Hopkins Bayview intern sued for central line placement

[ckent]

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Check this article out:
http://www.sunspot.net/news/health/bal-md.hopkins29jan29,0,6414603.story?coll=bal-local-headlines

This kind of stuff makes me really scared to start internship year. I've always thought that it was really easy to hit the carotid while placing an IJ, because you are so close to the damn thing. I'm certain that they had this risk on the consent form. And an intern too, that's sad. He or she will be screwed when he or she finishes and has to get a new malpractice insurance policy.

 

[ckent]

One of my prof's was just telling me how these malpractice suits against residents go. Residents and interns can really get screwed when it comes time for them to testify, because the plantiff's lawyer asks questions like "when did you graduate from med school? What did you do after you graduated? How many of these lines have you placed this year or ever?". And it's not like the intern was going to get the attending to place a central line just because the patient was worried about it. Sheesh, medical malpractice stinks. Our governor (a republican) pushed for caps but 2 trial lawyers who hold key committee positions have already promised to defeat it. Here is the article in case it gets deleted from their website:

Negligence claim filed against Hopkins


By Erika Niedowski
Sun Staff
Originally published January 29, 2004




A woman treated last year at the Johns Hopkins Bayview Medical Center filed a malpractice claim against the hospital yesterday, saying an intern had "negligently" cut an artery in her neck while trying to establish intravenous access.

According to the lawsuit, Dezirea M. Claxton of Baltimore visited Bayview's emergency department Nov. 5 and was admitted for further tests and treatment. Several days later, two physicians examined the 49-year-old in her room and said they had to place a catheter in a vein in her neck because they couldn't use those in her arms.

One of the doctors asked the other - described as an intern - whether he could handle the procedure, and the intern said he could. But according to the lawsuit, the intern "lacerated" Claxton's carotid artery while inserting the catheter.

Claxton underwent a blood transfusion and, two days later, more than two hours of surgery to repair the damage. She was discharged Dec. 15.

A Hopkins spokesman, Gary Stephenson, said that hospital officials had not reviewed the lawsuit and that he could not comment.



Copyright ? 2004, The Baltimore Sun | Get home delivery

 

[Linie]

Learning how to do procedures is such a tricky thing. We get "informed consent" from patients, but so often I'm not sure they really understand what it is we're going to do, what it's going to be like and what could go wrong. Also, we don't (or I should say I don't) specifically tell them that the person doing the procedure may be doing it for the first time. If someone asks me how many times I've done a particular procedure, I give an honest estimate, which is usually, "enough that I've stopped counting".

If I needed a procedure I would absolutely NOT want an intern to do it. But I was an intern once, and I did procedures on people. Everything has to be done for the first time once, by definition.

It's a very interesting ethical issue.

The article points out something else very important: what you say in front of patients is very important, even if you aren't directing it toward them, or think they aren't listening or can't hear you. Not that anything should have been hidden from the patient, but it sounds like the conversation that took place in front of the patient was somewhat less than professional.

 

[ckent]

Originally posted by Linie

The article points out something else very important: what you say in front of patients is very important, even if you aren't directing it toward them, or think they aren't listening or can't hear you. Not that anything should have been hidden from the patient, but it sounds like the conversation that took place in front of the patient was somewhat less than professional.

I don't understand how you got that from the article. All it said was that the intern said that he could handle the procedure, which he should have been able to. Even in the most experienced of hands, unless you are using an ultrasound machine to guide you, you are bound to miss or lacerate the carotid a certain percentage of times. Especially in really obese patients (which this patient may have been if they couldn't get a peripheral line), I've noticed that a lot of these procedures we do are just done blindly and just with a hope for the best attitude. I wouldn't want an intern to do a procedure on me either, but I also wouldn't sue an intern for something like a missed central line. Ironically, while at Bayview, my interviewer was talking about malpractice with me. According to him, there was a study a while ago which showed that even after patients were videotaped getting informed consent and shown the videotapes of the doctors giving them consent later, they still responded that the doctor had not warned them of the risks of the procedure. I think that this is a case of overzealous trial lawyers and a patient thinking that just because something "went wrong", she was entitled to some compensation.

