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

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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

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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)

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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. Mike says

    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?

    • says

      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. R Teh says

    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,

    • says

      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. KIM says

    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?

    • says

      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.

  7. CR says

    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.

  8. CR says

    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

  9. 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!

  10. Peter Korsten says

    Hi Scott,
    I really liked your tips on subclavian line placement. I agree that if you just use landmarks you find the subclavian vein deeper than with your approach.

    Two things:
    1. Why don’t you flush the catheter before introducing? I have seen anesthesiologists do it this way. What is the risk of air embolism?
    2. Subclavian and US: Í know of not many people who uses it, because it is a bit more tricky to visualize, but I really do like it if you have the right equipment (e. g. a smaller linear probe). There is an interesting paper on it from a few years ago.

    Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study.
    Fragou M, Gravvanis A, Dimitriou V, Papalois A, Kouraklis G, Karabinis A, Saranteas T, Poularas J, Papanikolaou J, Davlouros P, Labropoulos N, Karakitsos D.
    Crit Care Med. 2011 Jul;39(7):1607-12. doi: 10.1097/CCM.0b013e318218a1ae.
    PMID: 21494105 [PubMed – indexed for MEDLINE]

    Best,

    Peter Korsten, Resident Physician, Goettingen, Germany

    • says

      1. why do you flush the catheter. What is the risk of air embolism
      2. I place subclavians when I need a line immediately, ultrasound adds time. When I fail landmark, but still want a subclavian, i use ultrasound

      • Peter Korsten says

        Peter Korsten :

        Hi Scott, I have been using your technique placing subclavian catheters several times. Works great and I really do like this approach. There are very few people in Internal Medicine at my institution who place subclavian catheters. Now I use US only to get an idea of the anatomy and if there is time.

        Still not sure what the risk of air embolism is if you don’t flush the catheter. Have not found any studies on this.

        Best regards, Peter

  11. Nikolay Petrov says

    Hello Scott!
    Thank you for everything you do. Big fan of you and your website. Thank you.

    Nikolay Petrov, Cardiology fellow with interests in pacemakers and central lines. Cardiology Hospital Pleven. Bulgaria.

  12. Peter Korsten says

    Hi Scott,

    One question about troubleshooting: what do you suggest if the catheter gets displaced to the subclavian vein during placement of an IJ vein?

    Had a patient with known difficult central venous access and the same thing happened. Was able to “save” the catheter by retracting the catheter over the wire under US guidance and readvancing the guidewire while scanning the SV.

    Any easier way to do this?

    Best, Peter

    Resident from Goettingen, Germany

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  1. […] 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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