Landmarks for blind central line

[codeb1ue]

---

Members do not see this ad.

I am currently on cardiac anesthesia where we do all/most of our central lines by landmark and confirm wire with TEE. What are your tried and true methods for this technique? I have been getting different advice from nearly every attending i work with. Some say palpate the carotid artery and go immediately lateral to it, some go by the books and palpate sternal head of SCM and go medial to that. The one that has been working for me is to go along the level of thyroid cartilage, look for EJ and go one fingerbreath medial to it.

I wanted to get a broader sense of what other folks do for IJ landmarks.

 

[psychbender]

I go just lateral to the carotid, minimal medial/lateral angulation. The only times I hit the carotid were when I did not get it in my initial pass, and decided to angle medial to hunt with the finder. Usually, that works just fine, and you can get vein. Instead of changing the angle, come out, and re-enter a few millimeters medial, with no medial/lateral angulation. When you are inserting the line, are you standing at the head of the bed, or at the patient's left shoulder (so attending is at the head of the bed doing the TEE)? Perception of control and how you are angling the needle is different from those two points of view.

 

[IlDestriero]

Why are you doing blind IJs? I learned that way 20 years ago. 10 years ago US guided lines were taking hold. I'd never go back. Never.
Ultrasound is faster as well.
See vein, place line, done.👍
No palpating, pondering, angle calculations, body English, prayer, finger crossing, blind probing, etc. See vein, place catheter. You know how often you hit the carotid with the ultrasound technique? Never.
Landmarks is a great technique to learn. Maybe it will come in handy after the apocalypse, or on a mission trip to Tibet, but it's routine use in 2013 is silly. I'd be concerned if you wanted to give me an IJ without US guidance, and if you told me that you were better without it I'd be even more concerned and wonder what other things you didn't keep up with over the last decade or so.

 

[BobBarker]

Palpate the carotid with your left hand. Provide medial traction, about 1cm worth and stick where your fingertips were initially.

 

[WholeLottaGame7]

Why are you doing blind IJs? I learned that way 20 years ago. 10 years ago US guided lines were taking hold. I'd never go back. Never.
Ultrasound is faster as well.
See vein, place line, done.👍
No palpating, pondering, angle calculations, body English, prayer, finger crossing, blind probing, etc. See vein, place catheter. You know how often you hit the carotid with the ultrasound technique? Never.
Landmarks is a great technique to learn. Maybe it will come in handy after the apocalypse, or on a mission trip to Tibet, but it's routine use in 2013 is silly. I'd be concerned if you wanted to give me an IJ without US guidance, and if you told me that you were better without it I'd be even more concerned and wonder what other things you didn't keep up with over the last decade or so.

You can still hit the carotid with ultrasound, especially if you have one of those carotids that dives directly behind the IJ. For that reason I still use the low-pressure tubing check, follow the wire all the down with the ultrasound probe, etc.

 

[codeb1ue]

Why are you doing blind IJs? I learned that way 20 years ago. 10 years ago US guided lines were taking hold. I'd never go back. Never.
Ultrasound is faster as well.
See vein, place line, done.👍
No palpating, pondering, angle calculations, body English, prayer, finger crossing, blind probing, etc. See vein, place catheter. You know how often you hit the carotid with the ultrasound technique? Never.
Landmarks is a great technique to learn. Maybe it will come in handy after the apocalypse, or on a mission trip to Tibet, but it's routine use in 2013 is silly. I'd be concerned if you wanted to give me an IJ without US guidance, and if you told me that you were better without it I'd be even more concerned and wonder what other things you didn't keep up with over the last decade or so.

I know what you mean. I have been a resident for 5 years now (did a prior residency in diff specialty) and have done plenty of central line placements, ALL with u/s guidance only. In fact, when I started this current rotation and did my first non u/s guided technique, I actually had no idea how to use a finder needle and my attending was appalled that I had never touched one before. I told him why would I need one if there's an u/s showing me exactly where the vein is.

Having said that, I am very happy to finally have a sense of how to do these without u/s-guidance. I've been in a few general cases in the OR now where the patient began crashing unexpectedly and we had to place a central line quickly and were unable to get an u/s machine quick enough into the OR. Both times a very experienced attending just quickly threw one in without an u/s. I was very impressed and a bit concerned that I would never be able to do that (at least not prior to this month). Anyways just my 2 cent.

