Im having great difficulty in seeing the finder needle tip properly when placing the line please help me sought this out. As i have to puncture several times to get it correct. And the blood gas i do to confirm the correct placement show abnormally high pao2 and sao2 for venous bloods but CXR shows correct placement is this possible?
Regarding seeing the finder needle tip under ultrasound, this is made easier if you start looking for the tip when it is still very superficial. Please watch our Ulttasound-Guided Vascular Access video for more information. Use our “Creep Method” to follow the tip down as you slowly advance the needle. One thing we don’t mention that may also be helpful: spin the needle around a bit, which will “flash” the echogenic tip. Regarding confirming placement: a chest x-Ray consistent with placement at the cavoatrial junction is standard and typically sufficient for confirming placement. If the blood gas is making you uncertain, consider drawing an arterial blood gas and a peripheral venous blood gas and comparing them. Maybe you should also consider physiologic or pathophysiologic reasons why the patient may truly have increased venous oxygen saturation. Some people believe that critical illness like late stage septic shock can produce high Central venous oxygen saturation, reflecting poor peripheral oxygen extraction due to metabolic collapse.
Regarding Line confirmation- I have personally witnessed a Right neck Udall placed with a subsequent AP Chest xray that appeared Cavo-atrial junction to me, officially read by radiology attending at the community hospital, and 1 radiology attending unofficial review at the academic referral center Line ended up being in the innominate artery. Finally confirmed on CT. If unsure, useful bedside tests include the Blood gases you mentioned, or simply asking the nurse to hook up an Arterial line set up and transducing the pressure/ waveform.
Rotate the US probe 90 degrees to look at the vessel longitudinally and rock the probe ever so slightly, chances are you'll see the needle or wire intercept the view at some point.
@@leggomyeggro12345 “simply ask” is a massive indicator that you have zero experience with non-urban healthcare. Hell, there’s end of life vent patients with no central lines. Arterial lines are like a rare present!
Wow. As a patient, I had this done. (Twice, but the first time I was awake in the ER). There was so much going on around me. I don’t recall feeling any pain. I do believe that this was another part of saving my life. I don’t recall ultrasound guidance. Massachusetts General Hospital saved my life. This was about 13 years ago and I just celebrated 10 years with my new liver ❤❤💚💙
I’m currently at mass general now after a different er missed what is wrong with me. They are great at mass gen. I had multiple massive clots from a picc line. They were able to get most of it out. But now I need to get one of these done. So it wasn’t painful to get this type of catheter done? I’m so scared.
I am a nuring student and I appreciated how comprehensive this video was, everything was explained thoroughly. Obviously much effort was put into this. Thank you so much!
I’ve only put in the introducer (cordis) for swans and the main difference is that the dilator goes inside the catheter and you advance the whole thing together over the wire then pull the dilator and wire out together. These can be single or double lumen.
Awww takes me wayyyyy back! Disabled RN up at 145am and watching this lol I assisted with hundreds of temporary dialysis ij catheters with the nephrologist that raised me for 10 of my 17.5 yr career. Sooo much fun, I truly miss it so much 😔
I had the experience of seeing two put in, assisted some with the second one, and then I got one of my own. I am sure the person who placed mine had no idea my fingers were dripping sweat. Lol. Great video! TY
Random remarks: 1. If the patient is crashing and the femoral approach is your approach of choice, have both (seldinger) arterial and central venous lines ready on the tray, cannulate, and, depending on what type of blood comes rushing back/is aspirated, insert appropriate catheter. Then use said catheter as a landmark to insert the other one. 2. Keep a saline filled syringe attached to the port the guide wire comes through until said guide wire comes through into the syringe. This ensures the wire doesn't push out saline used to flush it while threading the wire through the catheter. After removing wire use one syringe of saline to aspirate first and then flush and then a second to flush clean. Removes potential air bubbles. 3. When removing the guide wire, after inserting the central venous line, use the same plastic sheath, it was stored in originally, to prevent a mess from it flailing everywhere. 4. Incisions prior to dilation increase the incidence of puncture site inflammation. Try to avoid those unless absolutely neccessary. 5. Instead of sewing the catheter to skin, try using fixing stickers (I have no idea what they're called in english and I'm too exhausted to bother looking it up) - less punctures = less chance of inflammation/infection. 6. Use some gauze or dressing to cover up puncture site before removing needle and also after dilation, to prevent making a (bloody) mess. Neat is classy. Apply pressure to insure wire is fixed/can't run away/be pulled out on you. 7. In a hypovolemic patient, on top of trendelenburg, use a smaller syringe (2ml) to advance the needle. Lower negative pressure on aspiration collapses the vein less. 8. When sowing: puncture skin only first, knot, thread through central venous line ear, knot. Prevents the line running out on you/being pulled out and improves patient comfort, particularly in jugular and femoral approach. I probably forgot a bunch of things but I hope these help. Thanks for the awesome video!
Holy crap dude, you're the first physician I have seen think about numbing where the sutures will go. I always make sure to numb where I think I may suture, that's usually the first area the patient complains about.
Awesome. I’ve had two of these, one while awake. There was a lot going on (massive GI bleed). It’s great that they did all this and it didn’t feel like a big deal. The other time was when I had a liver transplant. Thank you Massachusetts General Hospital for saving my life more than once.
Anesthesiology resident here. In my country the kit contains the finder needle, guidewire, dilator and the cath itself but the kit you've guys shown contains everything you could ask for. We also dont use the echo on a daily basis, just when it doesnt work out after several attempts. It also happens to hit the carotid every once in a while but its so recognizeable because of the brightness of the blood and the pulsatile flow. I'd love to practise more the subclavian access but it'll happen eventually. Great presentation, guys, of course there's much more to talk about but you've covered the basics excellently. And you couldn't be more right that the right preparation and making everything convenient for you is the key to smoothly carrying out the procedure. Greetings!
Just wanted to say that as an EM PA, these bedside procedure videos are absolutely phenomenal. Please keep them coming (possible ideas such as paracentesis, LP, I&D, tonometry, etc.)! Thank you for all of the hard work you are doing to educate. Cheers.
