Central lines and fistula sites...voodoo or for reals?

[namethatsmell]

I've had 3 patients recently who needed central lines who have also happened to have RUE dialysis grafts. The hospital I'm at this month greatly prefers IJs and various attendings have insisted I put in left IJs since "the renal people have concerns that putting an IJ on the same side as the graft could damage sites proximal to it"...is this a legit concern or is this just voodoo/the culture at one hospital?

I mean, I can understand that putting an IJ on the same side as a graft...puts it in closer proximity to the graft...but how much damage could one possibly do provided they don't mistake the arm for the neck?

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[Hernandez]

I've had 3 patients recently who needed central lines who have also happened to have RUE dialysis grafts. The hospital I'm at this month greatly prefers IJs and various attendings have insisted I put in left IJs since "the renal people have concerns that putting an IJ on the same side as the graft could damage sites proximal to it"...is this a legit concern or is this just voodoo/the culture at one hospital?

I mean, I can understand that putting an IJ on the same side as a graft...puts it in closer proximity to the graft...but how much damage could one possibly do provided they don't mistake the arm for the neck?

If they're sick enough to warrant a central line, then who cares what may happen in the future? If they aren't that sick, then why are they getting a line?

Left IJs are silly, they're slightly more technically challenging, more prone to clotting (anecdotally) and more prone to malpositioning. When the hospital pulls the "we prefer IJs over subclavians" I ask them if they'd prefer I risk a pneumo or a CLAB as technically the CDC CLAB guidelines still recommend subclavian over IJ & fem. and you can use the US to place a subclavian easily.

 

[Hamhock]

If they're sick enough to warrant a central line, then who cares what may happen in the future? If they aren't that sick, then why are they getting a line?

Left IJs are silly, they're slightly more technically challenging, more prone to clotting (anecdotally) and more prone to malpositioning. When the hospital pulls the "we prefer IJs over subclavians" I ask them if they'd prefer I risk a pneumo or a CLAB as technically the CDC CLAB guidelines still recommend subclavian over IJ & fem. and you can use the US to place a subclavian easily.

I'm with you until you state the "US to place a subclavian [is] easily" accomplished.

UTS-guided subcalvians require experience and UTS skill that many intensivists (unpublished data) lack.

HH

 

[Bostonredsox]

I'm with you until you state the "US to place a subclavian [is] easily" accomplished.

UTS-guided subcalvians require experience and UTS skill that many intensivists (unpublished data) lack.

HH

im more with hern here. i use us routinely for subclav. while not as easy as an ij, they are not hard. just have to get used to that steep angls towards the pleura. but still only takesa few min to do.

i disagee on ij side. if im planning swan or pacer, right side. if its just for access in a sicky, whicheve jugular is bigger caliber vessel, i stick. lefts are 100% as easy to do as a right.

 

[Hernandez]

I'm with you until you state the "US to place a subclavian [is] easily" accomplished.

UTS-guided subcalvians require experience and UTS skill that many intensivists (unpublished data) lack.

HH

I watched a you-tube video.....then put in 3 in one day back in fellowship........

 

[jdh71]

Out of all US guided lines subclavian is probably the easiest to do while watching the needle too. Once someone shows you once, you'll have no problem with the concept going forward - at least if you've done plenty of US guides IJ and Fems.

 

[jdh71]

I also don't have any huge problems with the left sides IJ. At lot of times if it looks like a patient is going to need some kind of external kidney I'll leave the right for renal and put the line in on the left. Too many places won't let us put in subclavians by policy.

 

[Hernandez]

I also don't have any huge problems with the left sides IJ. At lot of times if it looks like a patient is going to need some kind of external kidney I'll leave the right for renal and put the line in on the left. Too many places won't let us put in subclavians by policy.

I agree for temp dialysis cats, right side is only reasonable place to put unless you have no other choice, but for IJ Vs SUBif elect sided, I vastly prefer subclavian (link, page 11) CDC guidelines from CLAB prevention clearly states subclavian is preferable, and I've had this talk with the clip board nurses many times, who parrot the same line about IJs being safer. Complete bull crap, in experienced hands with decent pt selection, the risk of PTX is vastly over blown. I might have dropped 1 lung with a subclavian out of hundreds of lines, and I saw might as she had a procedure on the same side right after I did the line that could have also dropped the lung.

