do you transduce every CVC stick?

[Gas you down]

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i have always taken the technique of using the kit's tubing to help determine A vs V if there is any question. but today i was fooled by dark nonpulsatile blood. it was in SC artery.
do you think you should transduce every cvc stick? i have always done so if there was a question. now i am going to do it every time.

 

[pjl]

15 secs vs major consequences. yup, every time.

 

[sevoflurane]

No.

TEE and USD are more than enough for me. Never had an issue. 1 in 15-20 CVLs I might transduce or do a poor mans cvp.

 

[VentdependenT]

if any question i hook up iv tubing to the 18g catheter, pull blood back, and see if it drains to gravity

 

[cchoukal]

I try to transduce every line. There are times, however, when the access was difficult to obtain and I worry the extra jostling of the needle required to use the tubing will dislodge the needle from the vessel. In those cases, I'll go straight to the wire and then u/s the wire. I have to recognize, though, that it's always possible that even if I see the wire in the vein, it could always go through-and-through deeper than I can see with the u/s. That said, I do a lot of central lines and have never had this happen.

 

[Idiopathic]

if im using ultrasound in the IJ ill look for the wire in the vessel in the long axis. if im not then i thread off the 16g(?) catheter for better stability and hook up the tubing before i dilate and place the cvl.

id wager if you had dark nonpulsatile blood from your needle and your line ended up in the SC artery (where blood should be pretty bright) then you backwalled your dilator or something post-needle, in which case transduction of CVP would not have helped you

 

[BLADEMDA]

I try to transduce every line. There are times, however, when the access was difficult to obtain and I worry the extra jostling of the needle required to use the tubing will dislodge the needle from the vessel. In those cases, I'll go straight to the wire and then u/s the wire. I have to recognize, though, that it's always possible that even if I see the wire in the vein, it could always go through-and-through deeper than I can see with the u/s. That said, I do a lot of central lines and have never had this happen.

If normal BP or SBP greater than 100 I don't transduce my central lines. Heresy! I use U/S to scan the area and if the IJ is bigger than 10-12 mm in diameter then I utilize the static technique. The U/S scan determines if I need to go live or use static technique.

If the vein is smaller than 10 mm then I go Live. Since I use the large bore needle and not the angiocath there isn't much chance (way less than 1%) that a Carotid puncture will go undetected by me provided the BP is good.

Over the past 4 years I haven't transduced a single central line with the use of U/S; I have transduced a couple with the static technique because the systolic BP was less than 85.

One of my partners does a poor man's CVP with every central line. It adds only maybe 45 seconds to the procedure. I've got no issues with that approach.

If you are a beginner and want to fully follow ASA recommendations then by all means transduce the 18 gauge catheter or observe the wire in the Vein by turning the U/S probe to the longitudinal axis.

 

[BLADEMDA]

 

[BLADEMDA]

 

[BLADEMDA]

 

[BLADEMDA]

 

[Bostonredsox]

Really no need to transduce if you have an US. I have almost never had a problem confirming just with US. And in my case if I'm uncertain and it was an easy stick and the US doesn't help me confirm where I am, which is rare, I draw a gas and thread the wire to hold my place in the vessel while I wait for 90 sec for the gas to come back. If its arterial I pull out the wire, hold compression for a minute or two, in non coagulopathic pt, then restick. Hasn't failed me yet. Only catheter I have ever accidentally put into an artery was a fem during a code that yielded pulseless nearly black blood. Wasn't till an hour later after Levo and vasopressin had been ticking away and we finally got a measurable pressure that the line started to have resistance and the blood turned red. Initial ph was 6.6. I gave myself a pass on that.

