Triple lumen depth

[Bougie]

Very basic question...but one every attending and fellow I've asked has a different answer on. How deep should the triple lumen catheter go at the various sites (RIJ, LIJ, RSC, LSC)? 15, 16, 17cm.....

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[BLADEMDA]

Very basic question...but one every attending and fellow I've asked has a different answer on. How deep should the triple lumen catheter go at the various sites (RIJ, LIJ, RSC, LSC)? 15, 16, 17cm.....

Have you done a Medline search for the data? I remember reading a good study on this several (5-7) years ago. I can tell you that after 10,000 plus central lines my personal experience agrees with the published data. As you know each site has its recommended depth for the triple lumen.

When you get called at 0100 to pull back a central line your memory of the data will vastly improve.

Blade

 

[BLADEMDA]

Here are two EXCELLENT studies for you to pull up on your computer or at your Medical library:

1. Critical Care Medicine 1993 Aug:21(8):1118-23
ACCURATE PLACEMENT OF CENTRAL VENOUS CATHETERS: A PROSPECTIVE, RANDOMIZED, MULTICENTER TRIAL

2. Chest. 1995 Jun;107 (6):1662-4
Evaluation of formulas for optimal positioning of central venous catheters


Evidence based Medicine beats opinion (even mine) every time.

Blade

 

[BLADEMDA]

I was able to pull up those two articles and more without ever getting out of my chair. This is something I was not able to do as a Resident. In other words, you have all the info. plus more at your finger tips.

After reading the articles (you can easily print them out) see if you have more questions. I came across one more intersting article from JVR.

Central Venous Catheter Tip Position: A Continuing Controversy
Thomas M. Vessely, MD (author) J Vasc Interv Radiol 2003;14:527-534

The article is worth reading.

Blade

 

[Planktonmd]

In average adults:
For RIJ and RSC 15 cm.
For anything on the left: 20 cm.
Keep it simple.

 

[VentdependenT]

What plankton said, but if you wanna be more specific


RIJ 15
LIJ 18
RSC 19
LSC 21

 

[militarymd]

We have short catheters...I hub EVERY SINGLE one...and then call it a day.

The modern day soft tip catheters can go just about anywhere except into contractile and irritable structures...so it really just doesn't matter anymore.

 

[DrDre']

How does this compare to modern PICCs?

I have a friend that had an accidental endocardial bx occur when a PICC line was removed (tissue was visualized on end of catheter when removed). She has had PSVT ever since, with an inability to exercise ever since. No, she isnt psychy. SHe still tries to run through it on BBs with HRs in the 180s...

We have short catheters...I hub EVERY SINGLE one...and then call it a day.

The modern day soft tip catheters can go just about anywhere except into contractile and irritable structures...so it really just doesn't matter anymore.

 

[militarymd]

How does this compare to modern PICCs?

I have a friend that had an accidental endocardial bx occur when a PICC line was removed (tissue was visualized on end of catheter when removed). She has had PSVT ever since, with an inability to exercise ever since. No, she isnt psychy. SHe still tries to run through it on BBs with HRs in the 180s...

as I noted...NOT in contractile and irritable structures..

 

[DrDre']

Sorry, noted what u wrote that promptly spaced it.

So that begs the question, how sensitive is evidence of ectopy in "localizing" your line to intracardiac site?

I wonder how often we could be intraatrial without ectopy. Any idea?

as I noted...NOT in contractile and irritable structures..

 

[BLADEMDA]

In average adults:
For RIJ and RSC 15 cm.
For anything on the left: 20 cm.
Keep it simple.

Article points out really big dudes are more like 17cm RIJ. In fact, on my 6'2" and bigger guys I routinely place the RIJ at 17cm. As noted in the literature the tip of the catheter in the proximal Right Atrium may actually be preferential.

On my small ladies (less than 5'0") I limit the insertion to about 14cm RIJ.
These numbers are based on STUDIES and empirical experience. The original question was asking for FACT (literature based outcome) and opinion. When discussing the subject as a Resident it is helpful to read the literature and then discuss "how I like to do it" with the Attending.

Blade

 

[Planktonmd]

I can't believe someone actually wasted time and resources on studying something as insignificant as catheter depth!
As long as you are not in the ventricle, and none of your ports is out of the vessel, you are ok, trust me.

 

[jetproppilot]

I can't believe someone actually wasted time and resources on studying something as insignificant as catheter depth!
As long as you are not in the ventricle, and none of your ports is out of the vessel, you are ok, trust me.

 

[IceDoc]

When you get called at 0100 to pull back a central line your memory of the data will vastly improve.

Blade

It's especially fun to get called to pull back a central line SOMEONE ELSE put in and is at home sleeping soundly.

 

[bigeyedfish]

Rule #1 is don't advance the guidewire 50cm when doing a R IJ.

In this month's NEJM they have before and after images after someone did just that. They reported "quite a bit of resitance" when pulling the guidwire out. Evidently, they yanked anyway because the before image showed a IVC filter sitting right where it should be while the after showed it was in the SVC.

