Central lines in all the wrong places

[Pure Anergy]

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Does anyone have experience with troubleshooting a central line in the azygous vein? From what I'm reading, it's more common to cannulate the azygous vein if you do a left-sided line, and the azygous is not an optimal vein to use since it is so much smaller than the SVC and you're infusing fluids in the "wrong" direction. I've also seen some hinting that it's somehow possible to reposition an azygous vein catheter into the SVC. But it's not really clear to me how one would go about doing that, especially since catheters can apparently migrate back and forth between the two veins on their own over a period of days. Would appreciate any input.

 

[RustedFox]

IJ for the win.

 

[dotcb]

Leave it in and use it for meds, fluids. Let it be switched later in an ICU setting.

 

[southerndoc]

IR can reposition them under fluoro. Unless you have fluoro, you're blindly inserting the wire. Doesn't matter if you're doing a subclavian or an IJ.

My list of wrong places central lines have gone (I average 1-2 lines per week):

1. Subclavian that went cephalad,
2. Left IJ that went into the azygous vein,
3. Right IJ that went into a mammary vein in a patient with extensive collaterals from cirrhosis.

If you do enough lines, you'll see them in weird places. Unless you fluoro while inserting the wire, once the wire enters the vein you have no idea where it goes.

The azygous vein patient's CXR showed the line to not cross midline and to look curled. Transduced a pressure and checked a pO2 and all was fine. Did a lateral CXR and you could see the line going posterior.

The mammary vein patient's CXR looked like the line was in position (portable CXR). Got a CT that showed it was in the anterior mediastinum in a mammary vein. IR repositioned it with fluoro. (The CT was done non-contrast to look at a possible cavitary mass.)

 

[zinjanthropus]

👍

Leave it in and use it for meds, fluids. Let it be switched later in an ICU setting.

 

[Mudpile MD]

I put a right IJ in the axillary vein. IJ's are not immune to going to the wrong place. Did a guide wire exchange not under fluoro and the second line went to the correct place...

 

[Tiger26]

I put a right IJ in the axillary vein. IJ's are not immune to going to the wrong place. Did a guide wire exchange not under fluoro and the second line went to the correct place...

Same here--never expected that one

 

[Colbert]

I did an axillary IJ this week too. Glad we got the x-ray before we starting pushing the pressors.

 

[Rendar5]

Right fem cordis accidentally into artery instead of vein lol. Blind Fem placements without a pulse can be tricky.

 

[Bostonredsox]

Right fem cordis accidentally into artery instead of vein lol. Blind Fem placements without a pulse can be tricky.

Have had this multiple times in people who hit the door coding for 20 minutes. The artery has no pulse and that blood ain't red. Nurse calls, um the levophed won't infuse anymore doctor.

I put in side by side groin lines in these cases usually. one time despite being a full 4cm lateral from my cvc stick both my aline and cvc were in the vein.

Have had subclav turn cephalad in a tortuous vein and end up with tip in IJ multiple times. I usually retread a wire, pull catheter back and try and rotate it 90 degrees then readvance. Has worked a few times. Other times I just yank it and put one in the other side.

I have gone left IJ to azygous atleast a half dozen times. That's generally fine for pressures and such. The azygous is in fact a central large caliber vein. Can just retract it a bit and leave it In the distal subclav/inominate.

I had a surgeon tell me once they put in a subclav cordis threw in like 3L of fluid in 30 min on way to CT. They noticed during CT all that fluid was in the mediastinum. Oops. Patient would have died anyway he said.

Do enough lines and you will get all kinds of crap happen. I have seen a fellow resident cause a fistula going through IJ through carotid and back into IJ more distally. Surgeon was flabbergasted looking at it on US. Weird **** happens.

 

[45408]

If you do enough lines, you'll see them in weird places. Unless you fluoro while inserting the wire, once the wire enters the vein you have no idea where it goes.

If you see some PVCs, you're probably tickling the heart with the wire. I've seen a subclavian go up the IJ (not mine), but otherwise I've never seen one go astray.

