Pointers for central lines

[agr285]

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So recently I have been having a hard time placing central lines (IJ with ultrasound) on non-intubated/paralyzed patients. Obviously most of these patient are ill/hypotensive but still alert enough to thrash around while I'm trying to place the line, making it much more difficult. Given their low blood pressure and crappy vitals, nurses are understandably uncomfortable giving sedating medication. Any thoughts or tips.

 

[Apollyon]

There's a good thread in the surgery forum about this. It's on the first page, and recently posted in, so, it's near the top.

 

[Porfirio]

Use the catheter needle.

 

[Jabbed]

So recently I have been having a hard time placing central lines (IJ with ultrasound) on non-intubated/paralyzed patients. Obviously most of these patient are ill/hypotensive but still alert enough to thrash around while I'm trying to place the line, making it much more difficult. Given their low blood pressure and crappy vitals, nurses are understandably uncomfortable giving sedating medication. Any thoughts or tips.

Anything less than GCS 15 calm, oriented, and following commands gets at least bilateral soft wrist restraints and some form of sedation. I will routinely give either ketamine, versed, or fentanyl depending on circumstances.

If RSI'ing, give 1 mg/kg roc and then place your lines immediately after intubation.

If the issue is pain-related, make sure that you get a good distribution of anesthetic. I will often do SCP blocks for temp HD caths in the right IJ as the multiple dilators can be very painful.

When in doubt, go for the groin.

 

[Tenk]

As someone who has had versed during multiple procedures, give 1-2 mg versed. I give versed for lines, NG tubes, or any other minor but invasive procedure where the patient is not intubated. I give ketamine for chest tubes and propofol for reductions. Never have any problems with people moving.

 

[thegenius]

As someone who has had versed during multiple procedures, give 1-2 mg versed. I give versed for lines, NG tubes, or any other minor but invasive procedure where the patient is not intubated. I give ketamine for chest tubes and propofol for reductions. Never have any problems with people moving.

100% agree....I always give 2 mg versed when doing an LP for instance. It is so much easier

 

[Tenk]

100% agree....I always give 2 mg versed when doing an LP for instance. It is so much easier

Yes, this! I couldn’t remember what other common procedure I do it for: LP. Probably because I hate them so much I try to block them out of my mind. Thanks.

 

[EMdoc10]

As someone who has had versed during multiple procedures, give 1-2 mg versed. I give versed for lines, NG tubes, or any other minor but invasive procedure where the patient is not intubated. I give ketamine for chest tubes and propofol for reductions. Never have any problems with people moving.

Thanks Tenk, I definitely under-utilize these. Is it pain-dose Ketamine at 0.3 mg/kg? Are your Versed and Ketamine for above indications being documented as procedural sedation?

 

[thegenius]

Thanks Tenk, I definitely under-utilize these. Is it pain-dose Ketamine at 0.3 mg/kg? Are your Versed and Ketamine for above indications being documented as procedural sedation?

No it's not procedural sedation. My order is "versed 2 mg IVP once PRN anxiolysis" and of course I always give it. No documentation needed for procedural sedation.

 

[southerndoc]

A lot of patients get anxious under the drape. If they're awake, throw them on a non-rebreather. It'll keep oxygen flowing and they won't feel like they are suffocating or getting hot under the sterile drape.

 

[clibby]

Lots of lidocaine both subQ and u/s into the surrounding muscles (review some painless/less painful lidocaine injection videos to help improve your approach to injecting lidocaine), a nurse/medic/tech to help hold the patient's head, raise the legs and/or modified Trendelenburg to plump up the IJ, and talk the patient through what you are doing. If you can avoid their face being tightly covered, it helps with anxiety in addition to a nurse holding their hand and talking to them under the drape.

If that doesn't work and their habitus allows, go femoral and restrain their arms and legs.

 

[Tenk]

Thanks Tenk, I definitely under-utilize these. Is it pain-dose Ketamine at 0.3 mg/kg? Are your Versed and Ketamine for above indications being documented as procedural sedation?

The ketamine I give for non traumatic arrest chest tubes is a procedural sedation dose of 1-2 mg/kg. I do a formal procedural sedation for this. I still inject lidocaine for when they wake up. Patients really appreciate this (ketamine) as I’ve asked afterwards. I saw plenty of awake patients in residency to know they did not enjoy it.

The versed can be documented for either pain or anxiety and doesn’t need procedural sedation documentation as long as you don’t coadminister an opiate. Again from personal experience it’s one hell of a pain medication because you give zero ****s about anything. I had an anesthesiologist putting an art line in my arm and I’m just staring at her in my head going: “wait, I know how to do that... should I ask her if she needs help??? Naaaaaa, she’s good.... wait where am I?”

