In plane central line

[Simba1711]

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Do any of you guys do in plane for visualizing the needle and IJ when placing central line ? I’m just curious as I’ve never placed one this way but something I’m interested in. Anything you have to do differently especially when making the skin nick and threading the wire ?

 

[ucladoc2b]

I think most people do the out of plane to visualize the carotid. In plane wire visualization is a nice confirmation you are in the IJ.

 

[Status Sciaticus]

Do any of you guys do in plane for visualizing the needle and IJ when placing central line ? I’m just curious as I’ve never placed one this way but something I’m interested in. Anything you have to do differently especially when making the skin nick and threading the wire ?

Wait, is that person coming at the IJ sideways instead of coming down from cephalad???

 

[Simba1711]

Yeah this person is coming from the lateral side so they can visualize the carotid as well. I’ve never seen it done in person before but there is some literature of people doing it this way. My main question is does the wire thread once you are in the ij and how does it affect the other steps ?

 

[Maverikk]

I primarily do it this way, very helpful in fat necks. Get a normal view of the IJ with the probe perpendicular to the IJ, scan up and down to make sure it's not too tortuous and anatomy is normal. Rotate the probe until the IJ is taking up about half the screen, much more than in this shot, makes the length the needle has to go much less for really big necks. I usually don't visualize the carotid, but I always make sure to have my needle and IJ in the screen, the pre-scan to get a sense of anatomy is essential. Learned it from working with an IR buddy. Very helpful for large necks when you have to do a deep dive for out of plane. I also use the needle and catheter in the kit, place the catheter, hold it at the hub after it's in. Makes it much easier than stabilizing the rigid needle and having the get the wire. The rest of the steps are the same

 

[psychbender]

I do not generally go in-plane for IJs. If I'm doing an USD-guided subclavian, or a femoral on a larger person, then I often go in plane (visualizing the vessel in long-axis, and seeing the entire shaft of the needle). Regardless of technique, I always follow the wire in short and long axis as far as I can to confirm placement before dilating. Yes, one axis is fine, but checking again takes just an extra two seconds, and makes me feel better.

I will add, I have seen a handful of times where the wire seems tough to pass, I look at it on USD, and I can see that the wire doubled back on itself. I have been able to salvage a few of these by watching on USD, backing up the wire, then following it down and finagling it past whatever made it turn around.

 

[pgg]

That perpendicular approach in the OP image looks ridiculous. Just .... why? I would bet it causes far more problems with wire threading than it solves in getting access.

I mean ... 98% of IJs are chip shots. It's right there.

The argument that in-plane allows for better control of the needle is made by people who don't know how to use ultrasound. It's absolutely possible (and not that hard) to follow the tip of the needle out-of-plane when accessing shallow vessels like the IJ or a radial artery. You just have to move or tilt the probe to follow it.

I stick the IJ out of plane, wire in, follow the wire as far down as I can both in and out of plane, print a picture, done. If at any point there's the least bit of weirdness in appearance or feel, put an angiocath in over the wire and transduce before dilating.

 

[Anestheezee]

Definitely good to learn how to follow that wire wherever it goes. If you can get down into the chest with ultrasound you can sometimes see a wire going the wrong direction, or a subclavian where the wire accidentally turns cranially. For essentially all out of plans techniques I do a lot of scanning forward and back along the needle shaft, then confirm I'm intravascular by scanning down to the tip of the needle and making sure it disappears in the center of the IJ when I scan beyond the needle tip.

 

[Bertelman]

Not sure I’ve ever seen a tortuous IJ. Not so tortuous it would affect cannulation.

I’ve seen atresia/thrombus, etc. but aside from taking a deep dive, it’s pretty consistently straight.

 

[hankbb02]

I usually use the 20g catheter to gain access to the IJ and thread it in plane. I start with out of plane and advance until I'm centered in the IJ then flip to in plane while i advance the catheter. A lot of the time it looks like you are in the middle of IJ out of plane but when you flip to in plane you can see the superficial aspect of the vein wall is tented down which prevents the catheter from threading. This can be easily visualized in plane and is the reason I do it this way. On the occasions where I thread the catheter and its not in the vessel I switch to the medal needle and do it out of plane.

