Cite this post as:
Scott Weingart, MD FCCM. Podcast 156 – The Central Line Show – Part I: Avoiding Complications and Confirmation. EMCrit Blog. Published on August 29, 2015. Accessed on June 10th 2023. Available at [https://emcrit.org/emcrit/central-line-show/ ].
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
Original Release: August 29, 2015
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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Hi Scott – Great podcast! Long time listener but first time commentor. I am one of the ICU residents/ED registrars from a metropolitan hospital Down Under in Australia. Thank you for doing this fortnightly podcast! You’ve greatly contributed to my education so far. My tip in order to avoid losing the guidewire from a central line: As soon as I withdraw the guidewire through the central line and the distal part of the guidewire comes through the brown port, I use an artery forceps to clamp down on the guidewire, thus securing it (and the guidewire can never be sucked… Read more »
great stuff, Gavin. I will say, once the wire has popped out of the brown, you are already in the clear–you won’t lose your wire. Wires get lost because people do not push them all the way back through the line.
First, my disclaimer: I am the Director of Clinical & Medical Affairs in Europe, Africa & the Middle East for Teleflex (Arrow CVCs, EZ-IO, LMA, MAD Nasal, etc). My clinical background is ED nursing in South Texas. I just wanted to mention that there is a transduction probe which can be inserted through the back of the Raulerson syringe (using the same port the wire would go through). On the protruding end of the probe there is a luer lock which can be use for any of the methods you discussed in verifying placement. It basically creates an open pathway… Read more »
I use arrow and have the probe. Find the set-up unwieldy. Would love to see a 60 mm Hg non-electric, purely mechanical, strain gauge that pops up red between needle and syringe with a one-way valve
Such a mechanical valve (Turkey thermometer!) would be amazing.
Great podcast Scott, I think this is an incredibly important topic as it is one of the most common ICU and ED procedures out there and the consequences can be devastating if you botch this procedure. I’ve seen horrible outcomes from very senior anesthesia providers cannulating the carotid pre-CV surgery and it was a sobering sight to behold. I am an Acute Care Nurse Practitioner and my practice in three different ICU’s over the years has always been to have a sterile pressure transducer ready to go before I start the line so the nurse can hand me the transducer… Read more »
Hi scott, cool talk. ( regular listener and thanks for mail bag on emrap in AUG) I am an ED reg in Dublin. Just want to mention that one the most difficult bit I find is the dilatation. Especially with not dilating far enough, the cath then ends up kinking over the wire, some cases actually ripping the tip. But if going too far, end up causing lots of bleeding and further damage. At times not enough local so the patient in pain so I hold back and not advance far enough.. Just wanna know whether you have any tricks… Read more »
Pun, I find that the scalpel nick is important. If it is too small you can have issues with dilation. I will also use a bit of a twisting motion when advancing the dilator. Another issue that you can run into is when the angle of entrance into the neck or groin is to abrupt. IE the dilator has to bend a bit to stay inline with the wire. I run into this more with those with a very large neck. The issue with subclavian dilation is that if the needle passed just barely pass the periostium of the bone,… Read more »
I am a Nephrology / rheumatology resident from Germany. I think that for triple lumen catheters the skin nick with the scalpel is not necessary if you are not in an emergent situation. Try to gently twist and push the dilator and it will go deeper eventually. You need a little patience for this but you might avoid some of those small bleeders from the incision site that take you like half an hour to stop.
Great point Peter, I find this to be a valuable alternative when a patient has a bleeding issue…ex from uremia, on blood thinners etc. When I teach residents and fellows, I urge the operator to use some dilation. I think that it allows for ease of placement and in larger necks, you might run into difficulty driving a catheter. I have seen numerous residents and even fellows struggle with placement of the catheter if they are trying to force a very flexible line to go through skin. Typically once the wire is in the vessel the hurdle of advancing over… Read more »
Hi Scott, awesome talk and great tips. I am cardiologist in Bulgaria with interest in pacemaker implantation (permanent and temporary). The method that I am using for verifying that I am in vein and not in artery (with approach from the IJ and SC) is to sink down the guidewire in the inferior vena cava before insertion of the catheter. This is very reliable method to confirm the venous access. There is no way to be in artery and the wire will pass below the diaphragm on the right side of the spine. Of course it`s a little bit confusing… Read more »
Hi Scott, We don’t have the pressure transducer set up where I work (large community ER near Seattle). My preferred technique is simply to have an IV set up hanging and ready. As soon as I have placed my line I attach it to the IV. If it’s arterial, the blood will back up the line quite a way, even in a hypotensive patient (60 mmHg=80cm H2O), even allowing for the resistance of the tubing. Obviously this is after dilation, but if I access the vessel and am worried that it might be arterial I can attach it to the… Read more »
