Placing Central Lines

[LGMD]

In the hospital say a patient needs a central line. Say the cardiologist makes the decision that that is what the patient needs. Who places the line, the cardiologist or does a surgeon has to come in and do it?
Thanks

---

Members don't see this ad.

 

[Ashers]

In the hospital say a patient needs a central line. Say the cardiologist makes the decision that that is what the patient needs. Who places the line, the cardiologist or does a surgeon has to come in and do it?
Thanks

I was just on neurology, and the neuro resident would put the line in when we needed it.

Why?

 

[Blade28]

If the cardiologist is in academics, then one of his/her fellows/residents will do it.

But sometimes they're not comfortable, so they'll consult General Surgery.

 

[P Diddy]

If the cardiologist is in academics, then one of his/her fellows/residents will do it.

But sometimes they're not comfortable, so they'll consult General Surgery.

this is amusing, a general surgeon placing a line for a cardiologist or a cardiology fellow who is 'not comfortable' placing lines. I doubt either entity exists.

or perhaps you mean if the medicine residents are uncomfortable? even then, where I trained for residency we would never call Gen Surg to put in lines. In fact, Gen Surg would call us to place IJs when they couldn't place a subclavian. certainly as a cardiology fellow at my institution we are asked by various services to place lines since we have the most experience from placing innumerable venous and arterial lines in the cath lab.

for the OP, cardiologists place their own lines. it is variable for other services, with nonprocedural services like endocrine and ID never placing their own lines. of course, they are rarely the primary service caring for the patient.

p diddy

 

[JonnyG]

My school requires us to place a few to graduate (has to be documented). So far on the wards, it has been whoever wants to do it, does it.

 

[Winged Scapula]

It depends on the environment. During residency and fellowship I rarely, if ever saw surgery consulted for a line on other service's patients. And of course, we would never ask another service to do our lines (except IR when it wasn't emergent on a stable floor patient).

However, at a community hospital I moonlight at, which has no residents, general surgery is almost always consulted for lines...this includes by cardiologists, nephrologists, EM, (I should clarify that most of the EM physicians there are not EM trained), etc. Having a PICC team has been a savior because I have been known to place up to 9 lines in one shift!

I venture that while the cards guys and even the intensivists/critical care guys have the ability to place lines they do not want to spend the time for the little reimbursement it brings.

Bottom line is that the answer highly depends on your community.

 

[Law2Doc]

My school requires us to place a few to graduate (has to be documented). So far on the wards, it has been whoever wants to do it, does it.

Yeah -- at a teaching hospital it's often whoever hasn't done one yet gets to do it. I've seen lines put in by multiple specialties. It isn't something for which they have sought surgical consult.

 

[AmoryBlaine]

At my institution (home to residencies in nearly every field), 95% of central lines are placed by Surg, IR, or the PICC nurses. I don't know a single IM resident or fellow who is comfortable doing them. I suspect that the Pulm/CC fellows can do it but I have never seen them.

 

[njbmd]

At my institution, medicine placed their own lines period. The only vascular access in medical patients done by surgery was tunneled lines. Nephrology fellows placed their own temporary hemodialysis catheters too. Peripherally Inserted Central Catheters (PICC) lines were inserted by Venous Access, a division of interventional radiology. I could go down to the venous access service as an intern and do ten or 15 PICC lines for the experience.

 

[Blade28]

this is amusing, a general surgeon placing a line for a cardiologist or a cardiology fellow who is 'not comfortable' placing lines. I doubt either entity exists.

or perhaps you mean if the medicine residents are uncomfortable? even then, where I trained for residency we would never call Gen Surg to put in lines. In fact, Gen Surg would call us to place IJs when they couldn't place a subclavian.

I wish you worked here then. 🙂 We get consulted all the time to place lines - the one exception being Renal (who are used to VasCaths), and sometimes Cards. We also get consulted by hospitalists, as well as surgical services (Ortho and GU come to mind). I haven't heard of a consult for an IJ, though.

 

[njbmd]

I wish you worked here then. 🙂 We get consulted all the time to place lines - the one exception being Renal (who are used to VasCaths), and sometimes Cards. We also get consulted by hospitalists, as well as surgical services (Ortho and GU come to mind). I haven't heard of a consult for an IJ, though.