As you seemed to suggest, Dr. Franko doesn’t seem overly dedicated to realism of this video and the education it provided. Perhaps for the next version of this video, the two of you can switch places and you can how him real educational dedication.
This is a great video series/channel THANK YOU DOC! I'm a FM board certified, Geriatric medicine board certified doc, did a one year EM fellowship and find your videos very refining. Thank you so much. If I can help your video series in anyway, let me know.
Have really enjoyed these series of videos. Has given me a ton of confidence going into my first day as a gen surg intern on trauma/scc tomorrow. Thanks for what you do!
Really nice demonstration and discussion. I'm from the stone age and have never used US for this purpose. Even I find that odd since I've done tens of thousands of US examinations. I feel a little stupid that it never occurred to me. Nonetheless, with great care, I've placed at least 3 thousand central lines of one sort or another, all without complications. I would caution those using the subclavian approach that a very precise knowledge of how the position of the vessels varies with the morphology of the thorax and that the cupula of the lung can almost surround the vein sometimes. Then the site should not be used. I was called once when a resident was careless and the entire guidewire was inserted. One end was in the SVC and the other in the right PA. Happily the cath lab had a number and variety of snare catheters and retrieval took us only a few minutes at the bedside with portable fluoro. The resident was greatly relieved !
@@DrRussell In turn, we stood on the shoulders of giants. When I was starting out, I met physicians whose knowledge of medicine was literally encyclopedic and surgeons whose technical skills and awe-inspiring mastery of the art will probably never be matched again. The best of them were renaissance men and women who were both gracious and kind in dealing with young physicians and devoted to the welfare of their patients.
Very good video. I like how you mentioend having your equipment you're about to use right in front of you so that you're not turning etc possibly coming out of the vein with extra movements.
Have you had to put in a central line? Have you needed to get a central line? Either way, see how it's done in this video! Remember to subscribe if you want to see more content like this, and visit us on BehindTheKnife.org if you like our stuff!
Would tunneled venous caths be a possible topic? I know they're similar if not the same to put in but then you have the tunneling process? The different types of lines specifically? Like why some need heparin locks and others don't? Awesome channel! Haven't put in centrals. Only normal ivs
I do this process almost every 3rd-4th day completely blind without USG guidance ..n usually put completely line inside because to eliminate risk of kicking..
I’m a crna and I only placed right IJ introducers (cordis) to float swans for cabg surgeries. I feel very comfortable placing those with ultrasound but I never did a triple lumen. Thanks for the video.
Man, I'm super jealous, you have three-way catheters, sterile probe covers, where I work we have only mono way catheters available and improvise a sterile latex glove as probe cover. First world is another dimension.
Great video. I came here through the podcast and was very pleased to see a well done and thoroughly explained procedure. For people nervous about the procedure remenber that preparation and practice are key. I love central lines 👍👍
It's definitely scary at first to have one put in when ur awake. When they give you something to calm you down it doesn't work at first but somehow does .
Your expression!😮 I'm DYING!🤣😂 That's ME! 😒 I REALLY don't ENJOY doing lines! However, they HAVE to be done! 😩The thing is, they can be SO TIME CONSUMING; especially, if you have a patient who is squirming and agitated or, has torturous viens!☹ This was a GREAT instructional video! Thanks for sharing this with us!😃👍🏾👨🏾⚕️
Thank you doc. Looks good and a little knowledge goes a long way. We used to do this without US. I assisted a couple docs do this at the bedside some 20 plus years ago.
I’ve had a Hickman and 3 Broviac’s. Placed a little lower than this one, and mine were all done in IR. I wish mine were done under sedation bc the numbing process is so painful for me due to nerve damage from my spinal cord injury.. I’ve only had 2 of the 4 IR surgeons who placed my lines have any compassion towards me as I lay there crying in pain! So for all you aspiring doctors out there PLEASE LISTEN TO YOUR PATIENT!
Nicely done. Several key points that are lacking in other videos on CVC placement. 1. Allow time for lido to work. 2. Advancing the guidewire to the 20cm mark is sufficient 3. Criteria used to assess venous vs carotid puncture. 4. No need to "hub" the dilator 5. Insertion depth of the right IJ catheter 6. Issues with catheters placed via left IJ 7. Femoral site for "crash" lines 8. Infiltrate the skin where the sutures will go at the start of the procedure. Might add your target for catheter tip position on the chest radiograph - a bit of controversy on that topic but we use the cavoatrial junction (two vertebral bodies below the carina).
I have no reason to know how to place a Central line... i work in sales for godsake... but now i do.... i feel like this taught me more in 13:57 than an entire semester of my History professor
I havent had really any surgery except for a tonsillectomy, but just watching this video made me feel nervous... benzo me!!! In this situation maybe I'd lie down still lol. I love watching medical videos like these though good work.
I liked part, when you mooved the guidewire back and forth while inserting the dilator. I'll take this technique into service. Also i'd realy love to watch your video about ultrasound-guided subclavian line insertion.
Not sure how I stumbled on this video, but a little personal anecdote that might or might not be useful for those of you learning this procedure. I needed an unexpected abdominal surgery in the late 90s and had a central line put in just before. After the surgery there were complications that resulted in the central line staying in a bit longer than was planned. When the central line was eventually removed, the removal was surprisingly painless. But a few minutes later I was in real distress. I never had a heart attack, but I imagined this it what it would feel like. I felt like I was struggling for air even though my breathing was fine, and strangest of all, I couldn't stop coughing. One of the doctors who had rushed in to help me eventually asked me in an accusatory tone why I was coughing. I wanted to give him a few choice words beyond that I just don't know, but felt like I was too busy dying. Eventually the coughing slowed and stopped. Between the massive doses of prednisone I was on and none of us having the presence of mind to make sure I hold a pillow to my stomach while coughing like crazy less than 2 weeks after surgery, I later found out that I put multiple tears where the muscle had been put back together. I later had other complications that might have stemmed from this incident. I never got a clear answer in the hospital about what happened. But in talking to other people afterwards, it's seems likely that when the central line was pulled out there was vasoconstriction after and the coughing is a mechanism for the body to try to keep blood moving. The fact that the central line was in a bit longer might have been a factor. I also recall the doctor pulling the line out quite fast, but maybe that's normal.