 

[Foxxy Cleopatra]

ckent,

This is honestly the thing that bothers me most about residency and medicine in general. We all have to learn, and unfortunately, things don't always go the way you plan. I read Marino's ICU book, Mont Reid, and asked several different residents advice on how to place lines without hitting arteries/ dropping lungs. I don't want to curse my luck, but if you are very cautious when doing these things, hopefully things will be okay.

The "you owe me" mentality is rampant out there and I still think the perception of doctors in the lay public is that we have unjustifiably large salaries and can spare a few thousand. Sometimes you will get threatened out of patient anger, feeling of helplessness, or undesirable outcome (whether or not it was truly malpractice.)

This has made me realize the importance of documenting *everything* and (to the best of my ability) know what I am getting into when doing something to a patient. CYA medicine is the way it has to be done. Hopefully, some sort of malpractice reform will make a difference in the future.

 

[Bobblehead]

This indeed raises some very interesting questions. Making a lot of assumptions about the article it sounds like a more senior resident/attending asked an intern whether he could "handle" a central line. And he may very well have been able to under proper supervision. But would he or any of us have refused to do the procedure? I mean you know the "right" answer, don't do anything you're not fully comfortable doing, but on the other hand no one wants to look "weak" or have future procedures categorically taken away from them. Was he supervised during the procedure? Does his training program mandate that no intern procedures go un-supervised? The article doesn't specify but I hope the chart documents who was watching the intern perform the procedure.

There are a lot of near misses which don't get conveyed to patients regarding bedside procedures (retained wire, finding the artery, etc.) and some that just can't be ignored (dilating the artery requiring vascular surgery, needing VIR magnetic guidance to remove a lost wire, chest tube after pneumothorax). We could speculate what happened, i.e. finder needle was moved laterally while deep in the tissue, arterial blood was not properly identified and the artery was subsequently dilated but the bottom line is it sounds like a lot of factors came together in this case and a lawsuit ensued. You have to start off with a patient who is either predisposed to sueing, did not get along with the doctors (you generally don't sue people you like), was not told enough information, etc.

I've caused my share of hematomas and (so far only) one pneumothorax and I've found plenty of subclavian and carotid arteries. Thankfully all the factors have not come together and no lawsuit has ensued but sooner or later something may happen.

Unfortunately there's no magic to doing central lines, just repetition after repetition and once the memory fades you have to start over (i.e. I'd rather have a senior resident than a non-critical care attending placing a line). Using a micropuncture kit helps with technique because you can't brutalize the needle through the soft tissue (you'll bend the needle) which develops more finesse. It also cause a smaller hematoma which gives you more passes at the line.

 

[ERMudPhud]

This reminds me of a case when I was a resident. A GSW to the chest came in while the attending and another intern where busy with another case. As the senior ED resident I went to work on the GSW with a second intern. The patient was actually pretty stable, good vitals and yelling like crazy. I first asked the intern to put in a central line and after he flailed for a while I took it away from him. After that I asked him to do a chest tube. After he flailed on that for a few seconds that seemed like hours I went to step in on that procedure as well. From underneath the sheet covering the patients face came, "Yo, you M----er F----ers practicing on me or what?"

Students and housestaff have to learn sometime and somebody has to be the one to be the intern's first central line. That being said, there is no substitute for proper surpervision and teaching when house staff are doing procedures. Failing that obligation is dangerous, lazy and morally indefensible. Also, there really is no substitute for U/S guided placement of lines-especially the IJ.

On a side note, my wife was sued over a procedure during her residency. A very traumatic way to start your career in medicine. It never seemed to make a difference when she was applying for jobs, insurance, licensing etc... and a few years later the suit was thrown out of court as completely bogus.

 

[tussy]

It's hard to know the specific details of this case, but i think we should all learn from it.

By saying that he can "handle the procedure" without supervision was this intern's first mistake. Had the attending/senior been supervising more closely then they would share in more of the liability when the complication occurred. As it stands now, the poor intern has taken most of the blame.

As a resident it is important to get lots of procedures, and nobody wants to admit that they are not capable. However, we are responsible if we screw up, so we must practice a little CYA medicine.

