Central Line why ipsilateral nipple?

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ccuguy

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I've just started my ICU rotation and I've done a couple of IJV lines so far, some with total ease and some were a real pain in the neck. I generally use two approaches:
1) Just next to the carotid pulse at the medial SCM border
2)Apex of the SCM triangle.

At my institution, we generally use ultrasound before but not during the stick.
My question is: What is the reasoning behind the recommendation to shoot for the ipsilateral nipple using these approaches? I feel like it would make a lot more sense going straight down in a sagittal plane from the point of needle entry which would also correspond to the course of the IJ, especially the right IJ. This would also correspond to the anatomy seen by US before going for the stick..
Any experiences/thoughts?
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Use real time US.....it is best practice. You can follow the wire and see what the problem is if you run into trouble. If you have US, make the best use of it. Don't handicap yourself.
 
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The general idea is to go away from the artery. But this is all null and void given that everyone who has access to a sonosite uses real time ultrasound guidance
 
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I do realize theres a lot of people out there doing us guided lines only.
At my institution however they try to teach us the blind approach nevertheless, which I think is good since you can't have access to US 100% of the time and I think it's a good thing for a novice to be capable of doing a blind stick too. I've already experienced situations in which I was very grateful for that skill. But still I dont feel 100% confident and I've had some very tricky line placements (No carotid puncture, no PTX however) - which brings me back to my initial question: Using the blind technique - do you think it is worthwile heading straight down with maybe minimal lateral angulation to avoid carotid puncture instead of aiming at the nipple? And why is it that general recommendation is to head for the nipple - which would be far too lateral in many cases...
 
ccuguy said:
I do realize theres a lot of people out there doing us guided lines only.
At my institution however they try to teach us the blind approach nevertheless, which I think is good since you can't have access to US 100% of the time and I think it's a good thing for a novice to be capable of doing a blind stick too. I've already experienced situations in which I was very grateful for that skill. But still I dont feel 100% confident and I've had some very tricky line placements (No carotid puncture, no PTX however) - which brings me back to my initial question: Using the blind technique - do you think it is worthwile heading straight down with maybe minimal lateral angulation to avoid carotid puncture instead of aiming at the nipple? And why is it that general recommendation is to head for the nipple - which would be far too lateral in many cases...
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Do your patients know you are learning the "blind approach" on them? I would never want this for myself.
 
nimbus said:
Do your patients know you are learning the "blind approach" on them? I would never want this for myself.
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All lines are done that way here - with complication rates comparable to other institutions. But again - this is not about US vs blind line placement but about blind placement trivia...
 
Wisco answered your question. If I need to do a line blind I'll go subclavian.
 
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I started residency in 1983. I must have done a few thousand ijv central lines. I think I'm pretty good at putting in a central line having done a cardiac fellowship and a few thousand hearts during my career. Here is some advice for the beginner.

It is possible, with a little bit of experience, to feel the IJ and ballot it. You can see it fill up when you let go.

Always use a 22 finder needle. If you can't get the vein with a finder, do not go poking with a large needle. If you don't get anything with the finder, consider the possibility that the IJV is very small or collapsed from the patient being hypovolemic. Aldo consider the possibility that the IJV is clotted off from multiple previous cannulations especially in patients with ESRD.

Keep your finger on the artery and enter the skin at the lateral margin of the artery. Point your needle away from the artery. Do not have saline in your syringe. Venous blood looks very bright when mixed with saline.

Always look at both IJVs before you decide which one you're going to poke.
 
Wiscoblue said:
I started residency in 1983. I must have done a few thousand ijv central lines. I think I'm pretty good at putting in a central line having done a cardiac fellowship and a few thousand hearts during my career. Here is some advice for the beginner.

It is possible, with a little bit of experience, to feel the IJ and ballot it. You can see it fill up when you let go.

Always use a 22 finder needle. If you can't get the vein with a finder, do not go poking with a large needle. If you don't get anything with the finder, consider the possibility that the IJV is very small or collapsed from the patient being hypovolemic. Aldo consider the possibility that the IJV is clotted off from multiple previous cannulations especially in patients with ESRD.

Keep your finger on the artery and enter the skin at the lateral margin of the artery. Point your needle away from the artery. Do not have saline in your syringe. Venous blood looks very bright when mixed with saline.

Always look at both IJVs before you decide which one you're going to poke.
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Thats amazing, thank you so much.
Can you tell us more about feeling and ballotting the IJ? How do you do it?
 
