Listen to Part I – Avoiding Complications
Micro-Skills and Deliberate Practice
- You definitely need to watch the central line micro-skills video
Steps Of Central Line Insertion
Subclavian Insertion
Dilation
- The wire CAN'T BE ALLOWED TO ADVANCE
- I need to record dilator use as a microskill
- Move wire in out sequentially during dilation (racking the wire)
Internal Jugular
- Keep head in neutral not rotated for IJ (Journal of Emergency Medicine Volume 31, Issue 3 , October 2006, Pages 283-286)
Subclavian
- Subclavian is safe in mech vent pts (Anesthesiology:2009 – Volume 111 – Issue 2 – pp 334-339)
- Use lower shoulder position puncture site just lateral to mid-clavicular line [cite source='pubmed']15564937[/cite]
- Shoulder retraction (padding behind the back) was not helpful (Br. J. Anaesth. (2013) 111 (2): 191-196.)
- If you miss twice, consider abandoning the site (3 on a match)
Ambesh Maneuvers
- Finger in fossa technique to prevent guidewire malposition in subclavians (Ambesh SP, Anesthesiology. 2002; 97(2): 528-529.)
Checking Subclavian Placement after Catheter is In
- After subclav line placement, if you push on IJ and CVP increases 3-5 mmHg then the lumen is in the IJ instead of the SVC (Anesthesiology 2002;97(2):528), IJ occlusion test (Anesthesiology 2001;95(6):1377) and (Anesthesiology 2006;105(5):1062-1063)
Can We Place Central Lines in Anti-Coagulated Patients?
- Central line insertion while anti-coagulated seems safe and complications probably correlate with skill of physician (emerg med j 2011;28(6):536)
- Micropuncture Sets seem to be a very clever way to go
Guidewire Exchange
Guidewire exchange seems safe [cite source='pubmed']24004883[/cite] GWX-CVC’s and NI-CVC’s had similar rates of tip colonization at removal, CA-BSI and mortality. If the CVC removed by GWX is colonized, a new CVC must then be inserted at another site. In selected ICU patients at higher central vein puncture risk, guide-wire exchange may be an acceptable initial approach to line insertion.
Tips for Flushes
Drop a sterile 50 ml bag on to field; slash that bad boy with a scalpel. (Thanks Haney)
Update:
Chris Bond does an interview on hand motion analysis as a means of demonstrating expertise on the procedure
Additional New Information
More on EMCrit
- Podcast 156 – The Central Line Show – Part I: Avoiding Complications and Confirmation(Opens in a new browser tab)
- PulmCrit- Shrug Technique for US-guided subclavian lines(Opens in a new browser tab)
- Central Lines(Opens in a new browser tab)
- Podcast 80 – Uhmmmm, Maybe Groin Lines Are Not So Bad with Paul Marik(Opens in a new browser tab)
Additional Resources
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Great show as always Scott.
Thank you for mentioning that it is okay to dilate the vessel and to move the wire in&out during dilator insertion. I always have this battle when educating 2nd to dogma. I would say that ultrasound guided subclavian (ie axillary but I have been able to get to subclavian on some patients) wasn’t mentioned but is easy Another great one! Thanks!
Great stuff. I will also add that the micropuncture sheath makes a great arterial line or peripheral IV in a patient where the standard 2 inch angiocath is too short (particularly for brachial and basilic veins). The ones I’ve used are also nice because the needle is echogenic even though it’s small. (Oh and the kits I’ve used have a 2.5 inch needle, definitely long enough for subclavian).
So the Kitagawa article seems to indicate that a rolled up towel is beneficial. But this is not your experience? if done what is a small towel? a washcloth? what do you recommend.
btw, I’ve been at this for 30 plus years and you answer the questions i would have loved to have answered long ago- but better late than never.
Hi Scott, great podcasts about central lines! I will make all my residents listen to them. We use the subclavian a lot. If the patient complains about pain in the neck or ear when inserting the guide-wire it has often gone up the IJ. Retract the guide-wire until it’s in the needle again and have an assistant compress the IJ when you insert the wire again. Works every time to prevent accidental retrograde IJ placement. Reference: Ambesh et al. Anesthesiology 8, 2002.
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1943927
All the best, Niklas
Scott, With the cordis, you mentioned inserting the dilator and the catheter as one unit. While I agree that is the way this is designed (perhaps for speed of insertion?) as a resident I was having an issue passing this dilator/catheter combo. The person supervising me recommended using the dilator separate from the catheter (as a separate step) then putting the dilator back into the catheter and completing the procedure. Obviously it adds an extra step and a little bit extra time onto the procedure but since then I have never had an issue doing it this way. I feel… Read more »
Steve, while dilating separately may help, it should not be necessary. In general, when this is the case, it is due to inadequate skin incision
HI Scott, great tips about the dilation part, I have always have had problems with that. Currently I am using the micropuncture kit in all my lines and it works beautifully, no kinks doing this way, feel much safer. And the kit works very well with subclavians, actually the micropuncture needle is longer than the needle in the central line kit.
There are Gremlins! A colleague of mine was placing an IJ using a micro introducer kit when he got paged for a CPR. He left the guidewire in place sticking out at least 30cm, told the nurse to notify me and responded to the code. Because the code was not a real one we arrived simultaneously back in the OR and found the guidewire being gone… it was found later on the other side of the heart lying peacefully in the V.cava inf. and V.iliaca com.dx. I guess this would never have happened with the standard kit, the problem with… Read more »
oh, such a good anecdote!
Just wanna thank you for the cast,
took the advise of holding that wire tight while dilating…. Man … it worked a treat.
gonna pass on that skill to the rest ….. NO MORE KINK!!!
Pun
How do you hold the wire tight and keep tension on the skin whilst dilating?
Thanks
Scott
you don’t without a 2nd person
Great Podcast,
We will be incorporating this into our education for new hires. I’m curious if your facility (or any other subscribers) uses a set number for initial competencies and annual competencies.