Podcast 157 – Central Lines II – Placement Tips - a podcast by Scott D. Weingart, MD FCCM
from 2015-09-13T22:43:22
Listen to Part I - Avoiding Complications
* Confirmation of Proper Placement
Micro-Skills and Deliberate Practice
Image from S. Rezaie
* You definitely need to watch the central line micro-skills video
Steps Of Central Line Insertion
* Go to the Central Line Page
Subclavian Insertion
* Go to the Central Line Page
Dilation
* The wire CAN'T BE ALLOWED TO ADVANCE
* I need to record dilator use as a microskill
* Move wire in out sequentially during dilation (racking the wire)
Internal Jugular
* Keep head in neutral not rotated for IJ (Journal of Emergency Medicine Volume 31, Issue 3 , October 2006, Pages 283-286)
Subclavian
* Subclavian is safe in mech vent pts (Anesthesiology:2009 – Volume 111 – Issue 2 – pp 334-339)
* Use lower shoulder position puncture site just lateral to mid-clavicular line [cite source='pubmed']15564937[/cite]
* Shoulder retraction (padding behind the back) was not helpful (Br. J. Anaesth. (2013) 111 (2): 191-196.)
* If you miss twice, consider abandoning the site (3 on a match)
Ambesh Maneuvers
* Finger in fossa technique to prevent guidewire malposition in subclavians (Ambesh SP, Anesthesiology. 2002; 97(2): 528-529.)
Checking Subclavian Placement after Catheter is In
* After subclav line placement, if you push on IJ and CVP increases 3-5 mmHg then the lumen is in the IJ instead of the SVC (Anesthesiology 2002;97(2):528), IJ occlusion test (Anesthesiology 2001;95(6):1377) and (Anesthesiology 2006;105(5):1062-1063)
Can We Place Central Lines in Anti-Coagulated Patients?
* Central line insertion while anti-coagulated seems safe and complications probably correlate with skill of physician (emerg med j 2011;28(6):536)
* Micropuncture Sets seem to be a very clever way to go
Guidewire Exchange
Guidewire exchange seems safe [cite source='pubmed']24004883[/cite] GWX-CVC’s and NI-CVC’s had similar rates of tip colonization at removal, CA-BSI and mortality. If the CVC removed by GWX is colonized, a new CVC must then be inserted at another site. In selected ICU patients at higher central vein puncture risk, guide-wire exchange may be an acceptable initial approach to line insertion.
Tips for Flushes
Drop a sterile 50 ml bag on to field; slash that bad boy with a scalpel. (Thanks Haney)
Update:
Chris Bond does an interview on hand motion analysis as a means of demonstrating expertise on the procedure
Further episodes of EMCrit Podcast
Further podcasts by Scott D. Weingart, MD FCCM
Website of Scott D. Weingart, MD FCCM