What is your approach to difficult IV access?

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Twiggidy said:
I feel like the “through and through” method is way less successful when it comes to veins. It works with arteries but personally I didn’t like going through vessels in order to cannulate them especially if using the U/S
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Yep. Why make 2 holes when one hole will do?
 
GassYous said:
I just use the ultrasound to find the vein and then to an iv like normal. I've tried through and through with a wire and my success rate is horrible unless the vein is big and straight.

About masking a patient down, last time I tried was on a healthy young lady with a good airway where we tried 3 times but couldn't get an iv. As soon as she starts going under, a ton of liquid comes gushing out of her mouth. Literally hits the mask like a geyser. Turned the gas right off, suctioned like crazy and woke her up. She adamantly denies any po intake but we canceled case. She was fine but it shook me and haven't tried since.
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Sobering. I have become quite comfortable with mask induction in adults, perhaps too comfortable, hearing these anecdotes. I often offer it (in elective, NPO cases with no conditions suggestive of risk) for persons who have become abjectly miserable with multiple attempts. I mean, I very frequently mask with no IV for myringotomy, which can take more time than placing an iv, though not much. I do find that the iv is usually much easier to place, and the dorsal hand veins become prominent, such that slipping in a 22 can be done easily. But thanks, these stories do give me pause.
 
Norepi said:
With y'alls ultrasound IVs - how good are your linear probes at visualizing needle tips in soft tissue prior to venous cannulation? I've found that depending on the manufacturer (i.e. mind ray over GE), the probes do not visualize the tips as well and just show you displacement. Is this enough for you all or are you walking in the tip in the soft tissue?
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Our friendly Iraqi poster can still see it with his "EZONO" US...
forums.studentdoctor.net

My emergent USGIV in the OR

Dear Fellows, This is my video performing an USGIV emergently on a patient in the Ortho OR who experienced bleeding. Just an hour ago! Preparation time is one minute, procedure less than a minute. I presented the idea of keeping the tip in the middle of the vein (Basilic vein) Thanks for...
forums.studentdoctor.net forums.studentdoctor.net
 
Good read, underappreciated skill until I came out to PP and after 5pm all the IV therapy/PICC/IR people are at home and your night nursing staff can sometimes put in a 24 but usually lets anesthesia handle it, that is after you get everything set up in your room. I have been sent some large, unstable patients with 24Gs. You'll be faced with staff who says 'they've access, lets go,' patients who moan when the cuff inflates all before it's realized the gall bladder is tightly stuck to the liver. Does anyone have any good videos/resources for brachial/cephalic ultrasound access? I've noticed our IV therapy team has all of a sudden been doing a lot more cephalic vein access in the anterior shoulder

In plane vs out of plane for ultrasound: one difficulty with in-plane is that if the probe or vein moves a couple millimeters you can lose visualization, you need the probe, the catheter and vein to all stay in a small slice (it is a cinch for everyone on SDN though). What I've found works better after learning the technique for CVCs: scan the vein up and down out of plane, make sure you're at a semi-straight vein position. Get the probe in an out of plane position to the vein, rotate the probe past 45 degrees so the vein is taking up slighltly less than 1/3 of the screen. Now insert the catheter in plane into the angled out of plane vein. This takes the mobile vein out of the equation, usually needs a long catheter w/wo a wire when you start.

The long 18G catheters with the built in wire are fantastic. They have somewhat changed my practice, late night cases that blood loss could go either way and I have someone that I can get at least two decent 20Gs in I skip the CVC if I think I can put one in quickly and know the surgeon. They're easy to exchange. I wish there was an even longer version, in the super morbidly obese they're not long enough.

For people training: practice IVs, it's can be one of the annoying/frustrating procedures, find someone interested in teaching to show you on adults first, I wish I had asked to do month with the IV therapy and PICC team, I talk to them and they've good tricks. Don't be hands-off for IV access: get it in pre-op where people aren't standing around staring at you but are helping you and know the flow, don't be pushed into doing something just for the sake of other peoples schedules, they don't care about yours. You also have to be aware of what's safe, yes a lot can be done with 2 20Gs, but you always need a backup plan. I've gone to a few colleagues' call for help where 3-6 hours into a procedure with expected blood loss thing have slowly been inching toward the ledge and now access/pressors/blood are all trying to be managed with one slow 20G and access is needed in a prone obese patient clamped down (that long 18G can go into a prone patient much easier, no nicking/dilating, just need good skin traction).

