misplaced central line

[Kazu]

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Someone placed a central line in the subclavian artery by accident today. Why does that matter. If it doesnt make a big hematoma or start hemoraging...whats the problem. Also how do you know its in the vein and not the artery?

 

[Furpal]

Certainly no expert in subclavian lines at this point but I can offer coments and hopefully someone will point out any errors or admissions.

I like the transduction method of telling artery vs vein. Once you have found blood (if it squirts out like at interveals its probably the artery) but if youre not sure take some tubing and attach it to your needle and allow blood to fill 2/3rds of the tubing. Raise the tubing perpendicular to the patient--if the column continues to rise-artery. If it starts to come down then it is vein.

As far as artery vs vein you want drugs etc going to the heart to be dispersed and not headed out to the hand. Plus, especially subclavian like you are more likely to form a hematoma and that is the hardest of the line places to be able to apply pressure.

That's my understanding.

Feel free to add/edit.

As always, take knowledge from a message board with a grain of salt.

 

[jashanley]

If you aren't sure you can always send an ABG.

In general, the color of blood and the pressure are different. If its bright red and spurts = bad. Dark red blood and non-pulsatile = good.

Subclavian artery may not show a visible hematoma and one cannot place pressure on the bleeder properly (or at all).

Remember, what you place, eventually you must take out as the patient improves and the catheter leaves a pretty big hole.
Bleeding post removal might be a problem.

 

[droliver]

The column test described by Furpal, while usually OK, will fool you at the bedside occassionally. Elevated CVP will make the column keep rising. You can get what looks like pulsatile flow in the artery or vein sometimes (and vice versa with nonpulsatile flow). Arterial blood, usually a bright red, can look like venous to the naked eye & fool you.

Really the only fool-proof ways to tell are:
1. an ABG (and even this could be confusing in someone profoundly hypoxic/acidotic)
2. an arterial waveform (ACVYX) if you hook it up to a monitor
3. an arteriogram thru the catheter

What you worry about if you don't get immeadiate complications from an arterial central line (or worse case scenario is one of the monster hemodialysis catheters).
1. acute thrombosis of the subclavian or femoral artery which can knock off an extremity.
2. When carotid sticks you can stroke from thrombosis, emboli, or dislodged atheroma. Also mainlining some vasoactive drugs into the cerebral circulation is pretty bad kharma
3. you have to worry about bleeding post-removal from the arteriotomy
4. pseudoaneurysm formation requiring surgery or catheter based tx.

 

[Sachin]

We had a similar situation.. they transduced the pressure too and figured that it was a bad transducer.. the artery thrombosed and clots floated north.. not good.. I don't recall how long the catheter had been in - not long though..

Sachin

 

[Andrew_Doan]

Originally posted by Kazu
Someone placed a central line in the subclavian artery by accident today. Why does that matter. If it doesnt make a big hematoma or start hemoraging...whats the problem. Also how do you know its in the vein and not the artery?

Emboli, stroke, and death. A subclavian art line is not a good thing to have.

 

[Kalel]

Originally posted by Kazu
Someone placed a central line in the subclavian artery by accident today. Why does that matter. If it doesnt make a big hematoma or start hemoraging...whats the problem. Also how do you know its in the vein and not the artery?

Unfortunately, an intern doing this (actually hit the carotid with an IJ line) caused a medical malpractice suit at JHU Bayview. Makes it scary to think about graduating.

 

[Kazu]

people have mentioned clot being an issue. How is that more of an issue when its a missplaced central line. With the line in the vein you get a PE, with the line in the artery you get limb loss or stroke. And i thought veins form clots easier than arteries, so I would actually expect clot to be less of an issue with a missplaced line.

 

[Docxter]

Originally posted by Kazu
people have mentioned clot being an issue. How is that more of an issue when its a missplaced central line. With the line in the vein you get a PE, with the line in the artery you get limb loss or stroke. And i thought veins form clots easier than arteries, so I would actually expect clot to be less of an issue with a missplaced line.

