Subclavian Central Lines

[Southpaw]

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Allow me to answer your question with another question. If Ultrasound was not available for whatever reason, would you feel comfortable doing a Central Line? This is the case at multiple places that I do Cardiac. I never used U/S during residency, then when I got to fellowship at a different institution, it was used for all lines. I think it is an important skill to learn for all trainees. Kind of like how Video Laryngoscopy had replaced the need for the vast majority of Awake techniques, but it remains a very important skill to learn

I’d feel equally comfortable doing landmark based IJ or subclav. I’d much prefer using US for either as I find the argument that US doesn’t improve safety rather silly. If you were to dilate the artery on either you’d be forced to cancel the case, no? That lost revenue alone would pay for a couple US machines.

I guess next we’ll make the argument that US hasn’t helped us w blocks also....

 

[nimbus]

I dunno, it seems very doable to stick the carotid by accident even with US

Not if your careful and keep the needle tip in view. I’ve never stuck the carotid with US.

 

[nimbus]

I would also argue that I am less likely to have an arterial stick in the Subclavian position than IJ

This is true for blind sticks.

 

[sethco]

I’d feel equally comfortable doing landmark based IJ or subclav. I’d much prefer using US for either as I find the argument that US doesn’t improve safety rather silly. If you were to dilate the artery on either you’d be forced to cancel the case, no? That lost revenue alone would pay for a couple US machines.

I guess next we’ll make the argument that US hasn’t helped us w blocks also....

Never said it wasn't helpful. Just said not always available. Once again, never have dilated an Artery. That would certainly cancel the case. An arterial stick on the other hand, would not

 

[sethco]

It if your careful and keep the needle tip in view. I’ve never stuck the carotid with US.

I remember once during fellowship I stuck the Carotid with U/S. Extenuating circumstances though. Pt had a Type A that extendied into the Carotid. When I went to compress the vessel with U/S, I actually compressed the false lumen and was fooled into thinking it was IJ. Knew it right away, when I removed the syringe from the needle and pulsatile blood came back

 

[pgg]

I’d feel equally comfortable doing landmark based IJ or subclav. I’d much prefer using US for either as I find the argument that US doesn’t improve safety rather silly. If you were to dilate the artery on either you’d be forced to cancel the case, no? That lost revenue alone would pay for a couple US machines.

I guess next we’ll make the argument that US hasn’t helped us w blocks also....

Even without ultrasound, you can transduce before dilating. If you're not using realtime ultrasound for an IJ line (and there's a compelling argument that ultrasound for IJs is the de facto standard of care in the United States), you must transduce, or see the wire in the RA on TEE, before dilating that vessel. If you don't, and wind up in the carotid, it's simply indefensible.

 

[T-burglar]

It’s a good idea to do neck lines with ultrasound for a number of reasons. Just use the technology, it’s an improvement over blind sticks in the neck. It’s truly ridiculous to be a Luddite in medicine and anesthesia.

Just recently I had to stick a neck in a pre-arrest rhythm (ruptured AAA) and I used ultrasound because I wanted to be 100% sure I bagged the vein. If I started jabbing blind, I might have gotten the artery but the back flow might have been minimal with the rhythm and blood loss. But with the ultrasound I was certain and started running the Belmont immediately . You don’t even have to drape the probe and do a line sterile in extremely tight situations. It doesn’t slow you down at all to use ultrasound if you just need dirty large access ASAP

 

[deleted162650]

if you just need dirty large access ASAP

Ah, that takes me back . . . college . . . Friday night
. . . last call.

 

[chocomorsel]

I have stuck the carotid with ultrasound. Especially in anatomy where the carotid is right beneath the IJ and or the patient is volume down and I go through and trough. I don't always do the head tilt because I did a lot of head cases in the past with increased ICP.
As long as you don't dilate it is really what matters.

And I have done a few blind IJ's when I couldn't find an ultrasound. Less than five I would guess. And in my life I have probably done less than ten SC and I was in a busy spine/head practice for two years.

 

[Arch Guillotti]

Transduction is the way I’ve done it.

Do you put a catheter in and then transduce?