Where I trained. We did 99% of our IJ's on our cardiac rotation blindly. The thought process is it was not cost effective to buy 25-30 ultrasounds probes to for first round cardiac starts. I think we had 22-25 cardiac OR's with A B and C round cases. They did have enough TEE machines for all the rooms to be covered with staggered starts(could you just buy probes for the TEE machine). Probes cost 30K I believe. In practice all the central lines I have placed have been ultrasound guided in real time.
 
The best that I can simulate is if you fill a surgical glove with water, not too tense. Then put the glove under a sheet and try balloting one of the fingers. You can squeeze the glove with your other hand to make the glove more tense until you get a feel for the water. Then try feeling the IJV on your wife or girlfriend or on both depending on whichever is more cooperative!
 
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Timely thread.

ccuguy said:
At my institution, we generally use ultrasound before but not during the stick.
Click to expand...

Yesterday, at my institution, someone put a dialysis catheter in a carotid using the "scout then set aside the probe" technique.

I think it's dumb. I think that if you're not using ultrasound to watch the wire go in the IJ, you better be transducing before dilating.
 
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pgg said:
I think that if you're not using ultrasound to watch the wire go in the IJ, you better be transducing before dilating.
Click to expand...

I'm doing blood gas analysis before wiring and dilating..
 
In residency we had a surgical intern or resident (can't remember which) place a vascath in the vertebral artery after going through and through the IJ. Pt got dialyzed through it overnight and they only figured out the mistake after they drew a gas off the line and saw a PO2 of 100 :eek:. The vascular surgeon was real happy about having to come in early Saturday am to fix that one. Luckily this was at a VA so of course the pt did fine. You just can't kill those crusty old vets no matter how hard you try.
 
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SaltyDog said:
In residency we had a surgical intern or resident (can't remember which) place a vascath in the vertebral artery after going through and through the IJ. Pt got dialyzed through it overnight and they only figured out the mistake after they drew a gas off the line and saw a PO2 of 100 :eek:. The vascular surgeon was real happy about having to come in early Saturday am to fix that one. Luckily this was at a VA so of course the pt did fine. You just can't kill those crusty old vets no matter how hard you try.
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Did the pt. get an operation?

My experience is that it is very rare to get the vertebral artery operated on (on purpose, anyway).

That trumps getting the carotid dialyzed (which I have seen) anyday!
 
Regarding realtime u/s guidance: one mistake I frequently see junior residents or off service residents making when they use the u/s is that they fail to track the needle tip with the ultrasound. When doing an out of plane technique (ie the vein is in cross section), you only see a bright dot where the needle is. You have no way of knowing what part of the needle you are visualizing, and frequently the tip is well beyond the plane of the ultrasounds beam. This often results in piercing the back wall of the vessel unwittinglignly, and the resultant inability to thread an angiocath or wire. This can be averted by gradually pointing the ultrasound beam more caudally until the tip just disappears, then advancing the needle into view, and reiterating the process until you strike oil. I realize that this is not news for most of the Jedi masters here, but more for the non-anesthesia lurkers who follow here.
 
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pgg said:
Timely thread.



Yesterday, at my institution, someone put a dialysis catheter in a carotid using the "scout then set aside the probe" technique.
Click to expand...

What happened?
 
pgg said:
Apparently someone was confident in their skills and didn't use the standard-of-care tool right next to them and a patient got hurt.
Click to expand...

Outside of academic hospitals, has it become standard of care? Not sure about in ORs but a lot of EDs in the community and smaller ICUs still don't have U/S. U/S is a wonderful tool for sure but also very expensive and so some places don't have one which I concede is non-ideal but a reality. However, an argument I frequently have with people centers around if we are allowing our love of technology to erode the training for skills that are still needed for the 75% of residents who go out in the community.

I am not just referring to IJs but femorals, subclavians, a line, paracentesis, and thoracentesis, etc which can all be done blind or u/s guided /assisted.

Would be interested to know you guys thoughts...
 
inspirationmd said:
Outside of academic hospitals, has it become standard of care? Not sure about in ORs but a lot of EDs in the community and smaller ICUs still don't have U/S. U/S is a wonderful tool for sure but also very expensive and so some places don't have one which I concede is non-ideal but a reality. However, an argument I frequently have with people centers around if we are allowing our love of technology to erode the training for skills that are still needed for the 75% of residents who go out in the community.