 

[Ezekiel2517]

I've never done an IJ this way but I think I'd be a little uncomfortable about wiring+dilating using this technique, as I'm not following the natural course of the vessel.

 

[Simba1711]

That makes sense. I was just curious

I've never done an IJ this way but I think I'd be a little uncomfortable about wiring+dilating using this technique, as I'm not following the natural course of the vessel.

Short Axis In-Plane Ultrasound-Guided Technique for Internal Jugular Vein Cannulation

Real-time ultrasound (US)-guided venipuncture has become the standard of care due to its reduced complications and higher success rate. There are vari…

www.sciencedirect.com

https://rads.web.unc.edu/wp-content/uploads/sites/12234/2018/07/VascAccess.pdf

There’s two papers on it but it doesn’t talk about what you do differently once you get the view and pierce with needle.

 

[vector2]

I've seen oblique in-plane described a bunch

https://www.ultrasoundleadershipacademy.com/wp-content/uploads/2014/01/Oblique.pdf

Makes way more sense than trying to put in a wire and catheter totally orthogonal to the vessel's course

 

[lymphocyte]

Do any of you guys do in plane for visualizing the needle and IJ when placing central line ? I’m just curious as I’ve never placed one this way but something I’m interested in. Anything you have to do differently especially when making the skin nick and threading the wire ?

Poor technique is poor technique.

I've seen several backwall punctures with in plane visualisation, so it's no panacea, especially since it's easier for the needle tip to drift out of view. It's also more technically demanding to learn. No real data to support one technique over the other though.

I've tried the lateral in plane (so called half and half) but it's fidgety, doesn't seem that much more advantageous, and I don't like that I'm dilating at 45 degrees to the vessel. Not a fan.

Annals just had a paper on this topic if you're interested.

How to improve the efficiency and the safety of real-time ultrasound-guided central venous catheterization in 2023: a narrative review - Annals of Intensive Care

Central venous catheterization (CVC) is a frequent procedure, practiced by intensivists, anesthesiologists and advanced practice nurses in intensive care units and operative rooms. To reduce CVC-associated morbidity, it is essential to strive for best practices, based on the latest evidence...

annalsofintensivecare.springeropen.com

 

[james775]

I go out of plane but don’t aspirate. I hold it at the connection of needle and syringe. Have good control. It’s an ultrasound guided Iv at that point with a huge vessel. Keep following it in and then halfway in just thread. It’s honestly idiot proof this way.

New residents get thrown with all the steps. The aspirating is unnecessary if you are doing it with ultrasound.

 

[Arch Guillotti]

The aspirating is unnecessary if you are doing it with ultrasound.

Why bother with the syringe then?

 

[Beeftenderloin]

I get central access out of plane and follow my needle tip in like I’m placing an US guided PIV with the 20g catheter that comes with the kit. I confirm placement looking at the wire out of plane, as well as in plain. I like to pull the wire back all the way to the “J” then compress the vessel. There’s no way it can be backwalled or through and through in the carotid when you do confirm this way.

 

[vector2]

I go out of plane but don’t aspirate. I hold it at the connection of needle and syringe. Have good control. It’s an ultrasound guided Iv at that point with a huge vessel. Keep following it in and then halfway in just thread. It’s honestly idiot proof this way.

New residents get thrown with all the steps. The aspirating is unnecessary if you are doing it with ultrasound.

I do the same but without the syringe. Even if they do entrain air (which I doubt), it's probably microliters. And if you're worried you can just put your thumb over the hole.

 

[Bertelman]

I still stick with landmark. 90% of the time.

When I ultrasound, either because it's a fat neck or I've missed with landmark, it's always cross-section. Visualize my needle tenting the IJ, then I'm kind of done with ultrasound. Get aspiration with syringe and 18g, flatten out the needle while aspirating. Stabilize the needle with the left hand, twist off the syringe, then thread the wire. Key move in all this is your ability to disconnect the syringe without losing needle access. Can't let that needle move.

