Central Lines Prehospitally

[Handsome Robb]

What's the benefits? What's the risks? If you're system is placing them, when and why are you doing it? What criteria/protocols do you have for them? Where are you placing them, only IJs or are you using other sites? Are you rural, suburban or urban?

From recent posts it seems like they're placed in cardiac arrests or "anyone who needs one" in a certain system. With that said, what's the preferred route of medication administration in cardiac arrests? It's peripheral IV not central line. They don't even use them in the hospital during arrests. Are they being placed. In criticsl trauma patients? If so, why? What's the point? That person doesn't need a paramedic who can place a central line, they need a trauma surgeon, their team and a hospital. How long are transports being delayed while a central line is laced on scene?

Are there any studies out there supporting their placement in the field in regards to morbidity/mortality? I googled it briefly at work but we were slammed and I didn't have time to find anything of any value.

Are you using the to monitor CVPs? If so, what's the benefit and is it going to change your treatment?

Do the hospitals leave them in place or pull them? If they're immediately pulling them what's the point of even placing them and exposing the patient to the risk of infection? Not only have you created a much larger infection risk for the patient but you've also used a site that the hospital could have used for a line that was placed in a proper sterile field that can be utilized for an extended period of time.

I'm not trying to start a fight, I'm truly curious . I don't know a ton about them or the benefits vs risk in the emergency setting. What makes them so much better than a peripheral IV (including EJs, yes they're peripheral) and IOs?

Like I said, I just want to know. We are allowed to access them if a patient is in extremis but even then we are still looking for other points of access then switch to using that as soon as we get one.

Ready, set, go!

 

[Ecgg]

The following landmark study "An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU" was conducted in ICUs in Michigan. They were losing money heavily and had to find a solution.

This accompanied Appendix list the dangers if proper procedures are not followed.

Appendix A
Catheter-Related Blood Stream Infections
(CR-BSI) FACT SHEET​

Bottom line
1. CR-BSIs are associated with increased morbidity, mortality and costs of care.
2. CR-BSIs are a preventable complication that causes as many as 11 deaths every day in the
U.S.
3. The following interventions decrease the risk for CR-BSIs:
• Appropriate hand hygiene,
• Use of chlorhexidine for skin preparation,
• Use of full-barrier precautions during central venous catheter insertion,
• Subclavian vein placement as the preferred site, and
• Removing unnecessary central venous catheters.


Wash your hands before inserting a central venous catheter
Bottom Line: Proper hand hygiene is required before and after palpating catheter insertion sites, as well
as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. In
addition, the use of gloves does not obviate the need for hand hygiene. Category IA
Since 1977, at least 7 prospective studies have shown that improvement in hand hygiene significantly
decreases a variety of infectious complications. Proper hand-hygiene procedures can be achieved through
the use of either a waterless, alcohol-based product (1) or an antibacterial soap and water with adequate
rinsing (2). Compared with peripheral venous catheters, CVCs carry a substantially greater risk for
infection; therefore, the level of barrier precautions needed to prevent infection during insertion of CVCs
should be more stringent than proper hand hygiene alone.
Ref:
1. Pittet D et al. Lancet 2000;356:1307–9 2. Larson EL et al. Am J Infect Control 1995;23:251–69

USE OF FULL-BARRIER PRECAUTIONS DURING CVC INSERTION
Bottom Line: Maintain aseptic technique for the insertion of intravascular catheters. Category IA
Maximal sterile barrier precautions (e.g., cap, mask, sterile gown, sterile gloves, and large sterile drape)
during the insertion of CVCs substantially reduces the incidence of CRBSI compared with standard
precautions (e.g., sterile gloves and small drapes). (5,6)

You can read the rest in the said Appendix.

 

[JPINFV]

Considering it's hard enough getting hospital based personnel to observe proper sterile technique for central lines... having EMS put one is while gloving, gowning, preping, draping, and doing it under truly sterile technique would be... interesting.

 

[VFlutter]

http://www.emtlife.com/newreply.php?do=newreply&noquote=1&p=477262

You can probably guess my stance on the topic from previous threads but I am absolutely against prehospitally placed central lines. In my opinion there is just no benefit and there are just as effective alternatives with less risks. Central lines are extremely useful in certain situations when properly placed and utilized however not every cardiac arrest or trauma patient need one. Actually relatively few do.

The ambulance is no environment to be placing central lines. Ideally CVCs should be placed with ultrasound guidance with full sterile precautions. There used to be a time when we would throw femoral CVCs in all cardiac arrest patients in the hospital. Even during a code they would still do a thorough betadine cleanse and use basic sterile precautions (gloves/mask). If the patient was resuscitated they would place a subclavian or IJ CVC the proper way and immediately pull the femoral. Now we just use IOs and peripherals.