 

[Doctor Bob]

in experienced hands with decent pt selection, the risk of PTX is vastly over blown.

In hospitals with unsupervised resident coverage (ie: no attendings in house overnight), I can understand having policies about preferring US guided IJs.

But as with any hospital policy, when the attending is present, policies should only be a suggestion.

 

[VentdependenT]

I slam in 20cm mahuker dialysis caths all day. i dont give $hit which side or half of body. In general avoid SC if pt will need AV fistula on ipsilateral extremity.

US subclavs arent too bad. put one in on pt with heparin ggt. gotta love US.

Used US to do a transthoracic biopsy for lung ca staging last week. yes. yes i did.

 

[jdh71]

I agree for temp dialysis cats, right side is only reasonable place to put unless you have no other choice, but for IJ Vs SUBif elect sided, I vastly prefer subclavian (link, page 11) CDC guidelines from CLAB prevention clearly states subclavian is preferable, and I've had this talk with the clip board nurses many times, who parrot the same line about IJs being safer. Complete bull crap, in experienced hands with decent pt selection, the risk of PTX is vastly over blown. I might have dropped 1 lung with a subclavian out of hundreds of lines, and I saw might as she had a procedure on the same side right after I did the line that could have also dropped the lung.

I don't even know about the rates of line infections anymore. I've not seen one in so long in any line that wasn't some kind of indwelling thing. But still your point is well taken and its a silly policy to have.

 

[jdh71]

I slam in 20cm mahuker dialysis caths all day. i dont give $hit which side or half of body. In general avoid SC if pt will need AV fistula on ipsilateral extremity.

US subclavs arent too bad. put one in on pt with heparin ggt. gotta love US.

Used US to do a transthoracic biopsy for lung ca staging last week. yes. yes i did.

I won't "slam" a 20cm dialysis line in the right IJ because I don't like my patient being able to lick the ends of the catheter.

Heh.

 

[Bostonredsox]

I won't "slam" a 20cm dialysis line in the right IJ because I don't like my patient being able to lick the ends of the catheter.

Heh.

Haha.

I put the 15cm curved neck marukhars in the right IJ for HD. 20/24cm straight neck in the groin.

I try and avoid subclavs even with us in coagulopathic pts. Even though I'll prolly get it in one stick, if I miss or go out the back wall, and they bleed, it's hard to compress the chest. I have no fear with IJ lines in the coagulopathic pt. if they need a line badly I'll stick the neck regardless. Personal highs are platelet count of 1, and another with an INR of 8+. Would never stick the groin or subclavian in either of those pts.

I have never seen a clabsi. 200ish lines, still haven't seen one, knock on wood. So I prefer subclav to IJ not for infection risk, even though the data is better, but slightly offset by increased PTX, because of pt comfort. Chest lines seem to bother pts less then lines sticking out of and sewn to their neck fat. They hurt a bit more going in, require more lidocaine by a lot, so awake pts I prefer IJ. But on the whole, I prefer us guided Subclavians and am starting to do more and more of those if the situation allows for it. And I am right handed so I prefer left sided subclav.

 

[Hernandez]

Haha.They hurt a bit more going in, require more lidocaine by a lot, so awake pts I prefer IJ.

 

[psychbender]

They hurt a bit more going in, require more lidocaine by a lot, so awake pts I prefer IJ.

Agree with Hern, say what? I have not noted that subclavians awake require any more local than IJs.

 

[Bostonredsox]

Agree with Hern, say what? I have not noted that subclavians awake require any more local than IJs.

Depends on how easy they go in and how fat their chest is. IJs are quite often 1-1.5cm deep and not near any bony structures so they're super fast and easy. Subclavs often lie a lot deeper and when you enter you hit the clavicle and it's sensitive periosteum with the needle and then have to force the needle tip under it into the vein. Requires more force which can translate to more pain for the pt. not always, but often enough that I take more time appropriately numbing up the pt. some of the big fattys have subclavs lying 3cm+ deep. Requires a larger incision to get the catheter through all of the subq and more force on the dilator.

It's not as big a deal with US because the first stick rate is much higher, but most of my subclavs were blind before we got our new machine. And they often could take some poking around and manipulation working with the underlying anatomy trying to access the vein. All of that can be quite uncomfortable to the pt compared with the 20-30 sec image, stick, wire, dilator, catheter that is the typical us guided IJ.

