hurricanemd

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I dropped my first lung last night while putting in a subclavian. It was my 6th ICU admit of the night at 5:30am.... :( Really makes your heart drop when you pull back air in that syringe.

I'm gonna go get some sleep now.
 

WilcoWorld

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At least you didn't cannulate a non-compressible artery
 
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roja

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known complication with SCV cannulation. Where I trained, they used to say, if you haven't dropped a lung, you haven't done enough Subclavians. :)
 

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Been there. Ditto Roja.
 

txterp98

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Been there, done that. Just push the air back in when you aspirate it! Okay, maybe not.

Out of curiousity, did your patient have severe COPD? Sometimes you can get screwed by bad emphesymatous changes/blebs.
 

GeneralVeers

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Been there, done that. Just push the air back in when you aspirate it! Okay, maybe not.

Out of curiousity, did your patient have severe COPD? Sometimes you can get screwed by bad emphesymatous changes/blebs.
U/S - guided IJ for the win!
 

roja

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U/S guided IJ's are indeed awesome lines. Depending.

IJ's have the highest rate of long term infection. If you aren't careful, you can also give a PTX with IJ's. be wary of tiny thin necks and overconfidence thinking you can't drop a lung. The apices can come up higher than you think.

I love SCV lines. They are clean, they are easier. But they aren't right in everyone. Like everyother thing in medicine, there is no one right answer. Depends on the patient and the situation... and purpose.
 

GeneralVeers

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SCVs make me nervous, as I have no way of seeing where I am going with the needle. Usually if they are being placed, the patient is critical, and the last thing they need is a PTX.

Usually if I can't get the IJ, then I do Fem with U/S as well. If the intensivists really need CVP monitoring they can put their own in.

Also, you get to bill more for an U/S guided line.
 

roja

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SCVs make me nervous, as I have no way of seeing where I am going with the needle. Usually if they are being placed, the patient is critical, and the last thing they need is a PTX.

Usually if I can't get the IJ, then I do Fem with U/S as well. If the intensivists really need CVP monitoring they can put their own in.

Also, you get to bill more for an U/S guided line.


I certainly think comfort is an important issue. If you aren't comfortable doing it, I wouldn't recommend it. I used to be uncomfortable as a resident. I kind of made it my mission to do a bunch of them. Now, I am pretty comfortable, in the right patient.

I don't do them just for CVP monitoring. (you can do this in an IJ or even in a femoral.) SCV's have the lowest infection rate overall. They are better tolerated by awake patients as well. So, in appropriate patients, I like them.

I don't get reimbursed for u/s guided lines anyway, so its a moot point for me. :)

the only PTX I gave was a small one and didn't need a chest tube. If you are careful, even if you give a PTX it is often small.

Again, to each his own. with e-z IO's, ultrasounds, ej's, I think there are enough alternatives to work many ways.:thumbup:

I do think for residents in training, it is crucial to learn to place a SC ctl line.

(I love them in ESRD, APE pts who are hypoxic. You don't even have to lay them down. I can often times pop in a SCV ctl line easier than any other line.)
 
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Apollyon

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I LOVE the SC - remember the last time I put an IJ in (April 2008), and can't remember the last time I put in a femoral. I've gotten the air back in the syringe, with the vapor trail, but (knock wood) the post-procedure CXR was clean each time. (Not that it happens every time; also, just like some animals are more equal than others, so are interns.)
 

docB

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...just like some animals are more equal than others, so are interns.)
Totally off topic but I :laugh:d on that one. Purely coincidentally I am rereading Animal Farm right now. Love it.
 

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I LOVE the SC - remember the last time I put an IJ in (April 2008), and can't remember the last time I put in a femoral. I've gotten the air back in the syringe, with the vapor trail, but (knock wood) the post-procedure CXR was clean each time. (Not that it happens every time; also, just like some animals are more equal than others, so are interns.)
Just curious as to why so seldom with the fem stick?
 

dchristismi

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I try to mix them up, although haven't done a SCL in awhile. My U/S IJ is the go-to line, although I use the fem in code/crashy/backup situations.
 

