Cool central lines tricks

[Nephro critical care]

Recently I learned a couple of cool tricks at placing central lines. These may be known to the pros among you but still I wanted to share with general SDN community. These tricks are being used under real-time US guidance.
1. I always use the 18 gauge big needle from my arrow catheter kit rather the micropuncture angiocath needle. I feel it’s easier to hit the vein accurately with the 18 gauge needle. However once you get blood flow sometimes you can’t get the guidewire to go through the 18 gauge needle. The stiff guidewire is probably backwalling the IJ. Now unless you have a guidewire freely flowing into the vessel to 25-30 cm you shouldn’t dilate since if you do dilate a backwalled wire you can have a IJ vessel perforation in your hands.
I find in these cases the angiocath is very useful. It’s very flexible and if you leave the backwalled wire in place and remove the 18 gauge needle and try to get an angiocath in over the wire you will find you can coax the angiocath into the vessel deeper. Then remove the guidewire and hub the angiocath. Hopefully you are getting good blood flow you can also attach a piece of flexible tubing to your angiocath and perform “ the poor man’s manometry “ by holding up the tubing and seeing the colum of blood fall if you are in the venous structure.
Now slide the guidewire in over the angiocath and you will usually find that the guidewire will flow freely to 25–30 cm and now you can safely dilate.
2. One time I was putting an IJ in a pt who had a pacer on the left side. Despite good blood flow the wire was hitting the pacer leads and I was really nervous about dilating. I used the angiocath to try go past the confluence of the brachiocephalic veins but still the wire was sticking at the pacer leads probably because the angiocath was not long enough. I then had the nurses find an extra long angiocath. I got this into the vessel , got my wire out and this angiocath I was able to manoevure past the brachiocephalic junction into the SVC. Now I found the wire was passing smoothly to 30 cm and I dilated and got my catheter in. Bingo !
3. When you find someone has a collapsible IJ which will be hard to get a wire in you Trendelenburg the patient and ask him to take a deep breath and hold it. This will increase the intrathoracic pressure and cause the IJ to puff out like a balloon and you can hit it easily.

Please share any cool procedure tricks that you know.

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[tartesos]

Have IR/np/pa/anesthesia do them.
Best trick ever!!!


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[McPoyle]

I find my best trick is just put it in a damn vein and be done with it.


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[AdmiralChz]

3. When you find someone has a collapsible IJ which will be hard to get a wire in you Trendelenburg the patient and ask him to take a deep breath and hold it. This will increase the intrathoracic pressure and cause the IJ to puff out like a balloon and you can hit it easily.

Nice. You can do the same with a recruitment maneuver or increasing the PEEP briefly if someone is on the vent.

 

[Nephro critical care]

Nice. You can do the same with a recruitment maneuver or increasing the PEEP briefly if someone is on the vent.

Yes I didn’t think of that.

 

[BigRedBeta]

You really shouldn't be trying to push the dilator through the vessel wall in the first place. It's more meant to open up the skin/subQ tissues rather than create a larger venipuncture. There's usually little resistance entering the vessel wall, relatively speaking. You'll have fewer complications if you use it gingerly.

 

[leviathan]

You really shouldn't be trying to push the dilator through the vessel wall in the first place. It's more meant to open up the skin/subQ tissues rather than create a larger venipuncture. There's usually little resistance entering the vessel wall, relatively speaking. You'll have fewer complications if you use it gingerly.

Sometimes if you don't dilate enough of the subcutaneous tissue you end up with a central line that won't pass and a kinked guidewire. Then you have to go back and re-dilate over a kinked wire and it becomes difficult. I know the teaching is to avoid dilating the vessel itself, but sometimes I find it necessary. I still would advocate going just enough to enter the vessel and not pushing the dilator in to the hub in like I've seen some people do.

 

[Siggy]

If I'm concerned that the central line might need to be adjusted (e.g. subclavians and longer length lines on the right side), I'll suture the extra hub block and use a PICC line stat-lock for the line hub. Now the nurses can adjust the line themselves instead of having to resuture it into place.

 

[Ronin786]

Nice. You can do the same with a recruitment maneuver or increasing the PEEP briefly if someone is on the vent.

Caveat is you're also increasing your risk for a PTX at the same time.

