Central Lines

[southerndoc]

There was a post that caught my eye in the radiology/orthopod topic in the general residency forum. It mentioned a radiologist who read a central line as being placed in the subclavian artery. The woman died, which from the post implied that she died from the result of the misplaced line.

I've been told that any central line that's placed into an artery should have a vascular surgery consult. Some of the old guys argue just pull it.

My question is this...

What's the general census on what to do with arterial sticks in the subclavian artery? What about the carotid?

To quote one of the actors of Saturday Night Live's Coffee "Tawk" skit: Talk amongst yourselves.

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[tussy]

I've seen this happen several times and i've never consulted vascular surgery. We simply pulled the line (after correcting and coagulopathy), applied direct pressure for 20 minutes, then check distal pulses q30min for 2 hours, then q1h for the next 12 hours. I've never seen a problem although it can happen.

I did see someone lose a leg after a femeral art line though - the vessel thrombosed and the whole leg became ischemic - got a AK amp.

 

[Winged Scapula]

As a general rule here, we do just as tussy does, but we NOTIFY Vascular Surgery in CASE there's a problem (ie, a "heads-up") but don't formally consult them.

I've also seen the AK s/p femoral line thrombosis happen to a close friend of mine (the resident putting it in, not the patient).

 

[Skylizard]

Originally posted by Geek Medic
...It mentioned a radiologist who read a central line as being placed in the subclavian artery....any central line that's placed into an artery should have a vascular surgery consult...What's the general census on what to do with arterial sticks in the subclavian artery?

I will quote some Paul Marino:

"...The incidence of bleeding is no different in the presence or absence of a coagulopathy(26); that is, the presence of a coagulation disorder is not a contraindication to subclavian vein cannulation..."

While I can not find the source, I was also taught that trying to hold pressure after puncturing the subclavian artery is futile. I will keep looking for the source on that one... I am pretty sure it was Marino too.

Originally posted by Geek Medic
What about the carotid?

Paul Marino:

"...When the carotid artery has been punctured, no further attempts should be made on either side, because puncture of both arteries can have serious consequences....If the carotid artery has been punctured with a probing needle, the needle should be removed and pressure applied to the site for at least 5 minutes (10 minutes is recommended for patients with coagulopathy). No further attempts should be made to cannulate the IJ vein on either side, to avoid puncture of both carotids. If the carotid artery has been inadvertently cannulated, the catheter should not be removed, as this could provoke serious hemorrhage. In this situation, a vascular surgeon should be consulted immediately."

 

[Skylizard]

Originally posted by Kimberli Cox
...I've also seen the AK s/p femoral line thrombosis happen to a close friend of mine (the resident putting it in, not the patient).

I think I saw the same patient

 

[womansurg]

In my experiences (I've personally placed about 160 CVCs and supervised placement of many more) I've seen - and done myself on a couple of occasions - subclavian artery puncture WITHOUT placement of catheter. Never seen a complication from this.

My classmate has placed three separate subclavian artery lines by accident, and these 3 cases constitute the only ones I've ever seen. Each time removal of the catheter, upright positioning, pressure as well as you are able, all worked fine. No one talked to vascular surg.

For IJs, I always use a 'seeker needle' which is a 22 gauge needle, to find the vein prior to accessing with my cook needle. I've never stuck the artery, even with my seeker. The several times I've seen the carotid artery punctured were always (forgive me here - nothing meant by this) by anesthesia personnel. I attribute this to differences in approach. We use the insertion sites of the SCM muscle, go in between, 45 degree angle to skin, aim toward ipsilateral nipple. They are taught to palpate the carotid impulse (which using my approach I never even feel), and puncture lateral to the pulse, regardless of external landmarks. I also use a posterior approach with good results: 1 cm above clavicle, puncture behind SCM body with needle aiming to sternal notch.