*Disclamer: I am going off what I saw in a certain video. My assumptions could be wrong but I think it was pretty clear* Placing a central line in a "dirty" ambulance using non sterile gloves, no mask, no sterile gown or drapes and no betadine prep is absolutely inappropriate.

Any central line that is placed in an unsterile fashion will pulled as soon as possible. Most likely in the ER before the patient ever gets to the unit. So is it worth placing a central line that will only be used for a few hours? Especially with the effort needed to place them and the relative risks. Someone can try to convince me otherwise but I can not think of any situation where it would be necessary.

Risk vs Benefit: CVC are great because you have reliable access to central venous circulation. You can infuse large volumes of fluid and medications which will quickly be distributed. You can easily give medications (Chemo, Potassium, Pressors) that are caustic to peripheral veins. You can use a CVC for TPN, dialysis, or plasmaphersis. You can monitor CVP which is helpful however I do not think you would be able to get accurate readings in an ambulance due to movement artifact.

The major risks are infection, thrombus, arrhythmia, pneumothorax. CLABSI and sepsis is a major complication. To keep it short I won't go I won't go into all the statistics but there is a ton of data out there, especially from the Surviving Sepsis Campaign. Pneumos occasionally occur and happen more commonly with blind insertion without use of ultrasound. Thrombus either from the lines itself or DVT from the vein where the line originates is somewhat common if not anticoagualted. Ventricular arrhythmias are common but usually transient and resolve when the guidewire is removed.

Alternatives. IO's are much quicker, have less risks, and are pretty much as effective in a prehospital environment. Or just a large bore IJ would be comparable.

Bottom line: I do not see any reason to place a central line prehospitally. The risk does not outweigh the benefit and there are better alternatives. And as mentioned before the line will be pulled in the ER.

But it is a super cool exciting invasive procedure that you can brag about

 

[FLdoc2011]

I agree in that I don't see a need for prehospital central lines when an IO can fill the role of an emergency line much quicker and safer than placing a line in that environment.

I place them routinely in the hospital and the standard of care now is full body drape under sterile technique using ultrasound guidance (most for IJs). So right there that's not practically feasible prehospital.

Besides infections, I've seen pneumothoracies (even from experienced operators), arterial cannulations, and airway compromise from neck hematomas following central lines to name a few complications. Are you prepared to deal with those in a prehospital environment?

 

[Summit]

Echoing what others have stated above:
The benefits of a prehospital CVC over an IO are essentially nonexistant while the risks of a prehospital CVC over an IO are HUGE.

We don't even use CVCs for in-hospital codes except in the most extreme situation: blew two sternal IOs so anesthesia went gown/betadine/sterile glove/drape and did a femoral... the systemic solution was to switch the entire system to EZIO, so no more code CVC starts. If we have an in-hospital code and don't have existing access, we start an EZIO and we don't even bother with starting a peripheral .

 

[Ecgg]

I agree in that I don't see a need for prehospital central lines when an IO can fill the role of an emergency line much quicker and safer than placing a line in that environment.

I place them routinely in the hospital and the standard of care now is full body drape under sterile technique using ultrasound guidance (most for IJs). So right there that's not practically feasible prehospital.

Besides infections, I've seen pneumothoracies (even from experienced operators), arterial cannulations, and airway compromise from neck hematomas following central lines to name a few complications. Are you prepared to deal with those in a prehospital environment?

Pneumothorax? No problem. Needle thoracentesis, 2 invasive procedures back to back. It's all about hitting those numbers annually baby!


I have seen the above scenario play out often post resuscitation in the ER when residents were placing central lines via subclavian route with no ultrasound guidance. You can hear the needle lung puncture and the nurse going straight to get the chest tube kit.

 

[JPINFV]

Besides infections, I've seen pneumothoracies (even from experienced operators), arterial cannulations, and airway compromise from neck hematomas following central lines to name a few complications. Are you prepared to deal with those in a prehospital environment?

Also, in my limited observational experience as a med student, have seen atrial placements where the only "indication" that it was atrial in a severely hypotensive patient was provider gestalt followed by blood gas confirmation after they had already pulled it.

 

[Akulahawk]

Before the IO in adults came into more wide-spread use, I was a bit of an advocate for the prehospital placement of central lines. I'm not anywhere near as much an advocate for this as I was. Mostly I'm an advocate for being able to start a line in a vein that won't collapse, even in low-flow situations. The IO now fills that void (so to speak). Would it be nice to be able to place a central line? Sure. However, in the prehospital environment, such a start should be covered by ABX as soon as the patient gets to the ED. In my view, field IV lines should end up being done in this manner: peripheral → IO → Central Line (Like IJ or Subclavian). The whole thing should stop at the IO because most of the time, that's going to be successfully placed.

