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Ok or not? Google is not giving me a good answer.
Central line on same side as pacemaker?
- Thread starter BobBarker
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Thats what I was thinking. I placed a R femoral. Pt had a pacer on the R and a massive blood clot on the L.
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I think it depends. Obviously if the pacer box is subclavian that's no longer an option. I wouldn't have a problem with trying an IJ on the same side as a subclavian placed pacer and assuming the wire advances freely it should be fine. If the line is expected to stay in post-op for a while I would do that over a femoral. What was the case/indication for the line?
Agreed. I tend to shy away from femorals because of infectious risk. If the patient has a pacemaker, any IJ or SC line is going to be up against the wires in the superior vena cava anyways. I would generally try to go to the opposite side as the pacemaker, but it wouldn't really be a big deal to go on the same side with an IJ.
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The Pt is a 80 something year old MICU pt. His L SC TLC is no longer working secondary the clot.
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Isn't the infectious risk of an IJ pretty much the same as a femoral, with both being inferior to subclavian?
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I have been told that if you're gonna be trying to pass a wire on the same side as pacer wires, use the wire "backwards," i.e. feeding the straight end instead of the J-end into the patient.
Thoughts?
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My understanding is that it is very center-dependent. I looked through the literature on this subject once and it seems that some places have much higher femoral line infection rates, whereas at others IJ = femoral.
I remember one study at a center with low overall line infection rates, where they found their thin patients had higher colonization (EDIT: not infection) rates with the IJ, and fat ones with the femoral. (EDIT: found it - Parienti JJ, et al. "Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial." JAMA. 2008 May 28;299(20):2413-22.)
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does equal infection rate on femoral and IJ means poor care for those with IJ? Cause, when considering only location, femoral takes precedence
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Where exactly is the clot? For a clot to affect the ability to draw back on the ports (what nurses typically consider a central line not working), the clot would have to be in the SVC since that's where the port openings are. In that case I wouldn't do a line above the diaphragm. If, however, the clot is contained within the left subclavian system, my first choice would have been a right IJ (after verifying patency with US). Where was his pacer? Right subclavian (not the usual position)?
It's very reasonable approach. Sometimes when I can't pass a wire the normal way I'll turn it around. You really only need about 5 cm of wire in the vein anyway. Using a smaller catheter (maybe double lumen) helps too.
There's a definite increase in thrombotic complications with femoral venous lines. Plus, many nurses and PT won't mobilize a patient with any sort of femoral access.
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The pacer is a R subclavian. The clot was though the sc and up into the ij but the svc was clear.
This has always been a big debate since the studies vary in the answer. Usually someone who doesn't like subclavians (or can't do them safely) can find an article that shows IJs have equally low infection rate, with femorals being the worst.
I also did a lit review, and the short answer is that subclavians have the lowest infection rate, but both SC and IJ rates should be pretty dang low anymore.
From a pure mechanical standpoint, it makes sense that IJs would have more problems. They are more difficult to secure in an ergonomic and clean manner, and the vein is much closer to the skin, so as the patient moves his/her neck, it acts like a piston going in and out, inoculating the vein with skin flora. Of course, this is all theoretical.
