how many lines

[likes pizza]

how many central lines should I have half way through my intern year in surgery?

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[JackADeli]

how many central lines should I have half way through my intern year in surgery?

There is NO correct answer to this. Central lines are more a matter of pride and/or actually getting to do an independent procedure as a new surgical trainee. Head lacs, arterial lines, central lines, chest tubes represent those procedures that start to make you feel like a surgeon when you start residency. But, there is no real set "correct number" that you should attain during your internship. What you need to attain is proficiency and confidence in performing these with good surgical technique & principles. The number it takes to achieve this goal is resident dependent (i.e. changes depending on the individual's aptitude).

Regards,
JAD

 

[NJA61479]

Although I agree with the above statement, let me just give you my two cents.
The intern experience varies at different institutions. I am at an academic institution where the intern's job is to master the pre- and post-operative care of the surgical patient. We rarely see the inside of the OR at least as the first assistant and also rarely get to do procedures. I understand that residents in community programs do much more operative stuff.
Anyway no matter where you are, I think that if you are observed doing 5-10 central lines at any site you are on your way. Central line placement experience mostly comes during the second year which in most programs is devoted to critical care. During that time you should try to do at least 10 femoral lines (easy), 10 IJ's (w/ ultrasound as it is the standard of care), and 10+ subclavian lines. Obviously subclavians are the toughest to master. Just my two cents.

 

[USAFblue]

A question out of curiosity - are medical students in the States allowed to place central lines, arterial lines, suture in the OR, perform small procedures (under supervision of course)?

I am just trying to compare the extent of student practical experience between my school in Belgium and in the States. We are actually allowed to do all of the above, and in fact those who are interested enough to do voluntary hospital rotations (outside the schedule) get all kinds of "special treats", like a carpal tunnel release or even an appendicitis (at least part of the procedure).

Thanks

 

[JackADeli]

A question out of curiosity - are medical students in the States allowed to place central lines, arterial lines, suture in the OR, perform small procedures (under supervision of course)?...

Yes

 

[SLUser11]

Although I agree with the above statement, let me just give you my two cents.
The intern experience varies at different institutions. I am at an academic institution where the intern's job is to master the pre- and post-operative care of the surgical patient. We rarely see the inside of the OR at least as the first assistant and also rarely get to do procedures. I understand that residents in community programs do much more operative stuff.
Anyway no matter where you are, I think that if you are observed doing 5-10 central lines at any site you are on your way. Central line placement experience mostly comes during the second year which in most programs is devoted to critical care. During that time you should try to do at least 10 femoral lines (easy), 10 IJ's (w/ ultrasound as it is the standard of care), and 10+ subclavian lines. Obviously subclavians are the toughest to master. Just my two cents.

Still, even in programs that are anemic for bedside procedures, the intern should be doing more lines than in the above quote. Central lines are not really "operative stuff" and usually go hand in hand with learning pre and post-op care. I definitely don't think that you need to be at a community program that is operative-heavy to get exposure to tons of CVLs.

I would also think that the intern would have more experience with supra-inguinal CVLs since there aren't that many indications for femorals, outside of the anticoagulated patient, the coding patient, and the acute trauma.....I don't think they should be allocated to interns because they're easier, because there's no such thing as an "intern-level" central line....they're almost all "intern-level."


As for which line is the toughest to master, I think that this is completely institution-dependent, and I've found different comfort levels at different institutions, especially when choosing between IJs and subclavians. I feel comfortable with all these lines, but choose the subclavian primarily for what I believe to be a lower infection risk. When the line is tunneled, or with a portacath, the infection risk is equivalent, and I prefer IJs. I believe the most technically challenging line is the left IJ in a patient with multiple previous sticks....not for the procedure itself, but the possible bad outcomes. For this reason, I routinely use fluoro (if available) when placing a line from the left IJ.....it helps me feel better when I'm jamming a huge DLDC dilator and sheath into the left neck when I can say with some confidence it's not in the left chest.

 

[SocialistMD]

Still, even in programs that are anemic for bedside procedures, the intern should be doing more lines than in the above quote. Central lines are not really "operative stuff" and usually go hand in hand with learning pre and post-op care.

I think it depends more on each institution. At my medical school, there was a "central line service" that consisted of a surgical PGY-2 who put in every central line for floor patients. At my current institution, VIR performs the same service. As a result, the junior surgical resident only puts in supervised central lines when on their one-month intern ICU rotation or one of their 10 weeks in the ICU as a PGY-2. As many patients arrive with central lines in place and as each call team consists of 2-3 residents, it is reasonable that an intern would only do 5-10 lines during the intern year.

 

[dpmd]

It is absolutely institution dependent. At my institution we need a certain number before we can do them independently, then a certain number more before we could supervise. I think I reached the "allowed to supervise" level well before the end of my intern year (although I didn't actually start supervising lines until second year when i was trauma chief, or night float). I recently rotated at another institution (well known as academic and top heavy) where the second year residents still needed supervision for lines (and this is midway through the year). As long as you are getting the appropriate level of supervision for you comfort level in the procedure I can't argue that one way is inherently better.

