Subclavian central lines

[tsbqb]

Do you attendings in the community do many?

Just kinda concerned because ive only done a few as a resident and Im not very comfortable with them (as oppsoed to IJs and femorals which I feel fine with)

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[bravotwozero]

I placed maybe 1 subclavian during residency, but did a TON of IJs and femoral lines. I actually don't like subclavians and don't recommend them unless you absolutely have to, since there is a greater risk of pneumothorax and is harder to stop bleeding if your patient has a coagulopathy. If you're in residency you should try and get as much experience,'since that's the whole point. But other than that I avoid this approach like the plague


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[canigetawhatwhat]

Ive done between 50-100 lines in residency.
Lets say 50% IJs, 35% SCs, 15% Fems
Hate Fems
LOOOOOVE SCs. Takes < 5 minutes in an experienced provider from prep to suture done.

If someone is unstable, and Im placing a line, I will always go SC. I worry about IJs, because when placing a central line, thought process stop,s nurse has no access to patient, and IJs take longer time, and IMO are more difficult to thread and stuff. R SC to me is a super easy line.

 

[Janders]

I'd guess, as an attending, I place 60% IJs via U/S, most of the rest femoral (crashing patient, delirious and moving), and perhaps only 10-15% SCV.

That said, its good to know all of them, and I do find the SCV approach rapid and clean. I try to avoid them in patients with severe respiratory distress or coagulopathy.

 

[Siggy]

Interestingly enough, the CDC recommends subclavians to prevent central line related infections and gives it a class 1-B recommendation.
http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Obviously that isn't the only consideration for deciding where to place the central line.

 

[Old_Mil]

I just don't do them anymore. The ultrasound guided IJ is a great line and if for whatever reason the patient must have central access and cannot tolerate a neck line, 24 hours with a groin line is probably safer than running the risk of giving a sick patient a pneumothorax while trying to stabilize them. The inpatient team can pull it and order a PICC or subclavian or whatever and have surgery put it in.

 

[deleted547339]

Ive done between 50-100 lines in residency.
Lets say 50% IJs, 35% SCs, 15% Fems
Hate Fems
LOOOOOVE SCs. Takes < 5 minutes in an experienced provider from prep to suture done.

If someone is unstable, and Im placing a line, I will always go SC. I worry about IJs, because when placing a central line, thought process stop,s nurse has no access to patient, and IJs take longer time, and IMO are more difficult to thread and stuff. R SC to me is a super easy line.

How can you hate femoral lines????

 

[deleted547339]

http://www.ncbi.nlm.nih.gov/pubmed/22809915

 

[engineeredout]

Problem is, the patients who are sick enough that I need to be putting a subclavian in are usually the ones who have the most to lose by me dropping their lung.

In the sick/crashing patient, love me the femoral prep and CVC/A-line in in the same place. Quick and easy, no issues with positioning, compressible, and with ultrasound I can hit both of them pretty rapidly. And no ****ing around with the radial artery in a hypotensive, swollen, obese patient whose peripheral vasculature is completely clamped down. Not to mention the femoral artery is probably more accurate for pressure readings

 

[Tenk]

For central lines I only do IJs unless contraindication, then femoral which I haven't done in a long time. I did subclavians in residency but they were the only lines I saw major complications with so...

For the "crashing patient" I go either IO or an ultrasound guided 16-18 long catheter IV in the EJ right before it meets the subclavian. The vein is huge. Then IJ.

 

[deleted109597]

http://www.ncbi.nlm.nih.gov/pubmed/22809915

Paul Marik knows his ****, and that paper shows it really isn't where the line is, it's who keeps it clean (or doesn't).

That being said, you can certainly place an US guided SCV catheter. You just have to learn how.

 

[southerndoc]

Interestingly enough, the CDC recommends subclavians to prevent central line related infections and gives it a class 1-B recommendation.
http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Obviously that isn't the only consideration for deciding where to place the central line.

Keep in mind that an iatrogenic pneumothorax means CMS doesn't pay for your hospital stay.

 

[pulmoblast]

Problem is, the patients who are sick enough that I need to be putting a subclavian in are usually the ones who have the most to lose by me dropping their lung.