Rarely have the need to follow the wire down the IJ, and I've never gotten into the 18g-to wire-to catheter thing. That's just more steps and I don't have the patience. But I grew up in 2010 B.U., before ultrasound. Just a different skillset that can't really be taught anymore.

I have certainly heard stories of "I saw it enter the IJ, then backwalled it and I must have dilated/cannulated the carotid". That's why I don't rely on U/S. I like to maintain a high level of suspicion that I may be in the wrong vessel. And before you ask, no, I have never ever wired a carotid.

 

[lymphocyte]

I still stick with landmark. 90% of the time.

When I ultrasound, either because it's a fat neck or I've missed with landmark, it's always cross-section. Visualize my needle tenting the IJ, then I'm kind of done with ultrasound. Get aspiration with syringe and 18g, flatten out the needle while aspirating. Stabilize the needle with the left hand, twist off the syringe, then thread the wire. Key move in all this is your ability to disconnect the syringe without losing needle access. Can't let that needle move.

Rarely have the need to follow the wire down the IJ, and I've never gotten into the 18g-to wire-to catheter thing. That's just more steps and I don't have the patience. But I grew up in 2010 B.U., before ultrasound. Just a different skillset that can't really be taught anymore.

I have certainly heard stories of "I saw it enter the IJ, then backwalled it and I must have dilated/cannulated the carotid". That's why I don't rely on U/S. I like to maintain a high level of suspicion that I may be in the wrong vessel. And before you ask, no, I have never ever wired a carotid.

I agree ultrasound is very dangerous in the wrong hands with false reassurance, but surely it's now considered standard of care. By which I mean, if you did have a complication, and weren't using ultrasound visualisation, would it be defensible? Almost every study ever done on the topic supports its use, and it's made its way into guidelines as well.

I'm not challenging your practice, and I respect your skill and experience. Being trained AU (after ultrasound), I have literally never placed an IJ blind, only femoral or subclavians in crash cases.

Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2020;132(1):8–43.

 

[lymphocyte]

Why bother with the syringe then?

Longer lever means better control over the needle tip. Also less messy.

 

[deleted87051]

Do any of you guys do in plane for visualizing the needle and IJ when placing central line ? I’m just curious as I’ve never placed one this way but something I’m interested in. Anything you have to do differently especially when making the skin nick and threading the wire ?

I trained before ultrasound and a couple of our staff used this approach. The classic landmark approach was to insert at the crotch of the 2 bellies of the SCM. This approach was called the “lateral” or “posterior” approach because the insertion site was at the lateral or posterior border of the SCM. At that time, its champions claimed it was more comfortable for the patients, especially with movement, because the line or introducer was less likely to end up going through the SCM.

 

[Radetzky]

Line up carotid and IJ with the junction in the middle of the screen. Once I see needle tip under the skin and midline, tilt away from carotid and towards IJ and advance until you aspirate. Zero chance of hitting carotid or going back wall and into carotid if the direction of needle is away from carotid.

Technique depicted above is silly, you’re aiming directly at the carotid

Watching people use US without aspirating drives me insane

 

[GassYous]

Now there are screens that can show you both views at once

 

[james775]

Why bother with the syringe then?

Can slowly walk the catheter in without getting blood everywhere. Eliminate small chance of air embolism.

 

[Bertelman]

I agree ultrasound is very dangerous in the wrong hands with false reassurance, but surely it's now considered standard of care. By which I mean, if you did have a complication, and weren't using ultrasound visualisation, would it be defensible? Almost every study ever done on the topic supports its use, and it's made its way into guidelines as well.

I'm not challenging your practice, and I respect your skill and experience. Being trained AU (after ultrasound), I have literally never placed an IJ blind, only femoral or subclavians in crash cases.

Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2020;132(1):8–43.

You’re absolutely right. I wouldn’t reccomend anyone follow my practice. And I’m aware of the risk I take every time.