Apollyon

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Just curious as to why so seldom with the fem stick?
Staff is great for peripherals, so I don't have to do crash lines much AT ALL. Virtually all of the time, my central lines are not emergent. If I'm doing a line for access, #1 is SC, #2 is IJ, and #3 is femoral.

And the EJ is fine, too.
 

southerndoc

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Did a crash line the other day. 42 year old woman who weighed about 450 pounds found down, asystolic, intubated, no IV/IO access, given 2 mg epi down the tube. Had two paramedics hold up her pannus while I threw in a femoral. Got it on the first stick (I was like WTF?). A bigger WTF came over my face when I gave her 1 epi, 1 bicarb, she went into fib, got defibbed, and had a rock steady sinus rhythm with a pressure of 110 systolic without pressors. Needless to say she's probably permanently vent bound unless the husband lets them harvest her (if they can use any of her organs).
 

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i'm an intern, and during my EM month got quite comfortable with us-guided IJ's, they've become my go-to line. however, inexplicably, my ICU doesn't have an ultrasound, so i was forced to do only subclavians. it was a mixed blessing, as the learning curve has been a bit tougher, but i think it's a valuable skill, and there won't always be an ultrasound around. i still haven't dropped a lung though, so i suppose i haven't yet done enough... :)

do people feel comfortable with the supraclavicular approach? i haven't met anyone yet who could teach me in person.
 

WilcoWorld

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Did a crash line the other day. 42 year old woman who weighed about 450 pounds found down, asystolic, intubated, no IV/IO access, given 2 mg epi down the tube. Had two paramedics hold up her pannus while I threw in a femoral. Got it on the first stick (I was like WTF?). A bigger WTF came over my face when I gave her 1 epi, 1 bicarb, she went into fib, got defibbed, and had a rock steady sinus rhythm with a pressure of 110 systolic without pressors. Needless to say she's probably permanently vent bound unless the husband lets them harvest her (if they can use any of her organs).
Did you cool her?
 

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Of course there's always the IO. Last week I had a vasculopath who was sent to us from an OSH with a GIB because they could not get access, even with radiology's assistance. Our folks tried peripherals with US, no luck. The records stated that she had occluded IJ's bilaterally and that her EJ's were scarred down. They made no mention of the femorals, so I gave both a try -- no dice: got the lines but could not pass a the wire. So out came the gun and we placed an IO in her left tib. Quick and effective.

On follow up, our intensivists could only place a brachial line and since she was stable vascular opted to wait/watch.
 

kungfufishing

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do people feel comfortable with the supraclavicular approach? i haven't met anyone yet who could teach me in person.

I like the supraclavicular line. Before I became corrupted by the U/S IJ I learned to like the supraclavicular. Do find someone to teach you how. There is a decent instructional video on emrap.tv. I've found that in putting that one in, the key is to not try very hard - it is quite superficial. The couple people in whom it wasnt particularly superficial above the clavicle had a prominent, easy to hit vessel on the infraclavicular side, which makes some sense.

To second apollyon, I love the EJ. Do one most shifts it seems like.
 
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roja

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i'm an intern, and during my EM month got quite comfortable with us-guided IJ's, they've become my go-to line. however, inexplicably, my ICU doesn't have an ultrasound, so i was forced to do only subclavians. it was a mixed blessing, as the learning curve has been a bit tougher, but i think it's a valuable skill, and there won't always be an ultrasound around. i still haven't dropped a lung though, so i suppose i haven't yet done enough... :)

do people feel comfortable with the supraclavicular approach? i haven't met anyone yet who could teach me in person.


I love this line. You should definitely find someone to teach it to you. I learned it after talking to a guy who sometimes worked in podunk. He said he would often drop a 14g supraclavicular line and then once the patient was intubated, flip it over to a ctl line over a wire.

came back and found someone to teach me that line. Did a few, then taught a few people. I had an intern who did one as her first central line on a patient who was having chest compressions done. Its great when it works!
 

