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!

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?

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.

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

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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

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,

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?

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

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

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

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!

[…] http://emcrit.org/central-lines/  From the one & only Scott Weingart. […]

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

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

[…] Procedure Videos can be found on the EMCrit Procedure Page. […]

[…] EM Crit Central Lines […]

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.

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

Hey Scott

Love this post; incredibly useful teaching resource.

I love the subclavian and think it’s a crying shame our trainees seen to have lost this skill (or maybe just at my hospital. I wanted to share Matt Dawson’s lovely Ultrasound Podcast on the use of US to place subclavian lines. I like this method, and I’ve shown junior doctors how to place SC lines using US.

Here is the link:

http://www.ultrasoundpodcast.com/2012/12/little-itty-bitty-2-ultrasound-guided-subclavian/

Thanks again,mope to see you in Dublin.

Best wishes

Dr Dean Burns
Consultant in EM/ICM
UK

Hi Scott, I was wondering what your thoughts are concerning the recently publishd 3SITES trial in the NEJM. I think it is an important trial, however, there is one limitation that might not reflect daily practice: The authors of the study did not allow routine blood sampling from the CVC, This is, in fact, one of the reasons to PLACE a catheter. Difficult venous access and need for repeated blood samples.
Another thing was the median time of cath days, which was low with 5 days (ranging from 2 to 9). In our IMC and ICU, catheters are needed probably longer although I cannot prove this with data.

Best,

Peter

[…] de cateter venoso central – jugular, subclávia e […]

Sounds like the way to do it- either US or II if in theatre.
On that subject, when placing an IJ, as soon as your wire is through the needle tip, if you rotate the guidewire cover so that it’s over the patient’s head, the J tip will be facing medially, hopefully avoiding your wire going into the subclavian.

Best wishes,

Ben

[…] to consult a more experienced doctor or mastering a difficult surgical procedure like inserting a central line, interning medical students often stumble. They are forced to learn the hard […]

[…] of a subclavian line is not nessecarily complex but does require practice.  EMcrit breaks down all types of CVC placement and is worthwhile checking […]

[…] to consult a more experienced doctor or mastering a difficult surgical procedure like inserting a central line, interning medical students often stumble. They are forced to learn the hard […]

Hi Scott,
Does documenting “visual” manometry with extension tubing (height of blood column, pulsatile, etc) satisfy the safety guidelines of various organizations (Joint Commission) for confirmation of venous placement – or do they specifically require waveform analysis?
Thanks,
Rich

Hi Scott!
I’ve another question about not flushing the cvc before insertion, sorry. After insertion do you try to suck out the residual air in the catheter before flushing it with saline or do you just think the tiny amount of air in the catheter isn’t relevant and you just inject the air into the patient while flushing it with saline?

Thanks for all the great work you are doing. I’m quite impressed of all the small tricks you show in the video so you can put in a cvc with virtually no assistance. Most docs I know would state it’s a mission impossible to put in a cvc alone 😉

Sebastian Beck, Berlin, Germany