I would not mask down adults for IV placement, at least kids I can be more certain of their NPO status, ability to tolerate any hypotension or reactive airway events. I don't think it's a harmful or wrong practice (ie it's justifiable), just better ways to get it done. Aspiration can be horribly nasty, if I had an aspiration like the one above because of a procedure to gain IV access I would re-evaluate. If they're not severely mentally disabled some straightforward verbal anesthesia: your veins are difficult, I'll use numbing medicine, drink this cocktail (+/- intranasal fentanyl) and do you want to have your surgery done..all said much nicer but straight-forward, I've worked at a good knife, gun and needle club trauma hospital and sometimes the best skill in IV placement is being the driver behind the conversation wheel. This just works for me though and things can go wrong with sedation or anxious patients just like masking.
 
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Maverikk said:
Good read, underappreciated skill until I came out to PP and after 5pm all the IV therapy/PICC/IR people are at home and your night nursing staff can sometimes put in a 24 but usually lets anesthesia handle it, that is after you get everything set up in your room. I have been sent some large, unstable patients with 24Gs. You'll be faced with staff who says 'they've access, lets go,' patients who moan when the cuff inflates all before it's realized the gall bladder is tightly stuck to the liver. Does anyone have any good videos/resources for brachial/cephalic ultrasound access? I've noticed our IV therapy team has all of a sudden been doing a lot more cephalic vein access in the anterior shoulder

In plane vs out of plane for ultrasound: one difficulty with in-plane is that if the probe or vein moves a couple millimeters you can lose visualization, you need the probe, the catheter and vein to all stay in a small slice (it is a cinch for everyone on SDN though). What I've found works better after learning the technique for CVCs: scan the vein up and down out of plane, make sure you're at a semi-straight vein position. Get the probe in an out of plane position to the vein, rotate the probe past 45 degrees so the vein is taking up slighltly less than 1/3 of the screen. Now insert the catheter in plane into the angled out of plane vein. This takes the mobile vein out of the equation, usually needs a long catheter w/wo a wire when you start.

The long 18G catheters with the built in wire are fantastic. They have somewhat changed my practice, late night cases that blood loss could go either way and I have someone that I can get at least two decent 20Gs in I skip the CVC if I think I can put one in quickly and know the surgeon. They're easy to exchange. I wish there was an even longer version, in the super morbidly obese they're not long enough.

For people training: practice IVs, it's can be one of the annoying/frustrating procedures, find someone interested in teaching to show you on adults first, I wish I had asked to do month with the IV therapy and PICC team, I talk to them and they've good tricks. Don't be hands-off for IV access: get it in pre-op where people aren't standing around staring at you but are helping you and know the flow, don't be pushed into doing something just for the sake of other peoples schedules, they don't care about yours. You also have to be aware of what's safe, yes a lot can be done with 2 20Gs, but you always need a backup plan. I've gone to a few colleagues' call for help where 3-6 hours into a procedure with expected blood loss thing have slowly been inching toward the ledge and now access/pressors/blood are all trying to be managed with one slow 20G and access is needed in a prone obese patient clamped down (that long 18G can go into a prone patient much easier, no nicking/dilating, just need good skin traction).

I would not mask down adults for IV placement, at least kids I can be more certain of their NPO status, ability to tolerate any hypotension or reactive airway events. I don't think it's a harmful or wrong practice (ie it's justifiable), just better ways to get it done. Aspiration can be horribly nasty, if I had an aspiration like the one above because of a procedure to gain IV access I would re-evaluate. If they're not severely mentally disabled some straightforward verbal anesthesia: your veins are difficult, I'll use numbing medicine, drink this cocktail (+/- intranasal fentanyl) and do you want to have your surgery done..all said much nicer but straight-forward, I've worked at a good knife, gun and needle club trauma hospital and sometimes the best skill in IV placement is being the driver behind the conversation wheel. This just works for me though and things can go wrong with sedation or anxious patients just like masking.
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I've watched just about every youtube video ever made on ultrasound and venous access and I haven't come across one better than this

 
Really good video, thanks.