 

[Cadet133]

One trick I found which was very helpful; Once you stick your needle into the vein, you don't have to remove the syringe. You can thread the guide wire into the hole on the syringe that way you keep your needle in place and more stable.

 

[Nephro critical care]

One trick I found which was very helpful; Once you stick your needle into the vein, you don't have to remove the syringe. You can thread the guide wire into the hole on the syringe that way you keep your needle in place and more stable.

That is if your hospital stocks the cool blue Arrow syringe which has the hole on the syringe through which you can thread your guidewire. My hospital gets the ‘maybe’ cheaper arrow kit which doesn’t have that cool blue syringe. Instead we have a regular plain syringe with no hole. Worse we have two kits , one with the syringe and needle and the other with the guidewire and catheter and you have to open both which is a two step process.
I lay my left hand with which I am holding the needle on the patient’s neck to reduce the emphasis on my slight hand tremor which will cause the needle to come out of the vessel after I have gotten blood flow.

 

[turkeyjerky]

One trick I found which was very helpful; Once you stick your needle into the vein, you don't have to remove the syringe. You can thread the guide wire into the hole on the syringe that way you keep your needle in place and more stable.

I find it awkward to keep the syringe on and maintain a steady placement of the needle, also the wire sometimes gets stopped up a little while going through the syringe

 

[Laryngophed]

Superficial cervical plexus block for awake lines. That is all.

 

[engineeredout]

Superficial cervical plexus block for awake lines. That is all.

Seriously? Is this something people are doing?

 

[Laryngophed]

Seriously? Is this something people are doing?

Which part?

 

[nlax30]

I do a lot of groin/neck sticks for our procedures and besides using ultrasound, I've started to just use the 18gauge needle without a syringe on it. I think it takes some time but eventually you'll get a feel for when the needle is up against the front wall of the vessel and I can usually see some tenting on US. At that point I give a quick/short jab to puncture the front wall and then look for some bleed back in the needle and insert the wire. Anecdotally I think it helps minimize going through and through the vein. If I'm slowly advancing in with a syringe aspirating it seems like it's much easier to gradually push in on the anterior wall more and more until you puncture though both the front and back wall and then had to withdraw slightly until you get back in the lumen. Doesn't really work if you're using a micropuncture needle as you may not get a flash of blood if you're not using a syringe to aspirate.

Also, when using ultrasound it's very easy to push down too hard with the probe and collapse the vein so just be cognizant of this and use as light of pressure as needed to visualize.

 

[engineeredout]

Which part?

Doing a block for CVC placement? I'm genuinely curious

 

[Laryngophed]

Doing a block for CVC placement? I'm genuinely curious

Do you use local at the site for awake lines? If so, how is this different? I just use it in a targeted fashion and don’t have to make a wheal the size of Texas to cover insertion and suture sites. Plus, I’m soon to be an anesthesiologist, blocks are our jam.

 

[TooMuchResearch]

Coolest trick I've learned: Call the PICC team.

 

[WheezyBaby]

I find it awkward to keep the syringe on and maintain a steady placement of the needle, also the wire sometimes gets stopped up a little while going through the syringe

This is my experience as well. I was real hyped on the idea of not having to disconnect the syringe but it just doesn't work that well imo, particularly if the wire hangs up and you want to try to change your bevel orientation

 

[alphaholic06]

This is my experience as well. I was real hyped on the idea of not having to disconnect the syringe but it just doesn't work that well imo, particularly if the wire hangs up and you want to try to change your bevel orientation

Try using the angiocath. If flow stops you can always reconnect the syringe and reposition.

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[coffeebythelake]

Superficial cervical plexus block for awake lines. That is all.

You mean getting 10 cc of lidocaine and injecting it under the skin yo do a field block...

 

[deleted171991]

You mean getting 10 cc of lidocaine and injecting it under the skin yo do a field block...

That's not a superficial cervical block.

 

[coffeebythelake]

That's not a superficial cervical block.

i know i'm being facetious.

i put in CVCs fairly frequently on awake patients. you don't need a superficial cervical block for CVC, and anyone claiming to do this on a regular basis is practicing some boutique as **** medicine.

 

[The Physician Philosopher]

Learn to visualize the needle tip while placing your line. I use the angiocath and keep visualizing my needle until half of it is already in the vein. That way it always threads off.

