Dec 22, 2013
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So I am currently in my pre-lim year for anesthesiology and have had a chance to try a few central lines (4-5). For some reason or another (urgent situation, attending waiting to round, as well as just not being able to) I had a good bit of difficulty with this.

Was wondering if anyone has had issues with lines with the first ones being done. They always seem to be done so easily otherwise so I'm not sure why I'm having issues with it

Thanks for any feedback
 

bashwell

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So I am currently in my pre-lim year for anesthesiology and have had a chance to try a few central lines (4-5). For some reason or another (urgent situation, attending waiting to round, as well as just not being able to) I had a good bit of difficulty with this.

Was wondering if anyone has had issues with lines with the first ones being done. They always seem to be done so easily otherwise so I'm not sure why I'm having issues with it

Thanks for any feedback
Sorry nothing helpful here, but I did just want to say I remember you were deciding between IM vs anesthesiology, good to see you made a decision, and hope you have a bright future!
 

SaltyDog

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Would really help if you explained what in particular was giving you trouble when trying to place a CVL. Help us help you.
 
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okayplayer

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Would really help if you explained what in particular was giving you trouble when trying to place a CVL. Help us help you.
Agree but one thing I consistently saw when I was teaching junior residents as a senior was them not having the needle tip under the probe and instead having the middle of the shaft of the needle under the probe. You have to know where the needle tip is. Have to see the needle tip tenting the IJ before you penetrate the vessel.

Problem #2: after drawing back blood on the syringe, often people get excited and jiggle around the needle tip too much while trying to take off the syringe and inadvertently pull the tip out of the vessel before they can thread the guidewire in. This can also be avoided by using the angiocath to put in the catheter like an iv and then thread the guidewire through the catheter. This is what I do now, but I wish I would have done it all through training. Way better than guidewire through needle in my opinion.

If I can tell you anything, just be cautious when you are starting and do not dilate unless you are truly certain you are in the right place. Everyone will forgive you if they need to grab gloves to help you out but dilating the carotid is a mistake you don't want to make.
 

norwood

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Agree but one thing I consistently saw when I was teaching junior residents as a senior was them not having the needle tip under the probe and instead having the middle of the shaft of the needle under the probe. You have to know where the needle tip is. Have to see the needle tip tenting the IJ before you penetrate the vessel.

Problem #2: after drawing back blood on the syringe, often people get excited and jiggle around the needle tip too much while trying to take off the syringe and inadvertently pull the tip out of the vessel before they can thread the guidewire in. This can also be avoided by using the angiocath to put in the catheter like an iv and then thread the guidewire through the catheter. This is what I do now, but I wish I would have done it all through training. Way better than guidewire through needle in my opinion.

If I can tell you anything, just be cautious when you are starting and do not dilate unless you are truly certain you are in the right place. Everyone will forgive you if they need to grab gloves to help you out but dilating the carotid is a mistake you don't want to make.
This is good advice. A few other things that come to mind:

- You have the pt in Trendelenburg and are using ultrasound, right? For that matter, you're trying IJ lines, right?

- Think about the geometry of what you're trying to do. If you're perpendicular to the vessel with your transducer (which is how I trained), and a given pt's IJ is (say) 2cm deep where you're going for it, you can't make your skin puncture right next to the transducer and expect to get a good picture unless you follow the needle with the transducer - which is kinda difficult. Likewise, especially steep needle angles will make it harder for you to get the wire in.

- Color of the blood you're getting does not reliably show where you are. On room air, oxygenated blood (especially after several decades of smoking) may look sorta-kinda venous. Conversely, on an FiO2 of 1.0, even venous blood can be pretty reddish. If you have access to a sterile loop of tubing (the good kits have one), it works well as a confirmatory step. I've seen even good residents hit the carotid, but this should help detect it. As okayplayer said, dilating the carotid is not a good idea.

- Free the angiocath from the needle before using it - move it just enough (to avoid catheter shear) to ensure it's not sticking. It's awfully frustrating to get the needle placed well, then goof things up trying to get the angiocath to advance.