I'm sorry you went through that but thank you for sharing; this is the sort of experience left out from textbooks and I will be sure to withdraw more slowly and avoid excessive depth of insertion in the first place. Just out of interest, was it a left sided central line? I ask because they are inserted deeper, due to the greater distance to the heart from the left side to the right atrium.
Thanks @@DrRussell, I want to say that it was right sided, just based on the memory of where the doctor was standing when he pulled it out (this was in 1999). Another unrelated observation, getting the lines flushed was a very interesting sensation, almost like the sense of smell was getting triggered.
@@AntagonisticAltruist thank you for this. This sort of feedback helps us empathise with our patients much better. I hope to share your experiences with others; thank you for helping us to help our patients.
Hey, we regulary use endo-ecg (like Alphacard by Braun) to confirm central venous placement and determine the insertion length. It is a nice thing to save the xray to confirm the placement, presumed sinusrythm.
Nice video, will help to allay a lot of anxiety from baby docs and anesthetists. Quick comment on verification before threading the wire: if you don't have the fancy compass device or a pressure transducer line already set up (and zeroed), some line kits come with a bit of tubing that you can hook up to your finder needle/catheter. Fill the tubing with blood using gravity, then raise the blood-filled tubing. If the blood falls towards the patient, you're in a vein. If blood shoots out the top of the line, you're in an artery. Helpful during hypoxia (even arterial blood can be dark) and when you have a perfusing pulse. But this technique is old-school and carries the risk of a venous air embolism (mostly if patient is spontaneously breathing). If you can directly visualize under US, that's the gold standard.
As a patient, the thing I was worried about was the pain (I didn’t understand how complex it was). You’ll be great. Just take your time and there will be others to help you 👍🏽❤️🌸
When the vessel is thrombosed, you can actually see the hyperechoic clot within the vessel most of the time. However, while evaluating the course and anatomy of the vessel which I will target, I have developed the habit of checking for two more signs that suggest thrombosis to me, particularly when inserting lines in jugular or subclavian veins. In my experience, it is harder to see these signs when placing femoral lines. 1) When the changes in intrathoracic pressures during respiration are considered, I would expect a patent IJV or subclavian vein to shrink with inspiration and swell up with expiration in a patient who is spontaneously breathing. If the patient is on a mechanical ventilator, I would expect the vessel to swell up with inspiration and shrink somewhat (albeit to a lesser extent) during expiration. When I don't see these changes, I tend to suspect thrombosis somewhere on my way to the right atrium. 2) As you have shown in your video, I scan the whole neck and try to evaluate the vessel throughout its course. Being a vein, the IJV should get larger on its course down the neck. When I see it getting smaller down the neck, I suspect thrombosis. I also tend to look for the EJV. In my experience, when the IJV is thrombosed, the EJV tends to be much larger than usual, and most of the time, you can visualize the collaterals connecting the IJV to the EJV. If both IJVs have become inaccessible, I find that such dilated EJV's can be lifesaving, particularly in a PICU setting where access to the more sensible veins may prove impossible in chronically ill patients. I would very much like to hear your thoughts on these two findings :)
Love these details; especially the conditional variables. Just to make sure (noob here) if the IJV is decreasing in diameter proximally, I trust that is an indicator of a distal thrombus (distal to the probe), resulting in reduced venous return?
I find it useful to leave the ultrasound in place and watch the screen when you inject the lidocaine, also pulling back to ensure you aren't infusing lidocaine in the artery or vein; you should see the soft tissue expand while giving the subcutaneous lidocaine.
Had to watch this because when I was in the icu the attending doctor missed the first time (laughed and said he should've brought his glasses) then tried again. I was pretty delirious but I remember crying out in pain the first time he tried to get the needle in correctly. I passed out eventually lol
can you make some recommendations on a good video that discusses the different kinds of catheters and why, when you would use them... this was a great help
Great video!! I believe we aim for the ipsilateral nipple during IJ insertion. What about the femoral approach. Is there any particular angle? Is there any anatomical landmark to aim for with femoral approach ?
Thanks for this. Did my first today and wanted to check my work or see if there's any tips & tricks I missed. I'll definitely try the creep method next time. (And I wanted to comment for The Holy Algorithm.)
Hi, first of all i want to thank you for the great effort, the clear explanation and the amazing job on the details. Then, i would like to ask an unusual request, i live in a developing country and we don't always have the possibility to get an ultra sound while placing a CVC, although i never saw anyone place it on the jugular or subclavian, most of them go for femoral (maybe because they don't have the ultrasound to assist) and they use the technique you talked about with 2 fingers lateral 1 finger distal. So my question is : Is it possible to do jugular CVC without ultrasound ? If it is possible, may i ask you to do a short video going over a trick or tricks to do it smoothly without puncturing the vein ou going into the carotid ? :D Thanks a lot ^^
Using ultrasound is for an amateur, it is standard of care only when you are an amateur. Put your kit on the same side as your dominant side, right side for rightie... Keep all your needle and catheter inside the kit to keep it sterile and you will not lose them even your patient moves. Prepare your catheter and guidewire and syringes and needles as you have done but leave them inside your kit. Placing them outside of the kit will introduce contamination also. Your drape is not as sterile as you think. Use a smaller gauge needle to find the RIJ first then use your "finder needle" with the same angle as your small gauge needle to enter the RIJ. Thread your wire. Before you nick the skin with the knife thread the catheter over the wire until the tip is a little above the skin with the other end of your wire out the port, it will decrease bleeding because you can advance your catheter right after you nick the skin and the bleeding usually will stop after you advance your catheter.
I love this soooo much. My dream is to become a surgeon, and I know that if I try I can. Please post more videos, and check if the info are 100percent correct before posting plz, and thanks for the help. i.e first year of premed
***ALWAYS MAKE SURE TO NOTE THE WIRE IS OUT OF THE PATIENT*** I like to alert the bedside nurse that it's out, and they're often pretty good at keeping me honest.
