Do Other Specialties Use US for Central Lines?

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So if ultrasound guidance for central lines is the standard in the ED is it also the standard for other specialties who place central lines? Obviously it is for radiology but many other specialties place lines too. Anesthesia, surgery and its subspecialties, critical care, cardiology and so on. I've never heard of or seen any of these docs calling for ultrasound guidance for thier lines.
 
Where I did my surgery clerkship, there was a dedicated old school sono-sight machine with an itty-bitty screen. The surgery residents would sometimes use it to look at the anatomy before prepping but then they would just put the probe down, prep, and put it in blind.
 
Our hospital just ordered a Sonosite for the ICU. The CC docs plan to use it for lines and procedures I guess....I think anesthesiology has one in the OR to place lines as well...

When I worked at Kaiser, the PICC line RNs had one that they used for PICC line insertions.
 
WallowaWanderer said:
Where I did my surgery clerkship, there was a dedicated old school sono-sight machine with an itty-bitty screen. The surgery residents would sometimes use it to look at the anatomy before prepping but then they would just put the probe down, prep, and put it in blind.
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That's kind of funny, did they think they had "the anatomy" memorized?

At one of the places I rotated I saw IM residents using U/S routinely, although I suspect this had as much to do with EM's absolute dominance of the hospital as anything else.
 
AmoryBlaine said:
That's kind of funny, did they think they had "the anatomy" memorized?
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I think some people just do it that way. They use the ultrasound to establish the patency of the vessel, make sure there's no clot in the vicinity, pick the approximate point where the vein is closest the skin and overlap with the artery is minimal, and assess the course of the vessel .... then put the ultrasound down having established *that* person's subtle anatomic features and stick.

Others are more comfortable keeping the ultrasound on with the non-dom hand while they stick.

I've used both. I usually take a look and if it's just such a whopping vessel anyway, I'll often just put it down. If there is a lot of venous/artery overlap, for instance, I'll probably use the two handed approached until I get a good venous flash.
 
docB said:
So if ultrasound guidance for central lines is the standard in the ED is it also the standard for other specialties who place central lines? Obviously it is for radiology but many other specialties place lines too. Anesthesia, surgery and its subspecialties, critical care, cardiology and so on. I've never heard of or seen any of these docs calling for ultrasound guidance for thier lines.
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IM here and I routinely use US for putting in lines. I can and have put in lines during codes w/o it but much prefer to have some visual guidance. Both of our MICUs (as does the SICU, I haven't looked in the Neuro or Trauma ICUs) have Sono-sites and we routinely bring them to the floor if needed. I've also used them for thoracentesis on the fattys when I can't reliably tap out the effusion.

It is expected that we use them and our line insertion note templates have a place to note the use (or not) of US guidance.

Having said all that, I've seen one of our SICU attendings prep, insert and suture a subclavian line blind faster than I can put the little sterile condom on the US probe so there's certainly a place for being able to do it w/o US but, in most settings I think it's the way to go.
 
It seems like most anesthesia residency programs train their residents to be able to place central lines blindly. U/s is used for regional anesthesia/blocks.
 
We use U/S for all non-emergency central lines.

I always put a dot based on landmarks of where I would go. I then scan the neck with U/S. This way I can test myself on landmarks.

We use the U/S to visualize the placement of a Cordis, Double Lumen Cordis, or Veno-Veno dilators.

I always transduce to confirm venous guidwire placement. It takes an extra 15 seconds but it saves you from dilating the carotid. Nobody likes calling in vascular for dilating a big artery...major loss of bonus points.
 
Our ICU has a Sonosite that the CC docs use for line placement.

I read an op note by one of our surgeons where he was placing a port and in the process could not blindly access either the IJ or subclavian veins. He then used the U/S to access the IJ. I took away from it that our surgeons use the U/S as their backup if traditional landmarks fail.
 
gutonc said:
IM here and I routinely use US for putting in lines. I can and have put in lines during codes w/o it but much prefer to have some visual guidance. Both of our MICUs (as does the SICU, I haven't looked in the Neuro or Trauma ICUs) have Sono-sites and we routinely bring them to the floor if needed. I've also used them for thoracentesis on the fattys when I can't reliably tap out the effusion.

