Infraclavicular Subclavian Lines

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Groove

Groove

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Are any of you routinely using US on these? I was trained to do these blind with the landmark approach and it's easily become my go to line on most patients over the years if I'm not doing an IJ line or a crash femoral. I was talking to one of my IR guys lately who uses US for all his subclavian lines and swears by it. Every time I think about practicing, I just get frustrated because the probe never seems to sit flush with the chest wall and it's always a challenge to visualize the vessel during cannulation. I end up just going back to my landmark approach due to the familiarity.

Anybody regularly using US on these and have any tips? Are you going in or out of plane? Also, I don't have a small linear transducer typically used for regional blocks. It's one of the larger ones. Does that matter?
 
I should be doing more of those...the last one I did was on the right side, and the line curved up into the brain...

Apparently this happens less than compared to the left - but I'm right handed and it seems just natural to do it on the right side.

I dunno why I don't do it as much as I should
- sometimes the patients awake and it just feels weird seeing that they can watch me put a needle in their chest
- fear (of what?) I really think good technique you won't get a pneumo.

I've tried ultrasound and I agree it can be awkward especially if they are skinny and bony...hard to get the probe in the right spot.

Sorry not a very informative or interesting reply.
 
Much harder to do with big linear probes in my opinion. Small ones fit more easily under or above the clavicle.

Groove said:
Are any of you routinely using US on these? I was trained to do these blind with the landmark approach and it's easily become my go to line on most patients over the years if I'm not doing an IJ line or a crash femoral. I was talking to one of my IR guys lately who uses US for all his subclavian lines and swears by it. Every time I think about practicing, I just get frustrated because the probe never seems to sit flush with the chest wall and it's always a challenge to visualize the vessel during cannulation. I end up just going back to my landmark approach due to the familiarity.

Anybody regularly using US on these and have any tips? Are you going in or out of plane? Also, I don't have a small linear transducer typically used for regional blocks. It's one of the larger ones. Does that matter?
Click to expand...
 
thegenius said:
I should be doing more of those...the last one I did was on the right side, and the line curved up into the brain...

Apparently this happens less than compared to the left - but I'm right handed and it seems just natural to do it on the right side.

I dunno why I don't do it as much as I should
- sometimes the patients awake and it just feels weird seeing that they can watch me put a needle in their chest
- fear (of what?) I really think good technique you won't get a pneumo.

I've tried ultrasound and I agree it can be awkward especially if they are skinny and bony...hard to get the probe in the right spot.

Sorry not a very informative or interesting reply.
Click to expand...

I'm right handed and I reflexively prefer the right side but left is fine. I've always theoretically preferred the right for absence of thoracic duct and slightly lower lung apex. Although there seems to be a statistically higher chance of malpositioning, I don't seem to have many of those and if I do, it's usually solved by pulling and re-threading (worse case scenario just pull and let it sit in the distal subclavian and ICU can play around with it once they are upstairs but at least you can use it...). I'm not sure if this has anything to do with it but part of my technique is threading the wire after cannulation with the pig's tail curl in the wire aimed towards the heart instead of towards the head. It may be superstition, but I always felt that helped guide it into the SVC better though I've never found any mention of that in any literature over the years.

0.5-2% incidence in PTX but I agree, the number is likely lower with good technique. I'm due for several by those statistics. I've had two. One was an IJ line back in residency on a 15 yo girl. My second was in private practice with an old guy after a lengthy code which in hindsight probably wasn't the best choice in cannulation sites since his chest was broken all to pieces. I'm still not sure if the line was the cause of the PTX but since it was on the side of my line, I felt obligated to own it.

Glad to hear I'm not the only one having problems with US on these.
 
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It is my 'go-to' line nowadays, but I spend most of my time in the ICU. I think it is a far superior line from a physician, nursing, and patient perspective.

However, to do it reliably and safely, I think it takes a bit more training and perhaps more time than the typical ED will tolerate.