I then transduce to prove its not arterial by connecting a catheter to the angiocath prior to throwing my wire.

Arrogant comment of the day: People that tell you that you cannot visualize your needle tip out of plane and follow it during central line placement are really just admitting that they are not very good with ultrasound.

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[deleted171991]

i know i'm being facetious.

i put in CVCs fairly frequently on awake patients. you don't need a superficial cervical block for CVC, and anyone claiming to do this on a regular basis is practicing some boutique as **** medicine.

I have never done it myself, but I have contemplated it. Because it takes literally 2 minutes. Ask the patient to turn his head, lift the SCM muscle, inject 10-15 ml of 1% lido under the posterior border at midpoint, in a fan fashion. I would expect this to be much better than any field block we do.

On-topic, I always "transduce" with a piece of extension tubing, before putting in the wire and (especially) dilating, even if it looks perfect on U/S.

 

[coffeebythelake]

I inject 3-5 cc 1% lidocaine to make a wheal at the insertion point and where I intend to put my sutures. I don't do the field block, nevermind a superficial cervical block. The patient is more likely to be anxious (maybe some claustrophobia as well) than pain. A little reassurance, some supplemental O2 under the drape, talking them through the procedure usually does it. maybe a touch of versed if they are really a nervous wreck.

for the IJ's, i confirm placement with multiple methods. ultrasound on both long/short axes, and transduce with the tubing. i prefer insertions where the vein is not directly superficial to the artery, although sometimes you have no choice. dilating the carotid would be a ******** mess.

 

[deleted171991]

Also, if one dilates the carotid (or another artery), do NOT remove the dilator (if you did, slide in the catheter to plug the hole). Cap it and call vascular STAT. If you discover an arterial placement later (e.g. on CXR, or when transducing the line), do not use it and call vascular STAT. Do not attempt conservative management (i.e. observation) because the outcome can be abysmal (e.g. stroke).

 

[coffeebythelake]

Also, if one dilates the carotid (or another artery), do NOT remove the dilator (if you did, slide in the catheter to plug the hole). Cap it and call vascular STAT. If you discover an arterial placement later (e.g. on CXR, or when transducing the line), do not use it and call vascular STAT. Do not attempt conservative management (i.e. observation) because the outcome can be abysmal (e.g. stroke).

^^
this is the paper you're probably referring to, by Guilbert et al.,2008
https://pdfs.semanticscholar.org/5234/eb5987b9356ae25460c928d74487775a5c66.pdf

 

[jdh71]

Gotta admit seems like a lot of unnecessary work putting in a line in this thread. To me. I'm not saying anyone is "wrong". I think one should do whatever they think they need to for *their* procedure and level of comfort.

Unless a patient is awake I don't give any lido. And then surface for the stick and sutures.

I've never found it necessary to do a lot of extra confirming of the wire or to watch the tip during the whole process, though I used to practice that way for a time. Now I identify the jug and stick it. And while there is a first time for everything I suppose I've never had a a line placed into a carotid. I have a hard time understanding how it could happen to be honest. At least in my practice environment. I don't worry much about a needle into the carotid at least with my technique which only has the needle going straight in or out. I can't remember the last time I got return of bright red blood from an IJ if ever.

 

[coffeebythelake]

Gotta admit seems like a lot of unnecessary work putting in a line in this thread. To me. I'm not saying anyone is "wrong". I think one should do whatever they think they need to for *their* procedure and level of comfort.

Unless a patient is awake I don't give any lido. And then surface for the stick and sutures.

I've never found it necessary to do a lot of extra confirming of the wire or to watch the tip during the whole process, though I used to practice that way for a time. Now I identify the jug and stick it. And while there is a first time for everything I suppose I've never had a a line placed into a carotid. I have a hard time understanding how it could happen to be honest. At least in my practice environment. I don't worry much about a needle into the carotid at least with my technique which only has the needle going straight in or out. I can't remember the last time I got return of bright red blood from an IJ if ever.

when something bad happens to the patient, especially something so obviously cause-and-effect, i think it would be very hard to defend NOT confirming appropriate CVC placement. the color of the blood coming back or lack of pulsatile flow has been shown to be very poor indicators of venous vs arterial stick. it takes a few extra seconds of time and there is no risk to the patient. missing an arterial placement, as we all know, would be absolutely catastrophic. I agree that inadvertent carotid cannulation is an unlikely event, but in medicine we are always "playing a game" of risk. our goal should be always to minimize the risk.

