Central Line Placement Gems

[LovelyRita]

*When placing femoral lines on super obese folks, tape the primary panus. If a mons pannus is present , tape it as well. It can get in your way and make the stick more difficult.

And we've all seen this, haven't we? I support a movement where medicine ditches the idea of the "70 kg adult" for various treatment modalities and move to the "125 kg adult" since the odds are pretty damn good that one or more of your patients on any given service fits this description. It's one thing to know the sequence of putting in a central line, but it's another to add in the semantics of dealing with panni while doing said central line.

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[Apollyon]

And...just and addition to weird places lines end up...several years ago an attending told me he somehow wound up getting a line into the thoracic duct!

But that's one of the classically taught hazards of the left subclavian. Even though I've never seen it (although my sample space N is very small), everyone talks about it.

 

[augmel]

http://content.nejm.org/cgi/content/full/355/26/2725

Fresh off the presses in case someone doesn't beleive in gowing up.

 

[tussy]

Lots of good tips on this site, and i just wanted to add a couple of my own biases.

1. If you can't handle the complications of line placement then you shouldn't be doing the line by yourself. ie. if you don't know how to put a chest tube in the you should have someone who does close by just in case (i've had to sprint to a "non-surgical ward" on several occasions to put in an urgent chest tube).

2. Set-up is the most important. Don't rush thru this.
- make sure you have everything you could possibly need close by
- take time to properly position the patient. If that means moving them off their "air bed" and onto a proper stretcher then do it. If you have to move them out of their room and into a treatment room, then do it. If there isn't space then rearrange furniture to give yourself space, etc. Don't skimp on this step because it might make the difference of getting the line in or not. Make sure you use as much trendelenburg as the patient will tolerate; especially if they are dry.
- take your time finding your landmarks. If you're not happy with your landmarks then a blind stab isn't going to be successful and just will distort the anatomy and make future stabs more difficult. You might need to reposition the patient, or get someone to retract the fat, etc.

3. Always check the xray yourself. Nothing worse than trying to explain to someone the next day about how your jr. missed the pneuo when it was you who put in the line and is responsible.

 

[shag]

Always check the xray yourself. Nothing worse than trying to explain to someone the next day about how your jr. missed the pneuo when it was you who put in the line and is responsible.

Solid Advice.

ALWAYS check the Xray when you place a line. Also ALWAYS check the X-ray (after you make sure it was ordered) if someone else placed a line on your patient. For example, anesthesia placed a line on one of my patients during a case. No cxr was ordered, so I ordered one. Within 10 minutes, I was placing the chest tube.

 

[Dr. V]

Very good advice here.

I like to use the HUGE full body sterile drape and then use the patients body as my acessory mayo.

I numb them up and then lay out my tools on their chest in the order in which I will need them. That way I never have to turn around and never have to turn loose of the wire, everything is at my fingertips. It also gives the local time to work.

Another good thing is to loop the TLC in your hand so the ends don't flop around as you run it onto the wire and maybe break the sterile field.

One other little gem is be aware of any previous central lines. I found out the hard way that sometimes if they have had a line recently you just need to go to the other side because no matter how good the site looks by US or how good a stick/venous return you have the wire just doesn't want to run right if they have recently had one there. This has happened to me twice. It may be coincidence, but from now on I will just go somewhere else if possible.

 

[Blade28]

Be careful about using the patient's body as a table - if they're awake (or even if they're intubated and sedated, sometimes!), one quick jerk and all your sterile supplies go tumbling onto the ground.

 

[DrDawg]

Everyone has had good suggestions. Other things to consider
1. In a code or the trauma bay the clavicle is always in the same place and easily palpable. I can do a scv faster than a femoral in most pt especially the obese, or with faint pulses

2. To avoid you SCV CVL ascending the IJ hold pressure over the IJ if you are suspicious. Sometimes you can feel it. (I have had my share of Noodle lines)

3. Keep your flush saline clean and use your leftovers to clean the ports, and skin. It increases your standing with the nursing staff

4. If you are having trouble dilating and the skin incision isn't your problem, traction on the ipsalateral arm opens the space between clavicle and the ribs. If you get a bend in your wire or a burr on your dilator have someone grab a new kit. Its much easier than struggling, and you maybe be able to salvage your stick

5. If you encounter difficulty in removing a wire, STOP. Remove everything a once. I have heard but, never seen, of wires breaking

6. Don't be afraid. I missed a ton of SC lines as a intern just to watch a senior resident use the same approach, same angle, and hit the vien easily. The difference always was I was afraid to hub the needle.