 

[SLUser11]

I think it depends more on each institution. At my medical school, there was a "central line service" that consisted of a surgical PGY-2 who put in every central line for floor patients. At my current institution, VIR performs the same service. As a result, the junior surgical resident only puts in supervised central lines when on their one-month intern ICU rotation or one of their 10 weeks in the ICU as a PGY-2. As many patients arrive with central lines in place and as each call team consists of 2-3 residents, it is reasonable that an intern would only do 5-10 lines during the intern year.

That's fine that it's "institution-dependent," but it doesn't change the fact that 10-20 lines a year is inadequate. I also think that once a program becomes so top-heavy that central lines are considered a senior-level procedure, then something is seriously wrong. (purposeful exaggeration)

I just feel like central lines are sort of hard to teach since there's so much of a "feel factor" involved, and there's so much troubleshooting involved when things don't go perfectly. I can't imagine placing a few lines here and there will prepare you for the difficult line.

I have some experience with it, and the rest is speculation, but I can only imagine how many extra sticks, extra kits (at $200+ each), and extra complications occur because not enough time was spent teaching interns how to place lines....


Also, if you're really only doing 20-30 lines a year, and you get a single pneumothorax during your junior residency, you are matching up right next to the medicine residents in complication rates......

 

[JackADeli]

...Also, if you're really only doing 20-30 lines a year, and you get a single pneumothorax during your junior residency, you are matching up right next to the medicine residents in complication rates......

Probably not... since the medicine RRC has removed central line placement as a required procedure during training and IM PD are now handing them over to surgery and PICC nurses... I suspect the medicine complication rate can be expected to rise.

 

[filter07]

Forgive my ignorance but in what context do people do more than 30 CVLs a year? I average just over 25 a year, having been on trauma and SICU rotations multiple times now.

Is it that some programs get severe traumas that require massive resuscitation so often that they end up putting in a bunch? More ICU patients that require CVLs? Do they put them in for elective OR cases? In my program, placing a CVL is not a senior level procedure, but we just don't have the need to place hundreds of lines per year. We do have a PICC team, but don't order PICCs that frequently.

 

[Celiac Plexus]

Forgive my ignorance but in what context do people do more than 30 CVLs a year? I average just over 25 a year, having been on trauma and SICU rotations multiple times now.

Is it that some programs get severe traumas that require massive resuscitation so often that they end up putting in a bunch? More ICU patients that require CVLs? Do they put them in for elective OR cases? In my program, placing a CVL is not a senior level procedure, but we just don't have the need to place hundreds of lines per year. We do have a PICC team, but don't order PICCs that frequently.

Indications for lines... trauma, sick icu patients you need to resuscitate, any patient you need to get a cvp on, any patient that is a difficult stick e.g. chemo patients, chemoports, transplant patients, someone with "bad veins".

I did hundreds of lines in my residency. I think that after you feel totally comfortable putting lines then you don't need to do really any more. After a point, putting in lines it was just patient care and the educational value tapers off.

I do agree that good supervision is helpful to get the basics down, but it's really just a feel that you develop and you'll know when you're good at it. At some point your line karma kicks in and it's automatic. I think it's unavoidable to trash a bunch of expensive kits on the way to line-dom. I will also add that your particular line set-up is key in terms of where you position everything before you start. Early on I used to struggle with one hand holding the wire while I reached at some impossible angle for the dilator which I had placed on the other side of the bed...

How many to get to the comfort zone? For me it was somewhere between 100-200 which I probably accomplished by the end of my second year. Try to get as many lines done as early as possible because the sooner you get good at it, the better. Also, I saw more complications from lines than from most real operations. The more lines, the more weird line issues you will encounter and learn how to deal with.

 

[Celiac Plexus]

how many central lines should I have half way through my intern year in surgery?

You should do as many as possible. At least 50 by the 6 month point was very doable in my program and that's what most of us had.

I put in hundreds of lines in residency. I think that someone showing you the basics is important, but more than that you just have to practice a lot and develop a feel for line placement. It probably took me 100-200 lines before I felt absolutely fine with line placement. I achieved that by the end of my second year. I wound up placing a lot more lines in my 3rd year and then tapered of in my 4th and 5th years. After you develop a feel for lines, I don't think it's necessary to do any more really. I think it's like riding a bike...

I should add though that there is a benefit to doing as many lines as possible since I have seen a lot of darn wacky things with line placements. So, by doing a heck of a lot of them, you learn how to deal with the wackness.

 

[Celiac Plexus]

how many central lines should I have half way through my intern year in surgery?

You should do as many as possible. At least 50 by the 6 month point was very doable in my program and that's what most of us had.

I put in hundreds of lines in residency. I think that someone showing you the basics is important, but more than that you just have to practice a lot and develop a feel for line placement. It probably took me 100-200 lines before I felt absolutely fine with line placement. I achieved that by the end of my second year. I wound up placing a lot more lines in my 3rd year and then tapered of in my 4th and 5th years. After you develop a feel for lines, I don't think it's necessary to do any more really. I think it's like riding a bike...

I should add though that there is a benefit to doing as many lines as possible since I have seen a lot of darn wacky things with line placements. So, by doing a heck of a lot of them, you learn how to deal with the wackness.

