Peripheral-central IV line

[Angry Birds]

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Something f***ed up with my right IJ central line right when EMS arrived. I took an u/s and popped in a left IJ using a regular peripheral IV angiocath. It took a whole 20 seconds and works beautifully, vs central line which took me 20 minutes.

Why can't I do this always?

And what do I call this line?

 

[dchristismi]

That's a damn good question, because I did the same thing just the other day. I just documented that I'd used a longer angiocath than the usual ones and that after attempting both EJs, it was placed in the IJ under ultrasound guidance. Unfortunately, the patient wasn't the most cooperative and it didn't last, but it was enough to get some fluids in him to buy some time, and after those fluids, we got a "regular" peripheral line by ultrasound. But I didn't know what to call it either, and wasn't sure what the floor nurses were going to think. Ultimately, didn't matter, but I am wondering that same thing.

 

[alpinism]

Its called an Easy IJ.

You can also do an Easy Axillary in the upper arm which is just as quick and doesn't involve poking awake patients in the neck.

 

[gro2001]

Something f***ed up with my right IJ central line right when EMS arrived. I took an u/s and popped in a left IJ using a regular peripheral IV angiocath. It took a whole 20 seconds and works beautifully, vs central line which took me 20 minutes.

Why can't I do this always?

And what do I call this line?

I would call it a centrally inserted peripheral IV line (as opposed to a peripherally inserted central line, which is a PICC).

Why can't you do this always? I imagine because eventually someone is going to come down on you like a ton of bricks after they attribute some complication to this. For example, I don't know how this fits with central line infections which hospitals are supposed to track for CMS and such.

 

[Fox800]

Easy enough to do. Huge target. Not sure how it’s “dirtier” than the EJ which sits right next to it. Same catheter length.

Let the floor team remove it and put in a PICC or another ultrasound guided peripheral if they don’t like it.

 

[e30ftw]

I have done this in the rare situation the patient needs IVF/meds/access however has no other indication for a CVL, all other U/S PIV sites have failed, and yet the pt is likely to be discharged. At this point (which is very rare) if the pt needs to be admitted I would probably just put in a CVL and spare the med director the fall out.

This is a great area for research.

U/S guided IJ access with the long 18g angiocath is so easy and (imo) safe, but you need a few hundred safely inserted documented cases and a few ACEP articles as well as local institutional approval to make it within standard of care.

The way to get around having to do this is being good at U/S PIV insertion. Takes maybe 5 sec longer because you have to tie a tourniquet but is within SOC.

The majority of CVLs I place are in awake patients with peripheral access who need levophed for a short (<24 hr ) time period.

Literature is growing regarding the safety of peripherally administered vasopressors, however at present this is not standard at most institutions.

EM academic people: design a study comparing the safety of a 2.5 inch 18 gauge angiocath IJ placed under U/S guidance to the traditional triple-lumen CVL for awake, oriented septic patients who need a MAP >65 to be accepted by hospitalist services. End result is decreased complication rate with equal/superior results. Pull the angiocath within 24hr.

Guaranteed publication/paper/conference trip for any resident who convinces their director to approve the project and follows it through.

 

[KinesiologyNerd]

EM academic people: design a study comparing the safety of a 2.5 inch 18 gauge angiocath IJ placed under U/S guidance to the traditional triple-lumen CVL for awake, oriented septic patients who need a MAP >65 to be accepted by hospitalist services. End result is decreased complication rate with equal/superior results. Pull the angiocath within 24hr.

We have a solution for that: midodrine.

 

[DrDrummer]

This has been published on in a series from Highland (the esteemed professor teissman et al. http://www.emergencyultrasoundteaching.com/assets/articles/vascaccess_2012_Teismann_JEM.pdf ) and I believe by other authors since.

There’s another review here: More on the Easy IJ - R.E.B.E.L. EM - Emergency Medicine Blog

 

[Dr Mantis Toboggan]

I have started to put the 2.5 inch catheters in the EJ if it’s a plump one. I’ll also do baby IJ’s. I’ve run vasopressors through both. Works great. I say the same thing, if the unit/floor has a problem with my line they are welcome to place their own.

Easy enough to do. Huge target. Not sure how it’s “dirtier” than the EJ which sits right next to it. Same catheter length.

Let the floor team remove it and put in a PICC or another ultrasound guided peripheral if they don’t like it.

 

[TooMuchResearch]

I have done this in the rare situation the patient needs IVF/meds/access however has no other indication for a CVL, all other U/S PIV sites have failed, and yet the pt is likely to be discharged. At this point (which is very rare) if the pt needs to be admitted I would probably just put in a CVL and spare the med director the fall out.

This is a great area for research.

U/S guided IJ access with the long 18g angiocath is so easy and (imo) safe, but you need a few hundred safely inserted documented cases and a few ACEP articles as well as local institutional approval to make it within standard of care.