 

[vector2]

It’s a good idea to do neck lines with ultrasound for a number of reasons. Just use the technology, it’s an improvement over blind sticks in the neck. It’s truly ridiculous to be a Luddite in medicine and anesthesia.

Just recently I had to stick a neck in a pre-arrest rhythm (ruptured AAA) and I used ultrasound because I wanted to be 100% sure I bagged the vein. If I started jabbing blind, I might have gotten the artery but the back flow might have been minimal with the rhythm and blood loss. But with the ultrasound I was certain and started running the Belmont immediately . You don’t even have to drape the probe and do a line sterile in extremely tight situations. It doesn’t slow you down at all to use ultrasound if you just need dirty large access ASAP

When I put in crash lines for trauma I just grab a big chlorprep as my assistant is opening the kit and douse the patient, my gloves, and the probe in solution. Ultrasound is a must cause many of these actively exsanguinating pts will have an IJ the size of a peripheral vein.

 

[MirrorTodd]

Do you put a catheter in and then transduce?

We hooked the transducer tubing up to the needle, elevated tubing to show no pulsatile flow, then lowered to show slow drainage into tubing, then threaded wire, dilator etc. It's kind of awkward to do it with the needle cause there's always the chance of pulling or pushing the needle out but it worked fine this time. I'm sure I'll get better with more practice.

 

[Orin]

At the end of the day, optimal clinical practice means doing the best you can with the resources and within the system you have for the patient in front of you. For what it's worth, there are more recent studies suggesting that although you may want to stay away from the IJ or femoral, with proper technique the sites are equivalent for infection. The AHRQ guidelines even reference the first study, but then recommend the subclavian since not everyone can do stuff like the big academic centers.

The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care u... - PubMed - NCBI
The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a... - PubMed - NCBI

Still, subclavians are more fun. I liked the diving technique as it was scarier, but the staying parallel technique is safer, even if it does make changing a line over wire a bit more annoying. I never transduced and just hoped for it to be okay, as it seemed hard to keep an angiocath in there with the push/stay parallel technique. When I do the ultrasound guided infraclavicular approach, that's easy to transduce like an IJ.

I haven't been able to con anyone into doing a blind or ultrasound guided supraclavicular approach to it though, but it is so tempting to do as a line after the drapes go up

 

[Twiggidy]

The reality is in most non-trauma, non-emergency situations an ultrasound guided IJ should be the anesthesiologists bread and butter when it comes to central access. It's just safer and there's no reason we should be dilating carotids or dropping lungs/causing hemothoraxes. That's in normal situations. Yes, we should have the ability to do a subclavian but they really shouldn't be the "go to" line. Even at my institution where the cardiac surgeons have been verbal about sublcavians being more comfortable for patients they're still fine with IJs because we get them in faster and the risk is lower. I'm old school trained so I have the ability to do IJs pretty well without the ultrasound but we have like 3 machines plus 2 echo machines floating around our OR so there really isn't a reason to NOT use an ultrasound. Occasionally, if we have a normal sized patient and I'm not in a rushed situation, I'll do a non-US line to maintain skill, but otherwise, the probe is there and I'm not trying to slow the day down sticking a neck multiple times.

I'd say if you're not comfortable, then about once a month have a surgeon walk you through one if you're not comfortable just to re-establish that skill. On the days where I'm in the "stagger room" where I'm not rushed, I'll even do some fiberoptic intubations for the same reason, just to keep the skill, because even the glidescope has reduced the need for FOB intubations.

 

[Cryc_to_the_point]

Soo down the road would I have a reasonable expectation of getting the opportunity to master subclavians?

 

[Psai]

Soo down the road would I have a reasonable expectation of getting the opportunity to master subclavians?

You can do as much as you think you can do

 

[Twiggidy]

Soo down the road would I have a reasonable expectation of getting the opportunity to master subclavians?

.... some of my best days are where I get paid to do as little as possible to a patient.......