 

[Miami_med]

I think that the reality is that central lines are either a major part of intern or second year training (depending on the institution). I don't think it really matters when you learn them, as long as you get a lot of them when you do. At my institution, we do them supervised in the first year (usually by a second year resident). I think at this point that I have 6 or 7 bedside lines, where I legitimately did the entire thing myself, and 10 lines placed in the OR (TDCs, Ports, Hickmans, etc...). We have an ICU rotation at the end of intern year, after which, we can place lines on our own. The second year ICU resident probably places 70-80% of the lines for the entire hospital, and their numbers rise rapidly and dramatically. By the middle of the second year, everyone seems very comfortable with most types of central lines.

 

[JackADeli]

Forgive my ignorance but in what context do people do more than 30 CVLs a year? ...

Is it that some programs get severe traumas that require massive resuscitation so often that they end up putting in a bunch? More ICU patients that require CVLs? ...In my program, placing a CVL is not a senior level procedure, but we just don't have the need to place hundreds of lines per year...

I think you describe a real trend in some areas. There are programs that routinely put central lines even if just for blood draws. There are also high census programs that pride themselves on minimalist approaches including very limited usage of central line placement. So, it is possible to find your program with limited number of central lines and those that exist placed intra-op by anesthesia and a grumbling surgery attending.... If your program is stingy on CVL indication & placement, use that opportunity to learn about indications for placement, etc... You need to be aware of indications, risks, and benefits and you need to know your skill level. If you recognize a deficiency, seek out improvement. Some need 100 lines, others feel fairly comfortable in 1/4 that number.... Bottom line do the best with whatever opportunities you get.

JAD

 

[Celiac Plexus]

Sorry for the redundant post above. I had a problem sending the post and retyped it. So, 2 posts saying more or less the same thing. Infernal machines.

 

[dynx]

Forgive my ignorance but in what context do people do more than 30 CVLs a year? I average just over 25 a year, having been on trauma and SICU rotations multiple times now.

Before major elective cases. Every heart case is a chance to do a central line.

In my opinion you should be tired of doing lines by the end of your second year and should be teaching them...the number is different for everybody but I think its probably around 10 or so at each site (maybe less for femorals) before its real comfortable and then the hard ones become challenging rather than scary.

 

[JackADeli]

Before major elective cases. Every heart case is a chance to do a central line...

Ahhh, but those lines are very often owned by anesthesia and anesthesia residents. Also, true cardiac exposure is less and less these days. I don't even know if there is a cardiac requirement anymore... or if cardiac cases are required.

...the number is different for everybody but I think its probably around 10 or so at each site (maybe less for femorals) before its real comfortable and then the hard ones become challenging rather than scary.

Generally agree. You aren't a master after 10 at a given site, but you have reasonable familiarity and foundation to then face the challenge of not so simple cases....

 

[SLUser11]

Ahhh, but those lines are very often owned by anesthesia and anesthesia residents.

I absolutely hate most lines started by anesthesia. I really like the anesthesia residents and staff, but their mindset is just different since all they have to do is get the patient through the case. If their line fails at 2am after surgery, it's not really their problem.

For CVLs, they never do it sterile enough, they always place a big 8.5 french Cordis, which isn't necessary, they always do an IJ, rarely use ultrasound, usually put one stitch in it, and then thread the 30cm 2-lumen line (with swandom) through. The next day, if the line survived the night, it is flapping around in the wind without any protection, with lots of patient slobber all over it, and the 2-lumen is almost surely pulled out far enough where the tip is inside the cordis.

For art lines (where they feel they're superior to us), I am lucky if they even put on sterile gloves, they rarely do any draping, then hopefully rub some alcohol on the skin, and place it after about 5 attempts. Once it's in, they almost never put in even a single stitch, instead just dabbing some betadine ointment on there (you know, so it doesn't get infected), and then put fifty pieces of tape on it. It survives the night about half the time....unless of course, they used an IV instead of an actual arrow kit, then it might not even survive the case.

This might be specific to my institution, but I think at least part of it is a general anesthesia trend. As stated previously, I think they are great at doing what they do....just not lines. If I think my patient is going to get sick, I will generally volunteer to place the lines myself for the sake of sterility and durability.

In the defense of anesthesia, though, I very rarely encounter an infected art line.....

 

[JackADeli]

...For art lines... It survives the night about half the time....unless of course, they used an IV instead of an actual arrow kit, then it might not even survive the case...

I can not stand the arrow kits for radial arterial or even femoral arterial lines. For radials, I ALWAYS use a green IV catheter with a single stich and they last until the patient is ready to leave the unit and it is removed.

 

[likes pizza]

I can't help but wonder if the posters insisting that 100 lines per year is barely enough trained in the past and those saying to expect 10 are in training now.

Everywhere I've been (not too many places) lines are hard to come by. When a patient needs TPN they go for a PICC. When they need a port for chemo or HD a radiologist places the line. If they have a big elective procedure like a whipple or some vascular procedure anesthesia places it. IM residents will try to do their own lines instead of calling surgery.

That leaves big traumas and floor patients who unexpectedly get sick in the middle of the night for the surgery resident to get his/her lines. Depending on your institution either of those patients might not be all that common.

