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Jeff Black
Guide wire issues

Recently I have been encountering issues after vein access, I advance the wire and I encounter resistance after the wire has been advanced some distance. I have tried numerous tricks such as changing the angle of the needle etc. Any suggestions. This has become a major frustration as I have had to send a number of pts to IR. Any suggestions? Any ideas as to the problem? How can I avoid this? 




After you've placed enough
After you've placed enough PICCs you get a "feel"  for  the guidewire, if it's advancing smoothly in the vein, or is it not actually in the vein.  If you have the sense that it is advancing smoothly in the vein  but it then just stops, you can try several things.  Sometimes if you pull the quidewire back far enough but not out of the needle, you can readvance and it will go in all the way.  Sometimes the tip of the  quidewire since it's so tiny, will just get stuck somewhere along the way, especially in the axillary area where it just won't make the turn.  If this is the case, you're PICC will usually go in just fine.  But if there is any question about really being in the vein, you need to start over. Guidewires can tunnell up the side of the vein quite easily sometimes.
I agree... when you place

I agree... when you place the needle under ultrasound guidance, the needle will "appear" to be in the vein based on what your seeing on the screen, when in reality, you have never fully penetrated all the top layers of the vein wall that are invisible to ultrasound.

Don't go by looking for a flashback unless your first sure you are through the top wall.

A flashback is useful as a secondary confirmation, but not as a first as commonly used with normal IV accesses....

I've placed many wires with no flash at all in all with my needle, but I just knew I was in the vein. Thats always fun to do as another team member watches and marvels as they wonder how you knew you were in the vein...... by watching, they are not participating in the feedback and getting the advantage that only the one placing gets by "FEEL".

When advancing your wire, always do it very gingerly without any force at all... if the tip of the wire meets any resistance that would cause the wire to bend, you need to back off and play with it a few times by re advancing it several times each time making sure not to actually bend the wire...... that means you cannot force anything.

You should "never" have a problem with a bent wire, unless you were fooled into thinking you were really in when you weren't.

Try not to use the wire to "test" whether you are in, but rather try to be pretty confident you are in based on feel and what you've seen on the screen "before" you ever advance the wire.

If it doesn't go gracefully... somethings wrong.... just because you have a flash means nothing as commonly you are in the bottom wall, or you've fully pentrated the top walls but now are back in between the top walls from pulling the needle back up and since you have a hole established in that top wall you may get a flimsy flash can could trick you.

One technique I like to use is to take the needle when watching insertion of the ultrasound screen and pentrate far enough so that you bump the bottom of the vein... even if you completely go through and come back up.... thats better than not going far enough and threading into a wall. Although not desirable, a clean hole in the bottom of the vein will seal very cleanly and not cause any noticeable bleeding. Simply bumping the bottom wall will rarely fully penetrate anyway.

I've seem radiologists that routinely penetrate the whole vein "both sides" and then come back up.

I'm sorry to say.. some are so task oriented, let the end results, justify the means. 

I see that as rather tacky and unskillful unless other means are not working first.

One thing you can be sure of... if you bump or even penetrate the bottom wall a bit, when you come back up, you will often feel or even see the bottom wall release while you pull your needle back up.... you can be sure your through all the top layers with this technique.

Now another tidbit..... once you are confident you are most likely through all the top walls with your needle, before attempting to thread the wire, try to keep the needle tip at least in the top one half of the vein.

This will allow grace to "not" catch the bottom wall when you lower the angle of the needle as the wire is advanced.

As you know, simply lowering the angle of the needle actually tends to thread the needle in a bit farther.... so if your already on or very close to the bottom of the vein when you lower your needle, you will often catch the bottom wall and when you thread your wire, and will wonder why its not going smoothly as your really in the bottom wall of the vien.

A wire should always sail in like butter.

I've seen some who force things and then insert the dilator and force the picc with "two" wires.... I suspect they were in the wall if the first part of the insertion was hard and forcing with "two" wires as in a double lumen picc merely forced the picc to exit the wall as it encountered a bend..... how long do you think it would take for inflammation and or clotting to take place? the patient or staff is never the wiser as all the evidence of a tacky insertion is hidden deep inside the vein!


Hope this helps.

The second mouse gets the cheese!

"I've placed many wires with

"I've placed many wires with no flash at all in all with my needle, but I just knew I was in the vein. Thats always fun to do as another team member watches and marvels as they wonder how you knew you were in the vein...... by watching, they are not participating in the feedback and getting the advantage that only the one placing gets by "FEEL". "

I had to tell you Windstrings that I read the above entry about 1 month ago and NEVER thought that was possible, well it happened today!  I had a very dehydrated patient, "squishy" vein.  The ultrasound showed access dead center in vein, I had no blood flashback in my 21 gauge needle.  Well, I tried your technique and the surgical steel wire threaded smoothly and the double lumen PICC threaded smoothly into the SVC.  Thanks for your entry and advice.

Robbin George
That's why I prefer the
That's why I prefer the shorter "B" bevel needle for smaller close to the surface veins--The standard longer "A" bevel that comes in our PICC kit is too long for my touch--I find I have much more control less backwalling and a higher rate of first attempt success--Also sometimes threading an IV catheter can define the vein path for your wire better than a straight needle  

Robbin George RN VA-BC

Michael Drafz
What kind of guidwire are

What kind of guidwire are you using? Stainless steel  often has more rigid tip and might "get stuck" somewhere else (side branches, bifurcations ect.). Try a nitinol  or platinum tip wire.

Most of the time you probably are not in the vein. Having said that, I have noticed that we have an increased number of patients where we definetively are in the vein (good blood return from the introducer) and still the catheter doesn't go. I believe in some patients our wires are too sharp and they will just pierce through the peripheral vein wall at some point.

Sometimes it helps to pull the wire bback and gently re-advance. Also, what lenght wire are you using? If you are using a Rad wire and you are running into problems you likely deal with an occlusion, then you will have (depending on how high up the problem is) use a different vein or arm.

Otherwise I agree with the others, most of the time your wire probably not in the vein.Sometimes you can advance them quite a bit without never being in...... 

Michael Drafz RN, CRNI, VA-BC

Clinical Lead Vascular Access Service

Sharp Metropolitan Medical Campus

San Diego, CA


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