 

[glorfindel]

Have had subclav turn cephalad in a tortuous vein and end up with tip in IJ multiple times. I usually retread a wire, pull catheter back and try and rotate it 90 degrees then readvance. Has worked a few times. Other times I just yank it and put one in the other side.

I've threaded subclavians into the neck before, so I changed my practice and have had no maldirection problems with subclavians since.

1) occlude the IJ when you're threading the wire during a subclavicular subclavian line: http://academiclifeinem.blogspot.com/2009/12/trick-of-trade-subclavian-line-gone.html

2) Place my subclavians via the supraclavicular route, BANG! Right down into the SVC!
http://resus.me/supraclavicular-approach-to-subclavian-vein/

[YOUTUBE]http://www.youtube.com/watch?v=I3Jqbxa1_Ts[/YOUTUBE]

If you see some PVCs, you're probably tickling the heart with the wire. I've seen a subclavian go up the IJ (not mine), but otherwise I've never seen one go astray.

For all my IJs I get suspicious if I don't see the PVCs. They've been a pretty reliable guide for me.

 

[FutureInternist]

R "IJ" CVL by IM intern for TPN
Next day's CXR shows complete collapse of R lung and white-out
Chest tube to look for blood
TPN in the pleura for the win !!

 

[Pure Anergy]

IJ for the win.

It was a left IJ. I've never had this happen with a subclavian. At least so far.

Leave it in and use it for meds, fluids. Let it be switched later in an ICU setting.

Thanks. That's basically what I did, although it looks like the ICU didn't switch it either. I was looking through their notes, and they placed an aline and extubated the patient the next day, but I didn't see anything about changing the central line.

The azygous vein patient's CXR showed the line to not cross midline and to look curled. Transduced a pressure and checked a pO2 and all was fine. Did a lateral CXR and you could see the line going posterior.

I only had a portable AP. The line crossed the midline toward the right side of the heart, and it looked fine to my attending and me. But I went over it with the radiology resident later, and it did bend just slightly in the wrong direction. You should be able to see that more clearly on a lateral view, which I didn't have. If yours didn't cross the midline, do you think it was maybe in the hemiazygos?

R "IJ" CVL by IM intern for TPN
Next day's CXR shows complete collapse of R lung and white-out
Chest tube to look for blood
TPN in the pleura for the win !!

Wow.

 

[VentdependenT]

ER put one in the carotid and infused pressors. No es bueno. Dude got turned into palliative patient. It happens.

 

[Bostonredsox]

ER put one in the carotid and infused pressors. No es bueno. Dude got turned into palliative patient. It happens.

Ugh this should not happen in today's age with an US. Wire confirmation techniques and such. Accidental stick. Yes. But dilating a carotid and threading the catheter should never happen. No excuse. If you don't have an US, stick the chest. Or the groin. If you don't have time for it, stick the chest. Or the groin. And if you are just "old school" and Feel you dont need no stupid US...please use a damn finder Needle. if your not quite sure...hmm this bloods a little redder and pulsatile....send some of that blood for an abg before you dilate. I'm ok with pulseless guys femoral ends up in artery and gets some pressors through it for a bit but that shouldn't happen in the neck ever.

Very much no es bueno. And seeing as an IJ is essentially never emergent, if you need it that fast stick the groin, the above mentioned complication is always preventable.

 

[VentdependenT]

Believe it or not they DID use ultrasound. A CXR was never ordered. pt went to the unit, the unit ordered one, and they said "oh shieaut." Too late.

In addition it is not advisable to leave a line in the azygos and "let the unit deal with it." these things get forgotten. that line has a high rate of complications, one of which is erosion through wall. You do the procedure, YOU deal with the complications.

 

[sluggs]

A few random ones:
I see IJ lines in the carotid at least once a year despite ultrasound.
In my personal practice I view the wire in the IJ (but i guess you could still go through the IJ and into the carotid).
I do a chest x-ray STAT, and if I can't get one, send a gas or transduce a wave-form.
My new complication is doing a subclavian and ending up in the subclavian artery (did this once, full line in, took it out and replaced it, patient did ok).

 

[Arcan57]

Personally - left IJ that looped back up IJ, subclavian that goes up IJ (if they complain of ear pain when advancing wire or it stops cold at 20 cm be concerned) or crosses into other subclavian.

