flush a cordis?

[Hamhock]

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A bit ago a watched a resident stop insertion of a cordis during a trauma resuscitation to "pre-flush" the line.

Does anyone else do that? Is there any reason to? as long as you allow blood to flow to the of the side-arm before infusions

I had never considered it before, but....

Thanks, HH

 

[docB]

I don't pre flush any of my central lines. Once placed I draw from all the hubs until I get blood in the syringe and then I flush them.

In my shop the flushes come wrapped but are specifically marked "non sterile" so if I were to use those at the beginning of the procedure I'd be contaminated.

 

[SoCuteMD]

Some attendings insist that we pre-flush routine, non-code our lines. I just put in my first cordis the other day and I did not flush it. Blood flowed out of the line as soon as I removed the dilator, so I clamped it, sewed in the line and then flushed it. I probably wouldn't flush any line I was putting in during a code situation.

 

[southerndoc]

I don't flush code lines or a Cordis, but I do pre-flush our quad lumen catheters if it's not a code situation. Although it's happened only once, I have had a case where one of the ports clotted off before I got a chance to flush it. I eventually got it open with some fanagling.

 

[AmoryBlaine]

Never flush an emergency cordis, you are exactly right let blood run out of it then hook it up to IVF.

Always flush non-urgent lines. There is no reason to risk putting air into the circulation. You can find sterile flushes or just spray/dribble sterile saline into the kits.

 

[docB]

Never flush an emergency cordis, you are exactly right let blood run out of it then hook it up to IVF.

Always flush non-urgent lines. There is no reason to risk putting air into the circulation. You can find sterile flushes or just spray/dribble sterile saline into the kits.

Interestingly our bottles of sterile saline are all maked as non-injectable. So it's not suitable for flush. To get injectable sterile saline we either have to puncture an IV bag or squirt a lot of the flushes.

 

[southerndoc]

Interestingly our bottles of sterile saline are all maked as non-injectable. So it's not suitable for flush. To get injectable sterile saline we either have to puncture an IV bag or squirt a lot of the flushes.

I just squirt the flushes (or have the nurse do it) onto the tray and then use one of the included syringes to draw it up.

 

[gutonc]

I just squirt the flushes (or have the nurse do it) onto the tray and then use one of the included syringes to draw it up.

And I don't know about our ED, but our ICUs all have sterile saline flushes available that can be dropped on the field. Otherwise, the squirted flush thing works.

 

[deleted109597]

Always flush non-urgent lines. There is no reason to risk putting air into the circulation. You can find sterile flushes or just spray/dribble sterile saline into the kits.

Show me some evidence that a) this is actually a risk, and b) there is enough air in all of the ports combined to do anything and I'll consider it. But considering both posits are false, I'll not do so. Sorry, but the volume of air in the line is not enough to do anything. They get more air from the saline infusing in an IV than they would if you simply pushed without drawing back.

Do you put some sort of valve over the needle before threading the wire so that air doesn't get sucked in through that (which has less resistance, and theoretically, more risk)?

 

[Hernandez]

Show me some evidence that a) this is actually a risk, and b) there is enough air in all of the ports combined to do anything and I'll consider it. But considering both posits are false, I'll not do so. Sorry, but the volume of air in the line is not enough to do anything. They get more air from the saline infusing in an IV than they would if you simply pushed without drawing back.

Do you put some sort of valve over the needle before threading the wire so that air doesn't get sucked in through that (which has less resistance, and theoretically, more risk)?

I flush, more so due for clotting prevention, and to help flush the needle if its a more difficult stick that takes me a little while.

 

[deleted109597]

I flush, more so due for clotting prevention, and to help flush the needle if its a more difficult stick that takes me a little while.

That is at least reasonable and rational. How many have you had clot?

 

[Hernandez]

That is at least reasonable and rational. How many have you had clot?

