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Indian Journal of Critical Care Medicine
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 Table of Contents    
LETTER TO THE EDITOR
Year : 2017  |  Volume : 21  |  Issue : 4  |  Page : 247-248

The tissue dilator: A victim or the aggressor?


Department of Anesthesiology and Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

Date of Web Publication11-Apr-2017

Correspondence Address:
Prakash K Dubey
E 3/4, IGIMS Campus, Patna - 800 014, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijccm.IJCCM_64_17

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How to cite this article:
Dubey PK. The tissue dilator: A victim or the aggressor?. Indian J Crit Care Med 2017;21:247-8

How to cite this URL:
Dubey PK. The tissue dilator: A victim or the aggressor?. Indian J Crit Care Med [serial online] 2017 [cited 2018 Aug 20];21:247-8. Available from: http://www.ijccm.org/text.asp?2017/21/4/247/204276


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]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Raut MS, Gupta P, Joshi S, Maheshwari A. Bent guide wire of central venous catheter. Indian J Crit Care Med 2017;21:110.  Back to cited text no. 1
  [Full text]  
2.
Dubey PK. Beware of the twisted guidewire. J Clin Anesth 2008;20:70-1.  Back to cited text no. 2
    
3.
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. 3
    
4.
Dubey PK. Kinking, unwinding and retrieval of the Seldinger guide wire. J Anaesthesiol Clin Pharmacol 2014;30:581-2.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Robinson JF, Robinson WA, Cohn A, Garg K, Armstrong JD 2nd. Perforation of the great vessels during central venous line placement. Arch Intern Med 1995;155:1225-8.  Back to cited text no. 5
    




 

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