Dilated on a Carotid

[suckstobeme]

I just did the worst central line of my life.

Septic shock. US guided IJ. I got the flash of nice dark blood on a pt sat'ing 96%, the wire fed easy, I dilated, and when I pulled the dilator out I got a river of fast moving blood. Not really pulsatile, but too much pressure for someone with a BP of 80/40s. It was more than the standard post-dilator ooze, ya know?
Held pressure. Bleeding stopped. She's getting a carotid ultrasound tomorrow morning.

I kinda hate myself a little bit right now. I needed this catharsis.

Has anyone here ever dilated on a carotid?

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[Arcan57]

Condolences if in fact it was the carotid you dilated. Did you place the line or just pull the dilator and hold pressure? Did you place another CVL and if so what was the CVP? Was this under U/S guidance? I wouldn't expect a river on someone with a CVP of 2, but if they preexisting CHF or ESRD it can be difficult to visually tell the difference between venous and arterial. Especially in the absence of pulsatile flow.

From your description, it's about as likely that you just pulled a good IJ as it is that you stuck carotid.

 

[NinerNiner999]

Call me the optomist, but it sounds like you hit the IJ. Even with a pressure of 80, you would have Femoral pulses, so your Carotid pulse, being closer to the heart, should be stronger. It should have been pulsatile or at the minimum, VERY obvious you were in the carotid. You did the right thing by pulling out, but I bet all will be well...

 

[Kris1]

I had a similar situation last week. U/S guided right IJ. Aspirated dark blood that oozed from the needle after the syringe was removed. While trying to feed the wire the blood turned bright red. The wire wasn't threading anyway so I removed it and the blood came from the needle with more pressure than before. I removed the needle and held pressure. Blood was squirting out the tiny hole caused by the needle. The guy had a 2 cm pseudoaneursym of the common carotid that had to be embolized by IR. My thoughts are that I may have forced the needle through the back of the IJ into the carotid beneath while manipulating it to thread the wire.

 

[Apollyon]

I've written about this before: when I was a resident, left IJ, under U/S guidance (which was being held by my attending), with the attending being all spazzy, and I put the TLC into the L carotid. I figured to leave it, to stent it in place, but the surgical resident on vascular (one of the few I remember - she was HOT!) said to pull it immediately, and put pressure on it. I did, and it seemed to work, and I never heard more about it (so I figured there was no continuing morbidity).

 

[docB]

I've gotten pretty impressive, even pulsatile flow out of sticks that were definitely venous. If the patient has a component of cardiogenic shock that will happen. In a septic patient who is headed into multi organ system failure with global hypoxia and who has gotten a few liters of ivf you can hit them while they've gotten a bump in cvp. It can be pretty confusing. Running a gas on the blood and comparing it to a known bag can be really helpful.

 

[Punisher]

If you are unsure if you have the guide wire in the IJ, just pick up the ultrasound probe again and place it on the neck. You will be able to visualize the guide wire as a hyperechoic dot with a nice shadow behind it. You can follow the wire from the skin, all the way down the neck... it's very clear which vessel it's in. You should confirm this every time before dilating.

 

[Hamhock]

If you are unsure if you have the guide wire in the IJ, just pick up the ultrasound probe again and place it on the neck. You will be able to visualize the guide wire as a hyperechoic dot with a nice shadow behind it. You can follow the wire from the skin, all the way down the neck... it's very clear which vessel it's in. You should confirm this every time before dilating.

Additionally (and I know it was said before here or in the Anesthesiology forum), in uncertain clinical situations, you can always use the angiocath needle and then attach the angiocath up to pressure transduction...either a prepared CVP set-up or using the short length of IV tubing supplied in Arrow Cordis kits (not supplied in Arrow TLCs, usually) for a better sense.

If you use the tubing supplied (and I suggest you do before putting a relatively large Cordis into the Carotid artery when unsure), you let blood run into the tube a bit more than half way with the tubing horizontal, then raise the angle of the tubing...check to see if you have a CVP or ABP

Of course, it doesn't seem like this would have helped in the OP's situation, as the concerning flow didn't appear until after dilation.

HH

 

[suckstobeme]

I've gotten pretty impressive, even pulsatile flow out of sticks that were definitely venous. If the patient has a component of cardiogenic shock that will happen. In a septic patient who is headed into multi organ system failure with global hypoxia and who has gotten a few liters of ivf you can hit them while they've gotten a bump in cvp. It can be pretty confusing. Running a gas on the blood and comparing it to a known bag can be really helpful.

