Central line nervousness

[scummie]

About to start third year in a few weeks and I still dread putting in central lines. How can I get over this? I've been told my technique is fine, no issues. I start to think about "what if I can't get the line in? What if the guidewire doesn't go in smooth and I can't get it?" Am I just psyching myself out? Never had any complications with line placement. Until the CXR comes back, I get major anxiety. It's gotten better with time though. It's hit or miss getting lines so it's hard to arrange consistent practice. Is it crazy talk to think about doing more ICU as elective time next year? Have already done a total of 4 ICU months and have 2 more next year.

---

Members don't see this ad.

 

[mauricekenter]

Don't worry about failing and if you do make a mistake, learn from it. The more you do the better you get, as long as you are willing to learn. I would break down the steps and each time you put one in, have a goal in mind on what you are trying to improve upon.

I used to suck at LPs and didn't like doing them so instead I decided to dedicate time to making it my best procedure, now it's a piece of cake.

Ask other people about their tips and tricks, also watch the EMCrit video on it.

 

[RustedFox]

Once you get the flash... LAY THE NEEDLE FLAT.

 

[Venko]

It's okay to be nervous. It's different for each person and in each situation. It doesn't sound like you are too afraid to act which is the key. In my opinion, it wouldn't be wrong to add more icu time if you think you'll get more lines.

There will always be new challenges even after you graduate...

I had a wire not come out.

I had to put in an IJ CVC with a patient who could only breathe on their left side and didn't want intubation.

Things are always happening...remember you are training to learn a method for problem solving not just wrote reproduction of a series of moves of the hand.


Sent from my iPhone using SDN mobile

 

[southerndoc]

You're going to have complications if you do enough lines. I've had an IJ curl up and go into the other side (left IJ curled to the right), had subclavians go into the IJ, an IJ go into the azygous vein, hit a subclavian artery (thankfully not a carotid... yet), dropped a lung, etc.

If you haven't had a complication from a central line, you've not done enough central lines.

During residency we had a guidewire get caught in an IVC filter from an IJ placement. What did I learn from somebody else's complication? Don't thread the wire past the halfway mark under any circumstance.

I work in a very busy ER and have placed hundreds of central lines in my career. To this day, I still have a bit of butterflies in my stomach whenever I look at the post-placement chest x-ray. It's natural.

 

[alpinism]

Agree with the above, the only way to get more comfortable is to do more lines.

I will say though that after originally doing hundreds of blind central lines, doing them with U/S guidance here in the US is pretty straightforward in most patients.

Even though it might not be possible at some US programs I'd still recommend learning to do them blind on low risk patients before you graduate.

 

[CanadianEM]

I would try using the angiocath next time and thread that like you would a peripheral iv. Since I've started doing it this way, my IJs have been more successful. Still do the regular needle for SCV lines though.

 

[deleted547339]

With the advent of US for PIVs, IOs and PICC teams, I suspect the number of CVLs done in the ED will be exceedingly low if you plan on practicing in the community.

 

[gman33]

I wouldn't worry about it.
Just do them when you have the chance.
The more you do the better.

If anything i'd make sure you get good at placing peripheral u/s lines.
The last thing I want to do is waste time placing a central line if all they need is access.

If I could just convince intensivists to run pressors for 24 hours with peripheral access, I'd probably almost never place a central line.
Pretty much everyone going to the ICU is going to end up with a PICC at some point anyway.

 

[gman33]

FWIW - At the same point in my training I was nervous about intubating.
I went to an airway course which really helped.
Make sure you try to master anything that scares you.
Especially while you still have backup

 

[Phosphorus Ylide]

I feel similarly about chest tubes. Have never had any complications, but the left sided ones always make me feel iffy. I think we all have some procedure we feel weird about, for whatever reason. If it makes you feel any better, I dropped a lung once with an IJ and not even a SC. Chest tube and reinflated fine.

 

[GonnaBeADoc2222]

Definitely seen lots of wacky complications. I did a u/s guided subclavian that went up the IJ. Had a friend have an IJ go into the axillary vein (wtf?!). The line will go where it wants to go. I would say the only inexcusable complication is leaving a wire in someone (seen that a couple times...not from me thank God). My prediction is that within 10 yrs we will be doing almost no central lines anyway as things like midlines become more popular and peripheral pressors become more accepted...it's not a riskless procedure by any means.