Seen in training - left subclavian attempt into LIMA, U/S guided IJ into vertebral artery, Swann perf'ing pulmonary artery due to balloon being floated way too deep.

 

[jdh71]

That supraclavicular video is pretty hot. Just gotta talk someone into letting me try.

I personally haven't had any lines go stink on me yet - though there were a few times when I thought maybe they did. Like most of you I confirm the wire, as best I can, for as much length as I can in the vien I'm in, and then further confirm with CXR. It's simply the best you can do.

Blind sticks into the essentially dead patient's femoral neurovascular area when you don't have a pulse is going to occasionally give you problems. I personally think these patients just need simply an IO until you've decided they are going to live or not - get rid of the emergent femoral line if at all possible.

I don't personally mess with azygous lines. I just put in another one if necessary. If all you need is access, you got it. If what you need is central access, you basically got that too, though not in a preferable location - it will be fine for just about anything you'll want to put in anyway. If you need to dump fluids or blood, put in a new line.

 

[Dane07MD]

Finding an attending here is down to do a subclavian when it's not emergent is difficult. Nonetheless, I had a patient with past neck surgery that complicated the anatomy, and I had the one attending who trained in the south who loves subclavian lines.

So, I did it (this was early in intern year mind you). I neglected to hold the wire steady as I advanced the catheter, so the wire kept going in too. A few PVCs noted, then a brief V-tach and even more brief v-fib resulted. Pulled back on the wire, rhythm self-corrected (thank god). Learned a valuable lesson that day, and am still thankful things turned out alright. No unintended locations for CVCs yet, but haven't done enough to rack up stories.

First one I watched in med school was an R2 IM resident who threaded it backwards up the IJ.

One attending here saw a patient die with subclavian artery puncture, and she is vocal about it, so finding a subclav line is tricky...

 

[VentdependenT]

That supraclavicular video is pretty hot. Just gotta talk someone into letting me try.

I personally haven't had any lines go stink on me yet - though there were a few times when I thought maybe they did. Like most of you I confirm the wire, as best I can, for as much length as I can in the vien I'm in, and then further confirm with CXR. It's simply the best you can do.

Blind sticks into the essentially dead patient's femoral neurovascular area when you don't have a pulse is going to occasionally give you problems. I personally think these patients just need simply an IO until you've decided they are going to live or not - get rid of the emergent femoral line if at all possible.

I don't personally mess with azygous lines. I just put in another one if necessary. If all you need is access, you got it. If what you need is central access, you basically got that too, though not in a preferable location - it will be fine for just about anything you'll want to put in anyway. If you need to dump fluids or blood, put in a new line.

So you are ok leaving an azygous line in? Why?

 

[leviathan]

A few random ones:
I see IJ lines in the carotid at least once a year despite ultrasound.
In my personal practice I view the wire in the IJ (but i guess you could still go through the IJ and into the carotid).
I do a chest x-ray STAT, and if I can't get one, send a gas or transduce a wave-form.
My new complication is doing a subclavian and ending up in the subclavian artery (did this once, full line in, took it out and replaced it, patient did ok).

Even with ultrasound? That scares me. It seems like transducing a pressure is a quick and fool-proof way to know you're in the IJ and not carotid, or are there any drawbacks to it I'm not realizing?

 

[jdh71]

So you are ok leaving an azygous line in? Why?

Sure. While you need it. You can yank it when you get something better in place (new central line or picc) and don't need the access any longer. If your issue is access and access for meds that need central access then you've got it and do what you need to do. Don't have IR mess around with repositioning and fluoro and whatnot. Once you're done with your sterile field it's sub-optimal to have to do anything with the line that includes moving it in and out or instrumenting it.

 

[VentdependenT]

not busten yer balls. just curious as to others practice habits.

 

[jdh71]

not busten yer balls. just curious as to others practice habits.

I didn't think you were. Lots of these decisions depend to context, what's going on, why it's going on, what's the point of the line, etc. I think my general approach here is reasonable and carries with it a strong rationale, but it's clearly not "gospel" and others may triage the problem a bit differently from their perspective.