 

[Dr. V]

Could someone with buttons make this a "sticky". I found this thread very interesting and helpful. Don't forget July is coming up also and I am sure others will find it helpful.

One thing I would like to add, I do not like the angiocath. It can collapse and make it hard to tell if you have pulsitile or non pulsitile flow and in a patient that isn't oxygenating well the color won't be that much different.

I have heard of cannulation of the artery twice, and both times the angiocath was used. I wasn't there for either one, but my suspicion was that the angiocath collapsed and there appeared to be no pulsitile flow.

 

[2ndyear]

"One thing I would like to add, I do not like the angiocath. It can collapse and make it hard to tell if you have pulsitile or non pulsitile flow and in a patient that isn't oxygenating well the color won't be that much different.

I have heard of cannulation of the artery twice, and both times the angiocath was used. I wasn't there for either one, but my suspicion was that the angiocath collapsed and there appeared to be no pulsitile flow."

I like the angiocath for IJ's. When I thread it in, after checking for flow with a syringe and possibly manipulating it a little bit, I hook it up to an IV extension tubing, aspirate and then raise the tubing. It should flow down towards the patient. If it doesn't, then you have an 18 ga angiocath in the carotid. Institutional policies differ on what to do now. But if you're careful and willing to stick around and hold pressure it can be safely removed. The angio can collapse as you mention, but with manipulation and checking good flow with the syringe this can be overcome. Only really useful for IJ's I think though. Subclavians with the big steel needle for me.

 

[mytirf]

One alternative to a central line is an intraosseous. Can be placed in 6 places (even in the sternum in a pinch) and the insertion site in the proximal humerus has the same distance to the heart as a subclavian. Insertion is certainly faster than most central lines and while is not approved to be in longer than 24-48 hours, no infections have been recorded for even when left in for greater than 3 days.

just my two cents

 

[maxheadroom]

I haven't done a line in well over a year now (ah, plastics), but I saw a great line complication about a year and a half ago on vascular. I was called to see a patient in the ICU. She'd had a subclavian dialysis catheter placed in the ICU when she needed urgent dialysis. After a day of being tuned up, they noticed that her flow pressures were "pretty high". There's nothing more fun than pulling that bad boy out of the subclavian artery and "holding pressure" by pinching around the clavicle, especially when the patient is full anticoagulated.

 

[Winged Scapula]

Could someone with buttons make this a "sticky". I found this thread very interesting and helpful. Don't forget July is coming up also and I am sure others will find it helpful.

One thing I would like to add, I do not like the angiocath. It can collapse and make it hard to tell if you have pulsitile or non pulsitile flow and in a patient that isn't oxygenating well the color won't be that much different.

I have heard of cannulation of the artery twice, and both times the angiocath was used. I wasn't there for either one, but my suspicion was that the angiocath collapsed and there appeared to be no pulsitile flow.

This used to be a sticky, but the forums are being "Sticky" overloaded and the Admins have asked all forum leaders to lose non-essential stickies. If I have time I can put some of the "pearls" on a Wiki, but in the meantime there is always the SEARCH function if this thread falls off the first page. Its not like this forum is so busy that it will disappear rapidly.

 

[BurnOnMyYeeeow]

If you're a junior resident, and having trouble with IJ's, when you have a free moment, find the carotid going on that day, and watch it.

 

[LovelyRita]

The patients will also frequently complain about ear pain when you advance the wire up the IJ. If unable to get it to deflect down the SVC, just leave it in the IJ. It isn't going to hurt anything.

This happened to me today about 3am.....I took it out, was so tempted to leave it in (pt was circling the drain bigtime anyway), but chickened out. He had a big midline thoracotomy scar, was in heart failure, his groins were somewhat off-limits because of the bilateral scars indicative of the aorto-bifem bypass he also had in the past.... I backed off because the awesome ICU nurses were able to get peripheral access galore. Not sure a central line was going to make much of a difference other than ending his misery sooner. Anyway, it was frustrating. My wire advanced real nice to about 20 cm then got real grainy. I knew things weren't going to be pretty. I wonder if I had a glide wire if things would have worked better...I also could have tried switching to L subclavian too, but sometimes that is just technically more difficult even without jacked up anatomy like he had. Bummer.

