the 100% directionless thread

[VentMonkey]

I got stung by a wasp once. Mean sumbitch. Over and over. Probably a Murder Hornet. Eh, we’re all gonna die. The news never lies.

 

[silver]

Still not a Cordis, doe’.

I got a kick out of watching a senior resident watching their junior resident place a triple lumen on some clinicals a few years ago.

Everyone has their moments. I may have stuck the carotid on one of my first lines, this cannot be confirmed or denied.

 

[Peak]

I got a kick out of watching a senior resident watching their junior resident place a triple lumen on some clinicals a few years ago.

Unfortunately procedural competency is a struggle for many, even years or decades after residency/fellowship.

 

[DragonClaw]

Unfortunately procedural competency is a struggle for many, even years or decades after residency/fellowship.

I Google this and it's just got 3 pigtails for different things. What's the deal on it? (What's the issue about placing one)

 

[Peak]

I Google this and it's just got 3 pigtails for different things. What's the deal on it? (What's the issue about placing one)

Many IV medications are not compatible with each other, so if for instance you want to run an albumin drip, bicarb drip, and pressors you would need three different lumens. Each lumen on a central line will have a slightly different infusion port.

Typically the cause of most difficulty is in placing the needle or angio so that you can then place the wire. With a left subclavian, or right IJ you will almost always terminate in the VC, placement in the right subclavian or left IJ is much more difficult.

Care must be taken as attempted jugular placement can result in carotid artery placement, which is technically considered a surgical emergency (although vascular will almost always tell you to just hold pressure and watch the patient). Subclavian placement risks puncture of the plura and potentially some pretty decent pneumothorax.

Femoral placement is typically much lower risk, however these lines do not actually terminate in the cavoatrial junction. They are also at high risk of infection due to obvious anatomical considerations.

PICCs tend to be safer to place as the risks tend to be lower, but they are much more size limited. They present a very real risk of clot formation as the peripheral vasculature is much smaller and the line can obstruct a fair bit of the line. PICCs tend to be lower infection risk as while they are not truely tunneled like we would think of something like a broviac, they do tend to have a bit more tissue between the vein and the skin.

 

[DragonClaw]

Many IV medications are not compatible with each other, so if for instance you want to run an albumin drip, bicarb drip, and pressors you would need three different lumens. Each lumen on a central line will have a slightly different infusion port.

Typically the cause of most difficulty is in placing the needle or angio so that you can then place the wire. With a left subclavian, or right IJ you will almost always terminate in the VC, placement in the right subclavian or left IJ is much more difficult.

Care must be taken as attempted jugular placement can result in carotid artery placement, which is technically considered a surgical emergency (although vascular will almost always tell you to just hold pressure and watch the patient). Subclavian placement risks puncture of the plura and potentially some pretty decent pneumothorax.

Femoral placement is typically much lower risk, however these lines do not actually terminate in the cavoatrial junction. They are also at high risk of infection due to obvious anatomical considerations.

PICCs tend to be safer to place as the risks tend to be lower, but they are much more size limited. They present a very real risk of clot formation as the peripheral vasculature is much smaller and the line can obstruct a fair bit of the line. PICCs tend to be lower infection risk as while they are not truely tunneled like we would think of something like a broviac, they do tend to have a bit more tissue between the vein and the skin.

.... I really appreciate this answer and I feel like I just got a drink out of a firehose.

Infusion port
Angio -
Wire
VC-Vena Cava?

So basically he was trying to put a needle into a spot that was more high risk than needed?

Also what's the difference of an IJ vs EJ for use. Can you tell which is which by looking at the needle?

I think it was an EJ removed from this lady. A nurse couldn't remove it per protocol. The regular Dr was out so an OB resident removed it.

It had sutures, right lateral neck. Really long and floppy catheter, not nearly as stiff (I haven't felt a catheter so I dunno if that's even what I'm describing) looking as say a 20 Ga peripheral IV.

 

[Peak]

.... I really appreciate this answer and I feel like I just got a drink out of a firehose.

Infusion port
Angio -
Wire
VC-Vena Cava?

So basically he was trying to put a needle into a spot that was more high risk than needed?

Also what's the difference of an IJ vs EJ for use. Can you tell which is which by looking at the needle?

I think it was an EJ removed from this lady. A nurse couldn't remove it per protocol. The regular Dr was out so an OB resident removed it.

