Subclavian vs IJ lines

[Dr Serenity]

To the residents and attendings who post on this forum...

I'm an MS4 in the middle of a rotation in the SICU. Yesterday, while on call, I helped my on-call resident (an anesthesia resident rotating thru the SICU) place a central line...she started out doing a subclavian line and then eventually did an IJ after she and the ICU fellow were unsuccessful placing the line in the subclavian vein. Afterward, I asked which route she preferred...she without hesitation said IJ because of the risk of pneumothorax inherent in the placement of subclavian lines.

I had recently done some reading (in particular, in Marino's ICU book) regarding central lines, and according to what I've read, there is data suggesting that subclavian line placement does NOT necessarily place a patient at greater risk of PTX...also, patients tend to be more comfortable with subclavian lines since they have greater neck ROM with a subclavian line in place vs. IJ.

So...all the above brings me to my question...for central line placement, which route (subclavian vs. IJ) do you prefer and why? Also, any thoughts on what Marino, et al have to say on IJ vs SC lines?

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[Gas4Life]

I strongly prefer to place a subclavian line as I seem to have better luck with them and they are, at least in my opinion, easier to place. That being said, I have personally seen only one pneumothorax as a result of subclavian line placement and have never seen one as a result of an IJ line placement. The one PTX that I saw was in fact a line I first attempted to place and after about 6 or 8 sticks I called the attending in and let him have a go. On his second stick he got back nothing but a big whoosh of air, so he at least took responsibility for the PTX. He even let me place the chest tube which was cool of him. Anyway, I guess I don't have a lot of science to offer here, just that for whatever reason I feel more comfortable placing the SC vs the IJ for central venous access. I have to admit I am kinda surprised if there is in fact no greater risk of PTX with a SC line. At least logically, it seems the risk would almost have to be somewhat increased.

 

[jwk]

To the residents and attendings who post on this forum...

I'm an MS4 in the middle of a rotation in the SICU. Yesterday, while on call, I helped my on-call resident (an anesthesia resident rotating thru the SICU) place a central line...she started out doing a subclavian line and then eventually did an IJ after she and the ICU fellow were unsuccessful placing the line in the subclavian vein. Afterward, I asked which route she preferred...she without hesitation said IJ because of the risk of pneumothorax inherent in the placement of subclavian lines.

I had recently done some reading (in particular, in Marino's ICU book) regarding central lines, and according to what I've read, there is data suggesting that subclavian line placement does NOT necessarily place a patient at greater risk of PTX...also, patients tend to be more comfortable with subclavian lines since they have greater neck ROM with a subclavian line in place vs. IJ.

So...all the above brings me to my question...for central line placement, which route (subclavian vs. IJ) do you prefer and why? Also, any thoughts on what Marino, et al have to say on IJ vs SC lines?

Sticking a needle in the chest or the neck - of course there's a higher risk of pneumo with subclavians. I've seen pneumos from SC - never one from an IJ. I guess theoretically this risk should be reduced through the use of ultrasound guided placement, although I think most still end up going without it in the end.

My preference has always been IJ's, although for longer-term placement, most will agree that subclavian is the way to go because of comfort issues.

 

[deleted126335]

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[Noyac]

Personally I don't prefer one over another with the except of its use. I will place a SC if it will remain for an extended period b/c of comfort issues and cleanliness/sterility. I prefer the IJ if I am standing at the head of the table in the OR.

As far as the PTX risk. I am aware that the PTX risks are claimed to be similar with both approaches. But I will tell you that there is virtually no chance of PTX when I place an IJ due to my approach. Its not so much that I do it much differently its just that I have done so many that I barely use 1/2 of the needle. You just start to get a feel for when you should have entered the IJ and start retracting the needle for flow if you haven't seen it on insertion. If you bury the needle you are way past the the target. So I don't see how the PTX risk can be the same b/w the two.

 

[VentdependenT]

ultrasound guided ij if i had my druthers

 

[2ndyear]

Reasons I like the IJ:
1) I can do it under the drapes, even if the belly is prepped and I don't have to get out of my usual position behind the patient.