Just my experience.

 

[Hernandez]

When you write it like that it sounds barbaric, but the fact is many of us can place a subclavian with 5mL of 1% lidocain, even in a fat person, and place it in 1 stick without digging around ham handed and without the ultrasound, and without causing discomfort. AND in hypovolunemic pts, subclavian is magnitudes easier to get the wire in without the vein collapsing. It's all about technique,

Slow is smooth, smooth is fast, fancy isn't better.

 

[Bostonredsox]

When you write it like that it sounds barbaric, but the fact is many of us can place a subclavian with 5mL of 1% lidocain, even in a fat person, and place it in 1 stick without digging around ham handed and without the ultrasound, and without causing discomfort. AND in hypovolunemic pts, subclavian is magnitudes easier to get the wire in without the vein collapsing. It's all about technique,

Slow is smooth, smooth is fast, fancy isn't better.

90% of my subclavians go as you described. But the one pt it doesn't go smooth in can be in a lot of discomfort. IJs are just super smooth and easy. But as I said I am doing a lot more us guided subclavians now.

 

[ORL10]

You should put in a line wherever you feel most comfortable preferably using US. The data is very merky on infection rates that patients care about, not colonization. Agree with patient comfort is better in the SV, some people straight up refuse IJ. Also, if you see lots of trauma patients most end up with a subclavian because no access to IJ, or because the patient is in shock and going elsewhere is difficult.

Renal for some reason at my shop always does a femoral unless I put the catheter in for them, anyone else notice this?

 

[Bostonredsox]

You should put in a line wherever you feel most comfortable preferably using US. The data is very merky on infection rates that patients care about, not colonization. Agree with patient comfort is better in the SV, some people straight up refuse IJ. Also, if you see lots of trauma patients most end up with a subclavian because no access to IJ, or because the patient is in shock and going elsewhere is difficult.

Renal for some reason at my shop always does a femoral unless I put the catheter in for them, anyone else notice this?

Agree on the renal. Here emergency HD they put in a femoral. But if I'm the one putting it in or if they ask me for a line I always put in a jugular and I make sure to put it just above the clavicle so it can be exchanged over a wire for a permcath once they've stabilized. I have ended up putting in a lot of jugular temp dialysis lines. The radiology guys won't touch a patient with an INR above 1.4 or a patient on full dose heparin/lovenox. He'll they refused one last week on Asa and plavix. I end up putting in the temporaries on all of those pts for renal and then rads exchanges it later on.

 

[namethatsmell]

Thanks so much for the discussion on this, it's really helpful to hear different perspective on lines.

I agree that if its a crashing pt they get a line anywhere that can be accessed...making the renal guys (and nurses) understand this hasn't always been as straight forward as I'd expect.

If i'm getting the gist here then it seems that an IJ on the same side as a fistula would probably be fine, even if its not an emergent line...is that correct?

Also, when you guys talk about an u/s guided subclavian, are you going more lateral where it's technically axillary territory?

 

[namethatsmell]

.

 

[Bostonredsox]

Thanks so much for the discussion on this, it's really helpful to hear different perspective on lines.

I agree that if its a crashing pt they get a line anywhere that can be accessed...making the renal guys (and nurses) understand this hasn't always been as straight forward as I'd expect.

If i'm getting the gist here then it seems that an IJ on the same side as a fistula would probably be fine, even if its not an emergent line...is that correct?

Also, when you guys talk about an u/s guided subclavian, are you going more lateral where it's technically axillary territory?

Not really. I start scanning out towards he lateral edge. But where I end up sticking is invariably right about where I would have stuck had I done it blind.

 

[Hernandez]

Also, when you guys talk about an u/s guided subclavian, are you going more lateral where it's technically axillary territory?

I tend to be more inferior than when I do blind.

 

[TrustMe]

If pt has fistula or will likely need fistula I avoid large lines (introducer, HD cath, etc.) in ipsilateral SC vein but don't hesitate putting in triple lumen there if really needed. Ipsilateral IJ should have nothing to do with flow from the SC vein. That sounds like something a non-clinical bean counter came up with.

