Central lines, routinely with or without ultrasound?

[SLUser11]

While U/S has proven to be much more successful, what happens in an emergency situation when no ultrasound is available? If you were never taught how to how to do IJ's without U/S, how are going to do it in an emergency situation?

Put the line in the groin, where your misses have less catastrophic consequences.

Have never used ultrasound for lines and I've put in few thousand in private practice.

Agreed.

Ultrasound guided IJ access is safer only in the hands of inexperienced people and trainees.

Not true. I believe standard of care is more a legal definition that is restricted both geographically and by the type of setting you are in.

Ultrasound guidance for IJs is the standard of care. End of story. The ACS put out a position statement on that a couple years ago.

As for which line is safest, I agree that it really depends on the practitioner, and is based mostly on experience. A blind subclavian may be safer in Dr. X's hands, while a blind IJ is safer in Dr. Y's hands, while the US-guided line is safer in Dr. Z's hands.

It doesn't change the fact that it's the standard of care.

I'm not sure I want to open this can of worms, but just wait until ultrasound guided radial art lines become the standard of care.....

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[sevoflurane]

I'm not sure I want to open this can of worms, but just wait until ultrasound guided radial art lines become the standard of care.....

.....

I'm all for USD SLUser... I use USD for a-lines in edematous obese patients or septic patients that don't have a pulse.... that's about it. I've used usd for an a-line 1 time in the last 12 months. I think this is taking the USD controversy a little too far don't you think... ? I prolly put in anywhere btw 4 and 8 a-lines a week. They shouldn't be a problem to any competent anesthesiologist.

Just saying dude...

 

[SLUser11]

.....

I'm all for USD SLUser... I use USD for a-lines in edematous obese patients or septic patients that don't have a pulse.... that's about it. I've used usd for an a-line 1 time in the last 12 months. I think this is taking the USD controversy a little too far don't you think... ? I prolly put in anywhere btw 4 and 8 a-lines a week. They shouldn't be a problem to any competent anesthesiologist.

Just saying dude...

I agree that it's ridiculous, and that most people who put in lots of A-lines do it just fine without ultrasound.....but that doesn't mean that it's not coming.....

Can you link the position statement?

Does the ACS define the standard of care for anesthesiologists?

I still wouldn't call it a standard of care. A standard of care "must" be done, if I am correct. In private practice, it's probably an exception rather than the rule to use US for central lines.

I use it all the time though, only because I do lines awake and I like to pretty much guarantee one stick.

I'll look for the link. It was in an old blue journal, but should be easy to find. As for whether or not the ACS dictates your standard of care, they dictate the standard of care on subjects in which they are considered experts. Your logic would imply that you don't have to follow the Chest Physicians guidelines for DVT prophylaxis, or the gastroenterologists recommendations regarding screening colonoscopy.


Anyway, I don't want you guys to think that I'm saying you can't do IJs without ultrasound, but I'm just saying that you probably shouldn't. When you are in court after your complication, it will be hard to defend not using the sono when it was available, especially when there is an orgy of evidence that the approach is better, and there's position statements calling it the standard of care. You wouldn't have a leg to stand on.

 

[SLUser11]

I'm not sure what goes on at your hospital, but at the hospitals I've worked at, anesthesiologists do many more central lines than surgeons.

My point is that I would like to know what the ASA's position is on this. I have never seen where the ASA has called US a standard of care for central line placement.

Where I'm from, and other places that I've trained, the surgeons do many more central lines than anesthesia. But you are missing the point. This isn't a pissing match between specialties. There are anesthesiologists out there that are excellent at placing lines, and others that suck, just like surgery.

The point is that a professional society that represents physicians deemed to be experts in placing central lines has stated that ultrasound guidance should be used for IJs. If you don't use sono when it's available, and you develop a complication, e.g. sticking the carotid or PTX, you will be eaten alive in the courtroom.

Here's a nice review of multiple professional entities recommended ultrasound. It is a position statement from the Association for Vascular Access, since you find it absurd that surgeons would have the authority to make such statements.


Here's the link to the ACS position statement as well.

 

[proman]

The point is that a professional society that represents physicians deemed to be experts in placing central lines has stated that ultrasound guidance should be used for IJs. If you don't use sono when it's available, and you develop a complication, e.g. sticking the carotid or PTX, you will be eaten alive in the courtroom.

Here's a nice review of multiple professional entities recommended ultrasound. It is a position statement from the Association for Vascular Access, since you find it absurd that surgeons would have the authority to make such statements.


Here's the link to the ACS position statement as well.

While I don't disagree with the ACS statement, it's not establishing a standard of care. Professional associations only publish guidelines to practice in a certain manner. Deviation from those guidelines is permissible and does not necessarily imply practicing a lower standard.

I think someone else mentioned earlier that we have many standards of care. Most are regional, based on available resources. Hospital policy establishes an institutional standard of care. But, ultimately, a standard of care is determined by the legal system.

BTW, the way the ACS statement is worded, you should use ultrasound for femoral and subclavian central lines. That's crazy.

 

[SLUser11]

While I don't disagree with the ACS statement, it's not establishing a standard of care. Professional associations only publish guidelines to practice in a certain manner. Deviation from those guidelines is permissible and does not necessarily imply practicing a lower standard.

I think someone else mentioned earlier that we have many standards of care. Most are regional, based on available resources. Hospital policy establishes an institutional standard of care. But, ultimately, a standard of care is determined by the legal system.

BTW, the way the ACS statement is worded, you should use ultrasound for femoral and subclavian central lines. That's crazy.

We are arguing over semantics here. If I take back "standard of care," and change it to "really good idea endorsed by multiple professional societies," it doesn't change my point.

People don't want to use ultrasound because it can sometimes take longer. However, the only people that seem truly resistant to it are people that trained before it was widely available, and I think it's possible that their comfort level is actually higher with the blind stick, and they don't want to learn something new.

I just think it's time for everyone to accept that ultrasound is a good idea and learn how to become speedy and proficient with it.


