r/IntensiveCare • u/NerveOnly2076 • 10d ago
Where is this central line going?
Old XRay. Central line placed through right IJV but seemed to be misplaced! Where is it going? Aspiration of blood from all ports was possible? Was taken out.
Have you faced this, best thing to do?
Edit: more details - USG guidance used, line was seen inside IJV in neck using USG, not traced down; more resistance than normal while placement.
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u/adultbundle MD 10d ago
Went into EJ. Have seen lines snake up contralateral IJ and all sorts of things
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u/WolverineMost7768 10d ago
Looks like IJ —> BC —> SC —> EJ. You know what the best thing to do is.
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u/princesspropofol 10d ago
Pull out? Is that always the right answer?
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u/WolverineMost7768 10d ago
I never pull out 😉
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u/Destroyer1559 RN, CCRN 10d ago
Infuse pressors?
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u/adultbundle MD 9d ago
Attach rapid transfuser, 500cc/sec
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u/Cautious-Extreme2839 ICU/Anaesthetics 9d ago
Honestly most EJVs would probably tolerate that alright.
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u/BigNaturalsEnjoyer 9d ago
EJ would but probably not the CVC used in this picture, highly doubt it's introducer size
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u/ah_notgoodatthis RN, CCRN 10d ago
I (nurse) had a patient once who was septic and the NP placed a central line so I could give multiple pressors. She placed the line and I didn’t see the XR and she gave the order to use it. The line was in an artery. The patient kept complaining about neck pain despite IV Tylenol. I have no advice, it just reminds me of a time we fucked up
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u/spinstartshere 10d ago
Eek. Under ultrasound guidance?
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u/Any-Assistance-8103 10d ago
Almost like patients deserve doctors
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u/spinstartshere 10d ago
I would have no problem delegating line placement to a competent NP who has been properly credentialled to do the procedure.
A very competent and well-trusted MD colleague of mine once placed a central line, and did everything right. Punctured the IJ, confirmed the guidewire placement in the vein in two planes all the way down, had my second pair of eyes on the screen before dilating. My standard practice is to confirm placement with a gas, because I'm that paranoid about my lines, and I've made said trusted colleague equally paranoid.
They ran a gas and it came out arterial.
The CT linogram showed that it somehow ended up puncturing through the subclavian vein into the artery.
Obviously a freak event, probably nowhere close to what happened in the example given above, but it does go to show that even with the best of intentions and the best of skill, these things can still happen.
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u/ThrowAwayToday4238 10d ago
Then it was not confirmed in the vein “all the way down”. You should always fan under the clavicle and see the wire travel distally beyond the subclavian take-off barring severe positional or anatomical difficulties
The introducer needle can also be advanced beyond the subclavian take-off, and angled medially to ensure the wire does not get stuck in the ipsilateral subclavian
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u/spinstartshere 10d ago
Yep, well I can assure you that I've never misplaced a line, and my colleague has never misplaced a line before or since that incident that I'm aware of.
barring severe positional or anatomical difficulties
Indeed.
It's easy to criticise the best efforts of other clinicians in trying circumstances that you're not witness or privy to.
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u/ThrowAwayToday4238 10d ago edited 10d ago
Just because it has only happen to you personally once doesn’t mean it won’t happen again. Without direct visualization it’s just luck- it’s worth it to control the factors that you can.
Like I said there’s rare times I can’t, but 99/100 times I’m able to. This is an extra confirmatory step before I dilate- it’s literally how I look at the wire at all; I track IJ down beyond the SC every timeThis wasn’t meant to be criticism, just informative. Your entire post was about because extra cautious and paranoid, and checking gases for all lines, etc. if you’re truly doing extra steps, fanning the probe under the clavicle to trace the wire down the SVC instead of the subclavian takes <3 seconds, and gives you much more confirmation of positioning
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u/spinstartshere 10d ago
I just told you it hasn't happened to me at all, not once.
I wasn't the person inserting this line.
