Technique advice for placing lines

[Foxxy Cleopatra]

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The Hopkins-Baview thread got me thinking about central line technique. The idea of causing a PTX scared me to death when I first started internship, and though I have been lucky so far, I have not done hundreds of subclavians and IJ's and would really like to hear other's advice regarding technique. I'll start with some of my amateur advice:

1. Always keep one hand on the wire

2. (For subclavians) advance the needle in a plane parallel to the body. Press on the needle with your thumb if necessary as your advance but don't angle down towards the chest.

3. If you feel resistance when passing your wire, don't force it!

4. If arterial blood squirts back at you, pull out and apply pressure. Don't ignore it and thread a cordis anyways. When assisting in lymph node retreival on a organ donor, we found that the femoral cordis was in the artery (don't know who placed it) and it was not a pretty site.

5. Don't forget to order and follow up the chest X-ray when you're done.

 

[Docxter]

Here's my not-so-amateur advice. A couple hundred here.

1. Always use ultrasound guidance if available or even if it means getting it from the next room or down the hallway in the other ward. There will be a few cases that you can't tell if you're in the artery or vein. The color of the blood or its pressure or pulsatility helps, but not always. The morbidity (and even mortality) associated with central line placement is more than what medical students and more junior residents think. I have too many times seen and sometimes treated these complications. This is the 21st century. If there's anything that helps patient safety (e.g. US), use it. It will not make you less of a doctor or surgeon.

2. If you go without US guidance, you will puncture the carotid (IJ) and cause a PTX (SC vein) if you do enough of them. If haven't punctured a carotid, it's not because you're good, you just haven't put in enough lines. Though, as long as you don't dilate the carotid artery with the dilator, you should be fine holding pressure.

3. The right jugular is the site of choice, 2nd choice is the left jugular if there are no other issues that make other sites necessary or preclude any of these two.

4. After a while, the subclavian may seem to be an easier route of placement. I've seen people use subclavians as the site of choice, expecially those afraid of hitting the carotid. I think this is poor medicine. There is a very high rate of subclavian vein stenosis and occlusion after central line placement, even if it stays in for just a few days. Just because you don't see and don't have to deal with this complication immediately, don't be a ja***ss and put subclavians in everybody coming through the door. The long-term stenosis rate is much less for the IJs. A stenotic SC vein means no PICCs or subclavians in the future and infrequently chronic edema of that upper extremity. Fixing them is also not that trivial.

5. Don't try to puncture the internal jugular just below the mandibular angle (the so-called posterior approach) if you can do it the normal way.

6. Don't go through the sternoceidomastoid muscle. It will be painful when the patients move their head around or bend their necks. You might laugh, but it happens quite frequently.

7. Read a procedure atlas or watch a procedure video before doing this stuff. A lot of times, the person teaching you (e.g. your resident and god forbid attending) doesn't know how to do it properly either. Just because they've put in a couple more doesn't mean they do it properly.

8. Optimal tip position is at the cavoatrial junction in expiration in most cases.

9. AND FINALLY, CENTRAL VENOUS CATHETERS, (e.g. triple lumens) COME IN DIFFERENT LENGTHS. DON'T USE A RIGHT SIDED CATHETER (usually 15-16 cm) INSTEAD OF A LEFT SIDED CATHETER (usually 20-25cm) AND VICE VERSA IF YOU HAVE THE CHOICE. I am amazed how many senior residents and even attendings don't know this.

 

[dread]

Well, I'm probably one of the least experienced line placers on here, but I would just add to try to do everything to avoid using the subclavian in patients who have CRI or who are at high risk for developing ESRD. Subclavian thrombosis or stenosis can be problematic for patients who need dialysis since you've essentially cut off all access to one entire arm by ruining their subclavian on that side. Make sure that you check the EJ, and other peripheral sites like the foot or the shoulder before you place a central line too. Sometimes, central lines are placed only because no one has bothered looking closely at these peripheral sites for access.

 

[Been there]

1. Always keep one hand on the wire

Sorry Foxy, that is myth which had been used to scare students and interns. The wire will not go anywhere. The only time people loses the wire is when they lose control while advancing the introducer. Your hand should be on the wire when you advance the introducer and the line.

2. (For subclavians) advance the needle in a plane parallel to the body. Press on the needle with your thumb if necessary as your advance but don't angle down towards the chest.

That works well if your patients is not morbidy obese. The problem is most people edge the needle on to the subclavian bone. This makes it impossible to push down on the needle. Alway keep a finger on the sternal notch to steady your hand, and don't ram the needle into the bone (relax).

3. If you feel resistance when passing your wire, don't force it!

This is so true.