I am not just referring to IJs but femorals, subclavians, a line, paracentesis, and thoracentesis, etc which can all be done blind or u/s guided /assisted.

Would be interested to know you guys thoughts...
Click to expand...

My private practice anesthesia group of 240+ physicians has a practice guideline that recommends real-time USG whenever possible. So in the ORs in my community, it is the standard of care. The little 3 and 4 room surgicenters in my community all have ultrasound because we insisted. And it did not come out of vapor, but as a consequence of complications that could have been prevented with USG. I trained in the 1990s without ultrasound, and practiced without ultrasound for several years after. I've placed at least 1000 central lines without ultrasound. But for the last 7+yrs, I've used it every time. I would never go back, and seriously would not consider working at some podunk hospital without ultrasound.

Even if you think you have low complication rate without ultrasound, you are still doing more needle passes. What do you do if you don't get a flash where you think it should be? Blindly fan your needle? What do you do if you get a good flash but your wire won't pass? How do you troubleshoot that? Blindly stick the patient a few more times hoping for the best? Make a bloody mess?

I used to do interscalene blocks with a nerve stimulator and I was good at it. I know a guy who was good at doing them by landmarks and paresthesia. Neither one of us would consider doing them without US if one was available to us. It's just better patient care.

Practice evolves with progress in technology. I don't understand the insistence on continuing to practice inferior 1970s medicine. Especially in the case of the OP who has ultrasound available and prescans but doesn't use real-time. It's absurd and medico-legally indefensible. Is it an ego thing?

The genie is out of the bottle and he is offering you X-ray vision so you can see exactly where you are sticking your needle inside your patient. And your reply is, "No thanks, I don't need it."??

Maybe you'd like your orthopod to reduce your fracture without c-arm because that's how they did it in the olden days. It's a lost art, what a shame......
 
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narcusprince said:
Where I trained. We did 99% of our IJ's on our cardiac rotation blindly. The thought process is it was not cost effective to buy 25-30 ultrasounds probes to for first round cardiac starts. I think we had 22-25 cardiac OR's with A B and C round cases. They did have enough TEE machines for all the rooms to be covered with staggered starts(could you just buy probes for the TEE machine). Probes cost 30K I believe. In practice all the central lines I have placed have been ultrasound guided in real time.
Click to expand...

Narc - times have changed! Now, at your training place, now 95%+ of all IJs are WITH US - there are around 15 Sonosites now!
 
Ultrasound isn't fail safe but it is standard of care/best practice. There are some little tricks that can virtually guarantee that the line is in the IJ. One is to track the wire distally and proximally and to put Doppler on the vessels. Another is after placing your needle to simply attach an IV t-piece or a small extension and to hold it upright with the free end open to air. You will obviously see gushing pulsatile flow if you are in the artery.

I personally have placed a central line in the carotid under US and it is definitely possible if patients who have fat short necks and/or have had a million lines.
 
PainDrain said:
I personally have placed a central line in the carotid under US and it is definitely possible if patients who have fat short necks and/or have had a million lines.
Click to expand...

Did you just hit the carotid or did you actually dilate and put the central line all the way in?
 
I trained before u/s was ubiquitous and so learned to do lines without it, and blocks with just a nerve stim. I'm not going back.

Before I had u/s available, I transduced every single IJ before dilating. It took an extra 60 seconds but it's important.
20g needle with angiocath in, blood back, angiocath in, needle out, short length of IV tubing attached to angiocath, allowed to fill with blood, held in the air, blood level drops back down into the patient proving venous location, tubing off, wire in, angiocath out, dilator in and out, line in, wire out, done. If you're not using u/s, doing the "poor man's CVP" like above, or connecting the tubing to an actual monitor to transduce before dilating, I think you're wrong.

Learn from others' mistakes and complications.
 
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Wow Bigdan times have changed. Their were a few attending who hated putting in central lines under ultrasound. Great to see times changing!
 
I've done 200+ central lines now, and the poor man's CVP saved me once from wiring/dilating the carotid, even though all of mine have been using ultrasound. I think I went through and through the IJ and deeper down in the neck the tip of the needle ended up in the carotid. As Geogil notes, following the needle tip can be hugely helpful (although technically difficult in chunky people).

I also find it strange that you would wait to run an ABG when you can accomplish the same thing in 5 seconds with a short length of pressure tubing.
 
pgg said:
OK, can you describe exactly what you're doing then?

Surely you're not drawing blood for an iStat in the middle of the procedure and sitting there waiting for analysis with a finder needle or angiocath hanging out the neck?
Click to expand...

