Central lines and fistula sites...voodoo or for reals?

[Laryngophed]

I can't say I care if a medical student or resident has issues with a procedure, they don't know what they're doing anyways.

Sure, point taken. I'm fully aware of and comfortable with the fact that I don't know what I'm doing. And the same for the resident. But the fellow (who was training in anesthesia in another country before coming here) and the two attendings probably had a firm grasp on the procedure. But aside from the one Murharker our attending slid in, even he struggled. Arterial lines and central access were attempted multiple times, but all were failures. And the IR attending had some difficulty with access too. You could assume that it was just the people attempting the procedures, but it could (and I think, was likely) owed to his vascular diseases and obesity.

So this is the take away point you took for this pt?

What I gathered was what you'd alluded to, be generous with the skin nick. If you are still bending the dilator (and you feel you've made an adequate nick) when passing the dilator, open up a Cordis and use the dilator from that kit and insert your catheter of choice.

These statements don't seem congruent.

Sorry about that. I will admit to having sampled a few of my favorite fall wares the other night. He was a vasculopath, long standing uncontrolled HTN, HLD, and DM s/p bilateral BKAs and I think some bypass to one of his LEs, repeated placements of ports and other forms of access (he had a fistula that had was no longer usable, but I don't remember why precisely) demonstrating that it other had dealt with access issues before. His morbid obesity
led to bent dilators. When a suitable site was selected and the wire was able to be passed, dilators were bending repeatedly. It was the IR attending who decided to use the dilator on the Cordis kit to pass the dialysis catheter. I thought it was a neat trick and I'd share it here.

---

Members don't see this ad.

 

[deleted547339]

Sure, point taken. I'm fully aware of and comfortable with the fact that I don't know what I'm doing. And the same for the resident. .

I don't know where all of you train, but our EM residents get a TON of lines. I would trust a third year EM resident (and almost all 2nd year residents) putting in a CVL over almost anyone else in the hospital.

 

[VentdependenT]

Supraclavicular subclavian with in-plane visualization? Oh yes my friends. oh yes. its my new fav. go stuff your IJs where the sun dont shine.

 

[namethatsmell]

Supraclavicular subclavian with in-plane visualization? Oh yes my friends. oh yes. its my new fav. go stuff your IJs where the sun dont shine.

I've read about the supraclavicular and practiced it on a dummy and it seems like a great approach. Both times I've ask to try one on a patient I've been met with a blank stare from my upper year resident or fellow. Hopefully 3rd time is the charm

 

[Hernandez]

I've read about the supraclavicular and practiced it on a dummy and it seems like a great approach. Both times I've ask to try one on a patient I've been met with a blank stare from my upper year resident or fellow. Hopefully 3rd time is the charm

Don't bet on it, I've not met many folks who know that approach,

 

[VentdependenT]

Don't bet on it, I've not met many folks who know that approach,

Just did another one last night. Shiley, L supraclavicular.
1) ER put shiley in RIJ, it wound up traveling UP the LIJ
2)I tried LIJ, vein basically entirely collapsed and guy was NOT COOPERATIVE.
3)He had a huge muscle flap graft over his L pectoral.
4)I moved my drape opening over L clavicle, reprep, follow IJ until it meets subclavian, rotate probe 90, in plane with vessel, watch needle enter subclavian in-plane view real time...guidewire like butter, line like butter...off to urgent SLED for lithium overdose.

Yes my friends. Yes.

 

[jdh71]

Just did another one last night. Shiley, L supraclavicular.
1) ER put shiley in RIJ, it wound up traveling UP the LIJ
2)I tried LIJ, vein basically entirely collapsed and guy was NOT COOPERATIVE.
3)He had a huge muscle flap graft over his L pectoral.
4)I moved my drape opening over L clavicle, reprep, follow IJ until it meets subclavian, rotate probe 90, in plane with vessel, watch needle enter subclavian in-plane view real time...guidewire like butter, line like butter...off to urgent SLED for lithium overdose.

Yes my friends. Yes.

Oh gawd. You act like you're the only person to use U/S to put in a supraclavicular line.

here's your cookie:

I've done a few and I'm not excited for you. I don't even think it's magic. I'm pretty sure you are not a wizard.

 

[Bostonredsox]

Very nice and fancy.

I would have just exchanged there shiley over a wire, withdrawn the wire about 10 cm, rotated it 90 degrees, readvanced to the RA, and put a new catheter in over the wire, now in the appropriate place.

Should take about 4 minutes and not even require a stick for the patient apart from the new sutures.

I never put dialysis catheters in subclavian sites. They always end up with poor flow.

 

[VentdependenT]

Oh gawd. You act like you're the only person to use U/S to put in a supraclavicular line.

here's your cookie:

I've done a few and I'm not excited for you. I don't even think it's magic. I'm pretty sure you are not a wizard.

Actually I AM the only person to try this line at my hospital outside of a few ER attendings. My attendings havent even heard of this approach.

Good lord dude....good lord. You definitely fail as a telepathic.

Anyways its fun and cool. I like what I do and I hope to spark interest in others. Try this line!

 

[VentdependenT]

Very nice and fancy.

