Saline during central line insertion

[Sonny Crocket]

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I'm seeing a lot of residents fill the central line with saline before insertion. They also put some saline in the needle and syringe that they use before they stick the vein. I never do this and see it as a waste of time. Does anyone here do this? Why?

 

[Icefrog]

I'm seeing a lot of residents fill the central line with saline before insertion. They also put some saline in the needle and syringe that they use before they stick the vein. I never do this and see it as a waste of time. Does anyone here do this? Why?

My institution requires us to flush central venous catheters with saline prior to insertion. Theoretically it's to reduce the risk of air embolus. What makes this useless is that the saline dribbles out when you remove the clamp to thread the wire through. I agree that it's a waste of time.

I don't know why someone would fill the finder syringe with saline unless they're afraid they will actually inject instead of aspirate while hitting the vein. Also agree that it's a waste of time.

 

[Planktonmd]

I'm seeing a lot of residents fill the central line with saline before insertion. They also put some saline in the needle and syringe that they use before they stick the vein. I never do this and see it as a waste of time. Does anyone here do this? Why?

I am sure someone instructed them that the air in the line and in the needle could get in the circulation and cause a fatal air embolus or some other dreaded badness.

 

[Wiscoblue]

I've seen people fill the syringe with saline when sticking the vein. The problem with this is that the blood that is aspirated into the saline filled syringe looks very bright red and can confuse you into thinking that you're in the artery.

 

[Brookstacular]

Particularly with triple lumens, I put the Luer lock claves on the non-wire lumens and flush but leave the distal unclamped so it doesn't interfere with wire placement. I'm not so much worried about air entrainment unless it's a profoundly hypovolemic ICU patient that can't be placed in a little Trendelenburg. Flushing with the claves on just gives me primed lines that I've demonstrated are patent, takes 10 seconds, and then I've done the majority of the catheter set up and manipulation before its in the body. I've done it all uncapped/unclamped and just let it bleed back but it's messier and the time saving seems minimal. I think any time I'm fumbling with those awful pinch clamps I'm wasting more time and effort than is necessary.

As for the finder needle and syringe, I prevent air emboli by filling a 60cc syringe with heparin to about 50cc then use the remaining 10cc for finding the IJ. Once I get a flash, I bolus the whole thing. Saves that pesky step of having to remember give heparin prior to going on pump. /s

 

[deleted171991]

I'm seeing a lot of residents fill the central line with saline before insertion. They also put some saline in the needle and syringe that they use before they stick the vein. I never do this and see it as a waste of time. Does anyone here do this? Why?

It's not useless if some genius forgets to put the patient in Trendelenburg.

That's how I was trained, too. Flushing the line pre-insertion also makes sure that every port is working.

 

[deleted171991]

I've seen people fill the syringe with saline when sticking the vein. The problem with this is that the blood that is aspirated into the saline filled syringe looks very bright red and can confuse you into thinking that you're in the artery.

That is truly useless. All one has to do is to empty the syringe of air, before sticking the patient.

 

[deleted171991]

As for the finder needle and syringe, I prevent air emboli by filling a 60cc syringe with heparin to about 50cc then use the remaining 10cc for finding the IJ. Once I get a flash, I bolus the whole thing. Saves that pesky step of having to remember give heparin prior to going on pump. /s

You mean that you don't put in your central line until it's time for bypass? Or that the surgeons cut through the chest wall with the patient already heparinized? You're kidding, right?

 

[seinfeld]

My opinion its a wasted step, put the cap on the ports the wire doesn't come out and its not an issue. Even if someone accidentally injects the air in prior to aspiration it has a very low likelihood of causing harm. As someone who does bubble studies and TEE, air bubbles happen all the time as the gases dissolved in the cold IV fluid come out of solution in the warm blood.

 

[Brookstacular]

You mean that you don't put in your central line until it's time for bypass? Or that the surgeons cut through the chest wall with the patient already heparinized? You're kidding, right?

100% sarcasm. The idea that you need saline in the syringe to aspirate seemed as ludicrous as my pre-incision heparinization. Damned Internet and it's lack of intonation.

 

[jwk]

100% sarcasm. The idea that you need saline in the syringe to aspirate seemed as ludicrous as my pre-incision heparinization. Damned Internet and it's lack of intonation.

You need THIS look to go with your post...

 

[Arch Guillotti]

I flush everything more out of habit than anything. Do not put saline in the syringe nor have I ever seen anyone else do it. I do a fair amount of lines outside the OR when the bed may not always tilt.

