Ultrasound guided central lines

[narcusprince]

How do most of you place your central lines in plane our out of plane. I recently have become very proficient with the ultrasound and found that an in-plane approach with full visualization of the needle entering the vessel is the way to go. How about you guys. Also for your ultrasound guided blocks I'm sure you do them in plane too.

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[PMPMD]

How do most of you place your central lines in plane our out of plane. I recently have become very proficient with the ultrasound and found that an in-plane approach with full visualization of the needle entering the vessel is the way to go. How about you guys. Also for your ultrasound guided blocks I'm sure you do them in plane too.

I've been meaning to try that. Are you talking about IJs or SCs? Getting the in-plane view on US SCs (technically axillaries) is a little tricky.

 

[dhb]

in plane for me

 

[B-Bone]

out of plane for me. The reason I use US is to not stick it in the carotid. I like to see both the carotid and the IJ in my view until I get blood back. All it takes is a little lateral slide while you're looking at the needle and all of a sudden your probe is centered over the artery. Sure, it's pulsatile, but some people get blinders on and stick the needle into the long black vascular-looking structure. But, of course, you pay malpractice insurance for a reason, so have at it!

 

[narcusprince]

IJ's definitely their is a window for subclavian lines but I do not think I will ever place a subclavian line with ultrasound landmarks are good enough for me. I have seen people use it but its more for localization of the wire.

 

[BobBarker]

Get both the carotid and the IJ in classic cross section view. For a RIJ line rotate the US probe 45 degrees clockwise. This will leave your view essentially the same as cross section. Insert the needle midline to the probe on the lateral edge. This will allow you to view the length of the needle and maintain visualization of both vessels throughout the procedure.

 

[pd4emergence]

I like to keep both in view also. You can keep both in view and visualize the needle as above. For people with big necks or big scm's overlying the vessels I find myself doing more posterior approaches to the ij. I hate putting big lines through the muscle. Also as a check, I look for my wire in the ij before dilation. Does anyone have any good tips on doing subclavian lines with the u/s? Never tried it.

 

[BLADEMDA]

in plane for me

Out of plane for me. "static" look only 90% of the time. Live U/S used only when indicated such as Heparin, Previous neck surgery, s/p carotid endarterectomy, morbid obesity, etc.

For those of us used to doing lines for decades without U/S a static look is sufficient or more rarely, live U/S with an out of plane technique.

The most difficult lines in general are those patients with renal failure or severe vascular disease who have had MULTIPLE line placements throughout their body. This subgroup as a whole can be the toughest to get central access even with a normal looking IJ on U/S scan. Hence, I'm more likely to go "live" on these people and will always go live on a tiny IJ.

 

[BobBarker]

Doing SCVs with ultrasound is quite difficult. I have done a few on cachetic types. On normal size people the plane of my needle made me think I was headed straight for a pneumo.

 

[BobBarker]

Renal failure types tend to have a lot of collateral veins. Often, you can't really tell which vein is the IJ as they all look the same.

 

[sevoflurane]

Out of plane.

 

[BLADEMDA]

Renal failure types tend to have a lot of collateral veins. Often, you can't really tell which vein is the IJ as they all look the same.

No. That hasn't been my experience at all. Well over 10,000 central lines placed and identifying the IJ vein isn't the issue. I found that the tiny IJ can be difficult to cannulate and/or getting the guidewire itself to pass down through the vein into the RA. Sometimes if one side has a tiny vein the opposite IJ is much larger. Still, the use of U/S in this subgroup has been a welcome improvement/enhancement and I always prefer at least a "static" look in all my patients.

The failure rate of line placement rises as the size of the vein shrinks. This is why the use of live U/S becomes important as the vein becomes smaller than the carotid.

 

[Bertelman]

No. That hasn't been my experience at all. Well over 10,000 central lines placed and identifying the IJ vein isn't the issue. I found that the tiny IJ can be difficult to cannulate and/or getting the guidewire itself to pass down through the vein into the RA. Sometimes if one side has a tiny vein the opposite IJ is much larger. Still, the use of U/S in this subgroup has been a welcome improvement/enhancement and I always prefer at least a "static" look in all my patients.

The failure rate of line placement rises as the size of the vein shrinks. This is why the use of live U/S becomes important as the vein becomes smaller than the carotid.

Let's say you work 300 days/yr. That means you've been averaging 1/day for 33 yrs. Didn't know you were that old, dude.

 

[ssmallz]

Out of plane for me. I also move the transducer so that the artery and vein are never on top of each other so that I can avoid canulating the artery if I go through the vein.

