hitting the carotid...

[bkell101]

overnight cardiac call, heart transplant for 30 yo LVAD patient with ICD...some pulsatile flow, feel the radial and use the arrow....go to the neck....very small collapsible IJ, decent distance from the carotid on US....I stick what I believe to be the IJ based on US, thread the small catheter, transduce my small catheter......the column of blood doesn't fall down, it stays in the same place, so I flush out the blood redraw some blood in the tubing...now it slowly rises up the tubing but never comes out with what I think was a slight element of pulsatility. I'm not sure how high up I am holding the tubing....immediately I think I'm in the carotid and so does my attending (not sure how based on the US)....we abort and put the line in the other side. We never hooked up and actually transduced the pressure.

I've never hit the carotid before....what do you expect the pulsatile flow in the tubing to be like in a normal healthy patient? ....my fellow resident says he has hit the carotid and the blood literally flies up through the top of the tubing (which was certainly not the case)....is this true?

now the patient has an lvad with continuous flow (MAP is currently 85 while we are doing this) , what would you expect to see in the tubing in this patient if you hit the carotid?

is it possible I didn't hold the tubing up high enough, should have transduced the pressure, and prematurely aborted?

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[G0S2]

Heart failure. What was CVP ?

 

[deleted59964]

if the jugular is collapsable, i wouldn't expect it to have a high pressure.
did you thread your wire and then ultrasound it ? was it in the collapsable vessel?

 

[Icefrog]

overnight cardiac call, heart transplant for 30 yo LVAD patient with ICD...some pulsatile flow, feel the radial and use the arrow....go to the neck....very small collapsible IJ, decent distance from the carotid on US....I stick what I believe to be the IJ based on US, thread the small catheter, transduce my small catheter......the column of blood doesn't fall down, it stays in the same place, so I flush out the blood redraw some blood in the tubing...now it slowly rises up the tubing but never comes out with what I think was a slight element of pulsatility. I'm not sure how high up I am holding the tubing....immediately I think I'm in the carotid and so does my attending (not sure how based on the US)....we abort and put the line in the other side. We never hooked up and actually transduced the pressure.

I've never hit the carotid before....what do you expect the pulsatile flow in the tubing to be like in a normal healthy patient? ....my fellow resident says he has hit the carotid and the blood literally flies up through the top of the tubing (which was certainly not the case)....is this true?

now the patient has an lvad with continuous flow (MAP is currently 85 while we are doing this) , what would you expect to see in the tubing in this patient if you hit the carotid?

is it possible I didn't hold the tubing up high enough, should have transduced the pressure, and prematurely aborted?

Yeah, the CVP matters. The guy could have a CVP of 20 mmHg or more which would be about 30 cm H2O right? That's about a foot of tubing you'd need to test. Pulsatility in this case is not a good indicator of venous or arterial pressure. You didn't let us know how good the patient's own cardiac function is. If his stroke volume is crap and the LVAD is continuous, then the arterial pressure will not show much pulsatility if at all. Plus, venous blood may look like it has some pulsatility too (remember even the normal CVP waveform has peaks and valleys, and lesions like tricuspid regurgitation will create pulsatility). But, LVAD or not, if the MAP were 85, I'd expect the blood to rise really briskly. In your case, you could've done a couple of things: thread the wire and look with the US (or even better with TEE), really see how high that blood goes in the tubing, or just hook up the real transducer and measure the pressure quantitatively.

 

[Brookstacular]

In your case, you could've done a couple of things: thread the wire and look with the US (or even better with TEE), really see how high that blood goes in the tubing, or just hook up the real transducer and measure the pressure quantitatively.

Seems a little surprising these other steps were not tried first. Minimal harm to gently passing the wire and visualizing with TEE and continuous neck U/S... It's a cardiac room after all. If that probe's not in, it's not far away. MAP of 85 should be more than enough to send blood out the end of the pseudo-manometer.

 

[Triple AAA]

The problem with visualizing the guidewire under U/S is that it shows the entrypoint of the wire, but not the exit point. While the wire may enter the vein, it is possible that it may dissect through and through into the carotid, distal to where the ultrasound can visualize. For this reason, transduction in blood tubing or pressure tubing is usually superior. With that said, cases of heart failure, severe edema, or other reasons for elevated intrathoracic pressure can cause even venous blood to slowly rise into the tubing.

