Subclavian Central Lines

[DreamMachine]

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Wadup! I graduated from residency 2 months ago. The hospital I work at prefers that we do subclavian central lines, for comfort and infection. I only did a handful as a resident. I've been getting better, but could use some tips. I get it in only 75% of the time, otherwise I end up having to do an IJ, which is of course easy. I'm not satisfied with my subclavian central line skills. I know people have higher success rates than this. Any no fail methods? Any cool internet videos or links? Anyone with tips? What the heck am I doing wrong? What is the most common mistake beginners make?

 

[coprolalia]

Don't measure. Feel. Right at the curvature of the clavicle, insert the long needle as flat against the skin about 3-4 cm lateral and advance until you hit clavicle. Walk under the clavicle. You will likely have to hub the needle, as you draw back while inseriting. The wire should thread easily after you get the flash.

Nick the skin once and deeply. Then, when you dilate, push the dilator in and out until the wire moves freely inside the dilator. If you do this, you will be far less likely to run into the problem of being unable to pass the catheter over the wire into the vein.

This is a higher risk procedure for pneumothorax. I've done a few hundred (literally) without yet dropping a lung. It's only a matter of time. Good luck.

-copro

 

[periopdoc]

The problem I have seen with many of the residents is starting too close to the clavicle. This forces the trajectory of their needle to be too steep to be very successful (and likely increases your risk of PTX significantly) I have seen some of them bend the needle to try to make up for this. Visualize a very flat needle trajectory, parallel to the posterior surface of the medial clavicle and you will likely improve your success.

Like Copro I feel for the bend in the clavicle and insert my needle ~3 cm lateral and ~2 cm inferior. Point the tip at the sternal notch and insert until you hit clavicle. Walk just off the posterior border of the clavicle and hub your needle and withdraw slowly if needed. I have not tried that dilator trick, but I like it. I would recommend transducing a pressure before you dilate.

The traditional teaching is to place a towel under the spine to "bring the clavicles forward." I personally find that this often narrows the space between the clavicle and the first rib making passage of a cordis difficult. I don't use this towel, and if fact if I am having trouble with passing a cordis, I will pull the shoulder anteriorly and inferiorly to open the space up.

I have an old video from NEJM, but it is pretty worthless as it mostly talks about all of the stuff that is common to all central lines and it doesn't talk about selecting a site which is the most important part.

- pod

 

[pgg]

I would recommend transducing a pressure before you dilate.

Amen to that. Adds 20-30 seconds to the procedure and easily worth the effort if it prevents just one complication.

I've seen two strokes and at least 4 or 5 trips to the OR because some inexperienced unsupervised nontransducing cowboy dilated a carotid.


Although unlike that link, I do a poor-man's CVP with a length of regular IV tubing. Connect before dilating, let it fill with blood, hold it up in the air. Blood level drops if you're in a vein, keeps rising if it's arterial. Cheap, easy, fast, safe.

 

[Arch Guillotti]

Amen to that. Adds 20-30 seconds to the procedure and easily worth the effort if it prevents just one complication.

I've seen two strokes and at least 4 or 5 trips to the OR because some inexperienced unsupervised nontransducing cowboy dilated a carotid.


Although unlike that link, I do a poor-man's CVP with a length of regular IV tubing. Connect before dilating, let it fill with blood, hold it up in the air. Blood level drops if you're in a vein, keeps rising if it's arterial. Cheap, easy, fast, safe.

I like the poor mans CVP as well and do it for all IJ's. Normally I place the angiocath and connect the IV tubing to it as described. If I am using just the needle I will do it under u/s and directly watch the vein get punctured so I don't transduce then.

Do you do a poor mans CVP on subclavians? Seems like it wouldn't be possible since you have to use the needle rather than the catheter over the needle. Like the OP, I don't do a whole lot of those.

 

[pgg]

I like the poor mans CVP as well and do it for all IJ's. Normally I place the angiocath and connect the IV tubing to it as described. If I am using just the needle I will do it under u/s and directly watch the vein get punctured so I do't transduce then.

Do you do a poor mans CVP on subclavians? Seems like it wouldn't be possible since you hav to use the needle rather than the catheter over the needle. Like the OP, I don't do a whole lot of those.

No, I should have clarified, I only do this for IJs, exactly as you describe with the angiocath.

 

[periopdoc]

Right now, I do a true transduction of both IJ and SC in the OR because that is the protocol at my hospital. When working on my own, I will stop transducing U/S guided IJs because I have done enough U/S guided blocks and IJ's to know exactly where my needle tip is. For SC lines I will continue to transduce either in the manner I posted or with a poor mans transducer as I do not have independent confirmation of needle tip location.

If I am working with a resident I make them transduce all IJs because I am not confident that they know where the tip of their needle is on U/S.