Carotid puncture can be a big deal for several reasons: older folks might have embolus of plaque with resultant stroke, you might get a dissection with stroke, or the resulting hematoma might cause airway problems. That's why a SEEKER needle is so important in the IJ approach, in my own view. Complications from a 22 gauge are far less likely than from the huge cook needle.

A corollary: as much as we surgeons love subclavian sticks over internal jugular, THINK about your options and act responsibly. In someone with renal insufficiency, a subclavian line which causes stenosis might prevent placement of permanent dialysis access on that entire upper extremity. Very bad news. Try to use IJ whenever you can, and subclavian only when you have to. Last time I was on vascular service we did two femoral dialysis loop fistulas and one IJ to axillary artery: crummy last ditch efforts in folks who had been in the ICU in the past with multiple line placements, with stenosed bilateral subclavian veins. When those fistulas fail (and they will) these folks are going to be without much in the way of options.

regards,
-ws

 

[droliver]

I agree with womansurg. I always preferentally go to the neck (usually with the middle approach as she described) b/c I think its easier, safer, and the landmarks tend to be more consistent then subclavicular. The prospect of dialysis is also something to think about & was drilled into me by some vascular surgeons years ago.
I do not routinely use a seeker needle unless someone has poor definition of their SCM muscles & I think gently feeling for the carotid pulse is a good idea to make sure you're aiming lateral enough. Womansurg must be the queen of the neckline placement b/c I've stuck the carotid multiple times with just the needle before without incident. I've played around with that SITE-RITE ultrasound machine a bit for fun & it can be difficult sometimes to use - I've found you end up placing the stick in wierd anatomic spots of the neck you wouldn't ordinarily have done otherwise. It is nice with those people with short/fat necks to get a landmark though. I'll confess that I apparently am physically incapable of the posterior approach, I've done maybe 3-4 this way out of several hundred central lines. Some of my colleagues do it preferentially however.

I've seen many carotid & subclavian sticks, usually they don't cause problems. Vascular complications I've seen include carotid pseudoaneurysm requiring repair, neck hematomas requiring I&D, a shear injury of the thyrocervical trunk requiring emergent sternotomy, right atrial appendage rupture, and hemothorax. I think I've seen signifigant hemothoraces from subclavian artery sticks the most (usually by medicine residents who are trying to learns on some poor old lady or ER & surgery residents putting lines in on trauma patient who don't quit after 20 futile subclavian sticks). What will really make you nervous is that consult (I've had 3) with carotid artery placement of those huge bore Shiley dialysis caths - all did fine. I haven't seen the dead leg phenomena yet from a femoral central line (only from arteriogram sticks). A signifigant % of groin lines placed during ATLS/ACLS codes are placed intraarterial in several studies

In re. to the question posed for this thread. We would prob. just pull it out and watch it. I have heard of some people advocating doing it in the vascular IR suite with a sheath/catheter in to see if would leak on angio & require immeadiate covered wall stenting, but that seems a bit overkill according to most peoples benighn experience with this kind of event.

 

[Winged Scapula]

Originally posted by Skylizard
I think I saw the same patient

I'm sure you did...as I recall you were doing SICU that same month as our mutual friend.

 

[womansurg]

Originally posted by droliver
I think gently feeling for the carotid pulse is a good idea to make sure you're aiming lateral enough. Womansurg must be the queen of the neckline placement b/c I've stuck the carotid multiple times with just the needle before without incident.

O yeah, baby!

Hehe...now see, that's my whole theory. I think there are subtle differences in approach if you are localizing the cartoid impulse first. Subconciously you put your trajectory next to the impluse, thinking, "it must be right here". If you are using only your external landmarks, and truly aim to the IPSILATERAL NIPPLE, then you are far lateral to the artery. Without fail, if my first pass doesn't go, then I work toward midline, and always find the vein more medial than my initial search. I've never found it to be more lateral than that.

One of our vascular guys uses site rite on all his punctures, so the residents are all pretty comfortable with it. It's a handy tool if you're coming up empty after several passes.

