Cite this post as:
Scott Weingart, MD FCCM. Can We Place Neck Lines in Digoxin Toxicity?. EMCrit Blog. Published on September 7, 2012. Accessed on October 5th 2024. Available at [https://emcrit.org/emcrit/can-we-place-neck-lines-in-digoxin-toxicity/ ].
Financial Disclosures:
The course director, Dr. Scott D. Weingart MD FCCM, reports no relevant financial relationships with ineligible companies. This episode’s speaker(s) report no relevant financial relationships with ineligible companies unless listed above.
CME Review
Original Release: September 7, 2012
Date of Most Recent Review: Jul 1, 2024
Termination Date: Jul 1, 2027
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The fact that those patients needed pacers meant that they were sick. The natural history of sick digoxin toxic patients is to die. The first paper is no argument at all against placing neck lines IMO. In places I visited in Sri Lanka, in the absence of digibind, temporary pacing wires were commonly placed (recycled even!) for oleander toxicity. I have also seen transvenous pacing performed in remote Australia for digoxin toxicity when no digibind was available – the patient did fine. The bottom line, though, is don’t prance around getting central access when digibind administration should be the priority!… Read more »
It seems to me a pretty bizarre and groundless leap to make to say that these papers mean that IJ lines are contraindicated. It makes no first-principle sense, and an association with one or two cases which had heaps of confounders and plenty of reasons for rhythm badness already doesn’t make up for that fact. This isn’t evidence, it’s conjecture! I think we are scraping the barrel for support for the “femoral is best” lobby! My tuppence
This lends some support to something that I have thought (and said, to my colleagues/teachers) for a long time.
Why the hell is the central line guidewire so damn long to begin with ?
Give me 20-25 cm in a nice, tight little circular loading device. That’s all you should need. Its just longer than the actual catheter itself, and allows for good proximal control without having it fly all over the place while you clumsily try to thread the catheter over the guidewire a half-meter above the bed.
… and for those of you that say – “Well, coil the guidewire up when you thread the catheter”… you’ve eventually gotta straighten that sucker out anyways.
– and yes, it’s not unmanageably long, but it is just… too long for common sense. Period.
Guidewire is just the right length, people just use it wrong. The guidewire is designed so that you can thread in 20 cm or so, and then put the catheter on the wire while holding both at eye level, and then advance the whole catheter without any of the stupid feeding the wire back out of the vessel and into the catheter to get it to come out the back. The wire is not too long, we just have a long and almost unstoppable tradition of inserting the wire until an inch or two is left and then feeding the… Read more »
Whooaa. Weingart responded to my post. I’m not worthy! 🙂 Howdy, sir ! Its been a pleasure and an honor to read your blog over the years. Don’t ever stop. I agree with your statement. The wire is designed exactly as you described it. However, I feel that its silly to thread the catheter over the guidewire while is oscillates 30 cm above the bed in an ellipse, especially if you have one hand (your left hand, if you’re a right-y) maintaining proximal control, or pressure on the puncture site (god forbid, they should have a sky-high INR). The reason… Read more »
Lost me there brother. The guidewire must be long enough to extend into the vessel (~15 cm), have the catheter on it outside the body, and leave a couple of cm on either end of the catheter. For a 20 cm line, the actual length including the central lumen is actually ~25 cm. So 15+25+4=44 cm. So conceivably you could make 20 cm lines have guidewires that are 50 cm instead of the current 60cm… until you went to wire change a 30cm triple lumen and you would quickly realize you are kind of f*&(ed. I would argue just the… Read more »
Don’t your guidewires don’t have markings on them every 10 cm?
C
I’m a resident and almost always just pull the entire wire out b/c it is such a pain to thread. Moreover, at my institution, we have the syringe that is continuous with the needle, so we drop have to un-twist (ie and possibly lose my positioning) the introducer needle. The curved end always seems to be “impossible” to thread thru that apparatus. I had an attending that instructed me to use the “non-curved” end with insertion, as it made the process easier. I did it b/c I’m a resident, but I feel that it might increase my risk of complications… Read more »
Nickson–Nope, not ours.
I didn’t even know I wasn’t supposed to put in neck/chest lines in Dig toxicity!
Scott,
Thanks very much for posting this as a blog topic, it’s nice to hear the perspective of others, especially those who have much more experience dealing with this than I do.
Overall I think it’s safe to say that what these patients need is Digibind, not neck lines, but I think if it came down to requiring a line, I would be fine with any central access site.
Cheers,
Chris
Agree Chris. So there you go Mike, its not that you didn’t know; it’s that you didn’t need to know.
Scott,
This has little to do with the blog subject matter, but moreso with the pacing itself. If these wires can cause lethal cardiac arrythmias, why not use transcutaneous pacing until the Digibind works? Or am I way off base here? Sorry I strayed from the thread subject.
I think the issue is whether there is any likelihood of causing dysrhythmia at all. No reason not to try transcutaneous first.