As for your last comment, I agree that it's crazy, but it's just the way it is. Luckily, the literature for the US-guided subclavian isn't really there yet, as far as I know.

 

[Planktonmd]

The expression "standard of care" is not a medical expression and should not be the main argument when one is trying to have a scientific discussion among physicians.
Let's focus on medicine and leave silly legalese terms for the lawyers.
Ultrasound is a great tool and if you were trained to predominantly do lines with ultrasound you should not change, it's what works for you.
On the other hand you should not call your preferred technique (or the only technique you were taught) a "standard of care" especially if you are at the very beginning of your career and at the bottom of the learning curve for most of the essential skills required to be an anesthesiologist.

 

[proman]

We are arguing over semantics here. If I take back "standard of care," and change it to "really good idea endorsed by multiple professional societies," it doesn't change my point.

People don't want to use ultrasound because it can sometimes take longer. However, the only people that seem truly resistant to it are people that trained before it was widely available, and I think it's possible that their comfort level is actually higher with the blind stick, and they don't want to learn something new.

I just think it's time for everyone to accept that ultrasound is a good idea and learn how to become speedy and proficient with it.


As for your last comment, I agree that it's crazy, but it's just the way it is. Luckily, the literature for the US-guided subclavian isn't really there yet, as far as I know.

I agree we're really talking semantics, but lawyers live and die by semantics. The ASA does have a few standards of care (like every anesthetized patient should have ECG monitored continuously). I also agree with you that routine elective central lines should be placed with ultrasound, particularly if the operator is inexperienced. But I think most everyone here will also agree that the ability to place a central line in a vein that drains to the SVC without ultrasound is a mandatory skill for an anesthesiologist. It's up to you to decide how to learn and maintain proficiency.

The old guys will always resist change, it's what people do. People resisted the pulse ox and the nerve stimulator. Now the generation that's 10 years or less from retirement dismisses routine ultrasound. That won't last very long.

 

[Planktonmd]

I also agree with you that routine elective central lines should be placed with ultrasound, particularly if the operator is inexperienced. But I think most everyone here will also agree that the ability to place a central line in a vein that drains to the SVC without ultrasound is a mandatory skill for an anesthesiologist. It's up to you to decide how to learn and maintain proficiency.

So, if as a resident you place all "elective" lines with ultrasound how are you going to be able to place lines without ultrasound when the lines are not "elective"?

 

[drccw]

Here's the deal...
Complications due to central line placement are rare.
Litigation due to complications is rare.
If you have a complication and get litigated, you bet the lawyers are going to ask about ultrasound. if you used it, if you had it available etc. doesn't mind if it SOC or whatever....

drccw

 

[SLUser11]

Ultrasound is a great tool and if you were trained to predominantly do lines with ultrasound you should not change, it's what works for you.
On the other hand you should not call your preferred technique (or the only technique you were taught) a "standard of care" especially if you are at the very beginning of your career and at the bottom of the learning curve for most of the essential skills required to be an anesthesiologist.

Here's an interesting article I found in your anesthesia literature. It seems that you are not alone in your bias.

I think it's near-sighted to call US-guided CVLs "my preferred technique." It has been shown time and time again to be the safer approach to IJ CVLs. My question to you: Is ultrasound readily available where you practice? If so, what is your actual reason for not using it?

I'm not sure if you were referring to me or not with the last part since I'm not in anesthesia, but I promise that I'm not near the bottom of the learning curve with central lines of any type.

So, if as a resident you place all "elective" lines with ultrasound how are you going to be able to place lines without ultrasound when the lines are not "elective"?

While I agree that residents should be proficient without ultrasound, I don't see a way to approach this ethically, as you can't really expose the patient to a higher risk of complications for the sake of education. I understand the dilemma, though, because most of what we do as residents is sort of "practicing" on patients in a manner that may contain more complications than if the attending was to do all the procedures and make all management decisions.

Honestly, if a patient was in a true emergency where there was no time to get an ultrasound, I think the safest stick is the femoral vein. I've discussed this ad nauseam in the past, but in the crashing trauma patient, the coding floor or ICU patient, and several other emergency patients, the groin stick is safer for both the patient and the doctor.

 

[SLUser11]

Here's the deal...
Complications due to central line placement are rare....drccw

Not true. The complication rate is relatively high. Complication rate has been shown on several occasions to be significantly lower with ultrasound guidance.

It's not just about litigation. It's about what's best for the patient as well.

 

[Planktonmd]

I think it's near-sighted to call US-guided CVLs "my preferred technique." It has been shown time and time again to be the safer approach to IJ CVLs.

I think there is no evidence so far showing that Ultrasound in the hands of experienced people will decrease the already extremely rare complication rate.
Actually in the hands of an experienced anesthesioogist an IJ is probably the safest central access.
As for your question, yes we do have an ultrasound and I do use it for some lines if a patient is coagulopathic or seems difficult but I would not go as far as saying it has to be done on every line, and I would not call it a standard of care.

 

[Noyac]

I think there is no evidence so far showing that Ultrasound in the hands of experienced people will decrease the already extremely rare complication rate.
Actually in the hands of an experienced anesthesioogist an IJ is probably the safest central access.
As for your question, yes we do have an ultrasound and I do use it for some lines if a patient is coagulopathic or seems difficult but I would not go as far as saying it has to be done on every line, and I would not call it a standard of care.

I agree again.

My fear is that it will be made SOC out of necessity one day because there are apparently no residents that know how to place a CVC effectively and safely without it.

The other problem is that IM and Surgery don't place as many CVC's as anesthesiologist and they will call it SOC because of their own inexperience.

 

[Southpaw]

Not true. The complication rate is relatively high. Complication rate has been shown on several occasions to be significantly lower with ultrasound guidance.

It's not just about litigation. It's about what's best for the patient as well.

Well, if we're being honest with ourselves, and we really honestly care about what's best for the patient, you and I should never make a medical decision on a patient, as we're likely not the most qualified person available during residency, ever.