 

[Bostonredsox]

You can still hit the carotid with ultrasound, especially if you have one of those carotids that dives directly behind the IJ. For that reason I still use the low-pressure tubing check, follow the wire all the down with the ultrasound probe, etc.

I see people do this frequently when they have the head turned to the side and the probe angled laterally so that the image has the Ij above the carotid. 9/10 this is fixed by rotating the probe counter clockwise till it is straight up and down, perpendicular to the neck. the greater majority of the time, the carotid will now be beside the IJ, not under it. Very rarely am I not able to manipulate the neck and/or probe to get the vessels side by side and not on top of each other.

But I agree with Destr. IJs, and to be honest even subclavs, should always be placed with US if your facility has one. it is the standard of care. I also agree on time for the neck lines. The time it takes me to palpate the carotid, pull it medially, stick the 22 where i think the vein is, manipulate it a bit till I hit the vein, then stick the 18 behind it, can be several minutes. It literally takes me <30 sec to sleeve the US, short axis view, stick, wire, confirm wire, done. Blind actually takes longer on top of added risk. would never do one at this point unless as I said, no US available, and then I would still most likely stick the chest. Purely because I can fix a dropped lung. If I blow up a caoritd, well I have to make a phone call now.

Now, if your place insists on doing them this way, I use Bbarkers strat. for a right IJ, I am right handed, palpate carotid about 1/3 of the way up the neck, where there is the greatest % chance of the IJ being directly lateral, then tug the carotid medially, and stick the finder needle where I had originally felt the carotid pulse.

edit: I forget you guys are doing most of them under the drapes urgently so the chest isnt an option. In that case If there isnt an US right next to you I would go about it as I described.

 

[fakin' the funk]

Yeesh. Honestly. If you have a TEE in the room you can also do high-quality surface U/S. But that's the not the question you asked.

Head 45 degrees contralateral, insert 22g finder needle at apex of triangle joining the sternal and clavicular heads of the SCM, parallel to the clavicular head, towards ipsilateral nipple in coronal plane and 30 degrees posterior in sagittal plane. Upon flash of venous blood, leave the 22g finder and syringe right there and follow up with 20g angiocath/syringe setup, do low-pressure tubing/manometry test, then proceed with wire etc as usual.

For all you using ultrasound for the majority of your lines, you can still learn landmarks. It takes 2 seconds each time you use ultrasound to correlate with your landmarks. And this way, you learn both techniques. One of the major pitfalls of U/S, whether for lines or blocks, is NOT knowing your anatomy and landmarks, just going fishing, and getting lost.

 

[jwk]

Head 45 degrees contralateral, insert 22g finder needle at apex of triangle joining the sternal and clavicular heads of the SCM, parallel to the clavicular head, towards ipsilateral nipple in coronal plane and 30 degrees posterior in sagittal plane. Upon flash of venous blood, leave the 22g finder and syringe right there and follow up with 20g angiocath/syringe setup, do low-pressure tubing/manometry test, then proceed with wire etc as usual.

For all you using ultrasound for the majority of your lines, you can still learn landmarks. It takes 2 seconds each time you use ultrasound to correlate with your landmarks. And this way, you learn both techniques. One of the major pitfalls of U/S, whether for lines or blocks, is NOT knowing your anatomy and landmarks, just going fishing, and getting lost.

This is pretty much the way I've done IJ's for almost 35 years. Never dropped a lung, never stuck the introducer in big red, rarely stick anything bigger than the finder needle in the carotid. The folks that I've seen get in trouble are the ones that rush things and skip steps along the way. I realize it's pretty much becoming standard of care to use U/S, but there are times when it's just not possible for one reason or another and those of us who have done it the old-fashioned way will have a leg up on those who haven't. IMHO, those who haven't learned to do it using anatomical landmarks and are comfortable with it are frequently the same ones who prefer using a GlideScope for routine intubations on every patient.

 

[B-Bone]

what about this old chestnut? left hand flat with pinkie in sternal notch. IJ insertion 1 cm lateral/superior to index finger tip. I have actually had more luck with this than any other landmark based approach.