2) I can compress the bleeding if I happen to hit the artery.

3) It images real nice on ultasound.

4) With imaging so nice on ultrasound, my chance of PTX is very low, so I don't have to ask someone else to place a tube.

 

[militarymd]

Always Subclavian if I can...lower infection risk (if you believe some)...MORE comfortable for patients.

I've had one ptx...and it was with an IJ.

 

[Coastie]

Had a lecture on this today, actually.

SC has around 3% chance of PTX, IJ has 1.8%.

IJ infection rates are higher, though. SC won the argument at the lecture.

I proceeded to go back to the ICU, and place an IJ via ultrasound guidance, so....

 

[militarymd]

Had a lecture on this today, actually.

SC has around 3% chance of PTX, IJ has 1.8%.

IJ infection rates are higher, though. SC won the argument at the lecture.

I proceeded to go back to the ICU, and place an IJ via ultrasound guidance, so....

Here in lies one of the problems with ACADEMIA....3% and 1.8% chance of pneumo???????

WTF???......Those numbers are unbelieveably HIGH to me AND to any of my colleagues who do these procedures.

 

[Coastie]

Here in lies one of the problems with ACADEMIA....3% and 1.8% chance of pneumo???????

WTF???......Those numbers are unbelieveably HIGH to me AND to any of my colleagues who do these procedures.

lol....I don't know where my buddy (and subsequent professors who agreed) got the numbers...

 

[Planktonmd]

lol....I don't know where my buddy (and subsequent professors who agreed) got the numbers...

Well, studies are usually done at university hospitals where lines are placed by rookies (no offense intended to anyone) and where complications are more frequent.
That's life, people have to learn and that's what university hospitals are for.

 

[Pilot Doc]

The aversion to SC's in anesthesia really befuddles me. The SC PTX risk is overblown and what better place to have one than in the OR. It'll become immediately apparent as peak pressures rise. Although a chest tube will be needed for definitive mgmt, a 14ga angiocath will convert a tension ptx to a non-life threatening situation in about 5 seconds.

 

[usnavdoc]

The aversion to SC's in anesthesia really befuddles me. The SC PTX risk is overblown and what better place to have one than in the OR. It'll become immediately apparent as peak pressures rise. Although a chest tube will be needed for definitive mgmt, a 14ga angiocath will convert a tension ptx to a non-life threatening situation in about 5 seconds.

I agree. Ive had to do it twice in a blunt trauma setting. Anyway I dont really prefer one over the other and I use both on various patients.

 

[BADMD]

Here in lies one of the problems with ACADEMIA....3% and 1.8% chance of pneumo???????

WTF???......Those numbers are unbelieveably HIGH to me AND to any of my colleagues who do these procedures.

Not an anesthesia guy...

I think I'm running around 1% for my SC. One as a brand new second year and one as an attending (although that was after the EM 3rd year and Surgery senior all made their pokes).

As for the OP question, I choose the SC for the "easy" ones, since I can usually get one faster and choose US guided IJ for the "tough" ones.

 

[GasEmDee]

Here in lies one of the problems with ACADEMIA....3% and 1.8% chance of pneumo???????

WTF???......Those numbers are unbelieveably HIGH to me AND to any of my colleagues who do these procedures.

Geez man, You take every shot you can get man. Does anyone expect any differently from a training environment?

 

[GasEmDee]

To the residents and attendings who post on this forum...

I'm an MS4 in the middle of a rotation in the SICU. Yesterday, while on call, I helped my on-call resident (an anesthesia resident rotating thru the SICU) place a central line...she started out doing a subclavian line and then eventually did an IJ after she and the ICU fellow were unsuccessful placing the line in the subclavian vein. Afterward, I asked which route she preferred...she without hesitation said IJ because of the risk of pneumothorax inherent in the placement of subclavian lines.

