observation: IJ line with US

[caligas]

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Started using ultrasound routinely a few months ago. Noticed something interesting. We usually do a double stick in cardiac. Even a straight forward single stick of the IJ is sometimes enough to cause a little hematoma that partially collapes the vein. No wonder I've occasionally had trouble with the second stick/wire. Nice to see what's goin on in there.

 

[sevoflurane]

I rarely encounter this... but I never use the big needle (18G?) in the kit. I railroad a 20G angiocath (which comes in our MAC kits) and then place the wire. Smaller stick. Reliable... and if you cant' thread the wire, and have to go subclavian or L. IJ you have a smaller puncture site which will see 20-30k of heparin. Also, if you don't have TEE or USD, railroading a 20G angiocath can serve as a conduit for a "poor mans CVP"

Poor mans CVP: hook up some tubing to the angiocath, draw back 3 cc's and then lift the tubing and watch the heme fall against gravity... if it doesn't and it's pulsitile, you missed, but haven't put a big hole in the carotid (haven't been there yet...).
It is a small extra step... but I don't mind it.

My 2 cents.

 

[TrustMe]

When I was a resident we got two new cardiac attendings. One always double stuck (introducer and TLC) and always used U/S b/c he wanted a single needle pass since they were getting heparinized for CPB. Almost never had a problem. The other almost never used U/S (he didn't train with it and never tried to learn and so was terrible with it) and insisted that we use a through & through technique with the 18ga angiocath in the kit. He had more significant hematoma complications than I care to remember. Good call switching to U/S for hearts.

 

[periopdoc]

I had something like this happen once. Planning on a double stick. Good initial stick with real-time visualization. Threaded the wire easily and confirmed correct placement on TEE. Withdrew the needle with extremely subtle resistance encountered (if I was a resident with less than 100 IJ's under my belt I know I would not have even noticed it). Scanned for second needle placement and found the IJ to be compressed by lateral hematoma to the point that the lumen was obliterated despite increasing T-berg and doing a couple of valsalvas. Abandoned second stick and placed a Big Mac cordis (introducer with extra 16g port).

I suspect a small tear in the lateral wall of the IJ perhaps due to a change in the angle of the needle as I withdrew it twisting the wall onto the needle some way. Never seen it before or since.

Monitored throughout the case and afterward with no sequelae noted.

- pod

 

[excalibur]

In my view USG RIJ eliminates need for double sticking or the IV tubing trick to ensure venous access.

Prep and drape as usual. Open the pack contaiining sterile sleeve and the pack of sterile jelly. Pour some jelly in sleeve and on patient. Have nurse drop probe in sleeve. Stretch sleeve to cover probe, and you are ready. This takes 30 seconds probably. Don't even put the rubber band thingies on! You just need to visualize the structures for like 10-15 seconds to get access! Better yet you or the OR nurses can open the sterile sleeve pack and dump the jelly in before the pt comes in room. Saves a couple of steps and a few seconds.

Your US view will be a big ole compressible vascular structure superior and lateral to the pulsatile more circular vascular structure. Center structures on screen. Bounce the needle around the skin level until you see on the screen that you are aiming toward vein. Access, thread wire, remove needle.

Once needle is out and wire remains. 5-10 seconds to confirm venous access. Just put US probe back skin just below wire. Tilt probe handle to head so beam is directed more to the feet. On US screen you will see the silhouette of the wire in the vein. You will directly visualize that that the wire is in the vein before you dilate. Tough to beat that as a confirmation test.

I had to do the double sticking and the IV tubing trick in residency too. Good tips to know, but with an US probe, you don't need to do those extra steps. Plus with the US an additional 5 seconds will give you possibly the best confirmation test for venous access--direct visualization.

 

[periopdoc]

What you are referring to as a double stick (finder needle then larger needle) is different from what I believe Caligas is referring to, and definitely different from what I am referring to.

I am talking about placing two wires and two catheters (an introducer and a second smaller central venous line) which obviously requires two sticks.

- pod

 

[excalibur]

What you are referring to as a double stick (finder needle then larger needle) is different from what I believe Caligas is referring to, and definitely different from what I am referring to.