I would have just exchanged there shiley over a wire, withdrawn the wire about 10 cm, rotated it 90 degrees, readvanced to the RA, and put a new catheter in over the wire, now in the appropriate place.

Should take about 4 minutes and not even require a stick for the patient apart from the new sutures.

I never put dialysis catheters in subclavian sites. They always end up with poor flow.

RIJ was pulled before i got down there. BTW I had to silk tape this dudes head (mummy style) to the bed to get the line in and it was 730pm woth wife and kids waiting for me at home.

 

[Bostonredsox]

RIJ was pulled before i got down there. BTW I had to silk tape this dudes head (mummy style) to the bed to get the line in and it was 730pm woth wife and kids waiting for me at home.

Meh, very rarely does any form of IJ take me more than 10 minutes prep to dressing. And I tape the **** out of patients heads all the time. Or make the med student hold there heads to the side.

But if here being combative to the point whee an IJ is tricky....then there combative enough in my opinion to flail during my subclav attempt and drop a lung.

Super combatives = femoral for me. Double bonus for fem if your running late getting home to. Wifey. 90 seconds - 2 minutes and your done with that bad boy. Plus no waiting for X-ray

 

[jdh71]

Actually I AM the only person to try this line at my hospital outside of a few ER attendings. My attendings havent even heard of this approach.

Good lord dude....good lord. You definitely fail as a telepathic.

Anyways its fun and cool. I like what I do and I hope to spark interest in others. Try this line!

Bro, I saw a youtube over a year ago, showed an attending, and we did one and another and another. And then I did more. It's not special. Just forgotten.

 

[VentdependenT]

Bro, I saw a youtube over a year ago, showed an attending, and we did one and another and another. And then I did more. It's not special. Just forgotten.

And the ultimate goals of your responses are? To help others on this board? To help me? To encourage a new fellow/s? Or are your responses for yourself? If so, why? Now thats a good question.

I stand by my previous post.

Thanks again.

 

[VentdependenT]

Meh, very rarely does any form of IJ take me more than 10 minutes prep to dressing. And I tape the **** out of patients heads all the time. Or make the med student hold there heads to the side.

But if here being combative to the point whee an IJ is tricky....then there combative enough in my opinion to flail during my subclav attempt and drop a lung.

Super combatives = femoral for me. Double bonus for fem if your running late getting home to. Wifey. 90 seconds - 2 minutes and your done with that bad boy. Plus no waiting for X-ray

I was literally going nuts dicking around with this dudes nearly collapsed IJ. going through and through and pulling back only landed me return once then the dude coughed and it was gone. I too can usually crank out an IJ lickedy-split, but once Im about to leave nearly all things related to pt care become, well, more challenging. A Strange but ever true phenomenon.

 

[jdh71]

And the ultimate goals of your responses are? To help others on this board? To help me? To encourage a new fellow/s? Or are your responses for yourself? If so, why? Now thats a good question.

I stand by my previous post.

Thanks again.

I also stand by my previous posts which were made because I wanted to make them. If you don't like it, you can 1) deal with them, 2) not deal with them, or 3) eat a dick (those seem to be all of the legitimate options here). It's all up to you bro.

Thanks for your responses too!!

I love this game.

 

[VentdependenT]

I was literally going nuts dicking around with this dudes nearly collapsed IJ. going through and through and pulling back only landed me return once then the dude coughed and it was gone. I too can usually crank out an IJ lickedy-split, but once Im about to leave nearly all things related to pt care become, well, more challenging. A Strange but ever true phenomenon.

In my 9 years of training ive never had to fully mummy strap someones head to the bed.

 

[VentdependenT]

I also stand by my previous posts which were made because I wanted to make them. If you don't like it, you can 1) deal with them, 2) not deal with them, or 3) eat a dick (those seem to be all of the legitimate options here). It's all up to you bro.

Thanks for your responses too!!

I love this game.

Its all about you. bro.

 

[jdh71]

Its all about you. bro.

Nah, bro, it's about YOU.

EXTREME critical care, brah, delivered in it's mostest, bestest, broest fashion complete with raging hard ons and cheat thumps. It doesn't get much better than this.

 

[deleted547339]

Simmer down now, children.

We get it. Ventdependent was excited about a line. jdh wants to crush that joy.

Move on. k? thanks.

 

[Doctor Bob]

EXTREME critical care, brah, delivered ... complete with raging hard ons

Seems like that would make it tough to stand close to the bed...

 

[jdh71]

Seems like that would make it tough to stand close to the bed...

If you get the height right . . .

 

[jdh71]

Simmer down now, children.

We get it. Ventdependent was excited about a line. jdh wants to crush that joy.

Move on. k? thanks.

Actually it appears to me like both myself and Vent were done with our discussion. And ironically enough, does not appear to have been brought up for almost a whole day until you decided to walk back in and act like you even ****ing know us. This is a family fight and you should really sit down and shut up about it. Me and Vent don't need your help with our public disagreement over style.

And furthermore if we decide to continue our disagreeing we won't give a flying rats ass about your opinion regarding it. If I don't want to move on, I won't and you can kiss my ass. K? Thanks.