It is expected that we use them and our line insertion note templates have a place to note the use (or not) of US guidance.

Having said all that, I've seen one of our SICU attendings prep, insert and suture a subclavian line blind faster than I can put the little sterile condom on the US probe so there's certainly a place for being able to do it w/o US but, in most settings I think it's the way to go.
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I find the ultrasound cumbersome for the subclavian route anyway... plus, this is my "go to" line, so I'm much more confident with it. I suspect this was the case for your SICU attending.

However, if I've got time in a stable patient, my confidence game isn't as important to me, and I'll take the time to use an ultrasound to do an IJ. The more the patient trends towards unstable, the more I start to think about trying a subclavian approach, often with a wide prep with chlorhexidine while someone else gets the ultrasound ready in case I have to abort and try the IJ.
 
VentdependenT said:
We use U/S for all non-emergency central lines.

I always put a dot based on landmarks of where I would go. I then scan the neck with U/S. This way I can test myself on landmarks.

We use the U/S to visualize the placement of a Cordis, Double Lumen Cordis, or Veno-Veno dilators.

I always transduce to confirm venous guidwire placement. It takes an extra 15 seconds but it saves you from dilating the carotid. Nobody likes calling in vascular for dilating a big artery...major loss of bonus points.
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I like your style - using the dot to test yourself... but I'm not sure why you transduce so often.

An experienced operator should only rarely be uncertain that the flash is venous -- presumably in those patients who are hypotensive and/or hypoxic such that even an arterial flashback could occur suitably sluggish or dark colored respectively. Plus, the time it takes to set up the transducer, I suspect, is dependent on your environment. I can tell you in my ER, it would take a lot longer than 15 seconds 😉.

However, I have used it a few times for exactly these types of circumstances, so I do agree that it is useful to have in your arsenal. I just don't think there is any reason to be dogmatic about it for every line, given the time and effort.
 
I guess this thread has already been hijacked so...

My algorithm:

If a patient is crashing & needs a line while someone else is managing airway I'll put a Cordis in a femoral blindly - usually takes about 90 seconds start to finish, occasionally longer if they're scarred down, bone dry, etc.

If a patient needs a line pronto, appears septic (thus needing a neck line), and I have acces to the upper body I'll throw a triple lumen in the SC blindly(still not comfortable with putting a garden hose in a non-compressible site). Usually takes about 2-3 minutes.

If I have at least 5 minutes to work on the line, or if the patient is known to be coagulopathic, or if I suspect intravascular depletion will make things difficult I will go with an U/S guided IJ. I generally get someone to help & have one person's eyes on the screen - ensuring we're not off target - while the other eyes are looking for a flash. I have yet to have any complications with this, and almost never require multiple sticks. It takes an extra 3 minutes or so of set-up, and does require someone eles's hands. However, when you think of how much time gets used up when a coratid gets canulated or a lung dropped then I think you're still in the black even with those complications occuring only rarely.

Personally, I'd rather have an intern placing a central line in me with U/S guidance than an attending placing one blindly - there is just a lot less guess work when you can see the vessels. Sure, you need to know how to do both, but it's much better for the patient to do it with guidance when possible.
 
bulgethetwine said:
I can tell you in my ER, it would take a lot longer than 15 seconds 😉.
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I am pretty sure that he means he is transducing the "poor man's" way. that is, hook up a piece of IV tubing to your catheter, drop it down to let it fill, then raise it up and watch the venous blood level fall.
 
i once hit the carotid twice under US guidance when both myself and the ICU attending were 99.9% sure i was sticking the IJ. it was compressible (and next to a non-compressible vessel) and we could see the needle denting the vessel just before getting a bright red, pulsatile flash. same thing happened on stick #2. ended up placing a blind subclavian without problems. still not sure what the deal was, but there was a fair amount of swearing.
 
Hawkeye you say you saw it denting then I assume you are using the transverse view which is usually the first one taught. What you describe is not that uncommon if you are not also tilting the probe to follow the actual tip of the needle. Also it is pretty common to go through the IJ without a flash because it is so compressible - if the carotid is behind it you'll get a carotid flash.

