Care of central lines placed intraop

[9french]

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70cm? lol are you like across the room J/k you can use the standard extension set

Our kits do not come with manometer tubing. We have the choice between 20 cm and 70 cm extension tubing, and 20 cm may be too short depending on CVP.

 

[9french]

just a question, why not just hook the sterile tubing up to the steel needle and check for pulsatile flow-- why the xtra step of placing the angiocath?

thanks

The steel needle can easily move out of the vessel when hooking up the transducer tubing. It is very frustrating, when you have a difficult central line, you find the vessel, hook up the tubing to the steel needle, then lose the vessel. With the angiocath threaded into the vessel, it is much more difficult to lose.

 

[usnavdoc]

Our kits do not come with manometer tubing. We have the choice between 20 cm and 70 cm extension tubing, and 20 cm may be too short depending on CVP.

Yeah Iwas just joking around with the guy. When I first read his statement I was thinking 70inches. We use a 32inch spinlock extension.

 

[Gern Blansten]

At our institution we transduce all central lines with a T-Piece connected between the steel needle and the syringe. Line it up, pop the needle in, look at your screen for an appropriate pressure and waveform then go to town.

Could you elaborate on what type of central line kit you use and what type of t-piece this is? It sounds very useful. We have always just used the "filling the extension tubing" method, but I am open to trying new things.

 

[proman]

I don't tell the ICU when to d/c an endotracheal tube or what vent settings to use, I don't see how a central line is any different.

 

[coprolalia]

I don't tell the ICU when to d/c an endotracheal tube or what vent settings to use, I don't see how a central line is any different.

That's because you never find an endotracheal tube stuck in the groin completely clotted-off 10 days later that isn't hooked up to anything.

-copro

 

[periopdoc]

Could you elaborate on what type of central line kit you use and what type of t-piece this is? It sounds very useful. We have always just used the "filling the extension tubing" method, but I am open to trying new things.

Before you start, be sure that the scale on your screen is set appropriately for CVP. Once in a while I will look at the screen and see no waveform because the scale is set wrong. While the transduced numbers are great, they are no substitute for seeing a nice A C V waveform.


The majority of our central line kits are from Arrow although there are a few non-Arrow kits that come through from time to time.

The microbore t-connector is not included in the kit. We open it separately onto the field. It is manufactured by Medex and the part number is MX45F "T conn. w/ MLS" This one is shown with the caps removed.

View attachment DSC_3243.jpg


You connect your transducer to the long end of the T-connector with a sterile length of pressure tubing and place the T between your needle and syringe. Flush the system before you perform venipuncture.

View attachment DSC_3245.jpg

View attachment DSC_3249.jpg



Perform venipuncture in your usual sterile fashion, then look at your waveform. If you see

Thread that line. (and send your monitor to me so I can train the CA-1's on waveform analysis)



If instead you see

get a new monitor, be thankful you transduced and abandon this effort.


All of our kits that come with the Raulerson Spring-Wire Introduction Syringe (aka the syringe that allows you to thread the guidewire through it) come with a pressure transduction probe (needle) that looks like this

View attachment DSC_3253.jpg

to use it, remove the cover and attach the pressure tubing from the needle to your transducer like this

View attachment DSC_3254.jpg

After you have performed your venipuncture, you place this apparatus into the back of the syringe like this

View attachment DSC_3260.jpg

View attachment DSC_3259.jpg

When hubbed as in the latter picture, the pressure will be transduced from the tip of your steel needle and you can look at the waveform. You can also do this the old fashion way with a length of tubing attached to the transduction needle and look at the blood column, but it gets a bit awkward to control all of that bulk and keep the needle in the jugular.



pod

 

[periopdoc]

Updated my mini tutorial on CVP transduction and apologies to OP for hijacking your thread.


I would agree that epidurals, nerve catheters, and RICs are my responsibility until d/c'd and block is resolved because these are items that are never placed by my surgical or medical colleagues and they would have no idea how to manage them.

However, central lines placement and management is well within the scope of practice of these colleagues and there is no reason that I cannot transfer management of these lines to them. In fact most of my surgeons would be a little pissed if I wrote to d/c a central line in advance.

If it was an ortho patient, I would take responsibility for the line unless the patient was being co-managed by a medicine team. The ortho docs are certainly capable of managing it, but it really isn't their preference. Of course I am hard pressed to come up with an example of an ortho patient that would require a central line that would not require co-management.

I believe that once I have given report to ICU team (docs and nurses), my responsibility for central lines and arterial lines ends. That is why my ICU/ PACU report always ends the same way. With tubes lines and drains. I pull all of the covers off of the patient and go head to toe to be sure the receiving person knows where everything is.

Would you argue that I should be responsible for all 14 g peripheral IV's until they are d/c'd?

If there is a complication that develops that could potentially be due to placement issues, line infection etc, I would expect the primary team to contact me. However if the complication is due to a management issue, how can I be held responsible any more than if they mismanage a peripheral IV?


