Posterior approach to IJ

[neutropeniaboy]

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I used this for the first time the other day, and it was surprisingly easy. Since then, I've used it 4 times for central catheterizations/Perm-A-Cath placements.

After doing a rather unscientific poll, nobody seems to use this approach.

I reasoned that it fell along the lines of "if it ain't broke, don't fix it."

Thoughts?

 

[womansurg]

One of our staff - who did residency at Utah, Onc fellowship at Roswell Park (so I'm not sure from where it originates) - does this exclusively with his tunneled catheters (infusaport, groshong...). So, since HE likes 'em, WE do 'em 😉 .

He says it makes the line lay in a nicer configuration at the neck where it takes the curve - less noticable externally, and I tend to agree. It's also a nice trick to have up your sleeve. More than once I've gotten a posterior stick when it wasn't passing anteriorly for some reason.

 

[droliver]

I personally have never been very successful doing them posteriorly, although a few of my colleagues do it preferably. I just don't have the "zen" for it I guess. Out of somewhere ~ 300 central access procedures, I probably haven't done more then 4-5 posteriorly.

 

[surg]

I've generally only used the posterior approach when I'm desperate to get it in the neck and the anterior isn't working. Why? No good reason. One of my critical care attendings loves it and uses it often, almost everyone else seems to know about it but never use it. Basically, it's an issue of practice for me. To do a posterior approach, I have to sit around and think about it, or check up all the landmarks again to feel as confident as I do performing an anterior approach or a subclavian (both of which I could do in the dark and have basically done so when the rooms were poorly lit and it was night at the VA. I know the real answer should be that I force myself to do it (same way I forced myself to get better at IJ sticks at all), but I guess I'm getting lazy in my old age.

 

[DoctorDoom]

I think "if it ain't broke don't fix it" is right. I have never really been in a position where I had to become proficient at the posterior approach, so I'm not as good at it as I maybe should be. (Kind of moot now for me anyway.) I also sometimes had problems identifying the SCM landmarks on patients, probably from lack of familiarity. Usually I could finagle my way around problems with anterior approach so I used get away with rarely using the posterior approach.

Good on ya if you can do both proficiently, definitely worth having it up your sleeve.

 

[Turkster]

The posterior appproach works better when the patient is able to help, as one clearly needs to see the SCM muscle and it helps to see the EJ, so you dont make a hole in the wrong vessel. Also a skinny neck helps. It is best to ask the patient to turn their head the opposite direction and lift their head up slightly to see the muscle. Therefore cooperation is key. Need to point the needle up slightly and go towards the notch. Then, this is an ideal stick and you will almost always get it. Much easier than anterior. This is also a great way to get access in PEDS, as IJ is one of the largest vessels in the younger kids, where anatomy is easy to see. If the patient is sedated, intubated, it is a hastle to turn their head and its probably best to do the anterior approach.

 

[LaCirujana]

I learned how to put in a central line via the posterior IJ approach as a med student at Utah (must be a Utah thing, womansurg).

The place I'm training at now really isn't so crazy about that method--I got yelled at (gently, but reprimanded nonetheless) by my chief early in the year for going posterior. We generally go anterior around here, but I don't know the specific reasoning behind it.

 

[DoctorDoom]

I think people have this idea that the anterior approach is less of a "blind" stick... you're not as reliant on landmarks alone as you are directly palpating the carotid, maybe the extra palpation gives people the feeling that they have more control over the procedure. That could just be the bias of people who are used to anterior sticks though.

No attending has ever needed a specific rationale to reprimand a resident, right? 😉

 

[njbmd]

Hi there,
I go posterior when anterior isn't working but IJ lines are less tolerated than my standby subclavian. I tend to so subclavian to IJ most of the time. 😀
njbmd

 

[Tenesma]

i definitely believe that knowing different approaches to a vessel makes for a well rounded central-line-placer...

something i'd like to recommend for those who have some extra time on their hands while putting in a line: get a site-right (those portable ultrasound thingies) and draw out the IJ from base to top of the neck with a permanent marker (make sure you keep the skin relatively taught) - then you can start getting a good feel for how the muscles/carotid related to the IJ and can make for interesting approaches to that vessel.

for some reason, in our SICU portable ultrasound is becoming almost a habit - even though i am fully aware that it doesn't change adverse outcomes 🙂 it just makes you all warm and fuzzy 😀

 

[droliver]

njbmd- I think most junior residents initially feel more comfortable with a subclavian stick. As you get older & more paranoid (like me🙂 ) you tend to favor IJ sticks. Many vascular & transplant surgeons also go apoplectic when they see subclavian lines put in because they argue that you inevitably get stenosis from them & you never know when someone will need dialysis access that might get buggered up by venous outflow issues (for upper extremity fistulas & shunts). On those rare occasions I put lines in these days (privledge of rank 😀 ) I try to avoid SC sticks unless they are during trauma resuscitations

Tenesma- I used to be impressed with those site-rites when I was a junior, but I found that you can get misled by those images & you end up putting lines in @ really queer spots in the neck. I never had a complication for it, but I really was unnerved @ how low or lateral I would tend to creep while watching the ultrasound image (you tend to go straight down on the vessel with ultrasound versus the angling/tunneling trajectory when you do it as classically taught)

 

[Tenesma]

droliver- i couldn't agree more about site-rites!!! i can't stand them personally and it somewhat takes the art and fun out of getting a line.... however, for neophytes i think it provides a greater feel for the anatomy, and in tough patients with nasty necks (due to burns, reconstruction, etc) it can provide very valuable (when of course SC or fem. sites are ruined)

 

[DoctorDoom]

Originally posted by droliver
njbmd- I think most junior residents initially feel more comfortable with a subclavian stick. As you get older & more paranoid (like me🙂 ) you tend to favor IJ sticks. Many vascular & transplant surgeons also go apoplectic when they see subclavian lines put in because they argue that you inevitably get stenosis from them & you never know when someone will need dialysis access that might get buggered up by venous outflow issues (for upper extremity fistulas & shunts).

