Subclavian lines

[NDcienporciento100]

I’m a surgery Intern going into IR. And I am coming here with a small grievance.... someone I plead with you please someone tell what is the obsession with surgeons and subclavian lines!?!?!?! In my short time as an intern I have seen so many pneumo’s oh, and mean while a perfectly good ultrasound is two feet away waiting to let you slip that needle into the IJ like buttaa! For the love of humanity and modern technology please stop!!!!

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[HighwayVagabond]

Hmmm, this may be specific to your program or the service you are currently on. I tend to use SCLs more frequently in trauma, because the patient often needs a c-collar, and/or because it can be placed in two seconds in the chaotic trauma bay when necessary without using US. (Though depending on location of GSW, femoral might be preferred. We do a lot of ED thoracotomies, and you don't want to dump PRBCs directly into an injured vessel.). Likewise, in any emergent setting, sometimes SC is preferred to perform quickly if an US isn't available.
Maybe your co-residents just want extra practice with SC placement, particularly if they're managing to bag the lung as frequently as you suggest!

 

[Dr.LeoSpaceman]

This should be in the main GS thread.

But to answer:
1) The c-collar issue on trauma.
2) They're associated with lower incidence of DVT and CLABSI.

 

[NDcienporciento100]

This should be in the main GS thread.

But to answer:
1) The c-collar issue on trauma.
2) They're associated with lower incidence of DVT and CLABSI.

But at the increases risk of pneumo!

 

[NDcienporciento100]

Hmmm, this may be specific to your program or the service you are currently on. I tend to use SCLs more frequently in trauma, because the patient often needs a c-collar, and/or because it can be placed in two seconds in the chaotic trauma bay when necessary without using US. (Though depending on location of GSW, femoral might be preferred. We do a lot of ED thoracotomies, and you don't want to dump PRBCs directly into an injured vessel.). Likewise, in any emergent setting, sometimes SC is preferred to perform quickly if an US isn't available.
Maybe your co-residents just want extra practice with SC placement, particularly if they're managing to bag the lung as frequently as you suggest!

I disagree that’s it’s faster, I’ve seen people missing for 10 minutes using landmarks, ultrasound is much more consistent. Your point about the c-collar is obviously valid.

 

[Dr.LeoSpaceman]

But at the increases risk of pneumo!

Yes. But as with anything in medicine, you pick your poison. I'd argue that CLABSI and DVT are more clinically relevant than a pneumothorax that in some cases can be managed expectantly. And comparatively, I'd say even a pigtail for a day or two isn't as problematic.

Also, I'd caution you to be more circumspect as you approach these decisions through your training. The way you came in here essentially saying "LOL, look at these surgeons doing something wrong." raises red flags.

As you enter your second year of training, consider this quip as it is generally applied to junior residents: "Often mistaken, never in doubt."

 

[NDcienporciento100]

Yes. But as with anything in medicine, you pick your poison. I'd argue that CLABSI and DVT are more clinically relevant than a pneumothorax that in some cases can be managed expectantly. And comparatively, I'd say even a pigtail for a day or two isn't as problematic.

Also, I'd caution you to be more circumspect as you approach these decisions through your training. The way you came in here essentially saying "LOL, look at these surgeons doing something wrong." raises red flags.

As you enter your second year of training, consider this quip as it is generally applied to junior residents: "Often mistaken, never in doubt."

I did some digging, best data out there suggests 1.5 events per 1000 (0.15%) for subclavian CLABSI vs 3.6 events per 1000 (0.36%) for IJ. For DVT 0.5% vs 0.9% for subclavian vs IJ. For pneumothorax 1.5% for subclavians and 0.5% IJ.

Context and how the study is run is everything. These studies only showed data from highly experienced operators, meaning that the pneumothorax risk is much higher a teaching hospital that has traines doing them, IJ approach’s are much more forgiving no matter what level of training, (anecdotal data on my behalf I have never seen an IJ pneumothorax from in Interventional Radiologist, my guess is that 0.5% is mostly other specialty’s like surgery).

An older frail patients you really should not down play what a pneumothorax can do a patient that may be already tedering on the edge of decompensation.
Many severely sick patients will be on broad spec antibiotics and DVT prophylaxis, and I would argue you in that scenario the bases for rational is gone.