 

[deleted171991]

Gotta admit seems like a lot of unnecessary work putting in a line in this thread. To me. I'm not saying anyone is "wrong". I think one should do whatever they think they need to for *their* procedure and level of comfort.

Unless a patient is awake I don't give any lido. And then surface for the stick and sutures.

I've never found it necessary to do a lot of extra confirming of the wire or to watch the tip during the whole process, though I used to practice that way for a time. Now I identify the jug and stick it. And while there is a first time for everything I suppose I've never had a a line placed into a carotid. I have a hard time understanding how it could happen to be honest. At least in my practice environment. I don't worry much about a needle into the carotid at least with my technique which only has the needle going straight in or out. I can't remember the last time I got return of bright red blood from an IJ if ever.

A few caveats:
1. The blood may not be bright red. I have heard of carotid sticks with dark blood during our M&M's.
2. The blood may not be pulsatile, even in an extension tubing. Same M&M. However, it will rise much higher than a venous column.
3. It may seem to you that you did just fine on the U/S, and still you may have stuck an artery (different U/S planes).
4. I have seen vertebral artery sticks that looked just fine on the U/S during placement, because the resident went in too low in the neck. Again, different planes. They diagnosed it only after the patient had a stroke. Most people don't follow the tip of their needle at all times while placing a line out-of-plane, so they may run into other structures if not in the anatomically correct region. (Hint: use the top of the triangle, not the bottom.)
5. As we like to say in anesthesia: if you haven't had a certain complication yet, you just haven't done enough of them.

 

[jdh71]

when something bad happens to the patient, especially something so obviously cause-and-effect, i think it would be very hard to defend NOT confirming appropriate CVC placement. the color of the blood coming back or lack of pulsatile flow has been shown to be very poor indicators of venous vs arterial stick. it takes a few extra seconds of time and there is no risk to the patient. missing an arterial placement, as we all know, would be absolutely catastrophic. I agree that inadvertent carotid cannulation is an unlikely event, but in medicine we are always "playing a game" of risk. our goal should be always to minimize the risk.

Fair points. Though a carotid placement probably isn't going to be necessarily catastrophic. But it could be.

Even a "confirm" with US might not actually confirm the wire though.

 

[Laryngophed]

Fair points. Though a carotid placement probably isn't going to be catastrophic. But it could be.

Even a "confirm" with US might not actually confirm the wire though.

The gold standard for confirmation is a blood gas. I don’t think I’ve ever seen one done to confirm placement. Ever.

According to the literature, a modified Fabian is the next best test. Pulsatilitu, color, using the the U/S to visualize the wire, all under perform transducing the column.

There are some absolute nightmares in the literature of CVC complications. Including an “IJ” Cordis that drew clear fluid on aspiration.

 

[jdh71]

A few caveats:
1. The blood may not be bright red. I have heard of carotid sticks with dark blood during our M&M's.
2. The blood may not be pulsatile, even in an extension tubing. Same M&M. However, it will rise much higher than a venous column.
3. It may seem to you that you did just fine on the U/S, and still you may have stuck an artery (different U/S planes).
4. I have seen vertebral artery sticks that looked just fine on the U/S during placement, because the resident went in too low in the neck. Again, different planes. They diagnosed it only after the patient had a stroke. Most people don't follow the tip of their needle at all times while placing a line out-of-plane, so they may run into other structures if not in the anatomically correct region. (Hint: use the top of the triangle, not the bottom.)
5. As we like to say in anesthesia: if you haven't had a certain complication yet, you just haven't done enough of them.