Just to share a little story that happened to me last week on a related note:

I was in the clinic area, removing lumps and bumps with my attending. The last patient came in; booked as "removal of cyst from shoulder". My staffman went back to his office and left me to do the procedure. When i went to examine the patient the lump was actually on the neck (posterior triangle), and looked more like a lymph node. I took one look and asked the nurse to page the staff man. He was pissed but came back from his office. He removed the node, but found it wrapped around the spinal accessory nerve. If i had done the procedure there is a good chance that the nerve would have been damaged, and i would most certainly be sued. (As an aside: posterior triangle lymph nodes should always be biopsied in the OR, not in the office) I felt inadequate calling staff at first, but now realize it was the exact right thing to do. Live and learn!

 

[edmadison]

I just want to correct a big legal misconception. The informed consent process does not protect against negligence. You can have a form which warns of every possible complication including the sun exploding and jogging you hand during the procedure, but this does not protect against negligence.

The consent process protects against two things. First, it shows that the patient actually approved the performance of the procedure and any ancillary procedures. This removes the threat of an assault (an unwanted touching). Second, it warns of potential adverse effects. This protects against "failure to warn" which has a strict liability standard (thus no negligence need have occured).

Mistakes/poor outcomes are going to occur. Statistically, What keeps you from being sued is not your level of skill, but your relationship with the patient (friends don't sue friends).

Ed

 

[roja]

Originally posted by tussy
It's hard to know the specific details of this case, but i think we should all learn from it.

By saying that he can "handle the procedure" without supervision was this intern's first mistake. Had the attending/senior been supervising more closely then they would share in more of the liability when the complication occurred. As it stands now, the poor intern has taken most of the blame.

As a resident it is important to get lots of procedures, and nobody wants to admit that they are not capable. However, we are responsible if we screw up, so we must practice a little CYA medicine.

Just to share a little story that happened to me last week on a related note:

I was in the clinic area, removing lumps and bumps with my attending. The last patient came in; booked as "removal of cyst from shoulder". My staffman went back to his office and left me to do the procedure. When i went to examine the patient the lump was actually on the neck (posterior triangle), and looked more like a lymph node. I took one look and asked the nurse to page the staff man. He was pissed but came back from his office. He removed the node, but found it wrapped around the spinal accessory nerve. If i had done the procedure there is a good chance that the nerve would have been damaged, and i would most certainly be sued. (As an aside: posterior triangle lymph nodes should always be biopsied in the OR, not in the office) I felt inadequate calling staff at first, but now realize it was the exact right thing to do. Live and learn!

I agree with the idea that the biggest mistake is not asking for help. I have no problem saying that I am not comfortable doing a procedure. I feel like this is the key to internship. I am there to be taught and that means supervision.

It is more important to swallow your pride and ask for help than possible endanger your patient. The other reason, as an intern, that I like to have supervision for things like central lines/LP's, etc is that each attending/Sr. Resident has different ways of doing things. I think its important to draw from other peoples experience. The only way to develop a technique that works best for you is to see different techniques.

And I agree about U/S guided line placement. Nothing beats it.

 

[ERMudPhud]

Originally posted by tussy

By saying that he can "handle the procedure" without supervision was this intern's first mistake. Had the attending/senior been supervising more closely then they would share in more of the liability when the complication occurred. As it stands now, the poor intern has taken most of the blame.

Assuming the patient is going to be billed for the procedure medicare states that you can not bill for a procedure unless it is directly supervised by the attending and that you can't have different standards of supervision for medicare and non-medicare patients. It is really the attendings fault if they weren't actually there supervising regardless of what the intern said. I realize procedures happen all the time without attending supervision but thats not how medicare says it should be and if the hospital bills for the procedure you can be charged with fraud if it wasn't attending supervised.

 

[Foxxy Cleopatra]

Originally posted by edmadison
I just want to correct a big legal misconception. The informed consent process does not protect against negligence. You can have a form which warns of every possible complication including the sun exploding and jogging you hand during the procedure, but this does not protect against negligence.