 

[criticalelement]

My institution requires us to flush central venous catheters with saline prior to insertion.

Why doesn't your institution put in the central line for you instead of you since they know so much about air embolism.?

 

[Random Anesthesiologist]

Ever have a defective cvl? I have. That's why I flush the lines first. Takes an extra 30 sec vs time to change out a line.

 

[Planktonmd]

It's not useless if some genius forgets to put the patient in Trendelenburg.

That's how I was trained, too. Flushing the line pre-insertion also makes sure that every port is working.

How does having saline in the line prevent air from entering the vein if the CVP is low or negative???

 

[Icefrog]

Why doesn't your institution put in the central line for you instead of you since they know so much about air embolism.?

Eh, we're required to follow a check list that the nurses go over as we're doing the line, and flushing each lumen and clamping it is on that list. If we don't do a step, the nurses get quarrelsome.

 

[deleted59964]

Eh, we're required to follow a check list that the nurses go over as we're doing the line, and flushing each lumen and clamping it is on that list. If we don't do a step, the nurses get quarrelsome.

are you f#$king serious ?
your department needs to get some balls and tell the clipboard nurses to shut the hell up

 

[jetproppilot]

I'm seeing a lot of residents fill the central line with saline before insertion. They also put some saline in the needle and syringe that they use before they stick the vein. I never do this and see it as a waste of time. Does anyone here do this? Why?

Waste of time.

 

[FutureInternist]

I do this sometimes, but only to dribble a little out if I can't see the end of the needle

 

[deleted59964]

do you guys disconnect the syringe and thread the wire? (I do)
or do you use the canula, or the wire through the syringe thing?

 

[Random Anesthesiologist]

do you guys disconnect the syringe and thread the wire? (I do)
or do you use the canula, or the wire through the syringe thing?

I hate that syringe thing. I disconnect.

 

[HollywdAnesth]

At the burn hospital, we would flush our lines with ketamine. That way you didn't have to give fluid behind your dose to run it in.

 

[Planktonmd]

At the burn hospital, we would flush our lines with ketamine. That way you didn't have to give fluid behind your dose to run it in.

😕

 

[risnwb]

do you guys disconnect the syringe and thread the wire? (I do)
or do you use the canula, or the wire through the syringe thing?

I always use the canula and thread it in and confirm I'm venous with iv tubing. That way I only have to thread wire once and it saves a little time...

 

[bigeyedfish]

I only flush the rifampin coated lines. Sometimes the coating clogs the ports. The department can get a credit from the distributer for a clogged line but not after its been placed.

Otherwise flushing is a waste of time. I tell the residents this but they still always flush. It's part of the ritualistic dance they do prior to line insertion that usually includes lots of picking up items from the kit and putting them back down.

 

[twoliter]

I only flush the rifampin coated lines. Sometimes the coating clogs the ports. The department can get a credit from the distributer for a clogged line but not after its been placed.

Otherwise flushing is a waste of time. I tell the residents this but they still always flush. It's part of the ritualistic dance they do prior to line insertion that usually includes lots of picking up items from the kit and putting them back down.

From whom do you think they learned that ritual?

 

[bigeyedfish]

I don't know. Maybe someone their intern year. Most, but not all, break the habit their ca3 year. Maybe it's part of the process of learning. I probably did it too. I never rush the ca1's. But with the more good natured and easy going upper levels after around minute 5 of kit dancing I might say something like, "if you don't stick it you'll never get it." With the really slow ones at 10 minutes of kit-play Ill say something like "you need to go 10 times faster, then you'll be slow." That usually makes them laugh and pick up the pace a bit.

 

[deleted59964]

I always use the canula and thread it in and confirm I'm venous with iv tubing. That way I only have to thread wire once and it saves a little time...

I'm not sure I understand? what do you mean about only threading the wire once?

for comparison

I put needle in IJ under u/s guidance (out of plane - mostly), and aspirate blood
disconnect syringe
feed wire
remove needle over wire
u/s neck to show wire in vessel
dilate
place cvc over wire
suture and dress

 

[psychbender]

I believe he means as opposed to:
Needle in IJ via USD, aspirate
Disconnect syringe
Feed wire
Remove needle over wire
Place 18ga angiocath
Transduce with pressure tubing/fall to gravity
Re-wire angiocath
Angiocath out, CVC over wire
Suture and dress

The above is how I was initially taught to do IJs, as many of my staff wanted me to use the needle without the angiocath, and we weren't using ultrasound. I thought those few extra steps were pointless, if I could just thread the angiocath off the needle, transduce immediately, then place the wire.