 

[Idiopathic]

Really no need to transduce if you have an US. I have almost never had a problem confirming just with US. And in my case if I'm uncertain and it was an easy stick and the US doesn't help me confirm where I am, which is rare, I draw a gas and thread the wire to hold my place in the vessel while I wait for 90 sec for the gas to come back. If its arterial I pull out the wire, hold compression for a minute or two, in non coagulopathic pt, then restick. Hasn't failed me yet. Only catheter I have ever accidentally put into an artery was a fem during a code that yielded pulseless nearly black blood. Wasn't till an hour later after Levo and vasopressin had been ticking away and we finally got a measurable pressure that the line started to have resistance and the blood turned red. Initial ph was 6.6. I gave myself a pass on that.

ok, no offense but this is ridiculous. if its an easy stick and you have any doubt then you restick. if its an EXTREMELY CHALLENGING stick then i would advocate something like this (have also seen people call fluoro to follow their wire)

 

[VentdependenT]

If normal BP or SBP greater than 100 I don't transduce my central lines. Heresy! I use U/S to scan the area and if the IJ is bigger than 10-12 mm in diameter then I utilize the static technique. The U/S scan determines if I need to go live or use static technique.

If the vein is smaller than 10 mm then I go Live. Since I use the large bore needle and not the angiocath there isn't much chance (way less than 1%) that a Carotid puncture will go undetected by me provided the BP is good.

Over the past 4 years I haven't transduced a single central line with the use of U/S; I have transduced a couple with the static technique because the systolic BP was less than 85.

One of my partners does a poor man's CVP with every central line. It adds only maybe 45 seconds to the procedure. I've got no issues with that approach.

If you are a beginner and want to fully follow ASA recommendations then by all means transduce the 18 gauge catheter or observe the wire in the Vein by turning the U/S probe to the longitudinal axis.

What do mean by static vs going live?

 

[deleted59964]

... in my case if I'm uncertain and it was an easy stick and the US doesn't help me confirm where I am, which is rare, I draw a gas and thread the wire to hold my place in the vessel while I wait for 90 sec for the gas to come back...

i put an IJ line in a septic patient the other day - u/s of wire showed it in the IJ so I dilated and placed line.

then i took a gas (i wanted to know the svo2) and the sat was 90+%, i nervously waited to transduce the line and ... it was venous.

gas is not always definitive

 

[stonemd]

Today you need to do live ultrasound when placing central line. Dictated by Asa, shown in studies to reduce complications. Any complications from Central line done without us will be argued to be negligence by the prosecution.

 

[Idiopathic]

i put an IJ line in a septic patient the other day - u/s of wire showed it in the IJ so I dilated and placed line.

then i took a gas (i wanted to know the svo2) and the sat was 90+%, i nervously waited to transduce the line and ... it was venous.

gas is not always definitive

why are you guys checking gases while waiting to thread a line. seriously. if it was a non-challenging US-guided stick and you are REALLY CONCERNED (for some reason) just restick.

 

[deleted59964]

why are you guys checking gases while waiting to thread a line. seriously. if it was a non-challenging US-guided stick and you are REALLY CONCERNED (for some reason) just restick.

exactly, i was confident it was in the IJ & didnt take a gas (as is my usual practice).
if i'd taken a gas before dilating it would have been misleading ... i might still be there trying to hit the vein

 

[pgg]

I used to do the poor man's CVP with every line, before u/s was ubiquitous. Now that every place I work has ultrasound, I don't.

If u/s wasn't available I'd go back to transducing every time. You've got to do something more objective than eyeballing the color of the blood before dilating the vessel.


In a way I feel fortunate that I trained before u/s was everywhere, and was forced to learn to do lines and blocks without it. But at this point I'll never not use u/s if it's available.


I don't get the point of drawing a gas. Even if there's an iStat machine and a helper to run it standing right next to you, in the 120 seconds it takes to spit out some number you could've transduced and be 1/2 way done suturing the line in place.

 

[pgg]

What do mean by static vs going live?

Live = using u/s in sterile sleeve during procedure, watching needle/wire in real time.

Static = looking at anatomy before doing the line to verify 'normal' anatomy and mark the IJ, then putting the u/s aside and just sticking the neck where you know the vein is.


Static has the speed and convenience of not bothering with the sleeve and sterile gel. For those who learned with landmarks and were fast/safe without u/s, then a quick scan of the patient's anatomy added some measure of safety without the u/s slowdown. I used to do lines this way (still transducing before dilating), before u/s was the standard. I was fast and safe and if I wanted a sleeve / sterile gel it meant I had to go look for them.