 

[Skylizard]

Originally posted by SomeOne
I'm sure you did...as I recall you were doing SICU that same month as our mutual friend.

Fortunately the leg loss due to the multi-stick marathon was the least of the patient's problems in the setting of her hypercoagulable state...she doesn't miss that leg a bit.

As I recall, I think we left the leg and allowed the rest of the body to catch-up

How is our mutual friend?

 

[Winged Scapula]

Originally posted by Skylizard
Fortunately the leg loss due to the multi-stick marathon was the least of the patient's problems in the setting of her hypercoagulable state...she doesn't miss that leg a bit.

As I recall, I think we left the leg and allowed the rest of the body to catch-up

How is our mutual friend?

Later,
Skylizard

He's doing well - enjoying a little bit of Chiefdom on some services (BTW, you should see his hair. Down to the middle of his back now. )

Just finished an away elective at HUP which he loved - seems to thrive on that "malignant" atmosphere. Will be applying for Trauma/Crit Care next year.

I'll send him your best.

 

[embolicintent]

Greek med if your interested, that patient died because the line was not recognized as being in the artery and it was pulled without anyone ever recognizing the error even after pulling it or so I was told. I was ticked when I wrote that message and should not have posted it.

On another note just curious, but reading Dr. Olivers post brings up a question that has always bothered me. Why would anyone ever place any venous line without Ultrasound guidance. I guess that I am biased as that is how I have always done it. However it just does not make since to me to not take advantage of the technology for the sake of patients. With the advent of sonosite and other very portable machines it seems only reasonable to save the patient some pain/risk.

I have never missed a vein though I have had some very difficult ones that I cannot imagine trying to stick without U/S or possibly retrograde venogram. Quite frankly it has been my experience that sometimes I simply cannot distinguish arterial from venous blood solely by the appearance/pulsatility. Of course I am a little color blind , but I can guaruntee that I would NEVER make that mistake on duplex Doppler. In fact it is my opinion that arterial sticks should be done with U/S as well to minimize pseudoaneurysm and other complications. That opinion is not shared by most interventionalists that consider sticking an artery an art. Anyhow, just curious what the thoughts/standards are.

A votre sante!

 

[Winged Scapula]

I can't speak for others obviously but we aren't really trained in the use of the site-rite. I've only seen it used twice and frankly, don't even know where its kept (apparently somewhere in the Anesthesia work room in the ORs). I've been told that using it is a "sign of weakness" (like so many other things in surgery)...

 

[UI2003]

Originally posted by embolicintent


On another note just curious, but reading Dr. Olivers post brings up a question that has always bothered me. Why would anyone ever place any venous line without Ultrasound guidance. I guess that I am biased as that is how I have always done it. However it just does not make since to me to not take advantage of the technology for the sake of patients. With the advent of sonosite and other very portable machines it seems only reasonable to save the patient some pain/risk.

I too have been told that "a real surgeon doesn't need an imaging to show him/her anatomy that they ought to already know". On the other hand, I've seen Anesthesia faculty use the Doppler to place particularly difficult central lines in the SICU so I guess it all depends on your environment...

 

[surg]

I have to admit that I prefer the subclavian approach as I can basically find it with my eyes closed, but since the studies have shown fairly conclusively that even short term cannulation of this vessel can cause stenosis, I have switch to IJ's, especially if I they have any risk factors for renal disease.

as far as the site rite. I've tried using it a few times and always get tangled up with manipulating the extra instrument if you try to use the guide and doing the look, take away the probe then stick I found myself missing more often than without it, because of the distortion in the anatomy that happens from lifting off the pressure. Clearly I either need more practice with it, or I should just give up on it. That being said, I have never walked away from a patient that needed a line without one, but multiple passes are certainly not unknown to me either.
My guess is, if you are used to it, you should use it (our medicine residents use it on every line, and our anesthesia residents use it on the majority (but not all) lines), but in the hands of an experienced person, I don't think line placement is dramatically safer (or faster) with it or without it.