I am talking about placing two wires and two catheters (an introducer and a second smaller central venous line) which obviously requires two sticks.

- pod

Gotcha. Thanks.

 

[urge]

In my view USG RIJ eliminates need for double sticking or the IV tubing trick to ensure venous access.

Prep and drape as usual. Open the pack contaiining sterile sleeve and the pack of sterile jelly. Pour some jelly in sleeve and on patient. Have nurse drop probe in sleeve. Stretch sleeve to cover probe, and you are ready. This takes 30 seconds probably. Don't even put the rubber band thingies on! You just need to visualize the structures for like 10-15 seconds to get access! Better yet you or the OR nurses can open the sterile sleeve pack and dump the jelly in before the pt comes in room. Saves a couple of steps and a few seconds.

Your US view will be a big ole compressible vascular structure superior and lateral to the pulsatile more circular vascular structure. Center structures on screen. Bounce the needle around the skin level until you see on the screen that you are aiming toward vein. Access, thread wire, remove needle.

Once needle is out and wire remains. 5-10 seconds to confirm venous access. Just put US probe back skin just below wire. Tilt probe handle to head so beam is directed more to the feet. On US screen you will see the silhouette of the wire in the vein. You will directly visualize that that the wire is in the vein before you dilate. Tough to beat that as a confirmation test.

I had to do the double sticking and the IV tubing trick in residency too. Good tips to know, but with an US probe, you don't need to do those extra steps. Plus with the US an additional 5 seconds will give you possibly the best confirmation test for venous access--direct visualization.

I disagree. You can stick the vein thru and thru and end in the artery. If you only look for the wire in the vein you will miss it. Ultrasound is not as great as it is billed. It has a steep learning curve too.

 

[Mman]

I disagree. You can stick the vein thru and thru and end in the artery. If you only look for the wire in the vein you will miss it. Ultrasound is not as great as it is billed. It has a steep learning curve too.

On ultrasound with the patient's head turned 45 degrees away, the chances of the carotid lying directly beneath the IJ approaches 0%. I mean it's not never, but darn near. At most it'll overlap by a few millimeters. While I agree that a single static image of the wire and vein in short axis doesn't prove you did not go through the back of the vein, a simple scan up and down the vein does.

So with the needle being advanced under U/S guidance and towards the ipsilateral nipple, the chances of going through the vein and hitting the artery are almost zero.

 

[urge]

On ultrasound with the patient's head turned 45 degrees away, the chances of the carotid lying directly beneath the IJ approaches 0%. I mean it's not never, but darn near. At most it'll overlap by a few millimeters. While I agree that a single static image of the wire and vein in short axis doesn't prove you did not go through the back of the vein, a simple scan up and down the vein does.

So with the needle being advanced under U/S guidance and towards the ipsilateral nipple, the chances of going through the vein and hitting the artery are almost zero.

"Almost" doesn't cut it where I work.

In here "almost" gets you on unemployment benefits.

 

[excalibur]

With all confirmation tests, there are potential errors. The IV tubing trick could fool you. I have seen attendings in residency do the tubing trick, and the blood in the tubing didn't quite drain back, and wasn't obviously pulsatile. So that was a couple of minutes of doing something extra without getting confirmation.

One could argue that on US the wire is in a vessel that I "thought" was the vein, but in fact the artery. Through and through theory? Potential as well but extremely unlikely.

Again US confirmation takes 5 seconds. You see a wire in a compressible vein and not in the pulsatile artery. Given the speed of test and direct visualization, I find it tough to beat. After those 5 seconds, my confidence level of being in vein is extremely high.

 

[Uegis]

I have trained almost exclusively with ultrasound-guided CVCs and only recently started doing landmark technique for IJs at a different hospital I am rotating at. Prepping the ultrasound takes less than 30 seconds. The IJ,in most people in Tberg, is an extremely easy target to locate with ultrasonography and I have rarely encountered problems with it, except those with anatomically small IJs, which would be as difficult with landmark techniques.