We all form clots and throw tiny PEs all the time. One of the natural functions of the lungs is to trap small clots and prevent them from entering the arterial system. The brain doesn't have this luxury and most clots embolizing to the brain will cause infarctions of varying sizes. The lungs are much much more resilient to emboli than the brain (or distal extremities for that matter).

Foreign bodies in the arterial system is a big deal. Even when cardiologists and radiologists have a catheter traversing the aortic arch and the procedure requires to have the catheter in place for a little while, almost all patients will get some form of intraprocedural anticoagulation (usually heparin), just to prevent thromboemboli.

 

[fourthyear]

Kazu, you're talking clot, like blood clot. But what I think people are meaning when they talk of the danger of "throwing clot" from the carotid, they mean athlosclerotic plaque. These plaques are all over the arteries of older patients, but don't tend to build up on veins. So you can dislodge an old plaque that's been there for years and send it straight to the brain if you're poking into the carotid.

 

[jashanley]

No, they mean clot as is blood clot. Anytime you place a line in a vessel you have the potential to create turbulence i.e. loss of laminar flow. This leads to stasis and clot formation. Clot = badness, especially in an artery.

Another complication of subclavian lines are stricture of the vessel. There is an increased incidence in subclavian compared with IJ's and femorals.

 

[DoctorDoom]

Insertion of any potential infectious nidus such as an indwelling catheter into an artery is also more dangerous than in a vein, when one considers potential long term complications of central line placement.

Did one of your residents do this Kazu? what did they say when you asked them your original question?

 

[Kazu]

One of the residents did this. they said that there could be problems if certain things were injected into the line, like tpn. I think that doesn't make sense. h also said that there was a risk of clot, but didn't know more than that. he also said that it was bad spot if there was bleed because subclavian is difficult to compress. how is infection more of a problem in the artery than the vein?

 

[droliver]

Originally posted by Kazu
how is infection more of a problem in the artery than the vein?

It's usually less of a concern somewhat secondary to the higher Pa02 which tends to ****** establishing an infection. However, do not (as anesthesiologists love to do) take that to mean that you do not need to use sterile technique for arterial sticks & a-line placement. I've probably had to take care of 4-5 horrible radial artery a-line site infections which I'd attribute to contamination during placement.

 

[The_Id]

Originally posted by Kazu
One of the residents did this. they said that there could be problems if certain things were injected into the line, like tpn. I think that doesn't make sense. h also said that there was a risk of clot, but didn't know more than that. he also said that it was bad spot if there was bleed because subclavian is difficult to compress. how is infection more of a problem in the artery than the vein?

The main reason for a central line is for access for IV's, meds, TPN, etc. These are all delivered under low pressure (oftentimes merely gravity). As you know, fluids flow from higher pressure to lower pressure. Thus, the central line must be placed into a low-pressure vessel, i.e. a vein. If it is placed in an artery, and hooked up to an IV or anything else, blood will flow retrograde into the tubing and IV bag, with no fluids or meds or whatever being delivered at all. This is THE main reason to not place it into an artery. The issue of hemorrhage and difficulty in applying pressure is the biggest potential complication when comparing placement into an artery versus a vein. There is probably not much more risk of infection or clotting when comparing line placement in an artery versus vein. After all, there are a-lines and dialysis catheters which involve arteries, but always in a compressible location.

 

[RuralMedicine]

Originally posted by droliver
It's usually less of a concern somewhat secondary to the higher Pa02 which tends to ****** establishing an infection. However, do not (as anesthesiologists love to do) take that to mean that you do not need to use sterile technique for arterial sticks & a-line placement. I've probably had to take care of 4-5 horrible radial artery a-line site infections which I'd attribute to contamination during placement.

Yes, our anesthesiologists adopt the sterile schmerile philosophy with arterial lines as well. For this reason our intensivists require us to change the arterial line to a new site or remove it when the patient reaches the ICU after surgery. Obviously this is better than dealing with the infections down the road but wouldn't it just make sense to place these lines in sterile fashion?

