Skill atrophy

[migm]

I'm 6 years out from residency.
We have an a resident ICU team so I put in central lines once in a blue moon.
I had a left fem central line I struggled with yesterday
Right side was not an option
On US even with positioning leg there was a lot of overlap of the CFV and CFA. I am right handed. I dont usually stick with my left, never practiced that. I am adept at ultrasound and do lots of US guided lines. using my right hand to get an oblique approach on the CFV was very awkward, then getting the wire the vein while maintain that awkward needle position sucked. I know I used to do these all the time but I cant remember how.
I guess senility starts early.

Thoughts?

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[Jabbed]

I'm 6 years out from residency.
We have an a resident ICU team so I put in central lines once in a blue moon.
I had a left fem central line I struggled with yesterday
Right side was not an option
On US even with positioning leg there was a lot of overlap of the CFV and CFA. I am right handed. I dont usually stick with my left, never practiced that. I am adept at ultrasound and do lots of US guided lines. using my right hand to get an oblique approach on the CFV was very awkward, then getting the wire the vein while maintain that awkward needle position sucked. I know I used to do these all the time but I cant remember how.
I guess senility starts early.

Thoughts?

90% of the time when the CFA is above the CFV it's because you're too low. Panus retraction is key.

Just do more central lines. Then do more central lines with your left hand.

Or don't.

 

[dadaddadaBATMAN]

I agree with Jabbed. You could look above and below the location you are for a more optimal location, retract a pannus (be confident in your holder or use a lot of tape) or you could just use a different site. You could also just stand on the opposite side of the bed and use the same hands you usually do. It's slightly awkward but I prefer this over switching hands,

I suppose that if you were confident in the identification of the femoral nerve and that you could avoid it I cannot think of a reason you couldn't take a lateral approach either, but maybe someone else can think of a reason. I probably wouldn't do it.

additional edit because I keep thinking of other things:
This also might be a good time to use the angiocath that comes in most cvl bundle/kits. If you are having no trouble hitting the thing but having trouble maintaining your positioning with the needle, just place the angiocath, slide in the cathter, and boom, you have a steady spot to put in the wire.

The rare "crash" cvls I place during codes I use the angiocath so the bouning won't disrupt me

and another edit
if you're placing a crash central line consider just using an IO.

 

[migm]

90% of the time when the CFA is above the CFV it's because you're too low. Panus retraction is key.

Just do more central lines. Then do more central lines with your left hand.

Or don't.

i did look up higher but it looked like GSV was coming in so I thought I was getting too high with the CFV

 

[Fox800]

Pretty uncommon that both 5/6 central venous access points are toast. But it happens. Did you try US-guided subclavian?

 

[RustedFox]

Pretty uncommon that both 5/6 central venous access points are toast. But it happens. Did you try US-guided subclavian?

My least favorite approach. I just feel foolish looking at the bone with the US.
I know, I know; I can do it. Doesn't mean that I like it. Just something that my videogame brain doesn't like.

 

[Jabbed]

i did look up higher but it looked like GSV was coming in so I thought I was getting too high with the CFV

Yep, you were definitely too low then. The sono-anatomy that you want to identify is the confluence of the femoral vein and the greater saphenous vein to form the CFV. This is fairly high in the groin and may be in the inguinal crease (but below the inguinal ligament).

If you're seeing a bifurcation of the femoral artery you're also too low.

If the vessels look too deep, try sliding the probe medial.

I'll generally scan up and down a short segment to visualize all these structures in my mind as well as to get the needle trajectory in mind. If you're high enough the probe will be parallel to the inguinal crease and your movements will be more towards/away from the umbilicus than north/south. This essentially puts you on track to stick the CFV at its widest diameter in an orientation that you can pass the wire with minimal resistance into the iliac vessels (which run towards the umbilicus).

The main reason why I do left-sided lines with my off-hand is because reaching across the patient and orienting the needle to this trajectory involves a lot of wrist contorsion.

 

[Jabbed]

Pretty uncommon that both 5/6 central venous access points are toast. But it happens. Did you try US-guided subclavian?

This is one of my favorites. With enough trendelenburg the axillary vein is a good target and everything just feels easier and cleaner. I've never done a true sub-clavicular subclavian US line because it seems to require in-plane needling with the probe oriented in a weird position in order to get a window under the clavicle.

 

[aafisahar]

venous to the penis and go in the crease. You can crash these blind and be done in <10 minutes.

 

[PianoMedic]

Frog leg positioning of that leg will often get the artery out of the way. As mentioned above, you want to hit above the saphenous confluence. I find foam tape from the pannus to the opposite side bedrail invaluable in many patients to get the stupid thing out of the way.

 

[Groove]

This is one of my favorites. With enough trendelenburg the axillary vein is a good target and everything just feels easier and cleaner. I've never done a true sub-clavicular subclavian US line because it seems to require in-plane needling with the probe oriented in a weird position in order to get a window under the clavicle.

Do you go out of plane or in plane?

 

[Jabbed]

Do you go out of plane or in plane?

Out of plane. Never really got comfortable doing lines in-plane.

 

[Mount Asclepius]

I think many femoral line challenges are from inserting too distally. When I help colleagues that are struggling they are way down in the thigh fairly far from the inguinal crease. Proximally is usually only difficult when fighting a pannus, especially during CPR. In that scenario, I don't think central access is very important or emergent unless you have major access difficulties where PIV, EJ and IO are unsuccessful for some reason. I always use my dominant right hand. When needing to use the left femoral site, sometimes I stand on the patient's right and sometimes on the left. Just depends on body habitus and what position I think will work best. If you are on the patient's right you have to make sure you are angling back towards the umbilicus or your wire doesn't pass as smoothly. This is certainly more awkward, but as long as you are cognizant of the angles then it works fine. Taping and frog legging are key as mentioned above.

 

[RustedFox]

When we all recognize "taping the pannus" as a strategy, something is wrong.

 

[dadaddadaBATMAN]

When we all recognize "taping the pannus" as a strategy, something is wrong.

And from experience with tape failure, it’s gotta be a lot o tape.

 

[Mount Asclepius]

Agree, lots of tape. I've never done it, but obesity and femoral lines were so prevalent at one shop that a traveling RN told me they had a specific pannus bar (I visualize a wooden broom handle) that two people would use to retract and hold the pannus. Sounds like a job that's almost as bad as when I had to assist TAH-LSOs as a medical student on my OB/gyn rotation by holding the uterine manipulator from below with the Gynecologist repeatedly yelling at me, "Other left!"

 

[dadaddadaBATMAN]

Agree, lots of tape. I'ver never done it, but obesity and femoral lines were so prevalent at one shop that a traveling RN told me they had a specific pannus bar (I visualize a wooden broom handle) that two people would use to retract and hold the pannus. Sounds like a job that's almost as bad as when I had to assist TAH-LSOs as a medical student on my OB/gyn rotation by holding the uterine manipulator from below with the Gynecologist repeatedly yelling at me, "Other left!"

I’ve had three bent or compromised line/wire situations from trusting fellow humans with pannus retraction. Now I have no faith, only lots of tape

 

[Angry Birds]

I do right IJ. Almost no matter what.
ok sometimes I’m forced elsewhere but then I get mad