What do I want? Simple. Medication and fluid access. Nothing more, nothing less. Where I'm at, I would completely expect to never place a CL in the field because of the benefits of IO and risks of CL placement AND the proximity of hospitals. However, I feel that should a patient already have a central line in place, Paramedics should be allowed to access the line if IV access is needed.

 

[NomadicMedic]

When I worked in Washington, I was taught to place a subclavian CL. My protocols allowed placement of a CL. I never used it because I had access to an EZ-IO device. I'm of the belief that field placement of central lines should go the way of the PASG. There are easier, safer alternatives.

 

[Handsome Robb]

Seems like my train of thought is similar to the rest of everyone who has posted. Thanks for the responses.

Before the EZIO or even IOs in general I could see how a CVC would be useful and potentially have benefits that outweigh the risks. With that said, since the IO has pretty much wandered into nearly all EMS systems I don't see any reason to be placing them...a properly place and flushed IO will flow just fine, I've seen it with my own two eyes. Generally we will infuse a liter of NS in the first 10-15 minutes of an arrest with moderate pressure in the pressure bag. Crank the pressure up the flow rate goes up, to a point.

 

[Akulahawk]

When I worked in Washington, I was taught to place a subclavian CL. My protocols allowed placement of a CL. I never used it because I had access to an EZ-IO device. I'm of the belief that filed placement of central lines should go the way of the PASG. There are easier, safer alternatives.

I don't necessarily think that prehospital CL placement should go the way of the PASG... but it should be available in the event that you blow/are unsuccessful in peripheral line placement and your IO placement was similarly unsuccessful.

 

[VFlutter]

I don't necessarily think that prehospital CL placement should go the way of the PASG... but it should be available in the event that you blow/are unsuccessful in peripheral line placement and your IO placement was similarly unsuccessful.

In that situation I think a large gauge EJ/IJ would be sufficient without placing a central line.

 

[Aidey]

I don't necessarily think that prehospital CL placement should go the way of the PASG... but it should be available in the event that you blow/are unsuccessful in peripheral line placement and your IO placement was similarly unsuccessful.

I think it should depend on the system. I can understand it being used in a CCT/Flight situation working under an expanded scope.* With the EZ IO and the right needles you've got 6 sites to choose from. If your patient has none of those sites available, you've got bigger issues than venous access. At some point you have to realistically evaluate if it is necessary to spend so much time on venous access.




*As in an actual CCT environment. Not a flight agency with a couple add on meds.

 

[jwk]

In that situation I think a large gauge EJ/IJ would be sufficient without placing a central line.

An EJ is generally considered a peripheral IV, although it can be advanced into the central circulation with a long enough catheter.

An IJ by definition is always a central line.

 

[medicsb]

I don't necessarily think that prehospital CL placement should go the way of the PASG... but it should be available in the event that you blow/are unsuccessful in peripheral line placement and your IO placement was similarly unsuccessful.

Considering how rare this situation would be, I don't think you could ever justify the procedure due to infrequent practice. In my experience, plenty of medics forget that an EJ is peripheral and jump to an IO when they don't really need to.

 

[jwk]

I place them routinely in the hospital and the standard of care now is full body drape under sterile technique using ultrasound guidance (most for IJs). So right there that's not practically feasible prehospital.

Besides infections, I've seen pneumothoracies (even from experienced operators), arterial cannulations, and airway compromise from neck hematomas following central lines to name a few complications. Are you prepared to deal with those in a prehospital environment?

Full sterile barrier precautions is definitely the standard of care now, and US guidance is heading that way, although I still do my IJ's the old fashioned way. As with sticking an ETT in the wrong pipe, it's not a sin to hit the carotid with a finder needle or even the 18 ga needle/catheter used to place the guidewire, which I've done more than once. However, putting that 8-9FR introducer in big red will buy you nothing but pain and heartache. I've seen it twice, not by me thankfully, and it is quite impressive to see the resulting airway-compromising neck hematoma. (if by some chance you see someone do that, DO NOT pull out the catheter - call a surgeon). Pneumothorax from an IJ should be an exceedingly rare event, and in many studies, the incidence was 0%. Not the same with subclavians, where even successful placement in the SCV is associated with a fairly significant incidence of pneumo.

With all the restrictions and guidelines being placed on CVL use in-hospital, I can't see that it has a pre-hospital use any longer.