Why do you think you cannot do a poor mans transduction on a needle? You just hook it up exactly the same as if it were a catheter, granted it is a bit more awkward than my transducer setup, and you have to stabilize the needle better, but that really isn't too difficult with SC lines.

- pod

 

[proman]

Right now, I do a true transduction of both IJ and SC in the OR because that is the protocol at my hospital. When working on my own, I will stop transducing U/S guided IJs because I have done enough U/S guided blocks and IJ's to know exactly where my needle tip is.

- pod

I don't think you truly ever know where the tip is. Even in-plane US won't be 100% (does anyone do in-plane with US?). The only time I would not do an objective measure of CVP (either tracing or drop test) is when we have an echo in place and see the wire(s) in the bicaval view.

 

[starsop93]

Obviously this only works if you are using a TEE and are proficient with it, but using a TEE to confirm the wire is in the right atrium is a nice confirmation of venous placement. If I don't have a TEE in, I do the poor man's CVP.

Unless you're in a thrash situation, you should do something to confirm venous placement before you dilate. It only takes a minute or less and all but eliminates a serious and embarrassing complication.

As far as the original topic goes, I agree periopdoc.

 

[pgg]

Why do you think you cannot do a poor mans transduction on a needle? You just hook it up exactly the same as if it were a catheter, granted it is a bit more awkward than my transducer setup, and you have to stabilize the needle better, but that really isn't too difficult with SC lines.

I haven't been in the habit of transducing subclavians primarily for the same two reasons I don't transduce femoral sticks. 1) because the anatomy makes it significantly less likely that (compared to an IJ) an arterial stick will occur in the first place, and 2) because my most-feared potential complication (stroke) is far less likely with a subclavian than a carotid oops.

I'm not saying it's impossible or wrong to do a poor man's CVP through the needle on a subclavian stick, just that I don't. I also wonder if using the introducer needle rather than an angiocath (smaller lumen, rigid & perhaps more likely to be up against the vessel wall) is as sensitive. Though as in all things, I'm open to opposing viewpoints and may change my practice. It's been a whole two months since I've been free to do my own thing, so I'm not exactly set in my ways. 🙂

 

[Arch Guillotti]

Why do you think you cannot do a poor mans transduction on a needle?

Seems cumbersome but I may give it a try next time.

 

[Arch Guillotti]

If I am working with a resident I make them transduce all IJs because I am not confident that they know where the tip of their needle is on U/S.

It seems like a gigantic pain in the ass to do a real transduction every time. Keeping sterility seems like it would be a pain but maybe you have a different set up than I am used to. I have hit big red maybe twice. Once I put the angiocath in there! The 18 gauge, not the line itself. Let me tell you I knew it without a doubt because it was squirting bright red blood out. I realize it isn't always this clear cut but placing it in the carotid and not recognizing it is a serious mistake. Urban legend has it that some knob from IM put a vasc cath in the carotid and then dialyzed someone thru it😱

 

[2ndyear]

I don't like when hospitals 'prefer' to dictate how we do things. Are infection rates lower with subclavians? Yes. Does that mean I will do them without question? No. In my hands the safest line is an US guided IJ. I will use the full drape, surgical scrub, gown and glove. But if someone is going to tell me what line to put in then 'they' can come in and place whatever line they want. Sometimes you need a damn femoral line and someone tells us we prefer not to do those anymore. 'They' are usually the clipboard nurses that spend all day in meetings and on committees. Since central line infections are a big deal I think twice now. If I need it in the OR, no question I do the line. If the case doesn't call for central access or monitoring then I usually defer, where in residency we would have placed the line for post op access more than anything. We have PICC nurses for the post op stuff.

 

[periopdoc]

I don't think you truly ever know where the tip is. Even in-plane US won't be 100% (does anyone do in-plane with US?). The only time I would not do an objective measure of CVP (either tracing or drop test) is when we have an echo in place and see the wire(s) in the bicaval view.

Perhaps I will never understand the logic of anesthesiologists who believe that their ultrasound skills are good enough to safely place a needle tip within millimeters of a nerve, but also believe that you cannot tell if your needle tip is within a ~3 sq cm internal jugular target. I use an out of plane approach to identify the IJV and more importantly all arterial structures in the area. I then spin 90 degrees into an in plane view. I then watch the needle tip pop right into the IJV. Snap a picture for documentation. Thread the wire and throw the U/S back on to confirm the wire placement in plane. Dilate and place the line. Honestly, unless you have big red directly behind the IJV, even the in plane approach is probably overkill. People have done these lines for years based on just anatomical landmarks with an acceptable complication rate. Just knowing the anatomy by seeing it on U/S makes the risk even lower.

It seems like a gigantic pain in the ass to do a real transduction every time. Keeping sterility seems like it would be a pain but maybe you have a different set up than I am used to.