 

[Mman]

But I agree with Destr. IJs, and to be honest even subclavs, should always be placed with US if your facility has one. it is the standard of care.

While I believe it is kinda/sorta/almost standard of care for IJs, I don't think it has quite reached that legal standard yet. I strongly believe it will never be standard of care for a subclavian as imaging is just not straightforward enough. To do it you either aren't watching the needle continually advance into the vein or you aren't sticking the subclavian vein and are essentially doing an axillary line.



As to the topic I essentially never do IJs without U/S. But having done a bunch with U/S I'm thinking the next one I do without I'm just going to essentially visualize what it almost always looks like with the U/S. I'll palpate the carotid at the level of the cricoid cartilage with head turned about 30 degrees to the side and start just a tiny bit lateral to that aiming for ipsilateral nipple. The IJ is almost always either just lateral or slightly overlying the carotid at that level.

 

[excalibur]

1) apex of sternal and clavicular head of SCM and aim to ipsilateral nipple
2) Palpate carotid and one cm lateral
3) Make a line between mastoid process and suprasternal notch and divide in thirds. Going from mastoid to suprasternal notch, the needle entry point is where the "second" third meets the "third" third

This is almost impossible in the super fat neck patients. I was trying to cut and paste a pic of a classic fat neck...couldn't quite do it. Anyway in the super fat necks, you are likely guessing. So I just go to...

4) Ultrasound

 

[cchoukal]

All feelings about blind IJs aside, how do people feel about doing the TEE at the same time as the "maximal sterile barrier" IJ procedure? No one thinks the sterile field is disrupted and oral flora could contaminate the line?

 

[WholeLottaGame7]

I see people do this frequently when they have the head turned to the side and the probe angled laterally so that the image has the Ij above the carotid. 9/10 this is fixed by rotating the probe counter clockwise till it is straight up and down, perpendicular to the neck. the greater majority of the time, the carotid will now be beside the IJ, not under it. Very rarely am I not able to manipulate the neck and/or probe to get the vessels side by side and not on top of each other.

I think I'm not understanding what you're saying. Rotating the probe just changes the axis from short to long, it doesn't change the relationship of the IJ to the carotid.

I will move the probe caudad/cephalad to find the point with maximal lateral separation to minimize the chances of going deep and hitting big red (in addition to the other tips like angling ipsilaterally, etc).

To cchoukal, at our institution the TEE fellow will routinely drop the probe while I'm setting up for the central line so that it's under the drape and they can start the exam as soon as I'm done with the probe. No one seems concerned about it. Otherwise they wait til we're through. Maybe a lot of excessive manipulation of the neck/chin/oropharynx in the middle of the line placement would stir some stuff up? But minor adjustments of an already placed probe are surely of little consequence.

 

[G0S2]

Badass CT trained faculty taught me this:

Minimal or no change in head position. Palpate carotid and use finder to aim directly at pulse. When through skin, adjust angle 30-45 deg and advance lateral to pulse. BOOM. IJ. Now flatten out finder more lateral while still being able to aspirate. Place STEEL needle over finder. Not the cath needle. BOOM. I didn't trust this approach at first but works every time.

 

[jwk]

Badass CT trained faculty taught me this:

Minimal or no change in head position. Palpate carotid and use finder to aim directly at pulse. When through skin, adjust angle 30-45 deg and advance lateral to pulse. BOOM. IJ. Now flatten out finder more lateral while still being able to aspirate. Place STEEL needle over finder. Not the cath needle. BOOM. I didn't trust this approach at first but works every time.

🙄 Nothing works EVERY time - if it did, there would be no reason whatsoever to use U/S.

I've always used the catheter, not the steel needle. Just the way I was taught by really old bad-ass CT attending (writes cardiac anesthesia textbooks 😉 ). Theoretically, pulling the guidewire back through the needle has the potential for shearing off the wire.

 

[G0S2]

Catheters suck. Especially from double lumen kit.

Take a guide wire and try to cut it with steel needle. Very rare.

Had Ninja attending who would "find" the IJ with the steel needle.

Ok, not every time but is the way I do it now with 100% success thus far. If the pt is huge; sure, US.