 

[Planktonmd]

Rule #1 is don't advance the guidewire 50cm when doing a R IJ.

In this month's NEJM they have before and after images after someone did just that. They reported "quite a bit of resitance" when pulling the guidwire out. Evidently, they yanked anyway because the before image showed a IVC filter sitting right where it should be while the after showed it was in the SVC.

I have actually seen someone do this exact same thing and hook the IVC filter, the only difference is that they could not pul the wire out and it became a big deal (a real one not pretend like Jet would say) but that's a story for another day.

 

[cubs3canes]

You would think there would be some anatomic data based on autopsy. I can not find that data anywhere.

I mean we have formulas for the width of et tubes in pediatrics, depth of et tubes...that are based on autopsy data, but where is the line depth autopsy data?

 

[VentdependenT]

You dont need dead people when you have xrays

 

[VolatileAgent]

so who's a member of the lung-poppers club?

 

[militarymd]

so who's a member of the lung-poppers club?

Only one time...RIJ done under draps...resolved with observation.

 

[DrDre']

What endpoint did you get following observation, tension > PEA? JK...

With US now, we have only had 1 or so PTX this year. It led to death, despite prompt CT. I think something else occured as well.

We see more carotid artery cannulations despite US.

Our local vasc surgery advocates an extremely steep angle of puncture for IJs with US. THis makes sense as you are actually in the exact plane of the US image, rather than transecting it with the trad blind angle.

I think the risk of PTX should approach zero with a steep angle and not too close to cervicothoracic junction.

MMD, were you "low" on the neck with this PTX?
IN the OR, not the ICU, right?

Only one time...RIJ done under draps...resolved with observation.

 

[militarymd]

What endpoint did you get following observation, tension > PEA? JK...

With US now, we have only had 1 or so PTX this year. It led to death, despite prompt CT. I think something else occured as well.

We see more carotid artery cannulations despite US.

Our local vasc surgery advocates an extremely steep angle of puncture for IJs with US. THis makes sense as you are actually in the exact plane of the US image, rather than transecting it with the trad blind angle.

I think the risk of PTX should approach zero with a steep angle and not too close to cervicothoracic junction.

MMD, were you "low" on the neck with this PTX?
IN the OR, not the ICU, right?

I was a CA-2

low in neck..

case in progess...

lost iv

patient bleeding and hypotension...

patient moving because gas was turned down...

under drapes...

-those were the pertinent bad things that were going on....can't remember the other stuff.

 

[bubalus]

Rule #1 is don't advance the guidewire 50cm when doing a R IJ.

In this month's NEJM they have before and after images after someone did just that. They reported "quite a bit of resitance" when pulling the guidwire out. Evidently, they yanked anyway because the before image showed a IVC filter sitting right where it should be while the after showed it was in the SVC.

I know of a fatality from such a thing. Not very easy to explain when it is so easily avoided.

 

[Planktonmd]

I know it's really "cool" to use ultrasound to place central lines, but are the residents being taught the blind techniques as well?
It would be sad if our future anesthesiologists became unable to do lines without ultrasound.

 

[jetproppilot]

Rule #1 is don't advance the guidewire 50cm when doing a R IJ.

In this month's NEJM they have before and after images after someone did just that. They reported "quite a bit of resitance" when pulling the guidwire out. Evidently, they yanked anyway because the before image showed a IVC filter sitting right where it should be while the after showed it was in the SVC.

A little trick I do when I know something is in the vascular space....

I turn the guidewire around and insert the straight end.

The curved-tip of the wire thats designed to reduce puncturing stuff may act as a lasso if you run into a pacer wire, IVC filter, etc.

Just have to make sure you don't push if you meet resistance since you're using the straight end instead of the curved end.

Can't show you any data on the trick since there is none.

But I do it anyway.

 

[DrDre']

Plank,
I wa talking about my experiences in the ICU where we use US for IJS, blind for SC

I imagine in the OR, blind is still the norm?...

I know it's really "cool" to use ultrasound to place central lines, but are the residents being taught the blind techniques as well?
It would be sad if our future anesthesiologists became unable to do lines without ultrasound.

 

[Arch Guillotti]

All our IJ's in the OR are blind unless there is a reason to use the U/S such as if the pt. is fully anticoagulated or if they are likely to be difficult - ESRD pt. for example. If it doesn't go in the first pass - reassess landmarks, get the U/S out, or the attending jumps in. Sort of depends who you are working with and how antsy others are to get the case started. A couple of my attendings think that eventually we will just start out w/ the U/S on the first pass.

 

[OldManDave]

I know it's really "cool" to use ultrasound to place central lines, but are the residents being taught the blind techniques as well?
It would be sad if our future anesthesiologists became unable to do lines without ultrasound.

Plankton;

I think you make a superb point! I firmly committed myself from day one to have as many ways to skin the cat as was feasible. No matter how facile you are at one way, you WILL encounter situations where your fav tech simply will not suffice. Interestingly, our CV anesth group is divided into two camps.

