Infraclavicular Subclavian Lines

[thegenius]

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That makes me dizzy.

 

[thegenius]

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.

Ahhh....no
You do them once a year, and hit an artery once. LOL I'm not laughing at ya. I just think that's funny. But when they work, they work great!!!
So funny

 

[thegenius]

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.

That's kind of the way I feel about this too...IJ or fem, but the few times I've done a subclavian I always say "I should do this more often."

 

[thegenius]

Are you guys using US for your femoral lines? The only lines I typically use US for are IJs...

I do....anytime I have some time to put a line in I use ultrasound.

I've seen this a number of times: I prep the R fem area. Everything is all set up. Everything is sterile. I try to visualize the vein and the f&@#ker is right underneath the artery...the entire course. it doesn't even come out to take a peak. Doesn't follow standard anatomy. I get all pissed off because I'm not gonna try for that. I've done it before, very carefully and successfully...but it's not worth it. I look at the left fem and other places

 

[thegenius]

I do....anytime I have some time to put a line in I use ultrasound.

I've seen this a number of times: I prep the R fem area. Everything is all set up. Everything is sterile. I try to visualize the vein and the f&@#ker is right underneath the artery...the entire course. it doesn't even come out to take a peak. Doesn't follow standard anatomy. I get all pissed off because I'm not gonna try for that. I've done it before, very carefully and successfully...but it's not worth it. I look at the left fem and other places

I now scan before I prep just to get an idea of how easy it the line might be.

 

[RustedFox]

I now scan before I prep just to get an idea of how easy it the line might be.

Scan before prep every single time.
When I was working with dchristismi, I was going to put an IJ in a gal on like, my second shift.
Scanned right IJ.
Clot.
Scanned left IJ.
Clot.

Okay. Next come the femorals.

 

[thegenius]

Scan before prep every single time.
When I was working with dchristismi, I was going to put an IJ in a gal on like, my second shift.
Scanned right IJ.
Clot.
Scanned left IJ.
Clot.

Okay. Next come the femorals.

jeez that is a PE waiting to happen
Oh wait, I bet she had a PE that's why you puttin in a line.

You sneeze - you go into cardiac arrest

 

[RustedFox]

jeez that is a PE waiting to happen
Oh wait, I bet she had a PE that's why you puttin in a line.

You sneeze - you go into cardiac arrest

She was septic and had like, stage 6 lymphoma.
Was also U.colitis S/P colectomy with high-volume ostomy output.

dchristismi's old shop was truly a level-1 tragedy shop.

 

[MechEDoc]

Ahhh....no
You do them once a year, and hit an artery once. LOL I'm not laughing at ya. I just think that's funny. But when they work, they work great!!!
So funny

Yeah. I don't do them very often for a reason.

Once was putting in an IJ. Something terrible there (can't remember), so I scanned down farther... it looked great -> put the line in.

Next time had a 200 year old crashing patient that should have been DNR years ago (and was going to die in hours, family had not yet accepted it)... what the heck, I'll try again... whoops, artery.

Final time, CPR in process, lower trauma, some head trauma, couldn't thread a subclavian wire -> screw it, moved above the clavicle, instant access.

Basically it's line I use when it's stupid to be putting in a line and my other sites suck, but for some dumb reason, I'm putting in a line.

 

[Groove]

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.

No, though I've thought about it. Every time I've scanned there it seems awfully close to the lung in that lateral position of the vein. It also kind of defeats the purpose of the subclavian for me (not bothered by US and the vein is less prone to collapse in a hypotensive pt). Are you doing out of plane or in plane with the needle?

 

[nlax30]

No, though I've thought about it. Every time I've scanned there it seems awfully close to the lung in that lateral position of the vein. It also kind of defeats the purpose of the subclavian for me (not bothered by US and the vein is less prone to collapse in a hypotensive pt). Are you doing out of plane or in plane with the needle?

Out of plane and then dynamically adjust the probe to watch the tip. Nice thing is I can see the vein, artery and pleural/lung in one view here so as long as you are visualizing the tip and know what angle you’re going in at can avoid the lung. Probably not the most effective approach for a bone dry crashing patient but otherwise I think a nice approach.

 

[Fox800]

No, though I've thought about it. Every time I've scanned there it seems awfully close to the lung in that lateral position of the vein. It also kind of defeats the purpose of the subclavian for me (not bothered by US and the vein is less prone to collapse in a hypotensive pt). Are you doing out of plane or in plane with the needle?

I do in-plane. Easy enough to visualize and you can see the lung at the same time.

 

[thegenius]

Does in-plane and out-of-plane refer to how you orient the probe on the skin?

If so....I’m not used to hearing it that way. I always reference it as axial view vs longitudinal view, especially when referencing a vessel.

I always like longitudinal views when they can be accommodated

 

[nlax30]

I was going by in-plane meaning needle enters skin at US probe site ("in plane" to the beam) vs out of plane were you enter little bit back from the probe site and the needle tip then intersects the US beam further along the path.

 

[Fox800]

I was going by in-plane meaning needle enters skin at US probe site ("in plane" to the beam) vs out of plane were you enter little bit back from the probe site and the needle tip then intersects the US beam further along the path.

Correct.

In plane aka long axis aka longitudinal.

Out of plane aka short axis aka axial.

 

[suckstobeme]

For those that do the Axillary insertion with US, how many cm are you inserting the catheter?

 

[Apollyon]

What's up with the boldface?

 

[thegenius]

I don’t know man. Suckstobehim though

 

[suckstobeme]

What's up with the boldface?

Sorry, didn't realize I was doing boldface. I used my phone to respond, which I generally never do. My bad.

 

[thegenius]

Word.