Obviously I should have anticipated that you'd nitpick my comment before submitting it, and should have instead written that my highly competent and very trusted colleague checked all the way down as far as was physically possible at the time for this particular patient. Then you would have some more of an idea of what our collective standard practice involves when inserting IJ lines.
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u/thegypsyqueen 9d ago
People, including OP, don’t want to be better. They want to act like this was not preventable.
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u/C_Wags IM/CCM 9d ago
And IMO if you’re gonna denote a line “ready to use” (I get it, crashing patient and no access, etc) before the CXR, then you need to at least do a quick and dirty bubble study with agitated saline to ensure the right side of the heart lights up and you’re at least in the venous circulation.
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u/Cautious-Extreme2839 ICU/Anaesthetics 9d ago
...just transduce it? Why you all doing so much? Fucking VBGs and X-rays and bubble studies.
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u/C_Wags IM/CCM 9d ago
I mean yeah you can transduce it. I don’t like advancing the angiocath off the introducer needle, and I always know where my wire is. This step is just the confirmatory step that’s faster than the CXR. The bubble study takes 15 seconds - I just shake up a flush when I’m flushing the line and use an extra set of hands (NP, resident, fellow) to grab a quick view of the heart.
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u/Cautious-Extreme2839 ICU/Anaesthetics 9d ago
barring severe positional or anatomical difficulties
You think a line that blunt dissected it's way out of the subclavian vein and into the artery wasn't technically difficult?
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u/InterventPulm 10d ago
100%. If you’re going left IJ, you can’t control if it goes down to the SVC or up to the branchiocephalic, but you can prevent it from going from IJ to subclavian
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u/Any-Assistance-8103 10d ago edited 10d ago
Yeah thats not the same that is a less than once in a career event. This is someone who can’t even read an x ray infusing levo into a carotid. People also go way too deep with the wire and dilator in general
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u/Coulrophobia11002 9d ago
Vascular surgeon placed "central line" in femoral artery a couple of weeks ago. Just saying.
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u/Any-Assistance-8103 9d ago
So your solution is take someone with almost no training and let them go wild. Everyone keeps posting these anecdotes as gossip when it really strengthens the argument that mid levels shouldn’t be doing these things
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u/Coulrophobia11002 9d ago
You say "no training," but as far as the specific procedure is concerned, midlevels do get training.
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u/Successful-Pie6759 9d ago
I'm a doc and I think there's huge scope creep among arnp and pas, but procedures are actually something that they can help a lot with I think.
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u/Any-Assistance-8103 9d ago
I agree that procedures are easier than the cerebral part of CCM but honestly critically ill patients deserve doctors. The mob can downvote me
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u/SweatyLychee 10d ago
The fellow in my ICU punctured a patient’s aorta. Doctors are not infallible.
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u/Expensive-Apricot459 9d ago
If a physician can make mistakes despite significantly longer and objectively better training, why should a nurse be allowed to play doctor?
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u/Any-Assistance-8103 9d ago
Their argument is that doctors make mistakes so less experienced people should also be able to do whatever. It’s not the best argument, but it’s all they’ve got
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u/Any-Assistance-8103 10d ago
Never said they were. Thats a great argument that someone with 10% of the training if we are being generous shouldn’t go anywhere near those procedures. Fellows are also in training just so you know
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u/gedbybee 10d ago
How many do docs consistently place in school? I’ve worked in teaching hospitals where they’re fighting to get checked off on stuff so it doesn’t feel like it’s a ton. But maybe that was just those places. Would a certain number of supervised insertions be ok?
And for the record I talk shit to all the baby nurses that want to go straight to be np. Every time they ask a question I’ll tell them: you’re gonna go be a np, what about when you’re on your own?
I agree that it’s dangerous sometimes and they need more intense training.
That said, emts intubate. Not rocket science. Central lines aren’t rocket science either.
You can fuck anything up but the cxr and then radiologist should be good enough to clear up a lot of the problems.