 

[SpacemanSpifff]

Try a superficial cervical plexus block. Dense anesthesia with a simple block.

 

[sylvanthus]

Use the catheter needle.

Totally agree, most people F up when they try and remove the syringe from the straight needle and move it back and forth and either go through the vessel or back out. Much better to get good return, slide the catheter in and feed the wire through the catheter.

 

[Groove]

So recently I have been having a hard time placing central lines (IJ with ultrasound) on non-intubated/paralyzed patients. Obviously most of these patient are ill/hypotensive but still alert enough to thrash around while I'm trying to place the line, making it much more difficult. Given their low blood pressure and crappy vitals, nurses are understandably uncomfortable giving sedating medication. Any thoughts or tips.

Lots of good tips in here but are you sure you’re anesthetizing the skin and subcutaneous tissues prior to the procedure? Maybe I’ve gotten lucky, but I’ve never had to give sedation or large doses of IV analgesia prior to an IJ CVL. I give oxygen as @southerndoc mentioned and/or have the nurse open the drape and talk with them. My technique seems to be similar to @clibby . Before hand, I explain the procedure in detail as well as the importance of holding their head still and I generously anesthetize the neck with lidocaine. They should feel nothing but pressure. If they are too uncooperative/agitated and don’t warrant intubation/paralytics then I go femoral.

Perhaps you are selecting patients too far in the agitated category where you really shouldn’t be picking a CVL location where your needle tip is mere millimeters from their carotid. For those, just make your life easier and go groin. That...or tube/paralyze them.

 

[Radetzky]

+1 for superficial cervical plexus block

 

[Jabbed]

Try a superficial cervical plexus block. Dense anesthesia with a simple block.

Are you doing this at the time of placing the line or 15-20 minutes before? In-plane or out-of-plane?

I only really do this for HD caths and give it a solid 20 minutes before setting up. If an out-of-plane block is effective 30 seconds before the procedure I'd do it more routinely.

 

[Radetzky]

Are you doing this at the time of placing the line or 15-20 minutes before? In-plane or out-of-plane?

I only really do this for HD caths and give it a solid 20 minutes before setting up. If an out-of-plane block is effective 30 seconds before the procedure I'd do it more routinely.

What are you referring to with in plane vs out of plane? I do it without USS, seems to work well.

 

[SpacemanSpifff]

Are you doing this at the time of placing the line or 15-20 minutes before? In-plane or out-of-plane?

I only really do this for HD caths and give it a solid 20 minutes before setting up. If an out-of-plane block is effective 30 seconds before the procedure I'd do it more routinely.

As far as the needle approach goes, in plane. Procedure that seems to work best is: pre-scan the IJ you intend to use, ensure no clot or other surprises, do the block at that point with lidocaine, and then proceed with the line. Usually try to give 5-10 minutes prior to needlestick - so not an approach to use with crash lines.

 

[Rekt]

Lots of good tips in here but are you sure you’re anesthetizing the skin and subcutaneous tissues prior to the procedure? Maybe I’ve gotten lucky, but I’ve never had to give sedation or large doses of IV analgesia prior to an IJ CVL. I give oxygen as @southerndoc mentioned and/or have the nurse open the drape and talk with them. My technique seems to be similar to @clibby . Before hand, I explain the procedure in detail as well as the importance of holding their head still and I generously anesthetize the neck with lidocaine. They should feel nothing but pressure. If they are too uncooperative/agitated and don’t warrant intubation/paralytics then I go femoral.

Perhaps you are selecting patients too far in the agitated category where you really shouldn’t be picking a CVL location where your needle tip is mere millimeters from their carotid. For those, just make your life easier and go groin. That...or tube/paralyze them.

Agree. Really surprised how much sedation people are using. I used nothing more than lidocaine for all my awake CVLs so far and rarely had issues that were related to the procedure itself. Tell them it's going to be very uncomfortable and hot. Tell them why they need to stay still, etc. Use the US to watch where you anesthesize. I go almost all the way to IJ and you can see tissue separation and inject as you pull out. I see too many people spend way too much lidocaine making a wheal superficially at the skin and don't bother with further numbing lower. Same issue I see for a lot of LPs too.

