Line Access and Infection: clinical question

[Maverikk]

We had a case where a patient no access for an EGD, an attending said go ahead with a central line for the time of EGD (high risk patient). Internal medicine flipped out. I'm a first year resident, I always thought that prolonged central access increased infection but the case has made me question my assumptions. What's the difference between 2 18G in the antecubital v. central for short term? By central I mean IJ, I can see why femoral are more high risk. Thanks for any help by those more knowledgeable!

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[Bostonredsox]

Wtf cares. I've put lines in pts just so they can get a ct chest to rule out the PE I am pretty sure they dont have. If a pt needs access for one reason or the other and you cannot obtain peripheral access despite multiple try's by experienced personnel, which on a floor pt includes an US guided attempt by me, put a line in them. A conventional answer is a picc. But unless your expecting a need for long term access, I wouldn't subject them to the higher risk for DVT picc. Just throw an IJ in and dc it as soon as you can. This is of course in a pt who really needs that access. If you can't sedate them otherwise for a procedure they need and you really can't get peripheral access, do it. We have a lot of sick fatty bad diabetic ESRD pts who you can't get an 18 in for a CTA and we don't do v/q's at night. They get a line.

I know your question was about infection risk. But my answer is its irrelevant in the scenario you provided.

 

[bigdan]

OP -

Regarding infection and CVC, I think most agree that IJ and subclav vein are both less infection risk than femoral, and most important is probably getting the central access out as soon as possible.

I second Boston's mention of taking a look for a peripheral IV yourself. In both of the health systems I've worked in, the IV team was forbidden to place IVs in the lower ext or in the EJ, so things would unfold as follows: beside RN: "I can't get an IV, so I called IV team", then IV team says "...I even tried my favorite special vein, and couldn't even get a 22". And you, as the intern, are too slammed to go check things on your own. But if you have minute, put the pt in T-berg and see if an EJ pops up, or if you can see the EJ on US. Or, throw a tourniquet on mid-calf level, and let the pt's leg hang off the bed, then look at the medial ankle with or without US for a saphenous vein.