To add to the grievances against the anesthesiologist lines: they always cinch their knots down too tight so when the surgical intern pulls the line the next day he/she has to pull and tug and dig out a bare stretch of suture to cut. At this point in my intern year I've placed 2 central lines, pulled about 50, mostly anesthesia's IJs.

 

[SLUser11]

I can not stand the arrow kits for radial arterial or even femoral arterial lines. For radials, I ALWAYS use a green IV catheter with a single stich and they last until the patient is ready to leave the unit and it is removed.

I love the arrow arterial catheters, but this isn't the first time we've disagreed on things. When securing the radial art line, I think I'm one of the only people I know that uses the actual blue piece from the kit, and secures it in 2 places.

Probably the best way to secure it is a Stat Lock, but we don't have those at most of my hospitals.

As for the femoral kits, I agree that they suck.

I can't help but wonder if the posters insisting that 100 lines per year is barely enough trained in the past and those saying to expect 10 are in training now.

.........At this point in my intern year I've placed 2 central lines, pulled about 50, mostly anesthesia's IJs.

I'm still in training, and I am exposed to all of the same things: PICC line preference, anesthesia lines for OR cases, IM residents trying to do their own, etc etc. Still, I think you should have more lines.

It is quite possible that the mid-level resident is placing lines alone at 2am because it takes longer to walk an intern through it, and they're in a hurry. The real secret is to develop a good relationship with the PGY-2 or 3, and make sure they call you for lines.

On a side note, the decision for a PICC is always a tough one, trying to balance the potential complications of PICC vs. CVL. I often wonder which complication the patient can tolerate more, e.g. PTX vs. DVT.

I just did a quick lit search, and the rate of symptomatic DVT with PICC lines appears to be 5-10%. Of course, PTX rates with CVL placement vary between studies, but is around 1%.

 

[Winged Scapula]

I absolutely hate most lines started by anesthesia. I really like the anesthesia residents and staff, but their mindset is just different since all they have to do is get the patient through the case. If their line fails at 2am after surgery, it's not really their problem.

Yep.

For CVLs, they never do it sterile enough, they always place a big 8.5 french Cordis, which isn't necessary, they always do an IJ, rarely use ultrasound, usually put one stitch in it, and then thread the 30cm 2-lumen line (with swandom) through. The next day, if the line survived the night, it is flapping around in the wind without any protection, with lots of patient slobber all over it, and the 2-lumen is almost surely pulled out far enough where the tip is inside the cordis.

Absolutely agreed. The lack of sterility is appalling and it occurs in every hospital where I've worked. Ours almost always DID use ultrasound, however, they would drag the US cord over the sterile field they had laid down. And yes, one stitch...standard and usually half-assed knots. The next day the Op-Site/Tegaderm is no longer secured to the skin, is covered with sputum, underneath the c-collar or the trach ties, etc. To be fair, its residents placing the lines and the attendings need to be doing a better job of supervising. You can't blame the student if the teacher sucks.

For art lines (where they feel they're superior to us), I am lucky if they even put on sterile gloves, they rarely do any draping, then hopefully rub some alcohol on the skin, and place it after about 5 attempts. Once it's in, they almost never put in even a single stitch, instead just dabbing some betadine ointment on there (you know, so it doesn't get infected), and then put fifty pieces of tape on it. It survives the night about half the time....unless of course, they used an IV instead of an actual arrow kit, then it might not even survive the case.

I've rarely seen draping for an art line, but our guys did use sterile gloves. No sutures.

I can not stand the arrow kits for radial arterial or even femoral arterial lines. For radials, I ALWAYS use a green IV catheter with a single stich and they last until the patient is ready to leave the unit and it is removed.

I like the Arrows but only had them at 1 hospital for radials.

I can't help but wonder if the posters insisting that 100 lines per year is barely enough trained in the past and those saying to expect 10 are in training now.

Everywhere I've been (not too many places) lines are hard to come by. When a patient needs TPN they go for a PICC. When they need a port for chemo or HD a radiologist places the line. If they have a big elective procedure like a whipple or some vascular procedure anesthesia places it. IM residents will try to do their own lines instead of calling surgery.

I saw a sea change during my residency. When I started, the PICC time was only available during "business hours" - ie, nothing on weekends or after 4 or so. At the community hospital we did a couple of rotations at, there was no PICC or IV team at all, so we did all of the lines and often got called for CVLs when the nurses couldn't get a peripheral.🙄 No other residents there at all. The IM residents at the main hospital only called us for lines during codes if they couldn't get one. Ports were still placed by surgery but interestingly enough, I no longer place them because the reimbursement stinks and there is too much rigamarole for such low payment (I do take them out since there is much less risk, rigamarole and the reimbursement is only about $50 less than for putting one in). In addition, I trained at a time when CC replaced lines very 3 days, so there were plenty to do...although with the size of the SICU team, it still wasn't a ton.

So, yes it may very well be more difficult to get lines - what with all the changes.

To add to the grievances against the anesthesiologist lines: they always cinch their knots down too tight so when the surgical intern pulls the line the next day he/she has to pull and tug and dig out a bare stretch of suture to cut. At this point in my intern year I've placed 2 central lines, pulled about 50, mostly anesthesia's IJs.