My point was simply that over-reliance on ultrasound, or any other technology/monitor, can sometimes increase the complication rate you are trying to avoid if you aren’t careful.

And that your success in placing these lines without complications has much more to do with your skill and judgment than how you use an ultrasound probe.

 

[vector2]

You’re absolutely right. I wouldn’t reccomend anyone follow my practice. And I’m aware of the risk I take every time.

My point was simply that over-reliance on ultrasound, or any other technology/monitor, can sometimes increase the complication rate you are trying to avoid if you aren’t careful.

And that your success in placing these lines without complications has much more to do with your skill and judgment than how you use an ultrasound probe.

@pgg wrote a great post on this topic which sums up my feelings on the matter as well

I feel like everyone here and you know better, but I'll state the should-be-obvious anyway: the fact that someone can (most of the time) slam in a central line in 30 seconds doesn't mean either

A) that they can do it successfully every time

or

B) that they can do it with no morbidity every time

Because someone routinely gets away with something isn't a defense of the technique.

It is not (NOT!) a defense of outdated but "fast" techniques to say that sometimes in an emergency it's better to go faster with more risk. And in the occasional case when they don't hit it immediately, they end up being slower than if they'd just picked up the ultrasound in the first place.

You're not new to this and neither am I; we've both seen these old school guys quickly get lines. You and I did it too, before ultrasound was everywhere. We've also seen them miss, or tag the carotid, or take longer than they would've if they'd simply taken 60 seconds more to pick up an ultrasound probe.

I think we should stop admiring the dinosaurs who refuse to use new, proven, unquestionably superior techniques, because MOST of the time they're slick and quick with the old way. They're not great. They're just old in the outdated sense, not the wise sense.

You know how many times I've punctured a carotid in the last 5 years? Zero.

You know how many times that old timer has punctured a carotid in the last 5 years? Neither does he ... but it isn't zero.​

 

[Bertelman]

I think I understand every time that I do it, I shouldn't. But it's a skill that I have, and it has value (arguable, I know).

Believe it or not, there are situations like traumas, etc. where that time does count, because maybe the sonosite is on the other side of the hospital. Or the patient is already draped, with surgeons scrubbed and operating, so I just can't get a probe in there. I like to think I am using the technique responsibly, but who knows, maybe I'm fooling myself and putting everyone I treat at risk.

At the very least, I don't encourage my practice, and I wouldn't teach it to anyone.

 

[medicine2wallstreet]

I agree with berterlman and disagree with vector. I have taken it upon myself to sneak in landmark central lines because no one has the stones anymore to teach the technique to residents anymore. It's critical to have the skill in emergencies. Do you think that they have time wait for an ultrasound in the trauma bay? No. Sometimes you have to be able to stick landmark. Puncturing the carotid is not clinically significant. Dilating it is significant.

 

[deleted87051]

On rare occasion, I’ll put a probe on a patient’s neck only to find a thrombosed IJ (more common in dialysis patients.). I just pick a different sight and save myself some aggravation and save the patient at least a couple of needle sticks.

 

[deleted87051]

I agree with berterlman and disagree with vector. I have taken it upon myself to sneak in landmark central lines when the attending is occupied because no one has the stones anymore to teach the technique. It's critical to have the skill in emergencies. Do you think that they have time wait for an ultrasound in the trauma bay? No. Sometimes you have to be able to stick landmark. Puncturing the carotid is not clinically significant. Dilating it is significant.

Ummm your trauma bay doesn’t have a dedicated ultrasound?

 

[medicine2wallstreet]

Yes it does have a dedicated ultrasound but with chest compressions and all the damn people doing stuff and doing a fast exam sometimes it can be occupied.

 

[Status Sciaticus]

I agree with berterlman and disagree with vector. I have taken it upon myself to sneak in landmark central lines because no one has the stones anymore to teach the technique to residents anymore. It's critical to have the skill in emergencies. Do you think that they have time wait for an ultrasound in the trauma bay? No. Sometimes you have to be able to stick landmark. Puncturing the carotid is not clinically significant. Dilating it is significant.

