Central Line why ipsilateral nipple?

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Planktonmd said:
Did you also get a blood gas before dilating???
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No. Two reasons.

1 - it wouldn't be possible to get a gas done in seconds any place I've ever worked, sounds like fantasyland, most days I'm just happy if they didn't change the 4-digit code to get the iStats to unlock

2 - in a sick patient, I'm not sure what I'd do with a blood gas that told me the sat was 85% or so

But putting a line in a carotid is a totally avoidable complication that can kill people, so I'm not going to look down on anyone who takes an extra step to guarantee he will do no harm. **** happens.

You're probably the kind of guy who, a few years ago, was mocking everyone using ultrasound for lines and blocks, because you'd been doing Just Fine without it.
 
This thread just proves that there are more than a few ways to skin a cat. And in the right hands, most of them are correct. I personally wouldn't be getting a blood gas to confirm anything but I guess it could work. It just seems like a stupid waste of resources and time no matter how clever it is.
 
pgg said:
No. Two reasons.

1 - it wouldn't be possible to get a gas done in seconds any place I've ever worked, sounds like fantasyland, most days I'm just happy if they didn't change the 4-digit code to get the iStats to unlock

2 - in a sick patient, I'm not sure what I'd do with a blood gas that told me the sat was 85% or so

But putting a line in a carotid is a totally avoidable complication that can kill people, so I'm not going to look down on anyone who takes an extra step to guarantee he will do no harm. **** happens.

You're probably the kind of guy who, a few years ago, was mocking everyone using ultrasound for lines and blocks, because you'd been doing Just Fine without it.
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I have never put a line in the carotid and I have been in this business for a while.
If the patient is hypotensive to a point that you can't distinguish the pulsatile arterial blood don't do an IJ and go straight for the SC and that applies with or without ultrasound
 
Planktonmd said:
I have never put a line in the carotid and I have been in this business for a while.
If the patient is hypotensive to a point that you can't distinguish the pulsatile arterial blood don't do an IJ and go straight for the SC and that applies with or without ultrasound
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The SC approach is not immune to an arterial stick
 
I never do subclavians. Unless there's some reason I can't use he ij -- t-berg fixes hypovolemic collapse. The studies on infection rate sc vs ij are mixed - most studies show no difference. I've seen two people die as a result of subclavians going God knows where.... Never my cases thank god - One in residency -- fellow lacerated artery. The other in pp when the surgeon was placing a subclavian for dialysis access and ruptured something (likely venous based on the way things went - as I was eventually in the room to help after the code started) -- she ended up w hemothorax and a thoracotomy but she had been down too long. Moral of the story whether you do ij or sc - that wire should just slide in... If it doesn't dont make it
 
Couple of points....don't want to quote a bunch of people.

To the point of doing blind... I was in ass-crackistan and had an ultrasound!

I remember in 5th grade(?) my teacher making us use a slide rule while a calculator sat on the desk. I haven't seen a slide rule since. Technology keeps moving forward and becomes cheaper. Likely we will use something else soon. Doing blind is becoming very pointless.

@Planktonmd - that algorithm on both sides said you should always transduce. That is where the rubber meets the road. Everything thing else (blood gas, us, ekg, etc) can give a false answer.

@pgg - do you transducer everyone? I had a case where the wire - as far as I could tell - looked Ij but something was funny. Transducer poor man cvp and was clearly artery blood. Transducing everyone seems to be the best solution.

I do think there are certain rare cases you would check an istat.
 
1) If you're using needle without the angiocath (which is what I do), and for whatever reason you're not 100% confident, one thing to do is to thread the wire, then slide the angiocath over the wire and remove the wire. Now you can do your transduction or whatever you need to do, but if you have an angiocath in an artery you'll know it.

2) In residency we did live ultrasound 100% of the time, but when I was a fellow we had a few attending who believed in learning the old-fashioned way, and I thank them for that. What they'd do is scan the neck before prepping it to make sure the anatomy was normal, and the IJ was good caliber, wasn't right over the carotid, etc. If the anatomy was good, they'd then let us do it "blind." I feel this was a good teaching method.

3) Re: blood gases, you can also run a "poor man's blood gas"- draw out a syringe of blood from your insertion site, and one from your a-line. Same color? You have a problem.
 
sevoflurane said:
Angiocath first for me... from the get go.
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Curiously, you do it like an IV where you advance after flash or just thread after flash? I've always done Big Steel and thread wire but am considering switching if it's simple enough.
 
inspirationmd said:
Outside of academic hospitals, has it become standard of care? Not sure about in ORs but a lot of EDs in the community and smaller ICUs still don't have U/S. U/S is a wonderful tool for sure but also very expensive and so some places don't have one which I concede is non-ideal but a reality. However, an argument I frequently have with people centers around if we are allowing our love of technology to erode the training for skills that are still needed for the 75% of residents who go out in the community.

I am not just referring to IJs but femorals, subclavians, a line, paracentesis, and thoracentesis, etc which can all be done blind or u/s guided /assisted.

Would be interested to know you guys thoughts...
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I use it 100% of the time on IJ sticks at my county hospital with about 250 beds.
 