Exactly...

 

[RustedFox]

How can you hate femoral lines????

I'm not a big fan of the femoral line. The majority of my patients who need a STAT Central line are turbo-obese, smelly, gross, and filthy. Poor environment, poor anatomy, trouble positioning... Etc. I have placed IJs in people "too fat for a femoral line".

US guided IJ for the win.

 

[deleted109597]

Keep in mind that an iatrogenic pneumothorax means CMS doesn't pay for your hospital stay.

No, it means they don't pay for anything related to the complication. You don't get a free cholecystectomy because you got caUTI. You just don't get to charge for the extended ABx, etc.

 

[southerndoc]

No, it means they don't pay for anything related to the complication. You don't get a free cholecystectomy because you got caUTI. You just don't get to charge for the extended ABx, etc.

You're right. I am jumping ahead of myself as this hasn't been implemented yet. In 2018 it will be. In 2020, too many of these complications and your entire CMS reimbursement will be affected for the entire hospital.

 

[BoardingDoc]

No, it means they don't pay for anything related to the complication. You don't get a free cholecystectomy because you got caUTI. You just don't get to charge for the extended ABx, etc.

That's why you switch them to q4h straight cathing if they have a neurogenic bladder or a condom cath otherwise. ZERO difference in UTI rates, but the foley gets you a CAUTI ding and the other two don't.

I hate that I know this garbage.

 

[deleted547339]

I'm not a big fan of the femoral line. The majority of my patients who need a STAT Central line are turbo-obese, smelly, gross, and filthy. Poor environment, poor anatomy, trouble positioning... Etc. I have placed IJs in people "too fat for a femoral line".

US guided IJ for the win.

I mean, yea, I prefer US IJs if I have time, but a lot do time I don't. The tough his is that it's hard to get situated at the head of the bed when a patient is dying. I can drop a fem line quick.

And trust me, I get my fair share of fatties where I work.....I think I need to put the cheeseburger down and go workout.

Related note, are anyone else's fitness goals to simply not be fat enough that someone would have a difficult time doing an LP or CVL on you?

 

[TheBlueBlazer]

Each has its place. The reality of taking down a lung is real, but the likelihood is way overrated. Subclavians are really easy lines to take care of and if you do enough of them, they are really not hard. US IJs are very controlled, and give you that warm cozy feeling of being able to watch your needle. Fems allow you to stay away from the head in a sick/coding patient and are often not as mucked up in your HD patients or folks that have had lots of lines in the past. My patient population has lots of c collars, which made me get good at SC really fast. As an ED physician, you should been good at all of them, and if you're not, and you're still in training, you should find ways to remedy that.

 

[dienekes88]

Ive done between 50-100 lines in residency.
Lets say 50% IJs, 35% SCs, 15% Fems
Hate Fems
LOOOOOVE SCs. Takes < 5 minutes in an experienced provider from prep to suture done.

If someone is unstable, and Im placing a line, I will always go SC. I worry about IJs, because when placing a central line, thought process stop,s nurse has no access to patient, and IJs take longer time, and IMO are more difficult to thread and stuff. R SC to me is a super easy line.

Mostly agree. I do left subclavian rather than right subclavian, because it's easier to float a swan from the left.

I'm a big proponent of timing yourself to make sure you improve procedural/operative efficiency. However, I do roll my eyes a bit when I hear about how fast people can place lines and how many they have placed. Having said that, I myself was the BIGGEST offender on this very topic as a second year resident...

For central lines I only do IJs unless contraindication, then femoral which I haven't done in a long time. I did subclavians in residency but they were the only lines I saw major complications with so...

For the "crashing patient" I go either IO or an ultrasound guided 16-18 long catheter IV in the EJ right before it meets the subclavian. The vein is huge. Then IJ.

Good luck finding the IO. On 3 separate occasions, I've been cutting the suture on the subclavian line when someone finally runs in with the IO gun, and this is as a senior when I'm not usually the guy placing lines (definitely not <5 minutes like Speed Racer above).