Ummm your trauma bay doesn’t have a dedicated ultrasound?

+1 LMAOO what kind of trauma bay doesnt have USG for doing FAST? Whats next? Blind pericardiocentesis?

 

[vector2]

I agree with berterlman and disagree with vector. I have taken it upon myself to sneak in landmark central lines because no one has the stones anymore to teach the technique to residents anymore. It's critical to have the skill in emergencies. Do you think that they have time wait for an ultrasound in the trauma bay? No. Sometimes you have to be able to stick landmark. Puncturing the carotid is not clinically significant. Dilating it is significant.

The ultrasound is not tied up long enough in the trauma bay to preclude using it for lines. I'm at one of the busiest trauma centers in the country and the U/S is free for use on a groin line by the time I'm done opening gloves and setting up the MAC kit. After all, a FAST exam takes like 2 minutes.

Also, I bet your attendings, who think it's too unsafe to teach, would just love the fact that a resident is sneaking around doing landmark central lines without their knowledge.

 

[lymphocyte]

Yes it does have a dedicated ultrasound but with chest compressions and all the damn people doing stuff and doing a fast exam sometimes it can be occupied.

Who is throwing in a blind IJ during chest compressions? A blind IJ is fixing exactly zero problems in that scenario except for maybe inadvertently decompressing a tension.

 

[Beeftenderloin]

I think I understand every time that I do it, I shouldn't. But it's a skill that I have, and it has value (arguable, I know).

Believe it or not, there are situations like traumas, etc. where that time does count, because maybe the sonosite is on the other side of the hospital. Or the patient is already draped, with surgeons scrubbed and operating, so I just can't get a probe in there. I like to think I am using the technique responsibly, but who knows, maybe I'm fooling myself and putting everyone I treat at risk.

At the very least, I don't encourage my practice, and I wouldn't teach it to anyone.

I say this as a relatively young attending (less than 2 years out) who was fortunate to learn from some old timers along the way and can, have and do perform US and landmarks IJs, subclavian and fems when the occasion calls for it. But i’m still doing US guided IJ 98% of the time. The use case for the other techniques is just vanishingly rare. Also you can absolutely get a probe on someone’s neck who is draped for a laparotomy.

You have undoubtedly stuck some carotids and probably dislodged a plaque for two with your practice. I agree, the other techniques are good to know. But you aren’t doing your patients any favors by refusing to adopt the standard of care. It’s called the standard of care for a reason.

Or maybe you’re just special. /s

 

[lymphocyte]

I It's critical to have the skill in emergencies.

In the world of IOs, RICC lines, U/S PIVCs, I am yet to be convinced a central line is truly an emergent procedure.

 

[patriot6]

can we just vote medicine2wallstreet off the island already

 

[T-burglar]

I agree with berterlman and disagree with vector. I have taken it upon myself to sneak in landmark central lines because no one has the stones anymore to teach the technique to residents anymore. It's critical to have the skill in emergencies. Do you think that they have time wait for an ultrasound in the trauma bay? No. Sometimes you have to be able to stick landmark. Puncturing the carotid is not clinically significant. Dilating it is significant.

Lol Jesus. Christ

 

[PpfSuxTube]

In the world of IOs, RICC lines, U/S PIVCs, I am yet to be convinced a central line is truly an emergent procedure.

100%. I hate triple lumens in any form of emergency. Give me even a 20g in a decent acf vein any day. Flow is much higher

A 7fr introducer is obviously better than a piv but not worth it to do it with landmark technique.

I don't get involved in any one else's practice and I let dinosaurs be dinosaurs. They'll be gone soon.

Personally I always have a USS and I always have the newest model glidscope for example so why would I bother with inferior old techniques.

