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Anyone placing these in the hospital? My group is considering offering a daytime central line service and maybe doing temporary HD catheters. Most info online seems to be about tunneled catheters.
Just don't put it in the subclavian
That is an interesting point. If I put one in as requested by a nephrologist for an inpatient, I'd expect to be uninvolved in follow up care other than checking the chest X-ray. If the catheter subsequently thromboses or gets infected, or oozes or bleeds, would I be called back or held responsible? Or does the hospitalist and nephrologist take over? I would think it would be similar to putting in triple lumen catheter -- place it and the PCP owns it and the nurses run their protocols.
Do them all the time, for those people who don't do critical care regularly i can see how you might be afraid of placing this line on sick patients. Unfortunately I must place them for the survival benefit of my patient and I must say that an IJ stick and the complications from it in my hands regardless of the INR, or platelet count is very low. I live in a reality where if i am placing a Central line the patients needs it regardless of the patients cormorbidities so whats the point in fussing about all the numbers BS. Besides i learned in residency while placing lines in a liver txp patient that it can be done.
/nod.
Early on as an intern I put an IJ in pretty terrible looking liver pt. about 45 min later I threw another into a septic old gomer. My attending didn't tell me anything about the pts beforehand just said right after they hit our door they need lines fast. Liver pt had a plt count of 8 and an INR of 2.4. The septic was a fib'r on warfarin with an INR of 7. After I finished both and sat down to dictate and enter the admission paperwork, I noticed both coagulopathies and asked my attending.....wtf?? His response was if I had told you the numbers, you would have panicked, and would have had a higher chance of making a mistake. Both pts needed the lines regardless of the numbers, so why tell you and make you panic.
I've always kept that night in the back of my mind. If the pt needs the line, especially if they need one to be urgently dialyzed, who gives a damn about the coagulopathy.
Do them all the time, for those people who don't do critical care regularly i can see how you might be afraid of placing this line on sick patients. Unfortunately I must place them for the survival benefit of my patient and I must say that an IJ stick and the complications from it in my hands regardless of the INR, or platelet count is very low. I live in a reality where if i am placing a Central line the patients needs it regardless of the patients cormorbidities so whats the point in fussing about all the numbers BS. Besides i learned in residency while placing lines in a liver txp patient that it can be done.
I would want to know. I would go femoral in the setting of the coagulopathies you just mentioned.
i woud do the opposite. its easy to compress the jugular and IMO the least liky site to bleed heavily with US. double points for ij if theyre on the vent and the airway is already protected. femoral is A bigger vessel and often much deeper in fatty diabetic dialysis pts. harder to reliably compress IMO
I agree, I question how much safer a femoral stick is compared to an IJ. Seen too many people having retroperitoneal bleeds and SQ thigh hematomas that go unrecognized. Also have seen femoral thrombosis after femoral artery punctures where pressure is held for extended periods. ICU patients have there head up most all day. With a pressure of 15 or less (CVP) not much bleeding happens unless you're the type who likes to make an incision in the skin instead of letting the dilators do their job of dilating, i like it tight 😎
I do them routinely for the nephrologists. Live US jugular line as blade said. It's the exact same procedure as a IJ TLC...you just use a second, larger dilator, and then a larger diameter, dual lumen catheter. Takes me about 8 min.
Just to put some facts on figures on these lines on the table...
These temporary HD catheters have a bunch of different names. Trialysis, Mahurkar, etc, etc. They have at least 2 lumens, some have a third "pigtail" lumen for infusions/draws etc. The actual dialysis/plasmapheresis lumens are big and have multiple apertures along the catheter itself -- like fenestrations along the shaft.
Most of these that I've seen are 12fr. That's big. They come in various lengths for the different height and placement sites. We have 12cm, 16cm, and 20cm lengths.
As mentioned these come with two dilators. It seems like a lot of the time the 2nd, larger dilator isn't necessary, maybe because these catheters have a tapered tip and are pretty stiff.
Because the catheters are pretty stiff it makes the RIJ an even better site than the LIJ. But you gotta do what you gotta do.
I personally don't know why an IR guy would use a dirty old percutaneous central line to place a semipermanent tunneled cath. Why not just a fresh stick?
i woud do the opposite. its easy to compress the jugular and IMO the least liky site to bleed heavily with US. double points for ij if theyre on the vent and the airway is already protected. femoral is A bigger vessel and often much deeper in fatty diabetic dialysis pts. harder to reliably compress IMO
Just to put some facts on figures on these lines on the table...
These temporary HD catheters have a bunch of different names. Trialysis, Mahurkar, etc, etc. They have at least 2 lumens, some have a third "pigtail" lumen for infusions/draws etc. The actual dialysis/plasmapheresis lumens are big and have multiple apertures along the catheter itself -- like fenestrations along the shaft.
Most of these that I've seen are 12fr. That's big. They come in various lengths for the different height and placement sites. We have 12cm, 16cm, and 20cm lengths.
As mentioned these come with two dilators. It seems like a lot of the time the 2nd, larger dilator isn't necessary, maybe because these catheters have a tapered tip and are pretty stiff.
Because the catheters are pretty stiff it makes the RIJ an even better site than the LIJ. But you gotta do what you gotta do.
I personally don't know why an IR guy would use a dirty old percutaneous central line to place a semipermanent tunneled cath. Why not just a fresh stick?
15cm for right IJ, 20cm for everywhere else?
Seems unlikely you'd reach the ventricle though.
The dilators are stiff enough not only to tear a vein but they can also perforate the ventricle. I am as much of a cowboy as anyone but I can not stress the care that must be taken when placing these things. Interns placing them, listen! These things are orders of magnitud more risky than a standard TLC even though the procedure is very similar.
The dilators are stiff enough not only to tear a vein but they can also perforate the ventricle. I am as much of a cowboy as anyone but I can not stress the care that must be taken when placing these things. Interns placing them, listen! These things are orders of magnitud more risky than a standard TLC even though the procedure is very similar.
Anyone placing these in the hospital? My group is considering offering a daytime central line service and maybe doing temporary HD catheters. Most info online seems to be about tunneled catheters.