Subclavian definitely requires a certain feel, and you're not going to be good at it unless you're committed to placing it frequently to get over the learning curve.

You're right. I am jumping ahead of myself as this hasn't been implemented yet. In 2018 it will be. In 2020, too many of these complications and your entire CMS reimbursement will be affected for the entire hospital.

That's why you switch them to q4h straight cathing if they have a neurogenic bladder or a condom cath otherwise. ZERO difference in UTI rates, but the foley gets you a CAUTI ding and the other two don't.

I hate that I know this garbage.

The system rewards extraordinarily odd behavior, and the mandates from on high are too often misguided. Fortunately, we'll all serve our government overlords soon.

Interestingly enough, the CDC recommends subclavians to prevent central line related infections and gives it a class 1-B recommendation.
http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Obviously that isn't the only consideration for deciding where to place the central line.

They definitely seem a lot cleaner, though this meta-analysis suggests that they might not be. The dressing always lays very nicely. The patients tolerate them very well. The dressings on the neck lines are always getting partially pulled off when the patients move and the lines are tugging on it.

 

[Tenk]

Good luck finding the IO. On 3 separate occasions, I've been cutting the suture on the subclavian line when someone finally runs in with the IO gun, and this is as a senior when I'm not usually the guy placing lines (definitely not <5 minutes like Speed Racer above).

It's not called luck. It's called I know exactly where the IO is and I go there and get it (or have someone else if I'm busy). You'd do the same thing for a line. If you don't know where things are in your department then you haven't worked there long enough or are just plain bad.

 

[sum dude]

Do you attendings in the community do many?

Just kinda concerned because ive only done a few as a resident and Im not very comfortable with them (as oppsoed to IJs and femorals which I feel fine with)

Just know how to have 1 backup place to go if you don't have US (broken, someone else has, etc.) trust me on that--US guided is great and I use, but some new grads are hopeless w/o US.

In post-code pt's, try to be able to put a blind SC or Femoral in <10 min. EJ's are also huge skill to have, but yeah, I/o is way to go in a pinch.
Trust me...will come in handy.

 

[dienekes88]

It's not called luck. It's called I know exactly where the IO is and I go there and get it (or have someone else if I'm busy). You'd do the same thing for a line. If you don't know where things are in your department then you haven't worked there long enough or are just plain bad.

Hahaha. No need to call anyone names, buddy!

There are no IOs on the ward and only one in the Trauma ICU. I try to spend as little time in the emergency department as possible, so there may be one there, but you're right I don't know where it is. If that makes me a bad surgeon, then I'm ok with that, because I am not the kind of person who judges an emergency medicine physician on his ability to find a 26x21 Gore C-Tag or the EOPA cannulas... or even his ability to find the ORs for that matter. Not that you would have any trouble, you've clearly worked at your institution very long and are an excellent physician... I'm talking about normal people.

Typically, our anesthesia colleagues appreciate having access to the lines during the case in the event that they 1) want to float a swan or 2) want to troubleshoot if anything is going on while the patient is prepped and draped with the arms tucked. Please try to appreciate that different people have different demands on them. In virtually no situation is an IO advantageous to me or my patients.

 

[WilcoWorld]

Mostly agree. I do left subclavian rather than right subclavian, because it's easier to float a swan from the left.

I'm a big proponent of timing yourself to make sure you improve procedural/operative efficiency. However, I do roll my eyes a bit when I hear about how fast people can place lines and how many they have placed. Having said that, I myself was the BIGGEST offender on this very topic as a second year resident...



Good luck finding the IO. On 3 separate occasions, I've been cutting the suture on the subclavian line when someone finally runs in with the IO gun, and this is as a senior when I'm not usually the guy placing lines (definitely not <5 minutes like Speed Racer above).

Subclavian definitely requires a certain feel, and you're not going to be good at it unless you're committed to placing it frequently to get over the learning curve.





The system rewards extraordinarily odd behavior, and the mandates from on high are too often misguided. Fortunately, we'll all serve our government overlords soon.



They definitely seem a lot cleaner, though this meta-analysis suggests that they might not be. The dressing always lays very nicely. The patients tolerate them very well. The dressings on the neck lines are always getting partially pulled off when the patients move and the lines are tugging on it.