 

[shoal007]

im in the community 2 yrs. done 1 line. most get PICCs and run peripheral pressors for a few hours. standard of care here.

Sent from my Pixel using Tapatalk

 

[GeneralVeers]

im in the community 2 yrs. done 1 line. most get PICCs and run peripheral pressors for a few hours. standard of care here.

Sent from my Pixel using Tapatalk

Same here. I probably do one every 4-6 months. We do peripheral pressors until they can get a PICC line or pt gets central line with IR or surgeon in the morning. Being single coverage overnight, I don't put in a line unless it's a truly crashing patient. The ED is too busy otherwise to spend ~ 30 minutes or more on a procedure.

IO line is now my go-to in all crash situations and difficult access.

 

[RustedFox]

Central lines were my absolute favorite procedure during residency.
I'm a touch bummed that I don't do so many now.

Veers is right. IO for the win. Peripheral pressors overnight.

 

[brk81144]

Agree with above. Haven't put in a line for more than a year in the community. We start peripheral pressors and then they get a picc

 

[RustedFox]

This begs a question about which is better for the patient.... c-line early, or late?

All arguments regarding dept throughput be damned, for the purposes of this discussion.

 

[bravotwozero]

depends on two factors for me: 1) How good is the peripheral access? 2) Is the patient hemodynamically stable? If the answer to both of these questions is in the negative, then c-line earlier the better. Otherwise, not really time sensitive...

 

[gamerEMdoc]

Always better to resuscitate early, however the more important question is do you need the cental line for resuscitation. With the advent of emergent picc teams and IO's, I could easily see the triple lumen catheter going the way of the swan ganz catheter. You'll always need the cordis for the really sick folks, but putting a c-line in just for people with no access or just for pressors seems like un-needed risk. If Im the patient and need pressors, I want a humoral IO and then a PICC line when available to be placed. Much safer for the patient.

 

[da8s0859q]

Always better to resuscitate early, however the more important question is do you need the cental line for resuscitation. With the advent of emergent picc teams and IO's, I could easily see the triple lumen catheter going the way of the swan ganz catheter. You'll always need the cordis for the really sick folks, but putting a c-line in just for people with no access or just for pressors seems like un-needed risk. If Im the patient and need pressors, I want a humoral IO and then a PICC line when available to be placed. Much safer for the patient.

As much as I enjoy central lines, this is my feeling as well.

 

[southerndoc]

Definitely seen lots of wacky complications. I did a u/s guided subclavian that went up the IJ. Had a friend have an IJ go into the axillary vein (wtf?!). The line will go where it wants to go. I would say the only inexcusable complication is leaving a wire in someone (seen that a couple times...not from me thank God). My prediction is that within 10 yrs we will be doing almost no central lines anyway as things like midlines become more popular and peripheral pressors become more accepted...it's not a riskless procedure by any means.

Try a mammary vein in a cirrhotic. Looked perfectly fine on CXR, but seen on CT of his chest.

 

[engineeredout]

Always better to resuscitate early, however the more important question is do you need the cental line for resuscitation. With the advent of emergent picc teams and IO's, I could easily see the triple lumen catheter going the way of the swan ganz catheter. You'll always need the cordis for the really sick folks, but putting a c-line in just for people with no access or just for pressors seems like un-needed risk. If Im the patient and need pressors, I want a humoral IO and then a PICC line when available to be placed. Much safer for the patient.

I love the IO for emergent access, I don't place CVCs during codes - don't see the need when the IO is available.

Can't convince my trauma colleagues but while they're insisting on dicking around with trying to place blind introducers (I think they still believe US is just for pregnant chicks), I've got two IOs in before they even realize it.

That being said, at my hospitals patents can't leave the ED with an IO, so the patients will end up getting a CVC (if they live), but it enables me to place it in a sterile manor and with less complications because it's not an emergent rush to get it in.


And emergent PICC Lines? What is this sorcery?

 

[scummie]

Thanks for the responses!

Emcrit had some great videos about the other central line skills with some good tips, like optimal ways to use the dilator, going back and forth with the guide wire, etc.