The way to get around having to do this is being good at U/S PIV insertion. Takes maybe 5 sec longer because you have to tie a tourniquet but is within SOC.

The majority of CVLs I place are in awake patients with peripheral access who need levophed for a short (<24 hr ) time period.

Literature is growing regarding the safety of peripherally administered vasopressors, however at present this is not standard at most institutions.

EM academic people: design a study comparing the safety of a 2.5 inch 18 gauge angiocath IJ placed under U/S guidance to the traditional triple-lumen CVL for awake, oriented septic patients who need a MAP >65 to be accepted by hospitalist services. End result is decreased complication rate with equal/superior results. Pull the angiocath within 24hr.

Guaranteed publication/paper/conference trip for any resident who convinces their director to approve the project and follows it through.

I've placed few or possibly zero central lines in the five months since residency. At the big hospital, I call the critical care doc, unless they're getting killed worse than us, they'll generally place them upstairs, run peripheral pressors overnight on patients we expect will be off pressors by next day, or have a PICC placed. If they ask, I can place it downstairs. Frankly, they like the extra procedures, and I have more patients to see. It's a little weird how my thoughts on that have changed so much in five months. At our single coverage sites, no one I'm placing a central line in can stay, so I transfer on peripheral pressors. We used the easy IJ in residency, haven't needed it since then. I'm really not sure how sterile you need to be for those.

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[shoal007]

I've placed few or possibly zero central lines in the five months since residency. At the big hospital, I call the critical care doc, unless they're getting killed worse than us, they'll generally place them upstairs, run peripheral pressors overnight on patients we expect will be off pressors by next day, or have a PICC placed. If they ask, I can place it downstairs. Frankly, they like the extra procedures, and I have more patients to see. It's a little weird how my thoughts on that have changed so much in five months. At our single coverage sites, no one I'm placing a central line in can stay, so I transfer on peripheral pressors. We used the easy IJ in residency, haven't needed it since then. I'm really not sure how sterile you need to be for those.

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It sounds like your working at my shop. 2.5 years and have only put in 1 central line. 40k+ visits and plenty of sick people. We just run pressors peripherally, it's group standard of care.

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[TheTruckGuy]

So I've been really wanting to try this on patients where the nurses can't get an IV, but attendings appear too scared to allow it. I showed them the data posted above, still don't want to. I feel like it'd be so much faster than trying to fiddle around getting a basilic US guided IV, or even having to rely on the IV team.

 

[RustedFox]

So I've been really wanting to try this on patients where the nurses can't get an IV, but attendings appear too scared to allow it. I showed them the data posted above, still don't want to. I feel like it'd be so much faster than trying to fiddle around getting a basilic US guided IV, or even having to rely on the IV team.

The answer you're getting is the worst one of them all:
"We don't do that. Because reasons."

 

[Zebra Hunter]

So I've been really wanting to try this on patients where the nurses can't get an IV, but attendings appear too scared to allow it. I showed them the data posted above, still don't want to. I feel like it'd be so much faster than trying to fiddle around getting a basilic US guided IV, or even having to rely on the IV team.

Can’t do this as a fresh intern, but if you’re an upper level and in good standing, and have a good relationship with the attending you're working with, just do it and don’t ask for permission. I’m not talking about doing procedures like intubation or chest tubes where there are risks of major complications, but EJs/Easy IJs/US guided IVs/abscess drainage/lac repairs/nerve blocks I do these prior to even telling the attending about the patient, which is to be expected of upper level residents.

 

[namethatsmell]

I have done this in the rare situation the patient needs IVF/meds/access however has no other indication for a CVL, all other U/S PIV sites have failed

Just did one for this scenario while I️ was single coverage in a dumpster fire of an evening. Saves so much time, pt got what he needed with less morbidly than a cvc, rest of the dept didn’t suffer from a 20 min absence.

Tangential question: do any of your shops allow an RN or tech to position/clean/drape your CVC site after you mark it for them? That’s 10-15 min when I️ could be doing something else. If I️ could walk into a pt already prepped and draped the rest would only take ~5 mins.


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[littlejuan]

So do you guys use a probe cover, sterile gel, cover etc for these? I assume not if its much faster.

 

[gro2001]

Can’t do this as a fresh intern, but if you’re an upper level and in good standing, and have a good relationship with the attending you're working with, just do it and don’t ask for permission. I’m not talking about doing procedures like intubation or chest tubes where there are risks of major complications, but EJs/Easy IJs/US guided IVs/abscess drainage/lac repairs/nerve blocks I do these prior to even telling the attending about the patient, which is to be expected of upper level residents.