It really isn't difficult to set up at all. I usually have a tech to hand off the sterile extension used to connect to the transducer, but it is unnecessary. I can do this single handedly in the ICU and it adds maybe 20-30 seconds to my time. Here is a picture of the hookup.

Pop that needle into your target, glance at the screen, and see your wave form real time. Best part is that if you miss, you don't have to detach the poor man's transducer and hook up your syringe etc. Just pull out, flush, and try again. I haven't had to do that personally since I was an R-2.

-pod

 

[Jeff05]

just pop some a-line tubing or iv extension tubing onto the field. hook it up to angiocath and measure cvp directly - just let tubing fill about 10-15 cm and hold it up. it takes all of 20 seconds extra - and you're SURE you're not in carotid.

 

[periopdoc]

I don't think you truly ever know where the tip is. Even in-plane US won't be 100% (does anyone do in-plane with US?).

Not sure where the tip is? 😕

How about now? 😀

Is this any better? 😛

That dual lined structure under the nerve that appears to be coming out of the needle tip? Oh that's the catheter being threaded in real time. One hand threads the catheter through the needle while at the same time pulling the needle out. The other holds the U/S probe. And yes, that is the TIP of the catheter that you see on the right side of the picture.



Or maybe those needles are just a wee bit to big... Lets try a 22 ga stimuplex needle (the needles in the central line kits are 18 ga)

You may think that the tip is obscured, but it isn't. Follow the reverberation artifact and see where it bends and points at the needle tip. That dark spot under the needle tip is further confirmation. That is where I injected a spot of local to prove that it is the needle tip.


Still not convinced? How about a 24 ga stimuplex?

This is more like what you see when placing the needle into a vein since it is bathed in local in this image, and blood in the venous access situation. The other examples are not as crisp due to the tissue artifacts which you do not have to deal with in venous access. In motion those examples are even more convincing.

I could go on like this all day with the few teaching examples I have on my computer. Bottom line, if I can see my tip this clearly, I don't worry about it. If there is weird anatomy, small IJ, or I have any question then I would not dilate until I confirmed by transducing.

- pod

 

[Frank Rizzo]

I'm in the 'don't transduce with u/s, do without u/s' for my IJ's. When i transduce, i use sterile iv tubing and do it directly from the needle. I hate the damn angiocath.

 

[dhb]

I have never transduced because it was pretty obvious the times that i hit an artery. I don't dilate either for single lumens.

 

[proman]

Bottom line, if I can see my tip this clearly, I don't worry about it. If there is weird anatomy, small IJ, or I have any question then I would not dilate until I confirmed by transducing.

- pod

The major fault in your argument is that you assume the wire is ends up where the needle was. There have been several documented cases of an introducer going through the IJ and into the artery. You'll have a hard time defending your practice should you have a complication, and didn't transduce in some way. BTW, I do a drop test through a 16ga single lumen catheter, not through the needle.

 

[DO4lifer]

i found the key to be positioning.

head turned away. have patient ipsilateral arm "reaching" towards the ipsilateral foot. this stretch puts the shoulder joint in appropriate positioning for easier access. Drop under the clavicle as it angles cephalad and shoot for the sternal notch.

If the patient isn't dropping that shoulder joint down, the angles get mixed up on the anatomy.

 

[BLADEMDA]

i found the key to be positioning.

head turned away. have patient ipsilateral arm "reaching" towards the ipsilateral foot. this stretch puts the shoulder joint in appropriate positioning for easier access. Drop under the clavicle as it angles cephalad and shoot for the sternal notch.

If the patient isn't dropping that shoulder joint down, the angles get mixed up on the anatomy.

Correct. Although head position is not as important as you may think.

Try this maneuver and your % success on the first or second stick will be very high.

 

[periopdoc]

The major fault in your argument is that you assume the wire is [sic] ends up where the needle was. There have been several documented cases of an introducer going through the IJ and into the artery. You'll have a hard time defending your practice should you have a complication, and didn't transduce in some way. BTW, I do a drop test through a 16ga single lumen catheter, not through the needle.

Oh, I thought that you said the problem was that I could never be 100% certain where the tip is. Now that I have shown you that I can be 100% sure, you are saying that a floppy J tip wire placed through that needle will somehow bluntly dissect through the venous wall, through the connective tissue and through the arterial wall?

There have been no documented cases of inadvertent cannulation of the carotid when real-time, in-plane ultrasound was used to track the needle from the time it penetrates the skin until it enters and rests in the vein. The published cases of inadvertent carotid cannulation with U/S guidance report using an out of plane approach. It is much more difficult to definitively determine the location of your tip when using an out of plane approach. As far as I can tell, there is one documented case of inadvertent, trans-IJ carotid cannulation with U/S guidance, and that was out of plane.

Of course all of this is moot if you do like I do and throw the U/S probe back on after you have fed the wire. I do this all the time to print a picture for billing documentation. You get an image like this.

If you want to be really slick, then try threading the wire with real-time U/S visualization.

