Cite this post as:
Scott Weingart, MD FCCM. Podcast 157 – Central Lines II – Placement Tips. EMCrit Blog. Published on September 13, 2015. Accessed on March 28th 2023. Available at [https://emcrit.org/emcrit/central-lines-placement-tips/ ].
Financial Disclosures:
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.
CME Review
Original Release: September 13, 2015
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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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.