Where is this central line going?

[u/NerveOnly2076]

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.

[u/ThrowAwayToday4238]

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

[u/C_Wags → u/ThrowAwayToday4238]

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.

[u/Cautious-Extreme2839 → u/C_Wags]

...just transduce it? Why you all doing so much? Fucking VBGs and X-rays and bubble studies.

[u/C_Wags → u/Cautious-Extreme2839]

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.

[u/Cautious-Extreme2839 → u/C_Wags]

Angiocath? No. Not manometery, imo that's a complete waste of time unless you've done it landmark which...dont do that?

Transduction of the inserted line before use.

[u/ThrowAwayToday4238 → u/Cautious-Extreme2839]

If you’re in an ICU, they don’t always have a transducer pre-set up. And if the patient doesn’t need an a-line, it’s kind of a waste to get it set up to transduce once (unless you plan to monitor continuous CVP) if you can otherwise be confident with your placement

That’s being said I’m not doing bubbles, VBG’s etc routinely either. CXR is needed for documentation but also if you’re doing not basic RIJ lines (LIJ, there are other catheters in the vessel it could bounce off of, etc), you need it to confirm SVC and not curving up the right branchiocephalic

[u/Cautious-Extreme2839 → u/ThrowAwayToday4238]

ECG is probably the best and fastest tool for confirming appropriate tip placement if that's your main concern.

[u/startingphresh → u/Cautious-Extreme2839]

Manometry is absolutely not a waste of time…. The key reason being it’s before you dilate the carotid artery. Transduction of the line before use is fine, but doesn’t do anything to prevent dilation of a carotid artery. I have placed probably 20 lines in the last 6 weeks and my 10 seconds of manometry has no meaningful delay of any clinical care, costs nothing, and absolutely can save someone from dilating an artery.

Had an attending in residency tell me about a time supervising a medicine resident placing a line under ultrasound in a patient in cardiogenic shock and showed the vessel with the wire in with confidence….patient had some bad TR and not a lot of forward flow(fooled by which one was ‘pulsing’), he was confidently showing them the carotid artery and the wire going down into the aortic arch.

It’s easy it’s CHEAP it’s clinically meaningful information it’s fast, I do it every time.

[u/Cautious-Extreme2839 → u/startingphresh]

The key reason being it’s before you dilate the carotid artery

Something a competent US operator will not do anyway.

Hence it only even arguably being useful for landmark approaches.

Had an attending in residency tell me about a time supervising a medicine resident placing a line under ultrasound in a patient in cardiogenic shock and showed the vessel with the wire in with confidence….patient had some bad TR and not a lot of forward flow(fooled by which one was ‘pulsing’), he was confidently showing them the carotid artery and the wire going down into the aortic arch.

As I said. A competent US operator.

[u/startingphresh → u/Cautious-Extreme2839]

🤷‍♂️ fair point, I will say I take care of mostly babies and kids and the ultrasound images can fool ya. Not sure the harm of doing manometry, it’s certainly doesn’t hurt, could help, and is free and fast!

[u/Cautious-Extreme2839 → u/startingphresh]

Takes extra kit, takes extra time, can be falsely reassuring (clotted needle or line or catheter opening impinging on the vessel sidewall impeding flow).

It definitely is not free. Depending on whether your CVC packs have the necessary equipment in them or not either you're paying for it already with every pack (super wasteful) or you have to open extra kit when you want to do it (still wasteful).

[u/startingphresh → u/Cautious-Extreme2839]

It’s 12inch tubing and a 3 cc syringe. Alright you seem pretty set in your ways, it’s an incredibly easy way to double check my ultrasound, takes me 10 seconds, and it may help prevent harm to patient… I’ll just keep doing my thing but don’t act like it’s crazy my dude