Why are you floating Swans in the ED?

[edit] just saw that you don't work primarily in the ED.

 

[dienekes88]

Why are you floating Swans in the ED?

[edit] just saw that you don't work primarily in the ED.

Yeah. Agree my experience is not typical, and floating a Swan in the ED would be... unusual. I just was scrolling by on my way to the surgery forum and saw a thread about subclavian lines.

 

[Tenk]

Hahaha. No need to call anyone names, buddy!

There are no IOs on the ward and only one in the Trauma ICU. I try to spend as little time in the emergency department as possible, so there may be one there, but you're right I don't know where it is. If that makes me a bad surgeon, then I'm ok with that, because I am not the kind of person who judges an emergency medicine physician on his ability to find a 26x21 Gore C-Tag or the EOPA cannulas... or even his ability to find the ORs for that matter. Not that you would have any trouble, you've clearly worked at your institution very long and are an excellent physician... I'm talking about normal people.

Typically, our anesthesia colleagues appreciate having access to the lines during the case in the event that they 1) want to float a swan or 2) want to troubleshoot if anything is going on while the patient is prepped and draped with the arms tucked. Please try to appreciate that different people have different demands on them. In virtually no situation is an IO advantageous to me or my patients.

I wasn't referring to you. I was referring to people who run around screaming for things when they have worked in the ER for several years and never bothered to know where things are stocked. Those people are bad. Since you're not ER you fall into the first group. You just haven't worked there enough, you're not bad. 8)

I would beg to differ with that last comment. A humerus IO gets meds to the heart in seconds, tibial is like 10-20 or so (forget the exact). In a clutch resuscitation or code, you don't need a central line. You need an IO. Obviously in a major trauma this is different and you may need a cordis or triple lumen. But for bread and butter non-traumatic resuscitation, an IO is invaluable in experienced hands. Just something to consider. Also, all the research says you're wrong about your time. Next time you are going to put in a central line, pull out your phone, go to stopwatch, hit start. I mean the second you say to yourself: I need a central line here, NOT the second you have everything prepped and ready to rock. Hit stop after you're done suturing and the line is secured. You'll be surprised. I was. For an IO it's about 2-3 minutes at most from the point of me saying I need an IO -> flush (assuming patient is unresponsive and I don't use lidocaine). Just food for thought.

 

[UnderwaterDoc]

Crashing patient = IO first then femoral. Yes my IO is readily available.

Stable-ish patient = IJ

As someone posted above the rate of infections for femorals is not significantly different and our lines will come off within 24h in most cases anyways.

Could I do a subclavian? sure, but in my opinion in the age of US the IJ is so easy and safe to do that you are doing a disservice to the patient by electing subclavian. I have seen several dropped lungs by "experts" who have done hundreds of subclavians.

 

[pseudoknot]

We have better evidence now, and it is clear that the subclavian has the lowest infection rate, and is in fact the safest line overall (even with the increased pneumothorax rate).

http://www.nejm.org/doi/full/10.1056/NEJMoa1500964

(Prospective randomized trial involving 3,000 patients, finding the infection rate in the IJ was 2x that of the subclavian, and the femoral 3.5x.) Note that a pneumothorax is usually immediately obvious and easily treated, while line infections and DVTs are often more insidious. I'm an even bigger fan of the subclavian since this paper came out.

 

[RustedFox]

I wasn't referring to you. I was referring to people who run around screaming for things when they have worked in the ER for several years and never bothered to know where things are stocked. Those people are bad. Since you're not ER you fall into the first group. You just haven't worked there enough, you're not bad. 8)

I would beg to differ with that last comment. A humerus IO gets meds to the heart in seconds, tibial is like 10-20 or so (forget the exact). In a clutch resuscitation or code, you don't need a central line. You need an IO. Obviously in a major trauma this is different and you may need a cordis or triple lumen. But for bread and butter non-traumatic resuscitation, an IO is invaluable in experienced hands. Just something to consider. Also, all the research says you're wrong about your time. Next time you are going to put in a central line, pull out your phone, go to stopwatch, hit start. I mean the second you say to yourself: I need a central line here, NOT the second you have everything prepped and ready to rock. Hit stop after you're done suturing and the line is secured. You'll be surprised. I was. For an IO it's about 2-3 minutes at most from the point of me saying I need an IO -> flush (assuming patient is unresponsive and I don't use lidocaine). Just food for thought.

