Central Lines

Brought to you by Scott Weingart, MD FCCM and Haru Okuda, MD FACEP

Sterility

In the ED, there are only two ways to place central lines:

Full Sterile

or

Non-Sterile

There is no in-between. Sometimes (hopefully rarely), the exigencies of time or patient condition will prevent placing a full sterile line. This is acceptable so long as you inform the accepting service that the line is not full sterile. If however you state the line is full sterile, you are in effect

Swearing on Your Patient’s Life

that EVERY single step of the sterile placement process was followed without breaks. If you can’t swear on your patient’s life that this is true, then just say to the accepting service that the line was non-sterile and they will replace it.

Here is a video of how to place a full sterile line

Click Here to Download the Video

Look for this area in the lower right of the screen

Update for the new HHC bundle

How to Place a Line

How to perform a blind IJ line placement with all of the steps

Click Here to Download the Video

Look for this area in the lower right of the screen

How to perform an infraclavicular subclavian line, with just the steps
that are different from the IJ

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How to Place a Sheath Introducer (Cordis)

Click Here to Download the Video

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Tough Situations

Are you in the Artery or the Vein?

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This review article discusses the complications and pathways for misplacement of central lines.

Special thanks to John Ponessa for editing wizardry and Tim Clapper for the educational development.

Comments

  1. joe howton md says:

    Beautifully presented, Scott. Wish I had seen these 10 years ago! Will share with our ICU attendings for use with the residents.

    Do you have any videos on use of US for IJ placement? I couldn’t find any at this site.
    My friend John Rose has a nice tutorial at UC Davis…if you don’t plan to present one, you may want to suggest his or another.

    Many thanks for these great presentations. You are touching countless patients’ lives by helping us improve our practice.

    Joe

  2. Hi Scott. Wondering why you switch the needle to the catheter. Why can’t you just attach the extension tubing or wire-sheath directly to the introduce needle?

    • Mike,

      you can, but there are a few risks. If you move the needle when attaching the tubing, you will get a falsely low reading and may actually lose the line
      if you pass in the catheter, then make sure there is still flow
      you can be sure you will get an accurate transduction and then not risk losing the line when taking the tranduction tubing back off

  3. G’day Scott.
    Big fan of your show, big fan.
    And recently subscribed as a member.. please keep it coming, really appreciate what you’re doing on the site.
    Just wondering..
    This may be a wee bit beyond the scope of your site, but if you could perhaps do a show or a ‘series arc’ on the PiCCO system, and your thoughts and opinions about this system.
    Do you use PiCCO much in your ED-ICU patients? In your long-stayers?
    Cheers

  4. Matt Barden says:

    Hello Scott,
    I remember hearing you talk about this somewhere, but I can’t remember which EMCrit podcast it was. I had a patient with penetrating trauma in hemorrhagic shock. We had no access. I put a femoral cordis with ultrasound guidance. I was sure I was in, but the line wouldn’t draw back. At the time we thought it wasn’t in the vessel, but later on I was thinking about it, and I remembered you mentioning that drawing back on the line can collapse the vein if the patient has no volume. Is there a name for this? Is it described somewhere, or is it something you found in your experience? Thanks,

    • I call this the Subclavian Suck Sign, though as you have observed, it can happen in any central vessel. I am publishing a letter to the Annals on the subject.

  5. Tom Riley says:

    Excellent set of videos!

    A couple of extra things that I’ve found helpful –
    Once you have the wire in the vessel prior to dilating it, replace the ultrasound and check that you can see the wire in the vein (hopefully not in the artery!). Then scan down the wire and tilt the probe caudally, you’ll see the wire swing off medially towards the SVC, if you see it going laterally it’s gone into the subclavian and you can then pull it back and try and persuade it to go into the SVC. If you think this is important…. but even if you don’t someone else may and it can save you lots of time on the phone:-)!

    Thanks again for the excellent videos!

  6. Great Post Scott,

    Out of curiosity, are there any classes (CME) that you know of, where ED docs can practice/maintain their central line skills?

  7. Excellent video!
    Do you have information regarding the manufactor of the CVC kit?
    Thanks
    Moti

  8. Excellent video!
    Do you have information regarding the manufactor of the CVC kit?
    Moti

    • any of the companies will make these bundles. Arrow will actually build whatever you like into their central line set-ups so you have everything in one place.

  9. Great videos. I liked the comment about not pushing the dilator in all the way. Was good to review some of this stuff even though I put in about 150 lines per year on average. Also nice to see somebody showing some techniques to trouble shoot. One small thing I like to do during line placement is to make sure the open bevel side is up when doing a IJ line. I sometimes note that if the bevel is facing down that the wire may choose to go down and exit hitting the inferior wall of the vein. This may infact not be th case but since I started this minor adjustment I note less wires getting resistance when feeding them.
    I enjoyed the videos a lot.

  10. Great videos. I liked the comment about not pushing the dilator in all the way. Was good to review some of this stuff even though I put in about 150 lines per year on average. Also nice to see somebody showing some techniques to trouble shoot. One small thing I like to do during line placement is to make sure the open bevel side is up when doing a IJ line. I sometimes note that if the bevel is facing down that the wire may choose to go down and exit hitting the inferior wall of the vein.
    This may infact not be the case but since I started this minor adjustment I note less wires getting resistance when feeding them.
    I enjoyed the videos a lot.

    Thanks for posting

  11. Rachelle says:

    wow, your content is fantastic, not only for MDs but also for RNs! As an RN in the ED (also HHC) getting more familiar with the critical care area, I appreciate your work on these videos as it helps me become more familiar with the procedure and where I can offer my help. Many thanks!

  12. All your stuff is awesome! Been sharing with colleagues everywhere. Especially, the beer talks. Mike Mote PA-C St Rose Emergency Dept.

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  2. [...] a great overview of central venous catheterization, check out this post by Haru Okuda and Scott Weingart at [...]

  3. [...] How to Safely Place Central Lines in the EDIn the ED, there are only two ways to place central lines: Full Sterile. or … How to perform an infraclavicular subclavian line, with just the steps that are different … [...]

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