Also for those who have not done this much yet - in the supine patient, especially those on the vent, the IJ blood is often pretty red and pulsatile, the difference is it won't squirt like that from an a-line.
 
We use them on all necks and most legs. We also don't do a lot of subclavian lines.
 
IN SURGERY i make my juniors always use u/s for line placement. if it is readily avail
 
ESU indirectly makes a good point - I think you still need to know how to place a line blindly for those code/emergency situations where US is not available. It may be hard for some to believe but I have worked with at least one resident who I think had never done one blind and when asked refused to do so. I put it in myself.
 
I can't say that I've seen many of my surgical colleagues use it routinely. During residency there was a SonoSite in the Anesthesia work-room but to be honest, most of us didn't know where that was and only inquired about using it if we failed to be able to place the line blindly. I was never taught to use it but did see Anesthesia use it on rare occasions...usually a CA-1 with an obese patient.

Like most things, its probably a matter of who taught you in the first place (ie, whether or not they used U/S) or mistakes guiding your practice. And like Seaglass notes, it is important to be able to do it without U/S in emergent cases. In most places, the U/S is nowhere close to where you need it to be in an emergency.
 
Kimberli Cox said:
I can't say that I've seen many of my surgical colleagues use it routinely. During residency there was a SonoSite in the Anesthesia work-room but to be honest, most of us didn't know where that was and only inquired about using it if we failed to be able to place the line blindly. I was never taught to use it but did see Anesthesia use it on rare occasions...usually a CA-1 with an obese patient.

Like most things, its probably a matter of who taught you in the first place (ie, whether or not they used U/S) or mistakes guiding your practice. And like Seaglass notes, it is important to be able to do it without U/S in emergent cases. In most places, the U/S is nowhere close to where you need it to be in an emergency.
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Dr Cox,

If you were placing an IJ on a stable patient today, and there was an US in the corner of the room, would you use it? What I'm getting at is now that the technology is there and available (esp in the ED), aren't we obligated to use it since it is safer for the patient?
 
WallowaWanderer said:
Dr Cox,

If you were placing an IJ on a stable patient today, and there was an US in the corner of the room, would you use it? What I'm getting at is now that the technology is there and available (esp in the ED), aren't we obligated to use it since it is safer for the patient?
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No I wouldn't. Two reasons:

1) I am comfortable doing lines without U/S
2) anytime you change your routine you run the risk of hurting the patient.

Obviously should it become standard of care, or expected practice, then that would change but for the most part, I think that when you try and change your practice habits, especially when doing invasive procedures, you run the risk of hurting the patient. That isn't mean to imply that one should never change but rather if a change is contemplated, then it needs to become the new standard.

The risk of doing a line is not zero, but its one reason why I (and many others I know) am very meticulous about how we set up things...deviation from the usual = possible prescription for disaster. I have gotten to the point where I get almost any line in that I attempt and without complications. I would be willing to bet that if I changed to use the US everytime, that success rate would actually drop and the complication rate would increase...at least for a time. Sounds counterintuitive I know.

However, for the situation as you describe it, if one is training and starts from the beginning using US, its a good idea BUT everyone should be facile at putting a line in without US. As noted above, there are emergent situations and facilities that don't have an easily accessible machine.

And what is safer? The physician that can only put in a line under US or one who is facile doing it both ways and chooses one or the other because he/she is more comfortable? I use it every day in the office for biopsies on non-palpable masses and only use it on palpable ones that are close to the chest wall or to document placement of a clip but have no reason to do so for central lines or ports.
 
Kimberli Cox said:
2) anytime you change your routine you run the risk of hurting the patient.
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Thats always been my feeling as well.

When I first started doing US guided lines I was thinking, "What a pain" It was a pain to set up. It seemed like it increased my chances of breaking my sterility. Made me feel like I had two hands full of thumbs when what I needed was three right hands to hold everything. It basically made me feel all nervous and twitchy which you don't want to be when you are sinking a giant needle in someones neck.

Initially I used it only for difficult lines where someone had already failed a few tries. Now I'm comfortable enough to use it for routine lines but I still feel fine doing 'em blind.
 