 

[RuralMedicine]

Kazu,

Am I correct in infering that your residents opted to leave the Subclavian A-line in and try to use it? Personally I'm not a big Subclavian fan because of it being a difficult to compress vessel and the sclerosis risks but there are times when the IJ is not an option (all my not happy trauma patients in cervical collars for one) so in that case Subclavian it is. I was always taught that the key was not dilating the artery and if ever in doubt you should send an ABG and look at the transducer waveform before you dilate and thread the catheter. I've done this a few times and while it sometimes annoys the nurses it's better than the other alternative. I was fortunate and both the ABG and transducer waveforms appeared venous. Of course I was also taught that if you do place a Subclavian A-line you need to ask Vascular Surgey or IR to remove the catheter for you. I'm hoping to not have that experience. (Yes, I know it just means I haven't done enough lines--my goal is to end my career with just one less than whatever that magical number of enough lines is)

 

[droliver]

Originally posted by RuralMedicine
Of course I was also taught that if you do place a Subclavian A-line you need to ask Vascular Surgey or IR to remove the catheter for you.

The only time we really got antsy was when they were anti-coagulated, on anti-platelet tx., thrombocytopenic, or coagulopathic. Otherwise you just pull it & see what happens.

 

[Tenesma]

agreed that the sterile technique for arterial access is not very sterile in the OR - however, i don't think that practice is going to change much until literature shows that arterial lines are prone to infection or if the CDC starts recommending it. i think it is a bit of overkill to place a new arterial line for every patient coming back from the OR (especially since most post-op patients tend not to have an a-line in for more than 3-5 days)...

while i have seen my share of purulent appearing a-lines, i never noticed a correlation between that and systemic infection... i will have to look at the literature

 

[droliver]

Originally posted by Tenesma
while i have seen my share of purulent appearing a-lines, i never noticed a correlation between that and systemic infection... i will have to look at the literature

Any infected prosthetic device will cause at least a transient septic response if you leave it in. I've not seen MSOF from an infected a-line per se, but I have seen several cases of bad necrotizing fascitis of the volar forearm and infected radial artery pseudoaneurysms

 

[Tenesma]

droliver --- i hate to one-up you on this, but i saw a cerebral abscess in a patient who had a brachial a-line - and it was felt that not only did it get colonized, but vegetations were shot to the brain with every flush... yikes...

the interesting thing is that in the OR we do a full sterile prep for any a-line that we expect to be in the patient longer than usual... for example all long arterial catheters are placed under sterile conditions.... whereas when it is just a short 20g or 18g catheter that is going to be there for 2-3 days then it gets the same attention a peripheral IV gets...

 

[girlwithaknife]

Certain solutions like TPN and vasoactive medications cannot or should not be injected into an artery, because they will not dilute sufficiently before they reach the small vessels. A central venous line is required before TPN can be used, because it will stricture or sclerose small peripheral vessels if injected into a peripheral IV, and I would imagine it would do the same to the small arteries. The purpose of using a central line is to dilute the TPN or whatever with venous return from the rest of the body and allow the heart to distribute the amount you injected somewhat evenly throughout the body. If you inject anything vasoconstrictive or vaso-toxic into, say, the subclavian artery, you could take out that arm. Somewhere in the ED forum, there is a funny story of a junkie who injected meth into his radial artery and lost his hand. Imagine injecting vasopressors into someone's subclavian artery...

 

[LaCirujana]

One of the pt's in the TICU here somehow had a dialysis catheter put in the subclavian artery by a resident (not going to say what specialty he/she was in). Vascular surgery had to fix that one. The thoracic surgery attending was uh, less than thrilled w/that particular resident.

 

[droliver]

Originally posted by Tenesma
droliver --- i hate to one-up you on this, but i saw a cerebral abscess in a patient who had a brachial a-line - and it was felt that not only did it get colonized, but vegetations were shot to the brain with every flush... yikes...

I added the "per se" to my comment before to imply that I assumed you could get things like that 🙂 . I'm a little curious though as to how exactly you'd a cerebral abscess de novo from a brachial line. Whatever you flush is going to get pushed retrograde from the arterial pressure head its facing right back down the arm unless you were using one of those power injectors to overcome systolic pressure in a sustained fashion. The only way I could see that happen is if the tip of your a-line was long enough to get past (or a least right @ the takeoff of) the carotid or vertebral arteries. The brachial catheters I've seen would never approach that length (even with the femoral a-lines catheter if you used that in the arm).

