IJ central lines

[proman]

Just wondering how many people feel comfortable doing IJs without US. I do about 40% of my lines without US. Most of the reason is that someone, as an anesthesiology resident, I have to place IJs during a case, when ultrasound is not an option (neither are other sites). It's a skill I have to have. How about you?

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[Winged Scapula]

Clearly a good skill to have as US may often not be available.

I prefer subclavians but am comfortable placing an IJ without US.

 

[Arch Guillotti]

Just wondering how many people feel comfortable doing IJs without US. I do about 40% of my lines without US. Most of the reason is that someone, as an anesthesiology resident, I have to place IJs during a case, when ultrasound is not an option (neither are other sites). It's a skill I have to have. How about you?

40% of lines placed under the drapes while a case is underway seems like a very high percent. Are you extremely rushed to get cases underway, is it an institutional thing, do your surgeons stink meanie and get you in unexpected trouble or what?

Or do you mean that you don't have access to U/S in the OR (or something else, your post is a bit confusing)

 

[proman]

I see the confusion. I choose not to use US in ~40% of the time (mostly cardiac). It's something I've focused on because several cardiac attendings don't want us to use it. We have an US machine down in OB for lines (so no lack of machines). I've only done a couple of lines under the drapes.

 

[southerndoc]

Unfortunately we were required to use ultrasound to place IJ's during residency. I placed probably three IJ's without ultrasound during residency.

I almost always do subclavians now. The only exception is in a code situation or for a crash line, or if I'm putting in an introducer sheath for massive volume resuscitation (like this morning with the GI bleeder who had a pressure of 60 systolic).

All the ultrasound gurus claim that landmarks are off in about half the patients we do ultrasounds on. If that were the case, one would think people would have more difficulty with placement of IJ's without ultrasound. I see our pulmonologists and surgeons place them without difficulty, so I don't buy into the idea that such a large number of patients have landmarks that are not typical. The risk of carotid artery puncture is overrated. Very few patients will suffer sequelae of an inadvertent arterial puncture unless they have a toxic coagulopathy. Puncturing the carotid isn't a problem, but dilating it is.

 

[Winged Scapula]

Unfortunately we were required to use ultrasound to place IJ's during residency. I placed probably three IJ's without ultrasound during residency.

I almost always do subclavians now. The only exception is in a code situation or for a crash line, or if I'm putting in an introducer sheath for massive volume resuscitation (like this morning with the GI bleeder who had a pressure of 60 systolic).

All the ultrasound gurus claim that landmarks are off in about half the patients we do ultrasounds on. If that were the case, one would think people would have more difficulty with placement of IJ's without ultrasound. I see our pulmonologists and surgeons place them without difficulty, so I don't buy into the idea that such a large number of patients have landmarks that are not typical. The risk of carotid artery puncture is overrated. Very few patients will suffer sequelae of an inadvertent arterial puncture unless they have a toxic coagulopathy. Puncturing the carotid isn't a problem, but dilating it is.

Exactly.

 

[SocialistMD]

I learned how by using landmarks, but I use an ultrasound all the time now with my IJs. As mentioned above, I never do them in an "emergent" situation, so I always have time to get the ultrasound and have it available. My reasoning is, if I have the tool to make myself better, why not use it?

 

[Hernandez]

I trained with U/S, so I like U/S, but I do a little less than 1/3 with landmarks. I need to get much more comfortable with subclavians though.

 

[Tigerz_Fan]

The majority of my lines were mainly in people who had severe thrombocytopenia +/- coagulopathy. So, of my 70 lines I have done in residency, only 3 have been subclavians.

The beginning of my 2nd year, the US at the VA was broken. Even though we were trained to do IJs under US, I very quickly learned and got comfortable with my IJ landmarks.

I would love to get more subclavians before starting in July....

Totally agree with one thing: sticking the carotid isn't a problem. Dilating is..........

 

[cptcaver]

I really dislike using US for placing IJ's. I would much prefer to do them the old fashioned way. I find the machine cumbersome and it gets in the way. However, I do see the value. I find A-lines much easier with US.