I think the procedure butterflies will go away when I do more lines. The last two were crash blind fem lines that were difficult, so didn't help my confidence! Granted the attending couldn't cannulate one of them either. One, the artery was right on top of the vein, so didn't know that until after we put the ultrasound on. And you're right, you have to learn from your failures. So frog leg if you can and try not to go in the inguinal crease, but more distal.

Also, putting in a line while the patient is on the CT scanner table...no bueno

 

[Fox800]

The EMCrit central line microskills videos were money. Also, does your kit come with the syringes that you can feed the guidewire through? I've been using that lately and I really like it. It vastly reduces the incidence of the needle tip slipping out of the vein when you go to remove the syringe.

 

[Groove]

Always push yourself. Practice makes perfect. My fav line in residency was a subclavian line. I would find myself mentally shying away from IJs. You just have to push yourself to perform the procedure that gives you the most fear and anxiety. I pushed myself to do more IJs until I really didn't care about the type of line. You always have to push yourself in some capacity to keep your skills sharp, so get used to it.

P.S. I've never been a fan of passing guidewires through syringes. I like to see non arterial flow from the needle.

Also, remember with lines (or any procedure for that matter)... you WILL have complications, even if you are the best of operators. The numbers don't lie. I've cannulated arteries (though not dilated), dropped a lung, had the guidewire go in just about every direction, you name it... and I consider myself a very skilled proceduralist. Do enough and it will happen! Don't let that deter you though. Let it give you respect for the procedure itself so that you are meticulous about your approach. Overconfidence breeds sloppiness.

 

[deleted245139]

The EMCrit central line microskills videos were money. Also, does your kit come with the syringes that you can feed the guidewire through? I've been using that lately and I really like it. It vastly reduces the incidence of the needle tip slipping out of the vein when you go to remove the syringe.

Oh man I hate those... But personal preference. It pushes the center of gravity so far back that I've watched plenty of people lose their spot in the vessel... And you never see the blood flow so you never see it stop. If it works tho, you gotta do what's comfortable! Calm hand control is key for all of it

 

[emergentmd]

Central lines were my absolute favorite procedure during residency.
I'm a touch bummed that I don't do so many now.

Veers is right. IO for the win. Peripheral pressors overnight.

How do you get away with this. The two big places i work all want central lines for Critical/Severe sepsis patients. They never do peripheral pressors, PICC not avail 24 hrs a day.

If you are nervous, get good an u/s guided which you would be good after awhile. Or do what i do, and save the time and put in an Femoral. You can stick the groin a bunch of times without any complications. Fast, no need for U/S set up, no chest xray. Takes me 10-15 min from insertion to stich.

 

[shoal007]

How do you get away with this. The two big places i work all want central lines for Critical/Severe sepsis patients. They never do peripheral pressors, PICC not avail 24 hrs a day.

If you are nervous, get good an u/s guided which you would be good after awhile. Or do what i do, and save the time and put in an Femoral. You can stick the groin a bunch of times without any complications. Fast, no need for U/S set up, no chest xray. Takes me 10-15 min from insertion to stich.

plenty of articles showing peripheral pressors are safe in a large bore proximal vein or io. We dont have staffing or time to do this procedure. patient satisfaction is king (others cannot wait) -- so we dont.

Sent from my Pixel using Tapatalk

 

[Hamhock]

About to start third year in a few weeks and I still dread putting in central lines. How can I get over this? ... months and have 2 more next year.

Make yourself a proceduralist. Own it.
Place as many cordis catheters during trauma resuscitation as possible in residency.
If you have 2 more months of ICU next year, really try to put in every dialysis line you can. After a bunch of those stiff spears (especially a few with difficult placement), little TLCs will seem like a 24g PIV in the AC.
Also, try to get as many femoral arterial lines as possible.
If there are skilled proceduralists around, try to learn the "in-line" ultrasound-guided axillary/subclavian.
HH

 

[Hamhock]

I love the IO for emergent access, I don't place CVCs during codes - don't see the need when the IO is available.

Can't convince my trauma colleagues but while they're insisting on dicking around with trying to place blind introducers (I think they still believe US is just for pregnant chicks), I've got two IOs in before they even realize it.

IO for the trauma resuscitation? For massive transfusion?

I can see IO for quick access in difficult cases, but after that initial step, something else must be placed: 18g PIV (even "peripheral" IJ) or big central line or RIC or something.