Apollyon

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I'm curious.. what does it mean to drop a lung?
Title of the thread - iatrogenic pneumothorax. "Iatrogenic" - caused by health care providers (like doctors). Pneumothorax - air around (but not in) the lung, causing the lung to collapse.

There's not a lot of free space in the chest, so, when using sharp things like needles to try and enter blood vessels, if the vessel is missed, the sharp end can puncture a lung.
 

enfuegoEP

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I've only put in one SC and about 15-20 US guided IJ's and fems. Just this week I've seen two dropped lungs by another service doing SC's... and now i'm scared to do them :( As an intern I think the best thing to do is put in SC when trauma's come in and the pt ALREADY has a PTX.
 

VA Hopeful Dr

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I've only put in one SC and about 15-20 US guided IJ's and fems. Just this week I've seen two dropped lungs by another service doing SC's... and now i'm scared to do them :( As an intern I think the best thing to do is put in SC when trauma's come in and the pt ALREADY has a PTX.
That's exactly how I got my first SC.
 

leviathan

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I love this line. You should definitely find someone to teach it to you. I learned it after talking to a guy who sometimes worked in podunk. He said he would often drop a 14g supraclavicular line and then once the patient was intubated, flip it over to a ctl line over a wire.

came back and found someone to teach me that line. Did a few, then taught a few people. I had an intern who did one as her first central line on a patient who was having chest compressions done. Its great when it works!
Do you find supraclav is easier to do than infra approach? Based on the anatomy it almost looks like it would be easier to get it in that way, and less chance of dropping a lung too because of the superior approach.
 

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I caused my first ptx a month or so ago with a subclav. Pure arrogance. Bad anatomy. Pt was contracted and kyphotic. Really humbled me - sometimes the US guided lines are the best.
 

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Dropped my first lung during a subclavian last month. A very humbling experience needless to say. Evidence shows that even in experienced hands, a PTX is a documentated complication in 2-3% of cases. A study regarding this came out of the St. John's program in Detroit a few years back.
 

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I think I'm the opposite of most people in this thread.

All my troubles with cent lines come from the IJ approach. Yet I'm 100% with no complications with the subclavian approach. After the 20th subclav line, I just stopped doing IJ lines altogether unless I absolutely had to and then was nervous as heck doing it.

Maybe I'm the subclavian whisperer.
 

leviathan

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I think I'm the opposite of most people in this thread.

All my troubles with cent lines come from the IJ approach. Yet I'm 100% with no complications with the subclavian approach. After the 20th subclav line, I just stopped doing IJ lines altogether unless I absolutely had to and then was nervous as heck doing it.

Maybe I'm the subclavian whisperer.
What troubles are you having with IJ? PTX?
 

southerndoc

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After the 20th subclav line, I just stopped doing IJ lines altogether unless I absolutely had to and then was nervous as heck doing it.

Maybe I'm the subclavian whisperer.
Surely you're joking after only 20 central lines?

As the saying goes, if you haven't dropped a lung doing a central line, you simply haven't done enough central lines.
 

Doctor Bob

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Surely you're joking after only 20 central lines?

As the saying goes, if you haven't dropped a lung doing a central line, you simply haven't done enough central lines.

Errrm.... well it was after 20 that I gave up on the IJ approach... at the time I had 20 subclavians with no problems, and ~10 IJ's with lots of problems (PTX, inability to thread, guidewire takes a turn and goes down the arm, etc.), so I figured that even with an n of only 30 I was finding a clear personal preference. All the problems I was having were common issues with centlines, but I found it odd that with the small sample set they'd all be clustered with one approach.

Am I going to drop a lung eventually with the subclav approach? Sure, but with my track record I'd probably do it a lot more frequently with the IJ. <shrug> It's a personal preference.
 

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Been there, done that. Just push the air back in when you aspirate it! Okay, maybe not.

Out of curiousity, did your patient have severe COPD? Sometimes you can get screwed by bad emphesymatous changes/blebs.
I recently saw a patient with severe COPD admitted for PTX because of acupuncture. :eek:
 

kungfufishing

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I've apparently done twice as many central lines as I need to...although fortunately I have not put in enough as an attending yet.
 
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