 

[deleted171991]

It would have cost nothing to transduce the pressure. When in doubt, I think that's the best (especially with an LVAD in place).

 

[deleted59964]

The problem with visualizing the guidewire under U/S is that it shows the entrypoint of the wire, but not the exit point. While the wire may enter the vein, it is possible that it may dissect through and through into the carotid, distal to where the ultrasound can visualize. .

i think that's a good point, but if i see my wire in the vein and the carotid next to it ... and i scan down and it's the same as far as i can see ... then i'm going to dilate that vessel

 

[IlDestriero]

It would have cost nothing to transduce the pressure. When in doubt, I think that's the best (especially with an LVAD in place).

Exactly FFP.
You didn't know where the catheter was but you aborted the procedure and stuck the other side. That doesn't make sense to me at all.
These procedures can cause real harm. I would not have done that.

 

[Arch Guillotti]

I've never hit the carotid before....what do you expect the pulsatile flow in the tubing to be like in a normal healthy patient? ....my fellow resident says he has hit the carotid and the blood literally flies up through the top of the tubing (which was certainly not the case)....is this true?

One time I put the long 18 gauge catheter in the carotid. Bright red blood squirted out like crazy. In a pretty normal person it was obvious.

 

[Arch Guillotti]

i think that's a good point, but if i see my wire in the vein and the carotid next to it ... and i scan down and it's the same as far as i can see ... then i'm going to dilate that vessel

Same here.

 

[Arch Guillotti]

Exactly FFP.
You didn't know where the catheter was but you aborted the procedure and stuck the other side. That doesn't make sense to me at all.
These procedures can cause real harm. I would not have done that.

It may not really cost anything but it is a real pain to maintain sterility.

 

[SouthSideSteve]

It may not really cost anything but it is a real pain to maintain sterility.

Open sterile pressure tubing onto field, pass end off to hook up to transducer, flush, hook up to line. Boom.

 

[Noyac]

Couple thoughts.
First, depending on the length of your tubing the blood usually doesn't squirt out the distal end like you describe. It travels at a fairly good pace though. I usually allow it to travel half the distance then lift it. If it doesn't fall in the tubing I don't proceed. Yes, usually it will be pulsatile. But if it isn't going back down something isn't right.
Second, US isn't 100% accurate. Do your due diligence. Transducing is a PITA but it works. Its easier with a second pair of hands.
Third, moving to the other side is usually frowned on since the risk of bilateral PTX is there. This doesn't mean I haven't done it but if I screw up the RIJ then I usually move to the R SC.
Next, I always use the needle with the catheter for the IJ since I can slide the cath off the needle and usually you will see dark slow blood flow. But if in the carotid it is "usually" obvious. Brighter than expected and flowing rapidly, usually pulsatile.
At some point you will become extremely sure of your placement skill and it will save you and even a pt. I had a pt rushed to the OR with a large kitchen knife sticking out of his chest and moving with the beat of his heart. We were going to do a sternotomy and carefully remove the knife under direct visualization and repair of the ventricle. I induce the guy and then proceeded to place my CORDIS in the RIJ. I got somewhat a pulsatile flow with the catheter placement but the wire went very easily ( frequently if you are in the carotid the wire just doesn't pass as easily) and the color was dark. I proceeded with the cordis and the blood was shooting out of the end. The cardiac surgeon freaked cuz he thought I was in the carotid. I told him I believed it was back pressure from the knife in the RV. I was right. Oh, we didn't have US back then.
Another point, it seems that when I or someone else put the catheter in the carotid (I've done it twice) I just pull it out and hold gentle pressure for a minute. It never developed a hematoma. The radial artery even makes a bigger hematoma then the carotid. I've even seen a cordis put in the carotid and pulled without causing a hematoma. The carotid just seems to seal up real well.