 

[Arch Guillotti]

I agree that this is often the way many mess up from my brief prior teaching experience. One key point is to make sure you don’t have the needle plastered onto the syringe tightly from the start. If it is fairly loose it should come off easily with the left hand moving to stabilize the needle once you get blood return and the right hand then gently twisting off the syringe. I became facile with this technique and never really liked using the catheter needle technique because it seemed like a brief extra step, almost like a double seldinger technique.

I will admit though for femoral arterial lines sometimes I’ll just insert the needle not connected to a syringe at all as a non-completely tanked arterial pressure can give you blood return without needing to then even bother with removing the syringe.

I would not use a syringe at all for an arterial line if done using ultrasound.

 

[Arch Guillotti]

Try a superficial cervical plexus block. Dense anesthesia with a simple block.

Humor me. Why would you do this block for a central line instead of the usual route?

 

[Jabbed]

What are you referring to with in plane vs out of plane? I do it without USS, seems to work well.

Orienting the needle to parallel (in-plane) or perpendicular (out-of-plane) to the ultrasound probe.

 

[Jabbed]

Humor me. Why would you do this block for a central line instead of the usual route?

I was skeptical at first but it really makes IJ HD caths a painless procedure. It's also a good block to be proficient with for clavicle fractures.

 

[Arch Guillotti]

I was skeptical at first but it really makes IJ HD caths a painless procedure. It's also a good block to be proficient with for clavicle fractures.

Got it. I have done a few for clavicle fractures and they work OK depending on where the fracture is.

 

[Arch Guillotti]

I pretty much always place under US guidance. Even with US sometimes the syringe can be helpful, particularly with arrested or post-arrested patients with pressure in the tank or no pressure. Sometimes the needle alone also gets lost in the crevasse of the pannus in morbidly obese patients if truly shooting for the common femoral artery and particularly with ongoing chest compressions. Syringe also allows for a quicker ABG than waiting to pull from the line.

Your point is well taken. Blood should squirt out the end of the needle with "effective" chest compressions though.

 

[SpacemanSpifff]

Humor me. Why would you do this block for a central line instead of the usual route?

It's something I've been trying out - doesn't add a whole lot of time to the procedure, seems to be potentially more effective than a simple wheel and dump. I echo @Jabbed for larger bore lines the effect is probably greater.

 

[southerndoc]

Agree. Really surprised how much sedation people are using. I used nothing more than lidocaine for all my awake CVLs so far and rarely had issues that were related to the procedure itself. Tell them it's going to be very uncomfortable and hot. Tell them why they need to stay still, etc. Use the US to watch where you anesthesize. I go almost all the way to IJ and you can see tissue separation and inject as you pull out. I see too many people spend way too much lidocaine making a wheal superficially at the skin and don't bother with further numbing lower. Same issue I see for a lot of LPs too.

I think the only time sedation is warranted for a CVL is when the patient is acting erratic. I'm thinking the elderly demented patient who is septic who cannot lie still, reaches for their face all the time, etc.

I do, however, sedate patients getting LP's. Well, I give them meds for "anxiety." I also use Versed. I hate LP's and it's my worst skill. I feel like it helps me as much as it helps the patient. I remember when I was in Zambia I had to do LP's without lidocaine (lignocaine as they called it) because there was none available. People would sit still for them... they were tough. Luckily I was much better at LP's then than I am now. I rarely do LP's myself because our residents do almost all of them. The only time I do one is on days they are in lecture.

 

[Arch Guillotti]

I think the only time sedation is warranted for a CVL is when the patient is acting erratic.

I am not an ER doc but I disagree strongly. If I were a patient that needed an IJ I would want sedation. Stinks to be tilted on your head with a drape over your face and a needle in your neck.

 

[Arch Guillotti]

It's something I've been trying out - doesn't add a whole lot of time to the procedure, seems to be potentially more effective than a simple wheel and dump. I echo @Jabbed for larger bore lines the effect is probably greater.

How often are you guys placing dialysis catheters in the first place?

 

[SpacemanSpifff]

How often are you guys placing dialysis catheters in the first place?

Not terribly frequently in the ED - maybe 5 or so as a junior resident. I rotate through the MICU a lot, and do several per week up there.

 

[southerndoc]

How often are you guys placing dialysis catheters in the first place?

I've placed 3 in my 10-year career at a 150,000/year volume ED. So not frequently at all.

 

[GeneralVeers]

Never done one. Just call IR in to do it and move on...

 

[clibby]

I am not an ER doc but I disagree strongly. If I were a patient that needed an IJ I would want sedation. Stinks to be tilted on your head with a drape over your face and a needle in your neck.

