Pointers for central lines

[BoardingDoc]

---

Members don't see this ad.

make sure the bevel is pointed medially

I feel like I'm missing something here. How are you orienting a bevel medially when doing a subclav? I feel like the only options are anterior/posterior/cranial/caudal. In this case, I would orient it caudal and ensure the hook on the wire aims that way as well.

 

[WilcoWorld]

I feel like I'm missing something here. How are you orienting a bevel medially when doing a subclav? I feel like the only options are anterior/posterior/cranial/caudal. In this case, I would orient it caudal and ensure the hook on the wire aims that way as well.

I thought the question was about the supraclavicular approach, so that's what I was replying to. I agree that in a subclavicular approach the bevel should be caudally oriented, and in either case if you can make the hook of the wire bend in the direction of venous return to the heart you'll do even better.

 

[Groove]

Do you use any specific tricks to make the wire go to the right place? That's the only issue I've run into with this approach. Anecdotally, I found compressing the ipsilateral IJ may help prevent it from going up instead of down but I'd like to learn other techniques. I like the US guided subclavian for comfort reasons on people who are able to be calmly talked through line placement and cooperate with positioning.

I orient the bevel of the needle in the direction of the vein. Before threading the wire, I push a little bit of the wire out and verify which direction it will be curling. Then I rotate and thread the wire where the curl will be facing the direction of the vein where I want it to proceed. If I'm using the US, I then glance briefly at the major veins nearby to make sure it's not going in the wrong direction, otherwise I re-thread. With this technique, I can't remember the last time I had a wire go in the wrong direction. Keep in mind, my usual line is an infraclavicular subclavian and I prefer the R side which is an even more acute angle. You just have to be cognizant of the curl on the wire and making sure it's oriented in the direction that you want to line to progress. I sometimes forget to orient the bevel of the needle and as long as I'm focused on the wire, it still always threads in the right direction.

 

[RustedFox]

I orient the bevel of the needle in the direction of the vein. Before threading the wire, I push a little bit of the wire out and verify which direction it will be curling. Then I rotate and thread the wire where the curl will be facing the direction of the vein where I want it to proceed. If I'm using the US, I then glance briefly at the major veins nearby to make sure it's not going in the wrong direction, otherwise I re-thread. With this technique, I can't remember the last time I had a wire go in the wrong direction. Keep in mind, my usual line is an infraclavicular subclavian and I prefer the R side which is an even more acute angle. You just have to be cognizant of the curl on the wire and making sure it's oriented in the direction that you want to line to progress. I sometimes forget to orient the bevel of the needle and as long as I'm focused on the wire, it still always threads in the right direction.

Are you a lefty?

 

[Apollyon]

Are you a lefty?

I am, and the right SCL was always my go-to. In fact, I don't recall ever putting one in on the left side. Hey, it saved me from causing a chylothorax!

 

[Groove]

Are you a lefty?

No, I'm right handed actually. I just always liked the theoretical slightly lower lung apex on the right as well as avoidance of the thoracic duct altogether. Although I'm aware of the anatomical "line of sight" advantage on the left, I just never really had any problems with wire or catheter malposition on the right. I think I figured out how to orient the wire early on in training and just never really had problems with that on SCL lines. It's probably mental too because I learned on the right side and for whatever reason it always feels more natural to me.

 

[The Knife & Gun Club]

No, I'm right handed actually. I just always liked the theoretical slightly lower lung apex on the right as well as avoidance of the thoracic duct altogether. Although I'm aware of the anatomical "line of sight" advantage on the left, I just never really had any problems with wire or catheter malposition on the right. I think I figured out how to orient the wire early on in training and just never really had problems with that on SCL lines. It's probably mental too because I learned on the right side and for whatever reason it always feels more natural to me.

How common are these catheter malpositions?

I had my first one today on an IJ and was honestly totally unsure of if there was anything I could’ve done to prevent it.

Attending told me to angle the wire differently during insertion but I can’t understandwhy that would even matter...

 

[thegenius]

How common are these catheter malpositions?

I had my first one today on an IJ and was honestly totally unsure of if there was anything I could’ve done to prevent it.

Attending told me to angle the wire differently during insertion but I can’t understandwhy that would even matter...

I once did an IJ and the catheter went down the IJ and did a 180 turn and went up the EJ. Ended up in his brain (well it looked like it on the xray but it wasn't close to his brain...)
I never would have guessed. the catheter very easily went into the body.