Mandating IJ over subclavian again sounds like something some non-clinical hospital administrator came up with after a family member got a pneumo from a SC line.

 

[deleted547339]

Why would SCV be preferred over IJ? My understanding is that the rate of infection for all lines is exceedingly low, but you do run the risk of a pneumo in SCV, albeit low. Sorry if this is a dumb question - I'm an intern.

 

[Hernandez]

Why would SCV be preferred over IJ? My understanding is that the rate of infection for all lines is exceedingly low, but you do run the risk of a pneumo in SCV, albeit low. Sorry if this is a dumb question - I'm an intern.

In experienced hands, the rate of pneumo for IJ and subclavian is equivilent., you ever have one of these things hanging out of your neck?

 

[Bostonredsox]

In experienced hands, the rate of pneumo for IJ and subclavian is equivilent., you ever have one of these things hanging out of your neck?

I wouldn't say that....the rate of PTX with an US guided IJ is 0. And if you have seen someone drop a lung while sticking a neck WITH US, they need to be peer reviewed as it's flat out impossible unless they are A, sticking essentially at the clavicle and aiming caudally as if they were doing it land marked, or B, the patient is an alien and their lung grows up into their neck...

Now the rate of subclav PTX in experienced hands in particular with US as well, is exceedingly low, but I wouldn't say 0 and thus not equivalent to IJ.

Otherwise I agree with hern, subclav is more pt comfortable, has a slightly smaller infection risk compared with IJ, but not as significant as the difference between subclav/IJ and a femoral. The rate of PTX is low enough it should not be the reason you decide IJ over sublcav.

 

[namethatsmell]

If pt has fistula or will likely need fistula I avoid large lines (introducer, HD cath, etc.) in ipsilateral SC vein but don't hesitate putting in triple lumen there if really needed. Ipsilateral IJ should have nothing to do with flow from the SC vein. That sounds like something a non-clinical bean counter came up with.

Thank you, that's exactly what I was wondering and suspecting. Tis' voodooo. Vooodoooooooo.

 

[Hernandez]

I wouldn't say that....the rate of PTX with an US guided IJ is 0. And if you have seen someone drop a lung while sticking a neck WITH US, they need to be peer reviewed as it's flat out impossible.......

Karma would mandate that you will drop a lung this week with ultrasound. Speaking in absolutes and being condescending to colleagues will not win you any friends. I know a few fellows, who I trust more than some anonymous 3rd year DO resident, who've dropped a lung with ultrasound. I'm sure you'll quote some IR journal article that cites zero PTX, but keep in mind, many of these don't break out how many trainee procedures were done. And if you take the time to google, you can find ICD-9 data extraction that says iatrogenic PTX happen with u/s and I can find older data that shows U/S IJ ptx happen.

Don't speak in absolutes boy, it will bite you in the ass.

 

[Bostonredsox]

Karma would mandate that you will drop a lung this week with ultrasound. Speaking in absolutes and being condescending to colleagues will not win you any friends. I know a few fellows, who I trust more than some anonymous 3rd year DO resident, who've dropped a lung with ultrasound. I'm sure you'll quote some IR journal article that cites zero PTX, but keep in mind, many of these don't break out how many trainee procedures were done. And if you take the time to google, you can find ICD-9 data extraction that says iatrogenic PTX happen with u/s and I can find older data that shows U/S IJ ptx happen.

Don't speak in absolutes boy, it will bite you in the ass.

sorry i guess that was a bit harsh and maybe even out of line, apologies. but to be fair, i said subclav with us not IJ. i have actually asked every "line provider" ive worked with, ed docs, intensivists, surgeons, hospitalists etc, maybe an N of 40-50, not only have none of them ever caused an IJ ptx WITH us, they jave never met nor heard of anyone who has ever done it. betwern all kf them were talking 30,000+ lines atleast. i can see if you are stickkng blind, very low to the clavicle in anatomic direction, more of a common jugula line, but an actual IJ cannulation, half way between the mandible and the clavicle, with live US, in a 65-90 degree angle, i just cant se how its anatomically possible to drop a lung.

and whats with the "DO resident". am i more likely to dropa lung becausd im not an MD?

 

[Hernandez]

and whats with the "DO resident". am i more likely to dropa lung becausd im not an MD?

Myo fascia release during insertion increases PTX rates....obviously.....