- Likewise, get your guidewire ready (also freed up, with the tip of the wire loaded properly into its guide) before you get going.

- See a trend here? Take a moment at the beginning to get all your stuff ready, so that once you take the needle in your hand, you don't have to distract yourself with equipment.

- Remember where the IJ and carotid are when suturing, please.

That's all I can think of for now. Good luck!
 
OP
M
Dec 22, 2013
76
4
Agree but one thing I consistently saw when I was teaching junior residents as a senior was them not having the needle tip under the probe and instead having the middle of the shaft of the needle under the probe. You have to know where the needle tip is. Have to see the needle tip tenting the IJ before you penetrate the vessel.

Problem #2: after drawing back blood on the syringe, often people get excited and jiggle around the needle tip too much while trying to take off the syringe and inadvertently pull the tip out of the vessel before they can thread the guidewire in. This can also be avoided by using the angiocath to put in the catheter like an iv and then thread the guidewire through the catheter. This is what I do now, but I wish I would have done it all through training. Way better than guidewire through needle in my opinion.

If I can tell you anything, just be cautious when you are starting and do not dilate unless you are truly certain you are in the right place. Everyone will forgive you if they need to grab gloves to help you out but dilating the carotid is a mistake you don't want to make.
Problems with both 1 and 2. Great advice and thanks for the help. Hopefully I'll get some more practice in but it'll be hard, most of the lines we get to try are on our ICU month (which I have finished)
 
OP
M
Dec 22, 2013
76
4
This is good advice. A few other things that come to mind:

- You have the pt in Trendelenburg and are using ultrasound, right? For that matter, you're trying IJ lines, right?

- Think about the geometry of what you're trying to do. If you're perpendicular to the vessel with your transducer (which is how I trained), and a given pt's IJ is (say) 2cm deep where you're going for it, you can't make your skin puncture right next to the transducer and expect to get a good picture unless you follow the needle with the transducer - which is kinda difficult. Likewise, especially steep needle angles will make it harder for you to get the wire in.

- Color of the blood you're getting does not reliably show where you are. On room air, oxygenated blood (especially after several decades of smoking) may look sorta-kinda venous. Conversely, on an FiO2 of 1.0, even venous blood can be pretty reddish. If you have access to a sterile loop of tubing (the good kits have one), it works well as a confirmatory step. I've seen even good residents hit the carotid, but this should help detect it. As okayplayer said, dilating the carotid is not a good idea.

- Free the angiocath from the needle before using it - move it just enough (to avoid catheter shear) to ensure it's not sticking. It's awfully frustrating to get the needle placed well, then goof things up trying to get the angiocath to advance.

- Likewise, get your guidewire ready (also freed up, with the tip of the wire loaded properly into its guide) before you get going.

- See a trend here? Take a moment at the beginning to get all your stuff ready, so that once you take the needle in your hand, you don't have to distract yourself with equipment.

- Remember where the IJ and carotid are when suturing, please.

That's all I can think of for now. Good luck!
Thanks for the advice, very helpful. I've already learned the hard way you cannot be 100% based on color, took the angiocath off and.... well you can guess. I know practice is the most important thing, just frustrated as I feel I should've picked it up faster
 

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Hard to imagine difficulty placing an IJ with u/s since many of us did these blind for decades with high success rate.

Anyway, the issue isn't IJ line placement but rather lack of basic u/s skill which is needed in this specialty. Compared to the other things we do with u/s the IJ is a gimme (provided the vessel is greater than 6cm in size).

I highly recommend a few hours with u/s and those practice devices most academic programs have in place. You must practice out of plane sticks for IJ placement (although I do in plane as well these days).
 
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BLADEMDA

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OP
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Dec 22, 2013
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Hard to imagine difficulty placing an IJ with u/s since many of us did these blind for decades with high success rate.

