Today, the errors and procedural missteps I commonly observe while teaching 100 docs per year how to cannulate for ECMO (but the lessons are not about ECMO, they are about all vascular access in the femoral vessels.)
Finding Vessels
Can't use compression or pulsation
Have to use their appearance
Must Hit the Common Femoral Vessels
Needle Choice
Either a central line needle
or
Pajunk 1187-4K100
2 Ways of Ultrasound-Guided Needle Placement
Walking
(tip, advance or tile probe, no-tip, advance needle)
or
Vessel Trigonometry
I combine the two.
Must make sure you are seeing tip not shaft
Syringe or No-Syringe
How to Hold the Needle
for art, like a dart
hand resting on leg
Angle
shallower the better
Zig-Zagging
Must avoid, one-straight shot at consistent angle
Switch Hands once needle is in
Grab the hub, not the shaft with hand on the leg
Wire Prep
don't use the dumb thumb thing
get enough wire out of its holder to make it past the needle tip
learn what to do if no cheat
What to Place
4F or larger cordis/introducer
or
18G arterial line
ECMO Centers
Needle to floppy wire
to 7F dilator
to superstiff wire
Additional New Information
More on EMCrit
- EMCrit Wee – Central Line MicroSkills – Dilation
- EMCrit Wee – Central Line MicroSkills (Deliberate Practice)
Additional Resources
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thanks for this. I have always pulled the wire out of the holder and nice to hear im not alone. btw, which Pajunk needle to you use for vascular access?
Excellent podcast. Attended the course 3 years ago. Great course. Have been teaching my med students and residents vessel trigonometry for years. It really helps their spatial orientation with short axis ultrasound view in placing lines. Thank you Scott.
Why is the technique different for A lines? E.g. why the “dart” hand position, why does Scott say in his first microskills video he takes the wire out entirely for A lines?
veins can be sub-atmospheric and risk air embolism, arteries are always positive pressure. Can you explain what you mean by takes the wire out entirely
And why no syringe for A lines? I do these same adjustments but now it’s occuring to me to ask why the technique and equipment isn’t the same.
Great podcast especially the part about using a central line needle for femoral art lines. I tried to get CME for this episode but the link is not working. It just takes you to the same picture. Can this be fixed? Thanks!
should be working now!! thanks for the heads up
Hi Scott. Curious about your take on using an angiocath vs needle (we have the long 2.5 inch 20 Ga and 18 Ga Introcans).
Also, do you routinely pause CPR while getting access? Thanks.
-Aman.
I feel strongly and evidence bears out that the bare needle should always be used, not the angiocath. We never stop cpr for venous access. In an ecmo candidate, it is acceptable to stop CPR for <20 sec to get the arterial access.
I was debating this recently with a coresident. Do you happen to have a citation on any studies that show this evidence on angiocath vs bare needle? Thanks!
Fantastic Episode !!! Disclaimer : I’m an ED doc from the EZ-IO and peripheral pressor era, i’m far from an expert in line placement 😉 Just messing around with some ideas 1) Vein cannulation and syringe With ultrasound do you really think that the syringe is still valuable ? The “dart method” is so stable, so precise. I think, There’s an argument to be made that the syringe is a remnant artifact from the pre-ultrasound era 😉 haha Seriously, i’m not sure i see great value, especially for an ED Doc that rarely put central lines. The dart method is… Read more »
The key as you mentioned is not leaving a venous needle open to air. If you are going to use no syringe, then the win is to use WIRE-IN-NEEDLE approach (WIN) ala Mike Stone. As now, the wire is already there for you and it makes the needle much more visible.
During ECPR however, there is often situations where you may lose your needle tip for a moment, having a syringe with neg press is very helpful.
2
yep, i believed i mentioned tilting during the hybrid description during the podcast–totally agree
Nice Tips !!! Thanks
Sorry i missed the tilting in the podcast.
Fred
Awesome episode but it was the first time I heard of the downsides of the „wire holder“. Your argument totally makes sense, especially getting the wire right into the vessel in one movement.
Could you, if there is any time, show us a video of someone doing it correctly? Our central line wires all have this „mini pigtail“ so the little introducer which keeps the wire straight and connects to the needle hub is still necessary.
in vascular parlance–the thing that keeps the j-tip straight is a cheat or cheater
with the cheater in place, just pull out 6 inches of the wire from the wire holder.
pick it up at about the 4″ mark and shove it in the needle
Having started to place ECMO in multiple scenarios and then listening to this amazing episode, I realized a few things:
1) my ultrasound-guided needle placement sucks and needs improvement
2) the first time someone told me where the perfect spot for the vessel puncture lies: 2cm above the bifurcation but below the inguinal ligament
3) placing a stiff wire directly into a 7F introducer sheath is bs
thank you for teaching me this, no one ever did before
Hey Chris
On number 3, just want to make sure we are on the same page. Placing a stiff wire through an introducer sheath is just fine, just not necessary to place a sheath if you are going straight to cannulation. Key is not to place a stiff directly through a needle unless you are very experienced (which you probably are!) I think we are on the same page, but just wanted to make sure.
Excellent pointers, learned a lot. Wanted to comment on the “trigonometry” method. Works well for the experienced, but I don’t like to see this in early trainees. I call this the “point and shoot” method – where you mentally estimate these distances and hope everything lines up as planned. It is surprising how often you can lose a needle even over a short distance unless you are astutely attuned to its appearance/movement on ultrasound. This can be a challenge for the uninitiated and invite unnecessary delays/complications. I teach and much prefer your second method whereby you note the distances, then… Read more »
Hey, Scott,
thanks for a great podcast. I was wondering exactly which Pajunk needle you were referring to. In our distribution (Czechia, Europe) there is only the Tuohy needle tip or the 18G over the needle e-cat catheter with the 20G needle. Neither could I find anything in the international catalog. The visibility of Pajunk needles is indeed superior to anything else, we use them for regional anesthesia. It would be great to get them.
Thanks
Jan Benes
very cool pod, Scott. thank you. in march 2017 I took the Reanimate course. had no idea what the heck I was doing generally. you showed me femoral line placement.(I barely knew central lines)… but Reanimate (that one was #3) is much much more than learning ECMO. It is a whole mindset. paradigm for major resus. reboa. placing 19 and 24 French fem lines. and meeting an international family of teachers and “students” from Lionel and Alice form France, others from Scandinavia, Australia , and more. it’s technique, and science, but also an attitude. that we got this. way above… Read more »