A few tips:

1. "in-plane" every time. It takes a bit more ultrasound skill and a bit of extra "learning" but it is much safer once the skill is mastered

2. I prefer the left side, but I have little evidence for this....basically its preferred by me because I have only had mal-position problems from the right and all of the theoretical benefits of right over left disappear once in-plane ultrasound is used

3. again, there is a bit of time issue (esp in the ED); but use of a micropuncture kit (Micropuncture® Access Set | Cook Medical) makes the puncture easier and safer (and I used to teach residents that anything except straight to the big steel needle is for timid, unskilled pansies)

4. Bony or obese bodies can make this a difficult line, especially if you don't have two high-frequency probes with small and large footprints. That said, when given the choice by the morphology of the subclavian space, I prefer the "larger" linear probe. I think the angle entering the vessel is easier and safer. That said, it requires a more lateral puncture often (especially if bony) and the 20cm TLC is often needed for "ideal" placement (16cm falls too short; but it probably doesn't matter much).

HH
 
Groove said:
I'm right handed and I reflexively prefer the right side but left is fine. I've always theoretically preferred the right for absence of thoracic duct and slightly lower lung apex. Although there seems to be a statistically higher chance of malpositioning, I don't seem to have many of those and if I do, it's usually solved by pulling and re-threading (worse case scenario just pull and let it sit in the distal subclavian and ICU can play around with it once they are upstairs but at least you can use it...). I'm not sure if this has anything to do with it but part of my technique is threading the wire after cannulation with the pig's tail curl in the wire aimed towards the heart instead of towards the head. It may be superstition, but I always felt that helped guide it into the SVC better though I've never found any mention of that in any literature over the years.

0.5-2% incidence in PTX but I agree, the number is likely lower with good technique. I'm due for several by those statistics. I've had two. One was an IJ line back in residency on a 15 yo girl. My second was in private practice with an old guy after a lengthy code which in hindsight probably wasn't the best choice in cannulation sites since his chest was broken all to pieces. I'm still not sure if the line was the cause of the PTX but since it was on the side of my line, I felt obligated to own it.

Glad to hear I'm not the only one having problems with US on these.
Click to expand...


This isn't superstition; its how the interventional cards guys guide the wire to their desired target(s).
 
RustedFox said:
This isn't superstition; its how the interventional cards guys guide the wire to their desired target(s).
Click to expand...

Man, I can't remember if that's how I was taught or just something I picked up along the way. I guess all of you guys do that then, lol. Here, I thought I was special with my super special technique.
 
Groove said:
Man, I can't remember if that's how I was taught or just something I picked up along the way. I guess all of you guys do that then, lol. Here, I thought I was special with my super special technique.
Click to expand...

I actually said to my favorite interventional cards guy the other day:

"Hey; go ahead and make fun of me for asking you this - but just how do you get the guidewire to the vessel that you want?"

"I simply bend the wire, dude."

No joke. I could tell he wasn't being sarcastic, either.
 
Hamhock said:
It is my 'go-to' line nowadays, but I spend most of my time in the ICU. I think it is a far superior line from a physician, nursing, and patient perspective.

However, to do it reliably and safely, I think it takes a bit more training and perhaps more time than the typical ED will tolerate.

A few tips:

1. "in-plane" every time. It takes a bit more ultrasound skill and a bit of extra "learning" but it is much safer once the skill is mastered

2. I prefer the left side, but I have little evidence for this....basically its preferred by me because I have only had mal-position problems from the right and all of the theoretical benefits of right over left disappear once in-plane ultrasound is used

3. again, there is a bit of time issue (esp in the ED); but use of a micropuncture kit (Micropuncture® Access Set | Cook Medical) makes the puncture easier and safer (and I used to teach residents that anything except straight to the big steel needle is for timid, unskilled pansies)

4. Bony or obese bodies can make this a difficult line, especially if you don't have two high-frequency probes with small and large footprints. That said, when given the choice by the morphology of the subclavian space, I prefer the "larger" linear probe. I think the angle entering the vessel is easier and safer. That said, it requires a more lateral puncture often (especially if bony) and the 20cm TLC is often needed for "ideal" placement (16cm falls too short; but it probably doesn't matter much).

HH
Click to expand...

Thanks, very helpful.
 
RustedFox said:
I actually said to my favorite interventional cards guy the other day:

"Hey; go ahead and make fun of me for asking you this - but just how do you get the guidewire to the vessel that you want?"

"I simply bend the wire, dude."