I appreciate the discussion, but medical education has already lost so much over the past few decades due to discussions like this at higher levels. I did very, very few procedures as a medical student, and my experience has become the norm. It'll be extremely difficult for me as an anesthesiology resident to become proficient at subclavian and femoral CVLs due to the nature of my training. I'm sure we'd both agree that future patients will not benefit from this, and yet your point of 'what is best for the patient' still resonates. We have people in both of our fields across this country doing fellowships, who openly state they'd rather learn one small subset of medicine extremely well because they don't feel residency taught them all they need to know to practice broadly. Does healthcare on the whole benefit from this?

And if we're being honest, and looking at your literature, it's not far reaching to state that if we're really doing the best for the patient, we should use U/S for every intervention from central lines to nerve blocks to arterial lines to IVs.

You have great points, but I honestly believe Plank and Noy are also correct when they say that their patients do not suffer nor experience increased risk because they're both extremely experienced and proficient at what they do. My question to you becomes, if U/S continues to become a required crutch, as it seems it will be, how will physicians like you and I ever get that needed experience? Because you can apply this one case of U/S guided IJ CVL, and expand it to almost everything you and I do as residents.

 

[dhb]

Studies are done at academic centers where unexperienced people put the lines hence a big bias in all these studies.
Ultrasound is SOC for undertrained people.

 

[SLUser11]

I think there is no evidence so far showing that Ultrasound in the hands of experienced people will decrease the already extremely rare complication rate.
Actually in the hands of an experienced anesthesioogist an IJ is probably the safest central access.
As for your question, yes we do have an ultrasound and I do use it for some lines if a patient is coagulopathic or seems difficult but I would not go as far as saying it has to be done on every line, and I would not call it a standard of care.

I feel like neither one of us are making any new points, so we'll just have to agree to disagree on this topic.

Still, it's funny that you'll use sono on a coagulopathic patient where there's less room for error, as it implies that you think ultrasound will give you a technical advantage. That seems to contradict with your earlier statements.

My fear is that it will be made SOC out of necessity one day because there are apparently no residents that know how to place a CVC effectively and safely without it.

The other problem is that IM and Surgery don't place as many CVC's as anesthesiologist and they will call it SOC because of their own inexperience.

Where are you guys practicing? General surgery places a very, very large number of central lines, and we place them in multiple locations, so we are by no means a one-trick pony. Lumping us in with IM is ridiculous. I've personally placed hundreds of central lines, from normal CVLs to dialysis catheters, portacaths, cutdowns, etc. etc. I've placed plenty of IJs without ultrasound as well. I have an average general surgery resident's experience with lines.

What percentage of your lifetime central lines have been in a location other than the internal jugular vein? What do you think your case # is for this? Do you really think that anesthesiologists are the only ones who know how to put in central lines?

Nobody in surgery knows how to do portocaval shunts anymore. Does that mean that the patient is suffering? No, it means they came up with TIPS, which is a better approach. If ultrasound guided CVLs become universally accepted as the standard of care, I seriously doubt it will be because none of us know how to do it without the sono.

Because you can apply this one case of U/S guided IJ CVL, and expand it to almost everything you and I do as residents.

I agree that it's a slippery slope, as I stated earlier. However, I don't think these guys are choosing to not use ultrasound for the resident's benefit.


I didn't come to the anesthesia forums to pick a fight. I check this forum because I like the occasional intellectual debates. I understand that surgery and anesthesia have fundamentally different approaches to medicine, and I respect your opinions.

It's just hard to not get defensive when it's implied that surgery is somehow inferior at CVLs.

 

[Planktonmd]

It's just hard to not get defensive when it's implied that surgery is somehow inferior at CVLs.

Actually, surgery IS inferior when it comes to placing IJ lines.
The reason why we are better is because we do them all the time, and frequently they are the only choice we have from our spot at the head of the table.
Anyway, when it comes to elective lines my line of choice is actually subclavian.
And maybe twice a year I find a reason to place a femoral line.

 

[pgg]

Well, if we're being honest with ourselves, and we really honestly care about what's best for the patient, you and I should never make a medical decision on a patient, as we're likely not the most qualified person available during residency, ever.

I appreciate the discussion, but medical education has already lost so much over the past few decades due to discussions like this at higher levels. I did very, very few procedures as a medical student, and my experience has become the norm. It'll be extremely difficult for me as an anesthesiology resident to become proficient at subclavian and femoral CVLs due to the nature of my training. I'm sure we'd both agree that future patients will not benefit from this, and yet your point of 'what is best for the patient' still resonates. We have people in both of our fields across this country doing fellowships, who openly state they'd rather learn one small subset of medicine extremely well because they don't feel residency taught them all they need to know to practice broadly. Does healthcare on the whole benefit from this?

And if we're being honest, and looking at your literature, it's not far reaching to state that if we're really doing the best for the patient, we should use U/S for every intervention from central lines to nerve blocks to arterial lines to IVs.

You have great points, but I honestly believe Plank and Noy are also correct when they say that their patients do not suffer nor experience increased risk because they're both extremely experienced and proficient at what they do. My question to you becomes, if U/S continues to become a required crutch, as it seems it will be, how will physicians like you and I ever get that needed experience? Because you can apply this one case of U/S guided IJ CVL, and expand it to almost everything you and I do as residents.

Great post.


I'll add that the primary reason healthcare costs have gone up so much in recent decades has been new technology. Is it really in the best interest of patients to accept further substantial gadget-driven cost increases for some small, incremental, and dubious[1] improvement in safety? Where will it end?

Nearly all of us are frustrated with the medicolegal reasons for ordering medically unnecessary studies, whether it's another lab draw, or a CT, or anything else. I don't understand why there's less frustration in a medicolegally-driven push for using a very expensive piece of equipment for routine CVL placement.