 

[countingdays]

I used to do the poor man's CVP with every line, before u/s was ubiquitous. Now that every place I work has ultrasound, I don't.

If u/s wasn't available I'd go back to transducing every time. You've got to do something more objective than eyeballing the color of the blood before dilating the vessel.


In a way I feel fortunate that I trained before u/s was everywhere, and was forced to learn to do lines and blocks without it. But at this point I'll never not use u/s if it's available.


I don't get the point of drawing a gas. Even if there's an iStat machine and a helper to run it standing right next to you, in the 120 seconds it takes to spit out some number you could've transduced and be 1/2 way done suturing the line in place.

Ectopy.

 

[Idiopathic]

Live = using u/s in sterile sleeve during procedure, watching needle/wire in real time.

Static = looking at anatomy before doing the line to verify 'normal' anatomy and mark the IJ, then putting the u/s aside and just sticking the neck where you know the vein is.


Static has the speed and convenience of not bothering with the sleeve and sterile gel. For those who learned with landmarks and were fast/safe without u/s, then a quick scan of the patient's anatomy added some measure of safety without the u/s slowdown. I used to do lines this way (still transducing before dilating), before u/s was the standard. I was fast and safe and if I wanted a sleeve / sterile gel it meant I had to go look for them.

ASA recommends doing both techniques.

 

[Idiopathic]

Ectopy.

Still not perfect. While I think its more likely that a line stays in the aorta if its placed in the carotid or left subclavian, you can certainly get ectopy by touching the LV

 

[periopdoc]

Since leaving training, I have never transduced a line. Real-time U/S. Confirm wire placement in long axis on U/S (also with TEE if I am using it for the case).

If I was going to transduce, I would use the same setup we had in training where a three way attachment (without stopcock) was inserted between the needle and the syringe. The third arm goes to a CVP transducer line. Stick the vein, look up at the monitor to confirm waveform, and proceed.

If you search my post history, you can find pics of the setup from the time before the last time we had this same conversation.

-pod

 

[Dejavu]

Our little Clinic here in SE Minnesota mandates the use of US and one other means of verification of venous placement (such as gravity flow in tubing/transducing/US verification of wire in vein) before dilation and placement of catheter.

 

[BLADEMDA]

Our little Clinic here in SE Minnesota mandates the use of US and one other means of verification of venous placement (such as gravity flow in tubing/transducing/US verification of wire in vein) before dilation and placement of catheter.

For years you were doing the static technique if the IJ was large. Did you change last year to mandatory "live/real time" u/s for all internal jugular lines?

The ASA recommendation is overly conservative for experienced Anesthesiologists who have placed thousands of central lines. I agree that u/s use is a good idea I just disagree that every patient needs live u/s to pace a line.

 

[BLADEMDA]

Both static "quick look" assessment and dynamic visualization allow the clinician to evaluate the size and course of the vessel or, establish the presence of thrombus. This study found that almost 10% of participants had either variant anatomy or small (<5mm) vessels. Each cannulation attempt was undertaken according to the randomization allocation, with rescue dynamic ultrasound guidance available after 5 attempts or 5 minutes. These variations were discovered on rescue dynamic ultrasonography when initial attempts failed. In the discussion, the authors suggest that central catheter placement in internal jugulars measuring <5mm may be relatively contraindicated. They propose that vessels measuring 5-10mm should be cannulated under dynamic guidance and that those measuring >10mm on static assessment may be cannulated with rescue dynamic ultrasound guidance if necessary.

http://www.scribd.com/doc/126858754/05-Ultrasonography-of-Central-Venous-Cannulation-SOAP-3

 

[TrustMe]

Our little Clinic here in SE Minnesota mandates the use of US and one other means of verification of venous placement (such as gravity flow in tubing/transducing/US verification of wire in vein) before dilation and placement of catheter.

What about SC lines? How do you verify those?

 

[BLADEMDA]

Critical Care Medicine:
August 2009 - Volume 37 - Issue 8 - pp 2345-2349
doi: 10.1097/CCM.0b013e3181a067d4
Continuing Medical Education Article
An unseen danger: Frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance *
Blaivas, Michael MD, RDMS; Adhikari, Srikar MD, RDMS

Continued Medical Education
Abstract
Objectives: To evaluate the frequency of unsuspected posterior vessel wall penetration of the internal jugular vein during ultrasound-guided needle cannulation.