No joke. I could tell he wasn't being sarcastic, either.
Click to expand...
If your cards guy called you "dude', I'd have a beer (or two) with him.
 
RustedFox said:
This isn't superstition; its how the interventional cards guys guide the wire to their desired target(s).
Click to expand...

There was a small case series where they found a sig higher placement success with aiming the curve to the feet. I have also found a lot of success aiming the bevel... When I enter the vessel I have the bevel to the ceiling, then turn it 90 deg to the feet. Hasn't failed me yet
 
I can't see myself doing this out in a community ED, when it's just so much easier to do a femoral, or IJ line, and the risk of pneumothorax in the former is nonexistent in the former, and close to nonexistent in the latter.
 
bravotwozero said:
I can't see myself doing this out in a community ED, when it's just so much easier to do a femoral, or IJ line, and the risk of pneumothorax in the former is nonexistent in the former, and close to nonexistent in the latter.
Click to expand...

This.

I said to myself not long ago: "I should do more subclavians. Wait. Why the hell would I do that?"
 
ThoracicGuy said:
About five years ago...

And I'm not sure there's ever a good reason to do one these days...
Click to expand...

Oh, I strongly disagree. I use them all the time (I work predominantly in a tertiary, academic MICU). I think the risk of line sepsis leading to mortality significantly outweighs the risk of having difficulty with obtaining dialysis access so long as you don’t already have bad kidneys to start.
 
TimesNewRoman said:
Oh, I strongly disagree. I use them all the time (I work predominantly in a tertiary, academic MICU). I think the risk of line sepsis leading to mortality significantly outweighs the risk of having difficulty with obtaining dialysis access so long as you don’t already have bad kidneys to start.
Click to expand...

This was primarily my reason behind the initial thought of - "I should do more subclavian lines."
Its especially true when so, so many of our patients are gelatinous masses of adipose with redundant, sloppy, nicotine-stained, lipodermatosclerotic necks and thighs.
Its disgusting.
I hate it.
I am 5'6''. Once upon a time, I weighed 175 pounds.
Intern year.
I was round. Not terribly, awfully so - but still, round.
I am now 155 pounds. 157 this morning upon awakening, but this is after a nightshift and it was charge RN's birthday.
Unless there is an underlying endocrine issue; there is absolutely no reason why, in the year 2019, in America, that you are overweight besides your own choices regarding activity and diet.

Take me to the woodshed if you want on this one; but while you're there - get a good workout in.
 
ThoracicGuy said:
About five years ago...

And I'm not sure there's ever a good reason to do one these days...
Click to expand...


TimesNewRoman said:
Oh, I strongly disagree. I use them all the time (I work predominantly in a tertiary, academic MICU). I think the risk of line sepsis leading to mortality significantly outweighs the risk of having difficulty with obtaining dialysis access so long as you don’t already have bad kidneys to start.
Click to expand...

Dear Thoracic - Are you trolling with this Trumpian post? There's NEVER a good reason?

Obviously there are many reasons for subclavians and even without the risk-benefit discussion regarding subclavian stenosis in the general population from a single-stick 7F TLC, your post is inconsistent with the modern views of every CCM doc I have met, most nephrologists, and, although I have not discussed it specifically with them -- I bet vascular surgeons (generalizing). In fact, vascular would just roll their eyes if I asked them at either of my hospitals. I doubt they would waste a brain cell on the topic.

Like TimesNewRoman, I strongly disagree.

HH
 
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Hamhock said:
Dear Thoracic - Are you trolling with this Trumpian post? There's NEVER a good reason?

Obviously there are many reasons for subclavians and even without the risk-benefit discussion regarding subclavian stenosis in the general population from a single-stick 7F TLC, your post is inconsistent with the modern views of every CCM doc I have met, most nephrologists, and, although I have not discussed it specifically with them -- I bet vascular surgeons (generalizing). In fact, vascular would just roll their eyes if I asked them at either of my hospitals. I doubt they would waste a brain cell on the topic.

Like TimesNewRoman, I strongly disagree.

HH
Click to expand...

The nephrologists in my hospital are strongly against subclavian lines of any type. As for a typical CC patient, you have less risk of PTX with an IJ vs the subclavian. If you have a complication with a bleed, the IJ is easier to deal with than a subclavian bleed that could cause a hemothorax.