 

[Bostonredsox]

I think I'm not understanding what you're saying. Rotating the probe just changes the axis from short to long, it doesn't change the relationship of the IJ to the carotid.

I will move the probe caudad/cephalad to find the point with maximal lateral separation to minimize the chances of going deep and hitting big red (in addition to the other tips like angling ipsilaterally, etc).

To cchoukal, at our institution the TEE fellow will routinely drop the probe while I'm setting up for the central line so that it's under the drape and they can start the exam as soon as I'm done with the probe. No one seems concerned about it. Otherwise they wait til we're through. Maybe a lot of excessive manipulation of the neck/chin/oropharynx in the middle of the line placement would stir some stuff up? But minor adjustments of an already placed probe are surely of little consequence.

You are misunderstanding me. Not rotating it in your hand and thus changing axis, rotating it upwards, towards the ceiling, on the pivot point of its contact point on the neck. It's hard to describe without a picture. But imaging your holding probe on the neck and it is pointing out of your hand northeast, as in the upper end of the probe and the connecting cable is pointing NE out of the top of your hand, you are obviously on the right side of the neck. If you rotate your hand so you are taking more of a lateral image, the end of the probe is eastward, you will in essence be shooting a picture through the lateral neck, through the IJ, through the carotid and towards the spine. The images will be on top of each other as your "beam" for lack of better terms and yes I know its not an X-ray, is aiming laterally.

Now.

Rotate your hand so the probe is now straight up and down. The end of probe/cable is straight northwards. You are now perpendicular to the bed, not the neck. Now you are looking almost from an anterior approach not a lateral one and the vessels will appear side by side. You can do this in a back and forth motion, rotate in your pivot point till probe is horizontal then vertical. You will be ale to see the jugular move from a nearly over-top image to side by side image. Then you stick straight downward and you enter jugular. As the carotid is not under, it is now medial on the screen, if you miss deep, you will not have a carotid puncture.

 

[Bostonredsox]

This obviously now Cary's the risk of puncturing the posterior wall of the IJ, which for one is not a big of a clearing risk as puncturing big red, and two, is avoidable by altering the approach from a 90 degree stick to more of a 30-40 degree stick. If the IJ is under filled and small, collapsing with inspiration, sticking at a 90 degree angle is more difficult. That is when I modify the angle to make it flatter more like you would for a blind anatomical stick. But in general I hold the probe straight up and down with the head turned to the side as much as possible. I then pan cephalad/caudal for best spot and I nearly always have An image with side by side vessels. Sticking with This image As your guide yields the least possible chance of a carotid puncture IMO.

Obviously this technique cannot be done without US.

 

[WholeLottaGame7]

You are misunderstanding me. Not rotating it in your hand and thus changing axis, rotating it upwards, towards the ceiling, on the pivot point of its contact point on the neck. It's hard to describe without a picture. But imaging your holding probe on the neck and it is pointing out of your hand northeast, as in the upper end of the probe and the connecting cable is pointing NE out of the top of your hand, you are obviously on the right side of the neck. If you rotate your hand so you are taking more of a lateral image, the end of the probe is eastward, you will in essence be shooting a picture through the lateral neck, through the IJ, through the carotid and towards the spine. The images will be on top of each other as your "beam" for lack of better terms and yes I know its not an X-ray, is aiming laterally.

Now.

Rotate your hand so the probe is now straight up and down. The end of probe/cable is straight northwards. You are now perpendicular to the bed, not the neck. Now you are looking almost from an anterior approach not a lateral one and the vessels will appear side by side. You can do this in a back and forth motion, rotate in your pivot point till probe is horizontal then vertical. You will be ale to see the jugular move from a nearly over-top image to side by side image. Then you stick straight downward and you enter jugular. As the carotid is not under, it is now medial on the screen, if you miss deep, you will not have a carotid puncture.

OK, I think I'm visualizing more what you are describing. You're on the side of the neck pointing the probe medially to get a side-by-side image of the IJ and carotid. But you're still not changing the actual relationship between IJ and carotid, and if you come straight down with the needle you're just changing where the needle is going to enter the screen. It's like an in-plane short-axis view. If you go too deep, you'd still hit the carotid but as long as you keep the needle in plane you could theoretically control the depth better.