4. If arterial blood squirts back at you, pull out and apply pressure. Don't ignore it and thread a cordis anyways. When assisting in lymph node retreival on a organ donor, we found that the femoral cordis was in the artery (don't know who placed it) and it was not a pretty site.

Well, this can be a big problem if it is a subclavian attempt. However, most needle stick injury are not too bad. The problem comes when the patient has a coag problem, or you proceed to place a line in the artery.

Some time it is difficult to tell if you are in the artery or the vein when patient has been on the Vent. The trick here is ask your assistant/ nurse to get a CVP manometer (like the one in the LP kit) or if you are in the ICU, hook the artline transducer to the needle. These tricks can help you ID an arterial stick.

5. Don't forget to order and follow up the chest X-ray when you're done. [/B][/QUOTE]

While this is important, sometime the PTX will not show right a way. It is more useful as an placement confirmation. Just remember to get a CXR and listen to the chest if patient compliants of any chest discomfort (eventhought you checked after the line was placed). More importantly remember, PTX is a clinical diagnosis and not a radiographic diagnosis. If patient looks bad get the chest tube tray or try needle thoracostomy.


While the "Site-right" is a good invention, most line placement will not need it. I have seen many PTX or bad placements with the U/S.

I do agree with Right-IJ as the line of choice because you have more control than the subclavians.

The lenght of the catheter can make a different, but I have only seen this problem when people start changing lines over a wire (the short kits can't be use to change the long catheter). Once you remebered, the right Jugular is about 11cm, left IJ about 13cm, right SC about 13-15, and left SC about 15-17 (these are the markings on the cath), you should have not problem with the lenght of the catheters.

almost everybody will encounter these problem (sooner or later). You could be in your ten-th year of practice and still have these complication. Most peole quote a PTX rate of 1% or 1/150 sticks. So, if you have placed >100 than you are about due for one PTX.

 

[militarymd]

I stopped my central line count at 100, and I've certainly had just about every complication related to central lines that are in the text books, and some that are not.

I personally prefer the subclavian location for patients in the ICU who I predict will require the access for some period of time. This reason being slightly lower line infection rates as compared to the IJ location in the ICU where I practice.

Actually, I think it is actually a recommendation from the CDC for prevention of line infections.

 

[DoctorDoom]

Originally posted by Been there
Sorry Foxy, that is myth which had been used to scare students and interns. The wire will not go anywhere. The only time people loses the wire is when they lose control while advancing the introducer. Your hand should be on the wire when you advance the introducer and the line.

I have to disagree, this is no myth.

 

[droliver]

Losing the wire by letting go of it is not a myth, I've seen it done in person & its a very common story if you talk to people that have had it happen to them.

I agree with most of those general recommendations, but in real life you end up cheating sometimes when you have to in re to pushing the wire against resistence.

The points re. PTX were good. Frequently they do not show up on CXR for several hours. I can remember doing a stick on some guy flailing about in the trauma bay after a stab wound whom I knew I had gotten into the pleura (got some air back on aspiration). I did serial CXR's on him for about 8hrs before he finally droped his lung.

 

[Whisker Barrel Cortex]

Originally posted by Been there
subclavian bone

Uh.... what bone. Did I miss that in anatomy? Do you mean the clavicle?

 

[lattimer13]

Originally posted by Whisker Barrel Cortex
Uh.... what bone. Did I miss that in anatomy? Do you mean the clavicle?

i was just thinking the same thing!

 

[Foxxy Cleopatra]

I've enjoyed reading the different responses. My experience is kind of unusual; we have a great attending in the burn unit here that lets you do a ton. The few burn units I've seen (as a student and now here) generally do femoral lines, so between TLC's, a-lines, vas caths, I probably have done more than 200 femorals. I am very comfortable doing them but realize that outside of burns, they are generally used as a last resort.

I have never been unfortunate enough to lose the wire in the patient, however, while changing an IJ over a wire I was not holding on as I went to get something out of the kit and the wire came out. The patient apparently had been a difficult stick in the past so I felt bad that I lost access and had to put him through more needle sticks. Oops. At least he did well in the long run.

 

[southerndoc]

Have any of you guys ever had the dreaded problem of doing a wire changeout and the guidewire won't thread through the original TLC, thus making you have to do a new stick?

Or worse yet, inserting the TLC that will only aspirate 1 or 2 of 3 ports. (We had a batch of them like that. Maybe I should've tested it before using it.)

 

[Docxter]

Don't you routinely flush the three ports before putting them in?

 

[southerndoc]

Originally posted by Docxter
Don't you routinely flush the three ports before putting them in?

Actually, no, we never did.