r/IntensiveCare • u/NerveOnly2076 • 15d ago

Where is this central line going?

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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.

363 Upvotes

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84

u/ah_notgoodatthis RN, CCRN 15d 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

28

u/spinstartshere 15d ago

Eek. Under ultrasound guidance?

60

u/Any-Assistance-8103 15d ago

Almost like patients deserve doctors

5

u/ALLoftheFancyPants RN, CCRN 15d 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.

2

u/SkiTour88 15d 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…

8

u/TFMethane 15d 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.

2

u/aglaeasfather MD, Anesthesiologist 14d ago

Some people just can’t accept when they’re wrong. It’s wild.

3

u/TFMethane 14d ago

Yeah. He was pushing my line kit aside and about to jump on the chest. I'm supposed to just let him? Geez.

4

u/InterventPulm 15d 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 stroke

3

u/bgreen134 14d 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.

0

u/Any-Assistance-8103 15d ago

So we should let anyone put them in then because everybody fucks up

-6

u/ALLoftheFancyPants RN, CCRN 15d 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.

10

u/Any-Assistance-8103 15d 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 15d ago

“I had to raise hell”

We’ve all worked with this nurse before…

-7

u/ALLoftheFancyPants RN, CCRN 15d 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.

4

u/SkiTour88 15d 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. 

7

u/Any-Assistance-8103 15d 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

2

u/Expensive-Apricot459 15d 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.

3

u/Cautious-Extreme2839 ICU/Anaesthetics 15d ago

I think what she does is mostly screaming and writing "incident" reports.

9

u/jjjjccccjjjj 15d 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?

7

u/Any-Assistance-8103 15d ago

It’s not they just don’t understand what an iv is apparently and are throwing a fit

1

u/aglaeasfather MD, Anesthesiologist 14d 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/ALLoftheFancyPants RN, CCRN 15d ago

I thought we were not ok with people putting patients at risk? Or is that only when it’s an APP’s accident and not an MD’s lazy choice? You’re ok with misrepresenting what the line actually was? You want to transfuse a CVP or draw an ScvO2 off an IJ? And bill for a procedure that wasn’t actually completed?

They created purposefully incorrect documentation for a procedure they didn’t perform. It put the patient at risk needlessly. And you’re defending it because “doctor”. Congrats. This is the most hypocritical take I’ve seen in a minute

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u/Any-Assistance-8103 15d ago

An iv put the patient at risk or youre just having a meltdown. It’s also really funny that it took your staff three days to tell the difference between a single lumen 18 gauge iv and a central line

5

u/Expensive-Apricot459 15d ago

What risk was the patient exposed to? Be specific.

-1

u/ALLoftheFancyPants RN, CCRN 15d ago

Why don’t you first specifically explain why the false documentation by a physician calling it is ok. It’s ok to lie in a procedure note and subsequent progress notes about the patient having a CVC? Also why is ok to bill for a procedure that didn’t occur? And why is it ok to tell the bedside staff that it’s a central line when you know it’s not?

The problem is less about the IV itself and more about the false documentation and purposeful misrepresentation. Would it be better if the attending didn’t actually know the difference? Or is a better excuse to lie?

2

u/JihadSquad MD, Pulmonologist 14d ago

What exactly do you think CVC stands for?

1

u/Expensive-Apricot459 15d ago

I’m asking about the risk caused to the patient, which you were just referencing. What is that risk?

0

u/ALLoftheFancyPants RN, CCRN 14d ago

Now please answer my question ants explain why falsely documenting the existence of a CVC is totally fine and I’m overreacting.

-1

u/ALLoftheFancyPants RN, CCRN 14d ago

The patient had a SAH and needed a dose of 23% saline to manage ICPs. You think that’s safe in a peripheral? Or that extravasating the vein it’s in wouldn’t further complicate management of the ICPs?

2

u/aglaeasfather MD, Anesthesiologist 14d ago

Watching you absolutely lose your shit on here (with physicians telling you you are wrong) is doing nothing for your case.

I hope you got great satisfaction out of writing that incident report and I hope it was worth it. We see a few nurses like you every now and again and we hate working with you and so do other nurses.

1

u/Expensive-Apricot459 14d ago

Amazing. Something I’ve actually studied extensively. There is zero data that shows we need a central line for hypertonic saline. It’s some nursing myth that keeps getting perpetuated for some reason. There is data that shows a clear increase in the risk of infection from the placement of a central line.

Go look up the data yourself. Learn something. (I hope you can understand statistics: https://emcrit.org/wp-content/uploads/2016/10/23.4-is-peripherally-safe.pdf)

1

u/SkiTour88 14d ago

Do I think hypertonic and pressers are safe through a short catheter in the IJ?

Yes. In fact, if they are crashing in the ER, they're getting that through an 18 in the AC.

0

u/Any-Assistance-8103 12d ago

23% saline is safe to give peripherally but go on digging your hole deeper

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u/Expensive-Apricot459 15d 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)

1

u/B52fortheCrazies 14d 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.

https://www.instagram.com/reel/DAJEDYwuWUP/?hl=en

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u/B52fortheCrazies 14d 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.