- pod

 

[hoyden]

Wadup! I graduated from residency 2 months ago. The hospital I work at prefers that we do subclavian central lines, for comfort and infection. I only did a handful as a resident. I've been getting better, but could use some tips. I get it in only 75% of the time, otherwise I end up having to do an IJ, which is of course easy. I'm not satisfied with my subclavian central line skills. I know people have higher success rates than this. Any no fail methods? Any cool internet videos or links? Anyone with tips? What the heck am I doing wrong? What is the most common mistake beginners make?

I have done thousands of subclavians in my previous life both in kids and adults ( and only 2-3 in the US residency) and the most difficult sometimes is not getting the flash - it is threading the catheter ( or the wire), especially when the catheter is soft. Proper positioning helps a lot.

 

[coprolalia]

I have done thousands of subclavians in my previous life both in kids and adults ( and only 2-3 in the US residency) and the most difficult sometimes is not getting the flash - it is threading the catheter ( or the wire), especially when the catheter is soft. Proper positioning helps a lot.

Don't measure. Feel. Right at the curvature of the clavicle, insert the long needle as flat against the skin about 3-4 cm lateral and advance until you hit clavicle. Walk under the clavicle. You will likely have to hub the needle, as you draw back while inseriting. The wire should thread easily after you get the flash.

Nick the skin once and deeply. Then, when you dilate, push the dilator in and out until the wire moves freely inside the dilator. If you do this, you will be far less likely to run into the problem of being unable to pass the catheter over the wire into the vein.

This is a higher risk procedure for pneumothorax. I've done a few hundred (literally) without yet dropping a lung. It's only a matter of time. Good luck.

-copro

🙂

-copro

 

[hoyden]

🙂

-copro

As I have mentioned above I have done not more than 2 or 3 subclavians in the US - therefore you may be talking about magic dilators 😉

If it doesn't want to thread you won't use any dilators with a neonate or a small kid with platelet count of 45K...with an adult it was much easier to thread.
Our central line kits differed a lot.

 

[coprolalia]

As I have mentioned above I have done not more than 2 or 3 subclavians in the US - therefore you may be talking about magic dilators 😉

Of course! This is, after all, the U. S. of f*ckin'-A!

If it doesn't want to thread you won't use any dilators with a neonate or a small kid with platelet count of 45K...with an adult it was much easier to thread.
Our central line kits differed a lot.

I don't even think about touching neonates anymore, let alone putting a central line in one. I'm done with residency. 😉

-copro

 

[hoyden]

Of course! This is, after all, the U. S. of f*ckin'-A!



I don't even think about touching neonates anymore, let alone putting a central line in one. I'm done with residency. 😉

-copro

It's interesting that we haven't done any subclavians in my residency - neither in the OR, nor in SICU. Those were placed only by trauma guys in the ER.
Back at home however, I have never placed an IJ - only subclavian lines were in favor. Go figure 😉

I miss kids a LOT - I planned to do a fellowship first ( I used to be pediatric anesthesiologist/intensivist back at my home country), but a year more....

 

[HoyaBlue02]

I am going to reawaken this thread as I need some help trouble shooting my central lines. I am an R1 and have done about 15 central lines- mix of IJ, subclavian, femoral. I have gotten to the point that I am pretty good at hitting the vein on my first attempt, but then I run into some problems. My problem is usually threading the wire. Sometimes it will thread about 5-6cm and then meet resistance. At that point I try twist the wire and advance. When that does not work I end up taking out the wire and putting syringe back on and make sure I'm still in vessel. Then repeat with wire. Still wont advance. At that point need to come out with needle and start again. I am not sure what I am doing wrong. Unfortunately we dont have US at my hospital so we are doing the lines based on anatomy. Please help! The residents that I am working with are not experienced enough to help me trouble shoot and sometimes they just take over.

 

[countingdays]

I am going to reawaken this thread as I need some help trouble shooting my central lines. I am an R1 and have done about 15 central lines- mix of IJ, subclavian, femoral. I have gotten to the point that I am pretty good at hitting the vein on my first attempt, but then I run into some problems. My problem is usually threading the wire. Sometimes it will thread about 5-6cm and then meet resistance. At that point I try twist the wire and advance. When that does not work I end up taking out the wire and putting syringe back on and make sure I'm still in vessel. Then repeat with wire. Still wont advance. At that point need to come out with needle and start again. I am not sure what I am doing wrong. Unfortunately we dont have US at my hospital so we are doing the lines based on anatomy. Please help! The residents that I am working with are not experienced enough to help me trouble shoot and sometimes they just take over.

Is it 6cm from the hub or needle tip that you get hung up? Do you have good blood flow continuing as you start to thread the wire? Is it usually still bleeding back when you take the wire out? My first guess is that you are moving the needle before you place the wire.