Thanks for all the well wishes.
The pt was certainly in the scenario you describe. I was thinking about this most of the night. She was a septic pneumonia that we gave 5L to and when I got the CXR after my central line misadventure, you could see her developing pulmonary edema, so her CVP was probably pretty high.

If I had a little more poise, I probably should've picked up my probe and seen where the wire was on US, or used the angiocath to transduce. As soon as I saw the river of blood under pressure, I flipped out and pulled everything out and mashed down on the spot with my thumb.

There was no hematoma or anything, which I would think you'd have with a big whole in your carotid, but I don't know.

This all makes me feel better, but I want those carotid dopplers super-stat.

 

[doctorFred]

in my admittedly limited experiences, i confirm wire placement via u/s before cath entry. it literally takes 5 seconds.. not much of a reason not to do it.

 

[southerndoc]

From your description, it's about as likely that you just pulled a good IJ as it is that you stuck carotid.

Did the patient by chance have tricuspid regurg???

 

[suckstobeme]

Did the patient by chance have tricuspid regurg???

I didn't hear any murmurs.

 

[Arch Guillotti]

I didn't hear any murmurs.

Anesthesiologist here.

So what did the dopplers show?

Sounds to me like you stuck the IJ.

I have hit the carotid a couple of times. Finder needle, no big deal. Once I cannulated it with the 18 gauge angiocath. Blood was obviously pulsatile. Puleed out and held pressure for a little bit.

To ensure placement, I ALWAYS transuce with IV tubing. If there is any real question you can always do an electrical transduction and see what the pressure is and what the waveform looks like (or look for the wire on u/s, as stated previously).

 

[GoBuckeyes913]

Sounds like you hit the IJ.
I'd have to agree with the rest above. If you dilated Big Red I'd expect you would have gotten a bright pulsatile flow (a buttload), even with a low BP.

When I first started IJs, I used to check for placement in the IJ with the ultrasound. Helpful for confirmation.

Now I just do subclavians.

 

[12R34Y]

I just did the worst central line of my life.

Septic shock. US guided IJ. I got the flash of nice dark blood on a pt sat'ing 96%, the wire fed easy, I dilated, and when I pulled the dilator out I got a river of fast moving blood. Not really pulsatile, but too much pressure for someone with a BP of 80/40s. It was more than the standard post-dilator ooze, ya know?
Held pressure. Bleeding stopped. She's getting a carotid ultrasound tomorrow morning.

I kinda hate myself a little bit right now. I needed this catharsis.

Has anyone here ever dilated on a carotid?

No worries. I have dilated 2 carotids (one as a 4th year medical student with my senior resident in ICU helping). Second one as an intern in the ICU with my senior resident "teaching" me how to put an US guided IJ in.

Both were dilated and placed. Both were pulled. Both had pressure held and no problems with either.

Don't sweat it. it happens.

later

 

[deuist]

I dilated a carotid last year as a surgical intern. It happens. Hold pressure for 15 minutes and you should be fine.

 

[Khaos]

No worries man, that is one of the known risks of doing it. Learn from it, keep your wits together and put the US on it next time. Remember that with heart failure, pulmonary edema, or other similar conditions you can have blood just poor out, even pulsatile at times.

 

[Arch Guillotti]

I dilated a carotid last year as a surgical intern. It happens. Hold pressure for 15 minutes and you should be fine.

lol, this is not exactly reassuring.

 

[deleted65604]

put the US on it next time.

This was basically the point of the OP's post. They used US. I too have used US to access the carotid (watched it penetrate the IJ apart from the clearly pulsatile carotid with my ultrasound guru attending watching me. US doesn't necessarily prevent a misplaced line.

 

[BAM!]

wait, so you just dilated and are getting increased oozing blood. doesn't all blood turn bright red as it oozes out and is exposed to air regardless if it's arterial or venous?

 

[crewmaster1]

On any ultrasound guided central line, after you place the wire you can then ultrasound the wire to determine which vessel the wire is in to confirm you have a venous line. Not so great for subclavians, but helpful.

 

[No Pain All gain]

Angiocath technique helps to avoid many of these problems. Allows transduction, prevents accidentally advancing needle when threading the wire and going out the back wall and into Big Red. Once you have your wire through the 18ga you should transduce with tubing and/or confirm wire with U/S.

 

[The White Coat Investor]

I like the idea of confirming wire prior to dilation. I've never done that but it only takes a second.