 

[Idiopathic]

No. That hasn't been my experience at all. Well over 10,000 central lines placed and identifying the IJ vein isn't the issue. I found that the tiny IJ can be difficult to cannulate and/or getting the guidewire itself to pass down through the vein into the RA. Sometimes if one side has a tiny vein the opposite IJ is much larger. Still, the use of U/S in this subgroup has been a welcome improvement/enhancement and I always prefer at least a "static" look in all my patients.

The failure rate of line placement rises as the size of the vein shrinks. This is why the use of live U/S becomes important as the vein becomes smaller than the carotid.

the tiny ones in the arm arent central lines, dude

 

[Frank Rizzo]

out of plane

 

[dhb]

I should clarify that i go with a posterior approach; in the picture i would be coming with the needle from the right side of the image.

 

[BLADEMDA]

It makes sense that with an in plane technique you are choosing the posterior approach.
This keeps the guidewire wire going in straight and not having to make a bend/turn.

 

[BLADEMDA]

Trick of Trade

: If the internal jugular vein diameter is less than 7 mm, select a different

vein site. Independent predictor of unsuccessful line placement (Mey et al, 2003)

��
My Recommendation: Use ultrasound imaging for all IJ central lines, if time

allows.

 

[BLADEMDA]

The Supporting Literature

1. Hind et al, 2003: Meta-analysis showed US-guided IJ line had much lower failure rate

(RR 0.14)

2. Miller et al, 2002: Prospective study in teaching ED setting comparing US-guided

versus traditional landmark-guided IJ line

•
Time from skin puncture to blood flash: 115 sec (US) vs 512 sec (landmark)

•
Number of attempts: 1.6 (US) vs 3.5 (landmark)

•
For "difficult stick" patients, time to line placement: 93 sec (US) vs 463 sec

(landmark)

3. Denys et al, 1993: Similar study as Miller et al but in cardiology setting, looking at

complications

•
Artery puncture: 1.7% (US) vs 8.3 (landmark)

•
Hematoma: 0.2% (US) vs 3.3% (landmark)
-

 

[BLADEMDA]

Central Line Case Scenarios:

Which central line site would you first choose for a patient…

��
with severe orthopnea from flash pulmonary edema?

* Answer: Subclavian SC or IC (consider external jugular)

* Both can be done sitting up, but the SC approach has better success for CVP

positioning

��
in asystole?

* Answer: Subclavian SC or femoral

* Generally, select the site where you feel you can cannulate the quickest. IJ's

and IC subclavian lines are operationally difficult to insert during intubation

and CPR.

��
with sepsis?

* Answer: Subclavian SC > subclavian IC > US-guided IJ >> femoral

* Because infection is already a major concern, placing a line with the least

infectious complications is best—the subclavian line

��
with new renal failure?

* Answer: US-guided IJ > subclavian

* Dialysis catheters have been to cause venous stenosis when in the subclavian

vein

��
with an INR of 6?

* Answer: US-guided IJ or femoral

* Because of the risk of subclavian artery puncture, the IJ (under US-guidance

only) or the femoral vein should be cannulated. As the INR increases, the

femoral vein should be the primary site of central access, because of the

severe consequences of carotid artery puncture.

Bottom line:

Think of the subclavian site first


http://medresidents.stanford.edu/cvc/UCSF_procedures_workshop_handout.pdf

 

[BLADEMDA]

the tiny ones in the arm arent central lines, dude

Let's hope your comment above is an attempt at humor. Here are the facts Slim:



Denys and Uretsky (17) concluded that central venous catheterization should be anticipated to be difficult in a significant number of patients because in their study population the RIJ vein was not visualized (presumably thrombosed) in 2.5% of patients; the RIJ vein was unusually small in 3%; the RIJ vein was overlying the carotid artery in 2%, and the RIJ vein was described as "outside of the predicted path of the landmark" in 5.5%. Gordon et al. (14) found the RIJ vein to be medial to the carotid artery in 5.5% of patients.

RIJ vein diameter ranged from 2.5 to 61 mm (median, 17.3; interquartile range, 14.2–20.6).

 

[BLADEMDA]

Let's say you work 300 days/yr. That means you've been averaging 1/day for 33 yrs. Didn't know you were that old, dude.

More like 6-8 per day. Do your math again. There were several days per month I placed 12-16 lines per day.

Think about this: Place just 6 lines per day in a busy hospital and in 6 years it works out to 10,800 central lines.
12 years it is 21,600. I didn't post the real number ( well in excess of 10,000) because you wouldn't believe me.

I have no doubt there are attendings who have personally placed in excess of 20,000 central lines in their career.

 

[Bertelman]

Let's hope your comment above is an attempt at humor. Here are the facts Slim:

I suppose he is getting at the same question I was, specifically, break down how exactly you have amassed well over 10,000 CVC placements. Roughly how many years have you been practicing, and how many do you place per day. I assume you are counting 10,000 catheters, not 10,000 needle sticks.

