This is the next installation in the central line (and really any Seldinger procedure) microskills. You should have already watched the videos with the following microskills:
- Syringe Suction while Manipulating
- Needle Stabilization during Syringe Removal & Wire Insertion
- Wire Manipulation
- Dilation (this video)
- Bonus Skills (Wire Straightening without Cheater)
This microskill video discusses dilation. I see this being done improperly with incredible frequency, but people get away with their bad technique because they are using small dilators for small catheters. When you go big, you will do damage unless you know what you are doing.
Dilation Mantras
- Push & Rack
- Twist & Rip
- Pinch & Pull
Additional Tips
- Keep wire and dilator wet with saline (thanks for the reminder, Matt)
- Clots are your nemesis–if there are clots on the wire, clear them off before continuing to upsize your dilators
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Editor-in-Chief, EMCrit.org at EDECMO LLC
An ED Intensivist from NY. No conflicts of interest (coi).
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Vamsi Aribindi, Gen Surg Resident-
For the ripping manuver, aren’t you damaging the same fascia that you are hoping will seal around the tube and prevent infection for central lines and air leaks for pleural catheters? Steady pressure until you are through should result in less fascial disruption.
The racking though is a great tip and one I use, after learning the lesson about wire kinking the hard way.
nope
in an ideal dilation, the dilator would be able to spin without resistance. which is what you are achieving. there is no problem with seals. you can’t dilate a path larger than the dilator itself. gentle pressure is just grand until you get to large dilators. then you have a choice–less than gentle pressure or twisting.
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You play DOTA Scott?
Commended
I was exceedingly pleased to load up emcrit and see the Meeps.
gg wp commended
Really, I’ve got a PVC when I saw the old good meepo.
thank you, scott.
placed a 8.5 fr fem vein line today, and taught a “fellow”, using much of what you taught me.
also referred her to the nathanson video (paul marik. sept 1) regarding the politics of the edwards catheter.
thanks.
Great post! I was hoping I could ask a few questions about introducer sheath insertions as well as general questions about dilation. I know this was posted a long time ago so hopefully it is read. 1) Do you use the same technique for the insertion for a cordis, that is do you twist while inserting, or do you do the twisting and pull back method to break up tissue? 2) Can you explain why twisting the dilator during insertion is useful. I do it too but was wondering if there is an explanation why twisting works better than just… Read more »
1) Do you use the same technique for the insertion for a cordis, that is do you twist while inserting, or do you do the twisting and pull back method to break up tissue? twisting while inserting doesn’t really accomplish anything in any circumstance with a 9 F cordis, you don’t need twist and rip, not that you can do it with a cordis anyway. 2) Can you explain why twisting the dilator during insertion is useful. I do it too but was wondering if there is an explanation why twisting works better than just advancing. What is the physics… Read more »