HWN Suggests

Ultrasound for central line placement: crucial, or just a crutch?

Ok, so let me preface this with the fact that I walk around with a handheld ultrasound rather than a stethoscope, and that I examine ALL patients with a focused cardiopulmonary and abdominal exam. My bias towards bedside ultrasound is ridiculously huge. I think practicing without it, once the skill is acquired, is unethical.

Having said that, I have an issue with the fact that it now seems to be “standard of care” for all lines to be ultrasound guided.

Hmm…here are the problems as I see them:

1. I have come across junior staff intensivists who have never inserted a jugular or subclavian catheter without ultrasound, using landmark techniques. That is an utter shame…

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Featured

  Ultrasound-Guided Central Line Placement Made Easy: Step-By-Step Guide

Central line placement is an essential tool health providers must learn to care for critically ill patients. Using ultrasound to guide your central line placement can reduce the time needed to complete the procedure, the number of mechanical complications, and the number of catheter misplacements (McGee, D., Gould, M.). So why doesn’t every central line placement include ultrasound guidance? Well, often, beginners or those needing a refresher find it challenging to find a relevant, descriptive, yet concise step-by-step guide on how to perform an ultrasound-guided central venous line (CVL) and central venous catheter (CVC) placement. Luckily, you have come to the right place!

  Central Lines: Tips You Can't Miss

Central venous catheter placement is among the core skills and procedures required in the field of emergency medicine and intensive care. Early learners are taught the basics of central line placement in the appropriate setting and gain proficiency throughout residency training, but as any experienced physician knows, proficiency does not equal expertise.

  Easy IJ

Learn how to place a central line. By the end of this video, you'll master the Easy IJ technique for rapid internal jugular vein cannulation.

 Central Line Micro-Skills

Breaking down the pieces of the seldinger technique for deliberate practice

 Unlocking Common ED Procedures: Never Let Go – A Review of Central Venous Access Placement

This article will focus on the placement of CVCs including indications, contraindications, site choice, and complications. In addition, we will discuss the current literature behind the insertion site options and when pathophysiology should play a role in this decision. Since there are a variety of approaches and subtypes of catheters that can be placed depending upon the clinical scenario, the conclusion of this article will specifically review the placement of an internal jugular triple lumen catheter. Further posts under this broad overview will continue to discuss alternative approaches and catheter subtypes.

Articles of Interest

Central Line Part 1: The Basics

In this first installment on central lines, we discuss central line indications/contraindications/alternatives, anatomic considerations, and the upsides and downsides of the 3 major sites (subclavian, internal jugular, and femoral).

Central Line Part 2: Technique & Procedural Steps

Here we focus on technique and procedural steps. Enjoy.

General Tips on CVC insertion

When cannulating the vein be aware of the bevel position in order to direct the guidewire into the desired position. Eg. Bevel should be facing towards heart with subclavian insertions. With subclavian and IJ insertions be aware that the guidewire need not be inserted to its full depth and may irritate the myocardium causing arrhythmias.

Advanced Critical Care Ultrasound: Subclavian Central Venous Access - Dealer's Choice

When deciding which of the three typical sites (internal jugular, femoral, and subclavian) to choose for central venous access, much can go into the site selection. Infection rates, risk of bleeding, risk to surrounding structures, incidence of deep venous thrombosis (DVT), and specific complications such as pneumothorax are all things to consider.

Approach to Difficult Vascular Access

Most patients do well with a simple, landmark-based, blind placement of a superficial peripheral IV. However, we often encounter situations where this may be difficult or impossible to achieve, and so we all should have a repertoire of other sites and techniques to employ.

Central Line Placement

In emergency medical practice, there are three possible sites for CVL placement in the adult patient. Each has advantages and disadvantages. The placement sites include the internal jugular vein, femoral vein, and subclavian vein. The right internal jugular vein and left subclavian vein are the most direct paths to the right atrium via the superior vena cava. The femoral veins are compressible sites and as such may be more appropriate for coagulopathic patients.

Femoral Vein Central Venous Access

When obtaining the central venous access in the femoral vein, the key anatomical landmarks to identify in the inguinal-femoral region are the inguinal ligament and the femoral artery pulsation. In most instances, central venous access with ultrasound-guidance is considered the standard of care. Nevertheless, the understanding and use of anatomical landmarks are equally important and when used in combination with ultrasound guidance, lead to increased success.

Learning to do Central Lines

While there is no substitute to actually performing a procedure there are many online resources that should serve as a primer for this procedure and I'd recommend watching them before attempting your first CVC, and then re-watch them after the first few to get better at the procedure.

Needles or Port? A Cancer Patient Decides

The first question many cancer patients are asked at a doctor’s office or an infusion center is “Do you have a port?” I shake my head no, but add the words “not yet.” To port or not to port...

Pearls, pitfalls, tips and tricks for procedures: Part 1

If the artery cannot be felt, place a thumb on the pubic symphisis and index finger on ASIS, and use the apex of the V-shape of your 1st web space to find the femoral artery, then move 1cm medial at level of inguinal ligament. The optimal position is usually with the hip in external rotation & abducted.

Positively bloody!

….as in positive blood return when aspirating from central venous catheters (CVC). Positive blood return means a free flowing blood return easily obtained on aspiration, and the color of whole blood. In other words, bloody RED, not pink-tinged. What a great feeling, knowing that the CVC is properly functioning and ready to use.

Q&A: Tips to improve IV insertion skills

Here are some tips I find helpful when peripheral veins are hard to find.

Tricks of the Trade: A-Line Kits for Vascular Access

Ever struggle with vascular access? Ever tried a 20G A-Line kit? Even if you have, once a flash is obtained it is common to not be able to thread the wire. If you pull the needle out of the catheter, it is rigid and difficult to replace in the catheter and rarely results in salvaging the attempt.

Ultrasound Guided Subclavian Line Pearls

The CDC prefers a subclavian site as opposed to jugular vs femoral in adult patients to minimize infection risk. Also, the clinical scenario may preclude you from using the typical IJ or femoral sites (think trauma situations with c-spine immobilization, pelvic fractures, etc).

Which position is safest for central line placement: subclavian, jugular, femoral? (3SITES)

Where to place a central venous catheter is a decision driven mainly by individual experience and preference. The limited evidence available has not established any site as superior; the subclavian position has been reported as being less infection-prone, but more likely to cause pneumothorax, compared to other sites. A large French randomized trial adds significantly to the evidence base.

Resources

4 Good Lab Values From Intraosseous Blood - And Some Not So Good Ones Too

The intraosseous access device (IO) has been a lifesaver by providing vascular access in patients who are difficult IV sticks. In some cases, it is even difficult to draw blood in these patients by a direct venipuncture. So is it okay to send IO blood to the lab for analysis during a trauma resuscitation?

EMCrit Project

In the ED, there are only two ways to place central lines: Full Sterile or Non-Sterile There is no in-between. Sometimes (hopefully rarely), the exigencies of time or patient condition will prevent placing a full sterile line. This is acceptable so long as you inform the accepting service that the line is not full sterile.

Femoral

In this educational video you will see a demonstration of the ultrasound guided Ultrasound Guided Insertion of a Femoral Vein Catheter.

IJ

Ultrasound guidance for central venous access.

Subclavian

Placement of subclavian central venous catheter (central line, CVC).

AccuVein

Vein Illumination is revolutionizing venipuncture with AccuVein's award winning solution. In venipuncture, you have very little margin for error. Imagine how much more effective you'd be if you could visualize veins that are beneath the skin.