As a medical intensivist I am aware the blood might not be bright red or pulsatile and in my practice I wouldn't be placing an IJ in a situation where the carotid blood would be that ugly. Again, some of this is nuanced I think by where and what situation where a CVC is being placed. I've always found anesthesia to be a bit over-paranoid about a lot of things, but I'm not an anesthesiologist so that's just me looking in from the outside. Again, I'm not saying you are wrong, merely talking about my practice. And following the needle tip is really only a big problem if you don't know what structures are under your probe, so if your preferred technique is one where you go in at a shallow angle then you really do want to know where the needle tip is at all time. I like to run into the jugular vein almost perpendicular. While it is true and tautology that one could always have a complication, any complication, I think at some point one can suggest that enough of something is done that suggests its not being done wild, or stupid, or dangerous. If I've gone 10 years without a complication does that mean one couldn't happen? Of course not, but does it strongly suggest I'm not a farking ***** with an opinion on the subject and a practice that is essentially safe and reasonable? I do think so.

I hope there is room to possibly disagree without being disagreeable if necessary.

 

[jdh71]

The gold standard for confirmation is a blood gas. I don’t think I’ve ever seen one done to confirm placement. Ever.

According to the literature, a modified Fabian is the next best test. Pulsatilitu, color, using the the U/S to visualize the wire, all under perform transducing the column.

There are some absolute nightmares in the literature of CVC complications. Including an “IJ” Cordis that drew clear fluid on aspiration.

The case report literature exists for the weird, rare, and nightmares . . .

If a patient is sick enough that blood gas won't be helpful either. Wump. Wump.

 

[Laryngophed]

The case report literature exists for the weird, rare, and nightmares . . .

If a patient is sick enough that blood gas won't be helpful either. Wump. Wump.

Sad but true. I’ve seen enough left hearts failing because of right hearts that I’m not convinced anything can differentiate sometimes. Oxygenation is poor, columns are high in places they should be low and vice versa. It can be anxiety inducing. So I usually perform multiple imperfect tests and hope the combination has a PPV that lets me think I did what was best for the patient.

 

[nlax30]

I put in femoral, IJ, and axillary/subclavians every day for our procedures and I’ve just used ultrasound for guidance and confirmation. Granted mine are pretty much always done with fluoroscopy ready so I may snap fluoro once the wire is in just for extra-confirmation.

When using ultrasound I usually go in at a shallower angle so our larger/longer sheaths lay a little nicer and I always keep the needle tip visualized.

 

[coffeebythelake]

... I usually perform multiple imperfect tests and hope the combination has a PPV that lets me think I did what was best for the patient.

yes. absolutely.

 

[mimelim]

A few observations from someone who has to clean up the central lines that go wrong...

#1 The most frequent mistakes/issues come from those who are least experienced.
#2 The most catastrophic issues come from those with the most experience in life, but not quite as much in vessel cannulation.
#3 Wires are dangerous and without fluoroscopy, you really don't know where they are going.
#4 I'm pretty damn good at sticking using landmarks in emergencies, but anyone that doesn't use an ultrasound in this day and age when they can is an idiot. I am clearly biased as someone who does 15+ cannulations a week and deals with the complications of other people's sticks, but patients have all sorts of weird vascular anatomy. Most of the time it doesn't make any difference, but at least once a month I have to see someone that had a different vessel than what someone was aiming for get hit/injured. Most of the time it is from people not following the needle the entire way from skin to vessel. I get the argument that you could do a quick scan of the insertion area and know there isn't anything unusual and for experienced providers, likely all that is needed, but from a new provider stand point, I don't think anyone should be taught anything other than seeing the tip the entire way. TBH i'm kinda sick of the inferior epigastric injuries...

Tips? Mainly aimed at people starting to do lines...
1) Preparation is everything. You need a system. Not my system. Not your attending's system. YOUR system. You need to have a plan A that is incredibly well rehearsed in your head. Before you start a line, it should take you 10-15 seconds to run through the line in your head, all of your supplies and equipment should be identified and within arms reach.
2) You should always have a Plan B. It can be, "I don't feel comfortable unless everything goes perfect, so I'm going to stop, hold pressure and get someone to help me." But you need to have a plan B. If Plan B isn't, "get help", Plan C/D/E/F etc. needs to be at some point. Nobody is perfect and never needs help.
3) If there is a chance of a femoral line, always bring 2 inch silk tape.
4) Learn how to use an ultrasound and learn how to use it well. I'm not saying everyone needs to be RPVI certified, but knowing the basics goes a long way.

Again, fully acknowledge my bias, most of the lines I end up putting in are ones that others have failed or didn't bother trying to place, so I tend to be on the pessimistic side of things.