Go over the most critical steps of central line placement with Scott Weingart and Rob Orman in this lecture from Essentials of EM 2019. Get more pearls like this with EEM On-Demand: bit.ly/2YYDKgE
Great Job!!! Im a 28 year veteran of working ERs and this video helped the micro and macroskills explained better than anyone has ever done in my teaching or since in practice, kudos to you dr weingart, keep it up and much gratittude and respect
6:40 It does happen. I remember a delirous patient who was difficult do deal with already and much more so while being sterile. After wire insertion, I re-checked venous placement by ultrasound. In order to protect the wire in my subsequent skin nick I still had the needle in him. As I let go of the wire, it steadily started moving inwards, reaching speeds about a centimeter per second. A ghastly sight indeed. I did not undertake the experiment of whether it would still be sucked in without the needle to glide through.
They don't mention it but they are removing the syringe before inserting the guidewire through the needle hub. I usually pass the wire through the port on the back end of the syringe. It helps avoid displacing the needle tip when twisting off the syringe and decreases the likelihood of an air embolism
Good video. I do all those techniques except the rotation after skin nick. I typically poke with my blade parrallel to the wire for about 1/2 the length of the blade. One thing I would add when threading the wire and it does not go all the way through is to remove the needle. Replace an 18 guage catheter over the wire. Once 18 guage is in, take out the wire. Once can see if catheter is in if obviously blood flows out, or if you attach a syringe to it and blood flow out. NOw replace the wire to redirect, your wire should now move unobstucted. I also like the racking. I always teach that because I have seen so many people kink the wire. I just never had a term for racking, but now I do.
Fun nurse fact: central lines will trigger allergic reactions in patients with sulfa allergies. It’s on that paper you throw on the floor. Not a good idea to centrally place something that will induce insta-distributive shock. This is not common knowledge, and many hospitals don’t carry sulfa free lines due to expense.
Most hospitals don't carry chlorhexidine/silver sulfadiazine impregnated lines because they are expensive (along with minocycline/rifampin impregnated lines). It is the antimicrobial coating that causes the reaction and in the case of sulfa allergy the silver sulfadiazine specifically.
@@AssociationForVascularAccess as I said "It is the antimicrobial coating that causes the reaction and in the case of sulfa allergy the silver sulfadiazine specifically." As there is no disagreement on that fact, I don't understand the point of your "also have caused reactions" bit. It is also important to note that chlorhexidine/silver sulfadiazine impregnated CVCs have caused anaphylaxis in people without a sulfa allergy because the person was allergic to chlorhexidine and that most reported cases appear to be due to chlorhexidine allergy. But yes, the majority of reported cases came out of Japan in the 1990's (causing the product to be pulled from the Japanese market). This was probably due to underreporting, rather than it being an issue only in Asia. This is evidenced by the fact that currently at least 13 cases have been reported out of the UK, 4 out of Australia, 1 out of the US, and 1 out of New Zealand. As for what most hospitals carry, I'll take your word for it as you are a professional organization and should have a better handle on the details.
Scalpel nick: *I almost never do it in intubated patients. Especially when stasis is compromised. Just dilate and be done with it. Works even for shaldon catheters - no bleeding. * if you use the scalpel: ALWAYS use it when the needle is still in the tissue. U can pull back the needle a cm or two. Cutting over the needle prevents u from damaging the wire with your scalpel. Never happened to me, but I have seen it happen.
Thank you for sharing this with us! We have many patients with tortuous and sclerosed veins (w/ scar tissue). It can be REALLY tough to do this without the wire kinking? Anybody have any suggestions?
Except that scalpel will never cut that wire even if you actively try. The longer you leave the needle in, the higher chance you will injury the back wall or drop a lung
In this demonstration, he says to dilate into the vessel (where you've lost resistance). Is that done in every line insertion like dialysis catheters etc? How safe is that? Or does the dilation just have to get past the subq and muscle layers?
I've been taught to completely insert the dilator, right down to the vessel, including for Shaldon catheters. I have heard about only dilating skin in order to reduce bleeding and risk of vascular injury, but I haven't come across a somewhat official recommendation to do so. I'd say what's much more important before vessel dilation is to absolutely and positively exclude arterial cannulation (e.g. through visualising the Seldinger wire in the ultrasound), since that has a massive risk of causing dissection which you want on none of he insertion sites.