 

[FLdoc2011]

Even in hospital setting we have EZIO if needed for emergency access. Most of the time everyone already has at least a periph site but during a code or other urgent situation if that's not working we'll usually drill in an IO real quick.

Sometimes may do a quick femoral line but those are becoming more and more frowned on.

Really if prehospital providers are looking at a possible emergency access site for during codes then a femoral would make more sense since you can easily throw one in without interrupting compressions.

If you have time to properly do an IJ or subclavian then I doubt it's that urgently needed where an IO wouldn't suffice.

 

[46Young]

This thread is interesting. We discuss, ad nauseum at times, the desire to increase educational standards, with a reward of increased scope of practice. But here, we're scrutinizing the use of central lines in the pre-hospital environment. I've said, several times, that pre-hospital EMS has an upper limit on what is practical regarding education and scope. How far do we want to go? How much of an increased scope is appropriate when our real goal is treating the signs and symptoms of the patient's condition, ensuring their hemodynamic stability, and transporting to the definitive care of the ER? Where do we hit the ceiling, so to speak? Some agencies refer to their ambulances as "mobile intensive care units." I feel that this is going a little too far. In certain cases, we do similar work to what a patient will experience in an ER, but that does not mean that we should be able to do anything and everything that an ER can do initially. EMS does have its limits.

Based on this thread (I agree with the OP), central lines seem to be past that ceiling of reasonable pre-hospital interventions by paramedics. I feel that central lines in the field (when EJ's and IO's are an option) are relegated to a "gee whiz" status in pre-hospital care.

At some point, generally speaking, additional interventions become inappropriate in the pre-hospital environment when definitive care is readily accessible, and doing these interventions in the field has no positive effect on patient outcomes.

One more thing - this thread was motivated by the use of central lines by KCM1. If KCM1 were the average in pre-hospital care, EMS as a profession would have but a small fraction of the issues it currently has. We should applaud the relatively few quality EMS agencies, not pick them apart to the last minor detail. I ask all of you, if your employer put forth a recruitment video, which showed a few significant calls and testimonials from field crews and management, how would your department compare to KCM1? Not too favorably, for sure, in nearly all cases.

Try these videos on for size. The first one was made in 2004 or 2005, when I was working there as an EMT and in medic school. The second one is about NS-LIJ working in contract with Rockville Centre. Supervisor DeGeorge came in one class after me - great medic and great guy. What do you think about these videos?

http://www.northshorelij.com/hospitals/location/cems-videos













I've said

 

[JPINFV]

This thread is interesting. We discuss, ad nauseum at times, the desire to increase educational standards, with a reward of increased scope of practice. But here, we're scrutinizing the use of central lines in the pre-hospital environment. I've said, several times, that pre-hospital EMS has an upper limit on what is practical regarding education and scope. How far do we want to go? How much of an increased scope is appropriate when our real goal is treating the signs and symptoms of the patient's condition, ensuring their hemodynamic stability, and transporting to the definitive care of the ER? Where do we hit the ceiling, so to speak? Some agencies refer to their ambulances as "mobile intensive care units." I feel that this is going a little too far. In certain cases, we do similar work to what a patient will experience in an ER, but that does not mean that we should be able to do anything and everything that an ER can do initially. EMS does have its limits.

Based on this thread (I agree with the OP), central lines seem to be past that ceiling of reasonable pre-hospital interventions by paramedics. I feel that central lines in the field (when EJ's and IO's are an option) are relegated to a "gee whiz" status in pre-hospital care.

At some point, generally speaking, additional interventions become inappropriate in the pre-hospital environment when definitive care is readily accessible, and doing these interventions in the field has no positive effect on patient outcomes.

To quote a famous SCOTUS opinion in Jacobellis v Ohio, "I know it when I see it." No one is going to argue that EMS should be doing exploratory laparotomies in the back of the ambulance. However the line is always moving back and forth. In my mind, deciding on scope of practice is a two part test. First, given the time frame involved in the vast majority of cases, does this intervention improve some sort of outcome (decreased mortality/morbidity, decreased pain, increased provider safety, etc)? Second, given the skill of the average paramedic in the system, can it be performed safely? Probably the best example is RSI. Yes, I think an argument can be made that RSI is beneficial in some circumstances. Are all systems skilled and educated enough to implement it? Absolutely not.

Central lines, in my opinion, fails question number one when it comes to placing them in the field.

Try these videos on for size. The first one was made in 2004 or 2005, when I was working there as an EMT and in medic school. The second one is about NS-LIJ working in contract with Rockville Centre. Supervisor DeGeorge came in one class after me - great medic and great guy. What do you think about these videos?

http://www.northshorelij.com/hospitals/location/cems-videos

...Roll With It...