Dilated on a Carotid

[Instatewaiter]

Complications can happen from any central line with a fairly consistent rate of 5%. I even know a recent case of a compartment syndrome from an io that drew back well and flashed but somehow then infiltrated the deep compartment. I know I agree that the overall application rate is still lower than that for central time.
I would still find it hard to believe that anyone in IJ in the femoral line. You have to include the time that it takes for you or your nurse to set you up for it. A femoral line came place with in less than two minutes early. A sensual IJ choose to help take at least 5 to 10 minutes.

I realize that there are some people that think a femoral line should be done via us guidance too. I'm not sure if there any studies that show is lower complication rate for that as they do for other veins. I would love to see that though, as I have some time needed to use that for especially hard to several lines, at least in residency

A 5% complication rate is a high rate for an IJ (unless you're including a small hematoma). This sould be closer to 1% or less.

If you're using ultrasound guidance, an IJ should actually take less time to place than a fem line because it is easier to hit the IJ and much closer to the surface.

Now if you're going blind for the femoral and ultrasound for IJ, I'd argue that it doesn't take much more time to set up the ultrasound, especially because the needle is going into the IJ on the first attempt and a blind femoral can take some time.

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[Arcan57]

One wonders how many of those "bad groins" you're seeing are associated with emergent cardiac caths. Also, please provide data (preferably from an RCT but at least a prospective observational cohort study) on skin prep to line being secured times that supports your assertion that in a coding patient undergoing active CPR that a IJ is a faster line then a femoral.

 

[Birdstrike]

I have seen an absolute ton of "emergent" lines placed in the ER that ended up with terrible groin complications from missticks. RP bleeds, fistulas. So you guys may not see it but up in the ICU we get to see the fall out.

If you need quick access why not IO, stabilize and then put in an IJ when you have more time. Plus, most people can place an IJ just as fast as a fem line. Unless they have clots bilaterally in the neck, you don't have a great leg to stand on to put in a fem line anymore.

I suppose the point is to make a line choice and do it properly, beyond that it's all mental masterbation.

 

[Rendar5]

A 5% complication rate is a high rate for an IJ (unless you're including a small hematoma). This sould be closer to 1% or less.

If you're using ultrasound guidance, an IJ should actually take less time to place than a fem line because it is easier to hit the IJ and much closer to the surface.

Now if you're going blind for the femoral and ultrasound for IJ, I'd argue that it doesn't take much more time to set up the ultrasound, especially because the needle is going into the IJ on the first attempt and a blind femoral can take some time.

if you're not used to it, Femoral can take some time. But usually it takes maybe an extra 10 seconds If you've got a good pulse and an experienced provider. It takes 10 times as long as that just for the ultrasound machine to boot up. If you were trained for it, one can insert a blind line in the time it takes to set up the Ultrasound Into the right position and the probe cover over it. That applies to subclavian as well. I do all three lines depending on circumstances and I do them all full sterile 95% of the time. I actually prefer ij. But I think it's just wishful thinking to say there's no time difference. Especially when you also need a second person to even do an ultrasound guided line in any efficient fashion.

 

[WilcoWorld]

My ICU looks down on femoral lines and I love the IO, so I do almost no femoral lines anymore. (I do NOT think this position is as well-supported by the literature as Instatewaiter seems to think it is). But as to timing, US guided IJ isn't even close in an experienced provider's hands. When I did residency femoral lines had yet to be vilified, so I did a lot of them. By the time I was a 3rd year I could get a femoral line in so fast that we would get central access secured between the 1st and 2nd rounds of epinephrine on a coding patient, with active CPR in progress.

 

[Instatewaiter]

One wonders how many of those "bad groins" you're seeing are associated with emergent cardiac caths.

We probably also see similar rates. But the difference is that we see a much higher volume of post-cath STEMIs plus more importantly you're not just sticking in a little venous line. Youre actually sticking the artery and placing a sheath and they're on dual anti-platelet and either heparin or bivalrudin.

 

[WilcoWorld]

Moral of the story: When something bad happens in the ED, it's the ED's fault. When something bad happens in the Cath Lab, it's a known risk of the procedure.

 

[Instatewaiter]

Moral of the story: When something bad happens in the ED, it's the ED's fault. When something bad happens in the Cath Lab, it's a known risk of the procedure.