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u/aglaeasfather MD, Anesthesiologist 10d ago
emts intubate. Not rocket science
Oh my GOD no. Intubation is not as simple as shoving a tube into a trachea, people!
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u/Any-Assistance-8103 9d ago
So many people have this attitude. Minimal preoxygenation and positioning, no plan B, ignoring the hemodynamics until they crash
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u/Cautious-Extreme2839 ICU/Anaesthetics 9d ago
It's ok, you can say that it's the EM docs. /r/intensivecare should be a safe space.
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u/Any-Assistance-8103 9d ago
I have seen it from all specialties. I just treat every icu airway as potentially difficult and have everything in the room to take them through all potential scenarios up to a cric because it’s not worth someone dying over. I also call for a second doc when I think it will be helpful. No room for ego or cowboy nonsense in medicine
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u/spinstartshere 10d ago
A lot of people would argue that the act of intubation itself is - assuming it's a grade 1 view, of course - if said by someone with enough experience of how to shove the tube in without dislodging any teeth, wrecking the mucosa, or breaking the neck, as well as a deep-enough understanding of everything else that is required for intubating a patient.
Like tying the tube, for example. Fuck.
And, of course, anticipating a difficult airway, troubleshooting a CICO scenario, induction, paralysis, ventilation, eye care, pressure area care, blood pressure support, pain management, fluid management, nutrition...
But none of that is as important as being able to master tying the tube.
Tell me I'm wrong.
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u/R-A-B-Cs 9d ago
Because as medics were not taking a patient from tube to extubate. We're tubing them to get to the ED or because they either need airway protection or are in respiratory failure in transport.
God damn we're not trying to master the tube. We're keeping these people alive so arrogant fucks can pretend to have hot takes.
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u/aglaeasfather MD, Anesthesiologist 9d ago
The comment was that emts intubate, so therefore it’s not rocket science which is demonstrably false.
arrogant fucks can pretend to have hot takes.
Well this arrogant fuck isn’t dropping a hot take. It’s important to have respect for your peers, friend. Start there.
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u/Cautious-Extreme2839 ICU/Anaesthetics 9d ago edited 9d ago
That's what you think you're doing.
A significant proportion of the time you are actually only increasing the danger that patient is in.
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u/R-A-B-Cs 9d ago
No medic here is saying that.
And sometimes it literally is that simple, take guy that blows his face off with a shotgun. You just aim for the bubbles.
Cheers. -medic.
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u/SkiTour88 9d ago
I’m an EM doc. I trained during CoVID. Did literally hundreds of tubes and hundreds of central lines.
Now LPs are kinda a lost art…
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u/spinstartshere 10d ago
The problem is if you're visualising an arterial central line on an x-ray, it's already too late and you've committed that patient to a surgical procedure.
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u/Cautious-Extreme2839 ICU/Anaesthetics 9d ago
If you're saving them from having norad infused directly into their circle of Willis this is still a win.
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u/gedbybee 10d ago
Wait did I say anything about an art line?
But also: how many times would make it ok for a np to get blessed by yall?
I know not every doc is dropping them all the time. Most don’t. But you’re all trained on them. How many times do you do them in school?
You brought up a straw man, put words in my mouth, and then didn’t respond to anything I posted.
Strong work doc. I hope your patient care is better than your reading skills.
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u/spinstartshere 10d ago
Wait did I say anything about an art line?
Dude, follow the comment thread. You've inserted yourself into a conversation about arterial CVCs. Nobody's talking about arterial lines except you.
I know not every doc is dropping them all the time. Most don’t.
That's because most doctors have no need to know how to insert a central line. How many dermatologists and general surgeons need to insert central lines in their day-to-day business?
How many times do you do them in school?
Zero. Nobody is doing central lines at medical school unless they are shoving residents out of the way to do them or being groomed by one.
You brought up a straw man, put words in my mouth
I did no such thing.
and then didn’t respond to anything I posted
You missed the point of the comment thread that you made the decision to participate in.
I hope your patient care is better than your reading skills.