 

[Triple AAA]

i think that's a good point, but if i see my wire in the vein and the carotid next to it ... and i scan down and it's the same as far as i can see ... then i'm going to dilate that vessel

You would be perfectly fine 99.99% of the time. It's those rare instances when the guidewire dissects that transducing can be lifesaving. If I have blood tubing, I transduce. If I don't, I do exactly what you would do.

On a side note, I would argue that one can perform IJ lines without ultrasound if they were to transduce. The absence of pulsatile flow in the blood tubing confirms intravenous access prior to guidewire placement or dilation.

 

[painstop]

Couple thoughts.
First, depending on the length of your tubing the blood usually doesn't squirt out the distal end like you describe. It travels at a fairly good pace though. I usually allow it to travel half the distance then lift it. If it doesn't fall in the tubing I don't proceed. Yes, usually it will be pulsatile. But if it isn't going back down something isn't right.
Second, US isn't 100% accurate. Do your due diligence. Transducing is a PITA but it works. Its easier with a second pair of hands.
Third, moving to the other side is usually frowned on since the risk of bilateral PTX is there. This doesn't mean I haven't done it but if I screw up the RIJ then I usually move to the R SC.
Next, I always use the needle with the catheter for the IJ since I can slide the cath off the needle and usually you will see dark slow blood flow. But if in the carotid it is "usually" obvious. Brighter than expected and flowing rapidly, usually pulsatile.
At some point you will become extremely sure of your placement skill and it will save you and even a pt. I had a pt rushed to the OR with a large kitchen knife sticking out of his chest and moving with the beat of his heart. We were going to do a sternotomy and carefully remove the knife under direct visualization and repair of the ventricle. I induce the guy and then proceeded to place my CORDIS in the RIJ. I got somewhat a pulsatile flow with the catheter placement but the wire went very easily ( frequently if you are in the carotid the wire just doesn't pass as easily) and the color was dark. I proceeded with the cordis and the blood was shooting out of the end. The cardiac surgeon freaked cuz he thought I was in the carotid. I told him I believed it was back pressure from the knife in the RV. I was right. Oh, we didn't have US back then.
Another point, it seems that when I or someone else put the catheter in the carotid (I've done it twice) I just pull it out and hold gentle pressure for a minute. It never developed a hematoma. The radial artery even makes a bigger hematoma then the carotid. I've even seen a cordis put in the carotid and pulled without causing a hematoma. The carotid just seems to seal up real well.

Out of curiosity, how long did you hold pressure on the carotid? Did you have someone else hold pressure while you moved down to the subclavian vein?

 

[deleted547339]

You could feel the radial with an LVAD in??

Did you try to visualize in longitudinal? I'll do IJ's longitudinal from time to time if the anatomy allows. I do a ton of US-guided PIVs when access if difficult so I tend to favor in-line US when feasible. I universally look at the guidewire in longitudinal as soon as I place it. You can always try flushing an agitated 10cc syringe of NS with an echo probe on the chest.

A medicine resident at my institution dilated a carotid. The patient did fine with direct pressure.

I placed a fem vascath on an intubated pt with cirrhosis and got bright red blood that shot across the room. The pt had been intubated shortly before and the vent had an FiO2 of 100%. The increased intra-abdominal pressure from the tense ascites led to huge pressure.

I hope that makes sense....I haven't slept since yesterday.

 

[Arch Guillotti]

Couple thoughts.
First, depending on the length of your tubing the blood usually doesn't squirt out the distal end like you describe. It travels at a fairly good pace though. I usually allow it to travel half the distance then lift it. If it doesn't fall in the tubing I don't proceed. Yes, usually it will be pulsatile. But if it isn't going back down something isn't right.

The blood may not always fall back down. If I am sure I am in the IJ I proceed.

 

[Arch Guillotti]

Open sterile pressure tubing onto field, pass end off to hook up to transducer, flush, hook up to line. Boom.

This may be easy if you are in a heart room with a tech there to help you.

Not possible if you are in a regular hospital room and would take a lot of effort even in the ICU.

 

[Noyac]

Out of curiosity, how long did you hold pressure on the carotid? Did you have someone else hold pressure while you moved down to the subclavian vein?

Not long. Maybe a minute.

 

[Noyac]

You could feel the radial with an LVAD in??
.