*If your subclavian line tracks into the IJ on cxr, you can reposition the line using fluro. Position the patient and C-arm with the foot peddle easily accessable. Make sure you can see the line with fluro. Prep/drape, and procede as if you were changing the line over a wire. Place guidewire, remove old line. back the guidewire back in to the subclavian and advance. It may take a few tries, but you should be able to get the wire to feed into the svc. Place the catheter.

What I would have given for fluoro. I could hardly get the pissy xray tech to get my image up stat. rawr.

 

[johankriek]

prefer subclavian over IJ because i'd rather give someone a pneumothorax than accidentally raise a plaque in the carotid and give someone a stroke! not sure if this is reported in the literature but it is a theoretical concern. in this case, that's enough for me.

to confirm venous placement: i throw some sterile IV tubing on my sterile field and cut off about 30-40cm worth from the luer-lock hub with scalpel. once i access the subclavian, or IJ, with the the needle i disconnect my syringe and connect the IV tubing. allow the tubing to fill to about 25cm with blood passively as it lays horizontally on the sterile field. then, hold it up vertically. if it's venous, the blood should fall back into the vessel. if it's arterial, it will continue to climb. obviously, don't let all the blood poor back into the vein and run the risk of air embolism.

PS--this is not my idea.

prolly the most useful tip i think

you do not wanna be in the carotid.. If you thread a cordis introducer intothe carotid artery I wouldnt wanna be you explaining that.. so in order to rule it out.. feed the wire then feed an IV catheter over the wire then do the above with IVb tubing to confirm venous placement.. DO that every single time..

 

[sleeping]

To make sure I am not in the carotid, I always put my fingertip on the lock after I disconnect the syringe. You can feel a pulse, even with extremely low blood pressure.

What ever you can do to keep from placing an introducer or dialysis cath into an artery. As alot our patients are on dialysis or on coumadin or on plavix or liver failure.......the horror......the horror.

 

[mitchconnie]

I’m going to go out on a limb and suggest to you all that most major central line complications will be considered malpractice within 5-10 years. Why? Because ultrasound guidance is just too easily available in most places to do any thing else. I virtually never place a central line without ultrasound guidance.

Some of the residents think it’s a hassle, but once you figure out how to get it set up, ultrasound guidance is actually faster—one stick, first stick, every time. I started using it mainly on dialysis patients who often have occluded central veins due to previous lines, but then couldn’t think of a good reason not to use it on everyone.

Total learning curve is probably 10 cases. I teach the med students to do ultrasound-guided vein punctures during my laser vein cases and they usually are getting the hang of it after about three cases. Those with great hand-eye coordination can do it the first time with some coaching.

And once you get the hang of it, try using ultrasound to put in a regular IV when the nurses call for a central line because they “can’t get an IV.” You can easily hit a deep upper arm cephalic, basilic, or brachial vein with a micropuncture kit and ultrasound guidance and look like a hero. There’s no excuse for sticking someone’s neck if you haven’t even gotten out the ultrasound to look for a good peripheral vein.

 

[Smurfette]

I’m going to go out on a limb and suggest to you all that most major central line complications will be considered malpractice within 5-10 years. Why? Because ultrasound guidance is just too easily available in most places to do any thing else. I virtually never place a central line without ultrasound guidance.

Some of the residents think it’s a hassle, but once you figure out how to get it set up, ultrasound guidance is actually faster—one stick, first stick, every time. I started using it mainly on dialysis patients who often have occluded central veins due to previous lines, but then couldn’t think of a good reason not to use it on everyone.

Total learning curve is probably 10 cases. I teach the med students to do ultrasound-guided vein punctures during my laser vein cases and they usually are getting the hang of it after about three cases. Those with great hand-eye coordination can do it the first time with some coaching.

And once you get the hang of it, try using ultrasound to put in a regular IV when the nurses call for a central line because they “can’t get an IV.” You can easily hit a deep upper arm cephalic, basilic, or brachial vein with a micropuncture kit and ultrasound guidance and look like a hero. There’s no excuse for sticking someone’s neck if you haven’t even gotten out the ultrasound to look for a good peripheral vein.

As a PGY-3, I have never used ultrasound for central line placement. Furthermore, I have never seen a portable ultrasound machine for line placement in any of the 3 hospitals (2 teaching, one private) I rotate at.

While US is a good idea in theory, you can't easily place subclavian lines using ultrasound and those are our "preferred" line for intubated/trached patients and those patients whom an IJ would get easily pulled out or contaminated (i.e. pts who sundown frequently or who drool, etc.).