The bigger point, you are very young in your training, you can know all the books and all the studies, but real world isn't so straight forward, you're absolute is someone else's malpractice.

 

[Bostonredsox]

Myo fascia release during insertion increases PTX rates....obviously.....

The bigger point, you are very young in your training, you can know all the books and all the studies, but real world isn't so straight forward, you're absolute is someone else's malpractice.

haha, the average MD knows more osteopathy then me, ive worked that hard to ignore it completely.

and i get what your saying. but tbh, if my tag was attending and i had saif in prior posts i had 15+ years experience running a micu, would it make what i said as a third year resident any less valid? sure the weight of my opinion would mean more, but whether after 200 lines as of now, or 2,000 lines after 10 years practice, i would still, anatomically speaking, find it very perplexing how a lung could bs puctured with an US guided IJ attempt done with proper technique. the basis of your argument regarding my jnexperience is correct, but i still cant see how i am wrong in this case

 

[Doctor Bob]

haha, the average MD knows more osteopathy then me, ive worked that hard to ignore it completely.

Hehe, you and me both. It was my worst grade every semester through med school... and after step 3, I hit the flush button on that portion of my brain.

i would still, anatomically speaking, find it very perplexing how a lung could bs puctured with an US guided IJ attempt done with proper technique. the basis of your argument regarding my jnexperience is correct, but i still cant see how i am wrong in this case

Well, there is proper technique, and then there is doing something with what you think is the proper technique but is actually wrong. Sure, if your process follows the textbook an US guided IJ shouldn't hit the lung... but what often happens is people think they are following the textbook process, but either the patient has wonky anatomy, poor positioning, or a myriad of other bugaboos occur which makes complications occur even though the operator believes they are doing everything right. So I would venture that you're correct from a theoretical standpoint, but from a practical standpoint there are always ways things can go wrong.

 

[Bostonredsox]

Fair enough

 

[Hernandez]

haha, the average MD knows more osteopathy then me, ive worked that hard to ignore it completely.

and i get what your saying. but tbh, if my tag was attending and i had saif in prior posts i had 15+ years experience running a micu, would it make what i said as a third year resident any less valid? sure the weight of my opinion would mean more, but whether after 200 lines as of now, or 2,000 lines after 10 years practice, i would still, anatomically speaking, find it very perplexing how a lung could bs puctured with an US guided IJ attempt done with proper technique. the basis of your argument regarding my jnexperience is correct, but i still cant see how i am wrong in this case

You've never seen a cannulation go in and back out of a vein? You can't imagine a hypovolunemic pt with very collapsible veins force someone to go closer to the base of the neck where the vein is larger and where you're closer to the pleura? You use in-plane technique for all your lines? Not everyone teaches that technique, many places use out of plane approach,

Hell, have you never had an arterial cannulation with u/s? I've seen it twice, 1 a friend of mine with an attending I trust did it with the u/s, and I personally placed a fem line through and through the fem artery under direct u/s guidance, damn near killed the guy when it got pulled as I did not see the artery much less see the needle go through the artery.

"Proper" technique only works on "proper" anatomy in a "proper" non-emergent scenario and Ina. "Proper" text book pt. Exceptions exist, and you will get surprised more often than naught.

In my first month of Attending life, I saw more cases that made me to "wtf" and more weird presentations than I did my last year of fellowship, there were at least 3 times I asked one of my partners, if they'd ever seen this, or asked them if they thought that pathologist was good.

 

[Bostonredsox]

You've never seen a cannulation go in and back out of a vein? You can't imagine a hypovolunemic pt with very collapsible veins force someone to go closer to the base of the neck where the vein is larger and where you're closer to the pleura? You use in-plane technique for all your lines? Not everyone teaches that technique, many places use out of plane approach,

Hell, have you never had an arterial cannulation with u/s? I've seen it twice, 1 a friend of mine with an attending I trust did it with the u/s, and I personally placed a fem line through and through the fem artery under direct u/s guidance, damn near killed the guy when it got pulled as I did not see the artery much less see the needle go through the artery.

"Proper" technique only works on "proper" anatomy in a "proper" non-emergent scenario and Ina. "Proper" text book pt. Exceptions exist, and you will get surprised more often than naught.

