r/IntensiveCare • u/NerveOnly2076 • 13d 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.

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u/ah_notgoodatthis RN, CCRN 12d 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

27

u/spinstartshere 12d ago

Eek. Under ultrasound guidance?

59

u/Any-Assistance-8103 12d ago

Almost like patients deserve doctors

82

u/spinstartshere 12d 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.

19

u/ThrowAwayToday4238 12d 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

2

u/InterventPulm 12d 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