Steel needle in - aspirate blood - ask nurse to do the blood gas - in the meantime feed the wire - blood gas results 1 min later on the computer next to the bed - gas ok - dilate and place line. No big deal.
 
ccuguy said:
Steel needle in - aspirate blood - ask nurse to do the blood gas - in the meantime feed the wire - blood gas results 1 min later on the computer next to the bed - gas ok - dilate and place line. No big deal.
Click to expand...
And in your hypoxic patient? methemoglibinemic pt? Why not just transduce which takes about 15 seconds? Are you doing a full ABG or just an iStat?
 
ccuguy said:
Steel needle in - aspirate blood - ask nurse to do the blood gas - in the meantime feed the wire - blood gas results 1 min later on the computer next to the bed - gas ok - dilate and place line. No big deal.
Click to expand...

That's a wicked quick blood gas. Why not just transduce? Save the patient some money too.
 
Arch Guillotti said:
Did you just hit the carotid or did you actually dilate and put the central line all the way in?
Click to expand...

I actually dilated and placed the line and it was used for about an hour before it was picked up. In hindsight I never tracked the wire distal to my insertion under US. The wire punctured the back of the IJ and went into the CA. Vascular pulled the line and the guy did fine. Followed with several follow up carotid US to eval for possible fistula.
 
bigdan said:
Narc - times have changed! Now, at your training place, now 95%+ of all IJs are WITH US - there are around 15 Sonosites now!
Click to expand...

ccuguy said:
Steel needle in - aspirate blood - ask nurse to do the blood gas - in the meantime feed the wire - blood gas results 1 min later on the computer next to the bed - gas ok - dilate and place line. No big deal.
Click to expand...
This would never happen at my current and previous gig. The blood gas itself would take 15-20 minutes to run. We do not have the infrastructure to wait. I place mine under realtime ultrasound guidance. Steel needle flash place wire, then in plane track the wire in vessel, place angiocath over wire, drop my column, wire dilate, catheter. I have heard of patients with communication between the pulmonary veins and innominate vessels but this is rare and likely a communication distal to the dilation site. Really your trying to rule out carotid puncture which can be tracked by seeing the wire longitudinal and distal as possible under US.
 
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pgg said:
Timely thread.



Yesterday, at my institution, someone put a dialysis catheter in a carotid using the "scout then set aside the probe" technique.

I think it's dumb. I think that if you're not using ultrasound to watch the wire go in the IJ, you better be transducing before dilating.
Click to expand...
. Did your colleague pull the catheter or leave it in place?
Figure 1. Algorithm for central venous insertion and verification. This algorithm compares the thin-wall needle (ie, Seldinger) technique versusthe catheter-over-the needle (ie, modified-Seldinger) technique in critical safety steps to prevent unintentional arterial placement of a dilator or large-bore catheter. The variation between the 2 techniques reflects mitigation steps for the risk that the thin-wall needle in the Seldinger technique could move out of the vein and into the wall of an artery between the manometry step and the threading of the wire step. ECG = electrocardiography; TEE = transesophageal echocardiography. Used with permission, from Rupp SM, Apfelbaum JL, Blitt C, et al; American Society of Anesthesiologists Task Force on Central Venous Access. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2012;116(3):539-573.
 

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pgg said:
I think it's dumb. I think that if you're not using ultrasound to watch the wire go in the IJ, you better be transducing before dilating.
Click to expand...
Look at the image I posted closely. If you are using the "modified seldinger" approach you do not need to verify wire placement if the wire goes in easily. Only if it is difficult.
This is coming directly from the ASA Task force on central line placement.
 
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ccuguy said:
Steel needle in - aspirate blood - ask nurse to do the blood gas - in the meantime feed the wire - blood gas results 1 min later on the computer next to the bed - gas ok - dilate and place line. No big deal.
Click to expand...

i've done this technique once - in a coagulopathic liver failure patient with hematemsis. I had used the big steel needle under real time u/s guided but wanted reassurance before dilating, it was 4am and I thought I'd be clever and get a gas.
SvO2 was quite high (hyper dynamic and poor oxygen utilisation) -- about 85 from memory, and SpO2 trace on monitor was intermittent ... all I achieved was scaring myself.

From then on I adopted a no blood gas policy.
 