IO only is inadequate in my opinion for trauma resuscitation or hemorrhaging anything.

HH

 

[Fox800]

My love: MAC catheter.

 

[alpinism]

IO for the trauma resuscitation? For massive transfusion?

I can see IO for quick access in difficult cases, but after that initial step, something else must be placed: 18g PIV (even "peripheral" IJ) or big central line or RIC or something.

IO only is inadequate in my opinion for trauma resuscitation or hemorrhaging anything.

HH

At that point I'd just place a second IO in the femur or humerus.

Now don't get me wrong I'm not arguing against central lines like some other posters in this thread however I don't think they should be used during the initial phase of resuscitations when there are much faster and more reliable ways of obtaining vascular access. Your typical central line takes 2-3 minutes to place before its fully functional and it can sometimes take twice as long in patients with weird anatomy or morbid obesity. In contrast you can easily place an IO in 20-30 seconds in almost all patients.

 

[WildcatS11]

At that point I'd just place a second IO in the femur or humerus.

Now don't get me wrong I'm not arguing against central lines like some other posters in this thread however I don't think they should be used during the initial phase of resuscitations when there are much faster and more reliable ways of obtaining vascular access. Your typical central line takes 2-3 minutes to place before its fully functional and it can sometimes take twice as long in patients with weird anatomy or morbid obesity. In contrast you can easily place an IO in 20-30 seconds in almost all patients.

Best part about femoral lines - your nurses will use them without the "confirmatory chest XR."

 

[southerndoc]

Best part about femoral lines - your nurses will use them without the "confirmatory chest XR."

Nurses use my IJ's without confirmation. If it's ultrasound guided and you got dark venous blood, no reason they can't use it for the 5 minutes it takes to get a chest x-ray. There was a study about 10 years ago that supported this.

 

[GeneralVeers]

At that point I'd just place a second IO in the femur or humerus.

. Your typical central line takes 2-3 minutes to place before its fully functional and it can sometimes take twice as long in patients with weird anatomy or morbid obesity. In contrast you can easily place an IO in 20-30 seconds in almost all patients.

I wish it took 2-3 minutes......It's usually takes 5 minutes just to gown, glove, mask and put hair net on. That includes the time it takes for the nurses to find my sterile gloves in correct size, then hunt someone down to tie the back of the gown. Line is another 10 minutes (in my morbidly obese population with tiny veins) then 5 more minutes to secure it with a sterile dressing.

 

[WildcatS11]

Nurses use my IJ's without confirmation. If it's ultrasound guided and you got dark venous blood, no reason they can't use it for the 5 minutes it takes to get a chest x-ray. There was a study about 10 years ago that supported this.

You're kidding right? No reason?

There is one compelling, infallible reason - hospital policy. It's not so much a problem in our ED, but in the ICU, different story. Driven by policy.

 

[engineeredout]

Best part about femoral lines - your nurses will use them without the "confirmatory chest XR."

One of the techniques, I believe came from Weingart, to verify IJ (or subclavian or femoral for that matter) placement works extremely well:

After placement, use the ultrasound to find a subcostal or A4CH view. Have someone simultaneously push a flush through one of the CVC ports rapidly. You can easily visualize the turbulent flow in the right side of the heart. The nurses I work with like this because it's something they can visualize as well. Now does this 100% guarantee that you haven't migrated to the opposite subclavian or are too shallow/deep? No, but what it does guarantee is that you are in the venous system, so you are safe to start virtually any medication, without having to wait for X-ray to come up.

 

[engineeredout]

IO for the trauma resuscitation? For massive transfusion?

I can see IO for quick access in difficult cases, but after that initial step, something else must be placed: 18g PIV (even "peripheral" IJ) or big central line or RIC or something.

IO only is inadequate in my opinion for trauma resuscitation or hemorrhaging anything.

HH

I'm not saying IO would be the only access in the patient requiring resuscitation (whether trauma, GI Bleed, Medical Resus etc...) but I guarantee 100% I can put two of them in faster than it takes for someone to set up and insert a blind introducer. Too many times I've sat back and watched 2min, 5min, 10min go by without having access in patients that needed it. EZIO reports Tibial IO can have an infusion rate of 1000cc/hr, meaning with two IOs, I can have 2U prbc in by the time we have a CVC inserted, it's hooked up to the level 1 infuser, the blood is hanging and it actually starts. Or I can put in a humeral IO, get up to 5000cc/hr, and have a unit of PRBCs in in three minutes. It can make a huge difference.