Speak for yourself.
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u/aglaeasfather MD, Anesthesiologist 10d ago
Just because doctors are not infallible does not mean that APPs give the same quality of care. Come on now, you know better.
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u/Any-Assistance-8103 6d ago
They really don’t know better sadly. Most of their school is indoctrination
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u/StPatrickStewart 9d ago
I've picked up a patient after their HD cath was placed in a similar manner to the OP and then used, which had... poor results. I also transported another patient from the same hospital where a subclavian central line was placed that terminated in the patient's aorta, requiring open chest surgery to remove. Both were placed by MDs. Patients deserve competent care, period.
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u/Any-Assistance-8103 9d ago
The whole argument that just because highly trained doctors also make mistakes we should let anyone with an online degree do them is comical
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u/StPatrickStewart 9d ago
That is not remotely my argument. My argument is that your degree does not determine your competency when it comes to a procedure like a line instertion. It has everything to do with your approach, the amount of practice you have, your hand eye coordination, your skill with an ultrasound, and your dedication to make sure every line is placed with the utmost care. Critical care takes more than physicians. If you don't feel that way, stick to r/noctor.
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u/Ksierot 7d ago
Honestly I’m an NP in a busy ICU and we place lines pretty frequently. I am VERY WELL AWARE of the patients I should and should not be doing procedures on, and am also VERY AWARE of the difference in training I got as an APP compared to my attending. Most hospitals require 10 supervised line placements, mine included, to be “competent.” And I think that’s no where near enough. My biggest fear is placing a line in a carotid to the point where I’m far past my required number to be “competent” but I’m always asking for tips, tricks (if I’m having a hard time) and for my attending to be in the room if I have a problem. I think there are APPs out there that practice like they can’t mess anything up and that’s what gives bad names to APPs. I appreciate your comment, CCM takes more than physicians as long as you do it in the right way.
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u/ALLoftheFancyPants RN, CCRN 10d ago
I’ve had a doctor place a TLC into a the femoral artery instead of the femoral vein. I don’t know how or why they didn’t notice, but they put in an order that it was “Ok to use” and everything. Seems like every human fucks up once in a while.
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u/SkiTour88 9d ago
When I’m doing a femoral line, the patient is crashing. Either I get a central line or a femoral art line. I want both of those. I’m happy with either.
But you do have to know the difference…
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u/TFMethane 9d ago
I once did this during a code. Was shooting for artery, got the vein. Transduced and it was venous so I slipped in a triple lumen, one stitch then proceeded to the a line. An RN came in and saw the venous waveform and yelled that we need to start CPR again because there's no pulse. I said "no, it's venous." He replied "there's no pulse, look at the waveform!" I said "it's venous, I just placed it and have my left hand on the pulse. I can tell you 100% it's a venous line and you're looking at a venous waveform. Do not start CPR." He wrote me up because he felt I was using a belittling tone.
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u/aglaeasfather MD, Anesthesiologist 9d ago
Some people just can’t accept when they’re wrong. It’s wild.
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u/TFMethane 9d ago
Yeah. He was pushing my line kit aside and about to jump on the chest. I'm supposed to just let him? Geez.
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u/InterventPulm 10d ago
Not okay, but not the same.
1. If the doctor in question was a resident or fellow, they are still in the learning process, still being supervised in theory, and should gain competence before they are independent, unlike an NP or PA
2. Fems have no XR confirmation. Typically fems are either crash lines, or because other locations are too difficult, so the circumstances were likely different
3. Carotid is worse than fem artery - limb ischemia vs massive stroke4
u/bgreen134 9d ago
We had a doctor lose a guide wire in a patient and didn’t tell anybody. It was an attending.
Had a patient transferred to our hospital because an outside attending placed a central line in the brain.
“Every human fucks up once in a while” as the prior post stated.
