Brought to you by Scott Weingart, MD FCCM and Haru Okuda, MD FACEP
Sterility
In the ED, there are only two ways to place central lines:
Full Sterile
or
Non-Sterile
There is no in-between. Sometimes (hopefully rarely), the exigencies of time or patient condition will prevent placing a full sterile line. This is acceptable so long as you inform the accepting service that the line is not full sterile. If however you state the line is full sterile, you are in effect
Swearing on Your Patient's Life
that EVERY single step of the sterile placement process was followed without breaks. If you can't swear on your patient's life that this is true, then just say to the accepting service that the line was non-sterile and they will replace it.
Here is a video of how to place a full sterile line
SBM Version
[vimeo 136354142 w=750]
EHC Version
[vimeo 6686664 w=750]
Click Here to Download the Video
Look for this area in the lower right of the screen
How to Place a Line
How to perform a blind IJ line placement with all of the steps
[vimeo 16507522 w=750]
Click Here to Download the Video
Look for this area in the lower right of the screen
How to perform an infraclavicular subclavian line, with just the steps
that are different from the IJ
[vimeo 16555672 w=750]
Click Here to Download the Video
Look for this area in the lower right of the screen
How to Place a Sheath Introducer (Cordis)
this video is being rerecorded
Tough Situations
Are you in the Artery or the Vein?
[vimeo 16556049 w=750]
Click Here to Download the Video
Look for this area in the lower right of the screen
This review article discusses the complications and pathways for misplacement of central lines.
—
Special thanks to John Ponessa for editing wizardry and Tim Clapper for the educational development.
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
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?
Mike,
you can, but there are a few risks. If you move the needle when attaching the tubing, you will get a falsely low reading and may actually lose the line
if you pass in the catheter, then make sure there is still flow
you can be sure you will get an accurate transduction and then not risk losing the line when taking the tranduction tubing back off
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
Thanks my friend; haven’t used PiCCO in years; I will look into the series arc.
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,
I call this the Subclavian Suck Sign, though as you have observed, it can happen in any central vessel. I am publishing a letter to the Annals on the subject.
I’m a dialysis RN, and I frequently see what you two are describing. Often I see pretty sick patients who have what appears to be a well functioning dialysis catheter as I initiate the treatment. As I remove fluid and start draining their tank though, I start to notice that the pressure transducers on the dialysis machine are telling me that the catheter is experiencing progressively more resistance in pulling blood to the machine, which often makes the dialysis nurse think the catheter is bad. I’ve played with these guys over the years and seen what I think is this “suck” thing you’re talking about. If I give a little fluid bolus of even 100cc or maybe a bit more, the transducer pressure goes down on the machine indicating that the catheter tip is having an easier time pulling blood from the vessel (less resistance)…I’m presuming because I essentially am inflating the vasculature with my small bolus. Predictably, awhile later after I’ve removed more fluid and taken that bolus away, the pressures trend up again as the vasculature collapses. Give a little bolus to blow up the vasculature a bit, and the catheter runs well again. Wash, Rinse, Repeat. These days that’s my clue that the patient is probably just dry and I try to continue just cleaning their blood without further fluid removal. Otherwise the catheter pressures get so high that I have to slow the machine down so much that I’m not accomplishing much in terms of cleaning. And that would be bad in hyper-K obviously. I’ve had a hunch for years that this is due to the floppy, relatively dry vasculature collapsing on the inflow port of the dialysis catheter. It’s nice to hear you talk about this so I feel like I’m not making crap up in my head to rationalize what I’m seeing at the bedside. Sometimes when this happens, there will be sudden pressure spikes that automatically (temporarily) shut my machine down, and I’m guessing the inflow port has sucked against the wall of the vessel. I also sometimes notice that the transducer pressures are varying widely with the respiratory cycle. Seems less of an issue (or no issue) when the dialysis catheters has the tip located IN the right atrium. Did you ever get a letter published in this topic? I’d LOVE to find it if you did.
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!
Excellent Tip, Tom
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
any of the companies will make these bundles. Arrow will actually build whatever you like into their central line set-ups so you have everything in one place.
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.
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!
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
1. why do you flush the catheter. What is the risk of air embolism
2. I place subclavians when I need a line immediately, ultrasound adds time. When I fail landmark, but still want a subclavian, i use ultrasound
Peter Korsten :
Hi Scott, I have been using your technique placing subclavian catheters several times. Works great and I really do like this approach. There are very few people in Internal Medicine at my institution who place subclavian catheters. Now I use US only to get an idea of the anatomy and if there is time.
Still not sure what the risk of air embolism is if you don’t flush the catheter. Have not found any studies on this.
Best regards, Peter
no study needed. where would is the air that could embolize coming from?
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
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
Ben, there is no reason to rotate, you should have the j pointing where you like before insertion
Fair point! 🙂 Thanks for all the work you do Scott, love the podcast- loads of great pearls.
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
haven’t seen any actual guidelines specifying type of confirmation. if you have any, send them my way and i’ll take a look
Scott
It’s this checklist I was thinking of
https://www.jointcommission.org/assets/1/6/CLABSI_Toolkit_Tool_3-17_Central_Line_Insertion_Checklist_-_Template.pdf
fantastic! i would interpret their mention of manometry as separate from pressure transduction to be the exact method I described
Jackpot – thanks!
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
any air is too much air. you withdraw the air before flushing
I like your infraclavicular approach. I use a similar approach but with my left hand (assuming a right-handed right subclavian) I put an index on the notch and my thumb at the bend of the clavicle. The left index gives me a target, and I can use the thumb to depress soft tissue to get below the clavicle. Helps with “fluffy” patients……
To help prevent infection line should not be “hubbed” all the way to skin, this causes irritation to insertion site with head movement, this mechanical irritation can lead to infection. Plus this leaves room for your BioPatch. CHG prep is 30 seconds for EACH site. Unless wet skin then 2 min each site. Thanks for Vids.
Dr. Weingart or Dr. Okuda, could you please comment about whether a sterile ultrasound guided PICC line would be just as useful and just as quick but have fewer possible catastrophic adverse events than IJ central line? so should we be placing PICC lines instead of central lines in ER? Many Thanks Frank VanMiddlesworth, MD