Can We Place Neck Lines in Digoxin Toxicity?

So one of my readers, Chris, wrote in to ask if neck lines are contra-indicated in digoxin toxicity. He had been told of this prohibition by one of his attendings. It seemed to me that this is one of those things that are viewed as potential harms, but there probably is no evidence. He took the initiative to do a futher lit search and here is what he came up with…

 

Hey Scott,

After looking it up and checking Rosen’s and Goldfrank’s, I came upon this article, which seems to be the basis for the argument of no IJs/Subclavians:

CLINICAL TOXICOLOGY 1993;31(2):261-273

I’ve attached the key excerpt from the discussion here as well:

“Safety of cardiac pacing in the treatment of digitalis intoxication was assessed in 39 pacing-treated patients from Groups 1 and 3. Fourteen adverse effects (36%) were recorded. These iatrogenic accidents were pacing-induced arrhythmias (6 cases), pacing defects (6 cases), and infectious complications (2 cases). The six pacing-induced arrhythmias occurred during or just after insertion (1 ventricular tachycardia, 3 VF) or subsequent to pacemaker adjustment (1 VA after a brief pause of pacing to study the underlying rhythm; 1 VF during reduction of ventricular rate from 80 bpm to 60 bpm). The six pacing defects occurred after ambulance transport (1 VA), external cardiac massage (1 patient), or accidental removal of the pacemaker by a confused patient, while no causes were found in three cases. The two infectious complications were staphylococcus epidermidis septicemias. One septicemia was complicated by fatal septic shock. Five out of these accidents (13 %) had a fatal outcome (2 VF, 2 VA, 1 septic shock). Thus, the overall pacing-induced mortality was 42% (5 out of 12 fatalities).”

So, they showed that pacing someone with a dig OD is bad, and that complications of pacing often occurred “shortly after insertion”, which they don’t define in the paper in terms of time. I presume this leads to the inference that it may be the guide wire of the CVC kit that irritates the myocardium and precipitates the arrythmia/death. I’m not sure I can completely make that leap, as it seems to me that repeatedly shooting electricity into the already electrically abnormal heart will be a bigger problem than tickling it with a wire.

Some other things to consider are that the pacers were put into patients receiving lower/no digibind, and that the pacers were put in ahead of time at another hospital, and patients were then transferred to the ICU center in the study. Interestingly the cardiology center put in the pacers, but had no Digibind on hand. The digibind was only available at the ICU center where the patients would be transferred after having their pacer inserted.

Alright, overall I’m feeling like a CVC is probably fine, especially in an appropriately Digibound patient. However, pacing (especially without giving Digibind) looks to be a suboptimal plan.

So this prompted me to search as well. And I found this chestnut (always intended).

Cardiology 2004;102(3);152-155

Safety of Transvenous Temporary Cardiac Pacing in Patients with Accidental Digoxin Overdose and Symptomatic Bradycardia

Ju-Yi Chena, Ping-Yen Liua,b, Jyh-Hong Chena, Li-Jen Lina

Background: Patients with digoxin intoxication may need transvenous temporary cardiac pacing (TCP) when symptomatic bradyarrhythmias are present. However, it has been reported that TCP might be associated with fatal arrhythmias in patients with acute digitalis intoxication caused by attempted suicide. The aim of this study was to assess the safety of TCP in patients with accidental digoxin-related symptomatic bradyarrhythmias. Materials and Methods: Seventy patients (30 men; age 74 ± 12 years) were enrolled in this retrospective study. Patients were divided into two groups: group 1 with TCP and group 2 without TCP. A digoxin overdose was defined as a serum digoxin level higher than 2.0 ng/ml combined with the presence of digoxin-related symptoms. Detailed clinical characteristics were reviewed on the basis of the medical records. Results: Group 1 included 24 patients (34.3%, 10 men). The rhythms prior to pacemaker insertion in group 1 included sinus arrest with junctional bradyarrhythmias (n = 9), atrial fibrillation with a slow ventricular rate (n = 11), and high-degree atrioventricular block (n = 4). The mean duration of pacemaker implantation was 5.8 ± 2.9 days (2–12 days). There was no major arrhythmic event or mortality after TCP in group 1. Two patients in group 2 (4%) died of ventricular tachyarrhythmias. Group 1 had a higher level of blood urea nitrogen (45.1 ± 26.0 vs. 33.4 ± 19.3 mg/dl), of left ventricular ejection fraction (68 vs. 56%), and of digoxin (4.4 ± 2.1 vs. 3.4 ± 1.3 ng/ml) but a lower serum calcium level (8.7 ± 0.6 vs. 9.1 ± 0.8 mg/dl). Conclusion: TCP was safe for patients with a digoxin overdose complicated by symptomatic bradycardia and should be recommended in such situations. However, this conclusion does not apply to acute digoxin intoxication as a result of attempted suicide.

So what do you folks think? With proper wire management you can ensure it goes nowhere near the heart (insert <25 cm), but is it worth it? Or should we just make Dr. Marik happy and use the groin (hate that word!) in these folks?

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Comments

  1. The fact that those patients needed pacers meant that they were sick. The natural history of sick digoxin toxic patients is to die. The first paper is no argument at all against placing neck lines IMO.

    In places I visited in Sri Lanka, in the absence of digibind, temporary pacing wires were commonly placed (recycled even!) for oleander toxicity. I have also seen transvenous pacing performed in remote Australia for digoxin toxicity when no digibind was available – the patient did fine.

    The bottom line, though, is don’t prance around getting central access when digibind administration should be the priority!