Liam, Unfortunately this method will not work at all in the circumstances where differentiation is most critical and difficult. Almost all infusion sets have built in anti-reflux valves to allow injection without having to pinch tubing. These can be seen as little disks on the line. I would be very surprised if your standard infusion sets did not have them. If you want to use the method you describe , you need blood tubing, which lacks these valves. Even then, it is fraught with potential for misinterpretation in the setting of hypotension. An easy estimate of whether there will be… Read more »
HI Scott, I really liked the post. Some thoughts: First, I think the Bubble test really obviates the need of for a CXR. Where else should the catheter be if not (somewhere) in the svc? It’s not even necessary for the exclusion of a pneumothorax, which can be excluded using ultrasound, as you mentioned. How sure are you that the patient does not have a pneumothorax when you immediately scan the ipsilateral lung using ultrasound? Most pneumothoraces do not develop immediately with the exception of a tension pneumothorax. How do you deal with ‘misplaced’ cvc personally? For example, if it… Read more »
Keep hearing no chest x ray is needed. I argree that this is data supported but I have a few concerns. Have you guys not seen the IJ catheter go toward the skull before? My understanding is that the risk of thrombosis increases as the vessel lumen becomes smaller, so a caudal pathway may lead to venous thrombosis. Can this complication be discovered by anything other than CXR? If not what is the issue if any of infusion of epi, levo and the like toward the venous sinus? I dont get chest x rays in the ICU on my patient… Read more »
“I do not get the CXR to see if the line is in a vein at initial placement” needs to be clearer. I get a film but the reason is not to see if the line is in a vessel lumen its to see where the line is anatomically
sorry for the repost.. just forgot how to edit my post.
Getting a chest x-ray is still standard of care at my institution,too, to look for displaced catheters (especially those going cephalad). But with a negative flush test you already know that the line has been incorrectly placed or moved and you can correct it during the procedure and start scanning the vessels and find the cath. Sometimes this gets easier when you reintroduce the wire and scan subclavian, IJ, contralateral and so on.
I am assuming that fluroscopy is not being used for placement mind you… as that is adequate, but I rarely see the fluro machine come out for a good ole fashion central line…..
Great podcast again, particularly the section on managing inadvertent arterial placement. I’m currently updating our local guideline in response to some complications. We’re emphasizing that it really should be a 2 person job (at least), where possible. The second person’s main role is to audit the process, in our case on a single page checklist that also serves as the procedure note. On it is standard stuff plus the IN/OUT check: this ensures that 2 people are convinced, by whichever method, that the line is IN the vein, and that the guidewire is OUT. Both sign the form and take… Read more »
Hi Scott! Long time listener first time commenter. I’m a first year EM Resident at Morristown Medical Center in Morristown, NJ. While listening to podcast 156, you discussed the only way to lose sight of the guidewire is to get interrupted by someone entering the room and asking a question. I know it may sound simple, but while I was on SICU my first month before any other part of prep was done for a CVC, we ALWAYS closed the door/curtains and used that STOP sign in the kits (instead of throwing them away like I’ve seen done in the… Read more »
same thing when I was in the unit. It is the ED that is a chaotic disaster
You don’t get it both ways buddy. Either there are gremlins or not.
Having trained in Detroit in the mid 90’s in a busy ED, remember YOU and only YOU as the proceduralist are responsible for your sharps!
Amen to the sharps!
There are definitively gremlins, but they don’t grab the wire during central lines–they drink my 3rd and 4th beers and then hit me in the head with a hammer while I am sleeping.
Scott, Thanks for posting, I think I will pass all my residents to this podcast before coming to the unit with me. A few things, do you really do confirm most of your central lines before dilation? I gown up with residents and after they get flash and pass wire successfully I look in longitudinal and short axis view at the entry point, and as far distally as my sterile field will go. In the neck or subclavian this is pretty easy, and if the resident back-walled the vessel its ALMOST ALWAYS at the site of puncture, which makes it… Read more »
Dave, great comments!
Great episode Scott! I’ve gotten to demonstrate a number of these techniques at the bedside to the SICU and ED residents…they love em.
Just wanted to see if you’d seen the 3SITES study just published in NEJM that prospectively confirmed the old biases of central line infection (Subclavian cleanest, IJ=Femoral for infection rates, IJ/Fem have higher thrombosis rates than SC). I’d be interested in seeing what your take is given podcast 80…
Luke Duncan, MD
Albany Medical Center
yes, of course. it only confirmed my biases–so obviously i loved the study
Hello Scott, thank you for those great resources.I look at them regularly myself and can only recommend them to anyone. Regarding pausing ventilation briefly or not: I just read an article that contradicts with the one mentioned by you. Maybe you should take a short pause in ventilation if you: – use, landmark technique for the subclavian approach AND the patient has a low BMI or COPD “The pneumothorax rate was significantly higher in the mechanical ventilation group (2.2% vs. 0.4%; p = 0.012) with an odds ratio (OR) of 5.63 (95% confidence interval, CI: 1.17–27.2; p = 0.031). A lower body mass index… Read more »