 

[Maverikk]

For crash lines I prefer femoral. IJs anatomy is the most variable, everyone who frequently uses ultrasound recognizes this. Yes you may not dilate it, but the pseudoaneurysm that may later forms and may have to be repaired after sticking the carotid is not worth the risk imho. Subclavian and femoral are anatomically more consistent, I think either is more justifiable in a crashing situation. I would avoid subclavian bc if you can't resuscitate/ROSC you've complicated the situation by possibly causing a pneumo as the reason for why you can't resuscitate/ROSC. Femoral is easier to get anatomically, with adequate chest compression you should be able to get a thready pulse to palpate and either way when they get resusc/ROSC the lines should be replaced under sterile conditions

 

[CCM-MD]

For crash lines I prefer femoral. IJs anatomy is the most variable, everyone who frequently uses ultrasound recognizes this. Yes you may not dilate it, but the pseudoaneurysm that may later forms and may have to be repaired after sticking the carotid is not worth the risk imho. Subclavian and femoral are anatomically more consistent, I think either is more justifiable in a crashing situation. I would avoid subclavian bc if you can't resuscitate/ROSC you've complicated the situation by possibly causing a pneumo as the reason for why you can't resuscitate/ROSC. Femoral is easier to get anatomically, with adequate chest compression you should be able to get a thready pulse to palpate and either way when they get resusc/ROSC the lines should be replaced under sterile conditions

We've been using a lot of IOs during codes. Haven't had to place a central line during a code in a while.

Vascular access in resuscitation: is there a role for the intraosseous route? - PubMed - NCBI

 

[sethco]

For crash lines I prefer femoral. IJs anatomy is the most variable, everyone who frequently uses ultrasound recognizes this. Yes you may not dilate it, but the pseudoaneurysm that may later forms and may have to be repaired after sticking the carotid is not worth the risk imho. Subclavian and femoral are anatomically more consistent, I think either is more justifiable in a crashing situation. I would avoid subclavian bc if you can't resuscitate/ROSC you've complicated the situation by possibly causing a pneumo as the reason for why you can't resuscitate/ROSC. Femoral is easier to get anatomically, with adequate chest compression you should be able to get a thready pulse to palpate and either way when they get resusc/ROSC the lines should be replaced under sterile conditions

I don't think I have done a Femoral Central line in about 5 years now. IMHO, it is very hard for me to find a reason to justify going Femoral. In a crashing patient where drapes are going up. U/S guided IJ in Tberg position is my line of choice if I need central access. Just as easy as doing a Femoral in a Chest compression situation. However, I would really have to have terrible Peripheral access to waste time attempting Central access in a code

Also, by your pseudoaneurysm reasoning, I guess we shouldn't be doing arterial lines because they may turn into a pseudoaneurysm. How many pseudoaneurysm have you had? I can't think of a single patient of mine that had this as a complication and I go the through and through then seldinger technique. You would think I would have a lot more, but yet this is a very rare complication

 

[Maverikk]

if you've the time/experience and RESOUCES for U/S guided IJ faster than femoral than yes it's easier. If you get called to every code on the floor of a hospital without those it's different

 

[DocMcCoy]

As far as femoral lines, any of y’all make an argument for access above the heart? A lot of my disasters involved liver/IVC injuries so my argument is to get an IJ/subclavian even if they come in with femoral access

 

[T-burglar]

As far as femoral lines, any of y’all make an argument for access above the heart? A lot of my disasters involved liver/IVC injuries so my argument is to get an IJ/subclavian even if they come in with femoral access

Yes of course. Should be facile with all sites and even creative spots like the femoral in the adductor canal.

Penetrating chest trauma should probably get a femoral. Penetrating abdominal should probably get a SC or IJ. High risk lead extractions should be femoral. Etc

 

[DrAmir0078]

Use real time ultrasound and go lateral.

One of many on YouTube.