The consent process protects against two things. First, it shows that the patient actually approved the performance of the procedure and any ancillary procedures. This removes the threat of an assault (an unwanted touching). Second, it warns of potential adverse effects. This protects against "failure to warn" which has a strict liability standard (thus no negligence need have occured).

Mistakes/poor outcomes are going to occur. Statistically, What keeps you from being sued is not your level of skill, but your relationship with the patient (friends don't sue friends).

Ed

Interesting. Though regarding friends not suing friends, I think there are (unfortunately) exceptions. PCP's probably get sued less than surgeons partially b/c they do have a long-term relationship with their doctor.

However, I was described (when in medical school) as compassionate and enthusiastic towards helping patients (and I am not a condescening or abrasive sort to this day), yet I have been punched, screamed at, threatened, and berated using (literally) every explicit that the English language has to offer. Granted, I deal with a lot of indigent, so hopefully things won't be like this after residency, but the mentality and attitudes I have seen in the last 7 months has led me to always have my guard up and to keep one eye open while I sleep (so to speak) when dealing with any patient or family member.

 

[southerndoc]

Originally posted by Foxxy Cleopatra
Interesting. Though regarding friends not suing friends, I think there are (unfortunately) exceptions. PCP's probably get sued less than surgeons partially b/c they do have a long-term relationship with their doctor.

Probably another reason why EM docs get sued more frequently.

I have a feeling the hospital will lose this case if the intern wasn't using ultrasound. There is enough research out there to validate the use of ultrasound in central line placement that it's just begging for an attorney to use it in a malpractice case.

 

[DoctorDoom]

We don't really know whether there was negligence, what the intern's level of experience with the procedure was, nor what occurred during the actual placement, so it's hard to say whether the lawsuit is justified or not.

But not to worry Supes, so long as you are conscientious, mark the anatomical landmarks, know your limitations, and don't cut corners you'll be fine. I did residency at a kidney transplant and cardiac center, and did hundreds of lines. Never used US, and never got a hematoma or dropped a lung. Definitely hit the carotid a few times with the finder needle though. Lawsuits will happen sooner or later. As long as you keep in mind that no procedure is without risks or potential complications and make sure to follow up, you'll just have to be satisfied with doing the best you can. What else can mere mortals like us do?

*Edited because I have apparently developed an aversion to the letter "e"...

 

[Linie]

The article points out something else very important: what you say in front of patients is very important, even if you aren't directing it toward them, or think they aren't listening or can't hear you. Not that anything should have been hidden from the patient, but it sounds like the conversation that took place in front of the patient was somewhat less than professional.
----------------------------------------------------
I don't understand how you got that from the article. All it said was that the intern said that he could handle the procedure, which he should have been able to.

Well, apparently it was upsetting enough to the patient that it was quoted in the lawsuit.

In my opinion, any discussion about how comfortable you are with a procedure and any review of technique should not be done in the patient's presence.

 

[droliver]

Memorable experiences from my residency with central lines:

1. Day 1 as a Doctor July 1, 1998 my first central line as a resident (after doing about a dozen & a lot of wire outs as a student) I had the wire core break as I'm removing it after placing the line. The J-wires consist of a core (fine gauge steel wire) with a spring-like wire wrapped around it. I pull this wire out & am looking at it as it looks kind of "flimsy" & I figure out what just happened. After having acute angina I look down & see the distal part of the core wire peering up into the central line tubing moving with the venous pulse up & down. I was lucky enough that I was able to aspirate it up the tubing & retrieve it.

2. One of my fellow residents had someone day on the O.R. table as he was placing a line prior to doing a bariatric operation. On autopsy the wire or line had lacerated the right atrial appendage & caused an acute tamponade. There was a lawsuit over this which I think was eventually dismissed after 3 years working its way thru pre-trial motions.

3. I had one attending who had just done a lecture to the interns on line placement & had gotten two consults in an ICU for placement. I'm there putting one in & he's razzing me as I struggled briefly putting one in a very large woman. He goes "let me show you how its done" & immeadiately quickly does a femoral access on someone in about two seconds & starts crowing. He turns to grab the line to thread over the wire & whoosh! there goes the wire straight up into the femoral vein. He sits there in shock (and knowing full well I'm going to pay for this comment for years) & I say "Ohhhhhh! That's how its done."