Without derailing this high quality educational thread about iv placement, a note about inhalational induction in adults: It’s a useful tool. For people who haven’t done it before, consider offering it to patients for whom you are planning to place an LMA anyway, and who have an IV already, for your comfort and their safety. Learn about the different techniques, (tidal volume vs. vital capacity breaths, etc.) dosing, blending with nitrous or without, and get a sense of how much time these take to reach important states, like unconsciousness, or placement of an LMA. Performed slowly at low doses, it can be a very stable technique. Sometimes it it can be a useful alternative or adjunct to an “awake fiber optic intubation”. Have an IV infiltrate during a colonoscopy? Consider masking and getting everyone settled down instead of repeated attempts at another iv in the semi darkness with a semi sedated patient and a fully agitated staff.

Context is everything. For a case you plan for GA/LMA in a busy outpatient setting, where you can see veins you likely can get, but need a little time to “bring out”, partner is monopolizing US, patient is cranky, and delays are trouble, consider masking. For a sick fragile patient for whom there is a justifiable indication for a CVC anyway, sure, place one pre op. For an urgent/emergent case in a track marked no vein junkie, sure, place a long 18 in the IJ. $0.02
 
Hork Bajir said:
You should be able to get an IV in literally anyone with an US, and it should almost never take more than 5 minutes (max). If you can’t do this, you need to get better with US.

For deep vessels, no law against using a longer catheter (10cm arrow cath meant for fem art lines works nicely as a poor mans mid line).

You should never need to put in an IO. Period.
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Not sure I agree.
I’m pretty good with ultrasound and sometimes it takes a long time to cannulate sucker.
But most of the time is spent looking, not actually needling. Perhaps that was your point.
 
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I like the Accuvein a lot! (I bring it with me whenever I’m called to assist with access). Also find local anesthetic very helpful (TB syringe with lido), patients less likely to flinch/pull away when you finally get flash on that 22g worthy vein and you want to thread the catheter before they move and you’re out or back walled.
 
dr doze said:
Even today, lots of People die every year from complications of central line placement or bad care of these lines post placement. Not to be minimized.
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I agree. It’s just one of the risks but, chest tubes can cause issues long after they’re out. I’ve caused a pnx before; I’d be uneasy knowing that a pt had Pulm issues/ repeated thoracic surgeries because of a known risk I could have avoided.
If a pt needs central access, you’ve got to get it. It’s the gray area where I try to find a feasible alternative.
In non-emergent situations especially I try to think about how I’d like myself or my family members to be treated and try to be as minimally invasive as possible.
 
propofabulous said:
How do you guys manage difficult IV access intraop (say for your super morbid obese vasculopaths)? Any cool methods or tips/tricks that I am missing?

1) Peripheral IV in any extremity
-Blind saphenous if peds
-IO if emergency
2) US for obvious superficial targets in the extremities
3) US guided IV into deep vessel (basilic or brachial)
4) EJ
5) Central line
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Kinda like a spinal, i take the sharp thing and i stick it in until i get fluid. Except with an IV the fluid's red i guess.
I like to do it right first time too. Its faster that way ive found
 
You can get a solid basilic or brachial IV in almost anyone with an ultrasound and a 2 or 2.5" angiocath. If going for the brachial vein, identify the artery and median nerve first so that you can stay away from those structures.

For catheters, the 18G x 2.5" Braun Introcans are nice as they have an echogenic tip and are self-protecting once the needle is removed. The main downside is the somewhat limited flow rate (85 ml/min max), making it not ideal for a volume line. The 16G and larger Jelco 2" angiocaths (# 4802) are also very echogenic and easily identifiable even in obese patients, and have great flow rates as well.
 
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Just did one. Older guy freaked out in pacu, tore IV's out, poked a bunch of times, so attending told me to go over and see if I can get one. 2.5" 20g with US. I didn't even bother trying to feel or anything. Guy actually had **** for veins. Basilic buried directly under artery, no cephalic on topside. I found his basicilic finally emerged from under the artery about mid bicep. Used the technique mentioned earlier here. US guided, advancing little bit at a time, adjusting US with each advancement, didn't even bother to look at the flash. Advanced under US about halfway, then pushed the rest in like a regular IV. Worked great, was actually my first successful us guided IV. This is why I keep reading this site despite the other residents giving me **** for it.
 
