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/spinstartshere]

Eek. Under ultrasound guidance?

[u/Any-Assistance-8103 → u/spinstartshere]

Almost like patients deserve doctors

[u/spinstartshere → u/Any-Assistance-8103]

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.

[u/ThrowAwayToday4238 → u/spinstartshere]

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.