Introduction: Rethinking Vascular Access

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Nurses Edition Commentary

Mizuho Morrison, DO, Kathy Garvin, RN, and Lisa Chavez, RN

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Steve D. -

I have had great success with this technique in code situation when CPR is in progress. Easy to get flash, almost impossible to stay intravascular with the needle alone. With the catheter, once you get the flash and thread the angiocath you are golden. However, when using it for IJ's, I have noticed that if you miss the vein on the first attempt, the catheter often will not draw back with the needle as you try to reposition the needle to enter the vein. I have had to put down the ultrasound probe, grab the catheter and needle with my non-syringe hand, and hold them together as I draw back to reposition, then pick up the probe again, which is obviously not ideal.

Jeff S -

Dr. Strayer really makes it seem like a miracle that a CVL is every successfully placed without his technique.
In my experience, when using the traditional wire-through-the-needle approach, there is almost always a dribble of blood when you are in the lumen of the vein. If I see that dribble with a wire in hand, I pass the wire. If I don't see the dribble, I put the syringe back on and make sure blood aspirates freely. If it doesn't, I re-position the needle until it does, then pass the wire.
While I'm all for trying to techniques, I feel he overstates exactly how big of a problem this is. Seems like a nice "arrow in the quiver", but no need to "throw out the baby with the bath water" (to steal phrases from both Rob and Mel).

Geoffrey W. -

Thanks for the segment. As luck would have it (or lack thereof), I had the exact situation 2 weeks ago, and left feeling very frustrated at both of the patient's IJs that gave a great flash, but would not let me thread the wire. Nothing like pulling out a bent wire. Now I have another method to use when the central line is not going as planned.

Mike M. -

2 comments on this piece:
- Dr. Strayer recommends discarding the US probe, and not being concerned if it slides off the sterile field. I disagree! Those probes are really expensive! Dropping them on the floor can damage the crystal array permanently. Additionally, you may need the probe to confirm wire placement, or to guide your needle if you lose the vein.
- I share Scott W's concern with decreased ability to access the vessel. For this reason I access the vein with the needle (sans catheter) and then use the catheter as follows: if I'm meeting resistance with the wire I thread the catheter over the wire (small skin incision with scalpel) and into the vein. I then partially withdraw the wire and re-thread through the catheter. This almost always works to appropriately redirect the wire .

Aaron G. -

I specifically don't use the angiocath. You only need to see someone sheer off the tip of the angiocath once (either when threading the guidewire or pushing the needle back into the catheter after it was pulled it out halfway) to be somewhat leery.

If you're worried about your needle having moved between when you got flash and preparing to dilate, just use your US to confirm that your guidewire is in the vein, not the artery before dilating.

Omeed S. -

TSH is actually somewhat frequently abnormal in septic or critically ill patients. It is thought to be a normal adaptive response and the majority of patients recover normal thyroid function once well. Some studies have shown worse outcomes in patients with lower thyroid hormone levels during sepsis, so testing and treatment would seem to make sense; however, while animal studies of thyroid supplementation seemed promising, human studies have not shown an advantage. In fact, some studies have found a reciprocal decrease in TSH and resultant potential adverse affects. Something to consider when testing or diagnosing thyroid disorders in septic or critically ill patients as recommended in the episode.

Michael M., MD -

Suggestion for Sanjay and Mike in the area of imaging decision and shared decision making (apologies for being out of context re subject matter, but this is how I was advised to drop this in the sugggestion box):

AJEM December 2015
"Can physician and patient gestalt lead to a shared decision to reduce
unnecessary radiography in extremity trauma?"
Michael Mouw, MD, MPAff

Study Objective: To study the predictive value of patient and physician gestalt regarding the presence or absence of fracture or dislocation in minor extremity trauma.
Methods: This was a prospective observational study of patients presenting to an urban teaching hospital emergency department with minor extremity trauma, but without obvious deformity. Subjects were enrolled after radiography had been ordered by a physician. Exclusion criteria included arrival by ambulance, torso injury, and unreliable clinical examination. A questionnaire assessed patient’s and physician’s pretest prediction of abnormality (fracture or dislocation,) and the outcome was radiologist finding of an abnormality. Chi-squared analysis was done to evaluate the predictive value of patient and physician gestalt for radiographic abnormality.
Results: 191 subjects with 195 injuries were analyzed. Fifty-four (27.7%) were found to have abnormalities. There were 14 cases where the patient predicted there was “definitely not” an abnormality. All 14 had no abnormality, for an NPV of 100%. There were 87 cases where an attending emergency physician predicted <10% likelihood of abnormality - of these there were 5 (6%) abnormal x-rays. Multivariate regression analysis found that pain scores did not predict the presence of abnormality but that patients with abnormalities presented sooner after their injury than patients without.
Conclusions: In patients estimated to have a fracture risk of <10%, only 6% had fractures. When patients felt there was “definitely not” a fracture, there were no fractures. These results suggest that patient and physician gestalt should be studied further as variables for inclusion in future imaging decision rules.

Dallas H. -

Since this episode I've done one subclavian line and three fems with the trusty needle. Last night I decided to attempt this method with a fem line. While I love this technique in theory, I noticed several issues in practice. Firstly, as mentioned above, if you do not get flash on the first stick the catheter will not withdraw unless grasped at the hub. Secondly, once I obtained flash and disconnected the needle, the wire would not pass. Venous blood pulled easily suggesting the catheter was still in the vein but the wire would not advance more than a few centimeters. I ended up scrapping the angiocath and placing the line the old fashioned way with no issue. I'm not sure why the wire wouldn't pass with the angio but I wonder if the subq tissue pressure might have collapsed the lumen. I'll probably use this method for IJs but I think I'll stick to the needle for fem lines.

Nicholas M. -

MWU EM Dallas?

Dallas H. -

You know it!

Michael S. -

I've been using the catheter technique for years, and usually use it as my first attempt for IJs - the biggest drawback I've noticed, and the reason that I occasionally have to abandon it and use the regular 18ga needle, is that the 18ga catheter is over a smaller (20ga?) and thus much floppier needle than the full up 18ga finder needle. In the ideal (and usual) situation when you can insert the needle straight on in and no lateral manipulation is required, it works great - but if you have to jink sidewards at all, the "floppiness" of the smaller needle under the 18ga catheter markedly limits your ability to do so.

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