Lines only 1, the needle is more frequent, so i like to have 1-2cc in the syringe. Death by air embolism has been reported with doses as small as 40cc, the one pt i put a line in with eisenmenger's physiology was the one i was the most careful with on avoiding any air embolism. Literature states air embolism occurs with 0.1% of central line insertions. (Air embolism during insertion of central venous catheters. J Vasc Interv Radiol. *2001; 12(11):1291-5)

 

[Apollyon]

Death by air embolism has been reported with doses as small as 40cc

By fluid volume, that is not "small". That is more than twice the volume of a standard primary set of tubing, or, alternately, all three of the flushes (which are, of course, 10mL each). Sure, death has been reported with an amount of 40mL of air, but, likewise, MVC leading to death has happened at 12mph. Both are extremely uncommon, and are way, way outliers. The estimate needed in general is more in the way of 200-300mL (like with the power injector for CT) (Toung TJK, Rossberg MI, Hutchins GM. Volume of air in a lethal venous air embolism. Anesthesiology 2001; 94:360–1).

My point is that, yes, it CAN happen, but, WILL it? As long as you put your thumb over the port before you hook up the IV tubing or put the cap on, you'll be OK.

 

[deleted109597]

That was my point. "as little as 40cc" is still a ton of air. If you put a cordis in and left the clamp open during inspiration, you might get that if they're hypotensive enough to have negative pressure in their vasculature at that moment. Not a common occurrence.

Another one is the wire. I've never seen, nor has anyone I've ever worked with, a wire getting sucked in from not holding it. But everyone talks about it like VIR has to remove 3 wires per day from people just willy nilly letting them fall in. Yes you should be careful. No you don't need a death grip on it.
When we do things that are not evidence based (and I mean with good evidence), even if they are "expert opinion", we aren't advancing medicine.

Also, that article had 15 of 11583 patients with air embolism durine placement of tunnelled catheters. None of them were cordis or TLC. 1 patient died. I don't equate "asymptomatic (n=4)" with "dead" as similar outcome measures. Maybe I'm just weird like that.

 

[proman]

You should be more concerned about a known or unknown PFO or other right-to-left shunt. Even a small amount can cause a devastating stroke.

I rarely flush my lines (and practically all of mine are elective). I will draw back and flush before sewing them in though.

 

[Apollyon]

You should be more concerned about a known or unknown PFO or other right-to-left shunt. Even a small amount can cause a devastating stroke.

Actually, though, again, those "small amounts" are rare cases, and my (limited) literature review shows case studies that show transient morbidity. I mean, 1% of cardiac cath has a rupture of the ventricular wall, and, as a cards guy told me, "If you haven't perfed the ventricle, you haven't done enough caths". You're absolutely on target, but, also, how many people recall from first year of med school, in embryology, that, at autopsy, 25% of people have a probe patent foramen ovale?

 

[AmoryBlaine]

Show me some evidence that a) this is actually a risk, and b) there is enough air in all of the ports combined to do anything and I'll consider it. But considering both posits are false, I'll not do so. Sorry, but the volume of air in the line is not enough to do anything. They get more air from the saline infusing in an IV than they would if you simply pushed without drawing back.

Do you put some sort of valve over the needle before threading the wire so that air doesn't get sucked in through that (which has less resistance, and theoretically, more risk)?

I can't show you evidence, but it's not that big of a deal. I wouldn't stop doing something that seems like reasonable practice just because I couldn't find a case report of someone dying from not having this done. It takes me 45 sec to flush a triple lumen.

I guess an analogous thing would be that I'm not aware of any data that says that people would have the same # of line infections with 2 CHG preps as opposed to 3. So I can't tell you that I'm saving lives or preventing sepsis with my 3rd prep. Presumably after you have scrubbed the skin twice with CHG nothing is left alive there, but I'm going to keep doing 3....

I tend to think about these things as "what would I do if I had to put this in my grandma."

 

[southerndoc]

3 Chloropreps? We only do 1. How many institutions are scrubbing twice?

 

[deleted109597]

I tend to think about these things as "what would I do if I had to put this in my grandma."

And apparently the top of your list is "things that make this take more time than it should"

And certainly, I'm not saying we shouldn't treat patients differently than families (except that patients often want ACLS, and I wouldn't do that to my family, natch). However, this is just one thing that you can say "I feel more comfortable doing it this way, regardless of what the research shows". How many other things do you think you could identify in your practice habits that are the same?

 

[Hernandez]

And apparently the top of your list is "things that make this take more time than it should"

And certainly, I'm not saying we shouldn't treat patients differently than families (except that patients often want ACLS, and I wouldn't do that to my family, natch). However, this is just one thing that you can say "I feel more comfortable doing it this way, regardless of what the research shows". How many other things do you think you could identify in your practice habits that are the same?