4. One of my friends had a J-wire get stuck in a Greenfield filter
5. Another time my junior resident had the dreaded Swan-Ganz pretzel loop develop when he found he was unable to remove the catheter (where the catheter twists & manges to form a large slip knot in the right ventricle & won't pass thru the tricuspid valve). It required a thoracotomy to extract it

 

[Tenesma]

geek medic:

you are wrong about the ultrasound issue... there are many studies that show that ultrasound is beneficial for IJs in the setting of fewer sticks and a higher success rate... but (unbelievably), ultrasound does not decrease the incidence of arterial puncture.

what should happen more frequently is cannulation (with an 18 or 20 gauge) without dilation of the vessel and measuring waveform or using Kobe-tubing to determine pulsatile flow and pressure gradient...

 

[southerndoc]

droliver, your post was both funny and worrisome.

The things I have to look forward to starting July.

BTW, how did the guidewire get sucked into the femoral vein? I'm picturing the thing hanging out a ways and getting sucked in. Or did he "over advance" the wire so that only a nub was hanging out?

 

[lattimer13]

Originally posted by droliver
Memorable experiences from my residency with central lines:

...
3. I had one attending who had just done a lecture to the interns on line placement & had gotten two consults in an ICU for placement. I'm there putting one in & he's razzing me as I struggled briefly putting one in a very large woman. He goes "let me show you how its done" & immeadiately quickly does a femoral access on someone in about two seconds & starts crowing. He turns to grab the line to thread over the wire & whoosh! there goes the wire straight up into the femoral vein. He sits there in shock (and knowing full well I'm going to pay for this comment for years) & I say "Ohhhhhh! That's how its done."

about your quote.

🙁 for the patient.

 

[DoctorDoom]

Originally posted by Geek Medic
BTW, how did the guidewire get sucked into the femoral vein? I'm picturing the thing hanging out a ways and getting sucked in. Or did he "over advance" the wire so that only a nub was hanging out?

Venous return... never EVER let go of the wire...

 

[southerndoc]

Originally posted by DoctorDoom
Venous return... never EVER let go of the wire...

So when you have 6+ inches of the wire hanging out, ALL of that can be lost into the femoral vein by simply letting go?

Surely there must be more to the story... like only an inch of it was left hanging out or not.

Speaking of this, how much of the guidewire do you guys leave out? I see people "nubbing" those things all the time, for no good reason. Personally I leave out about as much as would be out when I go to thread the TLC catheter... but as a student, I'm bound to do what my resident requests, so sometimes he/she made me push it in more. Some wanted to see ectopy (a fun sight on the monitor, but definitely not the best thing for decreasing your likelihood of causing damage to the atrium or tricuspid).

 

[DoctorDoom]

Well, it's not as likely that six plus inches of wire will get sucked in, but it is possible since sometimes people let go of the wire after making the skin incision and even after passing the dilator. It's about building good habits, right? I rarely did a line with a cardiac monitor on, but there is so much extra wire (and hence for room for error even in obese patients) that you really don't need to advance the wire to the point of ectopy for a good line!!

I see the point of doing what your resident wants, but your practice of passing the wire to the length that matches the length of the catheter when passing it is a good one. There is plenty of wire so that you never ever have to let go of the wire... why take the risk?

 

[beyond all hope]

Sorry, I just had to add the above comment. It's probably better that you guys have so much backup.

Working as an intern in an almost third-world hospital, I regularly do central lines 1) Without supervision 2) Without ultrasound 3) Without a monitor. I prefer femorals in general because although they have increased chance of LATE complications they have a reduced chance of IMMEDIATE problems.

Probably not smart on my part, but you do what you've got to do. So far I've been lucky - no immediate complications, never lost a wire, no long-term complications that I'm aware of.

If anything ever goes wrong I'll be hanging on my own stethoscope.