 

[Apollyon]

Personally - left IJ that looped back up IJ, subclavian that goes up IJ (if they complain of ear pain when advancing wire or it stops cold at 20 cm be concerned) or crosses into other subclavian.

Seen in training - left subclavian attempt into LIMA, U/S guided IJ into vertebral artery, Swann perf'ing pulmonary artery due to balloon being floated way too deep.

Didn't that happen to Ronald Reagan at GWU Hospital back in 1981? Got his central line, and they didn't shoot an Xray. He was complaining of ear pain after, and they were blowing it off, until someone got a film and found it.

 

[doctorFred]

I don't personally mess with azygous lines. I just put in another one if necessary. If all you need is access, you got it. If what you need is central access, you basically got that too, though not in a preferable location - it will be fine for just about anything you'll want to put in anyway. If you need to dump fluids or blood, put in a new line.

+1. And I would add that even if you need to give large volumes of fluids or blood, it probably makes little difference.

 

[jdh71]

+1. And I would add that even if you need to give large volumes of fluids or blood, it probably makes little difference.

Agree. Though, what I was thinking but didn't spell out was that if you really want to DUMP in product, the tripple lumen CVC isn't what I'd use anyway. I'd put in a cordis. But I'm sure this goes without saying for the crowd in the EM forum.

 

[tkim]

Agree. Though, what I was thinking but didn't spell out was that if you really want to DUMP in product, the tripple lumen CVC isn't what I'd use anyway. I'd put in a cordis. But I'm sure this goes without saying for the crowd in the EM forum.

I recall some comparison between a cordis and a 14 ga angio, and if I recall, the 14 angio was better for fluid admin, because of the shorter length of the cathther.

 

[Daiphon]

I recall some comparison between a cordis and a 14 ga angio, and if I recall, the 14 angio was better for fluid admin, because of the shorter length of the cathther.

Yep. Poiseuille's Law. Shorter & fatter always wins the race... but if they're really clamped down, cordis trumps lack of access. d=)

Sent from my DROID BIONIC using Tapatalk

 

[Rendar5]

I nearly placed an u/s guided TLC into the carotid, hard to get true confirmation w/ u/s unless you do a longitudinal view which is tricky for other reasons. Cross-sectional view actually looked good. Only reasons I didn't actually place it was was that I took the syringe off the introducer needle and almost got hit in the face with a squirt of pulsatile venous-looking blood.

 

[Bostonredsox]

I nearly placed an u/s guided TLC into the carotid, hard to get true confirmation w/ u/s unless you do a longitudinal view which is tricky for other reasons. Cross-sectional view actually looked good. Only reasons I didn't actually place it was was that I took the syringe off the introducer needle and almost got hit in the face with a squirt of pulsatile venous-looking blood.

You can get this while being in the right vessel in severe pulmonary hypertensives. I pulled a syringe off a right IJ once and blood shot over my shoulder. Purplish but with wicked pulsation. Was like wtf...So I sent a gas and threaded wire to hold my place, waited 2 minutes, sure as **** gas was venous. US showed wire clearly though the vein. So huge right sided pressures with wicked TR can really put backwards force up the IJ.

 

[jdh71]

I recall some comparison between a cordis and a 14 ga angio, and if I recall, the 14 angio was better for fluid admin, because of the shorter length of the cathther.

I guess if you've got 14g angiocath laying around your shop, close at hand, put that in . . . probably can't it stuck in the azygous either . . . heh . . . though the key is probably which does better with pressure flow, rather than gravity flow, and I think the cordis wins in that scenario

 

[tkim]

I guess if you've got 14g angiocath laying around your shop, close at hand, put that in . . . probably can't it stuck in the azygous either . . . heh . . . though the key is probably which does better with pressure flow, rather than gravity flow, and I think the cordis wins in that scenario

I'm not so sure pressure bag versus gravity would make the cordis a superior line. I'm talking about sticking a 14 in the AC or EJ, versus cordis centrally. As mentioned, if you're dry or clamped down you may not have any peripherals to stick, so a cordis will need to be dropped, but I do recall, that even with pressure bags, 14 ga peripheral still beats a cordis.

