observation: IJ line with US

[Bostonredsox]

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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.

If I already have the US out from IJ attempt and need to move to the chest I slap the US on. I don't routinely use the US for a subclavian right from the start though.

 

[BobBarker]

I do not like USD guided subclavians at all. In any patient with some mass the angle of the needle is directed directly at the pleura.

 

[Idiopathic]

I do not like USD guided subclavians at all. In any patient with some mass the angle of the needle is directed directly at the pleura.

i dont have a problem with it, we do US guided infraclavicular blocks and have very low risk of PTX with those. you definitely need to know what you are doing

 

[reanimatore]

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.

A misdirected, "through and through" intra-carotid wire placement can be ruled out with the US by imaging the IJ in long axis (longitudinally). If placed correctly, the wire can easily be identified travelling the length of the IJ within the lumen and not passing through the back wall of the vein at any point. For extra confirmation, you can obtain the same long axis view of the carotid and confirm that the wire is not within it's lumen. In my opinion this provides fail-safe confirmation of correct wire placement.

 

[Oggg]

Usually when I do an axillary-subclavian central venous line, my best picture shows a clear vein, artery, and the pleura. The pleura or rib is just deep to the vein. So yes there is a chance of hitting the lung. But if you keep track of you needle tip you are quite safe. But tracking a needle tip with an out of plane view is not for novices, so this approach is definitely harder than an IJ. Sometimes I can get a nice long axis view of the vein, and I can hit it before it dives deep. Again, this is not a novice view