For real, B.

I have run LITERS of fluids thru IOs because there were seriously ridiculous-ass complications with every other central line site.

Its IO for the win when seconds count.

If you don't know where yours is (and you're a full-time EP in your usual shop) then you lose the game.

 

[Tenk]

For real, B.

I have run LITERS of fluids thru IOs because there were seriously ridiculous-ass complications with every other central line site.

Its IO for the win when seconds count.

If you don't know where yours is (and you're a full-time EP in your usual shop) then you lose the game.

You must have trained at an amazing residency program with a super cool director!

 

[filhodeinferno]

I'm not a big fan of the femoral line. The majority of my patients who need a STAT Central line are turbo-obese, smelly, gross, and filthy. Poor environment, poor anatomy, trouble positioning... Etc. I have placed IJs in people "too fat for a femoral line".

US guided IJ for the win.

I agree. I hate messing around down in the groin. No matter how many chlora preps you use it still feels like a cess pool.

 

[RustedFox]

You must have trained at an amazing residency program with a super cool director!

Yep. And she was a hottie, too.

 

[WilcoWorld]

You must have trained at an amazing residency program with a super cool director!

We do scavenger hunts in the ED as part of resident orientation and then repeat them each year. It's fun and useful.

 

[RustedFox]

We do scavenger hunts in the ED as part of resident orientation and then repeat them each year. It's fun and useful.

What's typically on the hunt list ? IOs ?

 

[WilcoWorld]

What's typically on the hunt list ? IOs ?

IO's, pelvic binder, Hare traction splint, trasvenous pacer, time sensitive stuff like that. We also put useful, but less time-sensitive, stuff like the tonopen on the list.

 

[medicsb]

Anyone doing US guided subclavians via the supraclavicular approach? If so, how has your experience with it been?

 

[Tenk]

Anyone doing US guided subclavians via the supraclavicular approach? If so, how has your experience with it been?

No because most of my patients look like Jabba the Hutt mated with the Michelin Tire Man.

 

[Psai]

No because most of my patients look like Jabba the Hutt mated with the Michelin Tire Man.

With amazing insurance I'm sure

 

[Tenk]

With amazing insurance I'm sure

Yeah it is pretty good, it's called: Everything Is Free Because I Don't Pay Anything. They are currently accepting patients in the 10s of thousands.

 

[dienekes88]

I wasn't referring to you. I was referring to people who run around screaming for things when they have worked in the ER for several years and never bothered to know where things are stocked. Those people are bad. Since you're not ER you fall into the first group. You just haven't worked there enough, you're not bad. 8)

100% agree that the times are all very optimistic. I timed myself the first half of my second year; that was a long time ago. I'm much slower now.

I would beg to differ with that last comment. A humerus IO gets meds to the heart in seconds, tibial is like 10-20 or so (forget the exact). In a clutch resuscitation or code, you don't need a central line. You need an IO. Obviously in a major trauma this is different and you may need a cordis or triple lumen. But for bread and butter non-traumatic resuscitation, an IO is invaluable in experienced hands. Just something to consider. Also, all the research says you're wrong about your time. Next time you are going to put in a central line, pull out your phone, go to stopwatch, hit start. I mean the second you say to yourself: I need a central line here, NOT the second you have everything prepped and ready to rock. Hit stop after you're done suturing and the line is secured. You'll be surprised. I was. For an IO it's about 2-3 minutes at most from the point of me saying I need an IO -> flush (assuming patient is unresponsive and I don't use lidocaine). Just food for thought.

I'll think about it. I've never fully heparinized someone for cardiopulmonary bypass with an IO, but I'm open to it.

