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In this episode I go over some tips and tricks for maximizing your success with peripheral IVs, arterial lines, central venous catheters and pulmonary artery catheters (Swan Ganz catheters).
CME: https://cmefy.com/moment?id=Ms0mgDd
The New England Journal videos that I recommend you take a look at for detailed reviews of each of these are here:
- Peripheral IV: http://www.nejm.org/doi/full/10.1056/NEJMvcm0706789
- Arterial: http://www.nejm.org/doi/full/10.1056/NEJMvcm044149
- Central: http://www.nejm.org/doi/full/10.1056/NEJMvcm055053
- PA catheter: http://www.nejm.org/doi/full/10.1056/NEJMvcm1212416
And this is a great article from Ausmed on assessing and caring for peripheral IVs: Click Here
Great episode.
I just wanted to add some of my tips and tricks:
– for arterial line placement always use lidocaine, even if the patient is under anesthesia – it reduces the risk of vasospasm
– always use ultrasound for arterial lines, unless it is an emergency
– if using ultrasound for arterial lines you can find a site proximal the wrist on the distal to mid-forearm … it is much more comfortable for the patient and movement of hand and wrist won’t interfere with the arterial wave-form
– if you use ultrasound for peripheral iv don’t look for the flush (it just means, like you said, that the tip of the needle is in the vessel), just look at your screen and slowly advance the needle a couple of mm if you are in the vessel and the advance the catheter and now look if blood is in the chamber … or just don’t bother at all about the blood 😉
– if you use an “angiocath” (we have FloSwitch) for arterial line placement, I find it to be beneficial if you have some of your angiocaths in the fridge, due to the low temperature the plastic gets a little harder and makes it easier to advance the catheter over the needle
– for central lines: always use ultrasound for subclavians as well, first look at your vessel in short axis and the rotate the probe 90° to get your vein in long axis, the you can move as far medial as possible to place your line
– for in-plane method for central lines I like the wire-in-needle technique: https://bostoncityem.com/2018/05/18/the-wire-in-needle-win-technique/
Thanks for your work and I am always happy to see a new post on your site.
Greetings from Germany
Thanks for sharing your own personal tips! I would caution folks to be careful with placing a-lines in the mid forearm as the median nerve travels very close to the artery there. Sometimes it’s necessary but maybe not preferred for that reason.
Best,
Jed
I only recommend mid forearm when using ultrasound, without it is nearly impossible (deeper location…). And visualisation of the median nerv should not be a problem at all.
Sounds reasonable to me, thanks!
Just found your podcast (great, by the way!) recently, although apparently our residents have been aware of it for some time now! Wanted to add something about IJs.
Remember way back in the day when, after several blind attempts, there was a hematoma in the front of the neck? A posterior approach — where the needle comes in from a bit higher in the neck and from behind the lateral edge of the SCM, makes passes (first with finder needle, then with larger needle) from superficial to deep, and is aimed at the contralateral nipple — was often a great rescue technique in that setting. In fact, it was a fine first-attempt technique as well (though relatively uncommon). Well that trajectory is only about 30 degrees from parallel to the IJ and it works well for an in-plane approach with ultrasound, even with patients whose anatomy and/or the width of your USN probe may make a longitudinal anterior approach more difficult.
Interesting! Thanks for sharing!