 

[EMSCC]

I like to confirm with US in long axis as well as short axis on any IJ line which I feel is higher risk prior to dilation--ie carotid directly posterior, very collapsible IJ, etc. In long axis I can make sure it's not back walled into the carotid and that it is indeed continuing to remain in the IJ.

 

[shookwell]

I agree with what a bunch of people here said. If you are using ultrasound, confirm where the wire is before dilating. I do this routinely. And it can be done with subclavians too although it's a little more difficult.

 

[Birdstrike]

I know this is an old thread, and maybe this goes against current teaching, but why not throw in a quick femoral?

If you truly need a line in the ED to save a life, your first choice should be large bore peripherals, anyways Then if you need a central line I never understood the need to always get THE PERFECT CENTRAL LINE.

Sure, there's a higher rate of infection with femorals, but that doesn't happen in the first 24 hours, and the infection rate of IJ/subclavian aren't zero. Secondly, this patient is septic and will be on every antibiotic known to man. Are you worried they're going to get septic, again?

In a crashing and critical patient the last catastrophe you want is a carotid thrombus and stroke, or a dropped lung which might not be picked up right away in a supine patient getting supine cxr's. Granted, the carotid stick in this patient is likely to amount to nothing but if it clots, it's catastrophic, and obvious what/who caused it.

The only real reason not to do a femoral is because the Hospitalist or ICU doc gets irritated that he/she has to place another line later. But so what? In a crash life-saving situation, you get the quickest line you can get. If it's not a crash life-saving situation the it can wait for ICU dude to get his perfect made to order central line later. If your femoral line gets infected, a week later that's his fault for not placing the ideal line, in ideal sterile and controlled icu conditions later once you've stabilized the patient.

If you can put in the perfect central line quickly, the fine, do it. But once you start talking about "oops, did I just cause a carotid perf/CVA or drop a lung?" then I'm immediately saying you made he wrong line choice.

I know they want every line done flawlessly now, with zero infection rate, done with ultrasound guidance and in OR like conditions, but sometimes that doesn't apply to true crash settings in the ED. So, before you do a central line, it's important to ask yourself a couple of questions:

1-Should I be placing another line choice (peripheral or IO) since you can get fluids in quicker with peripherals anyways, and should maximize that before starting pressors, anyways? And if you do decide to place a central line,

2-Am I placing, A- "The Perfect Central Line," or B- A crash life-saving central line?

If "A," the why can't it wait for perfect ICU-guy, with perfect ICU-guy hair, to place it later in perfect ICU conditions?

I don't know. Just some things to ponder.

 

[xaelia]

I know this is an old thread, and maybe this goes against current teaching, but why not throw in a quick femoral?

If you were the patient – do you want two sticks for central lines, or one?

All things being equal, it doesn't usually take that much longer to get a clean IJ as it does to get a clean femoral line. Your point on sepsis is reasonable, however, every hospital administrator in the country is watching their CLASBI rate and won't tolerate any suggestion of negative impact.

 

[shoal]

Femorals typically can be put in minutes, ijs usually take minutes to setup everything.. Ultrasound etc. Yes its only 5 to 10 minutes difference tops but sometimes that matters. Birdstrike makes some very reasonable points

Sent from my LG-D801 using Tapatalk

 

[Hair Police]

As much as I like to have things perfect for the guys upstairs, the above post mirrors my philosophy. Either it's crash line - femoral or IO - and I place it quickly and resuscitate the patient and leave pristine the places for longer-term access - IJ, subclavian. Many of these crash lines are placed in non-ideal, non-sterile situations and the ICU will replace them anyways.

Or it's something where I have the luxury of time (patient not crashing, department not busy) and I can place a line under sterile conditions, so I go for an US-guided IJ (compressible, easy to do, easy to clean, multiple ways to verify correct placement).

Similarly, if it's an issue of difficult access and I have time, I can do an US guided peripheral and patients go to the floor with them. If it's an issue of volume in a patient with good vasculature, then I get multiple peripherals. If it's an issue of blood for a test, I can do a fem stick.

OP - it happens. Next time, use the US to verify you are in the right spot. Just as a general rule, I also don't advance the dilator to the hub, as I've seen some do.

 

[pulmoblast]

Agree with Birdstrike. There are very very few reasons why you would need a perfect IJ in the ED. Just get a decent femoral, start your treatment, and leave it to the ICU to change the lines as soon as feasible. Just document that the line was not perfectly aseptic as it was placed in an emergency setting. Ideally the ICU should change the line within 24 hours. In fact I would go as far as to say that ED should not even waste thier time sticking necks at all, get the femoral in, stabilize the patient and ship him upstairs

 

[Hair Police]

If you were the patient – do you want two sticks for central lines, or one?