Why are you pulling CVLs on POD #1? If the line is only staying in 1 day, did they *really* need one? I actually have the opposite problem with these lines - they tend NOT to be stitched down very well and the knots often come loose, tear, etc. Hint for you - don't use those cheap scissors in the kits to cut the suture. Just use an 11 blade or the side of a Keith needle...easier and quicker. Works just as well when removing a line.

 

[proman]

Without going into point by point rebuttals, I can assure you that the practice described is widely divergent from how I was trained and practice. I'll be happy to describe what I do if anyone cares.

Has anyone tried to modify the practices you are concerned about? I don't mean as the line is going in, but maybe this practice area could be improved by a multi-specialty solution. After all, it isn't that hard to add another stitch around the hub.

As an aside, I stopped using the Arrows 2 years ago. I follow up on my patients as best as I can, and they tend to keep their a-lines a long time with the Angiocaths. Without having evidence either way, I think nursing practice is the determinant of an a-line's longevity.

 

[Winged Scapula]

Without going into point by point rebuttals, I can assure you that the practice described is widely divergent from how I was trained and practice. I'll be happy to describe what I do if anyone cares.

I know, at least for me, the above comments were not meant as a condemnation of all lines placed by anesthesia. I have certainly seen surgeons place them less than sterilely or with a single stitch, but less commonly.

I know that many anesthesia residents have gotten good training.

Has anyone tried to modify the practices you are concerned about? I don't mean as the line is going in, but maybe this practice area could be improved by a multi-specialty solution. After all, it isn't that hard to add another stitch around the hub.

Nah...its much better to simply complain about it.

Point well taken - rather than complain about less than best practices, the problems should be addressed and a multi-specialty solution agreed upon. Its certainly the way things work now out in practice - when radiology, pathology and anesthesia and I did things differently, we came up with a way that pleased us all and ended up giving patients better care.

As an aside, I stopped using the Arrows 2 years ago. I follow up on my patients as best as I can, and they tend to keep their a-lines a long time with the Angiocaths. Without having evidence either way, I think nursing practice is the determinant of an a-line's longevity.

Absolutely. I've never seen specialty as a predictor of how long an A-line lasts. I do have a problem with IJs and was trained to do subclavians preferably and am comfortable with them. Despite the advantages of the IJ (in terms of placement and dubious reduced PTx rate), when you see them several days out, they are almost always more inflammed and covered in snot than the SCs. Again, perhaps a nursing problem rather than placement, but I think the IJs are just prone to not having a dressing stick well or being covered by other accoutrements of the ICU.

 

[JackADeli]

I use the green angiocaths and a wire. our angiocaths that we use have a metal end with a groove makes for easy secure via stitch. we prep and drape out completely for a-lines including cap, gown, and mask.

we use central lines via IJ more often then not.... have difficulty getting folks to consistently use u/s... even though it is a leapfrog issue. I like the subclavian but there are concerns for future needs of upper extremity vascular access. concerns are that subclavian leaves a degree of stenosis that may ultimately impact upper extremity av access.

We (surgical) do a head to toe draping and prep out neck and subclavian.... just in case. Anesthesia is hit or miss as far as quality of surgical prep/technique/etc.... The more senior anesthesia attendings moan how good their anatomy is....because they suck with an u/s.... though, they miss with their anatomy pretty regularly!!!

 

[Winged Scapula]

I thought there was a Cochrane review a few years back which found in favor of subclavians for reduced infection, thrombosis, line related complications, etc and that the degree of *clinically significant* stenosis was low, not high enough to avoid using them.

 

[JackADeli]

I thought there was a Cochrane review a few years back which found in favor of subclavians for reduced infection, thrombosis, line related complications, etc and that the degree of *clinically significant* stenosis was low, not high enough to avoid using them.

I have to admit, never saw the Cochrane review on that.

However, other then emergencies.... elective IJ under direct guidance (i.e. u/s) is listed as something like.... ~one of the top ten things for better hospital outcomes.... per leapfrog. While leap frog does not equate standard of care.... it is getting pretty close. IMHO, it makes it increasingly hard to argue/defend a bad subclavian outcome in a non-emergent situation.

Don't get me wrong... I prefer and always have preferred subclavians. But, I do find anatomy driving of an IJ confirmed with u/s a little more stimulating. Subclavians just seem too easy to me.... a clavicle is a clavicle.

oh, found it:
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004084/frame.html

...No studies compared the neck access site with other sites so no conclusions can be drawn about the relative advantages or disadvantages of access in the neck...
Author's conclusions:
....Subclavian CVA is preferable to femoral CVA. Further trials of subclavian versus femoral or jugular CVA are needed...

 

[notinkansas]

Varies a lot by program. Where I went to medical school (in the southeast), medical students were allowed to do lines (and chest tubes) on selected patients on some rotations. And on any rotation when a line was done the medical student usually participated (ie maybe not doing the stick but being allowed to thread the wire, etc.). The interns did most of the lines, with the exception of rotations where the was not an intern, then the most junior resident did any lines necessary.