And it was funny.

 

[BLADEMDA]

I suppose he is getting at the same question I was, specifically, break down how exactly you have amassed well over 10,000 CVC placements. Roughly how many years have you been practicing, and how many do you place per day. I assume you are counting 10,000 catheters, not 10,000 needle sticks.

And it was funny.

 

[BLADEMDA]

I suppose he is getting at the same question I was, specifically, break down how exactly you have amassed well over 10,000 CVC placements. Roughly how many years have you been practicing, and how many do you place per day. I assume you are counting 10,000 catheters, not 10,000 needle sticks.

And it was funny.

Please read my above post. If you need help with the math let me know.

 

[Bertelman]

I am finding it hard to grasp how and why you place 16 central lines per day, but so be it. Sounds like you spend at least 6 hrs just lining patients up, if you are incredibly efficient.

Frankly, I'd guess there are many big-name academic centers that place less than 16 central lines total, in all ORs, in a given day.

/endhijack

 

[Bertelman]

Hah. Wonder how long she was squirreling that water away in her mouth, just to spit it out dramatically.

 

[BLADEMDA]

I suppose he is getting at the same question I was, specifically, break down how exactly you have amassed well over 10,000 CVC placements. Roughly how many years have you been practicing, and how many do you place per day. I assume you are counting 10,000 catheters, not 10,000 needle sticks.

And it was funny.

As usual I have quoted the literature and added my years of valuable experience to this thread including well over 10,000 central lines personally placed. I have no doubt there are some who are reading this thread who have peformed as many or more than me.

 

[WholeLottaGame7]

I'm less confused by 10000 total central lines than by somehow getting 16 lines a day. It'd have to be supervising 4 rooms w/ 4 cases big/sick enough to warrant a central line, each. That'd be crazy.

 

[BLADEMDA]

I am finding it hard to grasp how and why you place 16 central lines per day, but so be it. Sounds like you spend at least 6 hrs just lining patients up, if you are incredibly efficient.

Frankly, I'd guess there are many big-name academic centers that place less than 16 central lines total, in all ORs, in a given day.

/endhijack

You didn't practice in the 1990s. In those days we lined everyone. PICC lines weren't as common and I got stuck being the central line "intern" quite frequently. I routinely did 5 central lines in the operating room and another 4-5 on the floor. I also practiced Critical Care for several years and every patient (almost) got a central line.

These days I rarely do more than 3-4 per day.

 

[BLADEMDA]

I am finding it hard to grasp how and why you place 16 central lines per day, but so be it. Sounds like you spend at least 6 hrs just lining patients up, if you are incredibly efficient.

Frankly, I'd guess there are many big-name academic centers that place less than 16 central lines total, in all ORs, in a given day.

/endhijack

You are comparing different eras. Once you get good a central line takes less than 15 minutes. Many on here will tell you they can easily do a central line in under 10 minutes flat.

 

[BLADEMDA]

Sometimes I wonder why I bother posting on these threads. I was trying to share real world experience with the literature. I never used U/S for my first 10 years of practice. The next 2-3 after that I started using an older machine.

These days I'm glad I have U/S to back me up and I know when I need it LIVE.

 

[BLADEMDA]

I am finding it hard to grasp how and why you place 16 central lines per day, but so be it. Sounds like you spend at least 6 hrs just lining patients up, if you are incredibly efficient.

Frankly, I'd guess there are many big-name academic centers that place less than 16 central lines total, in all ORs, in a given day.

/endhijack

Give it another 10 years Grasshopper. You will understand much more.

 

[BLADEMDA]

Out of plane for me. I also move the transducer so that the artery and vein are never on top of each other so that I can avoid canulating the artery if I go through the vein.

Sometimes the IJ is right over the carotid. With my experience this isn't any big deal as I know how to judge needle depth very well. I assume you puncture the vein from the side (lateral wall) in order to avoid hitting the artery. I use the U/S to scan for location and depth. If the IJ is big (over 9 mm) I will just use the static technique even with carotid beneath the IJ. Again, look at depth as well as lateral/medial location so you don't stick your needle to deep. Remember, if you don't get blood on your way into the IJ you may get blood on the way out so don't just bury the needle. Instead, use your fancy $50K plus machine to gauge DEPTH.

Many times it helps to place the patient in trendelenburg and give a vaslva maneuver if the IJ is small (less than 6-7 mm). This will enlarge your target significantly.

When in doubt use a seeker needle first even with U/S; this is helpful for beginners and those just learning to do central lines.

 

[BLADEMDA]

I suppose he is getting at the same question I was, specifically, break down how exactly you have amassed well over 10,000 CVC placements. Roughly how many years have you been practicing, and how many do you place per day. I assume you are counting 10,000 catheters, not 10,000 needle sticks.