Yes.
You don't need a pulse to feel the radial.
I had an attending teach me to feel for the vessel not the pulse. She told me that one day it will save a life or something like that. I began to pay close attention to the vessel. It feels like a soft rope sort of. It is much different Han feeling a vein. Then one day in my first year of PP one of my seasoned partners was taking a ruptured AAA to the OR emergently. He had tried multiple times to place an A line. The pt had no pulses distally. I was able to feel the rope and stuck it.

 

[Arch Guillotti]

The time I put the 18 gauge catheter in the carotid I simply removed it and help pressure for a couple of minutes. No hematoma.

If I can't get the right IJ under u/s (which I can't remember ever really happening), I would have no hesitation switching to the left. I am not really worried about ptx with u/s guided IJ.

 

[Noyac]

The blood may not always fall back down. If I am sure I am in the IJ I proceed.

I have done that. It just seems to me that if it doesn't fall back down then the chance of the wire going smoothly is diminished. It's fine to attempt it but I've pretty much stopped trying this. I think. It's been a while since I've had this issue.

 

[Ipassgas]

If you dilate the carotid you only need some pressure.

If you dilate the subclavian artery, LEAVE THE CATHETER IN PLACE!
In case you missed it, if you dilate the subclavian artery, KEEP THE CATHETER IN PLACE!

There is no way to hold pressure on the subclavian, so it needs a stitch or two. But there is no easy way to access the vessel to sew it, so you need IR or a surgeon to close the hole. If you remove the catheter, there is nothing occluding the hole. If you dilate the subclavian artery, you are committed to placing a catheter to plug the hole until you can get help.

DO NOT REMOVE A SUBCLAVIAN ARTERY CATHETER!

Thank you, you may go about your regularly scheduled SDN thread now.

 

[bkell101]

So we use an 18g needle with a Cather over it. Slide the catheter in and hook up 20 cm large bore tubing to watch it fall.

Blood oozed out of the catheter prior to hooking up the tubing (didn't shoot out) , it wasn't as dark red as normal (but this guy was young).

Sounds like We definitely should have transduced it and saved the kid a few extra sticks.

We should have used the extra ultrasound in the room to confirm no pneumothorax prior to moving to the left side. (Beach sign, ants marching ect.)

As for the Aline , he did have some pulsatile flow , his echo had 15% ef and the aortic valve did open

Very interesting to hear previous experiences.

 

[Icefrog]

So we use an 18g needle with a Cather over it. Slide the catheter in and hook up 20 cm large bore tubing to watch it fall.

Blood oozed out of the catheter prior to hooking up the tubing (didn't shoot out) , it wasn't as dark red as normal (but this guy was young).

Sounds like We definitely should have transduced it and saved the kid a few extra sticks.

We should have used the extra ultrasound in the room to confirm no pneumothorax prior to moving to the left side. (Beach sign, ants marching ect.)

As for the Aline , he did have some pulsatile flow , his echo had 15% ef and the aortic valve did open

Very interesting to hear previous experiences.

Just some teaching points: EF has to be taken in the right context when using it to estimate cardiac function. In diastolic heart failure, you can have a great EF... because your heart barely fills and it ejects almost all of what little volume it has, but you have no stroke volume and therefore no cardiac output. Also if your patient has some right heart failure, then blood may not be moving well from the RV to the LV and again, you may have a decent EF but again no stroke volume and no cardiac output. Lastly, please don't use blood color to determine whether you are venous or arterial (especially if you work at a place that does congenital cardiac). I have seen people accidentally place dialysis lines in arteries because they thought the blood looked nice and dark, forgetting that the patient has a mixing lesion.

 

[Ignatius J]

if the jugular is collapsable, i wouldn't expect it to have a high pressure.
did you thread your wire and then ultrasound it ? was it in the collapsable vessel?

Good thread.

I've had some questionable ones.

You can always compare blood to arterial line blood.

You can transduce.

You can look at u/s.

One thing I've done in a pinch under the drapes is pushed the wire in more and looked for ectopy. I know it sounds weird but you gotta do what you gotta do sometimes.

 

[norwood]

This may be easy if you are in a heart room with a tech there to help you.