Compare that to where I did PGY1-3 as a surgical resident. Interns RARELY did any lines, lines are rarely done on a floor patient (unless situation for urgent access existed). Non urgent central access done by PICC nurse. In the ICUs (interns don't rotate, they are PGY 2,3 rotations) there are several midlevel providers to supplement the resident contingent who are trained to do lines. Several times I had a situation where the midlevel was sent to do a line b/c I was "needed" to help finish rounds. To this day I am not as comfortable with IJs a I feel I should be. I am much better at subclavians due to my medical school experience (that institution does more subclavians)

I fear we are in danger of producing a generation of surgeons who can't do lines as they are increasingly turned over to midlevels and specialized nurses.

 

[Winged Scapula]

I have to admit, never saw the Cochrane review on that.

However, other then emergencies.... elective IJ under direct guidance (i.e. u/s) is listed as something like.... ~one of the top ten things for better hospital outcomes.... per leapfrog. While leap frog does not equate standard of care.... it is getting pretty close. IMHO, it makes it increasingly hard to argue/defend a bad subclavian outcome in a non-emergent situation.

Don't get me wrong... I prefer and always have preferred subclavians. But, I do find anatomy driving of an IJ confirmed with u/s a little more stimulating. Subclavians just seem too easy to me.... a clavicle is a clavicle.

I dunno I like the "danger" of a possible PTX to drive me! 😉

oh, found it:
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004084/frame.html

Thanks - I remembered it, just not that there wasn't enough data to include IJs. I do think that the rate of stenosis that is clinically significant, especially with more and more Txp, is not as high as we've been led to believe.

 

[proman]

All good points brought up. As for infection, I have never had a central line that I've placed get infected. Ever. And it's tracked. We have our cardiac SICU at 13+ months and counting since a CRBSI. Our SICU went over a year before getting dinged (though it wasn't a CRBSI they didn't draw a peripheral culture so it couldn't be denied). CRBSI just should not happen. We do a full body drape, wash hands, gown up etc. But the biggest reason we don't have a problem with infections is (I think) because ANYONE can speak up and stop the procedure. No arguing, no complaining, we re-drape. That is key.

I learned subclavians as a med student. I really like that approach but it's not ideal for many of the OR cases. Unfortunately, the IJ is at risk of spoilage. I've started sewing the hub more posterior and hopefully out of the debris field of eating. I think it's a shame that some of my co-residents are not comfortable doing an IJ with landmarks a not ultrasound. It's a skill I consider mandatory for anesthesiologists to be able to do.

 

[JackADeli]

I dunno I like the "danger" of a possible PTX to drive me! 😉...

Maybe it's cause PTHx just don't raise any level of excitement in me anymore

 

[SLUser11]

All good points brought up. As for infection, I have never had a central line that I've placed get infected. Ever.

Then you haven't placed enough central lines. It's not like all infections are the result of poor technique.

I think it's a shame that some of my co-residents are not comfortable doing an IJ with landmarks a not ultrasound. It's a skill I consider mandatory for anesthesiologists to be able to do.

It's true that being able to do IJs without ultrasound is an essential skill, but doing an IJ without ultrasound when ultrasound is available is negligent. Ultrasound guidance is the standard of care, and there was a recent (?2-3 yrs ago) ACS consensus statement on it.

The hard part is all of us admitting that ultrasound helps. What's going to be even harder for us to accept is Sono-guided subclavians, which is currently a skill I don't possess. Also, sono-guided art lines will soon be the standard of care as well.


As for the previous post about anesthesia lines, I'm glad that you guys do things correctly in your institution. Maybe since it sounds like you staff the ICU, you are more interested in your lines' longevity. In my experience, bringing up such perceived deficiencies to anesthesia is a big middle finger/slap in the face, and I don't think it's worth straining the relationship. Instead, I simply volunteer to place the lines if I'm really worried about it.

 

[JackADeli]

...being able to do IJs without ultrasound is an essential skill, but doing an IJ without ultrasound when ultrasound is available is negligent. Ultrasound guidance is the standard of care, and there was a recent (?2-3 yrs ago) ACS consensus statement on it...

Generally got to agree with that with the caveat being... in non-emergent situations.

...What's going to be even harder for us to accept is Sono-guided subclavians, which is currently a skill I don't possess...

If you have any links and/or references to this application of u/s, it would be much appreciated. I too have not performed subclavs under u/s.

...sono-guided art lines will soon be the standard of care as well...

I think this one will be a harder one to prove.... You need to demonstrate some sort of significant complication rate followed by proof that u/s has a reasonable impact on decreasing said complication rate...

...bringing up such perceived deficiencies to anesthesia is a big middle finger/slap in the face, and I don't think it's worth straining the relationship...

Sort of... But, you should have a peer review and complications review... The current problem that promotes continued deficiencies between specialties is lack of communication of complications. Cards & IR are too often seperated from their groin complications. It is the same for anesthesia. they are too often seperated from their line complications. Instead of simply placing an extra suture in the line, you should communicate that the line was innadequately secured... These matters should come up at M&M or peer review. In worst case scenario, I have seen no additional stitch placed, line lost.... caught the attention of anesthesia and generated new protocols and requirements. It doesn't need to be a urination contests. I like anesthesia, they are usually fun to hang out with and they are usually very interested in literature and data for best patient care outcomes.... communicate with them.