My second guess is that you might be sticking EJs? When the line is finally placed, is your upper-level's entry point more medial than your stick or the same spot?

 

[aredoubleyou]

I am going to reawaken this thread as I need some help trouble shooting my central lines. I am an R1 and have done about 15 central lines- mix of IJ, subclavian, femoral. I have gotten to the point that I am pretty good at hitting the vein on my first attempt, but then I run into some problems. My problem is usually threading the wire. Sometimes it will thread about 5-6cm and then meet resistance. At that point I try twist the wire and advance. When that does not work I end up taking out the wire and putting syringe back on and make sure I'm still in vessel. Then repeat with wire. Still wont advance. At that point need to come out with needle and start again. I am not sure what I am doing wrong. Unfortunately we dont have US at my hospital so we are doing the lines based on anatomy. Please help! The residents that I am working with are not experienced enough to help me trouble shoot and sometimes they just take over.

take the wire out, see if you have flow. if you have flow rotate the needle 90 to 180 degrees, try again. If it still doesnt work, do what dream machine said. If it still doesnt work, restick the vessel. If it still doesnt work, try somewhere else. you can spend a lot of time trying to figgure out whats going on, but its also important to know when your just wasting time on a hopeless situation. In my own personal experience what you describe is 70% me moving the needle while grabbing for the wire, 30% something else which can usually be overcome by rotating the needle.

 

[Bobblehead]

I am going to reawaken this thread as I need some help trouble shooting my central lines. I am an R1 and have done about 15 central lines- mix of IJ, subclavian, femoral. I have gotten to the point that I am pretty good at hitting the vein on my first attempt, but then I run into some problems. My problem is usually threading the wire. Sometimes it will thread about 5-6cm and then meet resistance. At that point I try twist the wire and advance. When that does not work I end up taking out the wire and putting syringe back on and make sure I'm still in vessel. Then repeat with wire. Still wont advance. At that point need to come out with needle and start again. I am not sure what I am doing wrong. Unfortunately we dont have US at my hospital so we are doing the lines based on anatomy. Please help! The residents that I am working with are not experienced enough to help me trouble shoot and sometimes they just take over.

Next time you open a kit in your institution, feed the wire into the needle while you're holding it up and see at what distance the J hook exits the tip of the needle. If your wire gets stuck at 5-6cm, as others have pointed out the tip of the needle may have moved. If you're into the vessel, beyond the tip of the needle and get hung up at 5-6cm it could be due to the direction of your needle bevel placement or the direction your J hook is taking.

If you're right handed and controlling the needle with your left hand, in order to feed the J-hook in the direction that you'd like the catheter to take, you may have to cross your right hand over your left (depending on site), in order to point the J-hook "down" the proper way. The J-hook usually follows the curls of the plastic wire holder for easy reference in most kits I've seen.

Some other issues are:

- Tightening the needle too hard onto the slip tip syringe which requires then additional force when you're trying to detach the needle. This results in you displacing the tip of the needle inadvertently. I always detach and reattach the needle myself so I know exactly how much force I applied. This also enables me to standardize where my bevel is positioned in relation to the numbers on the syringe. I also break the "bond" of the rubber plunger to the plastic sides of the syringe as I do this in order not have any resistance when I'm actually aspirating.

- Pushing the needle further in as you're advancing the wire. I've seen this commonly occur in the excitement of the moment as you push the plastic hub of the wire holder that straightens out the J hook into the opening of the needle and displace your tip as a result.

- Using a bent wire. If you've managed to bend the wire on the last attempt, commonly just after the J-hook, it will thread to a point, then stop. It essentially behaves like central venous obstruction although I find that if I get a fresh wire, I can then pass the wire without a problem.

- Moving the needle as you reach for the wire. I avoid putting any equipment on the patient except for some 4x4s as I've had enough things fall on the floor as people move around. The wire should be relatively accessible. I find that if you grasp the needle with your thumb and index finger this allows you to gently rest your pinky on the patient's skin which will then stabilize your control of the needle. This is particularly important for small vessels.

- Collapsing vessel. Under US you can see a volume depleted person's IJ go from plump to non-existent in the span of a breath. This can result in a scenario where you get stuck at the end of the needle, but not due to movement of the needle, rather due to movement of the vessel. Those people I'll put into Trendelenburg to optimize my chances of success.

- True central obstruction. Rarer, but it does exist and if you're beyond the tip of the wire, have tried a couple/multiple ways at that site, it may be best to convert to the other site on the same side. I usually give myself the opportunity to simply go from the SC to IJ without having to re-prep or re-drape to save time.

See if your institution will invest in an ultrasound. For non-emergent lines it really should be standard of care, particularly for inexperienced operators.