The way I do IJs if you go out the back you can't hit the lung, as I stick at a near 90 degree angle to the pts horizontal axis when lying supine. I also stick relatively close to the clavicle where the veins nearer to 1-1.2mm in diameter, but still at 90 degrees and thus not near the lung. And if both IJs are collapsible to the point where I truly think I can't get in, I stick the probe on their subclavs, which are usually larger. If between the assessment of both, a collapsible IJ and let's say a deep but small subclav, make me think my chance of PTX is unacceptable, I'll stick the groin. Once they're tanked up and the IJ more properly fills, I'll put in an IJ and pull the fem. only ever had to do that once.

Most certainly I have seen and have even myself hit big red with an US. Never dilated it or put a catheter in it but I've struck it in a really sick shock pt with massively obese legs and thus inaccessible femorals getting compressions blocking the subclavian. But that I understand, as the carotid is anatomically next to the jugular and thus in range of a needle. What I was saying is where I stick is so far from the lung apex and at such an angle that cannulation of the pleura seems to me to be impossible. I wasn't saying, your dumb because you had an US and still had a complication, I was saying you had a complication that does not seem to me to be anatomically close enough to become a problem.

Like of I said you hit the spleen with your laparoscope you idiot! That would be wrong, the spleen is In the belly and an anatomical variant could result in you puncturing it on access.
But i can't see how you could put the trochar into the trachea. It's just anatomically too far away.

Where I stick and with the angle I stick I just can't see being anatomically close enough to hit a lung. Even if I stick low for me, which is really low compared to others I've seen, and stick with a more traditional 30 degree angle, I'd have to bury the needle to the hilt to even have a chance of hitting the lung.

 

[VentdependenT]

I rotate US 90degree to in-plane to visualize guidewire in vessel if i have had any difficulty. for reassurance. also check for ipsilat lung sliding occasionally for same indication.

i always do HVLA before i line someone up.

I love DO slams! When $hit hits the fan I can just bow out, "heyyyy im just a holistic ophthalmologist."

 

[bigtuna]

The incidence of ptx with IJ lines is definitely not zero.
I've done somewhere between 1200-1500 lines as near as I can calculate.
5 pneumo's - 2 IJ and 3 SC.

One of the pneumo's with the IJ - ventilated patient sat bolt upright as I was advancing needle.
The other one I never could figure out. Smooth U/S guided line in a lung txplant pt with CF.

There is a certain type of elderly, very low body weight patient that I've learned to avoid SC lines if I can. Very easy to drop a lung in some of them.

 

[VentdependenT]

I won't "slam" a 20cm dialysis line in the right IJ because I don't like my patient being able to lick the ends of the catheter.

Heh.

When i go through 4cm of neck blubber, i slam in a 20 on the R. all other sites get 20. If the 20 flops on the machine then they go to IR. donezo.

Ive botched one of these BIG time on a real BIG BOY. INR 1.8. Bent the big dilator and kinked and trapped the guide wire. Big ol' neck hole. Pressure, pressure, pressure. Had to throw in 4 whip stitches. scary. he went to IR. Groin...

 

[Laryngophed]

When i go through 4cm of neck blubber, i slam in a 20 on the R. all other sites get 20. If the 20 flops on the machine then they go to IR. donezo.

Ive botched one of these BIG time on a real BIG BOY. INR 1.8. Bent the big dilator and kinked and trapped the guide wire. Big ol' neck hole. Pressure, pressure, pressure. Had to throw in 4 whip stitches. scary. he went to IR. Groin...

I'm just a stupid student, but during a recent ICU rotation I learned that going through too much subcutaneous fat leads to many bent dilators. And that the cordis kit comes with a fat, very stiff dilator. After that little bit of knowledge, that mahurkar went right where it was supposed to go.

 

[Hernandez]

I'm just a stupid student, but during a recent ICU rotation I learned that going through too much subcutaneous fat leads to many bent dilators. And that the cordis kit comes with a fat, very stiff dilator. After that little bit of knowledge, that mahurkar went right where it was supposed to go.

Sounds like a waste of a second expensive kit and sounds like someone was too timid with the scalpel when making a knick in the skin. The only time I ever had issues with dialysis cath dilators was when we got a batch of bad ones where the opening was off center and the tip tended to mushroom out.