I had recently done some reading (in particular, in Marino's ICU book) regarding central lines, and according to what I've read, there is data suggesting that subclavian line placement does NOT necessarily place a patient at greater risk of PTX...also, patients tend to be more comfortable with subclavian lines since they have greater neck ROM with a subclavian line in place vs. IJ.

So...all the above brings me to my question...for central line placement, which route (subclavian vs. IJ) do you prefer and why? Also, any thoughts on what Marino, et al have to say on IJ vs SC lines?

I think subclavians are easier blind, but ultrasound makes them both pretty straightforward. Low risk of pneumothorax with either if done with good technique

 

[Arch Guillotti]

Here in lies one of the problems with ACADEMIA....3% and 1.8% chance of pneumo???????

WTF???......Those numbers are unbelieveably HIGH to me AND to any of my colleagues who do these procedures.

 

[militarymd]

Geez man, You take every shot you can get man. Does anyone expect any differently from a training environment?

With PROPER supervision, the rate should NOT be this high.

I PROPERLY supervised ALL of my central lines done by my residents.

How many times have YOU been allowed to flounder by your UCSF attendings?

Think about that carefully.

Even better, think about which of your attendings would you rather not have do YOUR central line....the answer should be zero...but we all know what the reality is.

 

[Ketamininus]

As trained anesthesiologists, we should be able to do either with relative ease...and with a vastly smaller percentage of PTX's happening than the numbers provided.

Most (probably 80%) of my central line placements during my training were done at a level 1 trauma center where patients often came in sporting a c-collar, so I became pretty adept at doing subclavian lines rather than IJ's. I've yet to drop anyone's lung <knocks on wood>, and have only had one patient who I had any trouble in placing their line. I've floated several Swan's thru my SC lines also, so I feel confident I could do so as well.

That said, I feel like I need more practice with my IJ's because I've been so entrenched doing the SC lines. Like I said, I want to be able to do both with an equal amount of skill and confidence.

- Ket

 

[coprolalia]

The problem of placing a subclavian line is not related to increased PTX incidence. It is the fact that you can't compress the area of you tear the vein and/or put the needle in the wrong vessel and dilate.

I love the left subclavian. If you do it properly, you won't get a PTX. I've done dozens (if not more) of each. In the OR, I usually place an IJ. In the unit, I place a subclavian. Usually if you are called to put a line in the unit, it's going to tend to be in a lot longer than one you put in the OR. And, Mil's point about comfort and infection rates is very valid.

-copro

 

[Dr Serenity]

Thanks for all the comments, everyone...very interesting arguments on both sides. More comments welcome...

 

[deleted9493]

Does anyone know the comparative rate of venous stenosis post-subclavian v. post-IJ? I've understood that it is a consideration, since it is higher in the subclavian population but I don't know how significant that difference actually is.

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

 

[Pilot Doc]

Venous stenosis is a consideration that strongly favors IJ lines in CKD/HD patients because good subclavian outfloww is important in UE HD access.

That said, I don't think I've ever seen a patient with symptomatic venous stenosis due to a central line.

 

[Magnus67]

In our ICU's the Left SC is the "prefered site" in our central line bundle, due to lower infection rates. But it is somewhat intuitive that generally ICU lines are in much longer than OR lines and infection rates and comfort should be more of a consideration. Cant comment much on our OR lines because im still living in the hell on earth that is intern year. Good topic though, interesting to get some other people's viewpoints.

 

[bogatyr]

The problem of placing a subclavian line is not related to increased PTX incidence. It is the fact that you can't compress the area of you tear the vein and/or put the needle in the wrong vessel and dilate.

I love the left subclavian. If you do it properly, you won't get a PTX. I've done dozens (if not more) of each. In the OR, I usually place an IJ. In the unit, I place a subclavian. Usually if you are called to put a line in the unit, it's going to tend to be in a lot longer than one you put in the OR. And, Mil's point about comfort and infection rates is very valid.

-copro

I dilated the subclavian artery not too long ago. 30 minutes of pressure seemed to compress it and stop the bleeding just fine. No angio or vascular surgery consult required.