In plane ij cannulation looks insane. Why point directly at the things you don't want to hit? Ij cannulation is done. It's perfected already. It doesn't need any of this nonsense so some guy can seem smart. Even with morbid obesity, out of plane is very quick and easy 99% of the time

 

[Status Sciaticus]

Lol Jesus. Christ

It's not quite often that you come across a person on here that is actually a danger to patients in such an obvious manner. I really do feel concerned for his/her patients.

 

[Status Sciaticus]

100%. I hate triple lumens in any form of emergency. Give me even a 20g in a decent acf vein any day. Flow is much higher

A 7fr introducer is obviously better than a piv but not worth it to do it with landmark technique.

I don't get involved in any one else's practice and I let dinosaurs be dinosaurs. They'll be gone soon.

Personally I always have a USS and I always have the newest model glidscope for example so why would I bother with inferior old techniques.

In plane ij cannulation looks insane. Why point directly at the things you don't want to hit? Ij cannulation is done. It's perfected already. It doesn't need any of this nonsense so some guy can seem smart. Even with morbid obesity, out of plane is very quick and easy 99% of the time

but then how will they write up this novel new technique to present at conferences and count as research to move up from associate professor to full professor (aka the academic circlejerk)

 

[abolt18]

I've seen oblique in-plane described a bunch

View attachment 375885

https://www.ultrasoundleadershipacademy.com/wp-content/uploads/2014/01/Oblique.pdf

Makes way more sense than trying to put in a wire and catheter totally orthogonal to the vessel's course

Have done this several times when I was a resident. One attending was all about it. It was fine but I was never bought in.

I prefer to just do out-of-plane and walk the needle w/catheter in the way I do with a PIV. No back-walling, no carotid sticks. Quick and straightforward.

For subclavian lines, I'll start with landmark, then readily switch to ultrasound if I'm not getting it pretty quickly. When I do have to use ultrasound, I find that the vein is always just a little deeper than I was comfortable sticking blindly. (Have typically done subclavian for CABGs, since they're going to open the left chest anyway)

 

[pgg]

The ultrasound is not tied up long enough in the trauma bay to preclude using it for lines. I'm at one of the busiest trauma centers in the country and the U/S is free for use on a groin line by the time I'm done opening gloves and setting up the MAC kit. After all, a FAST exam takes like 2 minutes.

Also, I bet your attendings, who think it's too unsafe to teach, would just love the fact that a resident is sneaking around doing landmark central lines without their knowledge.

Just add it to the list of ridiculous cowboy things he's written ...

 

[pgg]

Do you think that they have time wait for an ultrasound in the trauma bay?

Yes it does have a dedicated ultrasound but with chest compressions and all the damn people doing stuff and doing a fast exam sometimes it can be occupied.

So which is it? Do you have to wait for someone to go get an ultrasound because you don't have one in the trauma bay (where are you working?!?), or is there one present but somehow there's a ten-minute FAST exam in progress and you can't use it?

Chest compressions? Can you show me where in ACLS the compressions should be halted for placement of a central line?

Or are you going to admit you're just trolling again a few posts hence?

 

[deleted1130227]

I agree with berterlman and disagree with vector. I have taken it upon myself to sneak in landmark central lines because no one has the stones anymore to teach the technique to residents anymore. It's critical to have the skill in emergencies. Do you think that they have time wait for an ultrasound in the trauma bay? No. Sometimes you have to be able to stick landmark. Puncturing the carotid is not clinically significant. Dilating it is significant.

when i taught residents, I would try a hybrid technique. Before putting the u/s probe on the neck. Give them a sterile marking pen. draw the edges of the sternocleidomastoid triangle after prepping. Let them take one pass with a 21g finder needle on a syringe. 90+% of the time they would get venous blood. Immediately after this put the u/s probe on the neck and complete the procedure routinely. It was occasionally surprising.

 

[Bertelman]

In the world of IOs, RICC lines, U/S PIVCs, I am yet to be convinced a central line is truly an emergent procedure.

Let's see, the ascending aortic dissection that comes to the OR after hours with a couple 20 ga PIVs. Starts to decompensate on the OR table.