Thank you sir for the great video. But concerning the subclavian vein, sometimes the shoulder is internally rotated and impedes the horizontal trajectory of the needle. Do you recommend a more medial and caudad point of entry?
I like to line the bevel of the introducer needle up with the numbers/ markings on the syringe so I always know where the bevel is even if it is underneath the skin/ in the vein. I also like to make my nic in the skin with the 11 blade over the firmer surface of the introducer needle while the guidewire is in place/ before the needle is removed.
A great way to take some potential error out of the procedure is to use the finder-needle with the catheter pre-loaded on it! Once you're into the vessel, advance a fraction more so that the tip of the cath and not just the needle tip is in, then thread the cath on into the vein. Now you won't have to worry about moving the tip of the finder-needle by accident when you reach for the wire or remove the syringe, that cath isn't going anywhere. If you put on a cap you could go to lunch and it'd still be there when you get back.
Could you please talk more about that? I don’t undersrand how to load the catheter on the needle, but this problem with the moving the needle when reaching for the wire is a big pain in the ass for me.
@@hiagocabral6765 most of the commonly used central line kits, excluding specialty ones like cordis' etc. come with more than one finder needle, as he demonstrates in the video at about the 2:35 mark. There are often three, a long one, a short one, and a third (usually also long) that has a catheter already on it, like a regular IV needle; in the video he holds it up, I believe on the right. Since it's already on there, do everything just as you would have normally, but thread that catheter into the vein once you have access and it'll hold your place for you. You can either thread the catheter in then remove the finder needle completely without unhooking the syringe OR continue as you normally would with the added peace of mind that you won't lose the vein if you move.
I have not yet found such a kit with the catheter over the finder needle. Which size is that catheter? Would it be possible to use a common 18G catheter used in peripheral veins? Once there, I would them introduce the wire and etc. Thanks so much for your feedback, I’ve been fighting with this problem every day.
@@hiagocabral6765 it is theoretically possible to use a standard IV catheter, although the usual 32mm length will almost certainly not be long enough anywhere but the IJ. Also, most IV catheters at this point are of the modern 'safety' style, which include a needle guard that shrouds the needle as you advance the catheter, which reduces some of the utility, as you cannot attach it to a syringe and aspirate as you go. If you can find an 18 or 20ga 40-50mm or so old-fashioned IV, just a catheter over a needle with a hub, drop that onto your field and use it as normal. Just by quick search, it looks like centesis needles are exactly the same thing, just labelled differently. If you really want to get wild, go down to the ED and get a 14ga chest needle ;D
I appreciate the accuracy of your video but I think you should comment on the possibility of entrained air embolism via uncovered ports and more emphasis of the hazard of damage to the thoracic duct on the left sided jugular approach.
A tip regarding sterile ultrasounding: don't puncture through gel. Ultrasound gel is made for external use only and should not be brought into the tissue and blood. I usually put a few milliliters of saline solution into my finder needle and syringe and drip some onto the skin. Works perfectly, even when using a sterile glove as an improvised probe cover, and saline is suitable for intravenous injection. Also, it would be nice to talk a bit more about what to do if the wire meets resistance. The answer is: look at your needle again. A few days back I had a patient whose V. jug. int. dex. I could easily cannulate but when it came to inserting the wire, it always hit resistance. The ultrasound showed me that always after removing the syringe from the needle, I somehow moved down a few millimeters and hit the other vessel wall. The solution was to pull back on the needle et voila! In another case I had somehow moved to the medial wall of the vessel. A small adjustment in approach and in I was.
Im having great difficulty in seeing the finder needle tip properly when placing the line please help me sought this out. As i have to puncture several times to get it correct. And the blood gas i do to confirm the correct placement show abnormally high pao2 and sao2 for venous bloods but CXR shows correct placement is this possible?
Regarding seeing the finder needle tip under ultrasound, this is made easier if you start looking for the tip when it is still very superficial. Please watch our Ulttasound-Guided Vascular Access video for more information. Use our “Creep Method” to follow the tip down as you slowly advance the needle. One thing we don’t mention that may also be helpful: spin the needle around a bit, which will “flash” the echogenic tip.
Regarding confirming placement: a chest x-Ray consistent with placement at the cavoatrial junction is standard and typically sufficient for confirming placement. If the blood gas is making you uncertain, consider drawing an arterial blood gas and a peripheral venous blood gas and comparing them. Maybe you should also consider physiologic or pathophysiologic reasons why the patient may truly have increased venous oxygen saturation. Some people believe that critical illness like late stage septic shock can produce high Central venous oxygen saturation, reflecting poor peripheral oxygen extraction due to metabolic collapse.
@@behindtheknifethesurgerypo4986 thank you very much
Regarding Line confirmation- I have personally witnessed a Right neck Udall placed with a subsequent AP Chest xray that appeared Cavo-atrial junction to me, officially read by radiology attending at the community hospital, and 1 radiology attending unofficial review at the academic referral center
Line ended up being in the innominate artery. Finally confirmed on CT.
If unsure, useful bedside tests include the Blood gases you mentioned, or simply asking the nurse to hook up an Arterial line set up and transducing the pressure/ waveform.
Rotate the US probe 90 degrees to look at the vessel longitudinally and rock the probe ever so slightly, chances are you'll see the needle or wire intercept the view at some point.
@@leggomyeggro12345 “simply ask” is a massive indicator that you have zero experience with non-urban healthcare. Hell, there’s end of life vent patients with no central lines. Arterial lines are like a rare present!
Im an anesthestist. I enjoyed your video. It was comprehensive and well presented. Excellent work!!!
Hllo dctr
Wow. As a patient, I had this done. (Twice, but the first time I was awake in the ER). There was so much going on around me. I don’t recall feeling any pain. I do believe that this was another part of saving my life. I don’t recall ultrasound guidance. Massachusetts General Hospital saved my life. This was about 13 years ago and I just celebrated 10 years with my new liver ❤❤💚💙
I’m currently at mass general now after a different er missed what is wrong with me. They are great at mass gen. I had multiple massive clots from a picc line. They were able to get most of it out. But now I need to get one of these done. So it wasn’t painful to get this type of catheter done? I’m so scared.