After doing around 20 lines with landmarks, the learning curve is definitely not that steep. The advantages is obviously that you can be more autonomous without assistance from others. But I have never encountered a situation where I cannot get help with line placements whether from the anesthesia tech, nurse, or even the perfusionist. I do feel more like a badass when I can hit the vein with the landmarks though. Some would argue that ultrasound is the standard of care for IJ and femoral line placements. I think whatever you are most comfortable with is what matters.

On a side note, what do people think of ultrasound-guided arterial lines or IVs? When I was in the unit, I would routinely use ultrasound to place a-lines and difficult IVs for practice. I use it so I can train myself so when I encounter tough sticks, I can use it for a back up.

 

[IveGotTwins]

Double stick means double or triple lumen CVC plus a cordis for swan?

I'm in ICU this month as a CA-1. On day I was asked to place an a-line. After I finished and was securing it the attending asked where the US machine was. Turns out they use US for every line including a-lines. They also prep and drape. All I used was an alcohol swab like the OR. I think for a-lines it slows me down but I like getting to use the US more.

Does anyone else prep (ie chlorhexadine) and drape for a-lines? Routinely use US for a-lines?

 

[jetproppilot]

I have trained almost exclusively with ultrasound-guided CVCs and only recently started doing landmark technique for IJs at a different hospital I am rotating at. Prepping the ultrasound takes less than 30 seconds. The IJ,in most people in Tberg, is an extremely easy target to locate with ultrasonography and I have rarely encountered problems with it, except those with anatomically small IJs, which would be as difficult with landmark techniques.

After doing around 20 lines with landmarks, the learning curve is definitely not that steep. The advantages is obviously that you can be more autonomous without assistance from others. But I have never encountered a situation where I cannot get help with line placements whether from the anesthesia tech, nurse, or even the perfusionist. I do feel more like a badass when I can hit the vein with the landmarks though. Some would argue that ultrasound is the standard of care for IJ and femoral line placements. I think whatever you are most comfortable with is what matters.

On a side note, what do people think of ultrasound-guided arterial lines or IVs? When I was in the unit, I would routinely use ultrasound to place a-lines and difficult IVs for practice. I use it so I can train myself so when I encounter tough sticks, I can use it for a back up.

You're a smart dude man.

 

[urge]

I have seen attendings in residency do the tubing trick, and the blood in the tubing didn't quite drain back, and wasn't obviously pulsatile. So that was a couple of minutes of doing something extra without getting confirmation.

That in itself is a lot of information:
Either kinked or misplaced angiocath in vein. Do NOT PASS Go!! No way I'm ignoring this. Blood has to flow easily, otherwise no way I'm dilating that vessel.

Fix the kink or start over again.

 

[Impromptu]

I love using doppler ultrasounds for difficult A-line sticks. I have also used the standard visual ultrasound for A-lines with short advancements of the needle alternating with slight adjustments in my probe angle to follow the tip into the vessel. Between the two I have found the doppler to be more effective.

 

[pgg]

On a side note, what do people think of ultrasound-guided arterial lines or IVs? When I was in the unit, I would routinely use ultrasound to place a-lines and difficult IVs for practice. I use it so I can train myself so when I encounter tough sticks, I can use it for a back up.

I think it's worth learning to get lines without ultrasound, in case it's not available when you need to get a line in, but there's no denying that ultrasound makes us faster and better. I use u/s routinely now, even for sticks that look easy. There's just no reason not to.

Yesterday an anesthesiologist who was helping me with a case had a radial a-line in within about 15 seconds, in a patient with an exsanguination-caused cardiac arrest. Easy. No sewing-machine action, no oops-that-was-venous, no problem. Just squirted some goo on the arm, probe on, needle in, done. When you need a line in a hurry, u/s is gold.

 

[DrN2O]

Does anyone else prep (ie chlorhexadine) and drape for a-lines? Routinely use US for a-lines?

I think if you are in the ICU, the a-line should be placed sterily with chloroprep and sterile field and gloves. There is evidence that a-lines does become a source of blood stream infection in the critical care population. The rate of infection increases with ICU stay and catheter time. I used to do them with just alcohol and clean gloves in the OR, but as most of my patients now go to the unit, I'm glad the hospital policy has forced me to do them under more sterile conditions.