 

[Tenesma]

beyond all hope:

all the data shows that femoral lines have more complicationis both in the Immediate setting and in the Late setting... the only time somebody should get a femoral line is in a code/trauma situation - otherwise you are just going to get burned... Yes, i know they are the easiest based on anatomic landmarks, but just look at the numbers!! i have done more lines than i can count, and it is usually the femoral line that kills me: sure a chest tube can rectify a pneumothorax, but the repeat pseudoaneurysm repairs in the groin because of fem. lines is agonizing...

there is a good review on central line complications in last years New England Journal if you want to see the numbers

 

[Foxxy Cleopatra]

Originally posted by beyond all hope
Working as an intern in an almost third-world hospital, I regularly do central lines 1) Without supervision 2) Without ultrasound 3) Without a monitor. I prefer femorals in general because although they have increased chance of LATE complications they have a reduced chance of IMMEDIATE problems.

Haha, almost 3rd world, I love it! That's how we do it here. I've always likened it to Civil War medicine. I think there is something to be said for being left to fend on your own- after the feeling of drowning passes, you'd be amazed what you'll be able to think your way through. I think I secretly really like it.

A few of my favorite line-placing principles:
1. Always keep one hand on the wire

2. (For subclavians) advance the needle in a plane parallel to the body. Press on the needle with your thumb if necessary as your advance but don't angle down towards the chest.

3. If you feel resistance when passing your wire, don't force it!

4. If arterial blood squirts back at you, pull out and apply pressure. Don't ignore it and thread a cordis anyways. When assisting in lymph node retreival on a organ donor, we found that the femoral cordis was in the artery (don't know who placed it) and it was not a pretty site.

 

[neutropeniaboy]

Originally posted by Bobblehead
We could speculate what happened, i.e. finder needle was moved laterally while deep in the tissue, arterial blood was not properly identified and the artery was subsequently dilated...

Wondering...

Do you actually dilate the vein when you place a central line? If you do, I think that's horrible practice. The purpose of the dilator in the basic central kit is to dilate the skin.

Now, there are other instances (like placing Quinton catheters and percutaneous introducers) that simultaneously place the line and dilator, but you should not be dilating the vessel with the standard TLC kit. The catheter has a smaller diameter than the dilator. A hematoma is going to be a high probability.

 

[droliver]

The ?'s re the lost j-wire with the femoral line story => There was 5-6 inches out when it just got sucked in. I've never seen that happen again & I would routinely leave the wire flopping around when I did them (albeit with a good bit out in remeberence of that episode years ago). That scenario with the wire prob. happens about every 1-1.5 years among the residents here I think, so its rare but not that rare an event.

 

[DoctorDoom]

Originally posted by neutropeniaboy
Wondering...

Do you actually dilate the vein when you place a central line? If you do, I think that's horrible practice. The purpose of the dilator in the basic central kit is to dilate the skin.

Now, there are other instances (like placing Quinton catheters and percutaneous introducers) that simultaneously place the line and dilator, but you should not be dilating the vessel with the standard TLC kit. The catheter has a smaller diameter than the dilator. A hematoma is going to be a high probability.

Not in my experience... and with the narrow guage of the Seldinger needle, unless the vein gets dilated, how do you pass the TLC?

 

[neutropeniaboy]

Originally posted by DoctorDoom
Not in my experience... and with the narrow guage of the Seldinger needle, unless the vein gets dilated, how do you pass the TLC?

You cut the skin, dilate the skin, and insert the TLC. I've never had one go in without resistance. The vessel is so thin that the catheter slips in easily over the guidewire (which is smaller than the needle used to cannulate the vein).

 

[Apollyon]

Originally posted by neutropeniaboy
Wondering...

Do you actually dilate the vein when you place a central line? If you do, I think that's horrible practice. The purpose of the dilator in the basic central kit is to dilate the skin.

It's called a "venodilator", multiple references on PubMed call it same, and the Roberts & Hedges procedure book, and Tintinalli talk about the dilator into the vessel.

I don't know where your data is from, but all I can find (direct and indirect) is that the dilator indeed is for the vessel, because catheter>needle>wire. (By "indirect", I mean references to dilation of the artery accidentally, and so on, vis-a-vis the vein.)

If you've never had one go in without resistance, then, by definition, you are forcing the line - that is not a good example.