So the discussion seems to indicate that the use of US for lines in the rest of the hospital is intermittant or site dependent. So that begs the questions:
-Is it valid to say that something is the standard of care for one specialty but not another? Consider carefully because this question has some deep ramifications.
-If someone feels comfortable doing lines blindly and they have a complication, a known complication like an art stick or a pneumo, are they/should they face higher liability?
-If a center decides that US is the standard of care should they change their DOPs accordingly? That's hospital admin speak for should they make it so that only docs trained in US guided lines could do them? One could envision a situation where EPs are called up to the floors to put in lines (don't laugh, that's what happens to me once a week or so because the internists don't do lines).
 
We don't, although I bet it would be a really great teaching tool, or helpful on those really fractious/hard to find pts.

Edit: We already use US for cystocentesis, I don't see why it wouldn't be possible to use it for central line placement-since we already shave the hair for the line-it's not like the hair would interfere...

Kind of off topic here, but isn't there a training DVD one of the IVC makers puts out that covers central and arterial lines and what not?

Edit: It's MILA I guess. And I did also find some good info in the pearls section over on the anaesthesia forum
 
ERMudPhud said:
Thats always been my feeling as well.

When I first started doing US guided lines I was thinking, "What a pain" It was a pain to set up. It seemed like it increased my chances of breaking my sterility. Made me feel like I had two hands full of thumbs when what I needed was three right hands to hold everything.
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That's how I feel just starting out. I have this complex procedure (for me) with lots of steps, and the patient is moaning under the sheet while I stick a huge needle in their neck, and I'm just learning how to hold the needle and aspirate at the same time, and then I have to hold the freaking ultrasound probe as well. Geesh.
 
Orthonut said:
We don't, although I bet it would be a really great teaching tool, or helpful on those really fractious/hard to find pts.

Edit: We already use US for cystocentesis, I don't see why it wouldn't be possible to use it for central line placement-since we already shave the hair for the line-it's not like the hair would interfere...

Kind of off topic here, but isn't there a training DVD one of the IVC makers puts out that covers central and arterial lines and what not?

Edit: It's MILA I guess. And I did also find some good info in the pearls section over on the anaesthesia forum
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Not to be offensive, but why are you relating use of ultrasound in animals with a question about ultrasound in humans? Most people on this board have no interest what a veterinarian uses for intravenous access. It's a topic which I'm curious about, but it has no reason to be placed in the emergency medicine forum.
 
With regard to Doc-b's above comment - I think that the data is pretty clear that US guided IJ lines have less complications than blind sticks in the ED and ICU in teaching hospitals. I am unaware of any large studies in private hospital settings. One study of trauma residents showed decreased sucess (perhaps due to factors that Dr. Cox mentioned).

I do not think there are enough data yet to show that US guided IJ's are standard of care given the number of providers that place these lines and the differences in their training. I do think that if you have to opportunity to learn to do it then it can be very helpful for difficult lines and should (by the numbers) make your line placements safer.

I think it is definitely fine to say something is standard of care for one specialty but not for another. The 55 year old 4 day intermittent chest pain that gets an outpatient eval and sent home with f/u by the PCP would be different than our workup but would probably meet standard of care for FP/IM.

Regarding liability for complications, there are known complications for placing lines and unless a provider shows an unusually high rate of complications I don't think they should face a higher liability premium. Use of US does not completely prevent complications.

DOP (deliniation of priveledges - what you're allowed to do in the hospital for our newer members) is more political. I cannot see anesthesia or surgery willing to lose their priveledges for this due to evidence which currently is strong but not strong enough. I think if the hospital makes it a standard practice then the should be willing to get their docs trained in it so care can be delivered in more or less the same manner.
 
The above said I bet the Joint Commission will make US guided IJ a quality measure in the next 2-3 years. JCO doesn't care about quality of data.
 
I think an interesting topic is brought up here. The need for people to do lines blindly and therefore foregoing the use of ultrasound when it is available.

I think that when US is available, it should be used. If you do not have time to set it up, you should be able to do a line without it (i.e. crash line).

For those people that make the argument that people should do lines without US guidance when it is available, I try to equate it to patients presenting to the ED with STEMIs.

