Central venous line practice

[Cooker Power]

Hello everyone ! I am a surgical intern and this is my 3rd month into internship. I have just started placing central lines, in my institution we only use the subclavian approach. My first four attempts were not successful since I couldn't puncture the vein, even though I think I followed all the necessary steps of the procedure.

I was wondering if there is any possible way I can practice placing subclavian lines on my own (not on a real patient). Does anyone have any ideas on how to make a custom simulator of the anatomic landmarks ? I'd welcome any helpful tips. Thank you in advance.

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[tiedyeddog]

Hello everyone ! I am a surgical intern and this is my 3rd month into internship. I have just started placing central lines, in my institution we only use the subclavian approach. My first four attempts were not successful since I couldn't puncture the vein, even though I think I followed all the necessary steps of the procedure.

I was wondering if there is any possible way I can practice placing subclavian lines on my own (not on a real patient). Does anyone have any ideas on how to make a custom simulator of the anatomic landmarks ? I'd welcome any helpful tips. Thank you in advance.

Does your institution have a training center? Mine does and they have a subclavian CVC dummy that is somewhat realistic. Maybe inquire about that?

The key in subclavians is 1. entry point 2. aim. It just takes practice but also you must realize since it is blind that not every subclavian is possible due to aberrant anatomy some people will have.

 

[thedrjojo]

Does your institution have a training center? Mine does and they have a subclavian CVC dummy that is somewhat realistic. Maybe inquire about that?

The key in subclavians is 1. entry point 2. aim. It just takes practice but also you must realize since it is blind that not every subclavian is possible due to aberrant anatomy some people will have.

While I still do all my subclavian lines blindly, you can use ultrasound for them, and eventually (if not already) it will also be standard of care and any complications you have from subclavian lines without ultrasound guidance will equal an easy settlement for the patient. . .

 

[tiedyeddog]

While I still do all my subclavian lines blindly, you can use ultrasound for them, and eventually (if not already) it will also be standard of care and any complications you have from subclavian lines without ultrasound guidance will equal an easy settlement for the patient. . .

I have been taught how to do them using a supraclavicular approach with ultrasound. I never use this method myself. For sure is not standard of care currently and in my opinion is harder to master than an IJ or femoral by ultrasound.


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[deleted547339]

With all due respect to the above posters, don't try US for Subclavian lines. Also, I disagree that any complication will be an open your checkbook type of incident. Presumably your only two immediate technical complications are pneumo, which can be solved with a pneumocath, or arterial puncture, which isn't a big problem if you don't dilate. If you dilate, that's kind of a different problem (not recognizing arterial puncture).

US guided SCV, particularly the supraclavucular approach, is a much more technically difficult procedure, plus, depending on the footprint of your linear array probe, you potentially have to adjust your insertion site which can further complicate things.

Learning how to do US guided IJs will help, too. Learning the muscle memory, way to stabilize your hand, getting smooth with the needle and guidewire, getting comfortable taking the syringe off the needle without letting your needle move, etc will all help.

As above, the appropriate site of insertion and angle are super important. Also, patient selection is quite important. I really like subclavian lines, but they are more difficult on certain patients and US-guided IJ may be more appropriate. As with all procedures, patient position and bed height are are important. If the patients shoulder is in the wrong position and the bed is too low, you're setting yourself up for failure.

Start on the patient's left if you're right handed. It's a technically easier approach. It also gives you the ability to get the line in fairly deep, which I like not having much line outside of the skin.

Ask for someone experienced to watch you. This is invaluable.

Tough lines are a function of millimeters, most novices overadjust when theyre off.

Keep your needle fairly horizontal to the skin. When people are too shallow and angle down instead of dropping the syringe and needle, that's what causes pneumos.

Find someone who already has a pneumo and a chest tube. They're great to learn on.

 

[mimelim]

More practice is not the solution.

More perfect practice is. You need someone to teach you and spend the time to work through the lines with you.

What institution "only does subclavians"? Seems very limiting, unnecessarily risky and simply wrong in some patients. I would not try to learn how to use an ultrasound for subclavian lines, to perform correctly, you often need to change angles to get the correct windows which will put your patient at higher risk if you really don't know what you are doing.

 

[Psai]

More practice is not the solution.

More perfect practice is. You need someone to teach you and spend the time to work through the lines with you.

What institution "only does subclavians"? Seems very limiting, unnecessarily risky and simply wrong in some patients. I would not try to learn how to use an ultrasound for subclavian lines, to perform correctly, you often need to change angles to get the correct windows which will put your patient at higher risk if you really don't know what you are doing.

I forget which one it is but there was a guest on the emcrit podcast who said that they preferentially do subclavians so that their residents will get the experience. Seems like everyone wants to do ultrasound guided right sided ij 24/7

 

[mimelim]

I forget which one it is but there was a guest on the emcrit podcast who said that they preferentially do subclavians so that their residents will get the experience. Seems like everyone wants to do ultrasound guided right sided ij 24/7

Ultrasound guided R IJ is the safest, so why wouldn't people want to do it? It also preserves the arm outflow which is important, especially in certain patient populations.