I would guess that perhaps you patient ended up getting subclinical endocarditis (fairly common with vascular catheter infections) first then showed it from there to the brain

 

[Tenesma]

i agree with the endocarditis bit... (even though the TEE was negative - and so were the blood cultures ! - but that doesn't mean squat - so i agree with possible subclinical endocarditis)... the pressure on the transducer bags is about 300mm Hg (primarily so that blood doesn't end in the transducer tubing), so if the flush is held for more than a few seconds then it is entirely possible for backflow to the head to occur... in fact in the brachial artery literature there are reports of strokes because of prolonged flushing, but also because of bubbles in the a-line tubing .... so we have been using shorter and shorter brachial lines, but also with clear instructions on proper flushing...

 

[droliver]

Originally posted by Tenesma
so we have been using shorter and shorter brachial lines, but also with clear instructions on proper flushing...

Interesting. Yeah, the brachial catheters (on the very rare occasion I've seen them used @ all) I've seen placed were very short. What would proper flushing instructions be? (limiting duration?).

 

[Tenesma]

well i think the flushing thing is a nursing issue: but there is no reason to hold the flush wide open to clear the transducer tubing... instead a better technique is to use a syringe (with no bubbles in the pathway) to clear blood proximal to stopcock and then gently infuse a limited amount distal to the stopcock... too much flushing is usually a problem when nursing uses a stopcock far from the patient because that increases flushed volume....

cleveland clinic did a huge study 1200 pts, and Howard University did 2120 pts looking at brachial artery complications and the more common things they see are median nerve complications, pseudoaneurysms - and not as many ischemic forearm/hands as expected... interesting

 

[Winged Scapula]

Perhaps you should go into psychiatry...or change your your name to "clueless."

Mongo please check your PMs for a comment about your recent posts.

 

[Mongo]

Perhaps you should go into psychiatry...or change your your name to "clueless."

This post wasn't actually done by me. I think I left my account up on my school computers and someone came in and used them early this morning to post this and another post in this subsection. I'm very sorry that I have a$$holes at my school.


--Mongo

 

[thenavysurgeon]

the issue with arterial sticks is both psuedo-aneurysm formation and subclavian artery stenosis...both long-term problems...

my technique, if anyone cares is this:

1. don't do a subclavian unless you have to (try an IJ first)
2. know your landmarks for a subclavian line
3. left is easier than right
4. use a roll between the shoulder blades to open up the nangle between first rib and clavicle
5. if you get a questionable stick, don't dilate it...if its red and pulsatile...no question: stop....if its red, and flows steady enough to make you question the stick (pt might be on a vent and on 100% ox...even venous blood will be red) then have an RN transduce it for you, and send a gas. If you have scythed the artery, and are partially in it wit the needle, your transduction pressure MIGHT be low, but the simulataneous ABG will give you the answer.
6. if all else fails, get a groin line in and call a more experienced resident/staff to help you replace the groin line with a IJ or subclavian
7. as a junior resident, you should put in every line that you can...because as a attending, you don't get to, and you get rusty pretty quickly (like me)

Bye!

TNS

 

[Winged Scapula]

This post wasn't actually done by me. I think I left my account up on my school computers and someone came in and used them early this morning to post this and another post in this subsection. I'm very sorry that I have a$$holes at my school.


--Mongo

Thank you Mongo for your rapid reply to my PM. With your permission, I shall delete this and the other post in question.

 

[Mongo]

Thank you Mongo for your rapid reply to my PM. With your permission, I shall delete this and the other post in question.

Go right ahead.

 

[Winged Scapula]

Go right ahead.

Done.

 

[Celiac Plexus]

Well, this topic has been pretty much rung out... And I feel so much better now that Mongo has cleared his name.

Only one thing to add to the line business... The first time I was shown how to place a central line (Seldinger technique), I was told by the pgy-3 who is a very cool customer:

"Do not. Ever. Let go of the wire...." lol... Ever seen a cxr with a coiled up wire in the right ventricle? Makes ya wanna **** yer pants... Thank God for creating interventional radiologists... lol...