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MirrorTodd said:
Just did one. Older guy freaked out in pacu, tore IV's out, poked a bunch of times, so attending told me to go over and see if I can get one. 2.5" 20g with US. I didn't even bother trying to feel or anything. Guy actually had **** for veins. Basilic buried directly under artery, no cephalic on topside. I found his basicilic finally emerged from under the artery about mid bicep. Used the technique mentioned earlier here. US guided, advancing little bit at a time, adjusting US with each advancement, didn't even bother to look at the flash. Advanced under US about halfway, then pushed the rest in like a regular IV. Worked great, was actually my first successful us guided IV. This is why I keep reading this site despite the other residents giving me **** for it.
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Solid. Soon enough you’ll get a really bad vasculopath and have to do a radial a-line. I’ve had the arrow in the artery with no flash.

Advance until you get some flash, attempt to slide the guide wire. It may or may not crap out on you, but this way you’re not
1. blindly stabbing the wrist or
2. going straight to brachial or femoral artery.
 
D P356 said:
Solid. Soon enough you’ll get a really bad vasculopath and have to do a radial a-line. I’ve had the arrow in the artery with no flash.

Advance until you get some flash, attempt to slide the guide wire. It may or may not crap out on you, but this way you’re not
1. blindly stabbing the wrist or
2. going straight to brachial or femoral artery.
Click to expand...
Oh yeah, I've had that before. IR ended up putting it in under ultrasound.

Actually had a lady like that last night. Spent like 20 minutes trying to get the A-line. Knew I hit it after the fact when I pulled back and her wrist swelled up a little bit. Finally got it under ultrasound.
 
Lots of great tips in here. Ultrasound is definitely an excellent resource, though at times not available (e.g. limited preop area for a fluoroscopy / GI procedure). I've been the "go-to" person for difficult IVs in those situations.

For such situations (i.e. no ultrasound available), some other tips I have found helpful include:
-Double tourniquet (surprisingly helpful to better dilate a vein. Though that Esmark technique mentioned earlier sounds quite innovative...)
-Lower the head of the bed (often patients are seated up and laying the patient down can help with dilate an upper extremity vein due to gravity)
-Likewise, lower the arm below the bed (again using gravity to help dilate the arm/hand veins)

-And for your own comfort and precision, a chair is nice to sit on during difficult IV access.
 
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MirrorTodd said:
Oh yeah, I've had that before. IR ended up putting it in under ultrasound.

Actually had a lady like that last night. Spent like 20 minutes trying to get the A-line. Knew I hit it after the fact when I pulled back and her wrist swelled up a little bit. Finally got it under ultrasound.
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I’ve gotten to the point where I go straight to ultrasound for most A-Lines. Partly because 25 years of guitar playing have made it challenging to feel a pulse, and also because I’ve found it makes me faster on target and a better judge of what I’m sticking. There have been times where I’ve felt a strong pulse then I put the ultrasound on and found the actual lumen of the vessel is tiny and encased by calcification. At times it has changed the gauge of A line I use.
 
If I’m resorting to deep veins in upper arm I’m going with a micropuncture kit and some sort of long angiocath (femoral line kit, catheter from IR, etc). If I need something to truly infuse volume quickly I’m putting a central line in anyway.

I’ve had too many of these deep IVs blow during a case bc tip of catheter is barely in (even using 2-2.5” catheters). I’m in the south and patients are YUUUUUGE.
 
Shimmy8 said:
If I’m resorting to deep veins in upper arm I’m going with a micropuncture kit and some sort of long angiocath (femoral line kit, catheter from IR, etc). If I need something to truly infuse volume quickly I’m putting a central line in anyway.

I’ve had too many of these deep IVs blow during a case bc tip of catheter is barely in (even using 2-2.5” catheters). I’m in the south and patients are YUUUUUGE.
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Exactly. It’s destined for failure unless its a long catheter.
 
Of course if you want to give volume rapidly, a double or triple lumen CVL is far inferior to a simple 16 ga short peripheral IVC

PIV
  • 16G IV: 13.2 L/hr
  • 18G IV: 6.0 L/hr
  • 20G IV: 3.6 L/hr
Central Line
  • 5 Fr PICC/Port: 1.75 L/hr
  • 7 Fr TLC 16G distal port: 1.9 L/hr
  • 7 Fr TLC 18G proximal port: 3.4 L/hr
  • 12 Fr HD: 23.7 L/hr
  • 8.5 Fr Cordis/introducer sheath: 7.6 L/hr
  • 8.5 Fr Cordis/introducer sheath with pressure bag: 20.0 L/hr
 
propofabulous said:
Pre-op IV’s can fail, you can need more access, etc.
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No ****...