 

[SLUser11]

As a PGY-3, I have never used ultrasound for central line placement. Furthermore, I have never seen a portable ultrasound machine for line placement in any of the 3 hospitals (2 teaching, one private) I rotate at.

While US is a good idea in theory, you can't easily place subclavian lines using ultrasound and those are our "preferred" line for intubated/trached patients and those patients whom an IJ would get easily pulled out or contaminated (i.e. pts who sundown frequently or who drool, etc.).

Well, that's too bad, because mitchconnie is right. Ultrasound is not just good "in theory," it's good in practice. IJ lines are much easier and safer with the assistance of ultrasound, which is where the majority of your tunneled dialysis catheters should be going. In the really fat people, US can also make femoral sticks much easier.

If your hospitals don't have ultrasound, they should. I think it's not wise to brush it off as you did in your second paragraph. Just because you don't use it doesn't mean it's not good. Besides, as a PGY-3, you should at least know how to use it.

I guess I'm just a little thrown off by you first saying, "I've never used u/s for a CVL," then immediately following it with a statement that u/s doesn't work good for subclavians. HOW DO YOU KNOW IF YOU'VE NEVER DONE IT?

 

[Winged Scapula]

If you have never seen a portable ultrasound (aka "Site-Rite") in the SICU or OR, I suggest asking your anesthesia colleagues about it. I would be willing to be that THEY have one.

In the 3 hospitals I've worked at, I've found them in the Anesthesia work room. It can be hard to get "permission" to use it, or to locate it, but as others have said, particularly in the obese or otherwise difficult patient it can be a lifesaver. Admittedly, I don't use it often (because I most often get the line on the first stick), but as my ultrasound skills improved I definitely think of it more often when I am called about a difficult line.

 

[Blade28]

Admittedly, I don't use it often (because I most often get the line on the first stick), but as my ultrasound skills improved I definitely think of it more often when I am called about a difficult line.

Ditto.

 

[mitchconnie]

as my ultrasound skills improved I definitely think of it more often when I am called about a difficult line.

Exactly right. Surgeons tend to be dismissive of any new technology they don’t understand, but as you gain familiarity with a good technique you’ll see its value more and more. Since I’ve started using ultrasound, I cannot tell you the number of times that I’ve seen an IJ which was absent, thrombosed, very diminutive, or right on top of the carotid—even in a patient I thought would be a chip shot.

Don’t be one of the physicians who automatically dismisses every new technique before they learn it. Those are the same surgeons who in the early 90’s were dismissing the lap chole as a “fad,” then in the late 90’s thought endovascular AAA repair was a “flash in the pan,” and in 2007 look like troglodites.

And incidentally, availability of ultrasound for tough lines somewhere in the hospital is almost standard of care. If you don’t have a good machine available to you, then someone needs to yell and scream. Tell the administration that it’s an “urgent matter of patient safety” which will “meet the Agency for Healthcare Research and Quality recommendations.” Those buzzwords are sure to get them off their butts and opening their wallets.

Check out this link for some recent recommendations. http://www.ahrq.gov/clinic/ptsafety/chap21.htm

Maybe I’m just preaching to the choir here. But can someone please give me an “Amen.”

 

[Dr. V]

I love the sonosite for CVC with this one exception.

I think having the US has decreased the skills of people that use them/learned on them like I did when it comes to trauma/code lines when you don't have the US right there.

I know that 99% of the time the attending will say "sure use the US and place an IJ" when more elective/less urgent lines come up. Well then comes the code on the 6th floor that needs a line and it's a good possibility that the resident responding to the code has never placed a line WITHOUT US if they are at a place that regularly uses US for line placement.

I know my heart sure beats faster when I know I have to do it "blind" in those cases, but in the end I am thankful for those few opportunities because one of these days I'm not going to have any back up and I'm not going to have an US available.

 

[SLUser11]

I love the sonosite for CVC with this one exception.

I think having the US has decreased the skills of people that use them/learned on them like I did when it comes to trauma/code lines when you don't have the US right there.

I know that 99% of the time the attending will say "sure use the US and place an IJ" when more elective/less urgent lines come up. Well then comes the code on the 6th floor that needs a line and it's a good possibility that the resident responding to the code has never placed a line WITHOUT US if they are at a place that regularly uses US for line placement.