Residents need to learn how to treat STEMIs with both sending patients to the cath lab as well as treating them with thrombolytics. Afterall, they may work at a place where there is no cath team available. Just the same, residents should learn how to place lines with both US and without as they may work at a place where US is not available.

With that being said, we do not take a select group of STEMIs that present to the ED, and even though we can readily get the patients to the cath lab, state to them, "sorry, but you are the one that the residents need to learn how to treat using thrombolytics despite the fact that the data states you wil have a better outcome if we send you to the cath lab". Simply put, this is not acceptable. The patients that get thrombolytics are the ones that for one reason or another, cath lab is not available when we need it.

So, this should be the same thing for US for central lines. If for some reason we cannot use US (i.e. crash line), then we do them without US guidance. But, why should we take a patient, when we have something that has been shown to increase patient safety (US) and then not use it? Just does not make sense if you ask me.

Just my thoughts.
 
EMIMG said:
I think an interesting topic is brought up here. The need for people to do lines blindly and therefore foregoing the use of ultrasound when it is available.

I think that when US is available, it should be used. If you do not have time to set it up, you should be able to do a line without it (i.e. crash line).

For those people that make the argument that people should do lines without US guidance when it is available, I try to equate it to patients presenting to the ED with STEMIs.

Residents need to learn how to treat STEMIs with both sending patients to the cath lab as well as treating them with thrombolytics. Afterall, they may work at a place where there is no cath team available. Just the same, residents should learn how to place lines with both US and without as they may work at a place where US is not available.

With that being said, we do not take a select group of STEMIs that present to the ED, and even though we can readily get the patients to the cath lab, state to them, "sorry, but you are the one that the residents need to learn how to treat using thrombolytics despite the fact that the data states you wil have a better outcome if we send you to the cath lab". Simply put, this is not acceptable. The patients that get thrombolytics are the ones that for one reason or another, cath lab is not available when we need it.

So, this should be the same thing for US for central lines. If for some reason we cannot use US (i.e. crash line), then we do them without US guidance. But, why should we take a patient, when we have something that has been shown to increase patient safety (US) and then not use it? Just does not make sense if you ask me.

Just my thoughts.
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Good points. I think the most vocal proponents of US would argue that US should never be unavailable. I would say that the best way to train would be to have a program where the operator selects a site based on landmarks, then uses US to verify the site. Then the operator should be able to place with or without if needed.
 
The problem with making U/S guided lines a standard of care is that IJ's have been shown to have higher rates of catheter-related infections. Subclavians are by far the cleanest lines. The rates of infection and thrombosis secondary to lines in the IJ should not be ignored.
 
Excellent point Southerndoc.

EMIMG - regarding NOT using US when it is available so that you can learn to do it blindly - the difference between this and your STEMI analogy is that, at least for us, the difference in STEMI treatment is essentially the difference between calling a consultant and pushing a drug. Line placement is a tactile skill and you may "know how to do it blind" by reading a book, but you're not going to have the same level of skill. I thinkn that Doc-b's post about taking a lok and then going blind is probably a good compromise.
 
Southerndoc, you brought up infection rates.

I haven't seen this in awhile but do you know the difference in infection rates between IJ and supraclavicular approach to subclavian lines?

From a practical standpoint, it sure doesn't seem like there's much real estate in between the two. Just curious to see if that distance makes a difference.

Take care,
Jeff
 
Jeff, I'll see if I can drum up the data. We have data from our own institution, and I also have some data from prior studies buried in my filing cabinet.

The problem with IJ's is that with neck movement, the occlusive dressing often becomes dislodged. Hair and other things can come into contact with the catheter if this dressing is not intact. I once saw a CHF patient in the CCU getting dobutamine through a TLC placed in his R IJ trying to SHAVE AROUND HIS TLC! He had shaving cream around the catheter! That doesn't help with infection control that's for sure.
 