 

[Buzz Me]

Agreed that line experience varies wildly from program to program, and even within any given residency program from hospital to hospital. Some hospitals rely on PICC lines for long-term IV access/TPN and patients can obtain them quickly (within a day), so CVL opportunities for residents is more rare. Then there are the other hospitals (often county-type places) where PIV access is rare, consults from multiple other non-General Surgery services for CVLs is common, and lines get placed daily.

On some busy ICU-heavy months here I've placed 20-30 lines, and then only a small handful at the other places with heavy PICC line use. All told, I think I've done around 150 subclavians, 40 femorals (mainly in codes or burn patients) and 20 IJs so far.

 

[proman]

Then you haven't placed enough central lines. It's not like all infections are the result of poor technique.

Sorry but I'm going to disagree. I'm not going to say that line infection = poor technique because it does happen. They should be vanishingly rare, no matter what the acuity is. I'll see if I can share our hospital epidemiology data. Meanwhile, take a look at the NEJM Michigan Hospital Association Keystone article (Pronovost Dec 28 2006). Rates decreased from 2.7 (0.6-4.8) per 1000 catheter-days to 0 (0-2.4) per 1000 catheter-days 18 months after implementation. BTW we have data that indicates that VAP is also entirely preventable.

What is your hospital's data?

 

[JackADeli]

...we have data that indicates that VAP is also entirely preventable...

Not proven ..... can the numbers be decreased? Yes. But, "entirely preventable" is hyperbole.

 

[proman]

Not proven ..... can the numbers be decreased? Yes. But, "entirely preventable" is hyperbole.

It hasn't been published yet...

 

[JackADeli]

It hasn't been published yet...

A single institutions success over some set period of time does not equate.... "enitirely preventable"

I await to see your published data with instructions that if an ICU does a, b, c, etc.... they can be assured there will be NO VAPs, and thus it is "entirely preventable". I think that absolute statement makes for a good paper title and will stir great discussion.... but it's still hyperbole and your one institution experience will not prove your thesis.

 

[SLUser11]

Sorry but I'm going to disagree. I'm not going to say that line infection = poor technique because it does happen. They should be vanishingly rare, no matter what the acuity is. I'll see if I can share our hospital epidemiology data. Meanwhile, take a look at the NEJM Michigan Hospital Association Keystone article (Pronovost Dec 28 2006). Rates decreased from 2.7 (0.6-4.8) per 1000 catheter-days to 0 (0-2.4) per 1000 catheter-days 18 months after implementation. BTW we have data that indicates that VAP is also entirely preventable.

What is your hospital's data?

I've read that article and others regarding protocols, etc, and I agree that they definitely do decrease infection rates, but they don't bring them to zero.

I'm not going to argue with you, or get into an argument that "my hospital could beat up your hospital." If anything I should be pleased that anesthesiologists in your area actually use good sterile technique and follow protocols.

Still, line infections happen. There are plenty of variables outside the proceduralist's control that factor in, including the patient's status (burns, immunosuppression, etc), nursing care, # of accesses, other sources of sepsis, and length of time that the catheter is in. I think your comments about line infections in such an absolutist fashion are somewhat emotionally-driven since we sort-of knocked on anesthesia earlier.

Now if you'll excuse me, I have to go rub my ICU patients' poop all over their CVLs, and then not wash my hands afterwards....

 

[likes pizza]

Now that we've exhausted the topic of infection as a complication of line, I'd like to present another question:

if you drop a lung with a line how long until a symptomatic pneumo develops? I assume not very long if some one is on positive pressure ventilation.

When anesthesia places a line in the OR the CXR usually gets done in the PACU to confirm line placement. Given that these are usually big cases, does that seem a little late to anyone? If they didn't have any vent issues or hypotension aren't they probably out of the danger zone?

In anyone willing to admit to dropping a lung, how long did it take for sx? was it diagnosed on CXR or clinically?

 

[Winged Scapula]

I'll admit it: I caused a PTX while doing a central line as a junior resident.

How long it takes to develop signs/symptoms would depend on the patient, whether they are ventilated and how big the PTx was. Since I always got stat films after placing lines, the patient didn't have any symptoms before I discovered it and got a chest tube in.

 

[dpmd]

Have been lucky so far, but have been called on to place chest tubes when someone else has. With vented patients I have seen that despite a long time between the placement and the chest tube going in (because sometimes people are waiting for a read on a film instead of looking at it themselves), I haven't noticed any associated signs from the pneumo.

Considering how small the hole is likely to be and given the fact that we observe a lot of small traumatic pneumo's (even the occasional vented patient)with most going on to resolve without a tube I wonder if we are being too quick to treat.

 

[SLUser11]

Have been lucky so far, but have been called on to place chest tubes when someone else has. With vented patients I have seen that despite a long time between the placement and the chest tube going in (because sometimes people are waiting for a read on a film instead of looking at it themselves), I haven't noticed any associated signs from the pneumo.

Considering how small the hole is likely to be and given the fact that we observe a lot of small traumatic pneumo's (even the occasional vented patient)with most going on to resolve without a tube I wonder if we are being too quick to treat.

I agree somewhat. Treatment of iatrogenic PTXs needs to be individualized. If the patient has a small PTX and is asymptomatic, they can probably tolerate a trial of conservative therapy. However, if the PTX is large or the patient is symptomatic, or the patient is on positive pressure ventilation, some sort of drainage procedure is in order.