 

[jdh71]

I'm not so sure pressure bag versus gravity would make the cordis a superior line. I'm talking about sticking a 14 in the AC or EJ, versus cordis centrally. As mentioned, if you're dry or clamped down you may not have any peripherals to stick, so a cordis will need to be dropped, but I do recall, that even with pressure bags, 14 ga peripheral still beats a cordis.

I guess one of us should track down the spec's at some point.

Maybe tomorrow if I don't get slammed.

 

[VentdependenT]

I guess one of us should track down the spec's at some point.

Maybe tomorrow if I don't get slammed.

RIC for the win. 14g is the shnizzle. love that orange hub.

 

[jdh71]

I'm not so sure pressure bag versus gravity would make the cordis a superior line. I'm talking about sticking a 14 in the AC or EJ, versus cordis centrally. As mentioned, if you're dry or clamped down you may not have any peripherals to stick, so a cordis will need to be dropped, but I do recall, that even with pressure bags, 14 ga peripheral still beats a cordis.

I guess one of us should track down the spec's at some point.

Maybe tomorrow if I don't get slammed.

Here's a paper showing flow rates through two different rapid infusing system:

http://www.gdmedical.ch/media/DIR_234330/2cfb7ee2a75cff6bffff9b73ffffffe7.pdf

The flow rate through the 5, 6, 7, and 8.5fr is better than the 14g

I think at the end of the day, while some of us are fixating on length, that it's the radius of the tube to the 4th power denominator in Poiseuille's Equation that's the real culprit.

 

[tkim]

Here's a paper showing flow rates through two different rapid infusing system:

http://www.gdmedical.ch/media/DIR_234330/2cfb7ee2a75cff6bffff9b73ffffffe7.pdf

The flow rate through the 5, 6, 7, and 8.5fr is better than the 14g

I think at the end of the day, while some of us are fixating on length, that it's the radius of the tube to the 4th power denominator in Poiseuille's Equation that's the real culprit.

That's a great article, not the one I dimly recall reading but what's interesing is the while Hagen-Poiseuillie trumps length, length does affect flow rate:

"As dictated by Poiseuille's Law, the radius is the most important factor determining maximal flow of a given fluid. Flow (P1 P2) r 4/8L describes this relationship where P1 and P2 are pressures at the proximal and distal ends of the tubing, r is the radius of the tubing, is viscosity of the fluid, and L is length of tubing (2). The additional importance of catheter length is demonstrated when comparing the flows through the 14-gauge and 5F catheters. Although the radius of the 5F is smaller than that of the 14 gauge, its flows are faster with both the L-1 and the RIS (the length of the 5F is 52% less than the 14-gauge catheter). Although Poiseuille's Law demonstrates important factors, the actual flow of fluid under pressure is described as a quadratic equation because of the development of turbulence (3). This explains in part why even larger-bore catheters are not capable of delivering the flows predicted using only Poiseuille's Law (4)."

Then I checked the length of the 14 ga cath that they used in this study and it's the 2.5 in/64mm length, when we typically use a 1.25 in/32 mm length catheter in the ED.

I'm wondering if the reduction of length by half would increase flow rates that are comparable. Seeing as how the H-P equation predicts pressure drop from length P1-P2 and we use that as a yardstick for the flow rate, decreasing the length by half should also decrease turbulent flow and therefore increase flow rate as well.

 

[core0]

Left IJ to right IJ.

 

[Rendar5]

Left IJ to right IJ.

Now that's just impressive for it to even stretch that far, must be a long line.

 

[Bostonredsox]

Now that's just impressive for it to even stretch that far, must be a long line.

thats what she said.

 

[DocVirk]

Left IJ to right IJ.

Done it. Started looking for the line on the chest xray, and find this nice little plastic necklace. Oops.

I've also had a right IJ to right EJ. Tough to thread wire in a dialysis patient. Turns out his prior access in the right had caused bad stenosis of his SVC and my wire made a 180 degree turn. I am very wary of dialysis patient with sclerosed veins.

No complications in either case.

 

[gutonc]

Left IJ to right IJ.