Design: Prospective, single-blinded observational study.

Setting: Urban level I emergency department with an annual census of 80,000.

Patients: Residents who had previously completed a 2-day ultrasound course including a 3-hr didactic and hands-on session on ultrasound-guided central venous cannulation.

Interventions: Residents were asked to place an ultrasound-guided catheter on a human torso mannequin. Residents used a short-axis approach for ultrasound guidance. During the procedure, an 8–4 MHz convex (endocavity) transducer was used to observe the path of the resident’s needle without interference with the placement procedure.

Measurements and Main Results: Unknown to residents, researchers tracked the frequency of posterior wall penetration and the final needle location when the resident felt that optimal needle placement was achieved in the lumen of the internal jugular. Residents were also asked to rate their confidence regarding appropriate final needle position on a 10-point Likert scale. Statistical analysis consisted of descriptive statistics and Spearman correlation analysis. A total of 25 residents participated. All had placed at least one ultrasound-guided central catheter previously. The median number of previous ultrasound-guided cannulations was 8.0. Sixteen (64%) residents accidentally penetrated the posterior wall of the internal jugular vein during cannulation. The median number of posterior wall penetrations was 1.0 for all residents. In six cases the final location of the needle was through the posterior wall and deep to the venous lumen. In five of these cases the carotid artery was actually mistakenly penetrated. Median confidence by residents regarding appropriate needle placement was 8.0 out of 10. More training and more ultrasound-guided catheters placed were associated with fewer posterior wall penetrations (p = .04).

Conclusions: In this study, residents accidentally penetrated the posterior vessel wall of the internal jugular in a lifelike vascular access mannequin in the majority of cases. These results suggest that care must be taken even with ultrasound-guided central catheter placement and that alternative ultrasound guidance techniques, such as visualization of the vein and needle in longitudinal axis, should be considered.

 

[VentdependenT]

I try and teach every motivated resident/intern who works with me to do one IJ without US. Gotta know how to use finder and basics of anatomy. I saw a resident trying to put a line in an EJ on accident as she was mislead by US. She was having a hard time passing guidewire. I was called over and I said "why is there no carotid artery?" problem solved....

 

[VentdependenT]

Critical Care Medicine:
August 2009 - Volume 37 - Issue 8 - pp 2345-2349
doi: 10.1097/CCM.0b013e3181a067d4
Continuing Medical Education Article
An unseen danger: Frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance *
Blaivas, Michael MD, RDMS; Adhikari, Srikar MD, RDMS

Continued Medical Education
Abstract
Objectives: To evaluate the frequency of unsuspected posterior vessel wall penetration of the internal jugular vein during ultrasound-guided needle cannulation.

Design: Prospective, single-blinded observational study.

Setting: Urban level I emergency department with an annual census of 80,000.

Patients: Residents who had previously completed a 2-day ultrasound course including a 3-hr didactic and hands-on session on ultrasound-guided central venous cannulation.

Interventions: Residents were asked to place an ultrasound-guided catheter on a human torso mannequin. Residents used a short-axis approach for ultrasound guidance. During the procedure, an 8&#8211;4 MHz convex (endocavity) transducer was used to observe the path of the resident's needle without interference with the placement procedure.

Measurements and Main Results: Unknown to residents, researchers tracked the frequency of posterior wall penetration and the final needle location when the resident felt that optimal needle placement was achieved in the lumen of the internal jugular. Residents were also asked to rate their confidence regarding appropriate final needle position on a 10-point Likert scale. Statistical analysis consisted of descriptive statistics and Spearman correlation analysis. A total of 25 residents participated. All had placed at least one ultrasound-guided central catheter previously. The median number of previous ultrasound-guided cannulations was 8.0. Sixteen (64%) residents accidentally penetrated the posterior wall of the internal jugular vein during cannulation. The median number of posterior wall penetrations was 1.0 for all residents. In six cases the final location of the needle was through the posterior wall and deep to the venous lumen. In five of these cases the carotid artery was actually mistakenly penetrated. Median confidence by residents regarding appropriate needle placement was 8.0 out of 10. More training and more ultrasound-guided catheters placed were associated with fewer posterior wall penetrations (p = .04).

