Central lines

[Bougie]

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Ok, here is my standard method of starting an IJ CVC. Trendelenberg, neck turned slightly to contralateral side, at level of cricoid feel carotid pulse, 1cm lateral to pulse and/or at triangle formed by 2 heads of SCM and clavicle, finder needle at 45degree angle aiming for ipsilateral nipple.

Despite this textbook approach, my success rate for IJs sucks. Anyone have additional words of wisdom? Noticed this wasn't on the procedures thread.

 

[UTSouthwestern]

Ok, here is my standard method of starting an IJ CVC. Trendelenberg, neck turned slightly to contralateral side, at level of cricoid feel carotid pulse, 1cm lateral to pulse and/or at triangle formed by 2 heads of SCM and clavicle, finder needle at 45degree angle aiming for ipsilateral nipple.

Despite this textbook approach, my success rate for IJs sucks. Anyone have additional words of wisdom? Noticed this wasn't on the procedures thread.

Are you getting blood with your finder needle or just not able to cannulate successfully? One thing that tends to hinder pople is putting too much pressure on the carotid while they use the finder needle, which can occlude the IJ. I also see a lot of inexperienced people that place IJ's, take too superficial an angle when approaching the IJ with the finder. The classic approach is the middle approach that you describe. If you are seeing a lot of obese patients, I would use the low anterior approach. I would only use the posterior approach when all else fails and you can't place a subclavian in that particular patient.

 

[m32b]

remember, the ij is superficial...don't go too deep...that bit of advice boosted my success rate tremendously!

 

[ReefTiger]

I have personally had a difficult time with IJs myself, as I had not had many opportunities to attempt them.

I finally found a way that works easy for me. I don't know the name, but I find it much easier than the approach you described.

First I only slightly turn the head to the left. (I am right handed). I then take my left hand index finger and place it in the patient's sternal notch. My middle finger and ring finger are placed next to my index finger and all three fingers are pointing cephalad. I then pivot from my ring finger 90 degrees until my index finger makes contact with the neck. Your fingers should then all be pointing to the right side. You should feel the SCM muscle body just medial to your index finger. Try it on yourself and you'll see what I mean.

From there you just go in with the seeker just lateral to your finger towards the ipsilateral nipple. No carotid needs to be palpated. Your entry angle also does not need to be very steep. The IJ is very superficial here in my experience.

My success rate and quickness has increased exponentially with this technique. Hope it helps you👍

 

[lvspro]

2 thins in the previous posts have helped my success rate.
1. The vessel is pretty superficial. Even on obese pt's, a few(2-4) centimeters is all you need.
2. #1 only holds true if your angle is right. ~45 seems to work for me.

 

[militarymd]

1) feel for the carotid pulse

2) take your palpating finger OFF the neck

3) AIM DIRECTLY AT the carotid.

Use an ultrasound a few times...you will see that the IJ lies directly over the carotid....if you're aiming 1 cm lateral....you're aiming at the wrong place.

 

[Noyac]

Some good points here. All I will add is that the IJ is occluded easily so if you turn the head much it will occlude. I don't turn the head at all usually. Personally, I feel the carotid pulse and with my hand still on the pulse I advance just at the tip of my finger which is still on the pulse. I am aiming directly next to the carotid. I don't advance more than 2-3 cm. I pull back slowly if no flash of blood returns with insertion. Frequently, the tension of the needle while advancing will occlude the jugular and pass through the vessels anterior and posterior walls at the same time. Then pulling back will separate them enough for blood flow. I also never use a finder needle. Don't use the big SC needle, use the needle with the catheter on it. Slide the catheter down and remove the needle. No pulsatile Flow? Your golden.

 

[dhb]

I would only use the posterior approach when all else fails and you can't place a subclavian in that particular patient.

Why is that? i've only used the posterior approach until now (n=30 +-)

What tricks can you use when you encounter resistance when advancing the wire?

 

[MTGas2B]

Why is that? i've only used the posterior approach until now (n=30 +-)

What tricks can you use when you encounter resistance when advancing the wire?

This is one I've run into a lot lately. I use the ultrasound most of the time, I've had a bunch of attempts and central line placement, I verify with ultrasound, go to place the wire, 5 cm or so then stuck. My attending tries, no luck. Once, ended up going to a sub clavian, second time, my attending forced it and when we got the chest film the line had crossed over to the L subclavian.

 

[The_Sensei]

Why is that? i've only used the posterior approach until now (n=30 +-)

What tricks can you use when you encounter resistance when advancing the wire?

Start over. You are not where you need to be.

 

[Darwin]

What to do when...

on A-lines - good flash, thread the wire fine, advance the catheter, then pull out the wire and no flow.

So I back out the catheter about 1cm and get good flow...question is, can I re-insert the wire to try and re-thread?

 

[Planktonmd]

What to do when...

on A-lines - good flash, thread the wire fine, advance the catheter, then pull out the wire and no flow.

So I back out the catheter about 1cm and get good flow...question is, can I re-insert the wire to try and re-thread?

Learn doing them without a wire!
I use the good old # 20 Angiocath, just remember to advance your needle a bit after you see the flash and before you thread the catheter.

 

[Noyac]

Start over. You are not where you need to be.

Absolutely!

 

[Noyac]

What to do when...

on A-lines - good flash, thread the wire fine, advance the catheter, then pull out the wire and no flow.

So I back out the catheter about 1cm and get good flow...question is, can I re-insert the wire to try and re-thread?

Absolutely!

 

[Bougie]

Read the "Procedures Tips and Knowledge Pearls" sticky which gives excellent info on art lines.

 

[VentdependenT]

there is a good section in pearls.

More on A-LINES

I now go about 2mm MEDIALLY to where I feel pulse and just slam the arrow in. Even if I don't see a flash I pull the needle out, thread the wire out, and slowly withdrawl the catheter. Works MOST OF THE TIME. If you get good at the this "through and through" technique it'll save your ass. You can do TONS of passes very fast and hit what you need to. I do use the "old fashioned" way sometimes.

Recently I have started using U/S guidance for BRACHIAL ALINES. sometimes you get these edematous folks or big chunkies and radial/ulnar/pedal just not feasable. You can go FEMORAL if the line wont be in for a long period of time. However in the Unit, where I did this, that just wasn't the case. Worked like a charm using the femoral aline kit.

There is a concern with no collateral flow in the brachial line and if your patient is hypercoaguable, or you are f&$ken around there too long, you could thrombose/cause aneurysm in the only arterial supply to the forearm. I did 5 of em and they worked great. never positional, always drew back (for days and days), and were easy to visualize for infection purposes.

Put in an ulnar aline in the unit with ultra sound as well. Guy had been stuck about a zillion times on the floors during a code.

 

[dhb]

Start over. You are not where you need to be.

Actually what i meant was when you are in the vein: you have good flow of blood on aspiration but when you advance the wire it gets to the 10cm mark usually and you encounter resistance there. This usually happens in dehydrated patients
Last time it happened the attending took a 10cc syringe and injected 20cc of saline to "open up" the vein and was the able to thread the wire after that...