Anyway, the issue isn't IJ line placement but rather lack of basic u/s skill which is needed in this specialty. Compared to the other things we do with u/s the IJ is a gimme (provided the vessel is greater than 6cm in size).

I highly recommend a few hours with u/s and those practice devices most academic programs have in place. You must practice out of plane sticks for IJ placement (although I do in plane as well these days).
I definitely think its mostly due to my lack of u/s skill more than anything. Thanks Blade, great advice as always
 
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Last 5 minutes may be helpful to the OP
 

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BLADEMDA

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In plane approach- a little bit more advanced than the out of plane for IJ central line placement.


 

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Mman

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those pictures show terrible technique. You still need to aim for the ipsilateral nipple with the needle. I mean you don't have to with the ultrasound to get it done, but that's the safe plane for the needle to be taking and people need to do that even when using ultrasound. Both pictures show a needle headed for the middle of the sternum.

Just my 2 cents but just because we can use the ultrasound doesn't mean we should skimp on safe techniques. At some point aiming medial with the needle, even with ultrasound, will lead to a carotid stick.
 

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Hard to imagine difficulty placing an IJ with u/s since many of us did these blind for decades with high success rate.

Anyway, the issue isn't IJ line placement but rather lack of basic u/s skill which is needed in this specialty. Compared to the other things we do with u/s the IJ is a gimme (provided the vessel is greater than 6cm in size).

I highly recommend a few hours with u/s and those practice devices most academic programs have in place. You must practice out of plane sticks for IJ placement (although I do in plane as well these days).
Agree. I finished my training in 2004 just before U/S got popular.

I can't imagine residents these days doing it blindly (IJ).

Practice practice practice with U/S scanning. Find friends to lay down and scan them.

One word of advice. Be careful that u don't scan too low in the neck especially in super obese short people with short thick necks (Aka 4 foot 10 250 pound Samoan type of body habitus). U can get pneumo if u don't want how low the probe is going.
 

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My problem as an attending is doing subclavians. Have done less than 10 in my lifetime. I have watched videos, but it is not as easy as it looks.
Most people have been taught to go too lateral with the needle when doing subclavians which increases the chance of arterial puncture and missing the vein, that's the most common mistake I have seen with people who don't do subclavians regularly.
It's a very easy technique otherwise.
 
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Hoya11

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My problem as an attending is doing subclavians. Have done less than 10 in my lifetime. I have watched videos, but it is not as easy as it looks.
The chest is designed to protect your heart and great vessels, so getting in can be hard if you dont know where to go.

Feel on your own chest, below the mid-clavicle as you abduct your shoulder (try to bring in to midline). You will feel a divit (sp?) in the chest wall below the clavicle in the middle of the clavicle just where the clavicle takes a little turn (just after the turn). This is your entrance point, entering from other points locks your needle into strange trajectorys i have found (due to lots of muscle and tissue to go through), but this weakness in the chest wall is your access point. enter aiming to hit the clavicle, hit it, come back and redirect under the clavicle towards the sternal notch.
 
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ZzzPlz

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I tell the ICU nurse to prone the patient or I'm not coming.
 

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Left subclavian is my line of choice unless there's a contraindication. Did hundreds of subclavians in fellowship (actually if we didn't do a subclavian we would have to clearly document why) and when teaching interns/residents I noticed the most difficult part for them was getting the needle under the clavicle. But after you get that down, you realize how simple it is. You don't need to be that exact with your entry point. Just from experience I know that I usually like to enter about my middle finger's length away from the notch and a couple cm below the bone. But I've gone more medial/lateral than that without a problem. Just gotta be in that general vicinity. And you don't have to aim exactly at the notch. Just get that needle under the clavicle and keep the needle level and you'll be fine. When you start diving that needle, that's when you'll get burned. Especially on those skinny frail old ladies.
 