 

[southerndoc]

I really dislike using US for placing IJ's. I would much prefer to do them the old fashioned way. I find the machine cumbersome and it gets in the way. However, I do see the value. I find A-lines much easier with US.

Really? I rarely have problems getting an A-line. You can feel the pulse and know where to go. Once you get used to using ultrasound for IJ's, it becomes much less cumbersome.

 

[souljah1]

In a non-emergent situation, I can't think of a good reason not to use an ultrasound to guide the placement of a internal jugular CVC. We use US almost all the time unless time is an issue. It has definitely resulted in fewer subclavian line attempts where I train, but there is not evidence that subclavian catheters are better than internal jugular caths in head to head trials. US is not all that cumbersome once you get the hang of it.

That being said, most of us indirectly feel very comfortable using landmarks for line placement. I say indirectly b/c I think US has helped prove landmarks to me. Prior to placing the probe on someone's next, I use landmarks to determine where to place the probe. We also have a ton of immunosuppressed, coagulopathic patients which precludes subclavian lines as well.

I don't use an US for a-lines. Some people do. I've had the get the US machine out for art lines on people who are very anasarcic occasionally. We also use US to do thoracenteses all the time. It's also a great way to verify your physical exam. I like to tap out the effusion or have the medical student or intern tap out the effusion, and then place the probe to get a sense of how accurate our exam is.

 

[proman]

I've used US for a-lines. It's another tool but the palpation method is fairly reliable. US helps getting a-lines in patients with ventricular assist devices (who normally don't have pulses). I've also noticed a lot of arteries that can't be threaded are filled with thrombus. US also helps a ton with pediatric a lines.

 

[carrigallen]

I agree for I-Js the US is more time-consuming and difficult to use when you are by yourself. I think I-Js in general are just less useful lines unless you are swanning. They take longer to put it, conscous patients move their heads around, patients get annoyed by them, and I feel like they get yanked on more by virtue of their location.

 

[SLUser11]

There is a lot of literature saying that subclavians have lower infection rates, and there's other studies showing IJs have lower pneumothorax rates, and there's an equal amount of literature saying that there's no significant difference. What does that mean to me? Literature exists out there to support whatever bias we have, causing some people to do all IJs and others all subclavian, based on our comfort level.

As for ultrasound for IJs, it is the standard of care, and the ACS has issued a position statement to that effect. When it is available, and you don't use it, you will have a hard time defending your decision if a complication arises. Unfortunately, I have done lots of lines without sono, based on attending preference, so I'm comfortable with this, but I will never do this in practice.

As a first line, I usually place subclavians, mostly because I feel it is an easier line to take care of (nothing more common than seeing an anesthesia-placed IJ flopping around in the wind without a sterile dressing POD #1). Also, it seems that my junior residents have less experience with subclavians, so I walk them through it for that reason (on trauma, they'll have to place mostly subclavians due to the c-collar, and need the skillset). I buy into the lower infection rate, so that's my bias.

Dialysis catheters and CVLs in renal failure patients all go in the IJ with me. Portacaths, being tunneled, have no infection advantage in the subclavian, so I go sono-guided IJ for that as well, as I feel there's a smaller chance of pneumothorax with IJ (more bias, and I'm familiar with the literature).

Now, the future probably holds sono-guided subclavians, so I'm interested in developing this skill.

Finally, for arterial lines, I admit that I do most of them without ultrasound. If I miss, and sono is available, I usually use that on the same wrist prior to changing positions. If the patient has no pulse, but still has good ulnar perfusion, I will use ultrasound primarily. I am a big advocate of sono-guided a-lines, and I believe it's a skillset we should all develop. I very rarely am unsuccessful in placement, very rarely go to the groin, and very rarely spend more than 15 minutes in there trying to place it, because of my acceptance of ultrasound guidance.

 

[Intensivist]

well, to tell you my not so big experience with central line placements... so far vast majority that l put in were subclavian or IJV, and only did few using US, and as far as l see it it is more practical to approach this using landmarks and your own experience and "touch", l compared inserting JIV using US takes me at least 5 minutes more, while inserting it not relying on US takes around 5 minutes less, due to very quick punctuation.
l would use US when 2nd or 3rd attempts were failures
just my 2 cents