[1] I say dubious improvement in safety because the studies are typically done at academic institutions where the people performing the procedure are still on the steep part of the learning curve. Concluding that ultrasound is safer in all circumstances and should therefore be SOC is shaky.

 

[SLUser11]

Actually, surgery IS inferior when it comes to placing IJ lines.
The reason why we are better is because we do them all the time, and frequently they are the only choice we have from our spot at the head of the table.
Anyway, when it comes to elective lines my line of choice is actually subclavian.
And maybe twice a year I find a reason to place a femoral line.

That's a big blanket statement. There are plenty of surgeons who use IJ as the preferential stick site for regular CVLs, and all of our tunneled lines go in the IJ, like hickmans, dialysis catheters, portacaths, etc.

Maybe you feel superior in your current practice environment, but I promise that your statements don't hold true on a national level. I have my own bias about who is better at placing lines, but I don't possess the same blind arrogance as some, and I know there are practitioners from several specialties with excellent line skills. It's based more on the individual than the specialty, in my opinion.

Either way, it's obvious you are resistant to ultrasound technology. We'll see how that works out in the long run.

Great post.


I'll add that the primary reason healthcare costs have gone up so much in recent decades has been new technology. Is it really in the best interest of patients to accept further substantial gadget-driven cost increases for some small, incremental, and dubious[1] improvement in safety? Where will it end?

Wow. Now ultrasound is "gadget-driven" technology that's hiking up healthcare costs and providing "dubious" safety improvements?

I think I'm done here. Nothing helpful or evidence-based is going to come out of this discussion.

 

[Planktonmd]

Actually I am not resistant at all to "ultrasound technology" but I don't endorse it as the only safe way or the standard of care.
And talking about arrogance, I would argue that a surgery resident is not qualified to tell us what the "standard of care" is.
As for surgeons ability to do IJ's, I did not say you can't do them but we do them better and differently, we mostly do high IJ access which virtually eliminates the risk of pneumo while you are usually taught to acces the IJ at a lower point between the the 2 heads of the SCM, very close to the lungs.
saying that you are better at IJ access to an anesthesiologist is similar to saying that you are better at intubation! it just makes no sense.

That's a big blanket statement. There are plenty of surgeons who use IJ as the preferential stick site for regular CVLs, and all of our tunneled lines go in the IJ, like hickmans, dialysis catheters, portacaths, etc.

Maybe you feel superior in your current practice environment, but I promise that your statements don't hold true on a national level. I have my own bias about who is better at placing lines, but I don't possess the same blind arrogance as some, and I know there are practitioners from several specialties with excellent line skills. It's based more on the individual than the specialty, in my opinion.
Either way, it's obvious you are resistant to ultrasound technology. We'll see how that works out in the long run.

 

[Mman]

Not true. The complication rate is relatively high. Complication rate has been shown on several occasions to be significantly lower with ultrasound guidance.

It's not just about litigation. It's about what's best for the patient as well.

That is just not true. Got any studies to link to support that idea?

(Keep in mind I use ultrasound all the time for lines and I like it and I try to help others learn how to use it)

The incidence of major morbidity and mortality from a line placement is exceedingly small. The incidence of minor complications is on the order of 1-10% depending on the site and technique and practitioner. But let's stick to IJ lines. Would you consider hitting the carotid with a 25 g seeker needle to be a complication? What's the outcome from it and how many hundreds of times would you have to hit the carotid to see a major hematoma requiring surgical exploration or a stroke?


Central lines are very safe and the incidence of serious complications is exceedingly low in trained hands, regardless of technique chosen.

I still haven't seen a good study looking at incidence of major morbidity and mortality as it relates to ultrasound or landmark based techniques. So while I feel ultrasound is the superior technique, the literature doesn't really support it at this point.

 

[SLUser11]

As for surgeons ability to do IJ's, I did not say you can't do them but we do them better and differently....

Okay.👍

I could retort, but it's just going to turn into an anesthesia vs. surgery thing with no good outcomes. You can do central lines however you want, especially since you're so good at them. I'm sorry I got your panties in a bunch by suggesting that your approach was outdated.

 

[SLUser11]

That is just not true. Got any studies to link to support that idea?

(Keep in mind I use ultrasound all the time for lines and I like it and I try to help others learn how to use it)

The incidence of major morbidity and mortality from a line placement is exceedingly small. The incidence of minor complications is on the order of 1-10% depending on the site and technique and practitioner. But let's stick to IJ lines. Would you consider hitting the carotid with a 25 g seeker needle to be a complication? What's the outcome from it and how many hundreds of times would you have to hit the carotid to see a major hematoma requiring surgical exploration or a stroke?


Central lines are very safe and the incidence of serious complications is exceedingly low in trained hands, regardless of technique chosen.

I still haven't seen a good study looking at incidence of major morbidity and mortality as it relates to ultrasound or landmark based techniques. So while I feel ultrasound is the superior technique, the literature doesn't really support it at this point.

You're changing the argument from "complication rate" to "major morbidity," so your point is sort of different.

 

[Planktonmd]

Okay.👍

I could retort, but it's just going to turn into an anesthesia vs. surgery thing with no good outcomes. You can do central lines however you want, especially since you're so good at them. I'm sorry I got your panties in a bunch by suggesting that your approach was outdated.

I am glad you realize that you were wrong 👍
There might be hope for you after all.

 

[dhb]

Okay.👍

I could retort, but it's just going to turn into an anesthesia vs. surgery thing with no good outcomes. You can do central lines however you want, especially since you're so good at them. I'm sorry I got your panties in a bunch by suggesting that your approach was outdated.

Hey why don't you show us some good data??
Care to comment on the training bias i mentioned??

If you want to lecture us on how to place central lines you could at least have something to back your claims.

 

[pgg]

Wow. Now ultrasound is "gadget-driven" technology that's hiking up healthcare costs and providing "dubious" safety improvements?

🙄

So, what's the "# needed to treat" with u/s to avoid one dilated carotid, given a non-resident placing an IJ using landmarks and transduction pre-dilation?