And it was funny.

Here is some irony:

When I finished my residency at a top tier program I had performed over 200 central lines. This was a lot even for my program.

When I hit my practice I did 200 lines in my first 30 days. I, for one, am glad to have U/S for a quick static look on every patient and "go live" when needed using my clinical judgment.

 

[BLADEMDA]

Code (76937) is used specifically for central venous access with ultrasound guidance. The current CPT description is:
"Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting."
There are several unique aspects of the central venous and peripheral vascular access with ultrasound guidance code of which users must be aware. The first is that the code is intended for use only when the ultrasound is used with the "dynamic" technique, as opposed to the "static" technique which is not considered a reimbursable service.
The static technique utilizes the ultrasound to identify the vessel, but is not used during line placement. In the dynamic technique the physician uses the ultrasound throughout the procedure from initial identification of the vessel through direct visualization of the needle entering the vessel. A recorded image of the procedure is required for coding.
When coding a central line placement under direct dynamic visualization with ultrasound it is appropriate to code 76937 for vascular ultrasound guidance and 36556 for the adult central venous line placement.

 

[BLADEMDA]

This evidence specifically refutes the

dismissal of static ultrasound by the 2001

Agency for Healthcare Research and

Quality Evidence Report (20). Our data

show a much smaller difference between

static and dynamic ultrasound with regards

to cannulation success than the

findings of a previous study by Nadig et

al. (24), which had no control group. Regarding

dynamic ultrasound, our data

agree with the meta-analysis by Hind et

al. (27) that two-dimensional, dynamic

ultrasound increases overall and firstattempt

success for internal jugular procedures

and confirms the findings of recent

studies by Keenan and Randolph et

al (28, 29).


SOAP-3 TRIAL from 2005

 

[BLADEMDA]

Cannulation Failures



There were only two ultimate failures

of cannulation among the 201 patients

enrolled. Cannulation in one of the patients

initially randomized to the LM

group failed, and rescue dynamic ultrasound

failed. Cannulation also failed in a

patient randomized to the D group. Both

patients had vein diameters of 4 mm. In

both, venous blood was aspirated, but the

J-wire could not be advanced. Ultimately,

subclavian catheters were placed.


(LM-Landmark D- Dynamic/LIVE, S- Static )



http://www.ncbi.nlm.nih.gov/pubmed/16096454

 

[Bertelman]

You are comparing different eras. Once you get good a central line takes less than 15 minutes. Many on here will tell you they can easily do a central line in under 10 minutes flat.

I can do one in 10 min- I don't need anyone else to tell me that's possible. We didn't use U/S in residency, and I probably hit IJ on my first stick 90% of the time. U/S actually slows me down on most days. Unfortunately, as you well know this is not the 90's. I need a full body drape, gown, gloves, an RN to perform a timeout, a consent form, etc. That stuff takes time no matter how you slice it.

 

[BLADEMDA]

I can do one in 10 min- I don't need anyone else to tell me that's possible. We didn't use U/S in residency, and I probably hit IJ on my first stick 90% of the time. U/S actually slows me down on most days. Unfortunately, as you well know this is not the 90's. I need a full body drape, gown, gloves, an RN to perform a timeout, a consent form, etc. That stuff takes time no matter how you slice it.

Well my first 9,000 lines were placed in the 1990s. Different ERA. No time out just a consent. U/S should be utilized as a "look"/static technique (minimum standard) in every patient if possible.

 

[BLADEMDA]

 

[BLADEMDA]

U/S scan of the neck will show you whether there is an IJ, the location of the IJ in relationship to the Carotid and the SIZE of the IJ. Like in other things, size matters when placing a central line.

 

[Bertelman]

I swear sometimes you're just padding your post count.

 

[BLADEMDA]

I swear sometimes you're just padding your post count.

Nope. At this point my post counts don't matter any longer.

 

[BLADEMDA]

I swear sometimes you're just padding your post count.

At least some of my posts contain relevant, clinical information. How about yours?
It seems alll you do is post negative comments and criticism. How about adding some clinical value from time to time?

 

[BLADEMDA]

http://www.youtube.com/watch?v=6AbsvN-UXnc

Good video of a U/S guided IJ central line.

 

[Trisomy13]

I swear sometimes you're just padding your post count.

His real post count is well in excess of 10,000. You do the math.

 

[BLADEMDA]

His real post count is well in excess of 10,000. You do the math.

I'd lke to point out that the posts in the midlevel forum don't count. You do the math

 

[Mac4]

One of my cardiac attendings told me he did more CVL than PIV, He was trained in 90's at a place where IV drug abusers crowded. It was probably easier to start a CVL than a 20 G IV.