My point was, if a patient is truly difficult IV access, then generally it’s best to finish your lines prior to the surgeon operating. Of course there will be times when you place a line in the middle of a case, but those should be infrequent. Maybe “intraop” means something different to you than it does me? Place extra lines while the nurse is prepping.
 
Remember the MAC introducer from Arrow. Most of them has (under gravity) 30L/h (500mL/min) flow rate for its 9Fr port, and 12L/h (200mL/min) for its 12G port. Arrow also makes single lumen PSI (their "Cordis"), 8.5 or 9 Fr, but the flow rate is not listed on the packaging. I would estimate the flow rate of the PSI is somewhere between the two numbers above, and more than the listed number for Cordis. But if you are going to put in a PSI, you might as well put in MAC, the difference is 4mm in diameter.


For Arrow's 8 Fr double lumen CVC, the flow rate is 7.6L/h (120mL/min) and 6L/h (100mL/min) under gravity. Max flow rate is 10mL/sec under pressure, so that's theoretically 600mL/min. TL is for infusions, but DL is good enough for most non-CV cases.

The real issue is infiltration. I don't know about other people, I would feel much more comfortable using a central line for volume (under pressure) and pressor resusitation, than a deep IV in the arm tucked out of sight. And your longer IV is going to have lower flow rates anyway.

Btw this is test of various catheters. In it, 8.5 Fr Cordis is equal or faster than 16g PIV with every tubing they tested, and much faster with pressure tubings.

I don't get the aversion to central lines in some attendings. If you are going to take out an ultrasound, why not put in a line that can last more than a day on the floor. The patient and the phlebotomist will thank you for it. Don't get me started on EJ.

Aether2000 said:
Of course if you want to give volume rapidly, a double or triple lumen CVL is far inferior to a simple 16 ga short peripheral IVC

PIV
  • 16G IV: 13.2 L/hr
  • 18G IV: 6.0 L/hr
  • 20G IV: 3.6 L/hr
Central Line
  • 5 Fr PICC/Port: 1.75 L/hr
  • 7 Fr TLC 16G distal port: 1.9 L/hr
  • 7 Fr TLC 18G proximal port: 3.4 L/hr
  • 12 Fr HD: 23.7 L/hr
  • 8.5 Fr Cordis/introducer sheath: 7.6 L/hr
  • 8.5 Fr Cordis/introducer sheath with pressure bag: 20.0 L/hr
Click to expand...
 
DrN2O said:
Don't get me started on EJ.
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And what’s wrong with EJs? They are reliable, easy to place, visualized without ultrasound, you can place a regular IV in them without opening a kit, etc. If you are looking for long-term access I wouldn’t jump to an EJ, but in the right circumstance they are fine.
 
Urzuz said:
And what’s wrong with EJs? They are reliable, easy to place, visualized without ultrasound, you can place a regular IV in them without opening a kit, etc. If you are looking for long-term access I wouldn’t jump to an EJ, but in the right circumstance they are fine.
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Exactly. Use a long one - sometimes it bumps against a valve but they run like gangbusters.
 
OP:

Ran into this yesterday morning.
First case. TSA. Morbidly obese, COPD, s/p chemo. Get called at 630am saying that she had been poked 4 times and had nothing to stick an angio into.

Here is my thought process for difficult IV’s.

Looked at her hands and arms, scanned her A/C’s, scanned her saphenous, looked at her feet. Nothing.

1000% I would NOT put an EJ in for that particular case. Just did a 5-10 minute IJ triple lumen, sedated her, blocked her and back to the room.

I use them, but it has to be the right patient and the right procedure. This was not that case. Something goes wrong you are fuaked.
 
EJ failure rate >> IJ IMO.

If you don’t have access to the neck I just put in a proper triple lumen and call it a day.

EJ’s can blow especially with multiple pokes- wire can also perforate the less robust EJ if you like to wire your EJ’s. Mediastinum can hold a crap ton of fluids before you realize it. A few M&M conferences where this happened comes to mind.
 
sevoflurane said:
EJ failure rate >> IJ IMO.

If you don’t have access to the neck I just put in a proper triple lumen and call it a day.

EJ’s can blow especially with multiple pokes- wire can also perforate the less robust EJ if you like to wire your EJ’s. Mediastinum can hold a crap ton of fluids before you realize it. A few M&M conferences where this happened comes to mind.
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I don’t necessarily disagree with that, but if the list of potential complications scare you away, you wouldn’t do any procedure. In the past few years I’ve heard of retained wires, “IJs” that ended up being pleural catheters, and plenty of inadvertent carotid punctures....and this is with experienced attendings who have been practicing for years/decades.