 

[JackADeli]

I will leave this link as a jump point for folks that may be interested in thinking about the topic and or doing a little more research:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1125610/

...The evidence for this technology is stronger than for many other medical devices in routine use—for example, pulse oximetry or capnography in anaesthesia, which lack definitive controlled studies on outcome...I question whether is it ethical for practitioners with ultrasound skills and access to devices to revert to blind techniques for controlled trials...

For the record, I will say there is sugestion that even small sticks in arteries can result in potential nidus for plaque generation. Also, many hematomas are not recognized. Because the patient does not stroke out during the primary admission does not mean you have not caused them harm with a blind stick into an artery. Yes, emergencies can off set the risk benefit ratios.... But, with such technologies available in most institutions, I think it is somewhat cavalier to think it benign.

I am also amazed at how frequently lines placed by other specialties are ignored after placement. Most OR lines I have seen, it is up to the surgery resident to follow-up on the chest XRay and/or adjust the line as needed. I have not seen anesthesia follow their line post operatively or even take note when said line becomes infected 4 days post-op. Maybe some do.... but, it is hard to discuss data of better performance if your procedure is not followed. Surgery sees the patient in the office after discharge. I don't know that anesthesia schedules a follow-up clinic to see end results of their lines..... I have spent many a mortality/morbidity conference presenting patients because of line sepsis... though line was not placed by surgery. We just "owned the patient".

 

[rsgillmd]

JackADeli, you can't just attribute line sepsis to the insertion time. I'm sure you know just as well as I do that it is both insertion and maintenance of the line.

I don't know about your location, but where I trained if the patient went to the ICU, the ICU team assured the "proper" placement of the line -- not that I ever had to pull one back because of the lines I placed were Cordises, with the exception of when I was in SICU. If a patient went to PACU we followed up on the CXR.

I think the article was in NEJM that listed the five things that have been proven to decrease risk of infection: hand washing, sterile prep and drape, chlorhexidene better than betadine, avoid the groin when possible, and take it out when you don't need it (implied with this is don't put it in if you don't need it). I don't know of any resident that didn't follow these rules at my program. In the cardiac cases, after the tube was in we would go wash our hands while the attending secured the tube, so we could then place the central line.

I'm not even going to get into the U/S vs blind. I feel comfortable with both, and have placed more blind than I have with U/S. If I have one available I'll use it, but I'm thankful I'm not dependent on it.

 

[JackADeli]

....you can't just attribute line sepsis to the insertion time. I'm sure you know just as well as I do that it is both insertion and maintenance of the line...

I am not just attributing sepsis to insertion. What I am saying is that hospital complications surrounding an operative patient are often attributed to the surgeon even if said surgeon did not place the line. And, yes, poor insertion technique can be a major contributing factor. However, it may not be acknowledged or even recognized and the line is forgotten by the anesthesia physician that placed it.

...I don't know about your location, but where I trained if the patient went to the ICU, the ICU team assured the "proper" placement of the line -- not that I ever had to pull one back because of the lines I placed were Cordises, with the exception of when I was in SICU. If a patient went to PACU we followed up on the CXR...

Everywhere I have trained or practice, with limited exception, a surgeon followed up on their lines even if the patient went to the ICU. However, it was also expected that the surgeon follow up on the lines placed by anesthesia. If you place a line, and it is followed up by ICU or others, how are you keeping track of your complications with malposition/etc? I have known very very few anesthesia residents that felt the line after leaving the OR was sufficient to be trouibed and follow up. heck, often the line may be placed by one physician that has long since gone home by the time the patient left the OR.

...I'm not even going to get into the U/S vs blind. I feel comfortable with both, and have placed more blind than I have with U/S. If I have one available I'll use it, but I'm thankful I'm not dependent on it.

What I don't get (and may not apply to you) is the resistance to the technology... I like the quote from the Anesthesiologist I posted earlier:

...The evidence for this technology is stronger than for many other medical devices in routine use—for example, pulse oximetry or capnography in anaesthesia, which lack definitive controlled studies on outcome...I question whether is it ethical for practitioners with ultrasound skills and access to devices to revert to blind techniques for controlled trials...

I think it is quite easy for people to ignore tech as potentially beneficial if they often don't follow-up their procedures or have consistent tracking of outcomes beyond the immediate case. I have seen this with cardiology too. At some institutions, Intervent cards boasts a remarkably low complication rate for their caths.... because the patient shows up to the vascular surgeons office with the femoral pseudoaneurysms and or femoral thrombosis, etc.... Or, patient leaves cath lab and gets admitted to a surgeons service....

 

[proman]

And, yes, poor insertion technique can be a major contributing factor. However, it may not be acknowledged or even recognized and the line is forgotten by the anesthesia physician that placed it.

I agree with you. I look the post-op films of all of my lines and intubations. I don't know of anyone else who does, but it's good practice. It helps the patient on the very few times when there's something that needs to be addressed, but it also helps me know how my lines/tubes are. It should be done by more people.

I think it's pointless to argue who does better lines. Chances are it's the interventional radiologist who puts in 10 tunneled lines a day or the PA who is the line service. A general surgery resident taught me how to do central lines (subclavian), and she taught me well enough that I'm comfortable doing them. I've worked with private practice anesthesiologists who put 3-4 lines in a day, every day for 10-15 years or longer. Their performance likely wouldn't improve much with ultrasound (especially since they aren't as comfortable with the technique). But they still find the carotid a few times a month. I doubt a 22ga stick will do much but an 18ga certainly may (these guys don't consistently use finders).

 

[JackADeli]

...I think it's pointless to argue who does better lines...

I agree

...private practice anesthesiologists who put 3-4 lines in a day, every day for 10-15 years or longer...they still find the carotid a few times a month. I doubt a 22ga stick will do much but an 18ga certainly may (these guys don't consistently use finders).