That's not always our choice - in some places I've been, the ICU "doesn't trust ED lines" and replaces everything regardless of technique. But if time is an issue, you go for the method of access you trust the most. Only a live patient can complain about multiple sticks.

All things being equal, it doesn't usually take that much longer to get a clean IJ as it does to get a clean femoral line. Your point on sepsis is reasonable, however, every hospital administrator in the country is watching their CLASBI rate and won't tolerate any suggestion of negative impact.

I agree - If you are placing a clean line, then we should place a good clean line. But as I described above, that confluence of factors doesn't occur often in the ED (unless you have a Line Team or procedure-hungry residents).

 

[Birdstrike]

If you were the patient – do you want two sticks for central lines, or one?

All things being equal, it doesn't usually take that much longer to get a clean IJ as it does to get a clean femoral line. Your point on sepsis is reasonable, however, every hospital administrator in the country is watching their CLASBI rate and won't tolerate any suggestion of negative impact.

For me as the patient, in order of preference, with 1 being most preferred:

1-No central line, if another route can be used.

2-One central line that does not perforate my carotid or lung.

3- Two central lines (one placed in ED in emergency setting then changed out later in controlled ICU setting) neither of which perforate my carotid, lung or are left in long enough to cause infection.

4. Any amount of central lines placed in a fashion that cause carotid perf, dropped lung, infection, but still saves my life.

5. Any amount of central lines placed in a fashion primarily focused on what keeps a non-physician CMS, Joint Commission or hospital administrator happy with numbers on paper that increase his/her quarterly bonus. That includes any procedure motivated by the ED doc's fear of losing his contract, or any placed in any way or motivated by anything other than what that particular ED doc thinks is best and safest at the time for my clinical situation to save my life and stabilize me.

 

[GeneralVeers]

I agree with birdstrike. Now that the central line for sepsis has fallen out of favor, I do a lot less of these. If I can get IV access on these patients, I go for peripherals and start treatment. No peripherals and patient is unstable? He's getting an IO. You can use the IO for 24 hours, and has already been stated the ICU can always place one later.

Another alternative I've used in very select circumstances is a long 18 gauge angiocath placed with US in the IJ. Even if you hit the carotid by mistake, there's no guidewire or dilator to mess up the artery, and you can infuse pressors through it. With US I can literally put in one of these in less than 5 min.

 

[Hercules]

I keep hearing people talk about the extra time an u/s CVL takes. Do your nurses not set these up at your shop? If it's a crash line I'm doing a quick femoral. If it's a CVL for a declining patient in the ED i tell the nurse to prep the patient. I walk in to a prepped and draped patient with the kit opened up ready to go and the u/s at bedside. It takes me less than 5 mins at that point to walk in and place the line.

 

[RustedFox]

If "A," the why can't it wait for perfect ICU-guy, with perfect ICU-guy hair, to place it later in perfect ICU conditions?

I don't know. Just some things to ponder.

What does Perfect ICU-guy hair look like ?

 

[xaelia]

Another alternative I've used in very select circumstances is a long 18 gauge angiocath placed with US in the IJ.

Love this line. I did a billion u/s guided deep brachials/basilics for my "nurses" in residency, but now that I don't have the time to muck around I go straight to the neck. If the EJ is there, great. If the EJ isn't, the IJ is.

 

[Birdstrike]

What does Perfect ICU-guy hair look like ?

Exactly like this:

 

[RustedFox]

Guy needs to see derm.

 

[Birdstrike]

Guy needs to see derm.

And addiction psych, due to the unfortunate drinking choice of a Pina Colada. At noon. At Trader Vic's. But come on, put yourself in his shoes, man. Being a central-line placing werewolf ain't easy. Especially in London.

 

[RustedFox]

I live in Pina-Colada town down here in Florida. That stuff is gross, even here.

 

[dotcb]

Answer to the OP-

At my hospital, if you place a cordis or TLC in an artery, I'd leave it in, consult IR, and get another form of IV access. If we didn't have IR, I'd consult vascular or general surgery. It's sort of cultural, but you definitely need to own up to these complications. They happen in the ED, ICU, OR, etc.

Virtually 100% of our central lines are US-guided. I always trace the wire on US once it's been placed before dilating. I never do the fluid column, but it's an option if there's uncertainty.