 

[Pilot Doc]

I dilated the subclavian artery not too long ago. 30 minutes of pressure seemed to compress it and stop the bleeding just fine. No angio or vascular surgery consult required.

You're joking, right.

Even assuming you could compress the subclavian artery, it can bleed into the pleural space and there's no way to know if you stopped the bleeding or not.

I've punctured the subclavian before. In that case I just withdraw the needle. If I ever dilate the subclavian I will leave the line in place and call vascular.

 

[coprolalia]

Always transduce before you dilate. Always. Our anesthesia and surgical teams have never had a patient go to the OR to have a primary repair of a dilated artery. Why? They are taught to always transduce. Our medicine colleagues, for some reason, seem to send about one per month to the OR for repair. Why? They don't transduce.

Always transduce.

-copro

 

[2ndyear]

Do you transduce on a monitor with a pressure waveform, or do you do what I do: the IV extension tubing. I just open an IV extension onto the kit, attach it to the needle (or catheter if I'm doing an IJ), and hold it up. Flows down, it's venous and I calculate an old skool CVP. Flows up, art. Just curious. And if you do transduce it, can you do it one handed with sterile technique?

 

[Hernandez]

SC has around 3% chance of PTX, IJ has 1.8%.

These numbers are awfully high. Every reference I've seen, included the already mentioned Marino states 1.5ish% for SC and 1.3% for IJ

Complications of central venous catheters: Internal jugular versus subclavian access—A systematic review

In three trials (707 catheters), the incidence of bloodstream infection was 8.6% with the jugular access and 4.0% with the subclavian access (RR 2.24 [0.62–8.09]). In ten trials (3,420 catheters), the incidence of hemato- or pneumothorax was 1.3% vs. 1.5%​

 

[VentdependenT]

Do you transduce on a monitor with a pressure waveform, or do you do what I do: the IV extension tubing. I just open an IV extension onto the kit, attach it to the needle (or catheter if I'm doing an IJ), and hold it up. Flows down, it's venous and I calculate an old skool CVP. Flows up, art. Just curious. And if you do transduce it, can you do it one handed with sterile technique?

The cordis comes with a piece of tubing to do it "old school."

TLC? I use the Guide wire plastic tubing to transduce with...."old school."

 

[coprolalia]

Do you transduce on a monitor with a pressure waveform, or do you do what I do: the IV extension tubing. I just open an IV extension onto the kit, attach it to the needle (or catheter if I'm doing an IJ), and hold it up. Flows down, it's venous and I calculate an old skool CVP. Flows up, art. Just curious. And if you do transduce it, can you do it one handed with sterile technique?

Your first technique is what we call the "poor man's" transducer, but it works. Not sure what the "false negative" rate is, though.

To truly transduce, I have a Tech (or extra pair of hands) around. The Arrow kits contain a blunt needle. You drop the IV tubing in the kit off the field, hook-up the blunt needle, and have the "extra hands" flush from the pressure line already connected to the transducer. The insertion needle has a hole in the back of it where the wire can be pushed through. So, once you hit the vein and have good back flow, you just pop the blunt needle into the end of the insertion needle and, voila, you're transducing. You can actually see the waveform and CVP pressure. This tells you that you are in the vein. Probably the most reliable method, because if you see a pressure reading off the scale (even with dark blood) you know you're in the artery.

Also, if you are doing it under ultrasound, you can just thread the wire in and bounce the ultrasound probe up and down to catch a bright white spot and shadow of the wire. If it's in the compressible black hole, you're good. If it's in the non-compressable black hole, you better try again.

There are actually a few good techniques to make sure you're in the vein if you're doing an IJ (including looking for the wire on the TEE, if one's already in). But, you have to transduce a subclavian because the others are less reliable. Point is, don't dilate until you're sure you're in the vein.

-copro

 

[Planktonmd]

I have a better technique:
Look at the blood coming out of the needle:
If it's pulsating then it's arterial.
If it's not pulsating then it's either venous or the patient is dead.