Conclusions: In this study, residents accidentally penetrated the posterior vessel wall of the internal jugular in a lifelike vascular access mannequin in the majority of cases. These results suggest that care must be taken even with ultrasound-guided central catheter placement and that alternative ultrasound guidance techniques, such as visualization of the vein and needle in longitudinal axis, should be considered.

Had ER infuse and stroke a patient because of this. If you have sterile US for the procedure there is NO reason to not view guidewire in long axis...

 

[BLADEMDA]

Had ER infuse and stroke a patient because of this. If you have sterile US for the procedure there is NO reason to not view guidewire in long axis...

More proof that the use of u/s doesn't guarantee anything except a good view of the vein. It is still up to the Resident and Atending to use common sense, experience and u/s long axis to confirm the line.

I still firmly believe that a physician who has performed more than a thousand central lines is not in the same category as one who has done 50. You develop a feel and second sense after several thousand central lines for those occasions where things don't feel right. From the stick to the pulsation to the ease in which the wire passes down the vein the whole process becomes quite familiar.

I'm still a fan of u/s and use it regularly. But, live/dynamic u/s adds little benefit over the static technique in my practice in certain situations (large vein, good BP, no previous neck surgery or carotid surgery, normal anatomical relationship, etc)

 

[BLADEMDA]

Today you need to do live ultrasound when placing central line. Dictated by Asa, shown in studies to reduce complications. Any complications from Central line done without us will be argued to be negligence by the prosecution.

ASA has recommendations on central line placement and not standards. I'm quite confident that with over 10,000 central lines placed that the use of static u/s is more than adequate in my hands. I know when to go live/dynamic instead of the static technique. In fact, I'm about 50/50 these days compared to 10 percent live/90 static just 2 years ago

ASRA also treats nerve blocks like neuraxial anesthesia in terms of contraindications. Ridiculous. I block patients every day that I would not do a spinal or epidural.

While I respect my academic colleagues and their recommendations they don't practice in the real world with seasoned Anesthesiologists doing all the procedures. Hence, at times they have their heads up their asses.

 

[OB1🤙]

My practice:

Heart case: subclavian is my go-to line. TEE bicaval view->stick->wire in RA->line.

Sometimes I'll double stick by ICU requests, in which case live u/s of the IJ. Once wires are in I scan down to the clavicle in short axis to see the wires, then tilt the probe beam toward the heart (handle toward me) to follow them down toward the SVC.

This is better than a long axis shot IMO, as you see the wire(s) farther down the vein. Of course, if you do go through-and-through the vein you probably will see it proximally.

Non heart cases: live u/s IJ as above. If for whatever clinical reason I want to put in a subclavian instead, I'll turn the FiO2 down, and if there's any doubt about the stick, I'll compare the color of the aspirated blood to an aspiration off the a-line. A poor-man's blood gas. That said, I've never had to do this as an attending. If still unsure then just restick. Arterial sticks are usually pretty obvious.

I haven't transduced a line since fellowship.

 

[dhb]

Never transduced, put a line in the carotid at the very beginning of residency no problem since.

 

[countingdays]

Never transduced, put a line in the carotid at the very beginning of residency no problem since.

I don't transduce as a rule. IJs with ultrasound. Subclavians with landmarks, dark blood, smooth wire, ectopy. If anything is off I'll do poor man's cvp 1-2/yr. I may start doing CVPs on subclavians after this discussion. I've never dilated an artery and I don't think I need to transduce IJs, but with SCs it might be a good idea and why not?

 

[Mman]

Had ER infuse and stroke a patient because of this. If you have sterile US for the procedure there is NO reason to not view guidewire in long axis...