 

[nap$ter]

Perhaps I will never understand the logic of anesthesiologists who believe that their ultrasound skills are good enough to safely place a needle tip within millimeters of a nerve, but also believe that you cannot tell if your needle tip is within a ~3 sq cm internal jugular target. I use an out of plane approach to identify the IJV and more importantly all arterial structures in the area. I then spin 90 degrees into an in plane view. I then watch the needle tip pop right into the IJV. Snap a picture for documentation. Thread the wire and throw the U/S back on to confirm the wire placement in plane. Dilate and place the line. Honestly, unless you have big red directly behind the IJV, even the in plane approach is probably overkill. People have done these lines for years based on just anatomical landmarks with an acceptable complication rate. Just knowing the anatomy by seeing it on U/S makes the risk even lower.

hey pod i agree with everything you've said in general. most of the time with u/s IJ placement you're so sure it's in transduction is overkill, and if you're the least bit unsure (with residents) you just transduce - no big deal.

the thing i don't like is your technique of starting with a short-axis view, then turning 90 to a long axis view to watch the length and tip of your needle. i have seen residents identify the anatomy in short-axis, turn 90, and watch their needle tip (via beautiful pictures just like you just posted) enter - big red. in long axis view - you can only see one vessel at a time. usually pretty clear which it is, but not always. the 90 spin is great to confirm wire placement as you say, but when done before puncture can confuse and lose your place.

if you are as good as you say you are (and i believe you are), then you should be able to watch your tip enter the IJ in short-axis, with the virgin carotid in the same view, and then confirm wire placement in long axis. as you say, the IJ is usually a honkin 3 square cm - you don't really need to go long axis for pretty pix until ya got dark red blood.

my 2 cents. and how often are you doing SC's in the OR? and why?

 

[Apollyon]

- Using a bent wire. If you've managed to bend the wire on the last attempt, commonly just after the J-hook, it will thread to a point, then stop. It essentially behaves like central venous obstruction although I find that if I get a fresh wire, I can then pass the wire without a problem.

- True central obstruction. Rarer, but it does exist and if you're beyond the tip of the wire, have tried a couple/multiple ways at that site, it may be best to convert to the other site on the same side. I usually give myself the opportunity to simply go from the SC to IJ without having to re-prep or re-drape to save time.

See if your institution will invest in an ultrasound. For non-emergent lines it really should be standard of care, particularly for inexperienced operators.

These are good points. Virtually all of my lines in the ED are emergent, but I still have the same issues. One thing is to aim the bevel towards the feet (rotate it on the syringe so that the bevel is facing towards the feet). This will help guide the wire caudad, instead of inadvertently cephalad into the IJ (Ronald Reagan, anyone?).

In another case, you can turn the wire around if it gets bent; it won't have the "J" in it, but, if it is emergent, that can be the difference.

And the wide prep of the IJ and SC on the same side is golden advice. Golden.

 

[periopdoc]

i have seen residents identify the anatomy in short-axis, turn 90, and watch their needle tip (via beautiful pictures just like you just posted) enter - big red. in long axis view - you can only see one vessel at a time. usually pretty clear which it is, but not always.

you should be able to watch your tip enter the IJ in short-axis, with the virgin carotid in the same view, and then confirm wire placement in long axis.

how often are you doing SC's in the OR? and why?

If you keep the IJ in the center of your view as you rotate, there is no question which vessel you are going into. If someone can't tell the difference between a long axis view of the pulsating, non-compressible carotid and the much larger, thin-walled, easily compressible IJ then he shouldn't be placing lines. I have worked with doctors who should not be placing lines.

Once you have seen a single image of the vessels in short axis, you should be able to place the needle in the vast majority of IJ's without ANY further guidance (as Blade has noted here). The long axis view is just cream. If you think that there might be a problem (abberant anatomy etc), then place the needle through the skin in short axis until you see indentation of the IJ wall, then turn 90 degrees to see where in the IJ the tip ends up.

I am capable of knowing where my tip is in short axis although it takes a lot more spatial perception to reconstruct where the needle tip is when you cannot see the entire length. The vast majority of residents have no f-ing clue where their needle tip is in short axis. They routinely are WAY TOO DEEP medially or inferiorly in the neck and I have to tell them to stop and back the needle up.

I probably place a subclavian every other week or so either for folks with IJ clot, anatomical abnormalities, or other difficulty. I try to look for any excuse so that I can keep my skills up. Two of the partnerships that I interviewed with place both an IJ introducer with PA and a subclavian line for all hearts. The surgeons have requested the subclavian for IV access as they like to discontinue the IJ ASAP. I would love to have surgeons asking me to place two central lines for every case even if personally it seems like overkill.

- pod

 

[militarymd]

17 years since I finished residency.

Did a lot of US during my residency and fellowship for lines.......and right now, I find that the U/S is nice, but is something that wastes my time when I place a line.

In the rare circumstance that I can't place a line....it is helpful.



but then again...I don't do hearts right now.