We put a cordis in the subclavian artery about 2 years ago.

 

[Daiphon]

...in a rapidly dying patient, if they survive long enough to complain about being stuck twice (groin + IJ/SC), then I consider that a win.

I agree with Birdstrike above. Femoral FTW in a rapidly crashing patient. I can get the line into the groin in less time than it takes me to open the package; plus, this site avoids the whole US/"sterile"/bouncing equipment if you can put your line in below the compressions/intubation/etc.

Furthermore, as to the "infection rate" shenanigans that everyone likes to quote, I direct you here (in a CCM journal, no less, so the intensivists can't really b*tch): http://www.ncbi.nlm.nih.gov/pubmed/22809915

Finally, to the residents on this board, PLEASE spend at least a little time learning how to do these (fem/ij/sc) without the crutch that is US. When you're out in practice, some shops don't have US, some codes are like what I'm saying above and US is really tough to use, and sometimes the machine breaks. Knowing your landmarks is essential for getting the line the patient needs. Now, I'm not saying abandon US because, yes, it does improve the safety of the procedure... but only being able to do this with direct visualization under US guidance is like only learning how to intubate with a Glidescope; sometimes the excrement hits the oscillating air moving device, and you need to know another way... or just IO every bone they have and go at it. d=)

Cheers!
-d

 

[Birdstrike]

...in a rapidly dying patient, if they survive long enough to complain about being stuck twice (groin + IJ/SC), then I consider that a win.

I agree with Birdstrike above. Femoral FTW in a rapidly crashing patient. I can get the line into the groin in less time than it takes me to open the package; plus, this site avoids the whole US/"sterile"/bouncing equipment if you can put your line in below the compressions/intubation/etc.

Furthermore, as to the "infection rate" shenanigans that everyone likes to quote, I direct you here (in a CCM journal, no less, so the intensivists can't really b*tch): http://www.ncbi.nlm.nih.gov/pubmed/22809915

Finally, to the residents on this board, PLEASE spend at least a little time learning how to do these (fem/ij/sc) without the crutch that is US. When you're out in practice, some shops don't have US, some codes are like what I'm saying above and US is really tough to use, and sometimes the machine breaks. Knowing your landmarks is essential for getting the line the patient needs. Now, I'm not saying abandon US because, yes, it does improve the safety of the procedure... but only being able to do this with direct visualization under US guidance is like only learning how to intubate with a Glidescope; sometimes the excrement hits the oscillating air moving device, and you need to know another way... or just IO every bone they have and go at it. d=)

Cheers!
-d

I n t e r e s t i n g . Excellent reference. Thank you.

"CONCLUSIONS: Although earlier studies showed a lower risk of catheter-related bloodstream infections when the internal jugular was compared to the femoral site, recent studies show no difference in the rate of catheter-related bloodstream infections between the three sites."

http://www.ncbi.nlm.nih.gov/pubmed/22809915

 

[e30ftw]

fem lines are useful because you can place one during CPR.

you can also place IOs during CPR.

I tend to place a lot more IJs and SC lines than femorals however because at an academic center a lot of the lines are "well their BP is not responding to IVF so even though they're talking and alert admitting team wants central access in case of further deterioration." which is fine but means i have time to place a line that will be clean and stay. plus have you seen the average obese critically ill americans inguinal crease lately? imo it's easier just to stick their chest

For emergent lines I don't see anything wrong with just doing a subclavian with sterile technique unless you're actively doing CPR and can't get an I/O in which case go femoral.

I will say a few times in obese/dehydrated patients I have been unable to pass a fem line even w/ U/S probably due to unviewed thrombus/scar tissue/???? in which case I just place an IJ which is a pretty foolproof line if you use U/S correctly and double check your wire placement.

If I were a living conscious patient I would want an U/S guided IJ.

 

[GeneralVeers]

If I were a living conscious patient I would want an U/S guided IJ.

If I was living AND conscious I wouldn't want any form of central line. If I'm mentating enough to refuse, it probably means I don't need pressors and/or invasive cardiac monitoring. I would want peripheral access, and if that was insufficient then a PICC line. If I'm sick enough that I'm unconscious or intubated, then it doesn't matter.

 

[Instatewaiter]

I know this is an old thread, and maybe this goes against current teaching, but why not throw in a quick femoral?

If you truly need a line in the ED to save a life, your first choice should be large bore peripherals, anyways Then if you need a central line I never understood the need to always get THE PERFECT CENTRAL LINE.