Literally the best best TLC placement video i've seen online. Outstanding explanation and graphics. Thank you so much - was a great review.
I am a nuring student and I appreciated how comprehensive this video was, everything was explained thoroughly. Obviously much effort was put into this. Thank you so much!
"A smooth central line is all about preparation" this could not be more true
Not only was this explained in great detail, but you have time stamps for us to refer back to certain steps. Subscribed for sure. THANK YOU!
Different types of catheters will be a great vide too. Awesome video helped a lot!!!
I’ve only put in the introducer (cordis) for swans and the main difference is that the dilator goes inside the catheter and you advance the whole thing together over the wire then pull the dilator and wire out together. These can be single or double lumen.
I'm late but I would also like this if it isn't done already
Awww takes me wayyyyy back! Disabled RN up at 145am and watching this lol I assisted with hundreds of temporary dialysis ij catheters with the nephrologist that raised me for 10 of my 17.5 yr career. Sooo much fun, I truly miss it so much 😔
I'm nervous just watching this.
Mee too! glad I was "out" for this!
If you're not the patient, no need to stress
I had the experience of seeing two put in, assisted some with the second one, and then I got one of my own. I am sure the person who placed mine had no idea my fingers were dripping sweat. Lol. Great video! TY
me too
This is so fascinating! I had a central line placed in me yesterday and was super curious to know how it was done! Thanks for putting this together!
Did it hurt? Getting one today 😬
@@Lea.Latrice I was half under, I didn't feel a thing. And it didn't hurt to have it in at all either. The tape itched a bit, but that was it.
@@CholTaaim ahh that helps a lot. Thank you
Random remarks: 1. If the patient is crashing and the femoral approach is your approach of choice, have both (seldinger) arterial and central venous lines ready on the tray, cannulate, and, depending on what type of blood comes rushing back/is aspirated, insert appropriate catheter. Then use said catheter as a landmark to insert the other one. 2. Keep a saline filled syringe attached to the port the guide wire comes through until said guide wire comes through into the syringe. This ensures the wire doesn't push out saline used to flush it while threading the wire through the catheter. After removing wire use one syringe of saline to aspirate first and then flush and then a second to flush clean. Removes potential air bubbles. 3. When removing the guide wire, after inserting the central venous line, use the same plastic sheath, it was stored in originally, to prevent a mess from it flailing everywhere. 4. Incisions prior to dilation increase the incidence of puncture site inflammation. Try to avoid those unless absolutely neccessary. 5. Instead of sewing the catheter to skin, try using fixing stickers (I have no idea what they're called in english and I'm too exhausted to bother looking it up) - less punctures = less chance of inflammation/infection. 6. Use some gauze or dressing to cover up puncture site before removing needle and also after dilation, to prevent making a (bloody) mess. Neat is classy. Apply pressure to insure wire is fixed/can't run away/be pulled out on you. 7. In a hypovolemic patient, on top of trendelenburg, use a smaller syringe (2ml) to advance the needle. Lower negative pressure on aspiration collapses the vein less. 8. When sowing: puncture skin only first, knot, thread through central venous line ear, knot. Prevents the line running out on you/being pulled out and improves patient comfort, particularly in jugular and femoral approach. I probably forgot a bunch of things but I hope these help. Thanks for the awesome video!
Holy crap dude, you're the first physician I have seen think about numbing where the sutures will go. I always make sure to numb where I think I may suture, that's usually the first area the patient complains about.
Awesome. I’ve had two of these, one while awake. There was a lot going on (massive GI bleed). It’s great that they did all this and it didn’t feel like a big deal.
The other time was when I had a liver transplant.
Thank you Massachusetts General Hospital for saving my life more than once.
Excellent job going through basics and thorough enough to talk about the finer points of efficiency.
Anesthesiology resident here. In my country the kit contains the finder needle, guidewire, dilator and the cath itself but the kit you've guys shown contains everything you could ask for. We also dont use the echo on a daily basis, just when it doesnt work out after several attempts. It also happens to hit the carotid every once in a while but its so recognizeable because of the brightness of the blood and the pulsatile flow. I'd love to practise more the subclavian access but it'll happen eventually. Great presentation, guys, of course there's much more to talk about but you've covered the basics excellently. And you couldn't be more right that the right preparation and making everything convenient for you is the key to smoothly carrying out the procedure. Greetings!
I love the fact that he gathered all the items that needs to go first and the rest follows...wow! it was well understood...thanks😍
This is the best central line video I've ever seen!
I love placing central lines...I am so happy that Arizona is big on Respiratory Therapists placing CVC's.
the illustration is done very clear and professionally!!
Great job. I'm an emerg doc but always going through videos trying refne my skills. Thanks!
Just wanted to say that as an EM PA, these bedside procedure videos are absolutely phenomenal. Please keep them coming (possible ideas such as paracentesis, LP, I&D, tonometry, etc.)! Thank you for all of the hard work you are doing to educate. Cheers.
As you seemed to suggest, Dr. Franko doesn’t seem overly dedicated to realism of this video and the education it provided. Perhaps for the next version of this video, the two of you can switch places and you can how him real educational dedication.
Lol :')
That was extremely interesting. But extremely scary. My heart was pounding like crazy.
This is a great video series/channel THANK YOU DOC! I'm a FM board certified, Geriatric medicine board certified doc, did a one year EM fellowship and find your videos very refining. Thank you so much. If I can help your video series in anyway, let me know.
This is great. I work in a stand alone ED, and we don't get to do that many lines. I simply watch procedures over and over.
Have really enjoyed these series of videos. Has given me a ton of confidence going into my first day as a gen surg intern on trauma/scc tomorrow. Thanks for what you do!
Really nice demonstration and discussion. I'm from the stone age and have never used US for this purpose. Even I find that odd since I've done tens of thousands of US examinations. I feel a little stupid that it never occurred to me. Nonetheless, with great care, I've placed at least 3 thousand central lines of one sort or another, all without complications. I would caution those using the subclavian approach that a very precise knowledge of how the position of the vessels varies with the morphology of the thorax and that the cupula of the lung can almost surround the vein sometimes. Then the site should not be used. I was called once when a resident was careless and the entire guidewire was inserted. One end was in the SVC and the other in the right PA. Happily the cath lab had a number and variety of snare catheters and retrieval took us only a few minutes at the bedside with portable fluoro. The resident was greatly relieved !