Really? Why? I was always more afraid of the SC than the IJ, for several reasons, but probably because I trained at a transplant/CT center that made SC something you went for after you failed IJ and access was absolutely necessary. Are people usually just more scared of being in the neck?

 

[neutropeniaboy]

Well, I agree it always comes down to attending preference (when you're in the OR) or anatomic circumstances.

Personally, I find the "Save the Subclavian" campaign a little silly. If you need central access, create it where you can. I've created subclavian access on both the vascular and transplant services, and no one has gotten upset about it.

I've used ultrasound before (one of our residents had an "incident" and we were required to use it after the fact; it has since dwindled in use), and I found it cumbersome and unreliable.

Anyway...just curious.

 

[droliver]

"save the subclavian"..... I like that!

In my medical school I had never really heard much about avoiding subclavian access if possible. However, when you do a lot of work with people who do a lot of dialysis access, they really emphacise how you shouldn't jeoparidize those veins when not neccessary & that argument really stuck with me. There has been a lot published in the last few years about the incidence of venous stenosis after central access & the weight of the evidence is pretty clear that subclavian stenosis happens ALOT more often then they used to assume. I have just incorporated this into my daily practices & I now also think that jugular sticks are just much easier a lot of the time then subclavians so it's a pretty easy decision for me

 

[Winged Scapula]

IMHO like most things, it depends on who taught ya, what you're comfortable with, patient anatomy, etc.

I'm currently rotating at one of the local community hospitals and its apparently "lore" that all the residents from my university program do SCs. Not true really, but *I* prefer them only because it was what I was first taught and what I've had more success with (than IJs)/am more comfortable with. However, ask me after I stenose the SC or give a patient a PTx with this approach.

There are attendings (often Transplant or Vascular, as mentioned above) who will specifically request an IJ over a SC - I try to accomodate when I can, but I find a specific request often "jinxes" me and I can't get the one line they want. Better let me to go in and decide for myself! 😉

Now I've never done the posterior IJ approach or even seen it done, but, like others, have read about it. A friend of mine however does it, because HE was taught it, and likes it.

I figure having as many approaches in your arsenal as possible is always a good thing...unfortunately, I'm often not at the luxury of feeling comfortable "experimenting" with a patient.

 

[jawurheemd]

I'm just an ER guy, but I thought that I would chime in. I love the SC -- easy landmarks and for some reason I'm much faster doing them. Our patient population here also leans toward the "thick neck" side -- so IJ's (and SC's for that matter) are a bit harder. In these cases, I have started to use our ER ultrasound machine to help guide me. I don't necessarily do the line with the ultrasound machine on, but I use the machine as part of my prep so that I can visualize the course of the IJ through the neck beforehand. The times that I have used the ultrasound while I'm doing the line, I found the whole process very cumbersome -- it becomes a 2 person job -- sterility is harder to maintain -- etc.

Anyway, just my 2 cents. I have read that in Europe, it's very common to use a supraclavicular subclavian approach to central lines. I'm wondering if anyone has had experience with this approach.

-James

 

[RuralMedicine]

As an intern although I never had any problems or complications with subclavian lines I must admit they made me nervous. On the other hand I loved femoral lines where I could clearly identify the anatomy and stick more confidently knowing where the structures I didn't want to hit were. The first half of my intern year the femoral line was clearly my favorite line. I concede infection risks however I would still argue that a sterilely placed femoral that is not left in for too long may sometimes be the best source of access for some patients.

Halfway through my intern year I became comfortable with IJs and they quickly became my preference for a high line. I mostly use an anterior approach (making it very similar to what I liked about femoral lines as I can identify the SCM and the carotid artery and sweep the artery away from my lateral stick). But yes Kimberli I agree that having many approaches in your arsenal is always a good thing.

Of course the joy of being a med-peds resident is that this month I'm in the NICU putting UACs and UVCs in 26 week preemies.

 

[jawurheemd]

The UVCs and the UACs are the best lines -- you can actually see the vessels! None of this landmark stuff, just sink the line into the vessel under direct visualization. The trick is remembering how far to advance the line.

-James

 

[RuralMedicine]

Actually knowing how far to advance an umbilical catheter is pretty easy if you take into account the birthweight[(3xBW) + 9 approximates the UAC depth]. I always tend to err a little on the high side because you can always pull the line back a little after you get your xray. The real challenge seems to be avoiding creating a false track in the vessel while dilating and keeping your UVC out of the portal circulation (unless you are at an institution that likes low lines, or in a true code situation where you need access to give code drugs in the delivery room- in those cases you can place your UVC to the depth where you get blood return and push your epinephrine).

I'm not sure I'd go so far as to say umbilical lines are the best but I guess we all have our preferences. Personally I think they have more luck involved than other forms of central access, when I get a UVC in that the intern or another resident couldn't I'm often not sure what to tell them to try differently next time. (I am a big fan of retracting the stump to try to guide the UVC course though and sometimes that makes the difference).