Emergent Central Lines

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Perrotfish

Perrotfish

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I'm just interested your opinions: when do you guys think an Emergent central line (i.e. not sedated, intubated, and in a dedicated procedure room/OR) is indicated? I've heard a lot of differing opinions on this lately, and I've heard arguments that vary from 'just get it done in the helicopter so they're ready when they hit the door' to 'The only indication for an emergent central line is if you're out of IO kits'. What conditions do you guys think merit a central line vs an IO vs just trying for the IV?
 
emergent need for vasopressor drugs, and/or continuous drips of highly sclerosing agents, and rapid infusion scenarios where you need a cordis. I don't believe in its use as a hemodynamic monitoring agent, though i'm requred to offer it to patients who meet septic shock criteria on lactic alone. In that case I wouldn't call it an emergent procedure
 
Rendar5 said:
emergent need for vasopressor drugs, and/or continuous drips of highly sclerosing agents, and rapid infusion scenarios where you need a cordis. I don't believe in its use as a hemodynamic monitoring agent, though i'm requred to offer it to patients who meet septic shock criteria on lactic alone. In that case I wouldn't call it an emergent procedure
Click to expand...

Have you ever used an IO for vasopressor administration or rapid infusion? I was listening to an ICU rounds podcast that made it seem like a viable alternative to central lines for both, which would allow a central line to be placed later and under more controlled conditions. I was wondering if anyone had ever seen an IO used that way.
 
Perrotfish said:
I'm just interested your opinions: when do you guys think an Emergent central line (i.e. not sedated, intubated, and in a dedicated procedure room/OR) is indicated? I've heard a lot of differing opinions on this lately, and I've heard arguments that vary from 'just get it done in the helicopter so they're ready when they hit the door' to 'The only indication for an emergent central line is if you're out of IO kits'. What conditions do you guys think merit a central line vs an IO vs just trying for the IV?
Click to expand...

I don't know the answer to your question, but I know I've seen many a person jump to a central line and waste time when a patient has "no accessible veins anywhere" in the body, yet they have a honkin' big external jugular (put patient in trendelenburg and, pop!) or ankle/foot vein that's never been touched, that I proceeded to put a peripheral IV in that's of larger caliber than a central line, in about 3 seconds.

Skills.
 
Birdstrike said:
I don't know the answer to your question, but I know I've seen many a person jump to a central line and waste time when a patient has "no accessible veins anywhere" in the body, yet they have a honkin' big external jugular (put patient in trendelenburg and, pop!) or ankle/foot vein that's never been touched, that I proceeded to put a peripheral IV in that's of larger caliber than a central line, in about 3 seconds.

Skills.
Click to expand...

I feel like they normally try the foot in Peds, but the Jugular I have not seen before. I will remember that.
 
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In an emergent situation where someone does not have an IV or two attempts at such has been made, multiple studies show that IO is quick, easy, and a good way to start epi and other meds to buy you time to get a central line going. I mean, 30 seconds and your done with the IO...how many can say they can place a central line in 30 seconds.

Several times that I can think of to get an emergent central line are when you can't get an IV and have already placed an IO to give meds that the patient needs immediately. Another is when the patient is going to need multiple drips (multiple pressors, antibiotics, fluids, etc...) and you don't want to have 4 IVs on this guy when you can have one triple lumen. Usually when you need multiple drips it's because the patient is septic...most guidelines say if the patient is septic you will need to place a central line to measure CVP.

Those are just a couple. Non-emergent central lines are a little harder to determine when needed.
 
Perrotfish said:
Have you ever used an IO for vasopressor administration or rapid infusion? I was listening to an ICU rounds podcast that made it seem like a viable alternative to central lines for both, which would allow a central line to be placed later and under more controlled conditions. I was wondering if anyone had ever seen an IO used that way.
Click to expand...

As far as pressors go, if I need to get a pressor going, I will be lacing a central line, not an IO. If it's that emergent that pressores need to go in now, I will have them go in through a peripheral line while I placed the CVC. The only role for me with vasopressors and IO's is if there is no PIV access available whiel I placed the central line.

Never seen a rapid infuser used with an IO before. I guess a humeral IO could be sufficient enough, but I doubt your typical tibial or femoral IO could do that. Not to mention even with a push of lidocaine, infusion into an IO can hurt like a mofo. The IO itself not so bad.

By the way, just thought of a situation where you would not wanna bother with an IO: adenosine administration. Not that I've ever been forced to place a central line either for one.
 