Thank you for sharing your valuable experience to juniors like us, our lives are built on your foundations.
@@DrRussell In turn, we stood on the shoulders of giants. When I was starting out, I met physicians whose knowledge of medicine was literally encyclopedic and surgeons whose technical skills and awe-inspiring mastery of the art will probably never be matched again. The best of them were renaissance men and women who were both gracious and kind in dealing with young physicians and devoted to the welfare of their patients.
Y'all are the best, thank you for all your work!
Very good video. I like how you mentioend having your equipment you're about to use right in front of you so that you're not turning etc possibly coming out of the vein with extra movements.
Loved this video! Thanks for making it! As a med student, I would love to see more of these kinds of videos for different procedures!
Have you had to put in a central line? Have you needed to get a central line? Either way, see how it's done in this video! Remember to subscribe if you want to see more content like this, and visit us on BehindTheKnife.org if you like our stuff!
Would tunneled venous caths be a possible topic? I know they're similar if not the same to put in but then you have the tunneling process? The different types of lines specifically? Like why some need heparin locks and others don't? Awesome channel!
Haven't put in centrals. Only normal ivs
Sabong
I’ve gotten several central lines placed and have been the proud owner of a tunneled Hickman for the past 4 years. Fun times lol
Stresses me out to watch haha. Very interesting and hope to feel confident in doing them myself one day.
I do this process almost every 3rd-4th day completely blind without USG guidance ..n usually put completely line inside because to eliminate risk of kicking..
Nice. Learned a lot. Just asking, when do you wipe the gel? Looks slippery when the bungs are being connected.
I’m a crna and I only placed right IJ introducers (cordis) to float swans for cabg surgeries. I feel very comfortable placing those with ultrasound but I never did a triple lumen. Thanks for the video.
Man, I'm super jealous, you have three-way catheters, sterile probe covers, where I work we have only mono way catheters available and improvise a sterile latex glove as probe cover. First world is another dimension.
Where I work we doing it blindly. No ultrasound
I’m trying to say at least you have the ultrasound
Yeah, I've bought it with my own money, none hospital on my city (by the way, in Brazil) have a ultrasound for simple procedures like that
What is an ultrasound? And you have a device called central line? We use a urinary catheter
Great video. I came here through the podcast and was very pleased to see a well done and thoroughly explained procedure. For people nervous about the procedure remenber that preparation and practice are key. I love central lines 👍👍
Had this done and still can’t believe I was awake for the whole thing
It's definitely scary at first to have one put in when ur awake. When they give you something to calm you down it doesn't work at first but somehow does .
Good job Dr. And great attitude!
Your expression!😮 I'm DYING!🤣😂 That's ME! 😒 I REALLY don't ENJOY doing lines! However, they HAVE to be done! 😩The thing is, they can be SO TIME CONSUMING; especially, if you have a patient who is squirming and agitated or, has torturous viens!☹ This was a GREAT instructional video! Thanks for sharing this with us!😃👍🏾👨🏾⚕️
Thank you doc. Looks good and a little knowledge goes a long way. We used to do this without US. I assisted a couple docs do this at the bedside some 20 plus years ago.
Thank God I was never awake for the 5 Central lines I've had 😱😱
I’ve had a Hickman and 3 Broviac’s. Placed a little lower than this one, and mine were all done in IR. I wish mine were done under sedation bc the numbing process is so painful for me due to nerve damage from my spinal cord injury.. I’ve only had 2 of the 4 IR surgeons who placed my lines have any compassion towards me as I lay there crying in pain! So for all you aspiring doctors out there PLEASE LISTEN TO YOUR PATIENT!
Best video on central line placement. I'm subbed. Thank you!!
Congrats on making a really practical video, well done!
Best video on central line
Thank you so much for making this, much appreciated!
I was very disappointed Dr Franco wasn't the patient!!! Great explanation though!
Nicely done. Several key points that are lacking in other videos on CVC placement. 1. Allow time for lido to work. 2. Advancing the guidewire to the 20cm mark is sufficient 3. Criteria used to assess venous vs carotid puncture. 4. No need to "hub" the dilator 5. Insertion depth of the right IJ catheter 6. Issues with catheters placed via left IJ 7. Femoral site for "crash" lines 8. Infiltrate the skin where the sutures will go at the start of the procedure. Might add your target for catheter tip position on the chest radiograph - a bit of controversy on that topic but we use the cavoatrial junction (two vertebral bodies below the carina).
I have no reason to know how to place a Central line... i work in sales for godsake... but now i do.... i feel like this taught me more in 13:57 than an entire semester of my History professor
I havent had really any surgery except for a tonsillectomy, but just watching this video made me feel nervous... benzo me!!! In this situation maybe I'd lie down still lol. I love watching medical videos like these though good work.
Tonsillectomy would have scared me.
I liked part, when you mooved the guidewire back and forth while inserting the dilator. I'll take this technique into service.
Also i'd realy love to watch your video about ultrasound-guided subclavian line insertion.
Not sure how I stumbled on this video, but a little personal anecdote that might or might not be useful for those of you learning this procedure.
I needed an unexpected abdominal surgery in the late 90s and had a central line put in just before. After the surgery there were complications that resulted in the central line staying in a bit longer than was planned.
When the central line was eventually removed, the removal was surprisingly painless. But a few minutes later I was in real distress. I never had a heart attack, but I imagined this it what it would feel like. I felt like I was struggling for air even though my breathing was fine, and strangest of all, I couldn't stop coughing. One of the doctors who had rushed in to help me eventually asked me in an accusatory tone why I was coughing. I wanted to give him a few choice words beyond that I just don't know, but felt like I was too busy dying. Eventually the coughing slowed and stopped.
Between the massive doses of prednisone I was on and none of us having the presence of mind to make sure I hold a pillow to my stomach while coughing like crazy less than 2 weeks after surgery, I later found out that I put multiple tears where the muscle had been put back together. I later had other complications that might have stemmed from this incident.