 

[Winged Scapula]

Well, this topic has been pretty much rung out... And I feel so much better now that Mongo has cleared his name.

Only one thing to add to the line business... The first time I was shown how to place a central line (Seldinger technique), I was told by the pgy-3 who is a very cool customer:

"Do not. Ever. Let go of the wire...." lol... Ever seen a cxr with a coiled up wire in the right ventricle? Makes ya wanna **** yer pants... Thank God for creating interventional radiologists... lol...

Yes, so it makes me cringe when certain attendings will tell me to stop touching the wire, "its not going anywhere!!". Well, I wouldn't want to be responsible IF it did! 😱

 

[njbmd]

Hi there,
When I let go of the wire, it is clamped to the drape. 😉
njbmd

 

[Whisker Barrel Cortex]

Well, this topic has been pretty much rung out... And I feel so much better now that Mongo has cleared his name.

Only one thing to add to the line business... The first time I was shown how to place a central line (Seldinger technique), I was told by the pgy-3 who is a very cool customer:

"Do not. Ever. Let go of the wire...." lol... Ever seen a cxr with a coiled up wire in the right ventricle? Makes ya wanna **** yer pants... Thank God for creating interventional radiologists... lol...

Grabbing those are always fun cases. We had one last time I was rotating through interventional. Happened around midnight. Right IJ line. Put in by the attending who is the head of critical care. The wire was seen by the junior rads resident on call with a loop in the RA and extending down the IVC. It was so hard to see, the ICU resident didn't believe him at first. The attending admitted he had no idea he'd even lost the wire.

When we did fluoro, the wire proximal tip was still in the IJ. It looped once in the RA and went down the IVC all the way to the right iliac vein, right next to a triple lumen in the right femoral. We put a sheath into the femoral after removing the triple lumen over a wire and pulled it out from down below without a problem. Prett cool stuff.

Man, the way I wrote that, maybe I should do interventional.

 

[Whisker Barrel Cortex]

Oh, by the way, on interventional, we always let go of the wire once we're in there. Never seen it get sucked in.

 

[Hotsauce21]

replace all the a-lines? what a waste of your time.

Yes, our anesthesiologists adopt the sterile schmerile philosophy with arterial lines as well. For this reason our intensivists require us to change the arterial line to a new site or remove it when the patient reaches the ICU after surgery. Obviously this is better than dealing with the infections down the road but wouldn't it just make sense to place these lines in sterile fashion?

 

[CardiacSurgeon]

Someone placed a central line in the subclavian artery by accident today. Why does that matter. If it doesnt make a big hematoma or start hemoraging...whats the problem. Also how do you know its in the vein and not the artery?

jesus....

is this really a question??? from someone practicing medicine?

 

[Celiac Plexus]

jesus....

is this really a question??? from someone practicing medicine?

L.M.F.A.O.

 

[RuralMedicine]

replace all the a-lines? what a waste of your time.

Yep!! 🙁 And not exactly fun for the patient either 🙁

 

[Hotsauce21]

my experience is that if you really pry, some people cant answer seemingly "simple" questions. Id rather have him/her ask and learn than not know the answer. Did you know all the points about atheromas, psuedoaneurysms, transducing, getting a waveform, compressible locations for a-lines, etc? I didnt, I learned something from the question. Its really not quite as simple a question as it seems.

jesus....

is this really a question??? from someone practicing medicine?

 

[CardiacSurgeon]

my experience is that if you really pry, some people cant answer seemingly "simple" questions. Id rather have him/her ask and learn than not know the answer. Did you know all the points about atheromas, psuedoaneurysms, transducing, getting a waveform, compressible locations for a-lines, etc? I didnt, I learned something from the question. Its really not quite as simple a question as it seems.

jesus AGAIN...

If you are able (by the law) to place a central line and you dont know how to tell an artery from a vein, or if you dont know whats the problem with a misplaced central line, you are pathetic.

If you wait to kill someone to learn how to put a central line you are pathetic and DANGEROUS. I repeat DANGEROUS

 

[VentdependenT]

You'll know when you hit that artery because your patient will start crashing. That Hemopneumothorax you just caused is going to make your day a whoooollllleeeee lot sexier!

