabhu RS, Yovanoff MA, Han DC, Miller SR, et al. Building ultrasound phantoms with modified polyvinyl chloride: A comparison of needle insertion forces and sonographic appearance with commercial and traditional simulation materials. Simul Healthc 2018;13:149-53.  Back to cited text no. 5
    


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