That's troubling. Why would one just doubt that? Presumably most of these patients are less then healthy if getting central lines. There are plenty of occasions in which injury to an artery results in intra-mural hematomas and/or dissections. These are not likely to be seen at the time...unless your looking with some technology. These occult vascular injuries will likely demonstrate sequelae in the future.... but not known to these master artery finders that do not follow up. There are plenty of reported phrenic and recurrent nerve injuries in the literature. These too are often identified days if not longer after the line placement.

I understand the logistics of having an anesthesia clinic just to follow up your minor procedure is silly. But, it is disingenuous to assume ones artery stick was benign but not have any follow-up or imaging to show otherwise. It seems the logic is.... "line worked so no problem" or "patient made it out of the hospital so no problem".... Procedural outcomes and complications are actually more accurately assessed over longer periods of time then anesthesia attention span to their procedure.

For a physician to be skilled with the procedure to be so handicapped as to not be able to develop comfort with new tech that could improve safety is a hollow arguement. Hell, prep out the neck, use your palpation techniques, then use U/S prior to stick to confirm target.:

...The evidence for this technology is stronger than for many other medical devices in routine use—for example, pulse oximetry or capnography in anaesthesia, which lack definitive controlled studies on outcome...I question whether is it ethical for practitioners with ultrasound skills and access to devices to revert to blind techniques for controlled trials...

 

[Planktonmd]

What's up with all these surgery residents (possibly interns) that feel that they have what it takes to come here and lecture us about line insertion???
Here is the bottom line:
If you are a surgery resident and need to cannulate the IJ I think you must use ultrasound always because the way you are taught to do this procedure is unfortunately terrible.
The way most of us (anesthesiologists) access the IJ is different and safer, we don't go low in the neck as you are told to do and we keep our fingers on the carotid at all times which makes it very unlikely that the carotid is hit.
As for those complaining that they have to follow the lines post-op and we don't, I have to say that I feel for you but if you want to be a surgeon then it is your job to follow everything (lines, drains, catheters, bowel movements...) it is your job! Why do you want us to do it for you?

 

[lucy07]

I trained at a pretty good ivy league program that would not teach us how to do lines or regional blocks without U/S. My community hospital's U/S is currently out being serviced with no anticipated return date. I am now really nervous about learning how to do interscalene and supraclavicular blocks on the fly. I haven't put that many central lines in since residency, but it would potentially be a bit of a thrash if a ruptured AAA or some other trauma came in and I had to put a cordis in a super fat, no-neck patient.

 

[Planktonmd]

I trained at a pretty good ivy league program that would not teach us how to do lines or regional blocks without U/S. My community hospital's U/S is currently out being serviced with no anticipated return date. I am now really nervous about learning how to do interscalene and supraclavicular blocks on the fly. I haven't put that many central lines in since residency, but it would potentially be a bit of a thrash if a ruptured AAA or some other trauma came in and I had to put a cordis in a super fat, no-neck patient.

Thank you!
This was the point of this whole thread before surgery interns decided to come and teach us line insertion!
On that note, if I were you I would not attempt to do a supraclavicular block without ultrasound if you haven't done a few before, stick with interscalene and axillary until you get your Ultrasound back.
As for lines this might be your opportunity to do some subclavians.

 

[IN2B8R]

What's up with all these surgery residents (possibly interns) that feel that they have what it takes to come here and lecture us about line insertion???
Here is the bottom line:
If you are a surgery resident and need to cannulate the IJ I think you must use ultrasound always because the way you are taught to do this procedure is unfortunately terrible.
The way most of us (anesthesiologists) access the IJ is different and safer, we don't go low in the neck as you are told to do and we keep our fingers on the carotid at all times which makes it very unlikely that the carotid is hit.
As for those complaining that they have to follow the lines post-op and we don't, I have to say that I feel for you but if you want to be a surgeon then it is your job to follow everything (lines, drains, catheters, bowel movements...) it is your job! Why do you want us to do it for you?

Call me a nut, but here is what I say to such people in the hospital who always think that they can do my job better than me: "I don't always drink beer, but when I do, I drink Dos XX." Stay thirsty my friends! My aim is to actually look like that guy with my white coat having the Dos XX logo on it. No surgical cap either, just the facial hair and the cool hair-do...

 

[Winged Scapula]

What's up with all these surgery residents (possibly interns) that feel that they have what it takes to come here and lecture us about line insertion???

Thank you!
This was the point of this whole thread before surgery interns decided to come and teach us line insertion!

I'm not going to get into the argument about who is better (because its a pointless argument independent of specialty) or whether US is needed for central lines (I trained in an era where we did them without US, but I use US every day in the office for biopsies) but to verify (because I know IRL):

these "surgery interns" are a Chief general surgery resident and a fellowship trained general surgery subspecialty attending in a specialty with lots of critical care experience. They know what they are talking about from a surgical standpoint.

 

[JackADeli]

What's up with all these surgery residents (possibly interns) that feel that they have what it takes to come here and lecture us about line insertion????...

Not sure who you are referring to.... I haven't taught you how to insert any lines.... I have, however spent seven years teaching numerous anesthesia residents how to safely place lines, at the request of anesthesia attendings.

...

...worked with private practice anesthesiologists who put 3-4 lines in a day, every day for 10-15 years or longer. ...they still find the carotid a few times a month...

...If you are a surgery resident and need to cannulate the IJ I think you must use ultrasound always because the way you are taught to do this procedure is unfortunately terrible.
The way most of us (anesthesiologists) access the IJ is different and safer, we don't go low in the neck as you are told to do and we keep our fingers on the carotid at all times which makes it very unlikely that the carotid is hit...

Interesting theory. The two statements don't really jive.

...As for those complaining that they have to follow the lines post-op and we don't, I have to say that I feel for you but if you want to be a surgeon then it is your job to follow everything (lines, drains, catheters, bowel movements...) it is your job! Why do you want us to do it for you?