This is a little disingenuous for 2 reasons 1) it's takes very little time to flush central lines and 2) I listed the data on the frequency of air embolism from central lines. Whats missing is the data on frequency of clinically significant air embolisms. I'm sure you'll quip that the number I cited isn't a big number and I won't disagree, however there are lots of things we do in medicine to either look relatively rare dz for or prevent bad outcomes on the same order or rarity as air embolism

 

[deleted109597]

The difference is that I didn't come in and make a statement tantamount to telling me that I'm the one doing it wrong. Thinking critically is a skill, and if a line is truly an emergency, 45 seconds can mean a lot.
If you want to argue to do them for elective procedures, feel free to say that you aren't aren't going to harm people by adding some time. I will then argue that elective procedures don't have a place in the emergency department, and can be done by the admitting team.

Furthermore, just because we do things in medicine because of rare events doesn't make them right. Also, you only listed 1 article's data, not the data as it were. Also, those lines are completely different from either a cordis or a triple lumen. It's like defining the risk of cholecystectomy by demonstrating the risk of appendectomy. Similar, but not the same. If there is better data out there, feel free to point me in that direction.

 

[AmoryBlaine]

The difference is that I didn't come in and make a statement tantamount to telling me that I'm the one doing it wrong. Thinking critically is a skill, and if a line is truly an emergency, 45 seconds can mean a lot.
If you want to argue to do them for elective procedures, feel free to say that you aren't aren't going to harm people by adding some time. I will then argue that elective procedures don't have a place in the emergency department, and can be done by the admitting team.

Furthermore, just because we do things in medicine because of rare events doesn't make them right. Also, you only listed 1 article's data, not the data as it were. Also, those lines are completely different from either a cordis or a triple lumen. It's like defining the risk of cholecystectomy by demonstrating the risk of appendectomy. Similar, but not the same. If there is better data out there, feel free to point me in that direction.

1. There are several situations in the ED where placing a central line is neither emergent nor elective. Early goal directed therapy is a great example, or more broadly any need/anticipated need for pressors. Vascular access is another. These are not "emergencies" in the same way that tubing an acute resp failure is an emergency but that does not make them automatically something that should happen upstairs.

2. I whole heartedly agree with you that if you are putting a cordis into the SC or fem in a true emergency situation that you cut LOTS of corners with prep, drape etc. However if someone needs an emergency line then you should never be placing a TLC....

Again I don't feel incredibly strongly about this, like I said I wouldn't freak out if a resident said they forgot to flush the line. I do feel like we should minimize risk of complication.

You are probably right the risk of air embolism is very low and the risk of clin sig air embolism is even lower. I could also make it my practice that every person under the age of 40 who complaints of chest pain and does not appear acutely uncomfortable could be patted on the head and sent home without even a physical exam. If I did this I would guess I would be fine something like 199/200 times, maybe end up with a 0.5% miss rate for badness. Statistically that would be great practice - right?

 

[deleted109597]

1. There are several situations in the ED where placing a central line is neither emergent nor elective. Early goal directed therapy is a great example, or more broadly any need/anticipated need for pressors. Vascular access is another. These are not "emergencies" in the same way that tubing an acute resp failure is an emergency but that does not make them automatically something that should happen upstairs.

I would argue that early goal directed therapy is an emergency. That is, if you can get by the whole "Rivers' data is full of flaws and bias". I don't use SvO2 caths because there isn't evidence for them, and they're incredibly expensive. I have and will continue to fluid hydrate people through peripherals. If they need a pressor (evidence for these is lacking as well), then they might need a TLC at that point. Or if they don't have any access at all.

2. I whole heartedly agree with you that if you are putting a cordis into the SC or fem in a true emergency situation that you cut LOTS of corners with prep, drape etc. However if someone needs an emergency line then you should never be placing a TLC....

Septic people rarely need a cordis. Most people rarely need a cordis, but the ones that do need them quickly.

Again I don't feel incredibly strongly about this, like I said I wouldn't freak out if a resident said they forgot to flush the line. I do feel like we should minimize risk of complication.