Camp 1 - ALL IJs must be inserted under direct U/S - no exceptions. One of them even contests that to place an IJ w/o U/S, in her mind, amounts to negligence & malpractice.

Camp 2 - Mix it up! You should absolutely be able to place an IJ, or any other CVL, by both landmarks & by U/S. Never unnecessarily narrow your therapeutic options.

The irony? Both camps cite the same body of literature to justify their stance.

 

[VentdependenT]

I know it's really "cool" to use ultrasound to place central lines, but are the residents being taught the blind techniques as well?
It would be sad if our future anesthesiologists became unable to do lines without ultrasound.

Yes we also go by anatomy. Becuase U/S guidance is so prevalent we do end up using them on almost all lines except codes. HOWEVER, I choose my position of placement BEFORE I look with the U/S. Most of the time I'm in the right spot as confirmed by the siterite. Sometimes...well...not so much.

 

[Planktonmd]

Plankton;

I think you make a superb point! I firmly committed myself from day one to have as many ways to skin the cat as was feasible. No matter how facile you are at one way, you WILL encounter situations where your fav tech simply will not suffice. Interestingly, our CV anesth group is divided into two camps.

Camp 1 - ALL IJs must be inserted under direct U/S - no exceptions. One of them even contests that to place an IJ w/o U/S, in her mind, amounts to negligence & malpractice.

Camp 2 - Mix it up! You should absolutely be able to place an IJ, or any other CVL, by both landmarks & by U/S. Never unnecessarily narrow your therapeutic options.

The irony? Both camps cite the same body of literature to justify their stance.

It's fairly common in our specialty to see people trying to shape the world according to their personal view, these are unfortunately the same people who will gladly testify against their colleagues as expert witnesses and have no remorse about it because their way is the only way and everyone else is an idiot.
It's extremely disgusting to see a physician using legal terms as "negligence and malpractice" to terrorize fellow physicians even if they were residents.

 

[BLADEMDA]

It's fairly common in our specialty to see people trying to shape the world according to their personal view, these are unfortunately the same people who will gladly testify against their colleagues as expert witnesses and have no remorse about it because their way is the only way and everyone else is an idiot.
It's extremely disgusting to see a physician using legal terms as "negligence and malpractice" to terrorize fellow physicians even if they were residents.

A recent study in one of our Journals (within the past few months) pointed out that EXPERIENCED Anesthesiologists don't always use U/S even when it is readily available. In addition, the majority of Anesthesiologiss who use U/S regularly DO NOT USE IT for actual line placement. Instead, most just take a quick look for the relationship of the IJ to the Carotid (is it over the Artery or just next to it) and then proceed with the "old fashioned" technique.

This means that the MAJORITY of Anesthesiologists in the USA (even those who use U/S regularly) are committing malpractice per your attending. He is dead wrong and most likely an arrogant idiot with no real world experience.

Blade

 

[epidural man]

Plankton;

I think you make a superb point! I firmly committed myself from day one to have as many ways to skin the cat as was feasible. No matter how facile you are at one way, you WILL encounter situations where your fav tech simply will not suffice.

When I was an intern, I put in several right or left IJ's using the posterior approach. I have never seen an anesthesiologist use this approach except for one time when anterior and "top of the triangle" wasn't working. As an intern, I thought it worked well.

I know it's really "cool" to use ultrasound to place central lines, but are the residents being taught the blind techniques as well?
It would be sad if our future anesthesiologists became unable to do lines without ultrasound.

I'm not saying that Anesthesiologists should use ultrasound or not, but as far as the above comment - it seems like I read an article last year that addressed this issue and one of the conclusions was that when you practice with US to place central lines, your skills of doing blind improve.

 

[UTSouthwestern]

A little trick I do when I know something is in the vascular space....

I turn the guidewire around and insert the straight end.

The curved-tip of the wire thats designed to reduce puncturing stuff may act as a lasso if you run into a pacer wire, IVC filter, etc.

Just have to make sure you don't push if you meet resistance since you're using the straight end instead of the curved end.

Can't show you any data on the trick since there is none.

But I do it anyway.

What you can also do is use the curved end normally and if you feel resistance as you pull out, apply tension on the wire (pinch distally while pulling proximally on the wire) then move the wire out while maintaining this tension on the wire. Try it before you float the guidewire into the neck/SC. You will see the curved end of the wire straighten itself out. I usually do this if the plastic tip of the wire holder has fallen off the field or is contaminated and I have yet to put the wire in.

I know that I had hooked a pacer wire one day with the wire and instead of just yanking it out, I did the above and the wire slid out easily.

 

[serenity]

Very basic question...but one every attending and fellow I've asked has a different answer on. How deep should the triple lumen catheter go at the various sites (RIJ, LIJ, RSC, LSC)? 15, 16, 17cm.....

If you really want to be accurate there was this recent article in British Journal of anesthesia which used the the distance between the clavicular notch and the carina on pt's preop xray plus the distance between the point of insertion and clavicular notch.
I have attached the article with this thread,hopefully it will come through