I know my heart sure beats faster when I know I have to do it "blind" in those cases, but in the end I am thankful for those few opportunities because one of these days I'm not going to have any back up and I'm not going to have an US available.

Not to nitpick what you said, but every urgent scenario that you just described would most likely involve a femoral stick, which is the safest and easiest of the CVLs.

If you're trying to put a subclavian or IJ in a trauma patient for acute resuscitation, then you're doing them a huge disservice, compromising c-spine precautions or risking pneumothorax in an already unstable patient.

If you're poking needles into a coding patient's chest while someone else is doing compressions, you're putting that person and the patient in unnecessary danger as well.

I think it's safe to say that a surgical resident should be able to do lines comfortably with or without ultrasound. That being said, it's not a crutch, it's a tool....

 

[Dr. V]

Actually it's been my experience and I think it is documented in the literature as well, that the subclavian is the most dependable line in the severely hypovolemic patient.

The clavicle helps hold the vein open and you don't need to find a pulse to place it, the clavicle and it's landmarks are palpable whether the heart is beating or not.

And yes, even though I am one of those guys that "learned" with the ultrasound (I am still learning about central lines every day is why it's in quotes) I can admit that having the US has made me LESS confident when I didn't have it so I am including myself in that group. I will also admit that an incoming resident that did a prelim year at an institution that didn't have US is better at placing "blind" lines than I am because they never did an US guided line till they got here.

Yes it's a tool, but it also takes away from our "blind" line placement skills as well. I use it all the time and have done many, many lines, but I am not going to be silly enough to say that I can place a "blind" line as good as I could have if I didn't use the US so much.

 

[SLUser11]

Actually it's been my experience and I think it is documented in the literature as well, that the subclavian is the most dependable line in the severely hypovolemic patient.

The clavicle helps hold the vein open and you don't need to find a pulse to place it, the clavicle and it's landmarks are palpable whether the heart is beating or not.

First of all, I would be interested in seeing that literature. I believe you that it exists, and I'm not being a smartass. I really want to hear someone justify subclavian lines in these emergency situations.

When a patient is severely hypovolemic, as you've described, the subclavian vein is likely to be somewhat collapsed. Regardless of the fact that your landmarks are constant, your target becomes very small and your chance of a pneumothorax increases significantly.

Secondly, it only takes common sense to see why an IJ or subclavian would not be the best option in codes or trauma situations: It is a patient safety and healthcare worker safety issue.

Trauma:

The patient is in a c-collar, which negates IJ. Also, there are multiple people trying to assess the patient, intubate, place chest tubes, etc. Imagine using sterile technique and placing a subclavian during this. What if you drop the patient's only good lung?

It is much easier to place a temporary groin line (assuming that you can't get 2 large-bore peripherals), stabilize the patient, and then place a more sterile, long-term line once the patient is in the ICU. You can place the groin line in about 1-2 minutes, using the best sterile technique you can, and then d/c it before it can get infected.

Code:

The patient is very likely to be receiving chest compressions. How safe is it for the worker doing compressions for you to be sticking a large needle in the patient's chest? How safe is it for the patient? With his/her chest moving up and down with each compression, the chances of a pneumo would skyrocket.

Maybe I'm wrong, but to me it's just common sense.

Do any of the more experienced residents or attendings have more information regarding this?

 

[mitchconnie]

I think having the US has decreased the skills of people that use them/learned on them like I did when it comes to trauma/code lines when you don't have the US right there.

I agree with this.

But on the other hand, there are a lot of procedures that surgical residents are no longer quite as good at as they used to be. Like open cholecystectomy, gastric resection for ulcer disease, hand-sewn bowel anastomosis, open AAA repair, etc. In each case the volume has dropped because of better, safer treatments. It's hard to justify doing less safe procedures simply for resident education.

Blind central venous access may go the way of the open cholecystectomy--done only in fairly rare instances.

And by the way, why not use the ultrasound during a trauma? It's always sitting right there in the trauma bay anyway.

 

[Winged Scapula]

In regards to placement of lines in trauma patients:

I am not convinced there is a "best" location which fits all sizes/patients.

It is generally true that, in most trauma patients (especially blunt or MVCs), they will be collared and the IJ is not accessible.