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Stank811

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Agree with above post. Another common mistake early is not understanding how deep your needle is. The IJ is rarely more than a couple cm deep on US so there is no reason to have your needle buried. Since you said you are in intern my guess is that you are placing these lines in the ICU. Often ICU pts start off volume depleted and even placing your US probe on the IJ causes it to be compressed. In such a situation most of the time your needle with compress the vessel and go through the back wall of the IJ. In this case continue negative pressure on your syringe and slowly draw back the needle and often you will get good blood return on the way out. Early on people don't recognize they have already have passed the lumen of the IJ and keep driving the needle deeper in hopes of blood return and sometimes instead get air.
 
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Mman

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Left subclavian is my line of choice unless there's a contraindication.
As much as I kinda like them, every time I start doing more I end up getting a pneumothorax at some point. Don't get wrong, it's not a ton, well under 5% (maybe 2% or so), but it happens. My complication rate from placement of an IJ line with ultrasound is 0.0%. Never hit the carotid, never got a pneumothorax.

So while I understand the subclavian is both slightly more comfortable for the patient and slightly lower risk of line infection, any time I directly cause a complication I feel bad and go back to doing more IJs.
 

Hawaiian Bruin

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But might increase the chance of pneumo :)
Might. I honestly don't believe the absolute risk is increased. I think inspiratory volume matters more than end expiratory volume.

Or you can do what Mman does, though TBerg doesn't dilate the vessels to the same degree as PEEP.
 

teeva

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With ultrasound and IJ vein, keep the probe perpendicular to the skin and trace the IJ up and down to determine how it runs along the neck, so you know which parallel direction to go with your needle.

Look for a good point to insert your needle, usually as cephalad as possible and also where the IJ is most superficial and away from the carotid.

Don't put so much pressure on the IJ with the u/s probe or you'll compress it.

When you insert the needle, do it slowly while aspirating and make sure you see where you are at on u/s. At the same time, you need to be aspirating on the needle and cognizant of when you get flashback. I've seen so many times where the person doing the line is busy trying to visualize the needle tip but are totally unaware they already got flashback and yet are still pushing the needle deeper because they can't see it.

You need to be steady with your hand movements. After visualizing the needle tip and getting flashback, gently put the u/s probe down and keep the needle still by stabilizing with your now freed hand. Make sure you still get good flashback before whatever you choose to be your next step (mine below, or feeding the wire thru the special blue syringe, or taking off the syringe and feeding the wire).

After hearing stories of attendings or attendings supervising residents who cannulated the carotid artery, I changed my technique to copy that of an attending who it happened to. I use the angiocath needle, after getting good flashback, thread the angiocath, remove the needle, feed the guidewire, and use the u/s again in plane and out of plane to verify the wire is in the vein. Takes a couple more seconds of work, but can save a lot of headache.
 
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sluggs

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In re subclavians: the newest data shows no difference in infection between IJ and subclavian.
It is worth (if you have the time) using the US to assess the subclavian veins for size/plumpness.
With practice, you can use US to actually cannulate the subclavian (albeit you are slightly lateral).
I have had 2 pneumothorax with subclavians and 3 or 4 arterial sticks in about 250 lines. I have never had either in almost 500 IJs.
The latter are safer overall (not just my data) but you need to know both (trachs, trauma, IJ clot, patient preference, etc...)
 

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Taking this even further off topic but supraclavicular subclavian lines are also good to know. Usually, but not always, easy with ultrasound, depending on anatomy. With bigger catheters (like MACs), the ports will lie on the shoulder rather than tickling the ear, which I like.

Not the best video ever but gives you the idea.

But I usually just put in IJs. Mostly, so I don't get blamed for the occasional pneumos the CT surgeons cause by getting into the pleura and then pretending they didn't.
 

ecCA1

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Don't overly tighten syringe on the metal needle and it won't be an issue when removing to place wire. I don't like the angiocath approach-angio gets bunched up and cocks up the attempt.

Also, you can let go of the needle once syringe off. This way you're less likely to jiggle it out of position in the vein. The needle won't swing around and damage anything. Done it a thousand times and never once had an issue.
 
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