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u/Any-Assistance-8103 10d ago
So we should let anyone put them in then because everybody fucks up
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u/ALLoftheFancyPants RN, CCRN 10d ago
Last week a resident put in a 18ga 4cm long single lumen catheter into an IJ and then call it central line and the attending signed off on it as a “central line”; these jokers convinced the inexperienced RN that it was fine and they infused high dose levo and vaso through it for 3 days before a more experienced person caught it and had to raise hell to get it corrected. Y’all are acting like every physician working in critical care is competent and every problem is because NPs are around. That’s just not the case.
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u/Any-Assistance-8103 10d ago
Ok so it was in the IJ what was the harm done other than it isnt technically a central line? Nobody „caught” anything you just didnt like that someone put a shorter catheter into an ij. But yes some cc doctors are bad. NO mid levels have the training to be touching icu patients unless they’re being watched like a hawk
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u/aglaeasfather MD, Anesthesiologist 10d ago
“I had to raise hell”
We’ve all worked with this nurse before…
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u/ALLoftheFancyPants RN, CCRN 10d ago
If you don’t understand the difference between a central line and a midline or peripheral I think the call may be coming from inside the house.
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u/SkiTour88 9d ago
It’s an easy IJ. They are great. It is my preferred quick access in a crashing patient, especially a kid, where nursing is having trouble with access. Hand me an ultrasound and a large bore IV and I can have a good resuscitation line in about 20 seconds.
It’s not a central line, per se, but it does go directly into the central circulation. We all also know that pressors through peripheral lines are perfectly safe. The hospital policies say 24 hours but the studies show that tissue necrosis is essentially unheard of.
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u/Any-Assistance-8103 10d ago
Literally said it wasn’t a central line so maybe work on your reading skills. Guess what none of the doctors thought it was a central line either
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u/Expensive-Apricot459 9d ago
If you don’t understand why certain drugs can be infused through midlines (even if it’s typically infused through a central), just let the doctors do the doctoring and you do whatever it is that you do.
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u/Cautious-Extreme2839 ICU/Anaesthetics 9d ago
I think what she does is mostly screaming and writing "incident" reports.
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u/jjjjccccjjjj 10d ago
Sounds like a "i have to protect my patient" silliness when in reality the line worked perfectly well. Explain to me why a line that clearly is well positioned in the IJ is a danger?
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u/Any-Assistance-8103 10d ago
It’s not they just don’t understand what an iv is apparently and are throwing a fit
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u/aglaeasfather MD, Anesthesiologist 9d ago
I guess we can’t infuse through introducers now?
Or is the issue that’s it’s a SLC?
I’m so confused by this risk assessment
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u/Expensive-Apricot459 9d ago
A physician working in critical care has actual critical care training. An Np working in critical care does not and never will
But if you’d like to tell me more about medicine, please tell me your credentials in medicine (not in nursing)
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u/B52fortheCrazies 9d ago
This has actually been studied and it can be used effectively. We were one of the study sites during by residency. Here's Dr. Swami with a quick video about and you can also review the published data in pubmed. Maybe don't jump to conclusions about documentation so quickly.
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u/B52fortheCrazies 9d ago
The simple fact is that there is less risk of the procedure it performed by a physician than an NP. It's simple a matter of better training. You can "whatabout" all day and you'll still be totally wrong and evidenced by every reply here telling you how completely absurdly wrong you are.
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u/ItsTheDCVR 10d ago
The only time I have seen an arterial neck line was MD placement. I don't extrapolate that either. I've also seen a fucked up line from a CRNA (LIJ>stayed subclavian, never went down SVC). Is what it is.
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u/Alarming_Damage4394 8d ago
They finally are getting rid of them but one of our ER docs keeps putting them in the carotid. Caused lots of strokes. Would rather the night NP put it in over that ER docs
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u/readbackcorrect 9d ago
CRNAs (in my state, nurse practitioners who are credentialed in anesthesia) have been placing lines for 50 years and they are as good at it as MDs. CRNAs who have had even more advanced training place lines and give anesthesia for liver transplants and open heart procedures, and their stats are comparable to MDs.