I did RIJ TLC into LIJ once...the variable in that case being that he already had a Niagara in the LIJ. Took a little staring at the CXR to figure out WTH I'd done.

 

[docB]

You can get this while being in the right vessel in severe pulmonary hypertensives. I pulled a syringe off a right IJ once and blood shot over my shoulder. Purplish but with wicked pulsation. Was like wtf...So I sent a gas and threaded wire to hold my place, waited 2 minutes, sure as **** gas was venous. US showed wire clearly though the vein. So huge right sided pressures with wicked TR can really put backwards force up the IJ.

I learned this on a frequent flier back in residency. Pulmonary HTN, was always coming in for Flolan. You'd get this pulsatile dark blood every time when you were in the right place. A lot of learned central lines on her. She had big central veins from the pulm HTN but no peripherals from all the roids.

I learned on a pediatric CO poisoning that you can get bright red blood from a vein sometimes.

 

[Bostonredsox]

I learned this on a frequent flier back in residency. Pulmonary HTN, was always coming in for Flolan. You'd get this pulsatile dark blood every time when you were in the right place. A lot of learned central lines on her. She had big central veins from the pulm HTN but no peripherals from all the roids.

I learned on a pediatric CO poisoning that you can get bright red blood from a vein sometimes.

This can also happen in after an overzealous 'tern bags the airway prior to induction 37 times per second for 5 minutes and then they put them on 100% for 2 hours before checking a gas despite them actually being tubed for hypercarbia without hypoxia. Now there PaO2 is 650. Go and put in a line them and see how red that venous return is.

 

[TrustMe]

I guess one of us should track down the spec's at some point.

Maybe tomorrow if I don't get slammed.

All IV's tell you the flow rate on the package. As do the central line kits (at least introducer kits do). Don't remember specifics but am pretty sure introducer beats 14ga on flow rate since its so much bigger. Agree with Vent....RIC rules. I always give a peripheral IV vs TLC talk to interns/jr residents in the ICU and OR so they know what line to use for what indication. Mainly so they don't use TLC for volume resuscitation.

 

[goodoldalky]

Even with ultrasound? That scares me. It seems like transducing a pressure is a quick and fool-proof way to know you're in the IJ and not carotid, or are there any drawbacks to it I'm not realizing?

Sort of a pain in my opinion. Sometimes all your screwing around can occasionally cause the blood to clot while you're trying to get someone to help you transduce a pressure and then you have trouble threading the wire, etc. Seems like a gas is easier if you can get one point of care. Still have to be careful because if the blood /needle sit there stationary while you wait they will still clot. Plus, in the odd occasion that you have a systemically hypotensive patient with RHF (i.e: PE), transducing a pressure may not help you that much.

When an IJ gets put in the carotid it is almost always because the wire passes through the back wall of the IJ into the carotid. When you throw the US on you can see the wire in the IJ, which it is, but distally it goes into the carotid. To prevent this you have really got to try and follow the course of your wire to see it hit the junction of the brachiocephalic/SVC and ensure it's not diving through your IJ into the carotid.

 

[neusu]

My go to is left subclavian. Stay superficial under the clavical, look which way the pigtail is going on the guide-wire and make sure it's heading down on insertion. I like the idea of occluding the IJ on insertion but haven't adapted it yet. Even so, in my experience I've had 1 pneumo discovered after 2-weeks on positive pressure ventilation and 1 go up the IJ.

I like the US for IJ placement but will do them based on landmarks if needed. We prefer subclavian for our patients though based on a theoretical risk if a clot forms around the line in the IJ it could decrease venous return from the brain.

 

[UnderwaterDoc]

When an IJ gets put in the carotid it is almost always because the wire passes through the back wall of the IJ into the carotid. When you throw the US on you can see the wire in the IJ, which it is, but distally it goes into the carotid. To prevent this you have really got to try and follow the course of your wire to see it hit the junction of the brachiocephalic/SVC and ensure it's not diving through your IJ into the carotid.

This is what I do when I have doubts about my placement. Make sure you visualize the curve at the tip of the wire and that it is in the IJ (gently spin the wire in place while under the probe). In my opinion this is the fastest and most accurate confirmatory method.