Perrotfish said:
I feel like they normally try the foot in Peds, but the Jugular I have not seen before. I will remember that.
Click to expand...

I can't tell you how many times both patient and nurse have told me, "There's no way, all the veins are blown, it's got to be a central line or PICC". You put the patient in trendelenberg, get to the head of the bed, turn their head slightly to one side and there it is. A huge external jugular popping out that's never been touched. It's an easy to access, large, peripheral vein. You put in a peripheral IV like any other peripheral IV.
 
The other trick you can do on ANYONE who has a neck is to place a peripheral IJ. You need to have the 1 1/2" peripheral IVs. Get the U/S, find the IJ, place the peripheral IV. Can be done in the same amount of time as an EJ, and you can put pressors through it without difficulty. You can also use it to thread a guidewire over for formal central line later if you need to.
 
GeneralVeers said:
The other trick you can do on ANYONE who has a neck is to place a peripheral IJ. You need to have the 1 1/2" peripheral IVs. Get the U/S, find the IJ, place the peripheral IV. Can be done in the same amount of time as an EJ, and you can put pressors through it without difficulty. You can also use it to thread a guidewire over for formal central line later if you need to.
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That's interesting. I would think that converting it to a true central line later would be a no-no though, in terms of sterility.
 
you can run any drug through IO that we use in the ED except for tpa.
you can bolus 5 L per hour through an humeral IO.
You can leave an IO in for 24 hours.
you can obtain almost all labs through an IO.

I love IOs.
 
xaelia said:
Here's where I posted about the "peripheral" IJ:
http://www.emlitofnote.com/2012/07/the-peripheral-ij.html

Lots of comments and concerns, but, everything has a risk/benefit calculation associated with it.
Click to expand...

Interesting, however, I think a more accurate term would be, "Central IJ line, performed with small angiocath and ultrasound guidance, without a guide wire."

The point being it is in every sense of the word, a central line. The point of the guide-wire is to act as your place holder in the vein, so you know you are certainly in the vein, before you spear a patient with a long catheter that could do some damage, if not in the vein.

In the case of an ultrasound guided IJ line with a traditional "peripheral" angiocath, the ultrasound is your eyes, the catheter is much smaller in length and width and therefore much less damage inducing if misplaced. I've never done this, and I think it's a very interesting technique, but I think it should be considered a "central" line in every sense of the word. It still would have many, if not all, of the potential complications associated with "central" lines, such as major arterial injury, major nerve injury, bacterial introduction to central venous system ie sepsis, and catheter associated central vein thrombosis.
 
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Birdstrike said:
Interesting, however, I think a more accurate term would be, "Central IJ line, performed with small angiocath and ultrasound guidance, without a guide wire."

The point being it is in every sense of the word, a central line. The point of the guide-wire is to act as your place holder in the vein, so you know you are certainly in the vein, before you spear a patient with a long catheter that could do some damage, if not in the vein.

In the case of an ultrasound guided IJ line with a traditional "peripheral" angiocath, the ultrasound is your eyes, the catheter is much smaller in length and width and therefore much less damage inducing if misplaced. I've never done this, and I think it's a very interesting technique ,but I think it should be considered a "central" line in every sense of the word, since it still would have many, if not all, of the potential complications associated with "central" lines, such as major arterial injury, major nerve injury, bacterial introduction to central venous system ie sepsis, and catheter associated central vein thrombosis.
Click to expand...

Agreed.

I've never thought of doing this, but now GV's piqued my curiosity.

Are the central line kits + full sterile technique any more sterile than peripheral IV equipment + full sterile technique?

Seems like an interesting question. Is anyone here familiar with any literature on this?
 
I do IJs by first using a peripheral angiocatheter that comes in the kit.

Super easy with ultrasound--skin poke to definitve access is about 15 sec with no need to try and thread the guidewire while keeping the needle in the vein.

After this, I transduce using IV tubing and gravity.

Then, I thread the wire through the angiocath and proceed as normally. My overall time to line completion went down drastically with this.
 
Tiger26 said:
I do IJs by first using a peripheral angiocatheter that comes in the kit.

Super easy with ultrasound--skin poke to definitve access is about 15 sec with no need to try and thread the guidewire while keeping the needle in the vein.

After this, I transduce using IV tubing and gravity.

Then, I thread the wire through the angiocath and proceed as normally. My overall time to line completion went down drastically with this.
Click to expand...


I just woke up from a nap.

Wha-whaaa ?! Small-cath IJs ? a;sdlkjf;alkjf ;alkjf;alkjf

gotta go read the rest of the thread. brb.
 