A SC (which happens to be my fav line) can be the line of choice, IMHO, in the following:

- patient with chest tube(s) already in or will be needing one
- patient with pelvic or lower extremity trauma which may make femoral access difficult or unreliable (ie, if there is a femoral injury)
- no one is doing chest compressions, ED thoracotomy or some other neck, chest procedure on the same side
- a patient who is not severely hypovolemic

Now, most of us "oldies" were taught to place lines above and below the diaphragm in patients with hypovolemic shock, major trauma. The femoral is certainly preferable when it is the easiest access and as others have noted, in the patient who has bleed out, the larger size of the femoral vein gives you a much better chance to hit it.

Lines placed in the trauma bay are for IMMEDIATE access and are not to be considered the definitive line; since most of them are placed in less than aseptic conditions, you should be considering changes those lines when the patient gets to the SICU or OR. At any rate, it is my feeling that the best line is the line you can get which will work and places you and the patient (as well as others in the room) at least risk.

Thus, I have placed many SC lines when the patient has bilateral lower extremity injuries and Ortho or others are working down there and I have free room up top and I have placed them preferntially in patients with bilateral PTxs and I have placed femorals in patients getting chest compressions. Like most things it depends on the clinical situation.

As for using US in the trauma bay, I typically do not find it necessary and frankly, have not worked at places which have enough room to manipulate the FAST machine around the room easily. A portable Site Rite in the bay would be great, but until everyone becomes so facile with using them that it INCREASES the speed and accuracy with which lines are placed, I honestly prefer a intra-osseus (yes, in adults which BTW, is the board answer if you can't get them in the other usual places or do a cut-down - which no one does anymore).

 

[Dr. V]

Dr. Cox points are well noted and IMO she is spot on with saying it depends on the situation. I didn't say it was my first choice, I said that when there was a severely hypovolemic patient the clavicle helped hold the vein open allowing for access when it may be impossible in other areas. It became my first choice when I couldn't get a femoral.

When I said I "thought" it was supported by the literature it was because I only read it somewhere in a book like ATLS, Mont Reid etc, I never have seen studies done on it. I'm not sure which book it was, but with my poor reading habits it almost has to be ATLS, Mont Reid, Sabbistons, Washington Manual or On Call.

As for the chest compression thing, it only takes two words "hold compressions". Like Dr. Cox said, in that situation "sterile tech." is usually a half bottle of betadine poured over the site because you are removing the line in a few hours if the patient lives anyway. The safety issue is no different than the normal subclavian line if you have them hold compressions (aside from the urgency). It's like placing a chest tube when someone is doing compressions, before you cut/stick you just clear your field.

I don't remember the exact book I read it in, and I will try to find it because I really do believe SLUser11 would just like to see it. I do know that has saved me on more than one occasion.

Once two Cardiology fellows were trying in both femoral sites, neither with any success (they do fem sticks all day long). I tried once, couldn't get anything (no heart beat, questionable femoral pulse on compressions) and went to the subclavian and presto, first stick.

It even has helped me on non urgent lines. One day I was able to see the IJ collapse even with the patient in maximum trendellenburg using US. The needle just would not penetrate the IJ, and the carotid was directly under it so I couldn't go through and back up. Moved to the subclavian and got the line first stick. CVP of the patient was 0-1 when the monitor was hooked up and that was after the first litre of fluid.

Had an attending try both sides one night on a bad trauma with the same results, never able to get anything (this was after I had tried both sides as well). He moved up to the subclavian and got it first stick.

Those are just a few of the times I have seen it really appear like the clavicle helped hold open the subclavian when the femoral vein was collapsing to the point of not being able to place the line.

Our trauma FAST machine has a different transducer and you would have to change them out to do a line. The FAST transducer would suck for that.

I'll try and find that book in the next few days, I know I read it somewhere cause I am not smart enough to figgure out something that actually works on my own

 

[ruggerdoc123]

Trauma:

The patient is in a c-collar, which negates IJ. Also, there are multiple people trying to assess the patient, intubate, place chest tubes, etc. Imagine using sterile technique and placing a subclavian during this. What if you drop the patient's only good lung?

It is much easier to place a temporary groin line (assuming that you can't get 2 large-bore peripherals),.