Classic passive aggressive/reverse psych residency technique.... However, it is not so much complaining as it is an observation. You can not really claim technical success and low complications if you haven't actually followed the patient or made a reasonable attempt at collecting the data. Not only is 4 day outcomes not followed, but, I have not seen much documentation or recording of immediate data (i.e. arterial stick). This observation is not necessarily unique to anesthesia per se.... that is, you can not really proclaim low morbidity and/or good outcomes if your patients are "lost to follow-up".

PS: surgery texts and critical care teaching we got in surgery had us hold the carotid... it's not like anesthesia discovered the wheel here....

 

[Planktonmd]

I'm not going to get into the argument about who is better (because its a pointless argument independent of specialty) or whether US is needed for central lines (I trained in an era where we did them without US, but I use US every day in the office for biopsies) but to verify (because I know IRL):

these "surgery interns" are a Chief general surgery resident and a fellowship trained general surgery subspecialty attending in a specialty with lots of critical care experience. They know what they are talking about from a surgical standpoint.

And I am a board certified anesthesiologist with some years of experience and many of the people here are very experienced in the field of anesthesiology, so could that mean that we also know what we are talking about and we don't need your chief resident and attending to come here swinging and accusing us of practicing bad medicine?
When did surgeons start defining the "standard of care" for the practice of anesthesia?

 

[Planktonmd]

Not sure who you are referring to.... I haven't taught you how to insert any lines.... I have, however spent seven years teaching numerous anesthesia residents how to safely place lines, at the request of anesthesia attendings.

😀
So, some anesthesia department asked you to teach their residents how to insert lines and this makes you an authority on the subject?
Your opinion is simply your opinion and before you come here accusing people of being sub par physicians why don't you provide literature showing that in experienced hands ultrasound actually decreases IJ complications???
Until you provide that all you say is simply a biased bitter opinion.

 

[bullard]

1. I am really glad that I've been training at a program that teaches us how to put in IJs without ultrasound (I am shocked that there are programs out there that are not doing so). If the ultrasound is busted or just not available in the future (i.e. small hospital), I'll be OK.

2. That being said, if ultrasound is readily available to me as an attending, I'm gonna use it every time. If I take more than a pass or two with the finder, I think the time taken to sterilely prep the ultrasound probe is worth it.

3. The time to prep the probe is little compared to the time it takes to walk out of the room to wash your hands and walk back in and do a full sterile drape and all the stuff that Pronovost has researched that prevents central line-associated bloodstream infections. There are tasks in anesthesia that we can rush through (like the routine nonsterile prep for arterial lines, IVs, and single-shot nerve blocks), but I don't think central lines are one of those...

4. I'm comfortable placing subclavians (usually quicker than IJs!) but I see no good reason to place one if the IJ is available, and I do not plan on placing them as an attending for the reason "oh, it's more comfortable for the patient long-term." I'd rather have a bunch of uncomfortable patients than comfy ones plus one pneumothorax.

 

[SLUser11]

And I am a board certified anesthesiologist with some years of experience and many of the people here are very experienced in the field of anesthesiology, so could that mean that we also know what we are talking about and we don't need your chief resident and attending to come here swinging and accusing us of practicing bad medicine?
When did surgeons start defining the "standard of care" for the practice of anesthesia?

Oh, boy...look what I've done.

I'm pretty sure the "intern" comments were a bait so you could sound off on how awesome and experienced you are. Either way, this argument is going nowhere.

I take responsibility for my part in the heated discussion. I called US-guidance the standard of care, which got everyone's balls in a twist. I concede that US-guidance is not standard of care (yet). I stick by my comment that it's just a really good idea that has an orgy of evidence behind it.

Nobody is coming in here telling you how to do your job. However, I don't think non-anesthesia folk should be intimidated to post in here to advance topics of discussion. You guys have a private forum you can go to if you don't like opinions from other specialties.

 

[Planktonmd]

Nobody is coming in here telling you how to do your job. However, I don't think non-anesthesia folk should be intimidated to post in here to advance topics of discussion. You guys have a private forum you can go to if you don't like opinions from other specialties.

You did not post to "advance topics of discussion" you posted to tell people that if they don't agree with you they are practicing dangerous medicine and breaking your "standard of care".
You are welcome to participate in the clinical discussions but I don't remember seeing any posts from you that did not address "standards of care".

 

[JackADeli]

...we don't need your chief resident and attending to come here swinging and accusing us of practicing bad medicine?
When did surgeons start defining the "standard of care" for the practice of anesthesia?

I appreciate the defensiveness. I am not sure who has accused you of bad medicine. I have made some observations though.... Of note, it was not I that commented on experienced anesthesiologists hitting the carotid a few times a month. Nor, was it I that declared surgery residents are taught unsafe or imprioper technique. I definately did not say surgery defined the standard of care for anesthesia. again, I appreciate your defensiveness. What I did do was make some observations. I have also reviewed anesthesia commentary. If you note, the link I posted and comment I believe comes from individuals in the anesthesia community.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1125610/

...The evidence for this technology is stronger than for many other medical devices in routine use—for example, pulse oximetry or capnography in anaesthesia, which lack definitive controlled studies on outcome...I question whether is it ethical for practitioners with ultrasound skills and access to devices to revert to blind techniques for controlled trials...

So, some anesthesia department asked you to teach their residents how to insert lines and this makes you an authority on the subject?...

My training and experience make me an expert in certain components of my job as I am sure it makes you an expert in certain components of your job. My point in my teaching... was simply to respond to your declaration that surgical residents are taught inferiorly and/or wrong in the eyes of anesthesia. It was not a statement to me being an expert.

...Your opinion is simply your opinion and before you come here accusing people of being sub par physicians why don't you provide literature showing that in experienced hands ultrasound actually decreases IJ complications??? Until you provide that all you say is simply a biased bitter opinion.