 

[nap$ter]

If you keep the IJ in the center of your view as you rotate, there is no question which vessel you are going into. If someone can't tell the difference between a long axis view of the pulsating, non-compressible carotid and the much larger, thin-walled, easily compressible IJ then he shouldn't be placing lines. I have worked with doctors who should not be placing lines.

Once you have seen a single image of the vessels in short axis, you should be able to place the needle in the vast majority of IJ's without ANY further guidance (as Blade has noted here). The long axis view is just cream. If you think that there might be a problem (abberant anatomy etc), then place the needle through the skin in short axis until you see indentation of the IJ wall, then turn 90 degrees to see where in the IJ the tip ends up.

I am capable of knowing where my tip is in short axis although it takes a lot more spatial perception to reconstruct where the needle tip is when you cannot see the entire length. The vast majority of residents have no f-ing clue where their needle tip is in short axis. They routinely are WAY TOO DEEP medially or inferiorly in the neck and I have to tell them to stop and back the needle up.



- pod

agreed. personally in the vast majority of patients i don't see the need to go for the cream with a long axis view. short axis is sufficient up to wire placement. but, to each their own.

and i would add that many attendings can't find their needle tip in long or short axis.

 

[Mista Suprane]

Next time you open a kit in your institution, feed the wire into the needle while you're holding it up and see at what distance the J hook exits the tip of the needle. If your wire gets stuck at 5-6cm, as others have pointed out the tip of the needle may have moved. If you're into the vessel, beyond the tip of the needle and get hung up at 5-6cm it could be due to the direction of your needle bevel placement or the direction your J hook is taking.

If you're right handed and controlling the needle with your left hand, in order to feed the J-hook in the direction that you'd like the catheter to take, you may have to cross your right hand over your left (depending on site), in order to point the J-hook "down" the proper way. The J-hook usually follows the curls of the plastic wire holder for easy reference in most kits I've seen.

Some other issues are:

- Tightening the needle too hard onto the slip tip syringe which requires then additional force when you're trying to detach the needle. This results in you displacing the tip of the needle inadvertently. I always detach and reattach the needle myself so I know exactly how much force I applied. This also enables me to standardize where my bevel is positioned in relation to the numbers on the syringe. I also break the "bond" of the rubber plunger to the plastic sides of the syringe as I do this in order not have any resistance when I'm actually aspirating.

- Pushing the needle further in as you're advancing the wire. I've seen this commonly occur in the excitement of the moment as you push the plastic hub of the wire holder that straightens out the J hook into the opening of the needle and displace your tip as a result.

- Using a bent wire. If you've managed to bend the wire on the last attempt, commonly just after the J-hook, it will thread to a point, then stop. It essentially behaves like central venous obstruction although I find that if I get a fresh wire, I can then pass the wire without a problem.

- Moving the needle as you reach for the wire. I avoid putting any equipment on the patient except for some 4x4s as I've had enough things fall on the floor as people move around. The wire should be relatively accessible. I find that if you grasp the needle with your thumb and index finger this allows you to gently rest your pinky on the patient's skin which will then stabilize your control of the needle. This is particularly important for small vessels.

- Collapsing vessel. Under US you can see a volume depleted person's IJ go from plump to non-existent in the span of a breath. This can result in a scenario where you get stuck at the end of the needle, but not due to movement of the needle, rather due to movement of the vessel. Those people I'll put into Trendelenburg to optimize my chances of success.

- True central obstruction. Rarer, but it does exist and if you're beyond the tip of the wire, have tried a couple/multiple ways at that site, it may be best to convert to the other site on the same side. I usually give myself the opportunity to simply go from the SC to IJ without having to re-prep or re-drape to save time.

See if your institution will invest in an ultrasound. For non-emergent lines it really should be standard of care, particularly for inexperienced operators.

👍👍👍

to the person that brought this thread up again: this is an excellent post. during my cardiac month, i had similar problems, and heard most, if not all, of the above suggestions from my attendings. my success in threading the wire on IJs went up significantly.

 

[HoyaBlue02]

Thank you all for your wonderful advice. I have placed two subclavian lines since reading it, and they went off without a hitch. I am glad to have some new techniques to practice. I have been transducing even when I am sure of being in the vein so I can see what it looks like to have a comparison for the time I end up in the artery.
My newest problem, however, is alines. I have been using the angiocath kit. The past 3 times I hit the radial and got the flash, then lowered my angle and advance the wire then advanced the catheter, pull wire out, and have no flow 😡 What to do?

