Expertsie in subclavian lines

[redy]

I am starting my pulm/cc fellowship next year.

In my community IM program we are not taught subclavian lines. All of us learn US guided IJ and of course femorals.

How important, do you guys feel, is it for
a) an IM resident to learn
b) a pulm/cc fellow to learn to place a Subclavian.

Personally I dont like to be a ICU fellow who cannot place a subclavian. But where can I learn, nowhere.

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[Hernandez]

A) depends on what the IM resident is going to do after they graduate
B) as CC, you should be more than comfortable with svc. Like you I had done none when I had graduated IM, but done ~50 IJs, now, I've logged over 300 lines during my fellowship, and I have to have a reason not to put in a svc. I'd be shocked if your fellowship didn't teach you the tricks. Hell, I'll even go wild and do u/s guided svc from time to time.

 

[sluggs]

If an IM resident is primarily responsible for lines at a hospital at night, he or she should know how to do a subclavian.
All intensivists should have good facility with subclavians. Whether or not they are preferred is a whole 'nother story, but sometimes they are your best or only option.
Pick your teaching/learning lines carefully, use good trendelenburg, and keep peep off or to a minimum if the patient is on the vent.
It is a nice line!

 

[europeman]

Google "CDC central line guidelines" and u will actually see that subclavian a are the official recommended line over jugular!

Subclavian lines are more comfortable for patients and easier to take care of. In patients with hemorrhagic shock, it is the vein which least compresses. I do it blindly but there are ways to do lateral subclavian a under ultrasound.

Some patients have c collars from trauma associated with pelvic fractures. Some patients have clotted IJs.

The point is, yes, u should know how todo them.

There is nothing magical about a subclavian. Just read about it and do it. Don't like down into lung and u will be fine.


Worse comes to worse and the patient gets a pneumo, as long as u are around to quickly deal with it, it's not the biggest deal in the world.

We just had a dilator placed into carotid from ultrasound guides IJ.

The point is all the lines have risks. Learn them all. U have to be proactive learning though because WAY too many people are losing their subclavian skill set which is a disservice to patients

 

[redy]

Google "CDC central line guidelines" and u will actually see that subclavian a are the official recommended line over jugular!

Subclavian lines are more comfortable for patients and easier to take care of. In patients with hemorrhagic shock, it is the vein which least compresses. I do it blindly but there are ways to do lateral subclavian a under ultrasound.

Some patients have c collars from trauma associated with pelvic fractures. Some patients have clotted IJs.

The point is, yes, u should know how todo them.

There is nothing magical about a subclavian. Just read about it and do it. Don't like down into lung and u will be fine.


Worse comes to worse and the patient gets a pneumo, as long as u are around to quickly deal with it, it's not the biggest deal in the world.

We just had a dilator placed into carotid from ultrasound guides IJ.

The point is all the lines have risks. Learn them all. U have to be proactive learning though because WAY too many people are losing their subclavian skill set which is a disservice to patients

That's what I feel too. I think it's a shame we never see it or learn even once.

So just wanted to see what people in the field felt.

Thanks for the replies.

Sent from my Nexus 7 using Tapatalk 2

 

[glorfindel]

My favorite blind line and favorite subclavian is the supraclavicular approach to the subclavian. I learned it on my own, from an online video.

Here's the video explaining how to do it; the serious stuff starts about 1:30 in --

http://emrap.tv/index.php?option=com_content&view=article&id=122:EMRAPTV22-SupraclavicularLine

 

[ProwlerturnGas]

I do many subclavian lines in the SICU where I primarily work. 100% ultrasound guided. 1 pneumothorax in my practice (resident was driving the needle). After placement, I do a focused lung US exam and will know absence of PTX before the CXR.
With US, I can see the subclavian artery, vein, brachial plexus, lung viscera and all of their interactions. I look first out of plane with US then turn the probe 90deg to inplane with subclavian vein and watch my needle enter the vessel. Havent done a blind line in a few years.

 

[Bostonredsox]

Ive done somewhere around 100-120 lines during roughly half of an IM residency. Maybe 25-30 of them have been subclavians. Very easy to learn. Watch a few videos or find a good old time surgeon who has put in 5,000 of them. To me they are similar to LPs. They are about 'the feel". knowing where to stick and how far/deep to go you just learn with repetition. You don't have the US to just show you, "stick here, thread wire, go get sandwich". I prefer them honestly though by my above #s clearly they are not what I do most often. Theyh ave the lowest infection rate and I am frequently just too impatient to wait for the US to get brought up to me. Also they are supposively more comfortable to the patient than having a catheter hanging out the side of their neck.
Def a need to know line though. IJ more difficult without an US and femorals are basically trauma lines only. And I wouldn't worry about dropping a lung. It WILL happen. I have caused one PTX in >100 lines. Not a terrible #. And as the SICU surgeon who taught me told me, "If you havent caused a pneumo then you have not put in enough lines yet".

I am finding many academic trained internisits are entering CC fellowship without subclavian experience because all of the academic shops have top end US's and are worried about a PTX so they train all their residents to put in IJs. One of the few benefits to a community shop is for a while, we had no US. And the one we now have blows. Thus all of us have become quite proficient in subclavian lines. Learn the art of chest line, will serve you well.

cheers

PS i realise you can use US to aid your subclavians I have done this a few times, but honeslty given the poor quality of my shops US coupled with level of obesity of my patients its tough to see much in the chest. Plus, If I have time to get an US out, why not just stick the neck?