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LETTERS TO THE EDITOR

A Tale of Two Wires

Departments of Anesthesiology, Kosair Children’s Hospital and the University of Louisville, Pediatric Anesthesia, Kosair Children’s Hospital, Louisville, KY

To the Editor:

We agree with Nakayama et al. (1) that curved-end guidewires contribute to failed central venous access in infants . As they discussed, the radius of curvature of a "J-wire" is often larger than the vessel being cannulated. In addition, these wires are stiff, and their introduction can distort the vein. This combination leads to the too common tale of, "I had good blood return; I just couldn’t thread the wire."

Our solution to this problem is use of an extremely flexible, relatively straight wire (Fig. 1). We use a 0.018-inch diameter soft-tip wire (Argon Medical, Athens, TX; Ag’s-Hertogenbosch, the Netherlands). We initially used this wire when difficulty was encountered. As we gained experience, we progressed to primary selection of this wire when the vessel was small (<3 or 4 mm diameter by ultrasound). We now use this wire as our first choice in obtaining internal jugular access in any infant weighing <4 kg, and for femoral access in any infant weighing <8 kg.

View larger version (97K): [in this window] [in a new window]   Figure 1. The distal 2-cm portion of the 0.018-inch diameter "soft-tip" wire (at left) is extremely flexible. This wire is much more forgiving than either the 0.018-inch (center) or 0.025-inch (right) J-wires supplied with 4F and 5F central venous access kits, respectively.

Reference

1. Nakayama S, Takahashi S, Toyooka H. Curved-end guidewire for central venous cannulation in neonate. Anesth Analg 2003; 97: 917–8.[Free Full Text]

Response

Department of Anesthesiology, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Japan

In Response:

We thank Auden et al. (1) and appreciate their interest and comment on our letter regarding central venous cannulation in neonate. Actually, we often encounter difficulty in threading a guidewire into small vessels (<3 or 4 mm diameter) despite good blood return. In such cases, we used to choose a straight end by reversing the opposite side of a J-shaped tip guidewire. Since the straight wire has been implicated in perforation of vessel walls, we also prefer to use a flexible, slightly angled wire.

The course of the right internal jugular vein has been shown to be almost straight (2). We agree with their comments of using a flexible, relatively straight wire as a first choice in obtaining internal jugular access for small infants. However, when we access tortuous veins such as external jugular, antecubital, or basilic veins, the J-shaped tip has advantage over the straight tip. The smooth convexity of the J-shaped tip may enable the wire to pass corners easily.

As we mentioned in the letter (1), the J-shaped guide wire bends introducer catheter excessively. The angle shaped wire can also bend the catheter slightly. We would like to emphasize that the catheter material affects the distortion. Catheters made of Teflon, polyethylene, or polypropylene are relatively stiff so that they are difficult to bend with J-shaped guide wire insertion. Although new catheters made of polyurethane have superior mechanical properties (tensile strength and wearing resistance), the catheter is softer than the older materials. Hence it is not recommended for insertion of J-shaped guidewire. The introducer catheter should be used only for cannulation. Therefore, relatively stiff catheters may be desirable.

References

1. Nakayama S, Takahashi S, Toyooka H. Curved-end guidewire for central venous cannulation in neonate. Anesth Analg 2003; 97: 917–8.
2. Nakayama S, Yamashita M, Osaka Y, et al. Right internal jugular vein venography in infants and children. Anesth Analg 2001; 93: 331–4.[Abstract/Free Full Text]

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