I agree my opinion is opinion. Not sure how it is bitter? I have not declared you or anesthesia in general improperly taught.... (I think that was more up your alley). I have not accused you or anyone of being sub-par physicians (again, more up your alley). I have not said teach only u/s technique. In fact, I am not sure anyone has stated that. I do, IMHO believe anyone that will be placing elective central lines needs to be competent with their patients anatomy and u/s technique. As for providing literature, I again reference you back to folks in your own "community"

...The evidence for this technology is stronger than for many other medical devices in routine use—for example, pulse oximetry or capnography in anaesthesia, which lack definitive controlled studies on outcome...I question whether is it ethical for practitioners with ultrasound skills and access to devices to revert to blind techniques for controlled trials...

Can you provide lieterary data on everything in medicine? Honestly, I think much in medicine is difficult from an ethics standpoint to randomize and control studies. Not sure your issue or need to just spar and fight. However, the bitterness is not coming from me..... It really seems as if you are walking around and peeing in the corners to mark out your turf.

 

[Planktonmd]

too long to quote

I am not going to waste anymore time arguing with you but you are wrong on almost every thing you said:
You came here accusing and criticizing.
You did not provide an opinion but rather a teaching and almost a warning as did the other guy.
This in my opinion is arrogant, bitter and motivated by things other than just your wish to share clinical opinions.
Maybe you are bitter about your compensation? work hours? our compensation? what is it?

 

[JackADeli]

I am not going to waste anymore time arguing with you but you are wrong on almost every thing you said:
You came here accusing and criticizing.
You did not provide an opinion but rather a teaching and almost a warning as did the other guy.
This in my opinion is arrogant, bitter and motivated by things other than just your wish to share clinical opinions.
Maybe you are bitter about your compensation? work hours? our compensation? what is it?

👎Ah, sure....OK, it was you that declared me providing an opinion... You have thrown the accusations and commentary of the quality of specialty teaching.... I think you are correct, it is a waste of time to try and discuss with someone more intent on puffing themselves up such as yourself....

 

[Winged Scapula]

And I am a board certified anesthesiologist with some years of experience and many of the people here are very experienced in the field of anesthesiology, so could that mean that we also know what we are talking about and we don't need your chief resident and attending to come here swinging and accusing us of practicing bad medicine?
When did surgeons start defining the "standard of care" for the practice of anesthesia?

I can understand that this is a sensitive issue with flaring tempers but I'm not sure why you are "yelling" at me. 😕

I simply pointed out that your assumption that these were surgical interns (who presumably knew little about the practice of surgery, let alone anesthesia) was in fact, incorrect. It has nothing to do with whether or not you or they know what they're talking about, or who sets standard of care.

I WILL remind the surgery residents and surgeons here that going into another subspecialty forum is a difficult line to toe. It can easily be seen as criticism or trolling. You can disagree without insisting that anesthesiologists are doing things incorrectly or violating SOC (which of course US isn't yet). Just as we don't tolerate <insert specialty X> coming into the Surgery forum to complain about us, its not fair to this forum and its denizens to come in here and criticize in a way that is obviously anger provoking. Interspecialty discussion should be encouraged in a civil and professional manner, but it appears that this is not possible, at least on this topic, for many users. As Plankton notes, most *are* welcome to post in this forum but there are topics or approaches which are less well received.

Since anesthesiologists and surgeons are more alike and not, and practice symbiotically, it would behoove everyone if they refrained from making personal assumptions about each other when trying to respond to posts.

 

[Narcotized]

Hi everyone, when you guys put in your lines, do you use ultrasound, or go purely by landmarks? As an intern in the unit I've only done them with ultrasound. I recently asked this to one of the anesthesia residents at the hospital I work in, who said their attendings prefer they always use ultrasound. Is this the norm?

I'm going to start off by saying Narc LOVES the ultrasound. I feel very comfortable doing regional and central lines without it for the vast majority of procedures, but anybody not extremely competent with the ultrasound and making up excuses why it's not a necessary skill needs to get over it and sell their horse and buggy and buy one of those new-fangled automobiles.

I can't tell you how many old timers (who sadly to say were sometimes younger than me 🙁 would make up every pathetic excuse in the book why they were going to keep slaying the patients neck and not use that "piece of crap." I don't care if you are Stoelting himself, you have had trouble with somebody's IJ and DEFINITELY somebody's plexus, and you are basically committing assaulting by blindly stabbing away because you are too proud and too stubborn to get with the new millenium.

 

[Narcotized]

I'm frequently amazed how... often they lie practically on top of the carotid

Check this out. When I use the ultrasound, the IJ is NEVER on top of the Carotid. NEVER. Not today, not tomorrow, not NEVER (yeah yeah, double negative, whatever).

One word: ORIENTATION.

If I said go take a random x-ray of that guy's right lung and you took it from the side, would you say "I can't, it's lying on top of the left lung." No you would reorient and take the picture from the front (Ahhhh, some of your light bulbs went on... not everyone's yet).

So, when you place the probe and say, "crap, the IJ's on top of the Carotid," then REORIENT. Slide the probe to one side still aiming back at the IJ, indent in the neck a bit if you have to to maintain probe conduction, and WahLah!, what was on top of each other is now side by side (just like a lateral vs an AP chest). Hopefully more lightbulbs flickered.

The IJ often collapses before the needle pierces and therefore goes through the IJ. With the Ultrasound you NEVER need to stick an IJ with the Carotid right behind it that is screaming "Hit me, Hit me!!"

 

[Narcotized]

The absolutely biggest pearl to ultrasound (should even make Jet's list) is holding the damn thing right. Typically, what feels natural is to aim the needle at a lowish angle to the skin and hold the probe more upright to the skin, almost 90 degrees to the needle. Congratulations, you have just now become extremely dangerous. Your needle has crossed through the plane of the ultrasound and you have no idea where the tip is (you know, the pointy part that causes injury). You are even more dangerous than someone without ultrasound because you now have a false sense of security that you are safe to jab away.

You absolutely must hold the needle and probe as close to parallel as possible. And these are reasons exactly why you must become skillful with practice on straightforward sticks and with proper tutelage before you try to use it in an emergency difficult situation.