Or the acute abdominal dissection brought to the OR a couple weeks ago. Stable induction, lines placed, approximately 15-20 min later that dissections extended and we never got control of it.

Again, I'm not here to defend my practice. But it's a little misleading to say we simply never take care of emergencies, and please, take as much time as you want getting that patient ready for this procedure. Or maybe I just work at a place where we get those cases, and you don't. My cardiac surgeons don't like going on pump with an IO. I don't, either.

 

[Bertelman]

I say this as a relatively young attending (less than 2 years out) who was fortunate to learn from some old timers along the way and can, have and do perform US and landmarks IJs, subclavian and fems when the occasion calls for it. But i’m still doing US guided IJ 98% of the time. The use case for the other techniques is just vanishingly rare. Also you can absolutely get a probe on someone’s neck who is draped for a laparotomy.

You have undoubtedly stuck some carotids and probably dislodged a plaque for two with your practice. I agree, the other techniques are good to know. But you aren’t doing your patients any favors by refusing to adopt the standard of care. It’s called the standard of care for a reason.

Or maybe you’re just special. /s

Stuck carotids? yes, about once every three years.

Dislodged a plaque? You and I both know that's a reach.

Special? Nope. If anything, just stubborn. Judge me all you want. I didn't intend on making this a thread supporting landmark techniques. I think I have made that quite clear with every post. My point: ultrasound is not a 100% panacea that prevents everyone from ever puncturing, dilating then cannulating the carotid.

I also don't grab a glidescope every time an intubation looks difficult. Haven't had a complication because of it. And yes, when I get called to the Cath lab to intubate a STEMI without a pulse, flouro in the way while someone is doing compressions, I am super glad I've maintained that skill. Feel free to throw shade on that, too.

 

[Mehd School]

I'm two years into my attendinghood and have encountered one situation where I needed to place a blind IJ emergently. It was tamponade after an ablation and we rushed back into the cath lab after the patient decompensated in the pacu. The proceduralist was using our only ultrasound to enter into the pericardial space and he was struggling. This lady had one 20g that was of course infiltrated. During the case she had a femoral sheath which was since closed with a closure device. I needed a way to get big time volume to her fast, and I was with one resident and 2 crnas and each of them failed at least once with a PIV. I blind stuck the IJ and got a cordis in about the same time they tapped the pericardium. It was pretty wild and she thankfully survived.

After all that I went and changed my pants because I had done maybe 3 blind central lines in residency. We just didn't do them. I exhausted all options first. We didn't have another ultrasound nearby, they didn't have IO readily available. I was unable to get an EJ or PIV. She was being kept alive by IM epi and ephedrine. This has been something that stays in the back of my mind and I think it's a double edge sword. I got extremely lucky in this scenario. I think it's something someone should be able to do in a pinch if needed but I don't think it's something that should be done routinely. So then we're going to get rusty. Rocks and hard places.

 

[Arch Guillotti]

I'm two years into my attendinghood and have encountered one situation where I needed to place a blind IJ emergently. It was tamponade after an ablation and we rushed back into the cath lab after the patient decompensated in the pacu. The proceduralist was using our only ultrasound to enter into the pericardial space and he was struggling. This lady had one 20g that was of course infiltrated. During the case she had a femoral sheath which was since closed with a closure device. I needed a way to get big time volume to her fast, and I was with one resident and 2 crnas and each of them failed at least once with a PIV. I blind stuck the IJ and got a cordis in about the same time they tapped the pericardium. It was pretty wild and she thankfully survived.

After all that I went and changed my pants because I had done maybe 3 blind central lines in residency. We just didn't do them. I exhausted all options first. We didn't have another ultrasound nearby, they didn't have IO readily available. I was unable to get an EJ or PIV. She was being kept alive by IM epi and ephedrine. This has been something that stays in the back of my mind and I think it's a double edge sword. I got extremely lucky in this scenario. I think it's something someone should be able to do in a pinch if needed but I don't think it's something that should be done routinely. So then we're going to get rusty. Rocks and hard places.

Should have just put an an IO.