Sure, there's a higher rate of infection with femorals, but that doesn't happen in the first 24 hours, and the infection rate of IJ/subclavian aren't zero. Secondly, this patient is septic and will be on every antibiotic known to man. Are you worried they're going to get septic, again?

In a crashing and critical patient the last catastrophe you want is a carotid thrombus and stroke, or a dropped lung which might not be picked up right away in a supine patient getting supine cxr's. Granted, the carotid stick in this patient is likely to amount to nothing but if it clots, it's catastrophic, and obvious what/who caused it.

The only real reason not to do a femoral is because the Hospitalist or ICU doc gets irritated that he/she has to place another line later. But so what? In a crash life-saving situation, you get the quickest line you can get. If it's not a crash life-saving situation the it can wait for ICU dude to get his perfect made to order central line later. If your femoral line gets infected, a week later that's his fault for not placing the ideal line, in ideal sterile and controlled icu conditions later once you've stabilized the patient.

If you can put in the perfect central line quickly, the fine, do it. But once you start talking about "oops, did I just cause a carotid perf/CVA or drop a lung?" then I'm immediately saying you made he wrong line choice.

I know they want every line done flawlessly now, with zero infection rate, done with ultrasound guidance and in OR like conditions, but sometimes that doesn't apply to true crash settings in the ED. So, before you do a central line, it's important to ask yourself a couple of questions:

1-Should I be placing another line choice (peripheral or IO) since you can get fluids in quicker with peripherals anyways, and should maximize that before starting pressors, anyways? And if you do decide to place a central line,

2-Am I placing, A- "The Perfect Central Line," or B- A crash life-saving central line?

If "A," the why can't it wait for perfect ICU-guy, with perfect ICU-guy hair, to place it later in perfect ICU conditions?

I don't know. Just some things to ponder.

I have seen an absolute ton of "emergent" lines placed in the ER that ended up with terrible groin complications from missticks. RP bleeds, fistulas. So you guys may not see it but up in the ICU we get to see the fall out.

If you need quick access why not IO, stabilize and then put in an IJ when you have more time. Plus, most people can place an IJ just as fast as a fem line. Unless they have clots bilaterally in the neck, you don't have a great leg to stand on to put in a fem line anymore.

 

[dotcb]

I haven't done a groin line in over 2 years, but can you quantify "an absolute ton?"

I think that blind groin lines are unwise, but fem lines can be appropriate in some patients and should always be done sterile and with ultrasound.

 

[Rendar5]

I have seen an absolute ton of "emergent" lines placed in the ER that ended up with terrible groin complications from missticks. RP bleeds, fistulas. So you guys may not see it but up in the ICU we get to see the fall out.

If you need quick access why not IO, stabilize and then put in an IJ when you have more time. Plus, most people can place an IJ just as fast as a fem line. Unless they have clots bilaterally in the neck, you don't have a great leg to stand on to put in a fem line anymore.

Complications can happen from any central line with a fairly consistent rate of 5%. I even know a recent case of a compartment syndrome from an io that drew back well and flashed but somehow then infiltrated the deep compartment. I know I agree that the overall application rate is still lower than that for central time.
I would still find it hard to believe that anyone in IJ in the femoral line. You have to include the time that it takes for you or your nurse to set you up for it. A femoral line came place with in less than two minutes early. A sensual IJ choose to help take at least 5 to 10 minutes.

I realize that there are some people that think a femoral line should be done via us guidance too. I'm not sure if there any studies that show is lower complication rate for that as they do for other veins. I would love to see that though, as I have some time needed to use that for especially hard to several lines, at least in residency

 

[Doctor Bob]

A sensual IJ choose to help take at least 5 to 10 minutes.

I don't know how you do your IJs... but when I'm doing a sensual line it takes a bit longer than that. I mean... the prep alone... making sure the position is comfortable, plenty of lubrication on the probe...


Wait, what are we talking about?

 

[Instatewaiter]

I haven't done a groin line in over 2 years, but can you quantify "an absolute ton?"

I think that blind groin lines are unwise, but fem lines can be appropriate in some patients and should always be done sterile and with ultrasound.

Quantify exactly? Probably not but it is a high volume ICU at a quarternary care center. We are fed by about 20 ERs and even more hospitals. They send us their post-cardiac arrest patients so we see a lot of patients who crashed in an ER. We see a bunch of groin complications from the places that placed a groin line. I'd guess we see 2-5 bad groin complications per month.