Double stick right IJ?

[ToKingdomCome]

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All of the patients come to the CTICU with a double stuck right IJ 1. Cordis with a Swan and 2. A quad lumen

Is this common practice and would you double stick a right ij for other things like a dialysis catheter and other stuff or just do a differnt site ?

 

[Tipsy McStagger]

You can double stick a vessel. I try not to unless I've exhausted other options, and it seems more cultural depending on what hospital you're working at.

 

[psychbender]

Very cultural/local practice. A MAC introducer with a PAC, and a good PIV is all that's needed for the vast majority of cardiac cases. If they're doing an introducer (I'm betting Cordis, not MAC) and a QLC or TLC, likely one of the surgeons trained that way and pushed the anesthesia group to do it. They acquiesced, because it's easy, and they can bill for the extra line. I'm sure the PAC and introducer come out POD1 for most cases, and they leave the quad in for a few more days, until they are ready to leave. Surgeon probably trained the nurses to draw everything off the line, too, to minimize the sticks post-op, and either didn't bother thinking about line infections, or figures a line that's only in there <5 days that was placed in the OR won't be an issue.

 

[SurfingDoctor]

Wait till someone is extremist and no one can get it. I’ll be turning a 4 month old on rocket fuel fem’s into Swiss cheese and a hematoma the size of a grapefruit before I move to the next leg.

 

[chessknt]

I do this when someone needs 2 lines at the same time. Is there a compelling reason not to? I've never seen someone have venous drainage issues from a line ever outside of a cancer case.

 

[Robotic Wis-Hipple]

Have you ever seen a cath lab/EP case? Sometimes 3 or more lines/sheaths in the same vessel.

I typically place a line in the R SC that can go to stepdown and an introducer in the R IJ with a PAC for my hearts which comes out ~POD1/2. But if it’s a case where they may cutdown or use the R SC I double stick the IJ. Happens all the time.

 

[Teillard]

On the occasion where some rapid infusor device like the Belmont is a possibility, leaving a mac without anything through it and a separate TLC or whatever for everything else is a way to go.

 

[vector2]

On the occasion where some rapid infusor device like the Belmont is a possibility, leaving a mac without anything through it and a separate TLC or whatever for everything else is a way to go.

The proximal 12 gauge (white port) on the MAC can do over 200 ml/min to gravity alone, and over double that when pressurized on the Belmont. And even though the 9fr on the MAC is significantly slower when a catheter is going through the introducer port, it's not like it's 7fr TLC slow.

I've done plenty of thoracoabdominals, arch repairs with circ arrest, exsanguinating traumas, etc with just a MAC (and something, either a swan or the TLC companion, going through the introducer port). Belmont on the white, cold line for platelets and cryo on the brown, drips on whatever catheter is in the introducer port. Hasn't been an issue.

 

[vector2]

Regarding the double stick, I think it's wildly outdated. Just do a MAC or cordis+big PIV. When the pt gets to the ICU anyone can place a midline or two for something more durable when the introducer has to come out.

 

[bigdan]

I do like and periodically employ R IJ double stick, which has its place in particular cases.

We have a few RA+IVC+renal vein thrombectomy+nephrectomy cases every year, and those are *ALWAYS* sphincter puckering vis-a-vis volume loss. A double stick is appropriate for that case; making one of the R IJ lines an HD catheter can be helpful in the event of rocky postop course. And, by convention, our OLTxp are done with R IJ VVB cannula (usually a 16Fr Edwards arterial) + R IJ Arrow MAC w/PAC. We endeavor to remove the VVB line at the end of the surgery, so the pt only has 2 lines for 5-8h.

 

[chessknt]

My common use is for a temporary dialysis line and a CVL. We don't have the trialysis lines here. Done this many times without issue left in for weeks until they die/dont need them/get long term access.

 

[Tipsy McStagger]

My common use is for a temporary dialysis line and a CVL. We don't have the trialysis lines here. Done this many times without issue left in for weeks until they die/dont need them/get long term access.

Trialysis lines are so helpful. There are a few (minority) of Nephrologists who insist we don't get to use the third port. They generally say something like "that's my line, you can't use it." This is of course nonsense, we're the ones placing the lines and if we need the pigtail we'll use it. We don't use the larger ports except in emergencies. In any case, I used to dislike the trialysis lines, and the trays are atrocious, but it is so very nice to have the third port.

 

[Siggy]

Trialysis lines are so helpful. There are a few (minority) of Nephrologists who insist we don't get to use the third port. They generally say something like "that's my line, you can't use it." This is of course nonsense, we're the ones placing the lines and if we need the pigtail we'll use it. We don't use the larger ports except in emergencies. In any case, I used to dislike the trialysis lines, and the trays are atrocious, but it is so very nice to have the third port.

I always quip when putting in a trialysis line about how "it's the 21st century... why are we still using glass ampules?"

 

[Tipsy McStagger]

I always quip when putting in a trialysis line about how "it's the 21st century... why are we still using glass ampules?"

Right!? Glass ampules, no sharps pad, a cheap tegaderm... terrible kit
I'm also not a fan of the needle, but it works fine. I prefer the angiocath these days, but it all works.

Actually, I really like using micropuncture for most things, even though it's not 100% necessary. We don't stock them anymore and I have to steal them from the cath lab if I really want one, which is almost never worth the trouble.

 

[Siggy]

Right!? Glass ampules, no sharps pad, a cheap tegaderm... terrible kit
I'm also not a fan of the needle, but it works fine. I prefer the angiocath these days, but it all works.

Actually, I really like using micropuncture for most things, even though it's not 100% necessary. We don't stock them anymore and I have to steal them from the cath lab if I really want one, which is almost never worth the trouble.

I try to keep a ready supply of micropuncture kits as well. Likewise, cath lab and neuro intervention lab tends to be my go to source. It's like a cheat code for central lines.