Now, you are a noted EM basher, and I have mentioned EM texts; if there are surgical papers or texts that countermand this, quote them.

 

[Tenesma]

i think in older people there is no true need for venodilation... but in younger folks the veins can actually get quite tough, and as you start advancing the TLC you may push the vein away instead of actually entering it - in which case a bit of venodilation is helpful....

 

[Docxter]

Originally posted by neutropeniaboy
Wondering...

Do you actually dilate the vein when you place a central line? If you do, I think that's horrible practice. The purpose of the dilator in the basic central kit is to dilate the skin.

Now, there are other instances (like placing Quinton catheters and percutaneous introducers) that simultaneously place the line and dilator, but you should not be dilating the vessel with the standard TLC kit. The catheter has a smaller diameter than the dilator. A hematoma is going to be a high probability.

No, that's not true. In all kits, the dilator is either the same Fr size or 0.5-1 Fr less than the catheter, so overdilation is not a problem. The purpose of the dilator is not only dilating the skin, but skin, SQ tissue, and vein.

 

[Docxter]

Originally posted by Tenesma
geek medic:

you are wrong about the ultrasound issue... there are many studies that show that ultrasound is beneficial for IJs in the setting of fewer sticks and a higher success rate... but (unbelievably), ultrasound does not decrease the incidence of arterial puncture.

what should happen more frequently is cannulation (with an 18 or 20 gauge) without dilation of the vessel and measuring waveform or using Kobe-tubing to determine pulsatile flow and pressure gradient...

Tenesma, you speak very confidently but give unreferenced info. Where do you get your data?!!!!!!!!? Ultrasound clearly decreases the complications of central venous catheter placement, including arterial puncture, esp. for IJs.

See Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ. 2003 Aug 16;327(7411):361. for the definitive answer.

 

[DoctorDoom]

Originally posted by neutropeniaboy
You cut the skin, dilate the skin, and insert the TLC. I've never had one go in without resistance. The vessel is so thin that the catheter slips in easily over the guidewire (which is smaller than the needle used to cannulate the vein).

The wire is narrower in gauge than the Seldinger of course... but the catheter is not. I have used the venodilator always and have not had hematoma rates higher than normal. I think you may be forcing the catheter as a venodilator!!

 

[neutropeniaboy]

Originally posted by Apollyon

I don't know where your data is from, but all I can find (direct and indirect) is that the dilator indeed is for the vessel, because catheter>needle>wire. (By "indirect", I mean references to dilation of the artery accidentally, and so on, vis-a-vis the vein.)


It may be indeed for the vessel, but I've found in practice and in teaching that dilating the vein is a bad idea. The dilator is less flexible than the catheter itself. Everything is blind. You don't know where your wire is (unless you eyeball the length externally and know the distance from the skin to AC juniton), and you can't guarantee that when you insert the dilator you're not injuring the vessel wall on the opposite side. And unless you have great pressure over the actual site of vein dilation, there's no telling what can happen between removal of the dilator and insertion of the catheter.

I've evacuated neck hematomas that were thought to be caused by hubbing or pushing the dilator in too far. I don't have any texts to back up my statements (nor do I wish to investigate them now), but every surgical attending I have done a line with has told me not to dilate more than the skin and subcutaneous tissue. In my experience, deep to the dermis and subcutaneous tissue, there is little resistance that isn't already relieved by the venopuncture and the guidewire itself.

 

[neutropeniaboy]

Originally posted by Docxter
No, that's not true. In all kits, the dilator is either the same Fr size or 0.5-1 Fr less than the catheter, so overdilation is not a problem. The purpose of the dilator is not only dilating the skin, but skin, SQ tissue, and vein.

Well, I stand corrected. I checked our kits. It's the same diameter.

Nevertheless, I still think it's problematic.

Now, I don't profess to have Foxy's numbers, but I've done over 100 central line placements. I've hit the carotid 3 times, the subclavian artery once and some branch of the femoral once or twice, and I've never dropped a lung or known a patient to develop a DVT. One could say that I haven't done enough (maybe that's true), but I'm pretty meticulous, especially in the neck. I've never had a pseudoaneurysm or hematoma develop, so I'm pretty confident that I've been instructed well and do them well enough. Maybe you guys have never had a problem dilating the vein, but between the time of dilating and inserting the catheter, I see potential problems.