That's a terrible suggestion. BigTruck's attendings have specifically made it clear that they are uncomfortable with adopting this practice. If a PGY3/4 told me they had drained an abscess or repaired a lac before letting me know, I would totally ok with it. In fact, I would prefer it that way most of the time. I've had years to supervise them and teach them the "right" (ie: my) way of doing it and I trust them to do that. But if they did a procedure that they knew me or other faculty were not fully aboard with, and thats why they did it before telling me, I would definitely not be ok with it. That would seem like a serious professionalism issue, to be honest.

 

[Zebra Hunter]

That's a terrible suggestion. BigTruck's attendings have specifically made it clear that they are uncomfortable with adopting this practice. If a PGY3/4 told me they had drained an abscess or repaired a lac before letting me know, I would totally ok with it. In fact, I would prefer it that way most of the time. I've had years to supervise them and teach them the "right" (ie: my) way of doing it and I trust them to do that. But if they did a procedure that they knew me or other faculty were not fully aboard with, and thats why they did it before telling me, I would definitely to be ok with it. That would seem like a serious professionalism issue, to be honest.

Meh, feign ignorance and don’t do it again if they are that upset after it has already been done. I’ve got many old school attendings to adopt new practices by just doing them without asking (push dose pressors, Easy IJs, apneic oxygenation, nerve blocks). The key is that you already have a good relationship with the attending. Sometimes attendings need to be coaxed into 2018, and no amount of literature you provide them will change their mind.

 

[DrDrummer]

Hot off the press: http://www.annemergmed.com/article/S0196-0644(17)31531-7/abstract

Michael Gottlieb and Frances Russell put together an overview of the "Easy IJ" or peripheral US-guided IJ line. They reviewed five studies of various quality which reported complication rates, methods, and time to placement. While these studies were not powered to say that such practice is definitively risk-free, it seemed fast, generally safe (no identified complications relating to the IV placement in 151 patients in the included studies), and easy for practitioners to do. They review the various inclusion criteria, and some of the potential pitfalls (i.e. many of the patients were discharged from the ED, so this might not extrapolate to patients who would be admitted and have to wait a while for a PICC or something).

Good overview if you're looking to get buy-in from leadership or nursing, I think.

 

[Jlaw]

I used this for the first time the other day and it worked BEAUTIFULLY! My attending was initially hesitant but after the nurse tried five times, and I blew out 5 US guided attempts with the patient now crying hysterically, I said ok either you (the attending) try or I'm doing an Easy IJ. This was 20 minutes before shift change after a busy overnight so they quickly acquiesced and 2 minutes later we had access. FWIW I used a little lido prior and the patient said she didn't feel a thing.

I'm sure our medicine team was like wtf when she got upstairs, but whatever. They probably thought it was an EJ. Some at my shop use the long angiocaths for subclavian lines in code situations and apparently they work great, I haven't had the opportunity to try.

 

[Angry Birds]

I used this for the first time the other day and it worked BEAUTIFULLY! My attending was initially hesitant but after the nurse tried five times, and I blew out 5 US guided attempts with the patient now crying hysterically, I said ok either you (the attending) try or I'm doing an Easy IJ. This was 20 minutes before shift change after a busy overnight so they quickly acquiesced and 2 minutes later we had access. FWIW I used a little lido prior and the patient said she didn't feel a thing.

I'm sure our medicine team was like wtf when she got upstairs, but whatever. They probably thought it was an EJ. Some at my shop use the long angiocaths for subclavian lines in code situations and apparently they work great, I haven't had the opportunity to try.

Amazing how medical management can change 20 minutes before shift change. Awesome job!

 

[WilcoWorld]

I feel like @GeneralVeers made a good argument in favor of this sometime ago, but I can't recall what it was...

 

[leviathan]

I think you'd just consider it a peripheral IV, as the terminology for a central line would be something that terminates in the SVC or IVC.

 

[slatermd]

We have a solution for that: midodrine.

Yeah. Who needs IV access in the ED? Just give PO midodrine to your patients in shock. Your hospitalist will accept them without access as long as their MAP is >65. When they get upstairs, a floor nurse will casually pop an IO (no questions asked) to administer the rest of their lifesaving treatments.

 

[KinesiologyNerd]

Yeah. Who needs IV access in the ED? Just give PO midodrine to your patients in shock. Your hospitalist will accept them without access as long as their MAP is >65. When they get upstairs, a floor nurse will casually pop an IO (no questions asked) to administer the rest of their lifesaving treatments.

That wasn't my point and you know it.

 

[slatermd]

That wasn't my point and you know it.

Lol. We’d probably be friends IRL. But here on SDN...nemeses

 

[MechEDoc]

That wasn't my point and you know it.

Admit? You're chicken. Rx for midodrine prn presyncope + Z-pack and PCP (oops, PA or NP!) f/u sometime in the next eon for repeat evaluation... Oh, make sure they self titrate gatorade to urine output or they'll die. Just keep them in the ED for their lifesaving delta lactate...