 

[KCBarbarossa]

I have trained almost exclusively with ultrasound-guided CVCs and only recently started doing landmark technique for IJs at a different hospital I am rotating at. Prepping the ultrasound takes less than 30 seconds. The IJ,in most people in Tberg, is an extremely easy target to locate with ultrasonography and I have rarely encountered problems with it, except those with anatomically small IJs, which would be as difficult with landmark techniques.

After doing around 20 lines with landmarks, the learning curve is definitely not that steep. The advantages is obviously that you can be more autonomous without assistance from others. But I have never encountered a situation where I cannot get help with line placements whether from the anesthesia tech, nurse, or even the perfusionist. I do feel more like a badass when I can hit the vein with the landmarks though. Some would argue that ultrasound is the standard of care for IJ and femoral line placements. I think whatever you are most comfortable with is what matters.

On a side note, what do people think of ultrasound-guided arterial lines or IVs? When I was in the unit, I would routinely use ultrasound to place a-lines and difficult IVs for practice. I use it so I can train myself so when I encounter tough sticks, I can use it for a back up.

I've been able to avoid the groin in some nightmare patients +7 liters of fluid and vasculopaths by using US for A-lines. For radials, US allows you to go up higher where the pulse may not even be paable and where the location will be more variable than it is distal.

I don't routinely use it when I have a good pulse on an easier patient, but if it's been someone who's been there a long time with "rotating" A-lines and super edemetous, it's a handy tool for sure.

Regarding sterile technique, our SICU folks often cringe at the "sterile" technique we routinely employ in PreOP or in the OR. In the unit it takes some getting used to, but our practice is to gown and drape, sterilizng with chloroprep for every line, including A-lines.

 

[Mman]

"Almost" doesn't cut it where I work.

In here "almost" gets you on unemployment benefits.

Guess what, if you are doing the line with ultrasound guidance, you already know if the vein is superficial to the artery at any point. So the incidence is 0.0000000000000000%. I was merely commenting on the overall chances of them overlapping.

 

[urge]

Guess what, if you are doing the line with ultrasound guidance, you already know if the vein is superficial to the artery at any point. So the incidence is 0.0000000000000000%. I was merely commenting on the overall chances of them overlapping.

If that is so reliable why does excalibur look for the wire in the vein?

 

[periopdoc]

Billing purposes.

- pod

 

[deleted126335]

For those who routinely doublestick the IJ,

Do you after placing the first wire place the catheter and then second wire and second catheter?

or first wire, second wire, first catheter, second catheter?

 

[lushmd]

For those who routinely doublestick the IJ,

Do you after placing the first wire place the catheter and then second wire and second catheter?

or first wire, second wire, first catheter, second catheter?

I place both wires and then the catheters (distal then proximal).

 

[caligas]

For those who routinely doublestick the IJ,

Do you after placing the first wire place the catheter and then second wire and second catheter?

or first wire, second wire, first catheter, second catheter?

Yes, by double stick I meant two wires, one for swan and one for 3 lumen cvl. I put in both wires, confirm they are venous by US, then pass the 3 lumen followed by the cordis.

 

[pgg]

or first wire, second wire, first catheter, second catheter?

This is how I was taught, to prevent any chance of damaging catheter #1 with the needle for #2. It's also easier to put wire #2 in if the obstacle is just wire #1 and not the entire line #1 sticking out right next to your intended entry point.

 

[CambieMD]

I rarely encounter this... but I never use the big needle (18G?) in the kit. I railroad a 20G angiocath (which comes in our MAC kits) and then place the wire. Smaller stick. Reliable... and if you cant' thread the wire, and have to go subclavian or L. IJ you have a smaller puncture site which will see 20-30k of heparin. Also, if you don't have TEE or USD, railroading a 20G angiocath can serve as a conduit for a "poor mans CVP"

Poor mans CVP: hook up some tubing to the angiocath, draw back 3 cc's and then lift the tubing and watch the heme fall against gravity... if it doesn't and it's pulsitile, you missed, but haven't put a big hole in the carotid (haven't been there yet...).
It is a small extra step... but I don't mind it.

My 2 cents.