 

[NDcienporciento100]

One last thing which I think is borderline criminal in modern medicine is landmark guided IJ!! It makes make me want to scream why!!! The ultrasound is literally right next to you. I think it’s a surgery mocho thing just by a dartboard take it home and blindfold yourself and start throwing tell you hit the bullseye.

 

[metzthatcut]

Dude, what program are you in that, in 3 months, has turned you into such an enlightened soul that you can drop such huge knowledge bombs on all of us dumb scalpel jockeys.

Please give us more insight on how to prioritize the severity of complications on our older frail patients because of your vast experience in taking care of the critically ill. No, not all of our patients are on broad spectrum antibiotics. Guess what, some of our patients cannot get DVT ppx. Guess what, that does not mean patients are not at risk. Sounds like you need to spend some more time in the ICU, bud.

Surgeons need to be able to place subclavian lines. When you are the last resort, you pretty need every option at your disposal. Because do you what we are NOT doing when a crashing trauma patient comes in needing central access? Calling IR.

 

[LucidSplash]

Hello IR intern. I’m a Vascular attending.

Everyone needs to know how to do both. But the above posts are correct in that trauma sees a fair amount of SC CVL due to c-collar And infection risk. Also, they are easier to keep clean on a patient in the unit. Spend some time in the ICU and you’ll find those IJ lines covered in drool and sweat on your intubated patients.

And as for your semi-rant about PTX, you’ll find that the adage is true “if you’ve never had a complication, you haven’t done enough of that procedure.”

I do prefer ultrasound for all IJ and femoral access. But if the patient is coding and needs an emergent line, I can and will put it in without an ultrasound.

And as much as I love a SC CVL, I avoid them now as they are associated with SCV stenosis in HD patients, which is a concern in my patient population. But sometimes you gotta do what you gotta do.

But can you please walk a little before you run? Especially here in the Surgery forum.

 

[Lord.C]

It's all about money man. Lines are simple to place yet lucrative regardless the operator is IR or surgeon. But to be honest, for non-emergent purposes ie chemotherapy, I highly recommend IRs placing those, as the learning curve for radiologist is much more optimistic than surgeons. Not even to mention fewer staff needed and less sedation for the patient.

 

[NDcienporciento100]

It's all about money man. Lines are simple to place yet lucrative regardless the operator is IR or surgeon. But to be honest, for non-emergent purposes ie chemotherapy, I highly recommend IRs placing those, as the learning curve for radiologist is much more optimistic than surgeons. Not even to mention fewer staff needed and less sedation for the patient.

Central lines are the easiest procedures IR does.

 

[Gastrapathy]

Man, surgeons are kinder and gentler than they used to be.

 

[LucidSplash]

It's all about money man. Lines are simple to place yet lucrative regardless the operator is IR or surgeon. But to be honest, for non-emergent purposes ie chemotherapy, I highly recommend IRs placing those, as the learning curve for radiologist is much more optimistic than surgeons. Not even to mention fewer staff needed and less sedation for the patient.

Lucrative? 1.75 wRVU for a non-tunneled CVL age >5 isn’t what I’d call lucrative. And how is the learning curve more “optimistic” for IR vs surgeons? I put in about a billion of these as a junior resident. Fewer staff and sedation? Non tunneled line requires me only and some local.

Tunneled line >5 no port 4.59 wRVUs. Also needs only local.

Not sure what you’re going on about.

 

[LucidSplash]

Central lines are the easiest procedures IR does.

They are the easiest procedure that almost anyone procedural can do. Though remember watching medicine resident flail trying to put one in for like an hour in the same time I tossed in 3 as a resident on SICU.

 

[Radetzky]

Subclavian vein stays patent better when you’re bleeding out, easier to do when there’s a c collar and a fat pannus

Ultrasound is only safer if you know how to visualise the needle tip properly. Seen people go through the back wall but falsely reassure themselves they haven’t, seen people pointing the needle in all sorts of godawful directions because they’re staring at the screen and aren’t looking at what they’re doing.

 

[dpmd]

Lucrative? 1.75 wRVU for a non-tunneled CVL age >5 isn’t what I’d call lucrative. And how is the learning curve more “optimistic” for IR vs surgeons? I put in about a billion of these as a junior resident. Fewer staff and sedation? Non tunneled line requires me only and some local.