Source: http://www.teleflex.com/en/usa/ezioeducation/documents/EZ-IO_SAFIOVA-M-607 Rev B-PrintVersion.pdf

 

[WilcoWorld]

About to start third year in a few weeks and I still dread putting in central lines. How can I get over this? I've been told my technique is fine, no issues. I start to think about "what if I can't get the line in? What if the guidewire doesn't go in smooth and I can't get it?" Am I just psyching myself out? Never had any complications with line placement. Until the CXR comes back, I get major anxiety. It's gotten better with time though. It's hit or miss getting lines so it's hard to arrange consistent practice. Is it crazy talk to think about doing more ICU as elective time next year? Have already done a total of 4 ICU months and have 2 more next year.

Your anxiety may be mitigated by using the US to visualize the wire within the IJ prior to cannulation. It's very-easy to do and adds maybe 5-10s to your procedure time. Seeing the wire in the compressible vessel and not in the pulsatile vessel can give you a lot of extra confidence.

 

[gamerEMdoc]

I'm not saying IO would be the only access in the patient requiring resuscitation (whether trauma, GI Bleed, Medical Resus etc...) but I guarantee 100% I can put two of them in faster than it takes for someone to set up and insert a blind introducer. Too many times I've sat back and watched 2min, 5min, 10min go by without having access in patients that needed it. EZIO reports Tibial IO can have an infusion rate of 1000cc/hr, meaning with two IOs, I can have 2U prbc in by the time we have a CVC inserted, it's hooked up to the level 1 infuser, the blood is hanging and it actually starts. Or I can put in a humeral IO, get up to 5000cc/hr, and have a unit of PRBCs in in three minutes. It can make a huge difference.


Source: http://www.teleflex.com/en/usa/ezioeducation/documents/EZ-IO_SAFIOVA-M-607 Rev B-PrintVersion.pdf

Ive definitely infused tibial IOs faster than 1000cc/hr in non-awake patients. If you prime them well, you can infuse through them pretty quickly.

 

[scummie]

Your anxiety may be mitigated by using the US to visualize the wire within the IJ prior to cannulation. It's very-easy to do and adds maybe 5-10s to your procedure time. Seeing the wire in the compressible vessel and not in the pulsatile vessel can give you a lot of extra confidence.

Every so often, I hear about someone that swears up and down that the guide wire was in the IJ and then somehow it ended up in the carotid...not sure how that happens unless the needle backwalled?

Did a femoral line yesterday, was fine until the end when I was flushing all the ports again and the blue one wouldn't do it. Said a bunch of expletives in my head and then thought through it a bit--already had nice flow with the other two ports, it's probably up against the wall. Jiggled it a bit, no problems after that.

Another thing a coresident has mentioned to me is getting better with ultrasound guided peripheral IVs. He said it not only has helped him with central lines, but tough art lines and obviously tough regular sticks. Plus, the nurses like it.

 

[Empress1971]

Every so often, I hear about someone that swears up and down that the guide wire was in the IJ and then somehow it ended up in the carotid...not sure how that happens unless the needle backwalled?

Did a femoral line yesterday, was fine until the end when I was flushing all the ports again and the blue one wouldn't do it. Said a bunch of expletives in my head and then thought through it a bit--already had nice flow with the other two ports, it's probably up against the wall. Jiggled it a bit, no problems after that.

Another thing a coresident has mentioned to me is getting better with ultrasound guided peripheral IVs. He said it not only has helped him with central lines, but tough art lines and obviously tough regular sticks. Plus, the nurses like it.

Did you use Ultrasound to guide you? I always see they do that at the hospital in which I work.

 

[DrDrummer]

Another thing a coresident has mentioned to me is getting better with ultrasound guided peripheral IVs. He said it not only has helped him with central lines, but tough art lines and obviously tough regular sticks. Plus, the nurses like it.

Yes. This helps enormously with needle localization but will turn into an annoying time suck when you're busy and the RN "can't get access" because they know you can.