DB2013EM said:
you can run any drug through IO that we use in the ED except for tpa.
you can bolus 5 L per hour through an humeral IO.
You can leave an IO in for 24 hours.
you can obtain almost all labs through an IO.

I love IOs.
Click to expand...

as a former medic I also love IO's and EJ's.
last weekend I had a 550 lb pt in severe resp distress requiring intubation after failing bipap.
no IV access so dropped in a long yellow IO into the R tibia and used this for RSI meds. worked very well.
he ended up with a central line an hr or so later when the intensivist came down to admit him and placed one at bedside using u/s which took about 30 min.
 
Tiger26 said:
I do IJs by first using a peripheral angiocatheter that comes in the kit.

Super easy with ultrasound--skin poke to definitve access is about 15 sec with no need to try and thread the guidewire while keeping the needle in the vein.

After this, I transduce using IV tubing and gravity.

Then, I thread the wire through the angiocath and proceed as normally. My overall time to line completion went down drastically with this.
Click to expand...

Am i misunderstanding you? What do you mean you transduce using IV tubing and gravity? If the angiocath is in the vein, can you just thread the guidewire through that? Also, is there risk of fracturing off some of the angiocath with the guide wire? Since this isn't exactly standard of care, I imagine any problems with the modified procedure would be frowned upon.

That's a really cool idea though.
 
Khaos said:
In an emergent situation where someone does not have an IV or two attempts at such has been made, multiple studies show that IO is quick, easy, and a good way to start epi and other meds to buy you time to get a central line going. I mean, 30 seconds and your done with the IO...how many can say they can place a central line in 30 seconds.

Several times that I can think of to get an emergent central line are when you can't get an IV and have already placed an IO to give meds that the patient needs immediately. Another is when the patient is going to need multiple drips (multiple pressors, antibiotics, fluids, etc...) and you don't want to have 4 IVs on this guy when you can have one triple lumen. Usually when you need multiple drips it's because the patient is septic...most guidelines say if the patient is septic you will need to place a central line to measure CVP.

Those are just a couple. Non-emergent central lines are a little harder to determine when needed.
Click to expand...

Has anyone ever seen a multi-lumen IO? It seems like it might be a useful option to temporize for doctors/nurses who aren't terribly comfortable with emergent central lines.
 
TimesNewRoman said:
Am i misunderstanding you? What do you mean you transduce using IV tubing and gravity? If the angiocath is in the vein, can you just thread the guidewire through that?
Click to expand...

Transducing allows you to tell that you're in the venous side before you dilate.
 
TimesNewRoman said:
Am i misunderstanding you? What do you mean you transduce using IV tubing and gravity? If the angiocath is in the vein, can you just thread the guidewire through that? Also, is there risk of fracturing off some of the angiocath with the guide wire? Since this isn't exactly standard of care, I imagine any problems with the modified procedure would be frowned upon.

That's a really cool idea though.
Click to expand...

fwiw I think he is referring to the angiocath that is present in arrow triple lumen kits. it's the light blue cath/needle that you can optionally use instead of the traditional introducer needle. you just get access normally then thread the cath and withdraw the needle like a PIV, then thread the guidewire through the cath. The only extra step he adds is transducing. Since the cath is made for guidewire passage I doubt there is increased risk for fb embolism.
 
e30ftw said:
fwiw I think he is referring to the angiocath that is present in arrow triple lumen kits. it's the light blue cath/needle that you can optionally use instead of the traditional introducer needle. you just get access normally then thread the cath and withdraw the needle like a PIV, then thread the guidewire through the cath. The only extra step he adds is transducing. Since the cath is made for guidewire passage I doubt there is increased risk for fb embolism.
Click to expand...

Agree with above and Wilco. Atmy residency institution, transducing was the standard.

See below for an explanation on the technique:

http://academiclifeinem.com/trick-of-the-trade-use-the-angiocatheter-for-central-lines/
 
I guess it depends on what it's needed for. If its for Shock requiring massive transfusion or liters of fluid In minutes, it depends on how fast you can get some peripheral 14-16s in. We don't have IO at my place, atleast not on the floors or MICU. I think Ed does. So if I show up to a rapid/code on the floor and the pt has no access and is IN NEED of a pressor or access for induction agents or whatever, I can put a femoral in 98% of patients in about 60 seconds. I also have the option of making that femoral a short 12 French cordis so it can truly be a rapid infusing line as well if that's what they need.