Not possible if you are in a regular hospital room and would take a lot of effort even in the ICU.

Some kits come with a length of tubing (the ghetto pressure transducer) included. Back in my academic days, our kits had those. Worked well, and I had my residents use them routinely.

If you do have to hold pressure on the carotid, pay attention to the heart rate - you can cause quite a lot of vagal stimulation this way...

 

[Arch Guillotti]

Some kits come with a length of tubing (the ghetto pressure transducer) included. Back in my academic days, our kits had those. Worked well, and I had my residents use them routinely.

If you do have to hold pressure on the carotid, pay attention to the heart rate - you can cause quite a lot of vagal stimulation this way...

The kits I use have the tubing but I never use it since I use the needle, not the catheter over needle. We didn't u/s for lines much when I was in residency so we used the cheap tubing to transduce all the time. I think it's fine if you have a catheter in the vessel. A formal sterile transduction is a royal PITA though unless you are in the OR and have all the necessary equipment and people who know what they are doing.

 

[jwk]

Another point, it seems that when I or someone else put the catheter in the carotid (I've done it twice) I just pull it out and hold gentle pressure for a minute. It never developed a hematoma. The radial artery even makes a bigger hematoma then the carotid. I've even seen a cordis put in the carotid and pulled without causing a hematoma. The carotid just seems to seal up real well.

18ga catheter in the carotid not a big deal. A cordis is a much different animal - the one time I've seen one pulled was a disaster. In an ancient M&M conference at Emory, the consensus was these should be left in place and surgically explored/removed. We're seeing quite a few cold legs and femoral arteries screwed up as well from the big dilators the vascular guys are using for their "minimally invasive vascular surgery". I haven't seen anything that would change my mind - bad things happen with big neck hematomas.

 

[musli]

FYI: This is a technique that I don't usually use myself, but one of my colleagues swears by it.

In our hospital, we have small adaptors with a male Luer tip, a rubber diaphragm needle adaptor, and a ~10cm small-gauge side tubing. They often get hooked directly onto peripheral angiocaths on the floors.

My colleague opens one of these sterilely, then removes the rubber diaphragm, which reveals a female Luer tip. He puts this adaptor between the 10cc syringe and the angiocath. He hooks the sidearm up to pressure tubing. In this way, he is constantly transducing pressure *while* he makes his initial penetration into (hopefully) the IJ.

It's another step to set up, but it's pretty slick.

 

[nimbus]

Good thread.

I've had some questionable ones.

You can always compare blood to arterial line blood.

You can transduce.

You can look at u/s.

One thing I've done in a pinch under the drapes is pushed the wire in more and looked for ectopy. I know it sounds weird but you gotta do what you gotta do sometimes.

A wire in the LA or LV could also conceivably cause ectopy. If I know the wire is in the vein, ectopy is reassuring because I know it is not going out into the arm or up the neck

 

[fakin' the funk]

overnight cardiac call, heart transplant for 30 yo LVAD patient with ICD...some pulsatile flow, feel the radial and use the arrow....go to the neck....very small collapsible IJ, decent distance from the carotid on US....I stick what I believe to be the IJ based on US, thread the small catheter, transduce my small catheter......the column of blood doesn't fall down, it stays in the same place, so I flush out the blood redraw some blood in the tubing...now it slowly rises up the tubing but never comes out with what I think was a slight element of pulsatility. I'm not sure how high up I am holding the tubing....immediately I think I'm in the carotid and so does my attending (not sure how based on the US)....we abort and put the line in the other side. We never hooked up and actually transduced the pressure.

I've never hit the carotid before....what do you expect the pulsatile flow in the tubing to be like in a normal healthy patient? ....my fellow resident says he has hit the carotid and the blood literally flies up through the top of the tubing (which was certainly not the case)....is this true?

now the patient has an lvad with continuous flow (MAP is currently 85 while we are doing this) , what would you expect to see in the tubing in this patient if you hit the carotid?

is it possible I didn't hold the tubing up high enough, should have transduced the pressure, and prematurely aborted?

All this transducing and comparing blood drawn from the catheter to an arterial sample and ultrasounding the neck is the blind men and the elephant.