 

[Laryngophed]

Sounds like a waste of a second expensive kit and sounds like someone was too timid with the scalpel when making a knick in the skin. The only time I ever had issues with dialysis cath dilators was when we got a batch of bad ones where the opening was off center and the tip tended to mushroom out.

I would think that was a fair assumption, save for myself, the resident, the fellow, and the IR attending all experiencing the same bent dilator problem. It was the IR attending that came to the idea, but it wasn't his first shot either. This patient could redefine vasculopath, bilateral bkas, ESRD requiring dialysis, and you could count six or seven scars across the R hemithorax where a port-a-cath used to be. And he weighed close to 400 pounds, and he wasn't very tall before the BKAs. Our attending did slide a murharker into the femoral once, but that line was lost somehow.

 

[Bostonredsox]

I would think that was a fair assumption, save for myself, the resident, the fellow, and the IR attending all experiencing the same bent dilator problem. It was the IR attending that came to the idea, but it wasn't his first shot either. This patient could redefine vasculopath, bilateral bkas, ESRD requiring dialysis, and you could count six or seven scars across the R hemithorax where a port-a-cath used to be. And he weighed close to 400 pounds, and he wasn't very tall before the BKAs. Our attending did slide a murharker into the femoral once, but that line was lost somehow.

He doesn't redefine anything, he is my typical esrd pt.

Agree with hern. I used to have trouble with some dilators. Now I just make a bigger incision. No problems since.

I had a pt as you have described this one, morbidly obese esrd pt s/p pea arrest. visible clot in both IJs. Subclavian dvt on right. Prior permcaths in left subclav with known stenosis and subsequent steel syndrome. Right femoral HD catheter. Needed another TLC for all of his drips. I damn near did a full surgical cutdown to get the dilator to smoothly enter the left femoral vein.

 

[ORL10]

he isn't your typical vasculopath come on now, I worked in inner city Chicago with one working kidney for every 30 patients seen and the guy with 6/7 scars b/l BKAs esrd on HD and difficult IV access cause he still weighs 400 lbs isn't encountered that frequently.

As an aside I do a lot more axillary lines now than ever before. You can double set up for an A-line and CVC or PAC if you need to. The A-line is harder to cannulate because the vessel is so mobile (compared to a femoral).

 

[neusu]

If you need an ultrasound for a subclavian you're doing it wrong..

 

[jdh71]

If you need an ultrasound for a subclavian you're doing it wrong..

Technically we can do any line with landmarks. Why don't we hero?

Remember you are doing these things to real people. Save the bravado for nights out drinking with your idiot buddies.

 

[Doctor Bob]

If you need an ultrasound for a subclavian you're doing it wrong..

I can recall a patient who was so fat that none of us could even feel the clavicles; I'm sure the patient had anatomic neck structures as well but the shoulderfat came up to their ears.

I tried to use the curvilinear probe to at least find the cortex of clavicles so I could guess at anatomy... still no good. I ended up bringing in the xray techs with the portable XR (with the display screen on the machine) and doing a modified fluoroscopic approach.

Some patients just need imaging (be it ultrasound or xray, or whatever else) to get the line placed no matter how many of them you've done in the past.

 

[Hernandez]

save for myself, the resident, the fellow, and the IR attending all experiencing the same bent dilator problem. .

I can't say I care if a medical student or resident has issues with a procedure, they don't know what they're doing anyways.

I learned that going through too much subcutaneous fat leads to many bent dilators. .

So this is the take away point you took for this pt?

. This patient could redefine vasculopath, bilateral bkas, ESRD requiring dialysis, and you could count six or seven scars across the R hemithorax where a port-a-cath used to be. And he weighed close to 400 pounds, and he wasn't very tall before the BKAs. .

These statements don't seem congruent.

 

[Bostonredsox]

I can't say I care if a medical student or resident has issues with a procedure, they don't know what they're doing anyways.

So this is the take away point you took for this pt?

These statements don't seem congruent.

you hurt my feelings hern.

agree on lack of congruency. Massive obesity does not = vasculopath. I have had a 140 pound lady with b/l carotid endarterectomys, a femoral stent, a fem pop bypass and a 5 vessel cabg. That is a vasculopath. The obesity just makes there anatomic landmarks hard to find. Both pts can be difficult to place a catheter in, but for different reasons.