Central Line Questions

I received this message from Denis Colares:

Hi Scott, I’m an Emergency Medicine Resident from Brazil. Really love your podcast, thank you for all your help. Listen, I’ve watched your videos about central line placement and although they added a lot for my technique I still have a few questions. Having the U/S to guide the line placement is quite rare around here so the blind technique is standard. It’s very common to have to do a central line in a mechanically ventilated patient so I ask you: 1- regarding the IJV: do you increase the volume or the PEEP to enlarge the IVJ? I mean besides doing the Trendelenberg and the rest of the standard positioning? I found this paper: “Eur J Anaesthesiol. 2012 May;29(5):223-8. Effects of four different positive airway pressures on right internal jugular vein catheterisation” and I would really love to hear your opinion on this. 2- regarding the subclavian: do you disconnect the patient from the ventilator as you try to pass under the clavicle? I do exactly as you described in the video, usually don’t disconnect the patient, and have successfully done about 40 without a single complication but some people make a big deal out of this and tell me that I HAVE TO disconnect the patient otherwise the risk of a pneumothorax is greater… tell me, cause I couldn’t find anything on pubmed, is there any evidence on this? The ASA guideline simple don’t mention this issue! Sorry about the long text and really hope you can help me here. Thanks.

Denis,
Great ?s.

1. I don’t bother increasing PEEP for IJ placement, though in addition to the article you mention there are a bunch more saying the same thing in the anesthesia literature. I put my patients in Trend. and they all have at least 5 of PEEP. You can get it a bit bigger by going to 10 of PEEP, but the increase has never seemed worth it (a 15% increase is a small increase in actual vessel diameter).

 

2. I too have heard that stuff on subclavian patients. It seems like an old wives tale or medical myth. We routinely placed subclavians in patients on APRV with pHighs of 40 or 50 cm and never thought twice about it. Unless someone shows me GOOD evidence that this actual prevents pneumothoraces, I am not disconnecting my patients (the more PEEP they are on the more deleterious any vent disconnections).

 

Put any additional questions in the comments.

 

Scott

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Comments

  1. Jeff Siegler says:

    I have a similar question about CVC in the right IJ. Tonight on my shift, I had a patient that was so hypovolemic that the IJ was collapsing to the point of disappearing on US upon inspiration. Reverse trendlenburg did not improve the vessel size. I had a difficult time getting the needle to puncture the vein without driving it through the posterior wall into the carotid.

    Any suggestions for when I run into this again?

    Thanks,
    Jeff

    • you need to turn the head in both directions until the carotid doesn’t lie under the IJ in this circumstance. Also scan up and down the neck to see if you can find a spot where there isn’t overlap. Even with longitudinal ultrasound, you will sometimes compress the IJ and puncture the backwall, that is not a problem, just start pulling the needle out and you will get it on the withdrawal. Wire advancing int his circumstance requires patience; the wire will only advance during portions of the resp cycle.

      You may be better off going subclavian in these patients. Or defer central line until you put 4 or 5 liters through a peripheral.

  2. If you’re stuck on using the RIJ and this situation, have someone press the inspiratory hold button on the ventilator while you attempt canalization. This keeps the RIJ dilated for about 5 seconds, depending on your ventilator model.

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