If you have a question on your wire's location, use your TEE, or TTE in a 4-chamber subcostal view (e.g.), or fluoro for f**k's sake, to confirm the location of your wire.

 

[Noyac]

All this transducing and comparing blood drawn from the catheter to an arterial sample and ultrasounding the neck is the blind men and the elephant.

If you have a question on your wire's location, use your TEE, or TTE in a 4-chamber subcostal view (e.g.), or fluoro for f**k's sake, to confirm the location of your wire.

I'm not bashing you "fakin". So don't take this the wrong way but I have never thought of pulling out the TEE for line placement. Maybe I should but then again I have never had as much difficulty placing one either. When I'm not having success at one location I will move to another. If that doesn't work then maybe it's time for someone else to try. After watching a partner struggle the other day with a line it was so hard not to ask if I could give it a go. But I just stood back and asked what he needed. I could see what was happening but the urgency wasn't there so I didn't press the issue. I just made sutle suggestions. If you are struggling with anything frequently it is worth a try to let someone else attempt the task. They usually have been watching and can see something you may not have seen. This isn't a competition.

 

[psychbender]

I'm not bashing you "fakin". So don't take this the wrong way but I have never thought of pulling out the TEE for line placement. Maybe I should but then again I have never had as much difficulty placing one either. When I'm not having success at one location I will move to another. If that doesn't work then maybe it's time for someone else to try. After watching a partner struggle the other day with a line it was so hard not to ask if I could give it a go. But I just stood back and asked what he needed. I could see what was happening but the urgency wasn't there so I didn't press the issue. I just made sutle suggestions. If you are struggling with anything frequently it is worth a try to let someone else attempt the task. They usually have been watching and can see something you may not have seen. This isn't a competition.

At one location through which I rotated for CT during residency, all IJs were performed by landmarks only, but an attending was usually performing a TEE at the same time, so he could bring up a bicaval view to find the wire if there was any doubt, prior to placing the line.

 

[Noyac]

^^^ I guess I could see it used in this situatuon.

 

[Mman]

If you dilate the carotid you only need some pressure.

If you dilate the subclavian artery, LEAVE THE CATHETER IN PLACE!
In case you missed it, if you dilate the subclavian artery, KEEP THE CATHETER IN PLACE!

There is no way to hold pressure on the subclavian, so it needs a stitch or two. But there is no easy way to access the vessel to sew it, so you need IR or a surgeon to close the hole. If you remove the catheter, there is nothing occluding the hole. If you dilate the subclavian artery, you are committed to placing a catheter to plug the hole until you can get help.

DO NOT REMOVE A SUBCLAVIAN ARTERY CATHETER!

Thank you, you may go about your regularly scheduled SDN thread now.

That's not necessarily true. I have once put an 8 Fr double lumen catheter into the subclavian artery. I believe I went through the vein and into the artery. I had transduced the 18 g catheter and it was clearly venous but at some point the wire, dilator, then catheter ended up in the artery. Called a vascular surgeon. Pt was skinny. He said it's only 8 Fr, just pull it out and hold pressure for 15 minutes. I was able to get my thumb above the clavicle and fingers below the clavicle and sort of compress around it. Placed a radial arterial line on that side and did the case and nothing bad ever happened.

So if you hit the subclavian, the rule isn't DO NOT REMOVE, the rule is CALL A VASCULAR SURGEON and then maybe remove after talking to them.

 

[fakin' the funk]

I'm not bashing you "fakin". So don't take this the wrong way but I have never thought of pulling out the TEE for line placement.

The OPs case was a heart txp...TEE was either in, or going to be in. I wouldn't use TEE just for line placement either. If I really had doubt where the wire was, Id do a subcostal 4 chamber view w TTE, use a C-arm, or get a chest xray before dilating. Or just go to another site.

 

[Ignatius J]

A wire in the LA or LV could also conceivably cause ectopy. If I know the wire is in the vein, ectopy is reassuring because I know it is not going out into the arm or up the neck

Could in theory. But flow is away from the left ventricle (in addition to the aortic valve being between them) so good luck getting it in there. May want to pick up a lottery ticket as well if you manage that. But I suppose it's possible. Not likely. But possible. In theory.