It had sutures, right lateral neck. Really long and floppy catheter, not nearly as stiff (I haven't felt a catheter so I dunno if that's even what I'm describing) looking as say a 20 Ga peripheral IV.

Each lumen is going to be dedicated all the way to where it infuses into the blood stream. So at the tip of a central line (but not necessarily a PICC) each lumen is going to terminate at a slightly different point. For example on an arrow brand 16 cm line the brown line is going to be the largest lumen and terminates straight out of the tip (the most distal). Each line afterwards will then terminate somewhat to the side and a 1/2 to 1 cm back from the tip of the catheter, this allows the infusions to mix with the blood in order to not pull the other medications out of solution. Typically a PICC has seperate lumens all the way to the distal tip but they all terminate at the same point as the PICC is trimmed to length on insertion.

In seldinger technique you traditionally use a needle to access the vessel and then use a guide wire through the needle. Some of us cheat a bit by using an angiocath (still under full sterile technique) instead of a needle as once I place the angio I don't have to worry about going through the back wall of a vessel and I don't have to hold it perfectly still, I can essentially hub the angio and then only have to worry about advancing the wire. A 20 gauge will work with adult sized wires, a 22 with peds sized wires, and we have 24 gauge peel away introduces (which essentially skip the needle and wire bit) for neo PICCs.

VC- Vena cava, IVC- inferior ven acava, SVC- superior vena cava.

It isn't that the spot is more risky than needed, but that some procedures inherently carry more risk than others but also have different benefits. Central lines do typically carry more risk than peripheral access. You shouldn't be giving pressors, TPN, chemo, or many other vesicants through peripheral access.

Vascular anatomy is not always like a textbook. By the textbook definition the EJ branches off of the common jugular or subclavian vein, originates under the clavicle, and will pass over the sternoclavicularmastoid and back up under the jaw/ear. Because it has such a large muscle and a fair bit of fascia underneath it is pretty low risk as you have to be quite incompetent to enter the plura or damage the riskier anatomical structures (arteries, nerves, airway, esophagus, et cetera), although there are certainly case studies that prove that people are idiots and will attempt procedures that they are in no way competent to perform.

Not all patients will have an appreciable EJ or one at all, or it may branch off of the IJ very proximal. Some patients will essentially have a double IJ. Many patients will have other accessory vasculature in the neck which can be safely accessed with a peripheral cannula but are not by definition the external jugular vein.

It is very rare to use the EJ to place a central catheter, it takes a pretty sharp turn under the clavicle which makes passing a wire and line difficult. It is also typically much smaller than the IJ increasing the risk of clots. The IJ should not be routinely used for peripheral access, although there is some good literature that supports the placement of a single lumen peripheral IV into the IJ when other peripheral access cannot be found, I would not expect this in the field especially with the ease of placing an IO.

Central catheters need to terminate in the central vasculature by definition in order to be a central line. In practice this means that we would expect placement in the SVC, IVC, cavoatrial junction, or occasionally (and not ideally) it may terminate in the atria. If the line passes the tricuspid it must be pulled back. Often we will accept lines that are too short and terminate in the brachiocephalic vein if they originated distal to that vein and are just too short (for example in a hubbed PICC that the inserting clinician estimated to be shorter than the needed lenght), however this is not ideal.

How an IJ was approached can alter where it is inserted on the skin. I find in my practice that I insert very proximal to the clavical as there is less fascia to go through and I find dilation and line placement easier. Some clinicians prefer this long tract before they enter the vessel for reasons I don't fully understand, I think they believe it gives them a larger margin of error, but considering how often they go through the back wall I would say that this isn't exactly true. I would say it isn't uncommon to find IJs placed halfway up the neck, and on patients with more adipose tissue it may appear more lateral than where it actually enters the vessel. I also use ultrasound guidance on 100% of my insertions and I won't attempt insertion if I can't identify all of the anatomy, so I don't have as large concern for hitting the thyroid or inserting at a more acute angle than those who attempt blind or semi-blind.

Nursing scope of practice varies by state and protocols vary by hospital. I have a larger scope of practice in my state than almost any other, and I have to watch myself when I go to other states. There is not a state limitation on removing central lines here (or EJs for that matter) as long as it is considered part of the standard scope of practice and the RN is correctly trained in it.