We have better evidence now, and it is clear that the subclavian has the lowest infection rate, and is in fact the safest line overall (even with the increased pneumothorax rate).

http://www.nejm.org/doi/full/10.1056/NEJMoa1500964

(Prospective randomized trial involving 3,000 patients, finding the infection rate in the IJ was 2x that of the subclavian, and the femoral 3.5x.) Note that a pneumothorax is usually immediately obvious and easily treated, while line infections and DVTs are often more insidious. I'm an even bigger fan of the subclavian since this paper came out.

This is so freakin' awesome.

 

[UnderwaterDoc]

We have better evidence now, and it is clear that the subclavian has the lowest infection rate, and is in fact the safest line overall (even with the increased pneumothorax rate).

http://www.nejm.org/doi/full/10.1056/NEJMoa1500964

(Prospective randomized trial involving 3,000 patients, finding the infection rate in the IJ was 2x that of the subclavian, and the femoral 3.5x.) Note that a pneumothorax is usually immediately obvious and easily treated, while line infections and DVTs are often more insidious. I'm an even bigger fan of the subclavian since this paper came out.

This does not change my practice.

Article states 20 to 22 cases cases of DVT/infection for IJ and femoral lines out of 3400, respectively. I can't see the whole article but lets assume 1000 of the lines are IJs. That means 1/50 IJs will be infected with similar rate for femorals. I probably average 1-2 IJs per month at my shop, ditto for femorals. It would take me a couple of years to have a single infected/DVT IJ or femoral line, even more so if you consider that most of our ED lines are replaced by PICC lines within a day. And I think a pneumo is much more dangerous than a DVT or line infection but maybe that's just me.

They will have to pry US-guided IJ as my "clean" line of choice from my cold dead fingers

 

[Doctor Bob]

Article states 20 to 22 cases cases of DVT/infection for IJ and femoral lines out of 3400, respectively. I can't see the whole article but lets assume 1000 of the lines are IJs. That means 1/50 IJs will be infected with similar rate for femorals. I probably average 1-2 IJs per month at my shop, ditto for femorals. It would take me a couple of years to have a single infected/DVT IJ or femoral line, even more so if you consider that most of our ED lines are replaced by PICC lines within a day. And I think a pneumo is much more dangerous than a DVT or line infection but maybe that's just me.

It's more useful to use this article to guide practice from the ICU side. I put in 1-2 lines per shift, and so do my coworkers. So ~8 lines per 24hr period. So I'll underestimate and say 2500 per year. That infection rate becomes a real issue, plus our lines stay in longer. I would say that pneumothoraces are more acutely dangerous, but I lose a lot more people to sepsis than I do to tension PTX. So, for me in the ICU, as long as I have a choice, I'll go subclavian.

 

[TooMuchResearch]

This does not change my practice.

Article states 20 to 22 cases cases of DVT/infection for IJ and femoral lines out of 3400, respectively. I can't see the whole article but lets assume 1000 of the lines are IJs. That means 1/50 IJs will be infected with similar rate for femorals. I probably average 1-2 IJs per month at my shop, ditto for femorals. It would take me a couple of years to have a single infected/DVT IJ or femoral line, even more so if you consider that most of our ED lines are replaced by PICC lines within a day. And I think a pneumo is much more dangerous than a DVT or line infection but maybe that's just me.

They will have to pry US-guided IJ as my "clean" line of choice from my cold dead fingers

There were 900 people in that paper that the docs decided should not get subclavians for whatever reason, so the analysis is skewed. It's unclear if the "real" pneumothorax rate is higher.

 

[HooliganSnail]

I wasn't referring to you. I was referring to people who run around screaming for things when they have worked in the ER for several years and never bothered to know where things are stocked. Those people are bad. Since you're not ER you fall into the first group. You just haven't worked there enough, you're not bad. 8)

I would beg to differ with that last comment. A humerus IO gets meds to the heart in seconds, tibial is like 10-20 or so (forget the exact). In a clutch resuscitation or code, you don't need a central line. You need an IO. Obviously in a major trauma this is different and you may need a cordis or triple lumen. But for bread and butter non-traumatic resuscitation, an IO is invaluable in experienced hands. Just something to consider. Also, all the research says you're wrong about your time. Next time you are going to put in a central line, pull out your phone, go to stopwatch, hit start. I mean the second you say to yourself: I need a central line here, NOT the second you have everything prepped and ready to rock. Hit stop after you're done suturing and the line is secured. You'll be surprised. I was. For an IO it's about 2-3 minutes at most from the point of me saying I need an IO -> flush (assuming patient is unresponsive and I don't use lidocaine). Just food for thought.

