Central Lines

[DrQuinn]

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so this month since its only the second year of my program, all the July lectures are basically beginner/intro stuff for the interns to catch up to speed with each other. We had a lecture on EM procedures and of course Central Line Placement came up.

Do any of you guys use that blue syringe in the kits that you can thread the wire through? I always just use the large needle, find the vein, pull back for flow, take off the syringe to see blood return and to check for venous/arterial flow, then guide my wire. I think I tried that blue syringe once, didn't like it. I asked my colleagues and it was like a 6 to 2 (syringe to not syringe). They say it was easier for them as when they take off the syringe it often loses its place in the lumen. Now, I may be "cool hands" McQuinn but I never really have that problem.

So I'm debating if I should try to use that blue syringe more, but I just wanted to get a feel out there for what my colleagues are doing (attending vs. resident vs student).

In fact, I think I"ll make this a poll.

Q, DO

 

[Sessamoid]

Do any of you guys use that blue syringe in the kits that you can thread the wire through?

I've used them a few times, and they're okay. I don't generally lose the lumen once I'm in, but it happens from time to time. The kits at the hospitals where I work now don't have the blue syringes, so the point is moot for me.

 

[Seaglass]

I LOVE the blue syringes. I can tell exactly where I am and how much resistance there is. It's like smooth going --> resistance as you go through the needle --> easy again as you get in.

Without it it's like -->needle feel --> no change or wire stops threading, but why?

C

 

[docB]

I don't. I don't think they're bad or anything, I just am used to doing it with a 5cc regular. Just make sure you don't jam the needle on too tight.

 

[GCS:3]

Do any of you guys use that blue syringe in the kits that you can thread the wire through?

I never did, and in our intern lectures they discouraged it because you can't tell if you have pulsatile arterial flow. Guess I'll stay with my old technique. 😀

 

[DrQuinn]

I never did, and in our intern lectures they discouraged it because you can't tell if you have pulsatile arterial flow. Guess I'll stay with my old technique. 😀

I completely agree. I tried it once on an HIV+ female just for the heck of it, not that it would have done anything different, but I didn't like it, and was unsuccessful with that blue syringe (wonder if there's a technical name for it). I argued to my two attendings (one a grad from Temple, one a grad from Maricopa) that I like ot be able to see venous vs arterial flow from the needle, but they both said you can see the color of the blood in the syringe.

I think I will try it next month. I'm in the ED next month (CCU this month) so I will have plenty of chances to try it out.

Q, DO

 

[droliver]

[QUOTE I argued to my two attendings (one a grad from Temple, one a grad from Maricopa) that I like ot be able to see venous vs arterial flow from the needle, but they both said you can see the color of the blood in the syringe.
[/QUOTE]

While in general this is true you frequently see venous blood that's pretty red in people on supplemental oxygen or the vent, & depending upon someone's CVP you can occasionally even get pulsatile-looking flow from a vein (eg. cirrhotics & right sided heart failure).

If you need better evidence of correct placement you can get an ABG or more commonly (if you're in an ICU) hook it up to a CVP line to look @ the waveform.

BTW I never liked the blue-syringe. I also liked to see what the character of the blood & flow were like which you have more trouble seeing with the blue syringe. They also seem to stick more when you try to change them off the needle hub & I think you give up some of the control you have of the needle tip (your lever length is now several times longer needle+blue syringe then just the needle)

 

[Seaglass]

Well, I guess to each their own:

There is a name for it, but I forget what it is.

The syringe is catheter tip so IMHO it comes off much more easily than the leuer lock type

The lever is only as long as where you are holding it at. Once it's in I hold it down at the needle.

 

[southerndoc]

I don't. I don't think they're bad or anything, I just am used to doing it with a 5cc regular. Just make sure you don't jam the needle on too tight.

Yea, that always sucks. I did that once as a fourth year during a critical care rotation. I ended up pulling the needle out of the vein because I had to use so much force to get the needle off that I wasn't paying attention -- ended up pulling the needle back while twisting it.

Now I check to make sure the needle is on, but not too snug.

 

[drpcb]

Only time I ever dilated a femoral artery was with the infamous blue syringe. Kind of a drag. I still use it, but it really is hard to tell the difference between arterial and venous pulsations through that little hole. Don't count on color- often the patient is too sick; bright red means you're in the wrong place, but dark red doesn't always mean the vein. If its dark I remove the syringe and reassess.

 

[Nof55]

I think you all are talking about the angio cath that is attached to the syringe. I agree with the reply above. I usually switch out to the other syringe but if I am at all uncertain about the blood flow being pusatile or it is a ventilated patient and the blood looks a little red, I'll thread the angio cath over my wire and hook it up to the CVP. You can always recover from sticking the artery, not so easily from dilating it.

Nof55

 

[spyderdoc]

I'm old fashioned I guess. I prefer the 5cc syringe. As long as you keep the needle rock solid while removing the syringe, you should not be having any problems coming out of the lumen...Of course in the ER things can be suboptimal, like the patient moving, or during compressions, but hey, suboptimal conditions are what we are used to and expect, right?

 

[docB]

Is anyone ever really sure where the central line is in a code. All the blood is dark. The venous and the arterial sides pulse about the same with compressions. You're short on time and can't send for a gas even if the gas would help that much. I don't know but I'll bet I've cathed my share of arteries during codes.

 

[spyderdoc]

Is anyone ever really sure where the central line is in a code. All the blood is dark. The venous and the arterial sides pulse about the same with compressions. You're short on time and can't send for a gas even if the gas would help that much. I don't know but I'll bet I've cathed my share of arteries during codes.

Ditto. If any of these codes actually survive, I'd bet there would probably quite a few foot amputees running aroung from having necrosed many a foot by sending epi to the periphery via the femoral artery.... 😱

 

[docB]

Ditto. If any of these codes actually survive, I'd bet there would probably quite a few foot amputees running aroung from having necrosed many a foot by sending epi to the periphery via the femoral artery.... 😱

Or strokes from epi, atropine, bicarb, dopa, leave 'em dead and the kitchen sink all via my carotid artery line. 🙄

 

[droliver]

Is anyone ever really sure where the central line is in a code. All the blood is dark. The venous and the arterial sides pulse about the same with compressions. You're short on time and can't send for a gas even if the gas would help that much. I don't know but I'll bet I've cathed my share of arteries during codes.

This has actually been studied prospectively (believe it or not) looking @ arterial placement of catheters during codes. Femoral approaches had the highest incidence of arterial line placements I believe

 

[spyderdoc]

This has actually been studied prospectively (believe it or not) looking @ arterial placement of catheters during codes. Femoral approaches had the highest incidence of arterial line placements I believe

And then there was ULTRASOUND! Yipee. I can place a line, guaranteed into a vein in no time with the handy dandy vascular probe. In a code, one is not concerned so much with sterile technique, so just slap the probe on and there is that nice plump femoral (or jugular) vein.
Of course avaiability of the machine is key. I usually tell the tech to get the machine in the room before the code arrives, figuring I am going to use it anyhow to look for AAA and tamponade...Might as well use it to throw in a line too....

 

[Seaglass]

FYI: it's a Raulerson syringe.

 

[DrQuinn]

FYI: it's a Raulerson syringe.

Nice! Good pull. Let's see if I can recall that when I pull out the kit next month.

Q