We don't do CVLs on stable patients and the risks of adaquete sedation often outweigh the benefits. If the patient is stable, why do they need a CVL in the ED anyway? Once all my stuff is in the room, it only takes ~10 min to place a sterile line. I usually give the lidocaine before I make a sterile field to give it time to work. I personally don't usually have issues with pain. If you are so delirious that you can't stay still, then you aren't likely to remember much anyway and again, the risks of sedation often aren't worth it and there are other ways to mitigate anxiety as others have noted.

How often are you guys placing dialysis catheters in the first place?

Depends on the shop and the shift you work. Getting IR to come in between 8p-8a on a patient with a K of 8 can be more work than placing them myself especially if they are going to board in the ED or the MICU is busy. I probably did a dozen in the ED during a 3 year residency (lots more in the MICU); less as an attending but not zero. (i.e. I placed one 2 shifts ago)

 

[Siggy]

A lot of patients get anxious under the drape. If they're awake, throw them on a non-rebreather. It'll keep oxygen flowing and they won't feel like they are suffocating or getting hot under the sterile drape.

THIS... especially for trialysis catheters since the drape is much heavier. Those always get either a ventimask or a NRB.

 

[Siggy]

How often are you guys placing dialysis catheters in the first place?

In my critical care fellowship I've been called to the ED multiple times for HD catheters in unstable, hyperkalemic patients. It's always a wonder since the only difference between a CVC and a trialysis catheter is you dilate twice and if you let up pressure between the second dilator and the catheter it bleeds a lot. It's the same skill in a patient suffering from a life threatening emergency in an emergency department.

 

[GeneralVeers]

I placed multiple HD catheters during my ICU months in residency. I also changed out several triple lumen catheters over a guidewire for HD catheters once the patient was in the ICU. I’ve rarely ever placed HD catheters in the ED during residency or as an attending. Nephrology is very unlikely to emergently dialyze a patient right out of the ED in most places. Placing a HD catheter isn’t particularly hard. I can’t ever imagine calling someone to come to the ED to place for me. If a hyperkalemic patient is temporarily stabilized medically in the ED, I could though see an HD catheter being placed later down the line in the ICU for dialysis.

Right. They almost never get emergent dialysis. The hyperkalemic, renal failure patient can be medically temporized overnight if necessary

 

[Siggy]

Right. They almost never get emergent dialysis. The hyperkalemic, renal failure patient can be medically temporized overnight if necessary

...and I've seen those patients die shortly after they left the ED. As in come to the ED, place the line, move patient to the ICU with the dialysis machine waiting, and they code basically in the elevator. I don't think I've met a nephrologist yet that wouldn't dialize an AKI with a potassium of 7 or 8 with EKG changes emergently at any time.

 

[clibby]

I’d argue most CVCs done in the ED are done in quasi-stable, critically ill patients. You really shouldn’t be placing many crash central lines as IO or proximal large bore PIVs work about as well and more quickly in unstable patients.

Also not sure I understand how the risk of sedation outweighs the benefit. If a patient really does need a central line for whatever reason the benefit already might outweigh the risk of sedation (assuming sedation and not local anesthetic, anxiolysis or intubation/deep sedation is needed). I’d argue that the risk of sedation really means poorly prepared for and/or performed sedation. As EPs we should be good at sedating critically ill patients. Sure, some urgent, but non-emergent, poor sedation candidates should go to the OR with anesthesia, but if it truly is emergent you need to be comfortable as an EP sedating a critically ill patient.

I guess my point is that I almost never place lines just for access in the age of US, IO, and ez-IJ. If they are awake and need a line in the ED it is because they need pressers, 17 drips, or meds best given centrally and therefore there is a risk to sedation. Could I give them sedation? Sure, but why when it can affect BP that I am worried about and they don't often need it. Maybe I have been really lucky, but with enough lidocaine and a nurse I have been able to avoid sedation even in my severe DKA-ers and my delirious, septic, non intubated old people. Otherwise, why aren't they tubed or conversely why do they need the line in the ED vs the ICU when they have had more time to be resuscitated? It isn't whether I can, but more about whether I should.

 

[Rekt]

HD catheters probably going to vary by program and attending time of training. Imo specialists are getting lazier and lazier and trying to not do anything. Subsequently, in intern year I hit almost ten HD catheters in the ED alone, not sure how many I did micu. Although I do actively seek out sick patients heavily so probably skewed. Essentially the same thing as a CVL except more nerve wracking with the double dilation.