 

[deleted547339]

Actually it appears to me like both myself and Vent were done with our discussion. And ironically enough, does not appear to have been brought up for almost a whole day until you decided to walk back in and act like you even ****ing know us. This is a family fight and you should really sit down and shut up about it. Me and Vent don't need your help with our public disagreement over style.

And furthermore if we decide to continue our disagreeing we won't give a flying rats ass about your opinion regarding it. If I don't want to move on, I won't and you can kiss my ass. K? Thanks.

Just a joke, dude.

 

[jdh71]

The Internet is serious.

 

[deleted547339]

The Internet is serious.

Lol

 

[VentdependenT]

I still love you JDH!!!! Sorry dude. All this work is makin me fiesty.

 

[Doctor Bob]

You should put in a line wherever you feel most comfortable preferably using US. The data is very merky on infection rates that patients care about, not colonization.

Renal for some reason at my shop always does a femoral unless I put the catheter in for them, anyone else notice this?

Sorry to go off on a tangent but... I got s*** from a surgical intensivist the other day for putting in a femoral line.

Here's the deal... in my deployed location the intensivist who runs the ICU is the trauma surgeon... makes sense because 95%+ of the people we send to the ICU are trauma cases.

But I had a guy who came in with a big anterior wall STEMI, bedside echo had EF under 20%, had pulmonary edema from failure and was coughing up blood. Since the nearest cath lab is 8 hours away by fixed wing (and due to issues with incoming fire, the flight line was closed).

So he gets ASA, Plavix, Lovenox IV, Lovenox SQ, TNK. Nitro fails to make any difference in his declining respiratory status so he gets plastic in his airway (much to my chagrin, we didn't have the masks needed for NIPPV).

VT develops, pressure continues to tank. Amio goes in, Lidocaine goes in, amio drip goes up. Hemodynamics start to improve but now he needs more access. Because of all of the platelet inhibitors and clot busters rolling around his system I opt for a femoral line.

Surgical intensivist shows up to admit the patient and gives me heck for doing it. "Those have such a high rate of infection not to mention the DVT risk is very very real." I just stared at him. DVT? Really? I want a compressible site in the guy who has just had every anti-clotting drug I have available in the pharmacy. To which he responds with "Oh you can compress an IJ". Sure... you -can- but it's easier to do so in the femoral.

I dread sending a sick medical patient to our ICU.

 

[Bostonredsox]

Sorry to go off on a tangent but... I got s*** from a surgical intensivist the other day for putting in a femoral line.

Here's the deal... in my deployed location the intensivist who runs the ICU is the trauma surgeon... makes sense because 95%+ of the people we send to the ICU are trauma cases.

But I had a guy who came in with a big anterior wall STEMI, bedside echo had EF under 20%, had pulmonary edema from failure and was coughing up blood. Since the nearest cath lab is 8 hours away by fixed wing (and due to issues with incoming fire, the flight line was closed).

So he gets ASA, Plavix, Lovenox IV, Lovenox SQ, TNK. Nitro fails to make any difference in his declining respiratory status so he gets plastic in his airway (much to my chagrin, we didn't have the masks needed for NIPPV).

VT develops, pressure continues to tank. Amio goes in, Lidocaine goes in, amio drip goes up. Hemodynamics start to improve but now he needs more access. Because of all of the platelet inhibitors and clot busters rolling around his system I opt for a femoral line.

Surgical intensivist shows up to admit the patient and gives me heck for doing it. "Those have such a high rate of infection not to mention the DVT risk is very very real." I just stared at him. DVT? Really? I want a compressible site in the guy who has just had every anti-clotting drug I have available in the pharmacy. To which he responds with "Oh you can compress an IJ". Sure... you -can- but it's easier to do so in the femoral.

I dread sending a sick medical patient to our ICU.

Do you have US? If you do I'd stick the IJ every time in the patient you described. If you don't and your talking blind IJ or blind Subclaviam in a coagulopathic pt then I understand femoral. Although I have had a lot of success with 22ga finder needle and then 18 for non us guided IJs. In obese pts the IJ and carotid are definitely easier to compress then the femorals. In addition your pt was on the vent so his airway is protected in the event of a neck hematoma. If he bleeds into the retro peritoneum during his 8 hour flight he's toast.

I would probably would have gone IJ. But I don't think any option should have resulted in you getting ****. You did a great job in a pt that was dying it sounds like. Tell the surgeon to stfu.

 

[Trifling Jester]

I'm just a stupid student, but during a recent ICU rotation I learned that going through too much subcutaneous fat leads to many bent dilators. And that the cordis kit comes with a fat, very stiff dilator. After that little bit of knowledge, that mahurkar went right where it was supposed to go.

Were you going femoral? Sometimes this happens with a lot of sub q tissue. The wire can loop on itself while you're trying to insert the dilator. Once the dilator is bent you can bet that the wire is bent too, so you should try moving the wire farther in or out so you're advancing over the straight part of it. You can try pressing down with one hand to squish the excess tissue away from your area while you're getting access. Or use a stiffer wire, a longer wire, or stiffer dilator.