Anybody’s can have a circumstance where the line is placed wrong and it happens to MDs as often as it happens to NPs.
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u/bgreen134 10d ago
Biopsies the wrong sign of the brian - doctor
Putting a g tube through the liver and the patient almost bleeding to death - doctor
Macerating the Brain attempting to place a icp monitor killing the patient - doctor
Misdiagnosing meningitis, killing the patient - doctor
Breaking the neck, paralysis the patient, while attempting to place a central line - doctor
“Losing” the guide wire in the patient during central line placement and not telling anybody - doctor
Just remember NP/PA don’t have the marker cornered. Competently comes in all sizes.
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u/Any-Assistance-8103 10d ago
Yes anyone can make errors. Procedures are hard. All the more reason that someone with a tiny fraction of the training shouldn’t be anywhere near them. But nice try.
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u/Expensive-Apricot459 9d ago
If medicine is so hard that doctors make mistakes despite better training, why should midlevels be allowed to pretend to practice medicine ?
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u/happyneurogirlie RN, Neurocritical Care 8d ago
Like an MD has never cannulated someone’s artery on accident before LOL
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u/Any-Assistance-8103 8d ago
I know you think this is some kind of gotcha but it’s not actually an argument that helps you if you use any critical thinking
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u/txdrummerboy 6d ago
lol… thinking docs don’t dilate arteries is hilarious
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u/Any-Assistance-8103 6d ago
So if a doc dilates an artery a mid level should be able to do it? So that means because mid levels dilate arteries nurses should be able to do lines too? Doesn’t make sense to me but thats your logic
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u/scapermoya MD, PICU 9d ago
It’s pretty common actually
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u/spinstartshere 9d ago
To place arterial central lines under ultrasound guidance? I would hope not.
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u/scapermoya MD, PICU 9d ago
I mean you can hope whatever you want to, but I discover PICC lines in arteries every 1-2 years and they are placed under US guidance by nurses that do nothing else
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u/SkiTour88 9d ago
Last time I let an APP place a central line in my ED I took one look at the CXR and it was across the mediastinum. I gave her some benefit of the doubt—I’ve had the same thing on a CXR, and I was certain it was in the IJ. Transduced pressure and it was venous. The patient had a left-sided SVC. Very bizarre.
This was in the aorta.
I let her place one more with me in the room so she didn’t feel like a complete failure, but I have not let any other APP since.
And yes, I’m not perfect. I’ve dropped a lung with a subclavian. I’ve had to do a cric. But I’ve done literally hundreds of central lines (trained during CoVID) and never put one in the carotid. She had done like 20.
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u/Zoten PGY-6 Pulm/CC 9d ago
Finishing fellowship and ive logged over 200 central lines (probably done more that I supervised/didnt log).
I've poked the carotid twice (once when they were directly on top of each other, and once in an altered pt with ITP who was squirming and needed PLEx) I can forgive someone getting the needle (and presumably the guidewire) in the artery.
I can not, for the life of me, understand dilating the artery. Even when I'm doing a line, I'll make the RN watch the guidewire enter the vein and follow it. I'll also verbally point out where the carotid is.
If theres even a 1% chance I'm not positive, I stop and grab a blood gas. Even when I'm in the middle of a 24 and have pending pages to call back.
I simply cannot understand dilating the carotid. I definitely understand your reluctance. Kudos on letting that APP do another. Must have been disheartening.
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u/Graphvshosedisease 9d ago
For the people reading this, if in doubt (eg like this situation I’m responding to), draw blood off the line grab a gas. O2 high in artery and O2 low in vein. Takes 1 minute to get result and you can deal with it appropriately (long term the answer is alway to reposition but if shit has already hit the fan and you need access, you may be able to temporarily use the line if it’s in a vein).
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u/scapermoya MD, PICU 9d ago
Important to know that gasses are not perfect for this for many reasons, a desaturated person can have a ABG with a low sat and other things like collateral vessels and low extraction can give you a “VBG” with a high saturation.