IJs are definitely more clean than femoral lines.
The way we do it, is if you are going into the neck on anyone that is not actively dying (everyone else is passively dying), you should place it with the SiteRite. Risks of subclavians blind over IJs with U/S are too high, and I have personally seen too many people die from subclavian lines (n=3, and I didn't place any of them). I have seen 1 person die from a femoral, and 1 from an IJ as well, and I'm just an intern (not all of these happened during my intern year, and none of them are my fault, yet). Point is, central lines have a high enough mortality that you shouldn't do them without U/S guidance on just about everyone. I have seen people with anatomical anomalies this week trying to place femoral vas caths. One had the femoral vein under the femoral artery. Never would have hit that without ultrasound.
While people like to act like the ability to hit something is a skill, remember, it is just like starting an IV. Once you learn how to cannulate, the rest is just finding things to put the needle into. Too many things in the neck/chest that I don't want to stick something sharp in just because I didn't feel like wheeling the U/S down.
I compare it to the glide scope. For the life of me, I don't know why there aren't more of these things around. I know they aren't cheap, cleaning is a pain, etc, but you never see "just the arytenoids" with a glide scope, and you don't have your view obscured by the tube until it actually passes by the cords. But nobody uses them, instead sticking with the old standby. I can guarantee that in 10 years (maybe less), they will be everywhere, and will be the new standard as mandated by the IOM, JCAHO, or whatever other government organization feels like making it so (CMS).
 
I don't think anyone's disputing that IJ's are cleaner than femorals. A femoral left in more than 24-48hrs is just begging for an infection. Esp in an obese patient. But IJ's are more prone to infection than subclavians.

And I agree on the glidescopes . . . they rock! Although its good to know how to use a blade too.
 
Some recent-ish data on line insertion site and infection/colonization rate:

For those who are too busy/can't be bothered to read through, here's a summary in my own words.

Study 1 - Einstein/Monte/Jacobi, MICU, all lines done by MICU attendings and fellows: Subclavian = IJ << Femoral

Study 2 - Spanish hospital, Med/Surg ICU, all CVCs over a 3yr (2000-3) period: Subclavian < IJ << Femoral

Study 3 - Japanese hospital, all non-OR/HD unit central lines in a 1y period: ICU/ED - Subclavian < IJ << Femoral; General wards (Cards, Onc, Med/Surg) - Subclavian = IJ << Femoral

I only looked at studies in the past 3 years so I'm sure you could find older stuff w/ different data but I think it would be less relevant given changes in use of sterile technique and US guidance over the past few years.

As I see it, the moral of the story is, if you're going to get a CVC in the unit in the Bronx, it doesn't really matter if it's SC or IJ. If you're going to get one in Spain, ask for an IJ. And if you're going to get one in Japan, make it an SC unless you're on the floor, then SC or IJ will be fine.

1. Crit Care Med. 2005 Jan;33(1):13-20; discussion 234-5.

MEASUREMENTS AND MAIN RESULTS: In an intensive care unit population, we prospectively studied the incidence of central venous catheter infection and colonization at the subclavian, internal jugular, and femoral sites. The optimal insertion site for each individual patient was selected by experienced intensive care physicians (critical care medicine attendings and fellows). All of the operators were proficient in inserting catheters at all three sites. Confounding factors were eliminated; there were a limited number of experienced operators inserting the catheters, a uniform protocol stressing strict sterile insertion was enforced, and standardized continuous catheter care was provided by dedicated intensive care nurses proficient in all aspects of central venous catheter care.Two groups of patients were analyzed. Group 1 was patients with one catheter at one site, and group 2 was patients with catheters at multiple sites. Group 1 was the primary analysis, whereas group 2 was supporting.A total of 831 central venous catheters and 4,735 catheter days in 657 patients were studied. The incidence of catheter infection (4.01/1,000 catheter days, 2.29% catheters) and colonization (5.07/1,000 catheter days, 2.89% catheters) was low overall.In group 1, the incidence of infection was subclavian: 0.881 infections/1,000 catheter days (0.45%), internal jugular: 0/1,000 (0%), and femoral: 2.98/1,000 (1.44%; p = .2635). The incidence of colonization was subclavian: 0.881 colonization/1,000 catheter days (0.45%), internal jugular: 2.00/1,000 (1.05%), and femoral: 5.96/1,000 (2.88%, p = .1338). There was no statistically significant difference in the incidence of infection and colonization or duration of catheters (p = .8907) among the insertion sites.
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2. Crit Care. 2005;9(6):R631-5. Epub 2005 Sep 28