Ultrsound is the way to go.


Cambie

 

[sevoflurane]

No doubt. 👍

That is how I do all of my lines. Usually one pass/first stick.

The exception are the emergent lines on the floor where USD isn't readily available and the patient needs volume and/or pressors like.... yesterday.

I've been a big proponent for hospital wide USD usage for a long time. It is a great skill to have under your belt...but so is doing it 'ol school.

 

[periopdoc]

I place both wires and then the catheters (distal then proximal).

Same

-pod

 

[KCBarbarossa]

Geez. I've never seen a double stick as described!

Isn't that a little much even for a large vein such as the IJ?? What are the complications? It seems like that much sitting in the IJ lumen would/could even impede venous return, no?

Just never have seen it and it's definitely NOT common practice in the OR or the SICU.

Come to think of it n 8.5F introducer with a doubl lumen is still probably less diameter than an average sized Quinton, right?

 

[pie944]

Geez. I've never seen a double stick as described!

Isn't that a little much even for a large vein such as the IJ?? What are the complications? It seems like that much sitting in the IJ lumen would/could even impede venous return, no?

Just never have seen it and it's definitely NOT common practice in the OR or the SICU.

Come to think of it n 8.5F introducer with a doubl lumen is still probably less diameter than an average sized Quinton, right?

Where I trained all livers got the IJ stuck twice, 9Fr and MAC, limited experience but never saw or heard of any complications from both being placed in the same location.

 

[Mman]

Geez. I've never seen a double stick as described!

Isn't that a little much even for a large vein such as the IJ?? What are the complications? It seems like that much sitting in the IJ lumen would/could even impede venous return, no?

Just never have seen it and it's definitely NOT common practice in the OR or the SICU.

Come to think of it n 8.5F introducer with a doubl lumen is still probably less diameter than an average sized Quinton, right?

it's common practice in major cases at many institutions. Used to do it for lung transplants or triple valves, sometimes for redo sternotomies.

 

[badasshairday]

Billing purposes.

- pod

This is why I thought ultrasound guided IJ is so popular now. I hardly ever see anyone do a subclavian these days at my community hospital.

BTW, what do you guys mean by "double stick"?

 

[G0S2]

My livers: MAC and Edwards oximetric pref both in R IJ.

 

[92122]

Here's how it's done under GA:

1. TEE probe placed

2. Wires seen in IJ with epiaortic probe guidance

3. Wires visualized in SVC via TEE imaging

I think that if you record findings of #2 and #3, you can put the issue of carotid cannulation to rest.

 

[Jay K]

I would routinely use ultrasound to place a-lines and difficult IVs for practice. I use it so I can train myself so when I encounter tough sticks, I can use it for a back up.

Yes.

Geez. I've never seen a double stick as described!

Do an away to get a few liver transplants under your belt... even if you never do 'em again in PP.

 

[Oggg]

My last IJ line, it seemed that at the Apex of the triangle formed by the SCM, the IJ vein was lateral to the artery. When I scanned lower in the neck, the vein was overlying the carotid. So depending where you stab, you can backwall the vein and enter the carotid.

 

[periopdoc]

As you describe, the relationship of the carotid art to IJ vein is variable both between patients and in the same patient, and this relationship can change as you rotate the neck. Frequently you will see the carotid course behind the vein at some point although being adjacent to the vein at other points.

One of the key things that I describe in my narrative is that I scanned the length of the visible IJ for patency, and I describe the relationship between the carotid to the IJ as adjacent, overlapping, adjacent/overlapping, or well away. This is also helpful for justification for U/S use.

If you can do nerve blocks properly, you can easily determine the location of the needle tip in the IJ. It truly is the perfect setup for looking for the tip. A highly echogenic needle in a large target that is surrounded by fluid of homogeneous echogenicity.

- pod

 

[periopdoc]

Never did double sticks in residency or fellowship, but we frequently placed retrograde jugular bulb catheters in addition to a central line in residency for neuro cases. We double cannulate all the time here for hearts. Different strokes for different folks (no pun intended).