Could there be some uses for them? Sure, I suppose so. I put alot of them in during general surgery. Now I do IJ almost exclusively.

But you do you.
 
ThoracicGuy said:
The nephrologists in my hospital are strongly against subclavian lines of any type. As for a typical CC patient, you have less risk of PTX with an IJ vs the subclavian. If you have a complication with a bleed, the IJ is easier to deal with than a subclavian bleed that could cause a hemothorax.

Could there be some uses for them? Sure, I suppose so. I put alot of them in during general surgery. Now I do IJ almost exclusively.

But you do you.
Click to expand...

The problem is that your nephrologists have a myopic view given their selection bias - they see the ESRD folks who have difficulty with access. They don’t think about it when their folks don’t have access problems. Similarly, surgeons who have had to open a chest for a subclavian complication are inherently subject to recall bias. As far as ptx goes, I’ve never caused one and I’ve done a ton (knock on wood). Even if you do cause a ptx, I wouldn’t lose a lot of sleep - it’s not like you’re cutting their parenchyma with a serrated knife, you’re causing a tiny puncture wound. I’ve inherited a couple patients who have had a CVL induced ptx, and I’ve never seen them require anything more than a pigtail.

The fact is the matter is that the data supports their use, and not just in a one off manner. Both the cdc and ahrq list subclavian as their preferred site. I think any intensivist who is worth their salt thinks the same way.
 
Do you folks not have peripheral IVs, IOs, and PICC teams?
The frequency of CVLs since residency is so low I'm not sure I'd be able to gain proficiency with US without finding a different specialty to work with for practice.
Then again, I figured out the US guided LP pretty easily.
 
dumb question since no one does subclavians here so i never really learned, but for someone starting out, ive been taught that the site is fairly noncompressible, so when you remove a 14Fr line from the subclavian vein, how are you holding pressure to the vein to stop the bleed?

And if you accidentally puncture the sub artery during insertion, how do you hold pressure on that???
 
anbuitachi said:
dumb question since no one does subclavians here so i never really learned, but for someone starting out, ive been taught that the site is fairly noncompressible, so when you remove a 14Fr line from the subclavian vein, how are you holding pressure to the vein to stop the bleed?

And if you accidentally puncture the sub artery during insertion, how do you hold pressure on that???
Click to expand...

You just do your best. And fwiw, I’ve never hit the artery. My resident did once, but his approach was pretty atrocious in spite of correction.
 
Groove said:
Are any of you routinely using US on these? I was trained to do these blind with the landmark approach and it's easily become my go to line on most patients over the years if I'm not doing an IJ line or a crash femoral. I was talking to one of my IR guys lately who uses US for all his subclavian lines and swears by it. Every time I think about practicing, I just get frustrated because the probe never seems to sit flush with the chest wall and it's always a challenge to visualize the vessel during cannulation. I end up just going back to my landmark approach due to the familiarity.

Anybody regularly using US on these and have any tips? Are you going in or out of plane? Also, I don't have a small linear transducer typically used for regional blocks. It's one of the larger ones. Does that matter?
Click to expand...
Resident being taught to be able to do both. I try to preference the landmark based approach, because to me that seems to be the primary advantage to the subclavian. At this point I'm probably half and half (US:landmark). Josh Farkas over at pulmcrit is a big fan of the US-guided approach and put out a pretty informative (maybe over the top) deep dive. I agree with @Hamhock that the in-plane approach is ideal, but can be require a bit more time to learn for those used to out-of-plane.
One point that hasn't been brought up is changing your ultrasound's focal point -- if you have that ability. We have Phillips Sparq machines, and can vary the focal depth on the linear probe to bring a vessel into focus. Fairly helpful in folks with more tissue between the vessel wall and chest wall.
 
To all of you who talk about pneumo's, how many infraclav pain catheters do we do? ( and Paravertebrals fwiw but that a diff argument) With those we are literally millimeters from the pleura, way closer than with a subclavian vein target.