 

[Old_Mil]

I'm seeing a lot of residents fill the central line with saline before insertion. They also put some saline in the needle and syringe that they use before they stick the vein. I never do this and see it as a waste of time. Does anyone here do this? Why?

Because it would sort of suck to take the time to place a triple lumen that was defective out of the box...

 

[Random Anesthesiologist]

I believe he means as opposed to:
Needle in IJ via USD, aspirate
Disconnect syringe
Feed wire
Remove needle over wire
Place 18ga angiocath
Transduce with pressure tubing/fall to gravity
Re-wire angiocath
Angiocath out, CVC over wire
Suture and dress

The above is how I was initially taught to do IJs, as many of my staff wanted me to use the needle without the angiocath, and we weren't using ultrasound. I thought those few extra steps were pointless, if I could just thread the angiocath off the needle, transduce immediately, then place the wire.

My institution wants to go to this way of doing it. Ugh, painful. Is there a study out there with a benefit?

 

[deleted59964]

I believe he means as opposed to:
Needle in IJ via USD, aspirate
Disconnect syringe
Feed wire
Remove needle over wire
Place 18ga angiocath
Transduce with pressure tubing/fall to gravity
Re-wire angiocath
Angiocath out, CVC over wire
Suture and dress

The above is how I was initially taught to do IJs, as many of my staff wanted me to use the needle without the angiocath, and we weren't using ultrasound. I thought those few extra steps were pointless, if I could just thread the angiocath off the needle, transduce immediately, then place the wire.

oh - thanks, i've never seen anyone do that.

 

[Arch Guillotti]

The above is how I was initially taught to do IJs, as many of my staff wanted me to use the needle without the angiocath, and we weren't using ultrasound. I thought those few extra steps were pointless, if I could just thread the angiocath off the needle, transduce immediately, then place the wire.

It is pointless. I was also trained mostly without ultrasound and we always had to use the finder needle followed by the angiocath followed by transduction through the tubing.

 

[risnwb]

I believe he means as opposed to:
Needle in IJ via USD, aspirate
Disconnect syringe
Feed wire
Remove needle over wire
Place 18ga angiocath
Transduce with pressure tubing/fall to gravity
Re-wire angiocath
Angiocath out, CVC over wire
Suture and dress

The above is how I was initially taught to do IJs, as many of my staff wanted me to use the needle without the angiocath, and we weren't using ultrasound. I thought those few extra steps were pointless, if I could just thread the angiocath off the needle, transduce immediately, then place the wire.

Yes

 

[Mman]

I'm not sure how flushing the ports with saline prior to insertion can save time in any fashion. I mean you still need to aspirate blood and flush after you place the line. That's how you confirm the end of each port is intravascular. The point of flushing isn't to make sure the line is patent, it's aspirating and flushing to make sure the end of each line is intravascular (blood comes back) and is patent. If you flush the line ahead of time you would still need to aspirate and flush after placement of the line before being able to confidently use it.

Personally I've never had a line with ports that didn't work upon placement. That's out of roughly 2000-3000 CVP placements. Can it happen? Of course. Is it worth the 30 seconds to me to flush ahead of time considering the extremely low likelihood of having a problem? No. If I ever had such a problem it would take about 4-5 minutes to replace the line with a new one from a new kit (since I'd already have access to the vein). 30 seconds times thousands of times is >>>>> than 4-5 minutes once in a blue moon.

 

[jetproppilot]

I'm not sure how flushing the ports with saline prior to insertion can save time in any fashion. I mean you still need to aspirate blood and flush after you place the line. That's how you confirm the end of each port is intravascular. The point of flushing isn't to make sure the line is patent, it's aspirating and flushing to make sure the end of each line is intravascular (blood comes back) and is patent. If you flush the line ahead of time you would still need to aspirate and flush after placement of the line before being able to confidently use it.

Personally I've never had a line with ports that didn't work upon placement. That's out of roughly 2000-3000 CVP placements. Can it happen? Of course. Is it worth the 30 seconds to me to flush ahead of time considering the extremely low likelihood of having a problem? No. If I ever had such a problem it would take about 4-5 minutes to replace the line with a new one from a new kit (since I'd already have access to the vein). 30 seconds times thousands of times is >>>>> than 4-5 minutes once in a blue moon.

Nicely said.