Losing Blood Flow: This commonly occurs after successful aspiration of venous blood flow with a finder needle with subsequent loss of blood flow before threading the guidewire. Ultrasound confirmation in 2 planes has been shown to have 100% sensitivity and specificity for confirmation of venous system placement. It has been shown that inexperienced physicians have a high rate of posterior wall penetration and arterial system cannulation (3)Īfter placement of the guidewire, take advantage of the ultrasound already nearby to prove proper vessel placement from skin to central circulation. Additionally, blood color is not always reliable to differentiate arterial vs venous blood in hypoxic states. These are general skills that can be applied to all central line types and positions.Ĭonfirmation of Location: Even under ultrasound guidance, artifacts and misalignment of the probe may give false reassurance that you are in the vessel lumen or the right vessel. Line Placement Skills and Problem Solving: Now that you’ve done 90% of the work setting up everything to optimize the line placement, it is still important to remember the small things during the procedure to prevent procedure failure. This allows you to reach across their body to the insertion site to maintain a more comfortable and natural body position throughout the procedure. When placing a line opposite of your preferred side, position the bed lower and slide the patient closer to you. This often happens due to anatomical considerations or saving a site for future procedures (cardiac cath, ECMO, dialysis catheter sites). Practitioners will often place central lines on the patient side that matches the practitioner's own hand dominance, however, situations may arise where the opposite side needs to be accessed. In the femoral approach, this can help mobilize redundant abdominal tissue and open up your site of access. (1, 2)įor the internal jugular approach this position will help plump up your target vessel, which is especially helpful in volume depletion with small or easily collapsible veins. This is particularly helpful for rapid peripheral volume resuscitation that is even faster than a cordis. When placing these lines, be sure to have heparin flushed caps to maintain patency of these large central lines rather than standard central line caps flushed with saline.įor patients with an established PIV and a vein moving proximally in a straight line, the PIV can be converted into a wide bore peripheral line. Patients may present with such severe metabolic derangements or poisonings that they may need emergent dialysis via HD or CVVH. This is also a catheter that can accommodate a transvenous pacer when transitioning from transcutaneous pacing depending on your procedure kits available. Conveniently, a triple lumen catheter can be placed through an introducer sheath (ex Cordis) if multiple central access points are needed during resuscitation. This is the central catheter of choice in hypovolemic shock and most commonly used for volume resuscitation in massive hemorrhage. In a crashing patient without adequate access, an IO line may be your best option. Patients who are intravascularly depleted may present with difficult IV access. IO lines are quick with multiple potential points of access. Thus, procedural mastery beyond the basics is essential for any practicing intensivist.Īlthough central venous catheter placement is a standard skill of emergency medicine physicians and is versatile in many resuscitations, don’t forget that there are numerous other ways to obtain access that may be more appropriate than the standard triple lumen catheter. As with any procedure, there is situational, positional, and anatomic variability that may lead to unexpected difficulties during central line placement. 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. Written by Dr Jeremy Riekena, Edited by Dr David MischĬentral venous catheter placement is among the core skills and procedures required in the field of emergency medicine and intensive care. A collection of advanced central line considerations for intensivists.
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