Like with many of the things we do, the success of a procedure is directly related to the skill of the operator. Additionally, to mitigate morbidity associated with the procedures we do, it requires vigilance and actually paying attention to the patient. Sadly these are things that are lacking in many of our colleagues.
 
sevoflurane said:
EJ failure rate >> IJ IMO.

If you don’t have access to the neck I just put in a proper triple lumen and call it a day.

EJ’s can blow especially with multiple pokes- wire can also perforate the less robust EJ if you like to wire your EJ’s. Mediastinum can hold a crap ton of fluids before you realize it. A few M&M conferences where this happened comes to mind.
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Never wired an EJ.

Next time try a micropuncture. Avoids having to pass a long wire and dilate. Triple lumen isn’t necessary for a short case.
 
Arch Guillotti said:
Never wired an EJ.

Next time try a micropuncture. Avoids having to pass a long wire and dilate. Triple lumen isn’t necessary for a short case.
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IMO, timing of the case has nothing to do with decision making when placing an EJ. My decision is based on failure rate and what your options are if it indeed fails. I have been placing EJ’s for well over a decade with all sorts f techniques (micropuncture, 20G pedi cvl, long angio’s etc.). My experience is that they are not always reliable and if an alternative source is not available, the safer thing is to just do an adult triple lumen or pedi double lumen cvl. Just more reliable IMO.

Here is an early discussion on this forum regarding EJ’s. I was a little youger then. My view has definitely evolved.

8 years ago. lol:

forums.studentdoctor.net

EJ Central Line

Placed one today at my attendings direction intraop. Never have done one before. Looked like a major pain in the neck for the patient in pacu. Subclavian would have been better and quicker. Anybody place EJ TLCs routinely and what merit do they have?
forums.studentdoctor.net forums.studentdoctor.net
 
If you are unfamiliar with EJs and do them only rarely, then when you try to place an EJ, they are much more difficult and should not be the first option. Using a short catheter EJ placed at the most superior portion of the visualized external jugular vein over the SCM muscle does not result in mediastinal filling because the catheter tip has not pierced the deep cervical fascia. Any failure or migration is readily identified as long as visualization of the neck is possible. The EJ lies deep to the skin and platysma only and is so superficial that it is frequently visualized when the patient is in the supine position. Long catheters are not necessary to reach the EJ or be secured in the EJ. Long EJ catheters do fail as do catheters placed too inferiorly along the course of the EJ due to angulation of the vein as it pierces the deep cervical fascia, the tip entering the usually singular valve junction of the leaflet with the wall of the EJ at the terminal section of the vein just superior to the subclavian vein, or the angulation of the EJ/subclavian junction. The function of the valve is to inhibit the regurgitation of blood from the subclavian vein into the external jugular vein, which is under relatively lower pressure. If you need rapid infusion capabilities, long catheters do not make any sense anyway.

The vast majority of subclavian catheters or IJ catheters placed double or triple lumen relatively small channel catheters, not designed for rapid infusion, and have flow rates about the same as a 20ga peripheral IV due to their length. There are available much larger catheters up to 14Fr IJ, but it is rare the largest of these are placed by anesthesiologists.

That being said, any IV no matter how small can be used for induction, so I am not too picky about induction venous access and will take anything.
 
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sevoflurane said:
IMO, timing of the case has nothing to do with decision making when placing an EJ. My decision is based on failure rate and what your options are if it indeed fails. I have been placing EJ’s for well over a decade with all sorts f techniques (micropuncture, 20G pedi cvl, long angio’s etc.). My experience is that they are not always reliable and if an alternative source is not available, the safer thing is to just do an adult triple lumen or pedi double lumen cvl. Just more reliable IMO.

Here is an early discussion on this forum regarding EJ’s. I was a little youger then. My view has definitely evolved.

8 years ago. lol:

forums.studentdoctor.net

EJ Central Line

Placed one today at my attendings direction intraop. Never have done one before. Looked like a major pain in the neck for the patient in pacu. Subclavian would have been better and quicker. Anybody place EJ TLCs routinely and what merit do they have?
forums.studentdoctor.net forums.studentdoctor.net
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I meant a micropuncture in the IJ🙂
 
ASC would be like “wuuuuat did u say”😵

I hear ya though. 👍
 
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Anybody placing axillary central lines with ultrasound?
 