Also, I don't think we need to jump immediately to large-bore chest tubes. We can use pneumocaths, etc instead and cause less pain/morbidity in our patients. Of course, this depends on the situation, and some patients absolutely need a big tube in place. Others simply need the PTX to be drained with an angiocath or pigtail, then the catheter can be removed.

As for how fast the PTX can occur, this is extremely variable. Some people's lungs drop immediately, while others develop slowly over 24 hours or more. The extent of intrinsic lung disease matters as well, as sticking an 18 gauge needle into a healthy 18 yo's lung is different than popping a bleb in a 70 yo COPD patient.


As for personal experience, I've dropped 2 lungs myself over the last 3.5 years.....the old saying, which will probably irk Proman, is that if you haven't dropped a lung, then you haven't done enough lines. The published PTX rate with surgical residents and staff is 1%, and can be as high as 5-10% in the medical literature. I think I'm right around or possibly a little below the 1% benchmark, but I'm sure I'll drop some more lungs before I'm done practicing.

As for which patients to be especially careful with, I've found that the really skinny females, which were both middle aged or older with big smoking histories in my experience, are somewhat easier to screw up....on a subclavian, there's just less room between the clavicle and the ribcage in these patients.

 

[Buzz Me]

I've dropped a lung before...happened after approximately 50 subclavian CVLs, but *knock on wood* it hasn't happened since. Yet.

 

[Winged Scapula]

I agree somewhat. Treatment of iatrogenic PTXs needs to be individualized. If the patient has a small PTX and is asymptomatic, they can probably tolerate a trial of conservative therapy. However, if the PTX is large or the patient is symptomatic, or the patient is on positive pressure ventilation, some sort of drainage procedure is in order.

Also, I don't think we need to jump immediately to large-bore chest tubes. We can use pneumocaths, etc instead and cause less pain/morbidity in our patients. Of course, this depends on the situation, and some patients absolutely need a big tube in place. Others simply need the PTX to be drained with an angiocath or pigtail, then the catheter can be removed.

Absolutely. I think we/I were always trained that the chest tube was the immediate answer without questioning if it really benefitted the patient. Something about dogma and better now than emergently later which never made (much) sense to me.

As for which patients to be especially careful with, I've found that the really skinny females, which were both middle aged or older with big smoking histories in my experience, are somewhat easier to screw up....on a subclavian, there's just less room between the clavicle and the ribcage in these patients.

Yep...I did it twice during residency and both times were exactly the type of patient you describe above with SCs. I like to think that it was also a function of being used to obese patients in PA and using a more acute angle in these skinny old ladies than was necessary due to my prior experience going through several cms of fat. But two times put me under 1% rate as well. Haven't done one in over 2 years now, so probably would be higher now if I tried again.😛

 

[JackADeli]

I am well under .5% PTHx rate.
The treatment will obviously vary on a situational basis. Keep in mind all those "stat surgical consult" for PTHx after central line placement 12 hours earlier but post line cxr report is dictated ...12 hours later. Also, keep in mind all these patients in the community with spontaneous PTHx. Some of these folks walk around with a greater then 50% PTHx for several days before they arrive at ED with "not feeling right, a little short of breath". In such cases, if it appears the PTHx may have been ongoing for a day or two, you can place a pneumocath or tube.... but waterseal not suction as they are more prone to reexpansion pulm edema.

 

[proman]

I agree somewhat. ...the old saying, which will probably irk Proman, is that if you haven't dropped a lung, then you haven't done enough lines. The published PTX rate with surgical residents and staff is 1%, and can be as high as 5-10% in the medical literature.

Suspend your disbelief but I actually completely agree. It's a primary reason why we like IJs (although I've seen a medicine resident cause a PTX via the neck) compared to subclavian. Who's dropped a lung after an IJ? I haven't after about 250 (have done much fewer subclavians, mostly in the units).

 

[SLUser11]

Suspend your disbelief but I actually completely agree. It's a primary reason why we like IJs (although I've seen a medicine resident cause a PTX via the neck) compared to subclavian. Who's dropped a lung after an IJ? I haven't after about 250 (have done much fewer subclavians, mostly in the units).

Of course, playing devil's advocate, I can produce a few papers that show IJs to have equal % PTX to SC with a higher infection rate (granted they're from a pre-sono era)......and then you could probably find some papers that show IJs to have lower PTX rate with equal infection rate.....

This is why the IJ vs. subclavian argument is so difficult to win. Any good physician can produce literature to support their bias. I quoted this recently, from a lecture on the surgical literature, can't remember who said it:

"Surgeons use literature the way a drunk uses a lamp post: more for support than illumination."

I guess the real answer is that the subclavian line is safer in some people's hands, and the IJ is safer in other people's hands. Having watched some of the older attendings try to use ultrasound, I'm relatively convinced that they are safer doing IJs "old school" than with sono-guidance.

For surgery residents, one patient population where the subclavian is nearly always preferred is the trauma patients, as it is infinitely easier to place a subclavian (and then take care of it) in a patient wearing a c-collar.


As for dropping lungs with IJs, I have a co-resident who did it...with a 22-gauge seeker needle....and she swore that she only put the needle in about 2cm past the skin. Of course, this was without ultrasound, so....