METHODS: This is a prospective and observational study, conducted in a 24-bed medical surgical intensive care unit of a 650-bed university hospital. All consecutive patients admitted to the ICU during 3 years (1 May 2000 and 30 April 2003) were included. RESULTS: The study included 2,018 patients. The number of CVCs and days of catheterization duration were: global, 2,595 and 18,999; subclavian, 917 and 8,239; jugular, 1,390 and 8,361; femoral, 288 and 2,399. CRLI incidence density was statistically higher for femoral than for jugular (15.83 versus 7.65, p < 0.001) and subclavian (15.83 versus 1.57, p < 0.001) accesses, and higher for jugular than for subclavian access (7.65 versus 1.57, p < 0.001). CRBSI incidence density was statistically higher for femoral than for jugular (8.34 versus 2.99, p = 0.002) and subclavian (8.34 versus 0.97, p < 0.001) accesses, and higher for jugular than for subclavian access (2.99 versus 0.97, p = 0.005). CONCLUSION: Our results suggest that the order for punction, to minimize the CVC-related infection risk, should be subclavian (first order), jugular (second order) and femoral vein (third order).
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3. J Infect Chemother. 2006 Dec;12(6):363-5.

The most important targets of hospital-acquired infection control are to reduce the incidence of surgical-site, catheter-related, and ventilator-associated infections. In this report, we address previously presented infection-control strategies for central venous (CV) line catheterization, using a CV catheter-related infection surveillance system. Data concerning CV catheter insertion were collected from all facilities in our 650-bed hospital, excluding the operating and hemodialysis wards. Collected data included the insertion method, purpose, length of catheter inserted, duration of catheterization, infection rate, and complication rate. Catheter-related infection was diagnosed based on bacteriological examinations from blood cultures. The total number of catheterizations was 806 a year, and average duration of catheterization was 9.8 days. The purpose of catheterization was nutritional support in 210 cases, hemodialysis in 96 cases, cardiac support in 174 cases, and other treatments in 260 cases. In 66 cases, the purpose of CV catheter was not specified. The rate of positive cultures was 7.1%, and complications other than infection occurred in 0.5%. The main causative organisms were methicillin-resistant Staphylococcus aureus (MRSA) in 38.6%, coagulase-negative Staphylococcus epidermidis (CNS) in 33.3%, and S. aureus in 12.3% of infections. Infection rates were 3.8 per 1000 catheter-days in subclavian, 6.1 in jugular, and 15.7 in femoral vein catheterization. In high-risk departments (intensive care unit [ICU] and emergency departments) the infection rate was 5.4 for subclavian and 10.2 for jugular catheterization, whereas it was 3.6 for subclavian and 4.6 for jugular catheterization in noncritical-care departments. Considering complications such as pneumothorax, CV catheterization of the jugular vein is recommended in certain situations.
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southerndoc said:
Not to be offensive, but why are you relating use of ultrasound in animals with a question about ultrasound in humans? Most people on this board have no interest what a veterinarian uses for intravenous access. It's a topic which I'm curious about, but it has no reason to be placed in the emergency medicine forum.
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none taken! I apologize for the hijack. I was just researching ways to help my staff learn better CL placement techniques and was excited to find y'all discussing the same topic. I should have started a different thread! Thanks for the kick in the pants 🙂
 
Dr.McNinja said:
I compare it to the glide scope. For the life of me, I don't know why there aren't more of these things around.
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Man, I sure could have used one of those last night. I had what is possibly the worst view I've ever seen. Nasty trauma in a 60 y/o w/ known c-spine fractures and a horribly edematous airway. I used all the tricks in my toolbox trying to get an ET tube into her. Fortunately I was able to ventilate with a BVM and dropped an LMA in. I would have loved a glide scope. We've ordered them but they're not yet in.