Dr, Nimbus,
Thanks for the wonderful Video presentation, as I was an ER Technician between 2009 - 2016 at the George Washington University Hospital Emergency Room, I was taught to place UltraSound Guided IVs in the Summer 2011 or before that, and then I became one of the team who teaches this technique to staff, and also we discovered by practice, how to use USGIV for small caliber veins in the forearms. In very difficult patient like frequent hospitalization ones, or whom who were drug addicts or with Sickle cell anemia, it was really tough to place the line in the upper arm too, so we have to reach the axillary vein and to manipulate the arm!
So, after seeing your video, you have said at :

1- 04:20 "The beam width of most Ultrasound probes around 1mm which is about the size of pen tip"

2- 09:00 "In Longitudinal view, extra care should be taken to maintain the thin 1mm beam through the center of the vessel"

You have drawn 1mm as width ! (It was shown between the surface of the skin and the vein circle like), on the next screen while you were showing the procedure, there were 6 guiding green dots, the distance between them was not showing, so I am confused, because setting these dots, will help me to exactly knowing where the vein is located by how many centimeters ( eg; in the upper arm, sometimes 3 cm depth) !
So, what is 1 mm width? is this distance between the surface of the probe with skin separated by the US Gel?
Or, it is the distance between the probe on the skin to center of vessel?

Appreciate your answer !

 

[nimbus]

Dr, Nimbus,
Thanks for the wonderful Video presentation, as I was an ER Technician between 2009 - 2016 at the George Washington University Hospital Emergency Room, I was taught to place UltraSound Guided IVs in the Summer 2011 or before that, and then I became one of the team who teaches this technique to staff, and also we discovered by practice, how to use USGIV for small caliber veins in the forearms. In very difficult patient like frequent hospitalization ones, or whom who were drug addicts or with Sickle cell anemia, it was really tough to place the line in the upper arm too, so we have to reach the axillary vein and to manipulate the arm!
So, after seeing your video, you have said at :

1- 04:20 "The beam width of most Ultrasound probes around 1mm which is about the size of pen tip"

2- 09:00 "In Longitudinal view, extra care should be taken to maintain the thin 1mm beam through the center of the vessel"

You have drawn 1mm as width ! (It was shown between the surface of the skin and the vein circle like), on the next screen while you were showing the procedure, there were 6 guiding green dots, the distance between them was not showing, so I am confused, because setting these dots, will help me to exactly knowing where the vein is located by how many centimeters ( eg; in the upper arm, sometimes 3 cm depth) !
So, what is 1 mm width? is this distance between the surface of the probe with skin separated by the US Gel?
Or, it is the distance between the probe on the skin to center of vessel?

Appreciate your answer !

It’s not my video, but 1mm refers to the width of the ultrasound beam itself. 1mm is NOT describing the distance to any particular structure. You are essentially getting a flat planar 2 dimensional (1mm thick) slice of a 3 dimensional structure. And you can direct the beam (what slice you are getting) by angling the transducer.

 

[DrAmir0078]

It’s not my video, but 1mm refers to the width of the ultrasound beam itself. 1mm is NOT describing the distance to any particular structure. You are essentially getting a flat planar 2 dimensional (1mm thick) slice of a 3 dimensional structure. And you can direct the beam (what slice you are getting) by angling the transducer.

Gotcha Dr. Nimbus
My apologies, I thought it was yours!
Now is clear!
For me, I prefer Transfers view, it is quick, better outcome!

 

[dchz]

Not if your careful and keep the needle tip in view. I’ve never stuck the carotid with US.

Just the tip.

 

[fakin' the funk]

I remember once during fellowship I stuck the Carotid with U/S. Extenuating circumstances though. Pt had a Type A that extendied into the Carotid. When I went to compress the vessel with U/S, I actually compressed the false lumen and was fooled into thinking it was IJ. Knew it right away, when I removed the syringe from the needle and pulsatile blood came back

I think you get a pass on this one

 

[fakin' the funk]

I don't think I have done a Femoral Central line in about 5 years now. IMHO, it is very hard for me to find a reason to justify going Femoral. In a crashing patient where drapes are going up. U/S guided IJ in Tberg position is my line of choice if I need central access. Just as easy as doing a Femoral in a Chest compression situation. However, I would really have to have terrible Peripheral access to waste time attempting Central access in a code

Femoral is undesirable for a number of reasons. The most common reason I go there is in ICU patients who are either thrashing around/can't have the drape on their head, have some anatomic concern, or jacked up ESRD vessels (current or old tunneled lines, avoid subclavian, aberrant tortuous vessels etc)