Central Line Question

[BobBarker]

As an intern, most of my central lines are on awake patients. I've been thinking about the needle with the catheter on it that nobody uses. A lot of times I will get access and the patient will move or I'll screw up twisting off the syringe. Sometimes the patient is so dry that I'll have to time everything with the patients respirations. Wouldn't it be better to just use the needle with cath, get access and then immediately thread the cath off the needle into the vein. This would ensure you maintain access. You can run the wire through the cath and place as normal or worse case scenario sew in the cath and place a pigtail on it to have a makeshift central line if you can't get the wire to feed in an emergent situation. Just wanted to see what you guys had to say as I never have seen anyone place lines this way and I figure there is a reason for that that I haven't thought of.

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[2ndyear]

I do IJ's like that. 18 ga angio cath from the kit, aspirate, sometimes have to pull back to get flow. Then wire, dilate, done. You can even transduce the pressure of the catheter before you dilate and I still do this, though usually with IV extension tubing. If you have an assistant it can be nice to see a CVP and not arterial trace on the monitor. Especially nice if you're putting in an introducer. I don't think a makeshift line is ever a good idea. If you can't obtain definitive upper access the femorals rarely fail. Intraosseous is an option as well.

Subclavians are easier with the big steel needle though. It won't kink. I rarely place them now but it's an essential line to learn and master while training.

 

[fakin' the funk]

As an intern, most of my central lines are on awake patients. I've been thinking about the needle with the catheter on it that nobody uses. A lot of times I will get access and the patient will move or I'll screw up twisting off the syringe. Sometimes the patient is so dry that I'll have to time everything with the patients respirations. Wouldn't it be better to just use the needle with cath, get access and then immediately thread the cath off the needle into the vein. This would ensure you maintain access. You can run the wire through the cath and place as normal or worse case scenario sew in the cath and place a pigtail on it to have a makeshift central line if you can't get the wire to feed in an emergent situation. Just wanted to see what you guys had to say as I never have seen anyone place lines this way and I figure there is a reason for that that I haven't thought of.

The situations you list are GREAT reasons to use the angiocath/20g needle technique instead of the 18g needle alone, as you describe.

Many people DO use the angiocath, it just seems like for whatever reason you haven't seen it happen.

You'll find that the angiocath/20g setup is not as rigid as the 18g, and that the resistance to passage of the wire thru the angiocath is higher due to the smaller lumen. I have not used the angiocath/20g setup to do a subclavian - I'm not sure I would try either, since it may not be rigid enough to do the clavicle exploration you may need to do.

Other than that, there's probably not a great reason NOT to use the angiocath, and it can free up your hands and provide a little stabler venous access before you get the wire in, if you have a wiggly patient. Good luck

 

[Bertelman]

Sounds like your biggest problem is relying on ICU docs to help you place central lines.

 

[BobBarker]

We did a few with IR PAs at the beginning of the year but that has been it as far as anybody helping/supervising. I've done around 80. All US guided IJs.

 

[nap$ter]

As an intern, most of my central lines are on awake patients. I've been thinking about the needle with the catheter on it that nobody uses. A lot of times I will get access and the patient will move or I'll screw up twisting off the syringe. Sometimes the patient is so dry that I'll have to time everything with the patients respirations. Wouldn't it be better to just use the needle with cath, get access and then immediately thread the cath off the needle into the vein. This would ensure you maintain access. You can run the wire through the cath and place as normal or worse case scenario sew in the cath and place a pigtail on it to have a makeshift central line if you can't get the wire to feed in an emergent situation. Just wanted to see what you guys had to say as I never have seen anyone place lines this way and I figure there is a reason for that that I haven't thought of.

i never use the angiocath.

put the syringe on the needle loosely and don't screw up twisting it off.

timing it with the respirations is fine, but try more T-berg or if the pt will do it - Valsalva.

advancing the catheter after you get into the vein does not ensure you maintain access. the IJ is far thicker than any peripheral vein, and I have seen on multiple occasions the catheter advanced, pushing the IJ off the needle. the needle tip has to be quite a bit farther into the lumen in the IJ prior to advancing the catheter. thus the optimal angle of penetration is better shallow if using the angiocath, and as I'm sure you know, this can be difficult/impossible in dry fatties who somehow connect their heads to their thorax without a neck.

just my humble opinion. some people swear by the angiocath, but i think it's an unnecessary extra step.

 

[wine thief]

Wouldn't it be better to just use the needle with cath, get access and then immediately thread the cath off the needle into the vein. This would ensure you maintain access. You can run the wire through the cath and place as normal or worse case scenario sew in the cath and place a pigtail on it to have a makeshift central line if you can't get the wire to feed in an emergent situation.

I would be careful with using a catheter that will not accept a wire. Will the wire not pass because: You're not in the vessel? There a big IJ thrombus? You're pushing up against a plaque in the carotid? Especially in an emergent situation you really need good access. You can always pop a femoral in.

I hate the angiocaths. I had an attending who made all his residents use it. They can kink at the skin, you can lose the stick...and I didn't like the feeble drops of blood return from the catheter. Not as reassuring as the dark blood that pours out of the needle.

Try a lot of T-burg and have fluids running wide open while you set up.

 

[Mman]

I always use the angio cath. The 1-2% of the time that I struggle with it, I switch to the thin wall needle.

There is no right answer, though, it's whatever you feel comfortable with.

 

[Idiopathic]

have done my last 100 IJ lines with the angiocath but usually do not use it for subclavian lines, its easier to lose the vessel in that situation, IMO

 

[Idiopathic]

As an intern, most of my central lines are on awake patients. I've been thinking about the needle with the catheter on it that nobody uses. A lot of times I will get access and the patient will move or I'll screw up twisting off the syringe. Sometimes the patient is so dry that I'll have to time everything with the patients respirations. Wouldn't it be better to just use the needle with cath, get access and then immediately thread the cath off the needle into the vein. This would ensure you maintain access. You can run the wire through the cath and place as normal or worse case scenario sew in the cath and place a pigtail on it to have a makeshift central line if you can't get the wire to feed in an emergent situation. Just wanted to see what you guys had to say as I never have seen anyone place lines this way and I figure there is a reason for that that I haven't thought of.

there are times where you may lose the vessel while threading the catheter off, and in that case it may be significantly more difficult to gain access again (hematoma, etc). i think thats the biggest argument against it. I also do more landmark lines as opposed to US guided. If you can watch the wire into the vessel with US then you dont need the catheter any way. i do like the feeling of security it gives me though

 

[bullard]

have done my last 100 IJ lines with the angiocath but usually do not use it for subclavian lines, its easier to lose the vessel in that situation, IMO

I tried the angiocath for a subclavian once. Won't try that again.

 

[jennyboo]

the needle with the catheter on it that nobody uses.... Wouldn't it be better to just use the needle with cath, get access and then immediately thread the cath off the needle into the vein.

Nobody uses? I do this all the time as I find

1) it's a nice way to teach a resident who already knows how to place a simple IV
2) it's less traumatic than the thin-wall needle because it's a smaller bore
3) it's a nice way to avoid "losing" the vein when the needle moves.

Downsides:

1) if you go thru-and-thru the vein, or if you pull back and redirect, sometimes the catheter slides off the needle when you're withdrawing.
2) for subclavian lines, you really need the thin-wall needle, the angiocath is too bendy.

 

[dhb]

I've been thinking about the needle with the catheter on it that nobody uses.

I always thought it was there for a piv for people who couldn't place a central line.