It depends on what you need access for. If its a code, the IO is perfect for getting meds in fast.

If it is a crashing shocky patient and you need pressors, then the subclavian is a great line that isn't in the groin (central line infections always seem to be from the fem), and can be done very fast. My record is three minutes in a code (although that was not a sterile line, and truly central lines are not necessary in codes).

There has been several studies recently showing that vassopressors are safe to give through a peripheral IV for extended periods, so in my book, if I have a crashing patient who needs pressors, they get them through the PIV, and I put in a R Subclavian likity split.

 

[HooliganSnail]

I just don't do them anymore. The ultrasound guided IJ is a great line and if for whatever reason the patient must have central access and cannot tolerate a neck line, 24 hours with a groin line is probably safer than running the risk of giving a sick patient a pneumothorax while trying to stabilize them. The inpatient team can pull it and order a PICC or subclavian or whatever and have surgery put it in.

I agree that if you have the time, the U/S guided IJ is the safest line, hands down. Although if the patient has a trach, the subclavian is the preferred approach as it is further away from that nasty business.

In the ER though, I do a lot of Fem lines. They are fast, there is nothing bad to hit, if I accidently hit the artery, Great!, hand me the art line kit......and the legs are generally accessible while others are working on the patient up top. Fem line gets a bit of a bad rap, although most central line infections seem to involve the Fem......

 

[BoardingDoc]

(central line infections always seem to be from the fem),

The study that was just quoted literally shows no significant infection rate difference between femoral lines and IJ lines. Unless someone has some robust data to back up the claim that fem lines are more prone to infection, I wish people would stop saying it. Just because "it makes sense" doesn't make it correct.

 

[HooliganSnail]

The study that was just quoted literally shows no significant infection rate difference between femoral lines and IJ lines. Unless someone has some robust data to back up the claim that fem lines are more prone to infection, I wish people would stop saying it. Just because "it makes sense" doesn't make it correct.

I really wasn't quoting a study so much as from anecdotal experience. At my hospital, all central line associated infections in the last three years have been from fem lines. Granted, there were only 3 infections, and the sample size is small.....

 

[Doctor Bob]

They are fast, there is nothing bad to hit.

I probably see 1 RP bleed or AV fistulization or pseudoaneurysm per month as a result of a fem line CVC. Plenty of bad things to hit or cause.
Doesn't mean you shouldn't do them...

Fem line gets a bit of a bad rap, although most central line infections seem to involve the Fem......

Most of ours come from IJ lines. Now it might be because we don't generally leave fem lines in long enough for them to become infected. But even when we do (usually temporary dialysis lines in our vasculopaths), they don't cause problems.

 

[HooliganSnail]

I probably see 1 RP bleed or AV fistulization or pseudoaneurysm per month as a result of a fem line CVC. Plenty of bad things to hit or cause.
Doesn't mean you shouldn't do them...



Most of ours come from IJ lines. Now it might be because we don't generally leave fem lines in long enough for them to become infected. But even when we do (usually temporary dialysis lines in our vasculopaths), they don't cause problems.

Have you tried using the angiocatheter in the kit? You attach the angiocath to the syringe, once you hit the vessel, push the angiocathcath in, then thread the guide wire through the angiocath. It reduces all that fussing around with the guide wire while a sharp needle is wrecking the inside of your vessel, and thereotically reduces complication.

 

[Doctor Bob]

Have you tried using the angiocatheter in the kit? You attach the angiocath to the syringe, once you hit the vessel, push the angiocathcath in, then thread the guide wire through the angiocath. It reduces all that fussing around with the guide wire while a sharp needle is wrecking the inside of your vessel, and thereotically reduces complication.

I didn't say I saw the complications as a result of -my- placement