The patient is very likely to be receiving chest compressions. How safe is it for the worker doing compressions for you to be sticking a large needle in the patient's chest? How safe is it for the patient? With his/her chest moving up and down with each compression, the chances of a pneumo would skyrocket.

in a code- stick with femorals- you don't want to be screwing around at the neck when anesthesia is trying to tube/bag the pt. and if you miss and hit the femoral artery? there's your abg.

in traumas-
usually you do not do cpr. on the floor, you usually do cpr when there's no pulse, right? traumas are a little different. if there's no pulse in a penetrating trauma patient, you open the chest and do internal compressions (among other things). if a blunt trauma patient comes in with a pulse but loses it in the ED, you open the chest. if a blunt trauma comes in with no pulse, they are usually "dead."

try to avoid femoral lines in traumas if there is any injury below the diaphragm: you can have intraabdominal injury, injury to ivc/iliacs, pelvic fracture with hematomas...

think about placing a subclavian on the SAME side if the pt already has a chest injury (they're getting a chest tube anyway). and you don't want both lungs down because you dropped the good one.

 

[ruggerdoc123]

Vascular access in trauma. Options, Risks, Benefits, and Complications
Sweeney M - Anesthesiol Clin North America - 1999 Mar; 17(1); 97-106

 

[Blade28]

So there's a time and place for all three locations - the need to become proficient in placing an IJ, SC or femoral CVL with and without U/S should be obvious.

Practice, practice, practice!

 

[Mman]

I can't quite understand that argument against using ultrasound for lines because you won't know how to work without it. It's quite simple to get around. After sterilely prepping and draping the patient and covering the U/S probe, simply palpate some landmarks and pick the spot you would start with if you didn't have the ultrasound. Then stick the ultrasound on that spot and see what's there. You still get the practice of learning what the landmarks are and where you would go, but you also have the ultrasound to help avoid complications.

just my 2 cents

 

[Blade28]

But I think the people who advocate using ultrasound are using it as the needle's entering to vein - to help real-time visualization. They're not just using it to locate the vein, then putting it aside for the needlestick.

 

[f_w]

But I think the people who advocate using ultrasound are using it as the needle's entering to vein - to help real-time visualization. They're not just using it to locate the vein, then putting it aside for the needlestick.

I guess there are two schools of thought. There are the 'x marks the spot' guys who just use it to confirm the location and patency of the vein, then proceed to place the line the old fashioned way. Then there are the others who use real-time US to guide their needle into the vein (and only the vein).

imho, the main advantage of placing an IJ under real-time US is that you can go all the way down to the clavicle without having to worry about lung apices. Makes your tunneled lines look neater and work better. You can choose your spot freely, e.g. if you have to go high to avoid an existing line or pacer, you can put a CVL right behind the ear

 

[Smoke This]

imho, the main advantage of placing an IJ under real-time US is that you can go all the way down to the clavicle without having to worry about lung apices. Makes your tunneled lines look neater and work better. You can choose your spot freely, e.g. if you have to go high to avoid an existing line or pacer, you can put a CVL right behind the ear

Word. I like to place IJs as low as I possibly can, and U/S makes it safe to do that. I love subclavians too, but even for semi-emergent lines I'll get out the site rite when the last thing the pt needs is a complication of a ptx. As a practical matter, I wonder if there's a real difference in infection rates for a line below the crotch of the SCM heads vs a subclavian line 2cm distal to that on the other side of the clavicle.

 

[Dr. V]

Just learned something new on call last night.

One fault of the US?? Did you know the Transducer can get jarred "off" a little?

Yep, it can happen. The center of the probe is not what is showing as the center on the screen. Therefore if you don't watch the needle real time, just center it up and make the stick you can be off if this happens.

Ask me how I know LOL.

As it turns out, after an unsucessful stick and placing it back on the patient the center of the picture was actually the left end of the probe. Not a problem after I realized that it was off by about 1cm to the left.

 

[f_w]

The center of the probe is not what is showing as the center on the screen. Therefore if you don't watch the needle real time, just center it up and make the stick you can be off if this happens.

Who taught you how to use ultrasound for guidance ?

(your post reinforces a point that I made further up in the thread. US is only going to make placement safer if the person using it had sufficient training)

 

[Dr. V]

It wasn't my training, I've used US a great deal and am comfortable with it. I use it real time.

It was a malfunction with the transducer, maybe I wasn't clear on that. Put it this way, if you wanted to view the radial artery and you centered it in the picture the probe would end up being in the center of the wrist instead of on the lateral side making it appear as though the radial artery was in the flexor compartment.

It had been dropped or something and the angle was off so the transducer was "shooting" to the left instead of straight up and down into the tissue (no there is no adjustment on this particular unit to allow realignment that I am aware of).

I was just giving the heads up to those that "mark and stick" as opposed to watch it real time.