From my experience of 25 infra clav blocks (im no pain guy, and defo no expert) - the artery is about 1-2cm cephalad and posterior to the vein. Frequently the vein is pushed anteriorly when i hydrodissect the anterior cord off the subclavian artery (if thats what the artery is called there)

I would challenge everyone here to always dynamically scan when out of plane. You should always be saying to yourself 'needle, no needle', as you advance USS then scan back. It takes a while to get the hang of it, but it such a powerful skill. When you have a hemorrhagic shock bleeding out and your vein target is collapsing with even the slightest pressure you will thank me and save a life at the same time. Plus really reduce risk of a pneumo

I did a couple subclav vasc caths yesterday and it was a good time. im going to keep at them for a while. I went with out of plane, and really had my probe angled to look in under the clavicle as a final target. The vein is much shallower there and bigger too.

So i started obviously needle in view all the time and dynamically scanned until the USS probe was almost anteflexed 45 degrees away from me. That allowed my needle entry angle to be shallow enough that it was almost like doing an anatomical subclavian line. I used the small footprint probe but im not sure that really mattered. Case was regular size 90kg

The only issue i would have with subclavians is can we, should we put multiple lines into the 1 vein at the same time? I like to do my medical triple lumen and Vasc cath at the same time in same vein for speed. That fine in fem's and IJV that are huge. Its probably ok in subclavians too but might add to the stenosis issue. Anyone doing that? 2 lines in the subclavian same time?
 
TooMuchResearch said:
Sometimes I wish I was still doing as many procedures as in residency. Now I usually call the PICC service and move on.
Click to expand...

Wish I had a PICC service outside of 9a-4:30p, M-F only.

I still do a good bit of central lines (admittedly, they're my favorite procedure... I hate doing LPs for good reason) but I haven't done a subclavian since... hell, I think residency. With US-guided IJs, there's very little reason to go subclavian except in an actively coding patient, in which case... its IO until you get ROSC. If no ROSC, then.... G A M E O V E R.
 
Newtwo said:
To all of you who talk about pneumo's, how many infraclav pain catheters do we do? ( and Paravertebrals fwiw but that a diff argument) With those we are literally millimeters from the pleura, way closer than with a subclavian vein target.

From my experience of 25 infra clav blocks (im no pain guy, and defo no expert) - the artery is about 1-2cm cephalad and posterior to the vein. Frequently the vein is pushed anteriorly when i hydrodissect the anterior cord off the subclavian artery (if thats what the artery is called there)

I would challenge everyone here to always dynamically scan when out of plane. You should always be saying to yourself 'needle, no needle', as you advance USS then scan back. It takes a while to get the hang of it, but it such a powerful skill. When you have a hemorrhagic shock bleeding out and your vein target is collapsing with even the slightest pressure you will thank me and save a life at the same time. Plus really reduce risk of a pneumo

I did a couple subclav vasc caths yesterday and it was a good time. im going to keep at them for a while. I went with out of plane, and really had my probe angled to look in under the clavicle as a final target. The vein is much shallower there and bigger too.

So i started obviously needle in view all the time and dynamically scanned until the USS probe was almost anteflexed 45 degrees away from me. That allowed my needle entry angle to be shallow enough that it was almost like doing an anatomical subclavian line. I used the small footprint probe but im not sure that really mattered. Case was regular size 90kg

The only issue i would have with subclavians is can we, should we put multiple lines into the 1 vein at the same time? I like to do my medical triple lumen and Vasc cath at the same time in same vein for speed. That fine in fem's and IJV that are huge. Its probably ok in subclavians too but might add to the stenosis issue. Anyone doing that? 2 lines in the subclavian same time?
Click to expand...


I appreciate your contribution, but you MUST be anesthesia.
I've never heard the word "Hydrodissect" before.
I don't even know what an "infraclavicular pain catheter" is.
 
Newtwo said:
To all of you who talk about pneumo's, how many infraclav pain catheters do we do? ( and Paravertebrals fwiw but that a diff argument) With those we are literally millimeters from the pleura, way closer than with a subclavian vein target.