Noyac said:
Look at the image I posted closely. If you are using the "modified seldinger" approach you do not need to verify wire placement if the wire goes in easily. Only if it is difficult.
This is coming directly from the ASA Task force on central line placement.
Click to expand...
Both sides of that algorithm "use real-time ultrasound" for needle insertion, and have a step to "confirm venous placement (manometry, pressure measurement, or ultrasound)" before dilation.

A "scout with ultrasound" followed by needle-wire-dilate is not consistent with the ASA guideline and is beneath the standard of care.


Noyac said:
. Did your colleague pull the catheter or leave it in place?
Click to expand...
Left it in place and called vascular surgery for removal in OR with repair
 
Also, look at footnote 2 of that image. Even with the modified Seldinger technique ... even after using real time u/s to place the needle ... even after confirming venous position with ultrasound, pressure measurement, or manometry ... even after the wire is passed with no difficulty ... they STILL felt it was worth adding a footnote suggesting "consider confirming venous residence of the wire" at the end.
 
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pgg said:
Both sides of that algorithm "use real-time ultrasound" for needle insertion, and have a step to "confirm venous placement (manometry, pressure measurement, or ultrasound)" before dilation.

A "scout with ultrasound" followed by needle-wire-dilate is not consistent with the ASA guideline and is beneath the standard of care.
Click to expand...

I just don't see the need to continue to confirm that the damn thing is in the IJ. As the algorithm states, if you confirm venous placement with the modified seldinger technique and the wire passes easily then that is good enough for me. You can do it your way, nobody will fault you.
 
where narcusprince and I trained they said learn wo u/s in case you end up someplace with out it. i agree with the mentality and am glad i learned that way.... but! i am in east BFE now and we have ultrasound. i asked for u/s, gave them paperwork with cpt codes to show it would pay for itself (it didn't expect them to give a sh-t that it was the right thing for the patients ;-) and I got ultrasound (and a video laryngoscope, which is another story). my point is, if you go someplace without ultrasound you made a mistake somewhere. everywhere should have ultrasound. it should, imho, be the standard of care. if i get a neck line s/he better use u/s. now all my partners, all 55 plus years old highly resistant to the new kid on the block and her "toys" all use u/s. its just plain safer. that said, even w ultrasound I use a little bit of pressure tubing and transduce the initial angiocath i place to assure Im venous. one of my partners here put a line in the artery (through and through) even with ultrasound (which is an argument for getting as much experience with u/s as possible). takes two seconds and a couple bucks of pressure tubing for me to rest assured. learn the landmarks, get a feel for the anatomy etc. i personally think it is a--backwards to locate the vein with ultrasound and then blind stick... i do the exact opposite - look at the anatomy and then pop the probe on and watch my needle go in.
 
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Noyac said:
I just don't see the need to continue to confirm that the damn thing is in the IJ. As the algorithm states, if you confirm venous placement with the modified seldinger technique and the wire passes easily then that is good enough for me. You can do it your way, nobody will fault you.
Click to expand...
Don't get me wrong; I'm totally OK with the modified Seldinger technique described in the flowchart. It uses realtime u/s and confirmation of venous placement of the angiocath in the vessel prior to placement of the wire. Transducing with the "poor man's CVP" length of IV tubing prior to dilating is fine, and consistent with that recommendation.

What I'm critical of is the "ultrasound scout" technique that skips ANY confirmation.
 
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pgg said:
Don't get me wrong; I'm totally OK with the modified Seldinger technique described in the flowchart. It uses realtime u/s and confirmation of venous placement of the angiocath in the vessel prior to placement of the wire. Transducing with the "poor man's CVP" length of IV tubing prior to dilating is fine, and consistent with that recommendation.

What I'm critical of is the "ultrasound scout" technique that skips ANY confirmation.
Click to expand...
pgg said:
I trained before u/s was ubiquitous and so learned to do lines without it, and blocks with just a nerve stim. I'm not going back.

Before I had u/s available, I transduced every single IJ before dilating. It took an extra 60 seconds but it's important.
20g needle with angiocath in, blood back, angiocath in, needle out, short length of IV tubing attached to angiocath, allowed to fill with blood, held in the air, blood level drops back down into the patient proving venous location, tubing off, wire in, angiocath out, dilator in and out, line in, wire out, done. If you're not using u/s, doing the "poor man's CVP" like above, or connecting the tubing to an actual monitor to transduce before dilating, I think you're wrong.

Learn from others' mistakes and complications.
Click to expand...
The fact that you transduced every central line before ultrasound makes me think that you might be a pus*y
 
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