MirrorTodd said:
Oh yeah, I've had that before. IR ended up putting it in under ultrasound.

Actually had a lady like that last night. Spent like 20 minutes trying to get the A-line. Knew I hit it after the fact when I pulled back and her wrist swelled up a little bit. Finally got it under ultrasound.
Click to expand...

I've started following the catheter all the way into the vessel with the ultrasound and just bypassing the wire for arterial lines (mostly peds), and my first-pass success rate has gone up significantly. Avoids all the issues with trying to thread a wire into a false lumen, or half-in/half-out of the vessel I don't worry about not having flash as long as I can tell I am in the lumen.
 
I do “subclavian” lines with US with some regularity. I say subclavian in quotes because I’m looking at the vein below the clavicle (similar probe placement to an infraclav block), so even tho the tip of the line is usual in SVC or brachiocephalic, the venous puncture is typically near the junction of where the axillary becomes the subclav. They are very reliable and convenient lines, but safe placement requires an operator with expert US skills (this is NOT the line for someone who has done <100 IJs and is still learning how to follow their needle tip). The mechanics of placement are just like an IJ except it’s steeper and deeper approach, plus you have to be very confident that you can follow your needle tip into the vessel without backwalling. Distance from posterior vessel wall to pleura does vary a fair amount from person to person, though.
 
Hork Bajir said:
I do “subclavian” lines with US with some regularity. I say subclavian in quotes because I’m looking at the vein below the clavicle (similar probe placement to an infraclav block), so even tho the tip of the line is usual in SVC or brachiocephalic, the venous puncture is typically near the junction of where the axillary becomes the subclav. They are very reliable and convenient lines, but safe placement requires an operator with expert US skills (this is NOT the line for someone who has done <100 IJs and is still learning how to follow their needle tip). The mechanics of placement are just like an IJ except it’s steeper and deeper approach, plus you have to be very confident that you can follow your needle tip into the vessel without backwalling. Distance from posterior vessel wall to pleura does vary a fair amount from person to person, though.
Click to expand...
I will be honest, this seems less safe than doing a traditional landmark subclavian, and more cumbersome to get the US, so why the hassle?
 
dipriMAN said:
I will be honest, this seems less safe than doing a traditional landmark subclavian, and more cumbersome to get the US, so why the hassle?
Click to expand...

TBH, where I trained very few staff were comfortable with landmark guided subclavians, and it was hard to do many as a resident, so I never mastered them. I’ve done a handful and certainly feel comfortable placing one if need be, but for me it’s a matter of preference- having done literally thousands of US guided vascular pokes, I choose to do the thing that I’m good at. Not trying to make the claim that it’s better than a landmark subclav, just answering another posters question (does anyone do axillary central lines) to say that it’s definitely a valid and useful technique.
 
dipriMAN said:
I will be honest, this seems less safe than doing a traditional landmark subclavian, and more cumbersome to get the US, so why the hassle?
Click to expand...

how is it less safe when you have direct, in-plane visualization of your needle tip 100% of the time under ultrasound (versus blindly sticking based on landmarks) ?

I do the technique that was described by the previous poster to place subclavians all the time (and like the previous poster, I started doing them because I didn’t feel like I did enough landmark-based placements during residency)....but I have found to safe, fast, effective, and slick.
 
Last edited:
Urzuz said:
how is it less safe when you have direct, in-plane visualization of your needle tip 100% of the time under ultrasound (versus blindly sticking based on landmarks) ?

I do the technique that was described by the previous poster to place subclavians all the time (and like the previous poster, I started doing them because I didn’t feel like I did enough landmark-based placements during residency)....but I have found to safe, fast, effective, and slick.
Click to expand...
A traditional landmark subclavian my needle is going parallel to the chest at such a flat angle that I’m unlikely to hit pleura, I suppose it’s safer if you can gaurentee US guided to see your tip the whole time, but you still have a chance of back walking the vessel.
 
dipriMAN said:
A traditional landmark subclavian my needle is going parallel to the chest at such a flat angle that I’m unlikely to hit pleura, I suppose it’s safer if you can gaurentee US guided to see your tip the whole time, but you still have a chance of back walking the vessel.
Click to expand...
I never thought I would hit pleura until I did.
 
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