From my experience of 25 infra clav blocks (im no pain guy, and defo no expert) - the artery is about 1-2cm cephalad and posterior to the vein. Frequently the vein is pushed anteriorly when i hydrodissect the anterior cord off the subclavian artery (if thats what the artery is called there)

I would challenge everyone here to always dynamically scan when out of plane. You should always be saying to yourself 'needle, no needle', as you advance USS then scan back. It takes a while to get the hang of it, but it such a powerful skill. When you have a hemorrhagic shock bleeding out and your vein target is collapsing with even the slightest pressure you will thank me and save a life at the same time. Plus really reduce risk of a pneumo

I did a couple subclav vasc caths yesterday and it was a good time. im going to keep at them for a while. I went with out of plane, and really had my probe angled to look in under the clavicle as a final target. The vein is much shallower there and bigger too.

So i started obviously needle in view all the time and dynamically scanned until the USS probe was almost anteflexed 45 degrees away from me. That allowed my needle entry angle to be shallow enough that it was almost like doing an anatomical subclavian line. I used the small footprint probe but im not sure that really mattered. Case was regular size 90kg

The only issue i would have with subclavians is can we, should we put multiple lines into the 1 vein at the same time? I like to do my medical triple lumen and Vasc cath at the same time in same vein for speed. That fine in fem's and IJV that are huge. Its probably ok in subclavians too but might add to the stenosis issue. Anyone doing that? 2 lines in the subclavian same time?
Click to expand...
Wat
 
Any of you doing supraclavicular subclavian lines? I seem to do these about once a year. Hit an artery once. Not so wild about them now, but when they work, they're great.
 
MechEDoc said:
Any of you doing supraclavicular subclavian lines? I seem to do these about once a year. Hit an artery once. Not so wild about them now, but when they work, they're great.
Click to expand...

I haven’t done one in ages. I learned blind with finder needle but never got nearly as comfortable with them as blind infraclavicular lines. They look easier to facilitate with US. Are you using US or no? One of my older colleagues swears by them and that’s his go to line.
 
RustedFox said:
Wish I had a PICC service outside of 9a-4:30p, M-F only.

I still do a good bit of central lines (admittedly, they're my favorite procedure... I hate doing LPs for good reason) but I haven't done a subclavian since... hell, I think residency. With US-guided IJs, there's very little reason to go subclavian except in an actively coding patient, in which case... its IO until you get ROSC. If no ROSC, then.... G A M E O V E R.
Click to expand...
I think they do PICCs around the clock at the large referral center. Radiology will even happily do fluoro-guided LPs if it's before 8 or 9 pm.
 
TooMuchResearch said:
I think they do PICCs around the clock at the large referral center. Radiology will even happily do fluoro-guided LPs if it's before 8 or 9 pm.
Click to expand...

Damn, you've got a sweet gig over there. Our PICC team won't set foot in our ED and I think if I called IR for an LP they would laugh and hang up the phone. Actually, they might do the LP but the pt's back would have to look like bloody braille before they would take them back...
 
Honestly if I am putting in a TLC it’s going to be IJ or Femoral. No need for any complication potential especially with US. No need to possibly put in a chest tube.
I’m putting in a line because we need access, the ICU can worry about switching it to a better line. I have a whole department and no time to play in just one room.
 
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Groove said:
Are you guys using US for your femoral lines? The only lines I typically use US for are IJs...
Click to expand...

We are spoiled in that every single resuscitation room in our ED has an ultrasound machine built in, so I often use ultrasound for femoral lines. That said, I'm mostly supervising trainees so if using ultrasound I have them tell me exactly where they would go if the ultrasound machine broke, and then make them put the probe on the spot they chose to see if it would have been correct. That way they get the understanding of how to do it both ways.
 
RPedigo said:
We are spoiled in that every single resuscitation room in our ED has an ultrasound machine built in, so I often use ultrasound for femoral lines. That said, I'm mostly supervising trainees so if using ultrasound I have them tell me exactly where they would go if the ultrasound machine broke, and then make them put the probe on the spot they chose to see if it would have been correct. That way they get the understanding of how to do it both ways.
Click to expand...

Nice! What kind of machines do you have in your resus bays and are they hard mounted somewhere or do you mean each room has a separate mobile US machine that you can wheel around?
 
RPedigo said:
We are spoiled in that every single resuscitation room in our ED has an ultrasound machine built in, so I often use ultrasound for femoral lines. That said, I'm mostly supervising trainees so if using ultrasound I have them tell me exactly where they would go if the ultrasound machine broke, and then make them put the probe on the spot they chose to see if it would have been correct. That way they get the understanding of how to do it both ways.
Click to expand...