 

[evilbooyaa]

Ultrasound guided R IJ is the safest, so why wouldn't people want to do it? It also preserves the arm outflow which is important, especially in certain patient populations.

Spoken like the true vascular surgeon you are, worried about future AV Fistula access and sustainability in random patients on the internet.

 

[deleted547339]

I forget which one it is but there was a guest on the emcrit podcast who said that they preferentially do subclavians so that their residents will get the experience. Seems like everyone wants to do ultrasound guided right sided ij 24/7

That was in Europe.

 

[thedrjojo]

Spoken like the true vascular surgeon you are, worried about future AV Fistula access and sustainability in random patients on the internet.

its not incorrect.

I prefer the SCV simply because I don't like fussing with the US and can generally throw it in faster. But ill never throw in a SCV shiley and only have ever place 1 SCV cordis.

But I'm telling you, we should all learn how to do SCV central lines with Ultrasound. My estimation is in a few years, you won't be able to do it without one without massive scrutiny...

 

[tiedyeddog]

Ultrasound guided R IJ is the safest, so why wouldn't people want to do it? It also preserves the arm outflow which is important, especially in certain patient populations.

Subclavians are used almost exclusively in the neuro-ICU. I've done 10x more Subclavian CVCs than IJ CVCs with reason being:

1. No issue with cervical collar being in the way. Don't have to worry about it being in the way for cervical spine procedures.
2. No changes in cerebral venous outflow and thus my ICP is not messed with (data on this is nill, but it is the party line)
3. (reason I like them) don't have to mess around with the ultrasound thus faster than IJ

 

[tiedyeddog]

But I'm telling you, we should all learn how to do SCV central lines with Ultrasound. My estimation is in a few years, you won't be able to do it without one without massive scrutiny...

I think you're right but it is undeniable it is a much harder technique than using the US for an IJ. I kind of wonder if using the US actually will cut down on the rate of pneumos because the view isn't very clear.

 

[dienekes88]

My issue is that when people use ultrasound, a certain subset will stop paying attention to the needle and their hands. Having been consulted on a few central line disasters... I think there's something to be said for learning both ways.

It comes down to understanding the anatomy. If you're choosing the correct site and the correct angle, then it's because you understand the anatomy. That's where an experienced teacher comes in.

I really like subclavians: dressing lays flat so line care is easy for the nurses, very comfortable for the patients, lower incidence of infection, faster... only problem is that learning curve.

 

[Hamhock]

Subclavians are used almost exclusively in the neuro-ICU. I've done 10x more Subclavian CVCs than IJ CVCs with reason being:

2. No changes in cerebral venous outflow and thus my ICP is not messed with (data on this is nill, but it is the party line)

Nothing to do with the "data".
The "party line" is uneducated and non-physiologic.
Despite these phrases/statements, I don't feel strongly. And I place blind subclavians fairly frequently.
HH

 

[tiedyeddog]

Nothing to do with the "data".
The "party line" is uneducated and non-physiologic.
Despite these phrases/statements, I don't feel strongly. And I place blind subclavians fairly frequently.
HH

It's not uneducated my friend, we know venous hypertension can raise ICP. Idiopathic intracranial hypertension can be caused by venous sinus stenosis. Cervical collars that are too tight can raise ICP.

I'm not saying that IJ CVCs raise the pressure, I highly doubt it. But I don't think the idea is non-physiologic or dumb by any stretch.

 

[WheezyBaby]

Spoken like the true vascular surgeon you are, worried about future AV Fistula access and sustainability in random patients on the internet.

I imagine you see enough ESRD patients with failing hero grafts and translumbars it starts to eat at you when you see stenosed subclavs

 

[MediCane2006]

The subclavian is unfortunately one of those lines you just gotta practice. Then once it clicks it's like they all just start going in.

I found one of my main problems was starting too close to the clavicle. Starting a decent two finger-breadths below gets you enough of an angle to slide under the clavicle rather than trying to dive down under at a steeper angle.

 

[mimelim]

I imagine you see enough ESRD patients with failing hero grafts and translumbars it starts to eat at you when you see stenosed subclavs

Personally, I consider it wrong to place subclavians in patients that can get an IJ. @tiedyeddog 's points are well taken and if there is a reason to not do an IJ, perfectly fine. Sometimes you just have to take what the patient gives you. But, non-ultrasound guided access anywhere and subclavian over IJ access? It leads to very real complications. I get that that is how some people were trained, but that doesn't make it right. We have to clean up people's access messes. Does it happen often, no. Are they completely preventable? Absolutely. Blind sticks lead to poor sticks. Whether they be arterial canulation or sticking high or low. In the past month I have had to open someone's chest and a different patient's abdomen because of arterial cannulations during blind central line placements. Both times by experienced physicians with 2 decades+ of experience who refuse to use ultrasound or switch away from subclavian access because "in my hands blind sticks are safe". That isn't to say that IJ sticks are risk free. I've seen horrific complications from IJ approaches, but those have all been from trainees or people that frankly don't have the experience and shouldn't be doing them by themselves.

