My apologies, had technical issues with the video uploading so here it is in two formats:
…please let me know if there is a problem!
thanks
Philippe
cvc
Central line insertion: US-spotted “Blind” technique video. #FOAMed, #FOAMcc
So a few months ago I posted about central line insertion and my concerns about the current standardization of care of ultrasound guidance:
I promised a video so finally got around to remembering to do it. This one actually happens to be a dialysis catheter so a bit bigger, but otherwise the technique is the same. In this case I am using my standard ultrasound-spotted procedure with “blind” insertion.
So here, I spot the vein, confirm it is just lateral to the carotid, and that it collapses nicely, without thrombosis:
Now, I insert the line. A few important points to note that are not seen in the frame:
Line Insertion video:
a. my introducer needle/syringe and loaded guide wire (pulled pack and “loaded”) are ready and within my vision, and also nearby are the dilator and catheter.
b. note that the off hand (right hand in this line) protects the carotid and stays in place until there is venous flashback, then secures the needle position.
Note that in this particular case, I didn’t quite make a large enough incision so the dilator insertion was a little difficult – unnecessary delay, and also unfortunately lost the last few seconds as my iPhone memory was full.
Next, I confirm position in the internal jugular vein, and verify for lung sliding to rule out and anterior/apical pneumothorax.
In me experience, the key mistake I see inexperienced operators (and sadly, some experienced ones also) make is not to have a proper setup, such that once they do find the vein with the introducer needle, their subsequent steps are not immediately ready, and in the process, the relationship between needle tip and vein is lost, resulting in an inability to thread the guidewire (often blamed on mysterious anatomical abnormalities). It is key to find the vein with the freezing/searcher needle, fix the depth/angle relationship in your mind, withdraw and reach for the introducer needle/syringe using peripheral vision so as not to break the visual fix, and reproduce this while introducing it.
This is what I try to install in students/residents rounding with me, and in fact this approach is useful for any procedure. Not having to turn your head, reach and fiddle with things that are not ready prevents mistakes.
If you haven’t read my previous post on central line insertion, I’m not advocating agains the use of ultrasound guidance, but for the maintenance of the ability to insert blind lines if necessary.
cheers!
Philippe
Ultrasound-guided central venous catheter insertion: standard of care or preventing procedural skills? #FOAMed, #FOAMcc
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 and worse, a possible disaster in an instance of technology failure (ie the ultrasound is out for repair, etc…). Intensivists who would be unable to put in a line???
2. I have been teaching bedside ultrasound for the last 5 years, and practicing it for over a decade. I teach ultrasound-guided line workshops. The ability to safely and properly follow a needle tip to venous puncture is an expert-level skill. I cannot count how many times a participant has sworn that his beam is right at the tip of the needle and been befuddled when I point to the blue phantom and show him how he is scanning just a bit beyond the hub and that the tip is in fact several centimetres into the blue phantom (better the phantom than the lung!). The problem comes from a false sense of confidence and security that the procedure being “guided” provides. I’ve already seen several carotid insertions and pneumothoraces with IJ and SC guided procedures…
3. The evidence is shabby in the following sense: if you look at the papers comparing blind to guided, the stats on the blind procedures are not exactly very impressive to start with (time and number of attempts)… Also, did all trainees who are out there doing guided procedures receive the same training that those in the study did? All residents with a probe are not trained/created equal, hate to break it to you…
So…what is my preference? I spot all lines, meaning that I scan both sides of the neck for jugular size, position relative to the carotid and anomalies. I then do the IJ line blind, unless it is particularly small or really anomalous (eg right on top of the carotid), then I would do it guided. I use ultrasound for ventilated subclavians.
In the interest of science I have timed myself and recorded stats. I can generally get a functional line (puncture to catheter insertion – not including suture time) in 60-90 seconds, with an average of about 1.1 punctures (eg 1 in 10 times I need to widthdraw and re-angle/puncture). Obviously this comes with about 18 years of doing central lines (since I was an R1), but I know I’m not the only one out there with this type of skill – there are a lot of CC/ED/anasthesia..etc docs who can do the same. But it does take practice.
My suggestion would be for trainees to spot the vein and keep a ready ultrasound probe (sheathed and sterile), and do a blind puncture. If they find it on a first pass, then great. If not, then go ahead with the ultrasound (but here I would hope that they would have had some good training in guided insertion and not just that given by a senior resident who’s done all of 5 lines…).
So I think that this is yet another example of N=1, in this case the 1 being the physician rather than the patient, and I think we are in a bit of a tough spot with these recommendations, as the skills will deteriorate in time, and within a generation there will be few if any physicians well-versed in landmark insertion, which would be a shame. It has served us well in the last decades and, unlike the stethoscope, I don’t think its time has passed…
let me know what you think!
PR
ps when I have the opportunity, I will record a demo on my blind technique, for interested trainees.
Hi Philippe
just read your post on central line insertion. One of the things you mention is:
I cannot count how many times a participant has sworn that his beam is right at the tip of the needle and been befuddled when I point to the blue phantom and show him how he is scanning just a bit beyond the hub and that the tip is in fact several centimetres into the blue phantom
This is one of the critical issues that we face with our hands-on intervention course…we’ve made videos, taken photos regarding ‘fanning the beam’ to keep the needle tip in view, etc … and still there are those whose spatial conception are challenged by the imaging…. many understand, but some do not ( my best guess is that it’s the narrow-window 2D image of a 3D structure that throws some people off )
Do you have any suggestions on how we can modify our approach to teaching this skill ?
thanks for the great blog postings
Chris
Tough question. The only way i get around that is one on one when a resident/student/attending is acutally rounding with me and we have time to really teach that 2d/3d relationship. You’re right some just have a hard time. Sometimes the long axis in plane works for those people, especially in subclavian access where this problem is more concerning. But its a tough issue, which i’m sure is happening everywhere.
Good question to ask some of the other faculty at CCUS 2014.
Cheers and looking forward to meeting you in a couple months!
Philippe
thinking critical care 