Well when you're getting similar rates of complication with placing a venous line as someone else placing a larger arterial line on anticoagulation, something's not right.

Look this is just food for thought. Crash fem lines may look ok in the ER but a few hours later they may not look so hot upstairs.

 

[Instatewaiter]

if you're not used to it, Femoral can take some time. But usually it takes maybe an extra 10 seconds If you've got a good pulse and an experienced provider. It takes 10 times as long as that just for the ultrasound machine to boot up. If you were trained for it, one can insert a blind line in the time it takes to set up the Ultrasound Into the right position and the probe cover over it. That applies to subclavian as well. I do all three lines depending on circumstances and I do them all full sterile 95% of the time. I actually prefer ij. But I think it's just wishful thinking to say there's no time difference. Especially when you also need a second person to even do an ultrasound guided line in any efficient fashion.

You've seen code femoral lines. There's no pulse and they rarely go right in. At least with the ultrasound it's a lot less feeling around with the needle so fewer groin complications.

It takes 30 seconds for the machine to boot up, not much longer than it takes to set up your table sterilely. Both sites have to be draped. You're using the same kit. So there's not much difference. Plus, the IJ is closer to the skin, it is easier to hit.

So unless you're not doing it sterilely, there's not going to be much of a time difference between fem and IJ. And if you're not doing it sterilely why aren't you putting in an IO?

 

[e30ftw]

sometimes it doesn't matter how quickly you place the line, it still doesn't get used.

 

[shookwell]

I've started doing supraclavicular subclavian lines for codes and they are quicker than any other emergent access. Also if I am forced to do a line that's not 100% sterile I don't put a sterile dressing on it, just a piece of tape. That way I know the ICU will change it as soon as the patient gets upstairs.

For non-coding patients I will do femoral, IO, or subclavian depending on the clinical scenario. I like IOs and have been doing a lot more of those rather than central lines recently. I will also do the occasional saphenous cutdown in coding patients, although that's mostly to teach the resident how to do one.

 

[Birdstrike]

Look this is just food for thought. Crash fem lines may look ok in the ER but a few hours later they may not look so hot upstairs.

Omg

So cliche

 

[Hercules]

You have to include the time that it takes for you or your nurse to set you up for it.

I disagree on this point. As long as it's not a crash line, I only care how much of my time it takes at bedside, not so much the nurse's time. If I can go see 1-2 patients while the nurse is setting up and then spend <5 mins of my time placing the line then that works out great for me.

 

[namethatsmell]

Supraclavicular code line is on my list of things to learn. Anybody have a good guide/reference they think is particularly helpful?

 

[shookwell]

Supraclavicular code line is on my list of things to learn. Anybody have a good guide/reference they think is particularly helpful?

I did my first one on a coding UGIB patient after watching the EMRAP episode. It was really quick and took less than a minute. Haven't looked back since.

First few results on google search

http://www.emrap.tv/index.php?id=122:EMRAPTV22-SupraclavicularLine&option=com_content&view=article

http://emedicine.medscape.com/article/80355-overview

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691520/

 

[namethatsmell]

I did my first one on a coding UGIB patient after watching the EMRAP episode. It was really quick and took less than a minute. Haven't looked back since.

First few results on google search

http://www.emrap.tv/index.php?id=122:EMRAPTV22-SupraclavicularLine&option=com_content&view=article

http://emedicine.medscape.com/article/80355-overview

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691520/

Awesome, thanks! Do you usually do em blind?

 

[southerndoc]

I can throw a subclavian in as fast (if not faster) than a femoral. It's my go to line for a crashing patient (especially trauma). I usually start femorals for access when patients are getting compressions.

 

[shookwell]

Awesome, thanks! Do you usually do em blind?

Yes, usually blind. I did one ultrasound-guided but that was mostly because one of the ultrasound faculty was showing me her technique.

I can throw a subclavian in as fast (if not faster) than a femoral. It's my go to line for a crashing patient (especially trauma). I usually start femorals for access when patients are getting compressions.

I like supraclaviculars for patients getting compressions. You can stand in between whoever is doing compressions and whoever is doing airway.

 

[Rendar5]

I disagree on this point. As long as it's not a crash line, I only care how much of my time it takes at bedside, not so much the nurse's time. If I can go see 1-2 patients while the nurse is setting up and then spend <5 mins of my time placing the line then that works out great for me.