Ignatius J said:
Curiously, you do it like an IV where you advance after flash or just thread after flash? I've always done Big Steel and thread wire but am considering switching if it's simple enough.
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Yup. Slight pull back on the syringe, get some heme and then twist off into the IJ. Then I have 2 hands free. I place the wire, look at it in short and long axis, pull out the angiocath, slight knick, dilate and railroad the CVL. Start to finish in a straight forward neck 1-2 min. I like the fact that the angiocath is a smaller caliber than the steel needle.
 
sevoflurane said:
Yup. Slight pull back on the syringe, get some heme and then twist off into the IJ. Then I have 2 hands free. I place the wire, look at it in short and long axis, pull out the angiocath, slight knick, dilate and railroad the CVL. Start to finish in a straight forward neck 1-2 min. I like the fact that the angiocath is a smaller caliber than the steel needle.
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Bingo. That's how you do it. My technique exactly +/- the US.
Yes, I said it. I will forego the US in some situations. Actually put a CORDIS in my trauma pt the other day without US. TIME WAS CRITICAL. I was in the ER and I wasn't waiting for some ER nurse to go get it for 10min.

My reasons for using the catheter over needle (modified seldinger) technique are:
1) smaller needle I guess, but because I fear a larger one. Just more controllable since it's shorter. I use the large needle for SC approach.
2) frees up your hands like Sevo said.
3) slide the catheter in place and remove the needle. If you are in the carotid many times you will figure it out during this step. If you use the needle then you can't let go of it, now you have to do everything with one hand stabilizing the needle. Awkward.

Next tips that I'm sure many here already know:
1) thread the dilator over the wire before you make your skin nick. Stab and then drive in the dilator. Much less bleeding and saves you from having to hold pressure while threading the dilator on the wire.
2) make a deep enough skin nick. If you get scared or weak here then you will have trouble passing the dilator and everything can go south at this point. One stab along the wire and at least half the blade for 2-3lumen and nearly the entire blade for cordis/Mac line.
3) loop The wire in your hand as you remove the dilator so that you are working with only an inch or so of wire when trying to thread the 3lumen catheter on. Trust me this will help you as you get older and can't see things this small up close. Not necessary for the cordis obviously.
 
Another useful tip-

Once your wire is in, take a 4x4 gauze and put it under the wire (against the skin, with the edge up against the wire entry point). What this does is soak up any blood at the site, and leaves no doubt about the correct place to nick skin.
 
For the younglings on this thread... if you want to look like a rockstar... learn how to do one handed knots.... fast. Not only is it a great technique to know for CVL placement, but good to know in general as a physician. IMO, seeing an anesthesiologist throw down fast one handed ties at the end of the procedure elevates their game in my mind (and makes me proud and giggly inside). Doing them fast at the end of your CVL placement def. improves your times and there is nothing worse than a poor suture that comes undone in the ICU.
 
sevoflurane said:
For the younglings on this thread... if you want to look like a rockstar... learn how to do one handed knots.... fast.
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This was a pseudo requirement of my CA-1 cardiac month. I think being able to proficiently tie one handed also garners respect from our surgical colleagues (even though they're rarely around to see it).
 
WRT the subclavian arterial placement of a central line, two of my most regrettable experiences in the OR revolve around the unintended placement of a subclavian line in the artery. One was done by me and resulted in the delay of a CABG. It was early in my training and before the use of ultrasound. All aspects suggested that it was a venous placement (dark non pulsatile flow). The other was placed by a surgeon in a pediatric patient who had a much worse outcome due to denial of the surgeon to consider that the line was arterial. I think all should be transduced because they don't always act like you think they should.
 
I suppose you could spend $35 and transduce every stick.



University of Washington is using these. I suggested it to one of my surgical colleagues who does blind sticks. If I was working with trainees again, I would mandate that they use them.

If you can successfully put the tip of a needle within millimeters of a nerve for a block, you should be able to tell exactly where the needle tip is in the perfect echo field of the blood filled IJ.

You should also be able to tell when you don't know where the tip is due to unusual factors (collapsed vein, anatomical) and need to resort to confirmatory measures.

-pod
 
I said transduced, but I really meant that I like to hook up the tubing and make sure it does not rise against gravity before dilating the vessel. Basically, checking a CVP as was alluded to earlier in the thread.
 
Rising against Gravity is a poor test. Blood may not rise if the catheter is kinked or the tip is against the vessel wall. Watching a blood column Drop is the only definitive test to confirm venous placement. I hold the tubing down until it fills, then raise it up and watch the blood empty into the vessel.


Sent from my iPad using Tapatalk
 
Wiscoblue said:
Rising against Gravity is a poor test. Blood may not rise if the catheter is kinked or the tip is against the vessel wall. Watching a blood column Drop is the only definitive test to confirm venous placement. I hold the tubing down until it fills, then raise it up and watch the blood empty into the vessel.


Sent from my iPad using Tapatalk
Click to expand...
That is exactly how I do it as well. I did a poor job describing the technique. Your was much better.
 
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