In your case in Ed, if all you need is access for rapid boluses or induction agents or whatever, I would assume, never done, that an IO is the fastest. Agree with rendar, if they are in a form of shock requiring an immediate pressor I would throw in a femoral fast. They will need central acces so the pressor doesn't exstravisate anyway. If they're massively obese thrown in an IJ with your US but without the formal prep. Stick probe on, stick, feed wire, catheter and go. Stick em on antibiotics and if they survive the code or whatever your hour working them through ill pull the line upstairs and put in a formal one under sterile conditions.

Also agree on EJ. Although they are not always as fast and easy as they look. But if you just need access fast for a push of amio or something, an EJ is always a great idea.
 
Tiger26 said:
Agree with above and Wilco. Atmy residency institution, transducing was the standard.

See below for an explanation on the technique:

http://academiclifeinem.com/trick-of-the-trade-use-the-angiocatheter-for-central-lines/
Click to expand...

Any line you use an US for can be confirmed with the US, no need to transduce. Stick, wire in, take short axis and long axis views of the vessel. Either the wire is intraluminal or its not. If you don't have an US then transducing before dilation makes some sense, but virtually every non US guided line is femoral or subclavian for me. The chances of hitting the respective arteries there in a patient with a pulse is a lot lower than the carotid. I have slammed a few femorals into the artery doing a code. O well. They were Dying, once it was realized an hour or so later now that they had a perusing pressure, swapped fem for fem art and stuck am actual fem TLC right next to it. Or put in a controlled IJ and pulled the fem.
 
The ED docs at my facility place a ton of central lines. I did 4 my last shift. Nearly every intubated patient gets one (unless they're off the vent in 24 hours like a drug overdose), all septic patients, poor access, trauma lines for badly injured trauma patients, etc.

We do so many that I can place a subclavian in less than a few minutes from drape to completion. I think all but maybe 2 of our ED docs in my group are proficient at central lines. If they're conscious, I usually do an ultrasound guided IJ.

An IO is a temporary line at my facility. Patients who get an IO must have definitive access (peripheral line, PICC, central line) prior to going to the floor.

Luckily the nurses at my facility are extremely proficient at getting access. They can get IV's on a prune. So it's a rare thing that I'm called to get access on a patient. If I'm doing a central line, it's indicated for sepsis, trauma, etc. I love putting in lines, but I hate putting them in inappropriate patients who will only get an infection.
 
southerndoc said:
The ED docs at my facility place a ton of central lines. I did 4 my last shift. Nearly every intubated patient gets one (unless they're off the vent in 24 hours like a drug overdose), all septic patients, poor access, trauma lines for badly injured trauma patients, etc.

We do so many that I can place a subclavian in less than a few minutes from drape to completion. I think all but maybe 2 of our ED docs in my group are proficient at central lines. If they're conscious, I usually do an ultrasound guided IJ.

An IO is a temporary line at my facility. Patients who get an IO must have definitive access (peripheral line, PICC, central line) prior to going to the floor.
Click to expand...

If you have the time that's great, helps me out time wise upstairs. But as for the OP asking about emergent, if you can get an IO and the patient is coming upstairs within the hour or so anyway, we usually place the line. Now I know at some of your level one shops some of these patients might be with you for awhile, in which case I agree, the more definitive line should get placed so they're not getting peripheral Levo for 5 hours. I come to Ed often to help with this. If ICU is under control I will come to ED for any code or trauma and help with lines as the Ed docs are usually overwhelmed with volume. I bring an intern to get them lines they need.
 
southerndoc said:
The ED docs at my facility place a ton of central lines. I did 4 my last shift. Nearly every intubated patient gets one (unless they're off the vent in 24 hours like a drug overdose), all septic patients, poor access, trauma lines for badly injured trauma patients, etc.

We do so many that I can place a subclavian in less than a few minutes from drape to completion. I think all but maybe 2 of our ED docs in my group are proficient at central lines. If they're conscious, I usually do an ultrasound guided IJ.

An IO is a temporary line at my facility. Patients who get an IO must have definitive access (peripheral line, PICC, central line) prior to going to the floor.

Luckily the nurses at my facility are extremely proficient at getting access. They can get IV's on a prune. So it's a rare thing that I'm called to get access on a patient. If I'm doing a central line, it's indicated for sepsis, trauma, etc. I love putting in lines, but I hate putting them in inappropriate patients who will only get an infection.
Click to expand...

Southern--what's your workflow? I imagine you have good enough ancillary support that everything is setup so you walk in and do the procedure?
 