Most central lines are pretty flexible. Introducers like a Cordis, HD lines, and hard arterial lines are pretty rigid but being gentle is generally your friend in medicine.

 

[StCEMT]

14's whether extremities or in the chest. Although we took 14's off the truck, so 16 is as big as I can go for IV's now.

 

[Peak]

14's whether extremities or in the chest. Although we took 14's off the truck, so 16 is as big as I can go for IV's now.

I'm crying for you. How long are your 16s?

 

[DragonClaw]

Peak, I need to sleep before I process a of that. But I will.

The last time I was in the hospital (I was an adult), I had to get some diagnostic tests. They gave me 22 gauge in the forearm. I didn't have big veins. They poked me like 5-6 times with a 20 or 18 before they gave up.

 

[StCEMT]

I'm crying for you. How long are your 16s?

Yea, apparently they looked at the use and believed they were being used inappropriately too often. I didn't see the info or the patients so I'm not sure how true that is. I know I've done some unorthodox **** before. I don't agree with it, I would try to have bilateral 14's for those trauma patients I knew were MTP worthy. But we also have a tendency of taking useful things away because a small population misuses it instead of dealing with the problem children so....

I believe they're 1.25".

 

[Peak]

Yea, apparently they looked at the use and believed they were being used inappropriately too often. I didn't see the info or the patients so I'm not sure how true that is. I know I've done some unorthodox **** before. I don't agree with it, I would try to have bilateral 14's for those trauma patients I knew were MTP worthy. But we also have a tendency of taking useful things away because a small population misuses it instead of dealing with the problem children so....

I believe they're 1.25".

Idk about your agency but the local 911 group here places a LOT of 14s for ‘trauma’ but will then take them to a level III or IV and who don’t meet alert criteria anyway. There is certainly misuse, but also clearly by a small number of medics (who will also bring in patients with EJs who have ropes on their forearms). The problem children are certainly a easily identifiable group here.

That being said, needle decompression and tourniquet placement are two of the biggest life savers that can be applied in the prehospital environment, and ain’t any 1.25” making through the average fat American.

I’d even go so far as to say I’d be okay (not thrilled by any means) to take 14s off the table for IVs, but a 3-5” 14 at the 5th mid axillary can legit save a life.

 

[StCEMT]

Idk about your agency but the local 911 group here places a LOT of 14s for ‘trauma’ but will then take them to a level III or IV and who don’t meet alert criteria anyway. There is certainly misuse, but also clearly by a small number of medics (who will also bring in patients with EJs who have ropes on their forearms). The problem children are certainly a easily identifiable group here.

That being said, needle decompression and tourniquet placement are two of the biggest life savers that can be applied in the prehospital environment, and ain’t any 1.25” making through the average fat American.

I’d even go so far as to say I’d be okay (not thrilled by any means) to take 14s off the table for IVs, but a 3-5” 14 at the 5th mid axillary can legit save a life.

All the times I saw them were for GSW's and things of that nature, but it sounds like we were doing similar. Although I do anywhere between 1-5 EJ's a month, so I can't say much there. I've just found it's simpler on the OD's and diabetics with trashed arms and good skill maintenance for the medical patients that I need a line in. Between those 3, it's become a common go to.

We still have 14's for needle decompression. We have those North American Rescue ones that look like pens. Those are 3.25". It's just for IV access that we took them out.

 

[VentMonkey]

We still have 14's for needle decompression. We have those North American Rescue ones that look like pens. Those are 3.25". It's just for IV access that we took them out.

Ours are 10g 3 n’a ko-tuh.

 

[Jim37F]

n’a ko-tuh?

 

[VFlutter]

n’a ko-tuh?

Pronounced "And a quarter" aka 3.25 in

 

[Jim37F]

Meanwhile my nerd brain was thinking some form of klingon

 

[CALEMT]

Pronounced "And a quarter" aka 3.25 in

Hey, you know what they say... See a broad, to get that booty yak 'em. Leg 'er down 'n smack 'em yak 'em. Cold got to be. You know? Shiiiiiiit.

 

[NomadicMedic]

Cut me some slack, Jack! Chump don' want no help, chump don't GET da help!

 

[ffemt8978]

Pronounced "And a quarter" aka 3.25 in

Looks like tonight is a Don't Call Me Shirley marathon.