I never got a clear answer in the hospital about what happened. But in talking to other people afterwards, it's seems likely that when the central line was pulled out there was vasoconstriction after and the coughing is a mechanism for the body to try to keep blood moving. The fact that the central line was in a bit longer might have been a factor. I also recall the doctor pulling the line out quite fast, but maybe that's normal.
I'm sorry you went through that but thank you for sharing; this is the sort of experience left out from textbooks and I will be sure to withdraw more slowly and avoid excessive depth of insertion in the first place. Just out of interest, was it a left sided central line? I ask because they are inserted deeper, due to the greater distance to the heart from the left side to the right atrium.
Thanks @@DrRussell, I want to say that it was right sided, just based on the memory of where the doctor was standing when he pulled it out (this was in 1999).
Another unrelated observation, getting the lines flushed was a very interesting sensation, almost like the sense of smell was getting triggered.
@@AntagonisticAltruist thank you for this. This sort of feedback helps us empathise with our patients much better. I hope to share your experiences with others; thank you for helping us to help our patients.
Hey, we regulary use endo-ecg (like Alphacard by Braun) to confirm central venous placement and determine the insertion length. It is a nice thing to save the xray to confirm the placement, presumed sinusrythm.
Interesting. never heard of it. Gonna look it up.
Nice video, will help to allay a lot of anxiety from baby docs and anesthetists. Quick comment on verification before threading the wire: if you don't have the fancy compass device or a pressure transducer line already set up (and zeroed), some line kits come with a bit of tubing that you can hook up to your finder needle/catheter. Fill the tubing with blood using gravity, then raise the blood-filled tubing. If the blood falls towards the patient, you're in a vein. If blood shoots out the top of the line, you're in an artery.
Helpful during hypoxia (even arterial blood can be dark) and when you have a perfusing pulse. But this technique is old-school and carries the risk of a venous air embolism (mostly if patient is spontaneously breathing). If you can directly visualize under US, that's the gold standard.
Watching this as a med school student is so scary 🥵
Yuuup even unfolding sterile drapes without touching the wrong part gives me the absolute fear
I am a student like you and I thought I was the only one who was agitated
As a patient, the thing I was worried about was the pain (I didn’t understand how complex it was). You’ll be great. Just take your time and there will be others to help you 👍🏽❤️🌸
@@bekahtaylor9658 You’ll get used to it all 👍🏽🌸
Same here holy shit that is scary
Great job! I love putting in lines. I'm sure that'll wear off soon haha
I still love it to this day! So satisfying! Definitely my favorite bedside procedure.
When the vessel is thrombosed, you can actually see the hyperechoic clot within the vessel most of the time.
However, while evaluating the course and anatomy of the vessel which I will target, I have developed the habit of checking for two more signs that suggest thrombosis to me, particularly when inserting lines in jugular or subclavian veins. In my experience, it is harder to see these signs when placing femoral lines.
1) When the changes in intrathoracic pressures during respiration are considered, I would expect a patent IJV or subclavian vein to shrink with inspiration and swell up with expiration in a patient who is spontaneously breathing. If the patient is on a mechanical ventilator, I would expect the vessel to swell up with inspiration and shrink somewhat (albeit to a lesser extent) during expiration. When I don't see these changes, I tend to suspect thrombosis somewhere on my way to the right atrium.
2) As you have shown in your video, I scan the whole neck and try to evaluate the vessel throughout its course. Being a vein, the IJV should get larger on its course down the neck. When I see it getting smaller down the neck, I suspect thrombosis. I also tend to look for the EJV. In my experience, when the IJV is thrombosed, the EJV tends to be much larger than usual, and most of the time, you can visualize the collaterals connecting the IJV to the EJV. If both IJVs have become inaccessible, I find that such dilated EJV's can be lifesaving, particularly in a PICU setting where access to the more sensible veins may prove impossible in chronically ill patients.
I would very much like to hear your thoughts on these two findings :)
These are great, high level points! Knowledge of these fine details are what separate good doctors from excellent doctors!
Love these details; especially the conditional variables. Just to make sure (noob here) if the IJV is decreasing in diameter proximally, I trust that is an indicator of a distal thrombus (distal to the probe), resulting in reduced venous return?
What a WONDERFUL instruction! I don't like doing these!😣 However, they are sometimes necessary! Thanks for sharing this with us!👋🏾👨🏾⚕️🏨
Can I ask where do you buy the models for training?
Great video! I look forward to your video on arterial lines.
Coming soon!
Very well put! 👏🏻 👏🏻
Nicely done video... learned a lot from this one.
Great detailed video that actually covers all topics and questions i had!
Your a pilot and an RN???? If so, GOALS
Excellent video bro
I find it useful to leave the ultrasound in place and watch the screen when you inject the lidocaine, also pulling back to ensure you aren't infusing lidocaine in the artery or vein; you should see the soft tissue expand while giving the subcutaneous lidocaine.
After usg guided jugular detection u should remove or mop the gel and do invassive manuevers
Just getting ready for pgy1 love this
Had to watch this because when I was in the icu the attending doctor missed the first time (laughed and said he should've brought his glasses) then tried again. I was pretty delirious but I remember crying out in pain the first time he tried to get the needle in correctly. I passed out eventually lol
I just had my catheter taken out, interesting watch:)
I hope that you’re feeling much better.
Feel better. Soon.
can you make some recommendations on a good video that discusses the different kinds of catheters and why, when you would use them... this was a great help
enjoyed the video.. everything explained perfectly
Can you make a video for Central Vein Placement for Subclavian and Femoral any techniques or tips for it?
Thank you so much! That was really amazing and perfectly demonstrated
This always make me nervous, even tomorrow is going to be my 6th C-line for Chemotherapy.
Great video!! I believe we aim for the ipsilateral nipple during IJ insertion. What about the femoral approach. Is there any particular angle? Is there any anatomical landmark to aim for with femoral approach ?
Any plans on making a video about the different types of central venous catheters? That would be great!