US makes a femoral even faster and easier. If the kit is already opened Etc... I can place a femoral TLC with US in less than 3 mins.

They have access, we can resuscitate, no complication. ICU can do the rest upstairs when they have time
 
Groove said:
Nice! What kind of machines do you have in your resus bays and are they hard mounted somewhere or do you mean each room has a separate mobile US machine that you can wheel around?
Click to expand...

I think our county contract is with SonoSite. We have a SonoSite SII mounted on a movable boom arm in each room. We also have a few SonoSite Edge II in each pod as well as some SonoSite X-Porte in each pod as well. The X-Porte is really cool but it is also huge. I use that one for more technical studies, but it would be overkill for line placement I think. Our ultrasounds are all on WiFi and interface with the PACS system so you can wirelessly upload your images to a patient's chart automatically and it can be stored as part of the record, just like a formal radiology-performed ultrasound would be. We upload all our images we use for medical decision making, and every single one is reviewed by our ED ultrasound QI committee and we get feedback on the quality of our scans. This has allowed us to have enough credibility in our bedside ultrasound to allow for people to go to the OR, etc. based on our bedside images.


NYEMMED said:
US makes a femoral even faster and easier. If the kit is already opened Etc... I can place a femoral TLC with US in less than 3 mins.

They have access, we can resuscitate, no complication. ICU can do the rest upstairs when they have time
Click to expand...

Agree; since we have an ultrasound in the room that is always on, it is faster since you get it on the first stick. If your ultrasound machine is in some supply room and not charged, needs to be booted up, etc. then it probably adds a time drag to the placement of the line.
 
RPedigo said:
I think our county contract is with SonoSite. We have a SonoSite SII mounted on a movable boom arm in each room. We also have a few SonoSite Edge II in each pod as well as some SonoSite X-Porte in each pod as well. The X-Porte is really cool but it is also huge. I use that one for more technical studies, but it would be overkill for line placement I think. Our ultrasounds are all on WiFi and interface with the PACS system so you can wirelessly upload your images to a patient's chart automatically and it can be stored as part of the record, just like a formal radiology-performed ultrasound would be. We upload all our images we use for medical decision making, and every single one is reviewed by our ED ultrasound QI committee and we get feedback on the quality of our scans. This has allowed us to have enough credibility in our bedside ultrasound to allow for people to go to the OR, etc. based on our bedside images.




Agree; since we have an ultrasound in the room that is always on, it is faster since you get it on the first stick. If your ultrasound machine is in some supply room and not charged, needs to be booted up, etc. then it probably adds a time drag to the placement of the line.
Click to expand...

That sounds amazing.

I did them blind in residency but never got comfortable doing them. And to be frank, I don’t want to be dicking around learning a new procedure on a crashing patient or IVDU, especially in a place where we don’t have chest tubes in the ED. One day!
 
Groove said:
Damn, you've got a sweet gig over there. Our PICC team won't set foot in our ED and I think if I called IR for an LP they would laugh and hang up the phone. Actually, they might do the LP but the pt's back would have to look like bloody braille before they would take them back...
Click to expand...
It's just our standard radiologists, not IR. I think they're only in the room for about as long as it would take them to read a chest x-ray. We put in all the orders for the CSF, they take the shots and get the CSF.

Maybe the hospital gets paid more if their PICC nurse puts in a line versus the private EM group
 
RustedFox said:
I appreciate your contribution, but you MUST be anesthesia.
I've never heard the word "Hydrodissect" before.
I don't even know what an "infraclavicular pain catheter" is.
Click to expand...
Oops sorry I am. I thought I was in an anesthesia forum!
 
Anyone using axillary vein access for lines?

While I'm not really doing many central lines anymore I have switched to ultrasound guided axillary vein access (with micro puncture needle) as my default for pacemaker/ICD lead insertion. I've used US for Subclavian lines in training though learned to do those blind initially. Axillary easier to visualize on US in my opinion. Can be a small vein in some people and compressible (stick the US probe on next time and look while compressing) so can be tricky but with practice it's very easy.
 
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