The bright red pulsing jet sream of blood may be a give away that you are indeed in the artery. Try and stay superficial to the ribs eh.

 

[supercut]

How ironic this thread is revived just days after I get this consult, "curbside" from the MICU.

Pt who coded in the ED now in MICU in cardiogenic shock. They gave her L ptx from subclavian, put in chest tube that's kinked inside. Xray shows lung is up. They ask what they need to do with the chest tube. They they say, so the next question is about the R subclavian that's now in the subclavian artery! Yikes!!!

Just FYI folks, you don't need to put in a central line when a pt codes! Large bore peripheral IVs are much safer and more effective for rapid infusion of drugs/fluids. If you can't get peripheral access, a femoral line is the way to go. And if you cause a complication on one side doing a subclavian, please don't even try the other side.

A couple days later, they formally consulted us cuz now the pt has a small R ptx as well. When I reviewed all the pt's films, I figured out that it took them 3 tries to get the chest tube in. And that they had to first needle decompress the pt cuz they thought the first ptx was intially a tension ptx. They didn't mention any of that the first time,when they "curbsided" me.

Glad I don't have to be at that M&M...

 

[Foxxy Cleopatra]

I've put in hundreds (and that is not an overestimate) of lines- IJ's, subclavians, and femorals. I consider myself fairly experienced yet I'll admit subclavian arterial blood is not always overwhelmingly obvious. If in doubt, do as the other posters suggested (ABG, etc); if the suspicion occurs after the line is already in (perhaps blood draws forcefully from the line and makes you unsure), do an ABG and get the help of vascular surgery or interventional. Also, make sure the line does not get used in the meantime.


I think subclavian arterial lines occur more often than we'd like to think. Some people will pull their subclavian arterial TLC's and hold firm pressure beneath the clavicle though I personally would err on the side of caution and involve either interventional or vascular. I've heard of more than one case of someone presenting sometime down the line with a pseudoaneurysm, which is a bit more of a dilemma to care for that removal of the initial line.

It is unpleasant and an ego blow, I'll admit, to acknowledge that a complication arose from something you performed but it's better in the end if you deal with it up front and do what you can to remediate the problem.

 

[MustafaMond]

I always use IJ lines, using "Sight Right" USG guidance.

Its the way to go.

 

[RuralMedicine]

Just FYI folks, you don't need to put in a central line when a pt codes! Large bore peripheral IVs are much safer and more effective for rapid infusion of drugs/fluids. If you can't get peripheral access, a femoral line is the way to go. And if you cause a complication on one side doing a subclavian, please don't even try the other side.

Agreed! When patients code without any access the key is establishing access quickly and honestly in some patients an antecubital 18 or 16 gauge can be placed in seconds and is a much faster option than a central line. (In these situations I think someone should be trying peripherally concurrent with line attempts if possible; obviously in some patients the likelihood of achieving peripheral accesss is slim).

 

[Paulista]

If you are ever in doubt about hitting a major artery instead of vein, then there are few things you should do:

1- check if this is indeed an arterial puncture. The simplest way is connect your catheter to an IV line hanging high above patient to an IV bag. If it is arterial then due to high pressure you will see the bright red blood pulsating and creeping high above very fast. No need to do an ABG.

Now this changes if this is just an needle puncture instead of catheter puncture. Needle punctures can be treated initially with removing the needle and applying direct pressure over site for good 30 minutes while watching patients vitals.

Now if it was an catheter puncture to an artery then once determined it is within the lumen of an artery then you occlude the catheter tip and keep direct pressure over the catheter entry site without removing or moving the catheter. Ask the nurse or the junior resident to call your senior or chief or if they are not available ask for an vascular attending to take a look.

In some arterial catheter punctures should be removed in OR under the guidance of vascular surgery. Many times direct pressure over site of puncture would stop the bleeding but if that does not work you have to actually expose the vessel and do direct vessel repair..somewhat arduous work.

Learning how to manage complications is part of surgical training.

Sure, it would be nice do prevent all complications but that is not realistic at best.