Thanks for this. Did my first today and wanted to check my work or see if there's any tips & tricks I missed. I'll definitely try the creep method next time. (And I wanted to comment for The Holy Algorithm.)
Hi, first of all i want to thank you for the great effort, the clear explanation and the amazing job on the details.
Then, i would like to ask an unusual request, i live in a developing country and we don't always have the possibility to get an ultra sound while placing a CVC, although i never saw anyone place it on the jugular or subclavian, most of them go for femoral (maybe because they don't have the ultrasound to assist) and they use the technique you talked about with 2 fingers lateral 1 finger distal.
So my question is : Is it possible to do jugular CVC without ultrasound ? If it is possible, may i ask you to do a short video going over a trick or tricks to do it smoothly without puncturing the vein ou going into the carotid ? :D
Thanks a lot ^^
Ah yes, learning to place a central line will be an essential part of my programming career.
I would like a video on different central lines!
Does the guide wire come out at some point during central line placement?
Haha nice video Jace! 😁
I m dialysis technician. I have learn this process.I have do this processer patients and progress in our life 👍.
Outstanding period of instruction. Thank you!
I circled back because I thought I missed the removal of the guidewire but I assume it was done just before 9:40
Using ultrasound is for an amateur, it is standard of care only when you are an amateur.
Put your kit on the same side as your dominant side, right side for rightie...
Keep all your needle and catheter inside the kit to keep it sterile and you will not lose them even your patient moves.
Prepare your catheter and guidewire and syringes and needles as you have done but leave them inside your kit.
Placing them outside of the kit will introduce contamination also. Your drape is not as sterile as you think.
Use a smaller gauge needle to find the RIJ first then use your "finder needle" with the same angle as your small gauge needle to enter the RIJ. Thread your wire.
Before you nick the skin with the knife thread the catheter over the wire until the tip is a little above the skin with the other end of your wire out the port, it will decrease bleeding because you can advance your catheter right after you nick the skin and the bleeding usually will stop after you advance your catheter.
Kudos. I'm so glad I'm in dental hygiene and not hospital medicine. I couldn't do this
Thank you, maybe the gel is sometime annoying our technique
I love this soooo much. My dream is to become a surgeon, and I know that if I try I can. Please post more videos, and check if the info are 100percent correct before posting plz, and thanks for the help. i.e first year of premed
Yes please do video on catheters 🙏
***ALWAYS MAKE SURE TO NOTE THE WIRE IS OUT OF THE PATIENT***
I like to alert the bedside nurse that it's out, and they're often pretty good at keeping me honest.
Thank you sir for the great video.
But concerning the subclavian vein, sometimes the shoulder is internally rotated and impedes the horizontal trajectory of the needle. Do you recommend a more medial and caudad point of entry?
Videos are short n sweet...thanks👍🏻
Love 💞 you. Nice presentation 👍
I like to line the bevel of the introducer needle up with the numbers/ markings on the syringe so I always know where the bevel is even if it is underneath the skin/ in the vein. I also like to make my nic in the skin with the 11 blade over the firmer surface of the introducer needle while the guidewire is in place/ before the needle is removed.
A great way to take some potential error out of the procedure is to use the finder-needle with the catheter pre-loaded on it! Once you're into the vessel, advance a fraction more so that the tip of the cath and not just the needle tip is in, then thread the cath on into the vein. Now you won't have to worry about moving the tip of the finder-needle by accident when you reach for the wire or remove the syringe, that cath isn't going anywhere. If you put on a cap you could go to lunch and it'd still be there when you get back.
Could you please talk more about that? I don’t undersrand how to load the catheter on the needle, but this problem with the moving the needle when reaching for the wire is a big pain in the ass for me.
@@hiagocabral6765 most of the commonly used central line kits, excluding specialty ones like cordis' etc. come with more than one finder needle, as he demonstrates in the video at about the 2:35 mark. There are often three, a long one, a short one, and a third (usually also long) that has a catheter already on it, like a regular IV needle; in the video he holds it up, I believe on the right. Since it's already on there, do everything just as you would have normally, but thread that catheter into the vein once you have access and it'll hold your place for you. You can either thread the catheter in then remove the finder needle completely without unhooking the syringe OR continue as you normally would with the added peace of mind that you won't lose the vein if you move.
I have not yet found such a kit with the catheter over the finder needle. Which size is that catheter? Would it be possible to use a common 18G catheter used in peripheral veins? Once there, I would them introduce the wire and etc. Thanks so much for your feedback, I’ve been fighting with this problem every day.
@@hiagocabral6765 it is theoretically possible to use a standard IV catheter, although the usual 32mm length will almost certainly not be long enough anywhere but the IJ. Also, most IV catheters at this point are of the modern 'safety' style, which include a needle guard that shrouds the needle as you advance the catheter, which reduces some of the utility, as you cannot attach it to a syringe and aspirate as you go. If you can find an 18 or 20ga 40-50mm or so old-fashioned IV, just a catheter over a needle with a hub, drop that onto your field and use it as normal. Just by quick search, it looks like centesis needles are exactly the same thing, just labelled differently. If you really want to get wild, go down to the ED and get a 14ga chest needle ;D
Thank you so much
I appreciate the accuracy of your video but I think you should comment on the possibility of entrained air embolism via uncovered ports and more emphasis of the hazard of damage to the thoracic duct on the left sided jugular approach.
A tip regarding sterile ultrasounding: don't puncture through gel. Ultrasound gel is made for external use only and should not be brought into the tissue and blood. I usually put a few milliliters of saline solution into my finder needle and syringe and drip some onto the skin. Works perfectly, even when using a sterile glove as an improvised probe cover, and saline is suitable for intravenous injection.
Also, it would be nice to talk a bit more about what to do if the wire meets resistance. The answer is: look at your needle again. A few days back I had a patient whose V. jug. int. dex. I could easily cannulate but when it came to inserting the wire, it always hit resistance. The ultrasound showed me that always after removing the syringe from the needle, I somehow moved down a few millimeters and hit the other vessel wall. The solution was to pull back on the needle et voila! In another case I had somehow moved to the medial wall of the vessel. A small adjustment in approach and in I was.