But yes, my biggest issue is subclavian stenosis. In patients with CKD, unless there is a specific reason to not get an IJ or femoral, I think that it is malpractice to place a subclavian.

 

[rigid]

Personally, I consider it wrong to place subclavians in patients that can get an IJ. @tiedyeddog 's points are well taken and if there is a reason to not do an IJ, perfectly fine. Sometimes you just have to take what the patient gives you. But, non-ultrasound guided access anywhere and subclavian over IJ access? It leads to very real complications. I get that that is how some people were trained, but that doesn't make it right. We have to clean up people's access messes. Does it happen often, no. Are they completely preventable? Absolutely. Blind sticks lead to poor sticks. Whether they be arterial canulation or sticking high or low. In the past month I have had to open someone's chest and a different patient's abdomen because of arterial cannulations during blind central line placements. Both times by experienced physicians with 2 decades+ of experience who refuse to use ultrasound or switch away from subclavian access because "in my hands blind sticks are safe". That isn't to say that IJ sticks are risk free. I've seen horrific complications from IJ approaches, but those have all been from trainees or people that frankly don't have the experience and shouldn't be doing them by themselves.

But yes, my biggest issue is subclavian stenosis. In patients with CKD, unless there is a specific reason to not get an IJ or femoral, I think that it is malpractice to place a subclavian.

I completely agree with you

 

[tiedyeddog]

Personally, I consider it wrong to place subclavians in patients that can get an IJ. @tiedyeddog 's points are well taken and if there is a reason to not do an IJ, perfectly fine. Sometimes you just have to take what the patient gives you. But, non-ultrasound guided access anywhere and subclavian over IJ access? It leads to very real complications. I get that that is how some people were trained, but that doesn't make it right. We have to clean up people's access messes. Does it happen often, no. Are they completely preventable? Absolutely. Blind sticks lead to poor sticks. Whether they be arterial canulation or sticking high or low. In the past month I have had to open someone's chest and a different patient's abdomen because of arterial cannulations during blind central line placements. Both times by experienced physicians with 2 decades+ of experience who refuse to use ultrasound or switch away from subclavian access because "in my hands blind sticks are safe". That isn't to say that IJ sticks are risk free. I've seen horrific complications from IJ approaches, but those have all been from trainees or people that frankly don't have the experience and shouldn't be doing them by themselves.

But yes, my biggest issue is subclavian stenosis. In patients with CKD, unless there is a specific reason to not get an IJ or femoral, I think that it is malpractice to place a subclavian.

Agreed. An image guided IJ or femoral should be done over a subclavian for the reasons you mentioned above except for very specific situations.

 

[deleted547339]

Personally, I consider it wrong to place subclavians in patients that can get an IJ. @tiedyeddog 's points are well taken and if there is a reason to not do an IJ, perfectly fine. Sometimes you just have to take what the patient gives you. But, non-ultrasound guided access anywhere and subclavian over IJ access? It leads to very real complications. I get that that is how some people were trained, but that doesn't make it right. We have to clean up people's access messes. Does it happen often, no. Are they completely preventable? Absolutely. Blind sticks lead to poor sticks. Whether they be arterial canulation or sticking high or low. In the past month I have had to open someone's chest and a different patient's abdomen because of arterial cannulations during blind central line placements. Both times by experienced physicians with 2 decades+ of experience who refuse to use ultrasound or switch away from subclavian access because "in my hands blind sticks are safe". That isn't to say that IJ sticks are risk free. I've seen horrific complications from IJ approaches, but those have all been from trainees or people that frankly don't have the experience and shouldn't be doing them by themselves.

But yes, my biggest issue is subclavian stenosis. In patients with CKD, unless there is a specific reason to not get an IJ or femoral, I think that it is malpractice to place a subclavian.

I have a hard time agreeing with you given the Parienti paper.

 

[mimelim]

I have a hard time agreeing with you given the Parienti paper.

Have you actually read Parienti? Parienti does not factor in ultrasound use or non-use, which would only tip the numbers in favor of jugular and femoral. Even more than that, line care was not standardized, nor were anti-septic dressings. While DVT, infection and mechanical complications can all be devastating, the vast majority of infections and virtually all DVTs are dealt with relatively easily. ie removal of catheter and treatment of complication medically. The mechnical complications are on average much more expensive and harmful to the patient.

Sure, if you read only the highlights and go purely based on infection (see CDC), then subclavians are the obvious choice. On the other hand, if you go by minimizing harm to patients, ultrasound guided IJ >>> SC/Fem and it isn't really close.

 

[thedrjojo]

I have a hard time agreeing with you given the Parienti paper.

They should follow those patients 10 years out and see the rates of subclavian stenosis.

Parienti didn't address the long term issues and complications of Subclavian lines

 

[thedrjojo]

I have a hard time agreeing with you given the Parienti paper.

parienti is one of many examples of just because its in NEJM doesn't mean its a crappy paper