 

[Planktonmd]

Here is my advice:
Stop using wires and kits!
Get a # 20 regular angiocatheter (the one you use to start IV's), connect the catheter cover to the bottom of the needle or if you don't have this kind of catheter just connect a 3cc syringe.
Aim at the artery and enter the same way you do an IV (almost parallel to the skin) when you get arterial blood advance the needle 1mm, if the pulsating blood stops flowing into syringe pull back and advance again 1mm if the pulsating blood keeps filling the syringe slide the angiocatheter in like an IV.
Very simple, elegant and costs $ 0.20

Thank you all for your wonderful advice. I have placed two subclavian lines since reading it, and they went off without a hitch. I am glad to have some new techniques to practice. I have been transducing even when I am sure of being in the vein so I can see what it looks like to have a comparison for the time I end up in the artery.
My newest problem, however, is alines. I have been using the angiocath kit. The past 3 times I hit the radial and got the flash, then lowered my angle and advance the wire then advanced the catheter, pull wire out, and have no flow 😡 What to do?

 

[aredoubleyou]

Thank you all for your wonderful advice. I have placed two subclavian lines since reading it, and they went off without a hitch. I am glad to have some new techniques to practice. I have been transducing even when I am sure of being in the vein so I can see what it looks like to have a comparison for the time I end up in the artery.
My newest problem, however, is alines. I have been using the angiocath kit. The past 3 times I hit the radial and got the flash, then lowered my angle and advance the wire then advanced the catheter, pull wire out, and have no flow 😡 What to do?

Go through the artery (intentionally), remove the needle/wire. Slowly pull back the catheter until you have good blood flow, then advance the wire through the catheter, and advance the catheter over the wire.

 

[Planktonmd]

I never understood why people feel that they need to pierce the artery on both sides!

Go through the artery (intentionally), remove the needle/wire. Slowly pull back the catheter until you have good blood flow, then advance the wire through the catheter, and advance the catheter over the wire.

 

[dhb]

Go through the artery (intentionally), remove the needle/wire. Slowly pull back the catheter until you have good blood flow, then advance the wire through the catheter, and advance the catheter over the wire.

This is how i've salvaged a couple of lines

 

[pgg]

This is how i've salvaged a couple of lines

Yeah, me too. My approach is a plain angiocath, flash, spin 180, advance the whole unit, slide the catheter off ... but if it doesn't go easy, I just skewer the thing, needle out, pull cath back until it squirts, then wire it.

If there's no wire handy and I've skewered it, I pull the needle back about 1 mm (so the tip of the needle is just inside the angiocath), then withdraw them as a unit together until there's blood freely coming back, and then twist off the angiocath. I had a CT attending who did 100% of his a-lines this way and I've found it works well as a rescue technique if there's no wire available.

Unfortunately one of the hospitals I work at doesn't stock non-safety plain angiocaths or Arrows without wires, so I'm stuck using the ~$18 Arrow all-in-one kits. Maybe it's because I don't use them often but those integrated wires cause me to botch more lines ...

 

[rsgillmd]

....Unfortunately one of the hospitals I work at doesn't stock non-safety plain angiocaths or Arrows without wires, so I'm stuck using the ~$18 Arrow all-in-one kits. Maybe it's because I don't use them often but those integrated wires cause me to botch more lines ...

I've done it both ways. Angiocath way as an attending (my old hospital was like yours), and with the Arrow kits. I've heard of people complain about the Arrow kits, but quite frankly I haven't had any significant issues with them. But that may be because that was the only way I put in A-lines for 4 years.

I don't deliberately pierce both sides as my initial technique, but I have salvaged several using it as a rescue techqniue.

On the Blue Arrow kits that we have here you can't get the wire off, but on the red Arrow kits we had at Maimonides you could detach the wire if you wanted to.

 

[ProRealDoc]

All you need is one of these.

 

[proman]

All you need is one of these.

👍👍
And sometimes a short guidewire (0.018 inch)

 

[pgg]

All you need is one of these.

Unfortunately our Safety Gestapo only stock spring-loaded sealed catheters that don't allow more than about .5 cc of free flow blood to flow through. I steal a handful of the non-safeties whenever I'm at a less clipboard-nurse-plagued hospital.

 

[Licoricestick]

I never understood why people feel that they need to pierce the artery on both sides!

Me neither - but I do prefer the Arrow kits. Tried both standard IV and arrow kits as I was learning - initially much prefered the standard IV, until I started to learn how to rescue them and until I placed a couple in really calcified vessels, where I reckon the jelco would have crumpled, rather than pass through the calcifications.

 

[countingdays]

Me neither - but I do prefer the Arrow kits. Tried both standard IV and arrow kits as I was learning - initially much prefered the standard IV, until I started to learn how to rescue them and until I placed a couple in really calcified vessels, where I reckon the jelco would have crumpled, rather than pass through the calcifications.

Plus the catheter from the arrow kits is sturdier than a jelco, which is nice if the patient has more than a brief stay in the icu or if lots of arterial blood is going to be drawn.

 

[Licoricestick]

Plus the catheter from the arrow kits is sturdier than a jelco, which is nice if the patient has more than a brief stay in the icu or if lots of arterial blood is going to be drawn.

Hence the benefit in the calcified vessel where you have that awful crunching feeling!