I agree that we should do what we can, however there isn't evidence that flushing does anything to minimize risk. Just because we think it does, doesn't mean it is so.
Also, I don't feel strongly either, I just like to argue.

You are probably right the risk of air embolism is very low and the risk of clin sig air embolism is even lower. I could also make it my practice that every person under the age of 40 who complaints of chest pain and does not appear acutely uncomfortable could be patted on the head and sent home without even a physical exam. If I did this I would guess I would be fine something like 199/200 times, maybe end up with a 0.5% miss rate for badness. Statistically that would be great practice - right?

If you only miss 0.5% of badness with perfect exams then you're doing pretty well. Also, physical exam has low sensitivity.
How bad of badness are you willing to take as bad? If you stress everyone with chest pain, you're still going to only have about 50% sensitivity. You could CT them all, not increase sensitivity, and make their lifetime risk of cancer higher.
Point being, you pick and choose what you can do. We will never get all of them. Some things you can change. I would argue that how you do central lines has much less importance for flushing, and much more for sterile procedure and subsequent line infections as an inpatient.

 

[xaelia]

If they need a pressor (evidence for these is lacking as well), then they might need a TLC at that point.

Or you could save time, money, and multiple risks and run the pressor through an I/O. If the TLC is only needed for a CVP, it's not needed. Two pressors? Two I/Os. I really don't know why the I/O doesn't catch on....

How bad of badness are you willing to take as bad? If you stress everyone with chest pain, you're still going to only have about 50% sensitivity. You could CT them all, not increase sensitivity, and make their lifetime risk of cancer higher.

And, I disagree with some of the endpoints of a lot of these ACS studies. To me, death/MI/revascularization are not the same - death and MI, sure. The guy who had a negative stress last month, who goes home and follows up with his cardiologist, and then gets an elective cath with stenting of some 60-70% lesion...probably didn't get treatment for the source of his chest pain, and it's definitely an entirely different endpoint.

The rule-in rate in Australia is way higher - and the percentage of "missed" ACS they send home is not much greater than our practice. Catching STEMI is standard of care; catching the 19-year old with NSTEMI rule-in on her 3rd set is not.

Just like the ~70% sensitivity of plain x-ray means everyone in a minor MVC gets a CT scan now...when NEXUS missed 3 clinically important fractures out of 34,000?

Resource utilization will be a bigger deal in the future than it is today, I have no doubt.

 

[Hernandez]

Or you could save time, money, and multiple risks and run the pressor through an I/O. If the TLC is only needed for a CVP, it's not needed. Two pressors? Two I/Os. I really don't know why the I/O doesn't catch on....

I finally talked my previous icu into keeping IOs on hand for emergent code situations and now I'm at a micu that doesn't have them, I personally don't leave ios in longer than it takes to stabilize and get a central line.

 

[xaelia]

I personally don't leave ios in longer than it takes to stabilize and get a central line.

Any particular reason why, other than nursing comfort/experience?

 

[deleted77919]

…

 

[Hernandez]

Any particular reason why, other than nursing comfort/experience?

Compatibility issues with drips, and as already stated you shouldn't leave an io in that long. And the people vie put ios in don't leave the icu in 24 hours

 

[doctorFred]

I will then argue that elective procedures don't have a place in the emergency department, and can be done by the admitting team.

there is a third category somewhere between elective and emergent, and that is "important", and what you categorize as elective is probably better described as "important" 99% of the time.. and (appropriately) performed by the ED staff.

 

[AmoryBlaine]

I agree that IO is underutilized and central lines overutilized for resucitations. In other cases not so much, depends on how urgently you need access and the patient's expected clinical course. IOs shouldn't stay in for more than 24 hours. Central lines can stay in much longer, not an issue for the ER unless you're doing some serious ICU boarding but if the patient will need a central line eventually anyway I don't see why I shouldn't place it as opposed to exposing the patient to 2 different access procedures.

Having said that, at one place I worked the ICU called central lines placed in the ER enemy lines and would change them out within 12 hours, in that case IO would be perfect.

That is a hilarious term that I'm going to steal.

At my shop (and I suspect this is true for many of you) the ED line is likely the best one you can get outside of one placed in the OR by anesthesiology. IM people these days just don't get enough experience.