I use sterile U/S probe for 100% of IJs I place, but I obtain a long axis view of the guidewire <1% of the time. Why would I? I just find it in short axis and slide the probe distally watching it stay in the vein. You get no additional info from the long axis view, but it can add a few seconds as it can be annoying to get the guidewire lined up just right on the screen in the long axis to make a pretty picture. I only try for a long axis view if I'm having trouble seeing the guide wire in the short axis. For example, sometimes the wire hugs fairly close to the wall of the vessel and it can be tough to see.

 

[VentdependenT]

I use sterile U/S probe for 100% of IJs I place, but I obtain a long axis view of the guidewire <1% of the time. Why would I? I just find it in short axis and slide the probe distally watching it stay in the vein. You get no additional info from the long axis view, but it can add a few seconds as it can be annoying to get the guidewire lined up just right on the screen in the long axis to make a pretty picture. I only try for a long axis view if I'm having trouble seeing the guide wire in the short axis. For example, sometimes the wire hugs fairly close to the wall of the vessel and it can be tough to see.

My point is that if you are using the US, visualize the wire in the vein. I can deal with the 3 seconds it takes to rotate the probe and find the wire. And yes, its ALL about the pretty picture.

 

[Idiopathic]

I don't transduce as a rule. IJs with ultrasound. Subclavians with landmarks, dark blood, smooth wire, ectopy. If anything is off I'll do poor man's cvp 1-2/yr. I may start doing CVPs on subclavians after this discussion. I've never dilated an artery and I don't think I need to transduce IJs, but with SCs it might be a good idea and why not?

so if you are getting nonpulsatile dark blood, why does anyone think that transducing through that needle would alert you towards the possibility of an arterial puncture? (given normal BP)

 

[Idiopathic]

My point is that if you are using the US, visualize the wire in the vein. I can deal with the 3 seconds it takes to rotate the probe and find the wire. And yes, its ALL about the pretty picture.

i like this because it helps teach ultrasound imaging as well. takes literally 10 seconds and no additional prep

 

[Bostonredsox]

ok, no offense but this is ridiculous. if its an easy stick and you have any doubt then you restick. if its an EXTREMELY CHALLENGING stick then i would advocate something like this (have also seen people call fluoro to follow their wire)

Your are correct was a typo on my part. Easy lines I am concerned about I just restick. If it was difficult to access then I throw in a wire and get a gas.

I have never seen a line transduced, granted I am not an anesthesiologist. I run CVPs all the time so the concept seems simple enough to me, but with real time US, which I already have out as I used it for the line, I just dont see any need for any other confirmative tool. As many others have said, Longitudinal view, pan up an down in cross sectional view...its easy enough to follow your wire.

and as for someone mentioning about the gas being misleading because the IJs SvO2 was 90%.....for one, IJs dont measure SvO2 unless it is a PA catheter via IJ. A normal IJ CVC with tip in the SVC/RA gives you an ScvO2, not SvO2...the %sat will differ by 5-10%. No big deal just make sure you know what # youre looking at. And as for the sat being 90% in what you have described as a hyperdynamic septic pt...that should stil not confuse you on the gas. You have a pH, PaCO2, PaO2 and a %sat. The compilation of the four will always tell you whether its venus or arterial. One number only, such as a sat of 90% may not give you the answer, such as in the hyperdynamic septic....but in an arterial stick, a %sat of 90 will give you a Pa02 of 70 or greater most every time. I have yet to see a venous gas with a PaO2 of 70, unless you have been bag mask ventilating them for 5 minutes before a tube and then placing directly on the vent at 100% fiO2....but in that pt, an arterial stick is most likely going to give you a sky high paO2 and %sat, again, easily distinguishable from a venous gas.

All of that said...if your REALLY concerned because you dont like your gas and your standing there with a wire in a difficult pt you couldnt just restick....send a radial ABG at the same time as your line gas and compare them. takes <2 minutes. even faster for you guys because you have probably already put in an art line before your TLC, whereas I do them in reverse order.

 

[Bostonredsox]

Critical Care Medicine:
August 2009 - Volume 37 - Issue 8 - pp 2345-2349
doi: 10.1097/CCM.0b013e3181a067d4
Continuing Medical Education Article
An unseen danger: Frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance *
Blaivas, Michael MD, RDMS; Adhikari, Srikar MD, RDMS

Continued Medical Education
Abstract
Objectives: To evaluate the frequency of unsuspected posterior vessel wall penetration of the internal jugular vein during ultrasound-guided needle cannulation.