I think that it is prudent to scan the IJ to ensure that it isn't a pencil sized vein before you cannulate it, whether a single or double cannulation. I have only seen that once. The other IJ in that patient was massive. This is a well described developmental phenomenon.

- pod

 

[Oggg]

Yeah I see tiny IJs a lot. As small or smaller than the carotid.

 

[Bostonredsox]

Never did double sticks in residency or fellowship, but we frequently placed retrograde jugular bulb catheters in addition to a central line in residency for neuro cases. We double cannulate all the time here for hearts. Different strokes for different folks (no pun intended).

I think that it is prudent to scan the IJ to ensure that it isn't a pencil sized vein before you cannulate it, whether a single or double cannulation. I have only seen that once. The other IJ in that patient was massive. This is a well described developmental phenomenon.

- pod

I generally scan both IJs roughly before I even drape and prep. Every once in a while, in particular in the dialysis pts, i come across visible clot somewhere down the jugular near the pickup of the subclavian. usually its the ones that have had IJ permcaths in the past that I didn't have time to look up. I generally go to the otherside then to avoid getting my wire hung up and wasting 10 minutes of my time.

 

[sevoflurane]

We prep both sides for R/L IJ and subclavian. If I see a vessel I don't want to cannulate I scan and go to one of my other 3 options while still maintaining sterile precautions.

 

[Mman]

We prep both sides for R/L IJ and subclavian. If I see a vessel I don't want to cannulate I scan and go to one of my other 3 options while still maintaining sterile precautions.

I've considered doing that in the past but haven't seen the need yet. It's just so rare that you can't find a good IJ in a low risk patient (non dialysis). Now if they are a dialysis patient and have had lots of permcaths over the years I will scan both sides before prepping to see which (if either) looks usable.

But >99% of the time I'm successful on the first side without any difficulty.

 

[DrN2O]

We prep both sides for R/L IJ and subclavian. If I see a vessel I don't want to cannulate I scan and go to one of my other 3 options while still maintaining sterile precautions.

How do you keep the contralateral neck sterile when you scan the IJ? What kind of drape do you use?

 

[sevoflurane]

I've considered doing that in the past but haven't seen the need yet. It's just so rare that you can't find a good IJ in a low risk patient (non dialysis). Now if they are a dialysis patient and have had lots of permcaths over the years I will scan both sides before prepping to see which (if either) looks usable.

But >99% of the time I'm successful on the first side without any difficulty.

I concur. Just a force of habit. Prepping both sides while you are prepping one side just takes a couple of seconds... and it's while I'm at the back of the room gowning and gloving.

 

[sevoflurane]

How do you keep the contralateral neck sterile when you scan the IJ? What kind of drape do you use?

USD probe gets a condom.

I use the whole body drape.

 

[excalibur]

USD probe gets a condom.

I use the whole body drape.

Think he is asking if you don't like RIJ, do you just lift the whole body drape and slap the opening on LIJ/subclavian site? Or does your drape have multiple openings?

 

[Idiopathic]

Think he is asking if you don't like RIJ, do you just lift the whole body drape and slap the opening on LIJ/subclavian site? Or does your drape have multiple openings?

the right answer is that you prep out the subclavian at the same time as the IJ and if you go to the other side you get a new drape. ive gone to the RSC from RIJ a few times but always reprep and drape to go the left

edit: not criticizing, just saying that i havent seen the full body drape that allows for the entire neck to be exposed at once

 

[sevoflurane]

Holes for R/L IJ/subclavians. With clear sticky plastic. I've used these a lot. Pretty nice drapes, but expensive.

That being said, If prepped out correctly and you are careful maintaining sterility, then I don't mind picking up the drape and moving it over (edit: if I don't have the drape described above). A second prep is justified in this situation. If you loose sterility then you need to redrape.

 

[sevoflurane]

Think he is asking if you don't like RIJ, do you just lift the whole body drape and slap the opening on LIJ/subclavian site? Or does your drape have multiple openings?

My method of choice is first RIJ, second R. subclavian. In the rare event I need to go to the other side, then LIJ followed by L. subclavian.

Subclavians are butter... and yes, I use USD on occasion for subclavians if the body habitus is favorable for a USD guided subclavian CVL.