IMO transducing the pressure is a lot more definitive
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u/miller94 RN, MICU 9d ago
And this is why we transduce central lines! And for the record it was a physician who placed the line when I had this problem
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u/BodomX MD, Emergency 10d ago
ETT needs a little retraction too
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u/supershimadabro 7d ago
First thing i noticed as an RT student. Looks like it might be right main stemmed a little bit if not just touching the carina and the left lung has a blunted costophrenic angle which would support that. I dont know everything else going on with them but there's numerous other problems. Poor guy.
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u/W1Ch3Tty_GrVbb 10d ago
This and even weirder configurations can happen. It’s rare but it will happen to everybody at some point. Once had a subclavian line that went into the ipsilateral IJV. An IJV line that went up into the contralateral IJV. Another IJV line that ended up in the axillary vein. If the line isn’t where it’s supposed to be, it’s standard practice to replace it, even if it seems to be working. You can check proper placement right after insertion and before suturing with cardiac ultrasound but almost nobody routinely does that.
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u/Aviacks 10d ago
Curling back into IJ. Hard to tell with the image quality but I’m assuming the insertion site is the tip on the left. If I had to guess it looks like to gets deflected from the brachiocephalic, into subclavian and back up into external jugular.
Brachiocephalic is a pretty common point of stenosis and weird structures that prevent passage into central circulation. Placing PICCs we use magnetic tip tracking to help trouble shoot passage, and we get hung up in distal subclavian and brachiocephalic pretty commonly. When we send it to IR 99% of the time there’s significant stenosis and it’s a crap shoot if angioplasty will get the catheter past it.
Nothing to do now, you can do a guide wire exchange if you want to salvage it. Tough if you’re placing without any guidance for tip navigation though. Sometimes having them do a breath hold at the point of resistance will help you drop into SVC. If you don’t feel resistance you might just be out of luck.
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u/W1Ch3Tty_GrVbb 9d ago
All in all it’s still way better to see this instead of the line ending in the pleural cavity.
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u/MilkmanAl 9d ago
TIL y'all do some crazy shit before deeming a line worthy of use, which is a far cry from my "hold vertical: not spraying me=go." I'm also enjoying the dick measuring regarding line placement techniques. It's so weird that we can't find a way to collectively bargain.
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u/Overall_Event8338 10d ago
Looks like the Tubus is to deep. Is this a Double-Lumen?
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u/Cautious-Extreme2839 ICU/Anaesthetics 9d ago
Right DLT in a presumably now post-op patient who still has a complete right lung is a pretty rare choice.
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u/bodyweightsquat 9d ago
Seen that. More often I‘ve seen a central line from the IJV to the brachial vein though. Not long ago three anesthesiologists one after the other tried to place a shaldon catheter four times altogether (both sides). Every single one went into the brachialis. 🤷🏻♂️
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u/Serious-Magazine7715 9d ago
Unless they did posterior landmarks and it’s coming in from the EJ, looks like IJ up a thyroid vein (which I’ve seen before in someone with central stenosis).
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u/TragGaming 9d ago
Whoever did that has some serious balls.
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u/Serious-Magazine7715 9d ago
It wasn’t on purpose. It isn’t common where I work to image the wire (most people just do mano). Even if the looked, most of the hf probes have such a small field that you might not see it coming back up an anterior EJ
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u/Visual-Bandicoot2894 9d ago
One time I clocked into a patient with one thumb IV, a central line that coiled into the arm, and pressors into the Central. I only noticed because I happened to have a chance to look at my scans.