Shiit happens. That's why we get an xray! (and why I like femoral's because they can only go one direction).

 

[WheezyBaby]

I once did an IJ and the catheter went down the IJ and did a 180 turn and went up the EJ. Ended up in his brain.
I never would have guessed. the catheter very easily went into the body.

Shiit happens. That's why we get an xray! (and why I like femoral's because they can only go one direction).

I did this with a vascath up the contralateral IJ. ****

 

[Groove]

How common are these catheter malpositions?

I had my first one today on an IJ and was honestly totally unsure of if there was anything I could’ve done to prevent it.

Attending told me to angle the wire differently during insertion but I can’t understandwhy that would even matter...

The wire curls in a certain direction. Make sure the curl is in the direction that you want the wire to travel. If I'm doing a R IJ and I make it curl to the left, it's prone to cross to the L SCL. If I aim it to the right, it's prone to go into the R SCL. If I aim it towards the chest, it's prone to continue traveling down the IVC. Barring anatomical hindrances outside your control, with good technique, malpositions are very uncommon. If you're doing it by US, don't forget to glance at the other vessels while you're gowned up. That way you don't take everything off, shoot a CXR, see it's malpositioned and then have to gown up, get sterile and do it all over again. If I'm doing an US guided line in the chest or neck, I prep both sides of neck and both sides of chest with chlorhexidine. Once the wire is in, it's a quick scan to make sure the wire isn't malpositioned. If it is, you can address it then and not later.

 

[turkeyjerky]

I once did an IJ and the catheter went down the IJ and did a 180 turn and went up the EJ. Ended up in his brain (well it looked like it on the xray but it wasn't close to his brain...)
I never would have guessed. the catheter very easily went into the body.

Shiit happens. That's why we get an xray! (and why I like femoral's because they can only go one direction).

I saw a blog post not too long ago and the author maintained that malposition of femoral lines was probably far more common than realized, but it goes unrecognized b/c we never really check placement. Also that malposition is inconsequential most of the time.

I wonder if the direction of the bend in the wire really matters much--it's a fairly tight bend and unless it's exiting the needle at exactly at the confluence of the IJ and SC, I wouldn't think it has that much effect.

 

[Groove]

I wonder if the direction of the bend in the wire really matters much--it's a fairly tight bend and unless it's exiting the needle at exactly at the confluence of the IJ and SC, I wouldn't think it has that much effect.

Direction of the J-tip of the guidewire, in seldinger technique, is a significant factor in misplacement of subclavian vein catheter: a randomized, controlled study - PubMed

Misplacement of central venous catheters, predisposing to poor functioning including inability to aspirate blood, is common with the subclavian approach. In this prospective study we sought to determine whether the direction of the guidewire J-tip influenced the catheter tip placement during...

pubmed.ncbi.nlm.nih.gov

 

[WheezyBaby]

Direction of the J-tip of the guidewire, in seldinger technique, is a significant factor in misplacement of subclavian vein catheter: a randomized, controlled study - PubMed

Misplacement of central venous catheters, predisposing to poor functioning including inability to aspirate blood, is common with the subclavian approach. In this prospective study we sought to determine whether the direction of the guidewire J-tip influenced the catheter tip placement during...

pubmed.ncbi.nlm.nih.gov

Thanks for sharing, love to see that there's actually data for this

 

[turkeyjerky]

Direction of the J-tip of the guidewire, in seldinger technique, is a significant factor in misplacement of subclavian vein catheter: a randomized, controlled study - PubMed

Misplacement of central venous catheters, predisposing to poor functioning including inability to aspirate blood, is common with the subclavian approach. In this prospective study we sought to determine whether the direction of the guidewire J-tip influenced the catheter tip placement during...

pubmed.ncbi.nlm.nih.gov

Damn. Thanks for the paper

 

[WilcoWorld]

I saw a blog post not too long ago and the author maintained that malposition of femoral lines was probably far more common than realized, but it goes unrecognized b/c we never really check placement. Also that malposition is inconsequential most of the time.

Kinda makes you wonder how bad it actually is if the tip of your catheter ends up in the EJ or somewhere like that.

 

[bravotwozero]

I've had my IJ end up in the azygous vein. Thought that was weird, though I'd argue there's no real point in repositioning that, still in the vein with good flow.