 

[embolicintent]

I guess you do it differently than we do. We place a sterile cover over the probe and use sterile gel. I stick while watching real time. I watch my needle advance into the vessel and assure that I don't double puncture (and of course ensure I am in a vein and not an artey). With IJ's I was taught to use a 21 guage needle with extension tubing connected to a syringe with a slight negative pressure which lets me know precisely when I have entered the vessel if I can't see clearly. Of course it can be dificult to hold the probe and syringe in one hand and puncture with the other, but with practice it gets rather routine. I can put in a PICC in less than a minute easy and an IJ temp cath in about 5 minutes barring complications (emergently I am confident I could have access to either the IJV or EJV in under 30 seconds although it might be a bit sloppy). Likewise for CFV or Basilic/cephalic. It takes about fifteen minutes for a hickman or any other tunneled cath. One other advantage particularly in dialysis patients is that I can be sure there is no clot in the vessel before I go ramming a wire into it. In fact I was taught to generally do a quick venogram before placing the cath (of course, I realize that is rarely an option outside the IR suite).

As far as the anatomy goes, it can be rather variable and I can't understand the argument for blindly jabbing until you find it when there are better ways. "Placement of Internal Jugular Vein Central Venous Catheters: anatomic ultrasound assessment and literature review." Surg Rounds 1996;19:102-107.

Anyhow thanks for the feeback. Gotta get off here and go do some work.

Ziveli!

 

[southerndoc]

To add more fuel to the fire...

There are paramedic systems (very few though) that allow paramedics to place subclavian lines in the field. These services do not use ultrasound for guidance, nor do they obtain chest x-rays prior to using the central line.

Talk amongst yourselves. (Alright, I gotta lay off the coffee tawk stuff.)

 

[womansurg]

Originally posted by embolicintent
Why would anyone ever place any venous line without Ultrasound guidance.

Well, a good proportion of the lines that I have placed were done emergently - in the trauma bay, the ICU, during codes - to gain access in a hypotensive patient on whom the RNs had been unable to gain peripheral access. Waiting around for a siterite would not behoove a patient in these situations, obviously.

I think there is truth to the argument that skills are commensurate with experience. The bulk of my experience is with placing lines by using external landmarks, and my success rate is quite good. I can only think of two occasions out of hundreds where I couldn't get access and later got it with siterite. We have sort of an unofficial rule here that if you don't get the stick in three passes, you cease and desist, meaning either move onto siterite or let another person try.

Multitudes of blind attempts is unfair, as you suggest, when radiographic assistance exists which might expidite things. But assuring that a surgeon is facile with unassisted placement is probably in the best interest of everybody.

 

[ckent]

SDN just effected the medical management of an actual pt. I am a 3rd yr medical student, and my intern was getting ready to put a central line in a pt whom we could not get an IV in. He wanted to put a subclavian line, but since she has SLE (we don't know what her Cr is because we weren't able to stick her at all), I suggested that we put a IJ line in case she needs dialysis in the future and he agreed. I would not have known about the subclavian line and stenosis had I not read this thread. Who needs to pick up a journal when you've got people on SDN who will read them for you .

 

[southerndoc]

Originally posted by ckent
SDN just effected the medical management of an actual pt. I am a 3rd yr medical student, and my intern was getting ready to put a central line in a pt whom we could not get an IV in. He wanted to put a subclavian line, but since she has SLE (we don't know what her Cr is because we weren't able to stick her at all), I suggested that we put a IJ line in case she needs dialysis in the future and he agreed. I would not have known about the subclavian line and stenosis had I not read this thread. Who needs to pick up a journal when you've got people on SDN who will read them for you .

I've actually learned quite a bit from the people of SDN!

 

[womansurg]

It's the dawn of a new era....

Surgeons, anesthesiologist, radiologists, nurses, EMTs....all working together toward the greater good. All work valued; all opinions important. Ideas shared; knowledge communal.

Long live civility in medicine!