I'm not sure you actually disagree, since I'm not talking about the lines where you have plenty of time to wait. And that is what you are talking about. In that case it's not any longer for you to place it and the patients time delay isn't important. I'm talking about cases where Time is of the utmost importance. The time is just as important as anything whether it's yours or the nurses because it's really about how fast does it take to get a usable line. You are very lucky though in that they set up ev ry thing for you. Would love to work where they do that for me. Saves me a lot of my time.

I do agree with the above sentiment that subclavian is one of the fastest lines more so than femorals. Though I know for a fact that my subclavians have a higher complication rate than my other lines as much as I love the end results.

 

[deuist]

The only real reason not to do a femoral is because the Hospitalist or ICU doc gets irritated that he/she has to place another line later.

There are plenty of reasons not to do a femoral line such as any kind of arterial bypass surgery and high DVT.

 

[Hamhock]

In further support of deuist's comment: abdominal trauma (hepatic or IVC injury). Penetrating and some unstable blunt abdominal trauma gets the cordis in the subclavian.

I'll stir it up a bit (I think there can be some interesting and educational discussion):

1. Severe thrombocytopenia or coagulopathy: IJ...no more femorals: it is not safer!

2. Many of my EM-CCM friends are wondering at all if the "average" ED doc should be putting in central lines at all for the majority of medical arrests or cases when vasopressors are needed. The former can be managed with an IO until there is time to place a nice IJ/subclavian. The later -- more evidence indicates and hospital protocols support -- can be handled in the short term with peripheral lines (please don't tell me about "peripheral dopamine" as my head might explode) in the short term and then a thin "midline" with the tip parallel to the axillary or subclavian vein when there is time.

I have not made up mind on the second topic, but I have strong inclinations. I'd like to hear other perspectives.

HH

 

[link2swim06]

In further support of deuist's comment: abdominal trauma (hepatic or IVC injury). Penetrating and some unstable blunt abdominal trauma gets the cordis in the subclavian.

I'll stir it up a bit (I think there can be some interesting and educational discussion):

1. Severe thrombocytopenia or coagulopathy: IJ...no more femorals: it is not safer!

2. Many of my EM-CCM friends are wondering at all if the "average" ED doc should be putting in central lines at all for the majority of medical arrests or cases when vasopressors are needed. The former can be managed with an IO until there is time to place a nice IJ/subclavian. The later -- more evidence indicates and hospital protocols support -- can be handled in the short term with peripheral lines (please don't tell me about "peripheral dopamine" as my head might explode) in the short term and then a thin "midline" with the tip parallel to the axillary or subclavian vein when there is time.

I have not made up mind on the second topic, but I have strong inclinations. I'd like to hear other perspectives.

HH

So when the ICU patient ends up boarding in the ED for 30 hours and all the ICU staff are stuck at the other end of the hospital we should just run high dose levo and vaso through a peripheral until they get around to it?

I don't think there is much benefit to a femoral line vs. an IO during an actual code. Both are central access and offer medium to high flow rates. However, there are certainly non-actively arresting patients who aren't going to do well with only a peripheral while in the ED.

Most of the central lines at my hospital are put in by interns or 2nd years residents. It's unlikely the attending board certified ED doc would have less experience than me.

 

[Birdstrike]

There are plenty of reasons not to do a femoral line such as any kind of arterial bypass surgery and high DVT.

A DVT in the femoral vein?

Okay, but very uncommon. But you're right, femoral isn't appropriate there. Don't know that I've encountered that very often (if ever) after countless shifts, patients and resuscitations, but it's a valid point. That's probably a once every five to ten year situation, where you have a patient that's crashing, that you can't get a peripheral on, that must have a central line, that then also by chance happens to have a recent enough DVT all the way up to the femoral at the groin that you can't get a line in. But, sure.

If you want to be picky, you could play Devil's advocate some more and say, your patient could have a subclavian DVT or IJ DVT and therefore a femoral is better then. Or cellulitis over proposed line site, etc. It's patient dependent and operator dependent, obviously.

By the way, why is a history of arterial bypass automatically a contraindication to femoral venous line, for you? It's harder to feel your femoral pulse as a landmark, but also should be easy to feel the graft pulse to avoid hitting the graft/bypass vessel, not to mention visible scarring as a giveaway. Again, patient, site/location, anatomically dependent, but sure.