It sounds like you may have trained at Denver where I hear the motto among the surgical residents is, "Trust no one, do it yourself, expect sabotage."

pod

 

[Gern Blansten]

Before you start, be sure that the scale on your screen is set appropriately for CVP. Once in a while I will look at the screen and see no waveform because the scale is set wrong. While the transduced numbers are great, they are no substitute for seeing a nice A C V waveform.


The majority of our central line kits are from Arrow although there are a few non-Arrow kits that come through from time to time.

The microbore t-connector is not included in the kit. We open it separately onto the field. It is manufactured by Medex and the part number is MX45F "T conn. w/ MLS" This one is shown with the caps removed.

View attachment 11018


You connect your transducer to the long end of the T-connector with a sterile length of pressure tubing and place the T between your needle and syringe. Flush the system before you perform venipuncture.

View attachment 11019

View attachment 11021



Perform venipuncture in your usual sterile fashion, then look at your waveform. If you see

Thread that line. (and send your monitor to me so I can train the CA-1's on waveform analysis)



If instead you see

get a new monitor, be thankful you transduced and abandon this effort.


All of our kits that come with the Raulerson Spring-Wire Introduction Syringe (aka the syringe that allows you to thread the guidewire through it) come with a pressure transduction probe (needle) that looks like this

View attachment 11022

to use it, remove the cover and attach the pressure tubing from the needle to your transducer like this

View attachment 11023

After you have performed your venipuncture, you place this apparatus into the back of the syringe like this

View attachment 11025

View attachment 11024

When hubbed as in the latter picture, the pressure will be transduced from the tip of your steel needle and you can look at the waveform. You can also do this the old fashion way with a length of tubing attached to the transduction needle and look at the blood column, but it gets a bit awkward to control all of that bulk and keep the needle in the jugular.



pod

Nice description and pictures. I will have to see about getting one of those connectors to try it out. Thanks for posting the pics!

 

[kraphtymac]

Both completely inexcusable. This is why anesthesiologists need to remember that they are doctors and follow-up on their patients instead of beating a hasty retreat at 3:00 PM along with the CRNA's.

You know the old joke, right? "Why is there such a high death rate among anesthesiologists? Because they get run over by radiologists in the parking lot while running to their cars."

I think that if you put that line in, you own it. And, unless you trust that someone to whom you're transferring care, you better make sure it's managed properly. I'm sure the courts would likely agree.

OWN IT!

-copro

Next time I place an ET tube during a code, I'm going to pull it once the patient is stable since you clearly don't think anyone else can be trusted with it. Better yet, I won't even go to the code. Somebody else's patient = THEY should be owning it. Right?

 

[coprolalia]

Next time I place an ET tube during a code, I'm going to pull it once the patient is stable since you clearly don't think anyone else can be trusted with it. Better yet, I won't even go to the code. Somebody else's patient = THEY should be owning it. Right?

Again, endotracheal tubes are a bit more obvious than central lines. It's pretty damn hard to unintentionally leave an ETT in. Central lines can be ignored. If you don't document your transfer of care, you only have yourself to blame. And, yes, you should document placement of an endotracheal tube, as well as how hard it was to place, etc. We do this routinely (even post code), yet somehow we don't think it's as important to do so when we place a central line.

CYA, my friend.

-copro

 

[BubbleHead]

Peripherally Inserted Central Catheter. They're the bomb. Can stay in for weeks... even months... if cared for properly.

-copro

Manufacturer states ~12 months for one we use. Problem is the length leads to increased resistance, not so sweet for delivering volume in the OR.

 

[beezar]

The steel needle can easily move out of the vessel when hooking up the transducer tubing. It is very frustrating, when you have a difficult central line, you find the vessel, hook up the tubing to the steel needle, then lose the vessel. With the angiocath threaded into the vessel, it is much more difficult to lose.

In fact, if the carotid is underneath the IJ, the steel needle can move right into the carotid AFTER you've transduced and verified the previous position to be in the IJ. Wire, dilate, badness. It makes more sense to transduce an angiocath threaded into place, as that cath is not going to pierce the back wall and possibly into the carotid like a steel needle can.

 

[radslooking]

Thanks for the story. I have not had to deal with an arterial dilation, yet, so it is good to hear from someone who has seen the consequence. It seems your vascular surgeon was under the same impression I was. I wonder if there is any evidence-based guidelines as to what to do?

what if it was just the finder needle

 

[usnavdoc]

In fact, if the carotid is underneath the IJ, the steel needle can move right into the carotid AFTER you've transduced and verified the previous position to be in the IJ. Wire, dilate, badness. It makes more sense to transduce an angiocath threaded into place, as that cath is not going to pierce the back wall and possibly into the carotid like a steel needle can.

I thought you were talking about the SC CVL. As far as the IJ I agree I always use a 2inch 18g angiocath. Just wish the cath would stay on the needle when withdrawing rather than making hand adjustments.