Design: Prospective, single-blinded observational study.

Setting: Urban level I emergency department with an annual census of 80,000.

Patients: Residents who had previously completed a 2-day ultrasound course including a 3-hr didactic and hands-on session on ultrasound-guided central venous cannulation.

Interventions: Residents were asked to place an ultrasound-guided catheter on a human torso mannequin. Residents used a short-axis approach for ultrasound guidance. During the procedure, an 8–4 MHz convex (endocavity) transducer was used to observe the path of the resident’s needle without interference with the placement procedure.

Measurements and Main Results: Unknown to residents, researchers tracked the frequency of posterior wall penetration and the final needle location when the resident felt that optimal needle placement was achieved in the lumen of the internal jugular. Residents were also asked to rate their confidence regarding appropriate final needle position on a 10-point Likert scale. Statistical analysis consisted of descriptive statistics and Spearman correlation analysis. A total of 25 residents participated. All had placed at least one ultrasound-guided central catheter previously. The median number of previous ultrasound-guided cannulations was 8.0. Sixteen (64%) residents accidentally penetrated the posterior wall of the internal jugular vein during cannulation. The median number of posterior wall penetrations was 1.0 for all residents. In six cases the final location of the needle was through the posterior wall and deep to the venous lumen. In five of these cases the carotid artery was actually mistakenly penetrated. Median confidence by residents regarding appropriate needle placement was 8.0 out of 10. More training and more ultrasound-guided catheters placed were associated with fewer posterior wall penetrations (p = .04).

Conclusions: In this study, residents accidentally penetrated the posterior vessel wall of the internal jugular in a lifelike vascular access mannequin in the majority of cases. These results suggest that care must be taken even with ultrasound-guided central catheter placement and that alternative ultrasound guidance techniques, such as visualization of the vein and needle in longitudinal axis, should be considered.

To me this isnt really an issue unless 1) your pt is coagulopathic or 2) the carotid is lying directly under the IJ. For most every IJ I do, I have the head rotated enough and hold the probe in a vertical enough fashion that the IJ and carotid are nearly side by side. In this case, again in a non coagulopathic pt, penetrating the back wall and then withdrawing your needle a bit til your tip is back into the lumen and your syringe fills, really has no added consequences. If They are hypovolemic and the IJ has poor filling volume even in 'Berg and I cannot really separate the carotid enough from the IJ, I modify my technique and stick with a much smaller angle to minimize the chance of going through the posterior wall.

My (N) is only a few hundred and not 10,000 like Blades, just a young pup here , but I have only one arterial stick to date and that was actually by the intern I was supervising.

 

[VentdependenT]

To me this isnt really an issue unless 1) your pt is coagulopathic or 2) the carotid is lying directly under the IJ. For most every IJ I do, I have the head rotated enough and hold the probe in a vertical enough fashion that the IJ and carotid are nearly side by side. In this case, again in a non coagulopathic pt, penetrating the back wall and then withdrawing your needle a bit til your tip is back into the lumen and your syringe fills, really has no added consequences. If They are hypovolemic and the IJ has poor filling volume even in 'Berg and I cannot really separate the carotid enough from the IJ, I modify my technique and stick with a much smaller angle to minimize the chance of going through the posterior wall.

My (N) is only a few hundred and not 10,000 like Blades, just a young pup here , but I have only one arterial stick to date and that was actually by the intern I was supervising.

If IJ is flat and I just keep going through and through I go to subclavian or femoral. no amount of tberg is gonna help. That is my experience anyways.

 

[BLADEMDA]

To me this isnt really an issue unless 1) your pt is coagulopathic or 2) the carotid is lying directly under the IJ. For most every IJ I do, I have the head rotated enough and hold the probe in a vertical enough fashion that the IJ and carotid are nearly side by side. In this case, again in a non coagulopathic pt, penetrating the back wall and then withdrawing your needle a bit til your tip is back into the lumen and your syringe fills, really has no added consequences. If They are hypovolemic and the IJ has poor filling volume even in 'Berg and I cannot really separate the carotid enough from the IJ, I modify my technique and stick with a much smaller angle to minimize the chance of going through the posterior wall.

