Finder needle during central line

[dr.evil]

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Do any of you know of any study or real data showing that using a smaller gauge finder or seeker needle for IJ central line placement decreases the incidence of carotid injuries?

So people do this routinely while others think it's hokus-pokus. Some use a 25 gauge seeker needle prior to placement of the 18 gauge cook. These people of course don't use ultrasound.

thanks

 

[fourthyear]

All I know is I've never seen a surgeon use a seeker needle - that's for medicine residents. ha ha

 

[Celiac Plexus]

I've never used one. I can't imagine that using a slightly larger needle would make that much of a difference in the hands of a capable individual... then again that's just my opinion and I could be wrong.

 

[daredevil_2010]

i use the smaller needle for IJs and Femorals in non-emergent line placements. Why not? Less damage to the sof tissue when you're sticking around.

 

[thegasman]

All I know is I've never seen a surgeon use a seeker needle - that's for medicine residents. ha ha

At my hospital most surgical and anesthesia residents use the 25g needle first just on IJs. I don't really know if it makes a difference, but it doesn't hurt. As far as med residents, they either can't or won't do a line without ultrasound guidance.

 

[tripod]

At my hospital most surgical and anesthesia residents use the 25g needle first just on IJs. I don't really know if it makes a difference, but it doesn't hurt. As far as med residents, they either can't or won't do a line without ultrasound guidance.

yeah i usually use a finder needle for IJ's, especially if they have an INR of like 3 or something. Nothing like cric'ing a pt after a massive hematoma forms from multiple carotid sticks with an introducer needle to convince me that finder needles are good things.

 

[Tenesma]

1) finder needles are appropriate for IJs... using it doesn't decrease the likelihood of hitting the carotid, but it definitely makes a big difference in as much as a 22G hole is smaller then an 18G thin-wall hole.

2) there is nothing wrong with using an ultrasound... there are enough studies to show that using ultrasound decreases the number of complications, primarily by allowing for less attempts in order to find the vein. Especially in a patient who looks difficult or is over-anti-coagulated.... In fact, I have used ultrasound with great access for subclavian access in long-term sick ICU players who have been stuck a million times and are all edematous, it allows me to enter the subclavian vein a lot more distal without having to worry about the line/cordis getting bent under the clavicle.

3) what i love is how medicine residents do all their lines as femoral lines, because of some sort of false sense of security, even though those tend to have the most mechanical complications (AV fistula, pseudoaneurysm, etc....) , and then what makes it even funnier is when they insist they are volume resuscitating somebody through the 16G port on the triple-lumen.... only to have a very confused look when I tell them that the flow is equivalent to a peripherally placed 18/20G IV

 

[thegasman]

1) finder needles are appropriate for IJs... using it doesn't decrease the likelihood of hitting the carotid, but it definitely makes a big difference in as much as a 22G hole is smaller then an 18G thin-wall hole.

2) there is nothing wrong with using an ultrasound... there are enough studies to show that using ultrasound decreases the number of complications, primarily by allowing for less attempts in order to find the vein. Especially in a patient who looks difficult or is over-anti-coagulated.... In fact, I have used ultrasound with great access for subclavian access in long-term sick ICU players who have been stuck a million times and are all edematous, it allows me to enter the subclavian vein a lot more distal without having to worry about the line/cordis getting bent under the clavicle.

3) what i love is how medicine residents do all their lines as femoral lines, because of some sort of false sense of security, even though those tend to have the most mechanical complications (AV fistula, pseudoaneurysm, etc....) , and then what makes it even funnier is when they insist they are volume resuscitating somebody through the 16G port on the triple-lumen.... only to have a very confused look when I tell them that the flow is equivalent to a peripherally placed 18/20G IV

I have no problem with using ultrasound on a difficult patient, it seems it would be very helpful. But we should be able to do a line on a straightforward, non-morbidly obese patient without it if necessary. If you use the ultrasound EVERY time, what do you do if it is not available and you have to do a line. The way tenesma described it seems the right way to use it, but the med residents at my hospital use it as a crutch. (The surgeons ridicule them for it too.)

 

[Tenesma]

i agree... ultrasound isn't always available, and they really should know how to do it without it...

 

[RuralMedicine]

I always use a seeker needle when placing an IJ. As everyone else has said the consequences of a 22 gauge stick into the carotid and an 18 gauge stick into the carotid are different.

I was always taught that your flow rate with bolusing was dependent on both your lumen size and the size of the catheter so yes bolusing through a 16 gauge PIV is a great option. However, if I've already got a central line in place because they're septic, have yet to respond to the first three boluses, and we're starting Norepi I'm probably going to allow the nurse to bolus through the triple or quad lumen.

The literature supports ultrasound assistance for central lines so I think it's something we should be using, getting comfortable with, and identifying patients who will benefit. We don't have access to a site right in the middle of the night at most of our hospitals so I definitely still do more without than with. Does anyone use a site right for their subclavians? (I prefer IJs in general but we tend to do a lot of lines for our NUS and ortho colleagues and they usually haven't cleared the c-spine so Subclavian it is.)