EJ Central Line

[BobBarker]

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Placed one today at my attendings direction intraop. Never have done one before. Looked like a major pain in the neck for the patient in pacu. Subclavian would have been better and quicker. Anybody place EJ TLCs routinely and what merit do they have?

 

[deleted126335]

Placed one today at my attendings direction intraop. Never have done one before. Looked like a major pain in the neck for the patient in pacu. Subclavian would have been better and quicker. Anybody place EJ TLCs routinely and what merit do they have?

If you are talking about placing a peripheral IV catheter in the E.J., They last about 10 minutes longer than the case. If you are talking about placing a regular CVP cath in the EJ they work fine--IF you can get the wire to enter the central circulation. It usually doesn't. As you mentined they are less comfortable for the patient. But so are IJs

Their only virtue is that they can be placed easily under the drapes in a pinch.

 

[BobBarker]

Regular CVP cath.

 

[deleted126335]

I find that it is very easy to enter the EJ. Subsequently very difficult to get the wire past the valves into the central circulation. I have pretty much abandoned them except in a pinch under the drapes with unexpected blood loss (usually happy with a 2 inch 16g or 14g for this purpose).
I find little use for a regular CVP or 8.5 Fr introducer in the EJ. Mostly since success at placing them in my hands is low. Once they are there I have no problem with them. I suppose one could make the argument that you should prep the neck attempt the EJ first since in theory morbidity from this is less, and then if unsuccessful attempt the IJ, but I find that to be a reach.

FWIW Big EJ often means small IJ. Big EJ also doesn't mean that it will be easier tho thread wire.

 

[Idiopathic]

i read the thread title and knew immediately who was responsible. i never placed one, but it seemed like he had good success with them. id prefer an US or landmark-guided IJ, but to each his own.

 

[BLADEMDA]

i read the thread title and knew immediately who was responsible. i never placed one, but it seemed like he had good success with them. id prefer an US or landmark-guided IJ, but to each his own.

EJs are pain the arse. Wire sees to get stuck often. I dislike EJs and see little reason to do them wth the availability of u/s for IJ lines.

I have placed many EJ catheters (iv lines in the EJ) but they can be positional. That said, it is a skill worth learning in residency.

EJ central lines are more just an academic exercise (see I can do one) rather than an essential skill. You are much better off learning how to place a subclavian line quickly than fumble around wth an EJ.

I do agree if EJ lines are your thing then keep doing them. For many of us though the EJ central line is last on the list for placing central access.

 

[cchoukal]

I had one attending at U of Chicago who did TLCs via the EJ. This was before the widespread use of u/s, and his rationale was that he could get a central line without the risk of carotid puncture or PTX. I echo the others' concerns about wire passage, although I've never tried one.

 

[Oggg]

I think I've tried it once after residency, and I couldn't wire so I sutured the catheter that comes with the tlc kit. What a piece of crap. I think it came out when my partner took over the case and wasn't careful during the move to the gurney. Now if the IJs are not an option, I go for axillary-subclavian or antecub with US. Anyone put triple lumen catheters in an AC vein?

 

[deleted126335]

I think I've tried it once after residency, and I couldn't wire so I sutured the catheter that comes with the tlc kit. What a piece of crap. I think it came out when my partner took over the case and wasn't careful during the move to the gurney. Now if the IJs are not an option, I go for axillary-subclavian or antecub with US. Anyone put triple lumen catheters in an AC vein?

Done a few in residency, Even a few PA catheters. Basilic is easier than cephalic.

 

[sevoflurane]

I agree with all of the concerns above. However, they are sometimes extremely easy to place and can get you out of trouble if the neck is not easily accessible to do a sterile IJ (as Doze mentioned). They can be lightning quick to put in if the patient isn’t to adipose heavy...liberating you to take care of other (pressing) tasks. Some patients have bulging EJ’s. Just depends on the patient, IMO.

Use a central line or long IV’s when accessing the EJ. Wire it whenever possible. The short/medium IV’s will get you into trouble as they can easily come out. I routinely w/draw during the case to make sure you get heme as a confirmatory maneuver to ensure the catheter is still in the lumen. Once you pass a triple lumen, you shouldn’t have any problems. Getting a long 16G is nice when you need to resuscitate quickly.

I’ll typically pull them in pacu and place a formal sterile TLC if need be. I don’t like sending EJ IV’s to the floor (properly placed TLC I’m fine with). The concern with IV’s is that If it slips out once the patient starts moving their head and pressors start to run subq, you can run into undesirable issues.

Great line to place if you need central access quickly. Like less than one minute.

Again, all concerns mentioned are very valid and each patient needs to be assesed for suitability of EJ placement.

 

[nap$ter]

anyone ever put a RIC line in the EJ?

 

[2win]

Never.
Why to do it?
That's self flagellation
2win.

 

[pgg]

anyone ever put a RIC line in the EJ?

I haven't and I don't think I would. They're pretty short.

EJs are like IO lines, nice when you need them in a hurry but you shouldn't send the patient anywhere with one. 🙂

 

[HollywdAnesth]

There was a very famous M&M at my residency where a resident placed a PIV in the EJ and ended up infusing a few liters into the patient's mediastinum. The autopsy pics clearly showed the IV going straight through the EJ into the anterior mediastinum.

I have attempted to place 1 TLC in an EJ and it was an absolute nightmare. I will never do it again.

I do alot of vascular patients, many of whom have had fistulas on both extremities. I don't want to go through the drama of a central line for a small case, so I will put in an EJ if they have a good looking one. I make sure to aspirate back every so often to confirm that its in the vein.

Its a very good skill to acquire and can help you out of a bind when you need a big IV and can't easily make it to the patient's arms or chest.