My (N) is only a few hundred and not 10,000 like Blades, just a young pup here , but I have only one arterial stick to date and that was actually by the intern I was supervising.

Most of the time there is no issue going through the posterior wall of the IJ. But, more often than you would like the Carotid lies directly beneath the IJ. Hence, Residents need to practice their technique in a way that the posterior wall isn't punctured on a routine basis or they will end up puncturing the carotid without realizing it.

Larry Bird understood it is all about the fundamentals. He shot free throws for hours and hours every day. Why? So he could shoot the free throw under pressure during the big game. Same thing applies here.

Work on your fundamentals so the stick is clean, fast and reliable. Once you penetrate the anterior wall of the IJ then advance a few more mm so you are in the center of the vein.. If the vein has collapsed due to dehydration then slow withdrawal of the needle should get you that dark blood. Since most of us are sticking at least 10 mm Veins puncturing the posterior wall isn't necessary. The smaller the vein (6 mm and smaller) the greater the chance your needle will penetrate the posterior wall and hit the Carotid artery underneath.

Don't be a hero. Stick 10mm and larger veins whenever possible. 6mm veins can be a bitch even under u/s. If you must stick the 6 mm vein then taking the patient off the ventilator and using the Vasalva maneuver may increase the size of your target. I have used this trick in the past to get 6 mm veins without puncturing the posterior wall.

 

[Dejavu]

What about SC lines? How do you verify those?

We slide a IV type 18g over the wire and transduce it or poor man transduce it with gravity check. Then re-insert wire and then dilate.

Mandatory for several years now.

 

[Dejavu]

For years you were doing the static technique if the IJ was large. Did you change last year to mandatory "live/real time" u/s for all internal jugular lines?

The ASA recommendation is overly conservative for experienced Anesthesiologists who have placed thousands of central lines. I agree that u/s use is a good idea I just disagree that every patient needs live u/s to pace a line.

I think it has been a few years now that we have mandated live US for IJ CVCs.

I agree that most of us can get the job done without it, but you do what you are told by the powers, when they feel they have evidence to support a "best practice", I guess.

 

[Gas you down]

this was emergent situation. coming for pseudoaneurysm repair. bp 60/40 afib hr 130. transfused and resonsive to pressors. obese pt. anticoagulation held secondary to bleed. lost a couple of liters blood.
so of course she started brady'ing and more hypotension. took her postop to cath lab, she had clotted off a stent. did much better after fixing that.
but back today for thrombectomy to leg!
cvc line still sitting in L SC art

 

[BLADEMDA]

I think it has been a few years now that we have mandated live US for IJ CVCs.

I agree that most of us can get the job done without it, but you do what you are told by the powers, when they feel they have evidence to support a "best practice", I guess.

Do Residents place 1-2 IJ lines without live/dynamic U/S before graduating? What a shame to never have placed an internal Jugular line without u/s.

 

[VentdependenT]

Do Residents place 1-2 IJ lines without live/dynamic U/S before graduating? What a shame to never have placed an internal Jugular line without u/s.

1000% agree. same for ALL line sites

 

[Dejavu]

Do Residents place 1-2 IJ lines without live/dynamic U/S before graduating? What a shame to never have placed an internal Jugular line without u/s.

Not that I see all of their experience, but I bet they don't. At least by policy they aren't supposed to do it any other way.

Sad, I agree, but if it was my wife with the speared carotid that they did their one or two old fashioned attempts on, I don't know how I would feel, when there is a technology that might help protect against some of the complications of a procedure.

A tough philosophical question.

Do any of your residents graduate with trans-arterial ax blocks or plumb-bob supra-clavicular blocks, rather than US guided, in this day and age, and should they?

Do residents learn to do blind stellate ganglion or blind celiac plexus blocks any more (like I did), now that we have imaging that makes it a better, safer procedure?

Good questions, all.