Tunneled line >5 no port 4.59 wRVUs. Also needs only local.

Not sure what you’re going on about.

IR bills for imaging stuff in addition to the procedure which increases the reimbursement. Plus they do no preop or postop care for it which means less overhead and better money to work ratio for them. Because guess who gets called for the complications (as I am sure you already know).

 

[Dr.LeoSpaceman]

IR bills for imaging stuff in addition to the procedure which increases the reimbursement. Plus they do no preop or postop care for it which means less overhead and better money to work ratio for them. Because guess who gets called for the complications (as I am sure you already know).

Onc MD: "Yeah, we have a consult here for an infected Powerport."

Me: "Ok, did I/we put it in?"

Onc MD: "No, but IR says they're busy this weekend and don't think they can get to it."

Me: "OK, I'll take care of it."

Also, let me just say that the other day I was in the middle of a Whipple, and somewhere around the associated vein resection I thought to myself: "You know, I'm glad I'm not putting in a port today. Otherwise I might be a little bit stressed."

 

[LucidSplash]

IR bills for imaging stuff in addition to the procedure which increases the reimbursement. Plus they do no preop or postop care for it which means less overhead and better money to work ratio for them. Because guess who gets called for the complications (as I am sure you already know).

Agree with the postop care bit. But I bill for the imaging when using fluoroscopy putting in ports or tunneled lines. If you’re not you should be.

 

[dpmd]

Agree with the postop care bit. But I bill for the imaging when using fluoroscopy putting in ports or tunneled lines. If you’re not you should be.

I definitely am, that 10 or 12 bucks pays for my fluoroscopy license if I do it enough. My understanding is they bill some other code that we can't that pays much more. It could be just a fake rumor I suppose

 

[OrganRepo]

I definitely am, that 10 or 12 bucks pays for my fluoroscopy license if I do it enough. My understanding is they bill some other code that we can't that pays much more. It could be just a fake rumor I suppose

How would you be restricted in a code? You can literally code it anyway you want doesn't mean they will pay it.

 

[dpmd]

How would you be restricted in a code? You can literally code it anyway you want doesn't mean they will pay it.

The rumor is that IR will get reimbursed for stuff that I as a surgeon wouldn't. But like i said, could be a fake rumor.

 

[Cowy1]

9/10 it is IR dealing with other docs complications, not the other way around. If your IRs are refusing to see their ports etc postop that is crap; I wouldn’t touch that unless the doc in question asked personally. No reason for you to get dumped on.

 

[SpliceOfLife]

Some very sick patients will have multiple lines between a PICC, tunneled lines for chemo, HD access, etc. Some people have been instrumented a lot and will need new sites because of thrombus or stenosis. Femorals I don't mind but some people see them as dirty.

Surgery is all about seeing new things, no matter how rare. You always need to be able to have a plan B or the have the option to do something you've seen only once or twice in training. Hopefully your intern year in surgery teaches you that.

 

[NDcienporciento100]

This thread gained more attention then I would have thought.

 

[deleted50541]

This thread gained more attention then I would have thought.

If you ask folks about central lines in a surgical forum, you're gonna evoke some passionate responses. It was a frequent topic of debate in my training. Who's putting them and who's best trained to do it? Where's the best site? Who's responsibility is it when a complication arises? Et cetera.

I wouldn't say we had an "obsession" with placing subclavian lines. It was considered an essential skill to have along with placing IJ and femoral lines. Considering the majority of the our central lines were being done during our trauma rotations when many folks had c-collars on, that was the go to site most times. I definitely took pride in mastering the subclavian line and teaching those under me the same.

I didn't initially train with an ultrasound either and learned all lines by landmarks. Obviously, that's changed and it's practically impossible now to justify a line complication if an ultrasound is not used. These days I do prefer to use an ultrasound, especially from my cardiac training where almost everyone had an IJ introducer in for a PA catheter.

 

[LucidSplash]

This thread gained more attention then I would have thought.

You came to a surgery forum with a thimbleful of knowledge and a swimming pool of confidence in your perspective and proceeded to tell a bunch of people with more experience than you they needed to only do things a certain way.

WTF did you think was going to happen?