Correct me if I'm wrong on how I'm interpreting this.

How would it work as far as threading the catheter off or a wire in if you're at 90deg to the skin? Seems like it would be trickier. I've done plenty of central lines and haven't had a ton of difficulty so far, but I'm always curious and willing to consider new things if they seem reasonable. Also, wouldn't just doing the procedure in long-axis view to keep the needle in plane accomplish the same thing without requiring the funky angles?

 

[Bostonredsox]

OK, I think I'm visualizing more what you are describing. You're on the side of the neck pointing the probe medially to get a side-by-side image of the IJ and carotid. But you're still not changing the actual relationship between IJ and carotid, and if you come straight down with the needle you're just changing where the needle is going to enter the screen. It's like an in-plane short-axis view. If you go too deep, you'd still hit the carotid but as long as you keep the needle in plane you could theoretically control the depth better.

Correct me if I'm wrong on how I'm interpreting this.
How would it work as far as threading the catheter off or a wire in if you're at 90deg to the skin? Seems like it would be trickier. I've done plenty of central lines and haven't had a ton of difficulty so far, but I'm always curious and willing to consider new things if they seem reasonable. Also, wouldn't just doing the procedure in long-axis view to keep the needle in plane accomplish the same thing without requiring the funky angles?

No your not visualizing what I'm saying. Bah it's tough to describe this. Imagine you are putting the probe on the anterior part of the neck. Almost right over thyroid. Now slide the whole probe a bit to the right, but keep it completely vertical. Now rotate the head away from the probe. You are shooting an AP image, like a femoral line. The vessels are side by side . It's exactly like sticking the probe over the groin straight up and down. The vessels are side by side not over top of each other. You only get this image by holding the probe straight up and down and shooting in an AP fashion. Ten you see your needle coming in straight down into the jugular, with the carotid medial to your stick on the screen.

Now, you are correct on threading the wire. Once you are in, you have to drop your angle down tonormal 15 degrees or so, twist of the syringe and the. Feed your wire. I do this in one motion, but it. Takes feel to get used to. Commonly, people get the stick, fill the syringe, then while trying to lower and twist off they push a little deep or pull back and are out of the vessel. It's takes a certain feel to stay in the vessel.

For me, turn head away as much as possible. Image AP, straight up and down, get nearly side by side Image, I stick low, generally more of a common jugular line.as it is where the vessel is the largest, I stick 90 degrees to the skin unless the vessel is under filled and collapsing, get blood, drop probe, with two hands hands, lower the needle from 90 to 15 and draw back ensuring I'm still intraluminal at the sametime, twist off syringe, throw In wire

 

[TrustMe]

I find it interesting that some people want TEE to confirm wire but won't use U/S for placement. Doesn't make sense.

I feel like CT cases are the most important to use U/S. Hit carotid or make several passes through IJ and then give 30,000 units of heparin?? Sounds like a bad idea. When I was a resident we got a new cardiac attending that insisted on doing lines blind. Have seen some ridiculous neck hematomas after him walking junior resident through blind IJ and then give 30,000 units of heparin.

 

[psychbender]

I find it interesting that some people want TEE to confirm wire but won't use U/S for placement. Doesn't make sense.

I feel like CT cases are the most important to use U/S. Hit carotid or make several passes through IJ and then give 30,000 units of heparin?? Sounds like a bad idea. When I was a resident we got a new cardiac attending that insisted on doing lines blind. Have seen some ridiculous neck hematomas after him walking junior resident through blind IJ and then give 30,000 units of heparin.

I was doing a CT elective at one of our affiliated hospitals, and none of the CT guys used real-time ultrasound, most just looked for wire with the TEE. They also did a different technique with putting a micropuncture wire through the finder, then threading the angiocath, followed by the regular wire, then introducer placement as usual. Their rationale was that they never had a large needle in the neck, so risk of major vessel damage was lower. The only times we used ultrasound were either when neither the attending nor I could find the IJ with landmark techniques, or when they wanted practice on how to place lines with ultrasound (also pulled it out for a few difficult a-lines, since none of them place a-lines with ultrasound, either). After three months there, I have done more lines with their technique than with ultrasound, but I feel more comfortable doing them under live U/S.