Take care,
Jeff
 
I myself have got a flash off the carotid artery using ultrasound guidance (on accident of course). It was obviously pulsatile so we didn't dilate it. I also saw the internal jugular tent, start to collapse, a little deeper and $&!#. I swear I did everything right, and even had my ultrasound fellowship trained attending watching everything I did. One of my fellow residents did the same thing. My point is, ultrasound guidance is not fool-proof. It is a good tool to have, but if you actually have enough time and the line isn't that emergent, why not try deep brachial first? If the patient is actually trying to die on you at that minute (the only time somebody really needs central venous access in the ED), then they need a femoral or a subclavian without all the running around for the ultrasound and sterile goop and what-not. I'm not convinced that ultrasound is all it's cracked up to be. I plan to use it for FAST scans, locating abscesses, detecting pericardial effusions, and possibly big first trimester babies with large obviously beating hearts. I plan on never being able to see the common bile duct, or diagnosing masses in the adnexa. I don't think the medicolegal liability is worth it, or the extra-time spent on patients when you ultrasound every patient yourself that has and indication. Ultrasounding people slows down the ED by and large. That is what ultrasound techs are for. While they spend an hour measuring every organ in the belly, I will be dispositioning patients and catching up on charting.
 
Jarabacoa said:
I myself have got a flash off the carotid artery using ultrasound guidance (on accident of course). It was obviously pulsatile so we didn't dilate it. I also saw the internal jugular tent, start to collapse, a litle deeper and $&!# I swear I did everything right, and even had my ultrasound fellowship trained attending watching everything I did. One of my fellow residents did the same thing. My point is, ultrasound guidance is not fool-proof.
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We've had 2 residents cannulate arteries recently while using US, same situations as you describe above. I currently only use US on patients with poor landmarks/seriously large body habitus.
 
I guess that you could add AAA as well. OK, OK, that is a long list for things that US is good for in the ED, but I can't see doing an entire ultrasound fellowship unless you want to be in academics.
 
I had a resident tonight hit the carotid artery, despite me telling her not to advance the needle because she wasn't midline. Hitting the carotid artery itself isn't a bad thing. Dilating is. So after 5 minutes of holding pressure, she lifted up her hand and found there was no bleeding, no hematoma, and she was clear to try again. This time she went midline and got the IJ on the first shot.
 
Jarabacoa said:
I myself have got a flash off the carotid artery using ultrasound guidance (on accident of course). It was obviously pulsatile so we didn't dilate it. I also saw the internal jugular tent, start to collapse, a little deeper and $&!#. I swear I did everything right, and even had my ultrasound fellowship trained attending watching everything I did. One of my fellow residents did the same thing. My point is, ultrasound guidance is not fool-proof. It is a good tool to have, but if you actually have enough time and the line isn't that emergent, why not try deep brachial first? If the patient is actually trying to die on you at that minute (the only time somebody really needs central venous access in the ED), then they need a femoral or a subclavian without all the running around for the ultrasound and sterile goop and what-not. I'm not convinced that ultrasound is all it's cracked up to be. I plan to use it for FAST scans, locating abscesses, detecting pericardial effusions, and possibly big first trimester babies with large obviously beating hearts. I plan on never being able to see the common bile duct, or diagnosing masses in the adnexa. I don't think the medicolegal liability is worth it, or the extra-time spent on patients when you ultrasound every patient yourself that has and indication. Ultrasounding people slows down the ED by and large. That is what ultrasound techs are for. While they spend an hour measuring every organ in the belly, I will be dispositioning patients and catching up on charting.
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Judicious use of bedside US can definitely speed things up. Think about it - AAA answer in 5 minutes instead of 50 for the CT, IUP answer in 15 minutes instead of 60 for the radiology US. Where I'm at this is a big deal - we're turning over beds a lot faster than if we had radiology do these studies for us.

Additionally at a lot of smaller hospitals (read - where you will work when you are done with residency) there is no 24 hour availability of US - you keep the pt to the AM or do it yourself.

I'm not trying to be a big US fanboy, but I think it definitely has its place. In practice you may not use it as often as we want you to as a resident, but that's because we want you to get enough studies as a resident to be good at it.
 
If you want to truly appreciate the value of bedside US, try moonlighting in a place without it.

23y/o pregnant vag bleeder? Break out the snickers 'cause they're not going anywhere anytime soon.

Take care,
Jeff
 
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