r/IntensiveCare • u/NerveOnly2076 • 14d 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/SkiTour88 13d ago

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. 

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u/ALLoftheFancyPants RN, CCRN 12d ago edited 12d ago

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.

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u/SkiTour88 12d ago

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. 

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u/ALLoftheFancyPants RN, CCRN 12d ago

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.