When people are crashing, just get line in that you can best so quickly and without complication. That's all I'm saying.

 

[Hamhock]

So when the ICU patient ends up boarding in the ED for 30 hours and all the ICU staff are stuck at the other end of the hospital we should just run high dose levo and vaso through a peripheral until they get around to it?
.

I don't think you read my post very carefully. I never implied that it would be OK to have "levo or vaso through a peripheral" for "30 hours" in the ED. Rather, as stated in my post above, I said that peripheral pressors for the short term would be OK while the ED doc is preparing to place a midline single or double-lumen catheter with the tip in the axillary or subclavian vein (ultrasound-guided, of course).

I'd be interested in your careful thoughts on this.

HH

By the way, I am EM-trained and very "pro-EM".

 

[Doctor Bob]

Many of my EM-CCM friends are wondering at all if the "average" ED doc should be putting in central lines at all for the majority of medical arrests or cases when vasopressors are needed. The former can be managed with an IO until there is time to place a nice IJ/subclavian. The later -- more evidence indicates and hospital protocols support -- can be handled in the short term with peripheral lines (please don't tell me about "peripheral dopamine" as my head might explode) in the short term and then a thin "midline" with the tip parallel to the axillary or subclavian vein when there is time.

I certainly think EM people should be trained and proficient in the placement of these lines and if time permits (and patient condition imminently requires it) it's reasonable to place them in the ED. Certainly they should be placed in emergent situations. But often a patient is held in the ED for a long time when the ICU is ready for the patient, soley for the purpose of placing a central line.

And no, peripheral dopamine isn't something ED docs should be using... but peripheral phenylephrine perhaps...

 

[link2swim06]

I don't think you read my post very carefully. I never implied that it would be OK to have "levo or vaso through a peripheral" for "30 hours" in the ED. Rather, as stated in my post above, I said that peripheral pressors for the short term would be OK while the ED doc is preparing to place a midline single or double-lumen catheter with the tip in the axillary or subclavian vein (ultrasound-guided, of course).

I'd be interested in your careful thoughts on this.

HH

By the way, I am EM-trained and very "pro-EM".

I got your original point, I was using slight hyperbole to make my point.

The bottom line is that the patient shouldn't get different care/procedures just because of their physical location in the hospital. EM is trained in CVCs and it is within our scope of practice. If the patient only needs a midline period, then fine, just put that in. But if you are putting a midline in just to bridge to have the ICU replace it that makes no sense.

This shouldn't be an "EM shouldn't do CVCs" but rather a "all physicians shouldn't do CVC in the specific situations."

 

[Arcan57]

I don't think you read my post very carefully. I never implied that it would be OK to have "levo or vaso through a peripheral" for "30 hours" in the ED. Rather, as stated in my post above, I said that peripheral pressors for the short term would be OK while the ED doc is preparing to place a midline single or double-lumen catheter with the tip in the axillary or subclavian vein (ultrasound-guided, of course).

I'd be interested in your careful thoughts on this.

HH

By the way, I am EM-trained and very "pro-EM".

Please explain your rationale for the above approach. If you're trying to make an argument that CVCs are put in too frequently (or for the wrong indication), I think that's a discussion to have. If you're spouting some nonsense about specialty of operator or location of patient during placement as being contraindications, then I think how I worded my response makes my feelings clear. I don't know your practice environment, but "average" ED docs place the majority of CVCs in my hospital and our complication rates are as good or better than any other specialty that places lines in our hospital.

 

[Hamhock]

linkswim and wilco -

Like I said, I am still trying to forumlate an opinion on this topic. As linkswim clarified (maybe I should have), this is mostly about "all physicians shouldn't do CVC in the specific situations" (not just EM).

However, many of the posts and many comments from EM friends are about "any line" or "femoral" being just as good. And that is understandable when we have little time in the ED and have little time to predict the clinical course for a paitent. Maybe we should then be using midlines instead. When we (physicians in general) have more time to forsee the clinical course, this can be transitioned to an IJ/SC (although I am starting to feel all "long-term"/>48h central lines should be ultra-sound guided subclavians, if possible).

The "average EM" doc in the community often doesn't have this "luxury".

I completely agree with CVCs being within the scope of EM and was trained at a place were the ED was asked to put in central lines by the MICU residents "just in case" they migh be needed that night and there was no one around to teach the IM resident how to put a central line.

HH