    Chris (different one)

  2. It seems to me a pretty bizarre and groundless leap to make to say that these papers mean that IJ lines are contraindicated. It makes no first-principle sense, and an association with one or two cases which had heaps of confounders and plenty of reasons for rhythm badness already doesn’t make up for that fact. This isn’t evidence, it’s conjecture! I think we are scraping the barrel for support for the “femoral is best” lobby! My tuppence

  3. RustedFox says:

    This lends some support to something that I have thought (and said, to my colleagues/teachers) for a long time.

    Why the hell is the central line guidewire so damn long to begin with ?

    Give me 20-25 cm in a nice, tight little circular loading device. That’s all you should need. Its just longer than the actual catheter itself, and allows for good proximal control without having it fly all over the place while you clumsily try to thread the catheter over the guidewire a half-meter above the bed.

  4. RustedFox says:

    … and for those of you that say – “Well, coil the guidewire up when you thread the catheter”… you’ve eventually gotta straighten that sucker out anyways.

    – and yes, it’s not unmanageably long, but it is just… too long for common sense. Period.

    • Guidewire is just the right length, people just use it wrong. The guidewire is designed so that you can thread in 20 cm or so, and then put the catheter on the wire while holding both at eye level, and then advance the whole catheter without any of the stupid feeding the wire back out of the vessel and into the catheter to get it to come out the back. The wire is not too long, we just have a long and almost unstoppable tradition of inserting the wire until an inch or two is left and then feeding the 20 cm back out through the cath. The wire should never be inserted beyond the top of the patient’s head when inserting a neck line.

      • RustedFox says:

        Whooaa. Weingart responded to my post. I’m not worthy! :)

        Howdy, sir ! Its been a pleasure and an honor to read your blog over the years. Don’t ever stop.

        I agree with your statement. The wire is designed exactly as you described it. However, I feel that its silly to thread the catheter over the guidewire while is oscillates 30 cm above the bed in an ellipse, especially if you have one hand (your left hand, if you’re a right-y) maintaining proximal control, or pressure on the puncture site (god forbid, they should have a sky-high INR).

        The reason that we advance the guidewire so far is because there’s so much of it… and its hidden in its little plastic racetrack, so we have zero idea how much of it exists until we see the “end” of it. If your left hand is on the neck, holding proximal control and controlling bleeding/keeping a clean field, then your right hand SHOULD be no more than 20 cm away (as hands are kept “together” in the work environment), threading that sucker in… and in…. and in…. until you see the other end, and can grab it… and you’re tickling the right atrium.

        I will go so far as to say that I only need 10 (maybe 15) cm of guidewire. Pierce the vessel, slide the guidewire in 5 cm. Keep 5cm outside for easy threading/proximal control. Slide the catheter over the 5cm. Get it in. Pull the guidewire out. Period. If anyone says – “b-b-but, you could be in the subclavian”… then great. I’m still in the venous system, and am still getting return to the core. I can sort out the details later.

        Also, there’s no reason to have a needle thats 10cm long. Maybe I’m exaggerating, but that’s how long it feels. If you’re in someone’s neck more than 3cm, then back the eff up. 5 cm of needle will do the trick.

        Disclaimer: I can be wrong. Dead wrong.

        • Lost me there brother.

          The guidewire must be long enough to extend into the vessel (~15 cm), have the catheter on it outside the body, and leave a couple of cm on either end of the catheter.

          For a 20 cm line, the actual length including the central lumen is actually ~25 cm. So 15+25+4=44 cm. So conceivably you could make 20 cm lines have guidewires that are 50 cm instead of the current 60cm… until you went to wire change a 30cm triple lumen and you would quickly realize you are kind of f*&(ed.

          I would argue just the opposite, all central access kits should be highest common denominator. Cordis kits should include 60 cm wires so I don’t need to cut a triple lumen in order to wire change it.

          To address the issue of not knowing how much wire is left, being by the rusted in your handle I think you have been doing this for a while, in which case I am sure by now if I asked you to stop at any point of the wire advancement and estimate how much wire is in, you could tell me +-5cm. After doing it for a while, we know.

          But for juniors, here is the tip: never use that ridiculous thumb sliding method. Pull back on the wire case until you expose 10 cm of wire. Put your thumb down on it and advance the wire holder as a unit. Repeat until you see the end nearing you. then stop.

          • Don’t your guidewires don’t have markings on them every 10 cm?
            C

          • Matt Anderson says:

            I’m a resident and almost always just pull the entire wire out b/c it is such a pain to thread. Moreover, at my institution, we have the syringe that is continuous with the needle, so we drop have to un-twist (ie and possibly lose my positioning) the introducer needle. The curved end always seems to be “impossible” to thread thru that apparatus. I had an attending that instructed me to use the “non-curved” end with insertion, as it made the process easier. I did it b/c I’m a resident, but I feel that it might increase my risk of complications (ie wall/vessel perforation)? Again, thanks for a great podcast and the 10 cm teaching point.

            matt

  5. Nickson–Nope, not ours.

  6. Mike Jasumback says:

    I didn’t even know I wasn’t supposed to put in neck/chest lines in Dig toxicity!

  7. Scott,

    Thanks very much for posting this as a blog topic, it’s nice to hear the perspective of others, especially those who have much more experience dealing with this than I do.
    Overall I think it’s safe to say that what these patients need is Digibind, not neck lines, but I think if it came down to requiring a line, I would be fine with any central access site.

    Cheers,

    Chris

  8. Medic Jeff says:

    Scott,

    This has little to do with the blog subject matter, but moreso with the pacing itself. If these wires can cause lethal cardiac arrythmias, why not use transcutaneous pacing until the Digibind works? Or am I way off base here? Sorry I strayed from the thread subject.

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