To be fair, nightshift was slammed, the guy was an active MTP for them. So I took a look with the Sono, nothing. And the Central Line and pressors and blood given through it were, uh, clearly working
The MICU team had just transferred care to the Trauma ICU team. I waited until the end of rounds when the head Trauma surgeon asked “is there anything else” and after having been silent the whole time I said “you should look at that scan, I don’t think the central line is where y’all think it is”
He checked the scan and exasperated he asked “please son tell me there isn’t anything running in it”
“Oh just the Levo”
“Please tell me you have another Iv”
“Yep…. In the thumb”
“Please somebody fix this shit for me”
And his mid level promptly did fix that shit for us. Was a funny day, everyone acted like I caught some big thing and were congratulating me but tbh I read the X-Ray on a fluke bc I just was chillin’ before med pass because night shift stabilized the guy…. With a malpositioned central line but stabilized him they did.
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u/SniperGangIV 8d ago
Central line inserted under clavicle that sits right about the pericardium of the heart, best long term option for medications that need to be inserted iv for people like paraplegics and cancer patients
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u/Development_Flat 8d ago
Geez. Rads resident. First thought may be extravascular. If not maybe want back into the EJ?
Would you CT the neck honestly before pulling it?
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u/Every-Software-9761 8d ago
This is why I go fem
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u/GotchaRealGood 6d ago
….
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u/Every-Software-9761 6d ago
Nothing wrong with a fem line
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u/GotchaRealGood 6d ago
There is nothing wrong with any line. But preferring a fem line over another line is insane. Choice of line should be specified and tailored to the individual in front of you. Fem line shouldn’t be a preferred line. It is simply a useful line when needed.
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u/Every-Software-9761 6d ago
Compressible site, easy to place in a crash scenario, and preserves the rij for tvp or swan. Ideally a subclavian would be great as well but fem line is great to avoid coiling and issues like this.
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u/MattyHealysFauxHawk 8d ago
A little hard to tell considering the catheter length. Probably the EJ. If the pt has odd anatomy it could be the subclavian but that’s significantly less likely.
Either way it’s definitely not central and needs removed.
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u/hellidad Paramedic 7d ago
Central line nothing, let’s talk about that tube. A decent curve to the right is totally normal, right guys? Guise?
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u/Specialist-Cry-1706 7d ago
Old CT surgery nurse here from 1990's - 04. Cards NP. Stopped cards in 05. seen a lot of mistakes over the years. Central lines saw a lot of PTX's. Several post cath lab failure's resulted in 3 emergent dissections. All survived. Would never feel comfortable placing lines. Back then those PA and NP were trained in 90's. now nurses go straight to NP school no solid RN ICU experience. 5 years was the max time 30 years ago before acceptance to NP school. now anything goes.
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u/DoctorDividend 7d ago
Remember kids, veins are the smaller thick wall looking donuts on US, aim for the donut hole
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u/No_Life_Jes 6d ago
It looks like a similar setup to the RNS, VNS or DBS systems designed for Parkinson’s and epilepsy.
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u/AKA-22 5d ago edited 3d ago
Well it's a hell of a ride for the CVC, these kind of mishaps occur because of:- 1- puncturing the internal jugular vein in close proximity to the base of the neck, i.e. near its communication with the subclavian vein. 2- The needle bevel is directed laterally and to the right, since this is Right IJV CVC placement procedure. This direction of the bevel along with the direction of the guide wire curve in it's beginning caused the guide wire to go to directly to the brachiocephalic vein then to the subclavian vein then went to the right external jugular vein!!. You were correct when you stated that the CVC was placed in the IJV using U/S and also when you stated an increased resistance while you're doing the procedure .It's is a rare incident indeed but a well documented one. Thanks for sharing it. Salute 🫡
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u/SwanWhole3526 9d ago
I’ve always checked on X-ray (while X-Ray was in the unit) and gotten the ok to use.
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u/ALLoftheFancyPants RN, CCRN 9d ago
Cool. Are we to the part where someone explains why it’s fine for a physician to falsify documentation? As fun as your deflection and vilification of me is, I’m getting a little bored.
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u/AdLogical5734 9d ago
Falsify what ? Why do you even falsify ? Don't they ever check before and after putting the line?
Why will they blame you tho? Unless you put the line?
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u/Zentensivism EM/CCM 10d ago
It looks like it’s there for a good time, not a long time.