 

[BoardingDoc]

I like the superficial cervical plexus block idea. Never done one, but I included a couple links (text vs video) at the bottom of this post that make it look pretty simple. Have been trying to use nerve blocks I never learned in residency a lot more recently. E.g. just started doing posterior tibial blocks for anyone with a bottom of the foot lac (not super common, but very painful to repair normally). Has worked amazingly well for the last 2 I had.

Text/images: Ultrasound-Guided Cervical Plexus Block - NYSORA

Video:

 

[Tiger26]

Use the needle with the catheter and just advance it into the vein like a peripheral IV, which is usually 1/10 the size. Getting something that stays in the vessel is the only difficult part of the whole procedure.

 

[Jabbed]

I like the superficial cervical plexus block idea. Never done one, but I included a couple links (text vs video) at the bottom of this post that make it look pretty simple. Have been trying to use nerve blocks I never learned in residency a lot more recently. E.g. just started doing posterior tibial blocks for anyone with a bottom of the foot lac (not super common, but very painful to repair normally). Has worked amazingly well for the last 2 I had.

Text/images: Ultrasound-Guided Cervical Plexus Block - NYSORA

Video:

Make sure that you're going just deep to the SCM (in, anesthetic should go ABOVE the nerves). Below the superficial cervical plexus is the prevertebral fascia. If you go below the nerve plexus you can do a deep cervical plexus / brachial plexus block inadvertently. Also worth reviewing posterior triangle neck anatomy to understand the transition from the scalenes to the levator scapula.

With all that said, it's a very easy block technically.

 

[Buckeye1992]

Anyone routinely do landmark subclavians?

 

[southerndoc]

Anyone routinely do landmark subclavians?

Yes

 

[Jabbed]

Anyone routinely doing supraclavicular subclavians?

 

[Fox800]

I work at a CAH with no ICU, so the need for central lines is rare (patient gets flown out and they get placed at the receiving ICU). Can usually save the day with an US-guided PIV. From a personal standpoint, I find that IJ CVCs are my least favorite. The patient moves around, they don't like the drape, etc. It's still my go-to, but I don't enjoy it. If the patient isn't turbo-obese but is tubed/lying flat, I'll go femoral all day.

I have taken to the ultrasound-guided infraclavicular subclavian. Easy to visualize both the subclavian artery in vein, switch to in-plane view of the vein, boom. Allows you to visualize your needle the entire time, and you can see the pleura underneath to avoid a PTX.

 

[RuralEDDoc]

For those doing subclavaians - I imagine these are all truly emergent, eg sick trauma or crashing medical patient, so you can defend yourself if a pneumo occurs. Is anyone doing these routinely outside of these indications? I’ve seen way more iatrogenic pneumos from subclavians than I ever expected, including one of my own, and it could be hard to defend it if patient not exceptionally sick.

 

[RPedigo]

For those doing subclavaians - I imagine these are all truly emergent, eg sick trauma or crashing medical patient, so you can defend yourself if a pneumo occurs. Is anyone doing these routinely outside of these indications? I’ve seen way more iatrogenic pneumos from subclavians than I ever expected, including one of my own, and it could be hard to defend it if patient not exceptionally sick.

I am at a residency training program, so I supervise my residents doing subclavian central lines in patients with normal coagulation status and where a pneumothorax would not be catastrophic. If they have a tenuous respiratory status and a pneumothorax could be a really big deal I avoid the site. That said, randomized controlled data show it is a great line (https://www.nejm.org/doi/full/10.1056/nejmoa1500964) and the higher pneumothorax rate is counterbalanced by a lower symptomatic thrombosis and lower infection rate. Knock on wood, have placed quite a few of these and have been fortunate to not have a pneumothorax occur (yet). I think it is an important skill for the residents to acquire so when they have the crashing trauma patient who has a cervical spine collar and an open pelvis and you *have* to go subclavian, it is in their wheelhouse. I probably would not be placing as many if not at a program where they needed to acquire the skill though, to be honest...

 

[Jabbed]

For those doing subclavaians - I imagine these are all truly emergent, eg sick trauma or crashing medical patient, so you can defend yourself if a pneumo occurs. Is anyone doing these routinely outside of these indications? I’ve seen way more iatrogenic pneumos from subclavians than I ever expected, including one of my own, and it could be hard to defend it if patient not exceptionally sick.

I would not place a central line in a patient that was not critically ill. The rate of PTX is definitely operator-dependent and likely on the order of 1% for a proficient proceduralist. I personally go back and forth on whether or not to use US for infraclavicular subclavians. I feel safe doing it with or without US, but it is nice to see the vein buckle right before you draw back and know that you're in.