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Occasionally I have done the "peripheral IJ", but I've always done it with full sterile prep, US, drape, mask, gown, etc, and marked the tegaderm with sharpie as "central line." You can't cut corners with central access. I'm not very good at US guided PIV's, so if i can't get an EJ, I usually just place a 1 or 3 lumen central line.
 
Tiger26 said:
Southern--what's your workflow? I imagine you have good enough ancillary support that everything is setup so you walk in and do the procedure?
Click to expand...
Yes, our nurses and techs are great. They will set up everything for you. If it's a really sick patient, then everything is in one of the shock/trauma rooms. If it's in one of the main ED areas, then the nurse, tech, charge nurse, etc. will get you all equipment you need. I have never had to go get the ultrasound, probe cover, central line kit, etc. myself.

The staff is so great that they will anticipate anyone who needs a line and have the equipment at the bedside before you can even tell them you plan to place one. Septic with a lactate of 6? You'll find an Edwards presep catheter at the bedside immediately after the nurse notifies you of the lactic acid value (which is 20 minutes if sent to the lab; 2 minutes if you ordered an ABG/VBG since these are done at the bedside with i-stats).
 
southerndoc said:
Yes, our nurses and techs are great. They will set up everything for you. If it's a really sick patient, then everything is in one of the shock/trauma rooms. If it's in one of the main ED areas, then the nurse, tech, charge nurse, etc. will get you all equipment you need. I have never had to go get the ultrasound, probe cover, central line kit, etc. myself.

The staff is so great that they will anticipate anyone who needs a line and have the equipment at the bedside before you can even tell them you plan to place one. Septic with a lactate of 6? You'll find an Edwards presep catheter at the bedside immediately after the nurse notifies you of the lactic acid value (which is 20 minutes if sent to the lab; 2 minutes if you ordered an ABG/VBG since these are done at the bedside with i-stats).
Click to expand...

Sounds awesome! Any openings for a soon to be grad?
 
Dr.McNinja said:
You must not be from around here.
It's spelled y'all.
Click to expand...

Birdstrike said:
Well, actually, it's y ' a a a w l
Click to expand...

Never lived north of the mason-dixon. My current location could best be described as the deep-south. I always used to spell it y'all, then I had a couple people vehemently defend the spelling of ya'll, almost to a fault, so I changed to ya'll......
 
Aren't apostrophes, when used in contractions, meant to indicate missing letters? If so, I s'pose the spelling should be "y'all" for "you all".

Now, if you'll excuse this Chicagoan, I'm gonna go have some saahsige and beah.
 
TimesNewRoman said:
Never lived north of the mason-dixon. My current location could best be described as the deep-south. I always used to spell it y'all, then I had a couple people vehemently defend the spelling of ya'll, almost to a fault, so I changed to ya'll......
Click to expand...

Those people were wrong. They probably pronounce moot as "mute" as well.
(Had a friend try to make fun of me for saying moot one time)
 
..which I must say is a completely appropriate and groundbreaking inclusion to the English language.

most other Germanic and Romantic languages have a separate plural second-person personal pronoun however English does not.

American English, as a mix of all languages, has changed the original language enough that adding such a saying is not linguistically out of character.
 
TimesNewRoman said:
Never lived north of the mason-dixon. My current location could best be described as the deep-south. I always used to spell it y'all, then I had a couple people vehemently defend the spelling of ya'll, almost to a fault, so I changed to ya'll......
Click to expand...

I was born in Alabama and have lived here the majority of my life. I've never heard of or seen this misspelling you speak of. Anyone who would argue in favor of "ya'll" should immediately have their Southener card revoked. They probably like their tea hot, fail to recognize the football supremacy of the SEC, and may even have an alternate spelling for grits.
 
Hercules said:
I was born in Alabama and have lived here the majority of my life. I've never heard of or seen this misspelling you speak of. Anyone who would argue in favor of "ya'll" should immediately have their Southener card revoked. They probably like their tea hot, fail to recognize the football supremacy of the SEC, and may even have an alternate spelling for grits.
Click to expand...

Strange, I grew up in Louisiana and only seen it spelled, "ya'll." I guess that says a lot about the Louisiana education system.
 
Texan here - y'all all the way. Still not happy about this SEC-dominance though. Looking forward to the (eventual) rise of the longhorns.
 
alehar said:
Texan here - y'all all the way. Still not happy about this SEC-dominance though. Looking forward to the (eventual) rise of the longhorns.
Click to expand...

The SEC exists in Texas. Just happens to not be your school.




Gig 'em
 
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