As a resident who has improved a lot this year on lines, three things that helped me the most with getting much faster at CVCs were 1.) Practice/time, which helps everyone 2.) Deliberate practice not on patients with an opened-but-unused kit that I took home and worked with a few times after watching 3.) Scott Weingert's central line micro skills video (EMCrit Wee - Central Line MicroSkills (Deliberate Practice)) someone mentioned this earlier but it is really worth watching. He makes a point in it about how good pool players hold a cue, maximizing the surface area of their hand against the table (in this case, your hand against the patient) to stabilize the cue (in this case, the needle) and setting yourself up for success by having the things you need available so that you don't lose your location in the vessel lumen when removing the syringe or trying to place the wire.

Another thing I've used which was also mentioned above sans-link to source is the included catheter for floating the wire instead of the solid needle, the way Rueben Strayer advocates. There are pros/cons to this (cf. EMCrit's "rebuttal" to this), and I don't do it for femoral lines or subclavians but I do like it for IJs, where the risk of the needle backwalling and puncturing the carotid is higher, or where the patient is obese and the tissue might push the needle back out after I get flash.

 

[bravotwozero]

FWIW cannulating the artery during a central line placement is really not that big of a deal - as long as you realize it. Just pull out, hold pressure and try again. I've had that happen numerous times, with minimal problems.


Sent from my iPhone using Tapatalk

 

[WilcoWorld]

FWIW cannulating the artery during a central line placement is really not that big of a deal - as long as you realize it. Just pull out, hold pressure and try again. I've had that happen numerous times, with minimal problems.


Sent from my iPhone using Tapatalk

Agreed - so long as you realize it before you dilate.

 

[bravotwozero]

Actually I've even dilated and realized later...still removed the line and held pressure, patient did fine. But yeah, best to avoid that


Sent from my iPhone using Tapatalk

 

[Druggernaut]

Did a femoral line yesterday, was fine until the end when I was flushing all the ports again and the blue one wouldn't do it. Said a bunch of expletives in my head and then thought through it a bit--already had nice flow with the other two ports, it's probably up against the wall. Jiggled it a bit, no problems after that.

Another thing a coresident has mentioned to me is getting better with ultrasound guided peripheral IVs. He said it not only has helped him with central lines, but tough art lines and obviously tough regular sticks. Plus, the nurses like it.

Definitely sounds like you're psyching yourself out. Practice will help with some of that, but also realize that there's almost no such thing as a truly emergent central line. Can't advance the guidewire, or not getting blood return through all ports? Who cares? They've either got peripheral access or you can put in an IO and the only thing damaged is your ego. Sounds like you've never had a complication, but even those are manageable.

Agree completely with ultrasound guided peripherals. I hate doing them since they're such a time-suck, but they definitely help build your skills. I also have a pretty low threshold to escalate from the long angiocaths to our arterial line kits and put the long 20 gauge catheter in with Seldinger technique so it's an almost identical procedure as placing a central line.

 

[Fox800]

Definitely sounds like you're psyching yourself out. Practice will help with some of that, but also realize that there's almost no such thing as a truly emergent central line. Can't advance the guidewire, or not getting blood return through all ports? Who cares? They've either got peripheral access or you can put in an IO and the only thing damaged is your ego. Sounds like you've never had a complication, but even those are manageable.

Agree completely with ultrasound guided peripherals. I hate doing them since they're such a time-suck, but they definitely help build your skills. I also have a pretty low threshold to escalate from the long angiocaths to our arterial line kits and put the long 20 gauge catheter in with Seldinger technique so it's an almost identical procedure as placing a central line.

The bottom bugger in the Arrow art line kits is the ****. I wish we had them packaged separately for ultrasound-guided peripheral lines.

 

[brk81144]

The bottom bugger in the Arrow art line kits is the ****. I wish we had them packaged separately for ultrasound-guided peripheral lines.

Anyone using these Arrows for peripherals? The thoughts crossed my mind in several occasions but I usually end up just using a 1.88 20gauge

 

[WildcatS11]

Anyone using these Arrows for peripherals? The thoughts crossed my mind in several occasions but I usually end up just using a 1.88 20gauge

Yes used to use them during intern year because they are much easier to place. I stopped because our radiology dep't won't use them for angiography - you can't flush those lines as quickly, apparently.