So the interesting thing for me is the part about dilation. I do most of the other things that were listed for central lines already, but it appears that you guys are suggesting going in as far as you can with the dilator until you can no longer rack the guidewire? Maybe it's because I've never used that method but I'm concerned that doing it like that would increase the risk of posterior wall perforation?
not issue because you wont even be thru front wall if you cant "rack" usually, especially if you do it very often w every half centimeter advance even , especially after inital flash
So fired up for next central line. Wish I was working today. Maybe too enthusiastic. Anyone have a problem pushing the wire forward while it is still in the rolled-up assemble, especially when glove is wet from gel, blood, etc? I have started making sure I have a square of gauze ready to place on top of wire to get friction and push forward. Would love know to others' experience.
Thanks for asking! Yeah I do the same thing but instead of gauze I'll just grab any old dirty rag when connecting hydraulic lines to a tractor. It will provide just enough psi friction to get those lines connected and back on the fields
One big trick is not to use ultrasound gel in the sterile field at all. What I do is I fill my the syringe of my finder needle with some excess saline and then just drip that onto the area where I want to put my probe. I get just as good an image and usually I am quick enough to be done with the ultrasound before it dries. Alternatively one can use disinfectant. The main reason is that ultrasound gel is for external use only. It shouldn't be brought into tissue and blood by sticking a needle through it. A secondary advantage is that I have one thing less that will annoy me in the rest of the procedure. I don't really have that much of a problem with blood, since it dries quickly and becomes sticky rather than smeary. I do however also keep some gauze ready to clean my fingers, personally I wouldn't use it to push the wire though, since I lose a lot of tactility through it.
“Don’t cap until you get the line in”. Increasing chance of air embolus if a clamp comes undone or you forget to clamp. “The magical sucking” doesn’t happen. Yes it does although rare. “Rip it out”. No comment needed
Good Lord! What a circus.Never saw that pull,rotate,go in whatever technique.Even less opening skin with scalpel... Using the old Seldinger, a wire and an introducer (dilator),I get from femoral to the heart with a pigtail in 5 minutes...
Contimeter?
Great Job!!!
Im a 28 year veteran of working ERs and this video helped the micro and macroskills explained better than anyone has ever done in my teaching or since in practice, kudos to you dr weingart, keep it up and much gratittude and respect
6:40 It does happen. I remember a delirous patient who was difficult do deal with already and much more so while being sterile. After wire insertion, I re-checked venous placement by ultrasound. In order to protect the wire in my subsequent skin nick I still had the needle in him. As I let go of the wire, it steadily started moving inwards, reaching speeds about a centimeter per second. A ghastly sight indeed. I did not undertake the experiment of whether it would still be sucked in without the needle to glide through.
They don't mention it but they are removing the syringe before inserting the guidewire through the needle hub. I usually pass the wire through the port on the back end of the syringe. It helps avoid displacing the needle tip when twisting off the syringe and decreases the likelihood of an air embolism
It's called racking because its a similar movement/mechanism to racking the slide of a handgun.
Good video. I do all those techniques except the rotation after skin nick. I typically poke with my blade parrallel to the wire for about 1/2 the length of the blade. One thing I would add when threading the wire and it does not go all the way through is to remove the needle. Replace an 18 guage catheter over the wire. Once 18 guage is in, take out the wire. Once can see if catheter is in if obviously blood flows out, or if you attach a syringe to it and blood flow out. NOw replace the wire to redirect, your wire should now move unobstucted. I also like the racking. I always teach that because I have seen so many people kink the wire. I just never had a term for racking, but now I do.
excellent demonstration....very useful practical skills. thank you so much
Great demonstration... Well explained 🎉🎉
Fun nurse fact: central lines will trigger allergic reactions in patients with sulfa allergies. It’s on that paper you throw on the floor. Not a good idea to centrally place something that will induce insta-distributive shock. This is not common knowledge, and many hospitals don’t carry sulfa free lines due to expense.
Most hospitals don't carry chlorhexidine/silver sulfadiazine impregnated lines because they are expensive (along with minocycline/rifampin impregnated lines). It is the antimicrobial coating that causes the reaction and in the case of sulfa allergy the silver sulfadiazine specifically.
@@MarblesAK Most hospitals DO carry Chlorhexidine/silver sulfadiazine impregnated lines also have caused reactions (more so in Asia).
@@AssociationForVascularAccess as I said "It is the antimicrobial coating that causes the reaction and in the case of sulfa allergy the silver sulfadiazine specifically." As there is no disagreement on that fact, I don't understand the point of your "also have caused reactions" bit.