I have plenty of friends in programs where General Surgery does all of the central lines. It makes for pooly trained Internal Medicine folks but many do not know (and are not interested ) in learning central venous access. I can imagine that Ortho and GU, if they don't have residents, might want consult for central lines, not because they don't know how to place these lines but because they don't do very many to keep up their skills or don't want to put in the chest tube when the lung "falls".

I don't know where my final place of practice will be but General/Vascular Surgery is the final common denominator when it comes to central venous access in many hospitals. If it turns out that I practice in one those locations, I will be putting in lines (for a nice consultation fee). 😀 It's all part of the job.

 

[Smurfette]

Obvious given all the different scenarios above, it is highly variable.

Where I am: surgery will get consulted for Ortho, OB, GU, ENT, etc. lines as those residents are not trained to do central lines or their attendings do not have privileges for them (afterall, how many central lines will an orthopod place in an average year?). Medicine will usually do their own (but aren't comfortable with subclavians; I've actually had medicine residents, anesthesia residents and a CC fellow ask to watch me do a subclavian since they had never seen/done one)

In the private hospital I rotate at, most of the time it's a surgery consult due to convenience (i.e. a surgery resident is in house 24/7 so anything urgent/emergent goes to us), but some of the private practice guys will do their own.

Picc team or IR does PICCs for long-term ABx or TPN therapy

 

[Blade28]

In the private hospital I rotate at, most of the time it's a surgery consult due to convenience (i.e. a surgery resident is in house 24/7 so anything urgent/emergent goes to us), but some of the private practice guys will do their own.

Sadly this is often the case. I get annoyed when I get the 6 pm consult for central line placement in a patient who's needed IV access for a while.

What's also scary is seeing femoral pseudoaneurysms from an over-reliance on femoral central lines simply because they're "easier."

 

[montessori2md]

At my institution (home to residencies in nearly every field), 95% of central lines are placed by Surg, IR, or the PICC nurses. I don't know a single IM resident or fellow who is comfortable doing them. I suspect that the Pulm/CC fellows can do it but I have never seen them.

So, if you're interviewing for an IM residency, you should ASK if you'll be learning how to place a central line? This never occured to me, I just thought it was one of those things everyone would eventually "feel comfortable with" ....I figured M3s and M4s generally would be given the opportunity if they were willing....is there a reason for this (eg, liability?)?

 

[Blade28]

So, if you're interviewing for an IM residency, you should ASK if you'll be learning how to place a central line? This never occured to me, I just thought it was one of those things everyone would eventually "feel comfortable with" ....I figured M3s and M4s generally would be given the opportunity if they were willing....is there a reason for this (eg, liability?)?

I don't understand your question - are you asking if all residency applicants should ask what the central line policy is at that institution? Or are you afraid that you might end up in an Internal Medicine residency without a lot of central line placement?

 

[SinaiMiami]

I'm a surgery resident at Mount Sinai hospital in Miami. We have a small surgery program here and two large medical residencies. In my experience, medical residents do not know how, and never learn to place central lines. I show them from time to time, and I think they even have to do ten of them to graduate from the program, but I've still yet to see one ever gain confidence or comfort with the procedure. The official policy here is that they are supposed to attept to place a line before consulting surgery, but the reality is that they attept on their own maybe 1% of the time, and only if they are on an MICU rotation and really have nothing else to do and are bored. You would be pretty silly to base any residency selection on whether or not the medicine residents do central lines because truthfully, you will have the opportunity to place central lines in any residency. It's simply a matter of pride versus laziness in whether you will be the one doing them as a medicine resident.

 

[souljah1]

I'm an IM resident at a large academic program. We put our own IJ, Subclavian, and (rarely) femoral lines in - as well as arterial lines, lumbar punctures, thoracenteses and paracenteses. The lines that sometimes IR will assist us with are Dialysis catheters and pheresis catheters in acute leukemics who are coagulopathic. I'm about midway through my residency and I've done a bunch of central lines and arterial lines. In the ICU, we are expected to (and do) all of our own lines when someone hits the unit septic. If there is a rapid response or code, we throw lines in. If someone is a difficult access on the floor and for whatever reason we can't get a PICC in, we put central lines in. I would argue that all of us are competent at putting in central lines (emergently and nonemergently).