 

[Idiopathic]

anyone ever put a RIC line in the EJ?

seems like a terrible idea

 

[sevoflurane]

There was a very famous M&M at my residency where a resident placed a PIV in the EJ and ended up infusing a few liters into the patient's mediastinum. The autopsy pics clearly showed the IV going straight through the EJ into the anterior mediastinum.

That is terrible. Vigilance is paramount. Give 100mcgs of neo... and if the BP doesn't go up, check for heme... if both are negative you are out of the EJ.

 

[sevoflurane]

anyone ever put a RIC line in the EJ?

All the RIC's I've ever placed were through the AC's in either the liver tx room or the trauma bay.

 

[Arch Guillotti]

That is terrible. Vigilance is paramount. Give 100mcgs of neo... and if the BP doesn't go up, check for heme... if both are negative you are out of the EJ.

I like this as well. Sometimes I use esmolol instead.

 

[Oggg]

Even suturing the catheter to the skin didn't help my last EJV PIV stay in

 

[ProRealDoc]

anyone ever put a RIC line in the EJ?

No, only in the AC vein.

 

[sevoflurane]

Coupla pointers for the residents.

1. Prep. Goes w/o saying. But like all IV's, especially those going central under the drapes, use sterile technique.
2. Flick the EJ like you do with PIV's. It will cause it to become less spongy and it will become more prominent.
3. Hold distal pressure over the EJ with your left middle finger to slow flow into the heart and distend the proximal EJ providing you with a larger lumen to enter.
4. With your left thumb, hold cephalad tension on the skin. This straitens out the EJ and fixes it into place as you take a pass.
5. Unlike IJ's, enter the vessel via a parallel stick (like 5 degrees). I actually like to place a little downward parallel pressure to my catheter in order to create a slight curve to my catheter (not bending it... just flexing it).
6. If you want, you can attach a 3 cc syringe with 1-1.5 cc's of saline. It will be very evident when you enter the vessel.
7. Railroad your catheter to where it is flush to the skin. Confirm heme.
8. If you are placing a TLC or want to dilate your EJ to accommodate a bigger gauge PIV, place a .025" spring wire guide, nick the skin, +/- dilate and railroad new PIV/TLC.

Hope this helps.

 

[TrustMe]

anyone ever put a RIC line in the EJ?

Yes. Once in residency. And it worked great. Had a pt. for a liver resection. He had had multiple rounds of head/neck radiation for tonsillar SCC. Tried to place a left subclavian introducer and hit the subclavian artery twice. His neck was like a rock from the radiation but his EJ was the size of my thumb. Decided that an 8.5 Fr RIC in the EJ would give us adequate ability for volume.

I like the 7 Fr. RIC catheters in the wrist/forearm if they have something straight. I hate anything in the A/C.

 

[urge]

I placed an introducer and and floated a PA catheter from the right EJ a few months ago, because that's what my resident stuck while attempting an IJ line. It wasn't hard, but that's a N of 1.

I saw an attending do it during residency, so i knew it could be done.

 

[proman]

I placed an introducer and and floated a PA catheter from the right EJ a few months ago, because that's what my resident stuck while attempting an IJ line. It wasn't hard, but that's a N of 1.

I saw an attending do it during residency, so i knew it could be done.

The IR guys use the EJ all the time. Their advantage is using fluoro to get the wire in the right spot.

 

[Yangkower]

Another option is to place a pediatric CVC in the EJ. They are less likely to work themselves out of the vein and go sub q.

 

[beavis]

Coupla pointers for the residents.

1. Prep. Goes w/o saying. But like all IV’s, especially those going central under the drapes, use sterile technique.
2. Flick the EJ like you do with PIV’s. It will cause it to become less spongy and it will become more prominent.
3. Hold distal pressure over the EJ with your left middle finger to slow flow into the heart and distend the proximal EJ providing you with a larger lumen to enter.
4. With your left thumb, hold cephalad tension on the skin. This straitens out the EJ and fixes it into place as you take a pass.
5. Unlike IJ’s, enter the vessel via a parallel stick (like 5 degrees). I actually like to place a little downward parallel pressure to my catheter in order to create a slight curve to my catheter (not bending it... just flexing it).
6. If you want, you can attach a 3 cc syringe with 1-1.5 cc’s of saline. It will be very evident when you enter the vessel.
7. Railroad your catheter to where it is flush to the skin. Confirm heme.
8. If you are placing a TLC or want to dilate your EJ to accommodate a bigger gauge PIV, place a .025” spring wire guide, nick the skin, +/- dilate and railroad new PIV/TLC.

Hope this helps.

As someone who has left a hematoma after attempted EJ with short 14g catheter, these tips are very helpful. Wish I would have had this kind of instruction at the time.

 

[Oggg]

We have these long single lumen catheter kits that we use for femoral art lines. Not as long as a TLC, but I might try stuffing that one down the EJ some time

 

[urge]

That's the cleanest ej I have seen. Not a speck of blood anywhere. Congrats!

 

[sevoflurane]

That's the cleanest ej I have seen. Not a speck of blood anywhere. Congrats!

Thanks bruh! Means a lot coming from the cardiac dude who coined "pent, sux, tube" !

As someone who has left a hematoma after attempted EJ with short 14g catheter, these tips are very helpful. Wish I would have had this kind of instruction at the time.

I’m glad you found the write up helpful. That’s what this forum is all ‘bout. 👍

Keep at it Beavis... you’ll develop the system that works for you.

No one gets everything perfect 100% of the time.
When you do something that could have gone smoother ask yourself “what could I have done do make this process better.” Reflection is a big part of learning. 🙂