It is also important to note that chlorhexidine/silver sulfadiazine impregnated CVCs have caused anaphylaxis in people without a sulfa allergy because the person was allergic to chlorhexidine and that most reported cases appear to be due to chlorhexidine allergy. But yes, the majority of reported cases came out of Japan in the 1990's (causing the product to be pulled from the Japanese market). This was probably due to underreporting, rather than it being an issue only in Asia. This is evidenced by the fact that currently at least 13 cases have been reported out of the UK, 4 out of Australia, 1 out of the US, and 1 out of New Zealand.
As for what most hospitals carry, I'll take your word for it as you are a professional organization and should have a better handle on the details.
Scalpel nick:
*I almost never do it in intubated patients. Especially when stasis is compromised. Just dilate and be done with it. Works even for shaldon catheters - no bleeding.
* if you use the scalpel: ALWAYS use it when the needle is still in the tissue. U can pull back the needle a cm or two. Cutting over the needle prevents u from damaging the wire with your scalpel. Never happened to me, but I have seen it happen.
What regional accent says “sawntimeter”?
Thank you for sharing this with us! We have many patients with tortuous and sclerosed veins (w/ scar tissue). It can be REALLY tough to do this without the wire kinking? Anybody have any suggestions?
good review- when making the skin incision, I find it safer to leave the needle in and cut along the needle over the wire- it'll protect your wire.
Except that scalpel will never cut that wire even if you actively try. The longer you leave the needle in, the higher chance you will injury the back wall or drop a lung
very useful tips
dam that man good at catching contamination! great instructor!
Think of a pool table when you think of "racking". You're returning something to its original state after movement from that position.
anyone ever figure out what a sonometer is?
In this demonstration, he says to dilate into the vessel (where you've lost resistance). Is that done in every line insertion like dialysis catheters etc? How safe is that? Or does the dilation just have to get past the subq and muscle layers?
I've been taught to completely insert the dilator, right down to the vessel, including for Shaldon catheters. I have heard about only dilating skin in order to reduce bleeding and risk of vascular injury, but I haven't come across a somewhat official recommendation to do so. I'd say what's much more important before vessel dilation is to absolutely and positively exclude arterial cannulation (e.g. through visualising the Seldinger wire in the ultrasound), since that has a massive risk of causing dissection which you want on none of he insertion sites.
So the interesting thing for me is the part about dilation. I do most of the other things that were listed for central lines already, but it appears that you guys are suggesting going in as far as you can with the dilator until you can no longer rack the guidewire? Maybe it's because I've never used that method but I'm concerned that doing it like that would increase the risk of posterior wall perforation?
not issue because you wont even be thru front wall if you cant "rack" usually, especially if you do it very often w every half centimeter advance even , especially after inital flash
So fired up for next central line. Wish I was working today. Maybe too enthusiastic. Anyone have a problem pushing the wire forward while it is still in the rolled-up assemble, especially when glove is wet from gel, blood, etc? I have started making sure I have a square of gauze ready to place on top of wire to get friction and push forward. Would love know to others' experience.
Thanks for asking! Yeah I do the same thing but instead of gauze I'll just grab any old dirty rag when connecting hydraulic lines to a tractor. It will provide just enough psi friction to get those lines connected and back on the fields
One big trick is not to use ultrasound gel in the sterile field at all. What I do is I fill my the syringe of my finder needle with some excess saline and then just drip that onto the area where I want to put my probe. I get just as good an image and usually I am quick enough to be done with the ultrasound before it dries. Alternatively one can use disinfectant.
The main reason is that ultrasound gel is for external use only. It shouldn't be brought into tissue and blood by sticking a needle through it. A secondary advantage is that I have one thing less that will annoy me in the rest of the procedure. I don't really have that much of a problem with blood, since it dries quickly and becomes sticky rather than smeary. I do however also keep some gauze ready to clean my fingers, personally I wouldn't use it to push the wire though, since I lose a lot of tactility through it.
Like it
Thx
santimeter???
Zack Snyder, is that you?
What's a contimeter? Lol
French pronunciation. Kind of like how duodenum has a British pronunciation
“Don’t cap until you get the line in”. Increasing chance of air embolus if a clamp comes undone or you forget to clamp.
“The magical sucking” doesn’t happen. Yes it does although rare.
“Rip it out”. No comment needed
Good Lord!
What a circus.Never saw that pull,rotate,go in whatever technique.Even less opening skin with scalpel...
Using the old Seldinger, a wire and an introducer (dilator),I get from femoral to the heart with a pigtail in 5 minutes...
No no no disagree do not throw items on the floor the bedside nurse deserves better than this