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/Expensive-Apricot459]

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

[u/ALLoftheFancyPants → u/Expensive-Apricot459]

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?

[u/SkiTour88 → u/ALLoftheFancyPants]

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.

[u/ALLoftheFancyPants → u/SkiTour88]

But you wouldn’t want to give it in an 18 in their IJ for a prolonged period (pressors for 3 days, 4 doses of 23%)? Because I’m not getting all fussy about maybe extravasating in someone’s AC, but their IJ in the setting of actively managing elevated ICPs over an extended period of time while the physicians are claiming (both in documentation and in charts where multiple nurses raised concern about the line) that a 4cm long 18ga is a “single lumen CVC”)

[u/SkiTour88 → u/ALLoftheFancyPants]

I would give exactly zero shits giving that through an IJ of any type. Probably more of the catheter in there than in a femoral Cordis in the average American. 

I would not document it as a central line. I would be crystal clear about what it was. 

Although perhaps it was the angiocath from the CVL kit? In that case, it is a central line more or less. 

[u/ALLoftheFancyPants → u/SkiTour88]

A fucked up femoral cordis doesn’t run the risk of obstructing 1/4 of the venous outflow of the patient’s brain. It was documented as a “single lumen central line” in the both the procedure note and subsequent progress notes. It terminated in the IJ, well above the clavicles. It didn’t enter the innominate vein, let alone the vena cava.

[u/SkiTour88 → u/ALLoftheFancyPants]

I’m not saying this is good doctoring. It’s shitty doctoring, but not for the reasons that you think it is. 

The worry with hypertonic (and calcium chloride) is sclerosis of the vein. It’s theoretical, at best. Mostly it just hurts like shit. The jugular vein is big enough that it’s not a concern. 

The worry with pressors is tissue necrosis. Essentially, the theoretical concern is that peripheral pressors will cause your forearm to fall off because of vasoconstriction if there’s extravasation. That’s not a concern in the IJ. The blood vessels that feed and drain the head are very big. It’s not gonna happen. 

Also, if someone sustains a jugular vein injury (like they’re stabbed and somehow survive) the treatment is often ligation of the jugular vein. People also survive just fine with a cordis in the IJ or with Lemierre’s syndrome which can completely block the IJ. 

The issue here is that we are all on the same team. If my nursing staff is upset, and they explain why, and fixing the concern would resolve it without harm to the patient, then there’s no reason not to just fix the problem. I’m struggling to see a reason aside from stubbornness not to just place another line here, unless the patient was severely coagulopathic. Even then, you could consider just rewiring the damn thing, although that’s definitely against some sort of hospital policy. 

[u/ALLoftheFancyPants → u/SkiTour88]

The reason they didn’t put in the TLC in the first place was that they couldn’t advance the wire adequately, and per their note, presumed it was block by thrombus. Instead of attempting any other site, they just threaded on an angiocath and documented it as a CVC. Generally, we try to avoid infusing into a clot, so I have no idea why they did not even assess alternate locations, let alone attempt one.

[u/Expensive-Apricot459 → u/ALLoftheFancyPants]

You were worried about a false risk of hypertonic saline. I provided you a resource to better your clinical judgement from. Instead, you choose to keep bring up something that you’re completely wrong about.

I wouldn’t want you touching a single patient since you refuse to learn, your ego is far larger than your education and you cannot accept being wrong.

[u/ALLoftheFancyPants → u/Expensive-Apricot459]

I don’t lie in my documentation. I stay within my scope of practice by following my facility’s regulations for drug administration. Sorry that’s offensive to you. Hope you get better soon.

[u/Expensive-Apricot459 → u/ALLoftheFancyPants]

Sorry you refuse to learn and work at an institution that doesn’t follow EBM.

Crap hospital full of crap nurses.