I mean, all the following have been described as attributed to the dilator:

1. laceration of the internal jugular/subclavian/innominate
2. laceration of the trachea, and heart
3. perforation of the carotid/subclavian/vertebral arteries
4. arteriovenous fistula
5. hematoma
6. thoracic duct injury
7. air embolism
8. pericardial tamponade secondary to vessel or cardiac perforation.

I feel dilating the vein (or potentially the artery) to be an unnecessary risk.

 

[neutropeniaboy]

Originally posted by Apollyon

...and I have mentioned EM texts...

As an aside, Apollyon, I own the Tintinalli comprehensive study guide and an older Current Diagnosis book. I use them from time to time, as they are helpful.

As such, textbooks never consult me; EM physicians do.

 

[Tenesma]

docxter:

1) the BMJ study is a thorough meta-analytical view of success rates versus failure rates in central line placements... and it doesn't discuss the issue of frequency of arterial puncture rates. So to use that study to prove something is kinda useless. There are quite a few studies that actually have frequency of arterial puncture as part of their subgroups, and those studies have shown that ultrasound doesn't decrease arterial puncture rate... which in of itself makes more sense and it is surprising that there isn't a higher arterial puncture rate with ultrasound guidance.
The reason behind this: the vein and the artery are very close to each other and for the most part the vein is lying right above the vein as you get closer to the clavicle....with palpation(landmark based approach) the person placing the line tends to start with a more lateral stick and carefully approaches more medially towards the vein - which is different from the ultrasound technique where you aim for the vein which is sitting right above the artery.... i am on-call between cases so i don't have the studies on this computer to support this but i will PM them to you and also post them on this board tomorrow.

2) neutrapeniaboy - i always enjoy your postings, but you definitely sound (a bit too) authoritative considering you are halfway through your PGY2 year... trust me, when you have done enough lines you will have seen a lot more complications no matter how meticulous you are....

 

[Docxter]

Originally posted by Tenesma
docxter:

1) the BMJ study is a thorough meta-analytical view of success rates versus failure rates in central line placements... and it doesn't discuss the issue of frequency of arterial puncture rates. So to use that study to prove something is kinda useless.

The BMJ metaanalytical article explicitly looks at not only success vs. failure, but complication rates by site as well, including inadvertent puncture.

 

[eddieberetta]

Originally posted by neutropeniaboy
As an aside, Apollyon, I own the Tintinalli comprehensive study guide and an older Current Diagnosis book. I use them from time to time, as they are helpful.

As such, textbooks never consult me; EM physicians do.

Textbooks don't consult me either -- otolaryngologists do.


Ed
Pgy-1, Radiology

 

[neutropeniaboy]

Originally posted by eddieberetta
Textbooks don't consult me either -- otolaryngologists do.


Ed
Pgy-1, Radiology

For what?

 

[neutropeniaboy]

Originally posted by Tenesma

2) neutrapeniaboy - i always enjoy your postings, but you definitely sound (a bit too) authoritative considering you are halfway through your PGY2 year... trust me, when you have done enough lines you will have seen a lot more complications no matter how meticulous you are....

True. True.

I take issue, however, with the thought: "if you haven't had x,y, and z complications, you haven't done enough." That's a cop-out, in my opinion, espoused by people who could be more careful or don't know when to pack it up and ask for help or try another method. Sure, the longer you're in the business, the more you'll be exposed to complications; I won't contest that.

 

[Tenesma]

docxter:

i just reread the BMJ article and didn't see any reference to assessment by complications with regard to arterial puncture rate...

are we talking about the same article?

 

[eddieberetta]

Originally posted by neutropeniaboy
For what?

For help with histories and physicals, how-to lessons on how to hold scalpels, you know stuff like that.

 

[Tenesma]

here it is - a good overview including a specific look at arterial puncture rates:

Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature.
Crit Care Med. 1996 Dec;24(12):2053-8.
Randolph AG, Cook DJ, Gonzales CA, Pribble CG