If you watch it real time then if this were to happen it would be easy to pick up, you wouldn't see your needle even though you were entering under the probe.

That's how I noticed it, because I like to see the needle enter the vein. It wasn't happenin so I had to move my stick. This particular model also has a needle guide for placing PICC lines that is centered. Well it wasn't even close, like I said off by about 1cm, almost the total length of the transducer.

Had I been one that just marked it and stuck without viewing real time it would have been very frustrating and I doubt anyone would have ever figgured it out because the "mark" would have been in line with the needle guide which was off. It would most likely have been chalked up to " I just couldn't get it".

 

[f_w]

It wasn't my training, I've used US a great deal and am comfortable with it. I use it real time.

Well, in a way it was. First thing you should learn when using US for guidance is that in either plane, the US beam may or may not be aligned with the center of the housing. Depending on the type of transducer, this is either a design feature or may indeed be result of damage (mostly in old-fashioned mechanical sector transducers, phased arrays either break or not, no real mechanical way to knock them out of alignment).

I have a 17Mhz and a 12Mhz transducer that I use for breast work and thyroids. One has the image plane at the 'top', the other at the 'bottom', both very precise but just different in design (each of those transducers costs about as much as an entire site-rite).

This particular model also has a needle guide for placing PICC lines that is centered.

That needle guide is a crutch for nursing staff not properly trained in the use of US for guidance.

 

[BlackSails]

I fail to see how having the US center not matching up with screen center has any effect on anything.

 

[f_w]

I fail to see how having the US center not matching up with screen center has any effect on anything.

If you assume that the center of the transducer represents the center of the beam and stick without following your needle track, you are going to be off if that assumption was incorrect. Usually, it is only a couple of mm and it doesn't matter if you have to hit a barn-door sized IJ, but if you use US for less monkey-handed tasks it can be a problem.

 

[BlackSails]

If you assume that the center of the transducer represents the center of the beam and stick without following your needle track, you are going to be off if that assumption was incorrect. Usually, it is only a couple of mm and it doesn't matter if you have to hit a barn-door sized IJ, but if you use US for less monkey-handed tasks it can be a problem.

Dont you see the needle on the US?

 

[butterfly0660]

This really has nothing to do with central line placement, but today I was looking at our upcoming OR cases, and one of my attendings (I'm currently at a private hospital) has a "port-a-cath removal from left common carotid" on the books for next week. I wonder how common that is....seems kinda crazy to me!

 

[f_w]

Dont you see the needle on the US?

That is the point 'Dr.V' made, you have to follow your needle.

(smaller needles like 25Ga are very difficult to see unless you have needles with a sonoreflective tip. You see the effect of the needle on the tissue you go through more than the needle itself.)

 

[Pir8DeacDoc]

I always make sure to push the skin lightly with the needle before inserting to make sure it compresses the IJ that I am seeing on the screen. Then, I make sure to follow the needle in by looking at the US screen. It seems like marking the spot and then setting down the US would be sort of silly. Why not just keep it going and use it to follow the needle in??

 

[f_w]

It seems like marking the spot and then setting down the US would be sort of silly. Why not just keep it going and use it to follow the needle in??

The only time that would make sense is if you don't have a sterile probe cover available.

I have seen one 'expert' dab the tip of the transducer with betadine but then proceeded to hold it with his gloved hand by the wire....

 

[Winged Scapula]

The only time that would make sense is if you don't have a sterile probe cover available.

I have seen one 'expert' dab the tip of the transducer with betadine but then proceeded to hold it with his gloved hand by the wire....

Reminds me of the numerous procedures I witnessed in the Rads suite where they went to all the trouble of putting on sterile gloves and prepping the field but then touch the tip of the non-sterile gel bottle to the non-sterile transducer (no cover) and drag the cord across the field.

 

[Blade28]

Reminds me of the numerous procedures I witnessed in the Rads suite where they went to all the trouble of putting on sterile gloves and prepping the field but then touch the tip of the non-sterile gel bottle to the non-sterile transducer (no cover) and drag the cord across the field.

A lot of people (not necessarily Rads, mind you) don't fully understand the concept of a sterile field. I mean, they get it, but in practice it's never quite done correctly. It's like when I see someone placing a central line, and after they've got the needle into the vein they then proceed to drag the guidewire all over the unsterile bed before inserting it, Seldinger-style.

Hell, it takes most surgery residents a few months of internship before they figure out how to stay sterile!