central lines

[pjdk9]

We have a thoracic surgeon who will put in a subclavian line. He orders a chest X-ray (per policy) then insists if he writes the order to use it we should, without waiting for xray results. Also he recently had a triple lumen that ws found to be coursing upward toward head. He also insisted this is Ok to use as there is no documentation to prove it's harmful. Please advise. We have been arguing with this Dr for years.

[mags-rn]

Originally posted by pjdk9

We have a thoracic surgeon who will put in a subclavian line. He orders a chest X-ray (per policy) then insists if he writes the order to use it we should, without waiting for xray results. Also he recently had a triple lumen that ws found to be coursing upward toward head. He also insisted this is Ok to use as there is no documentation to prove it's harmful. Please advise. We have been arguing with this Dr for years.

Referring to this specific question whether a line in the jugular vein could be used, the answer is no for the reasons given below. There may not be evidence in the literature about such things where common sense is needed!

I would say that a check X-ray is mandatory for all central lines inclusive of peripherally inserted lines. Apart from recognising complications like pneumothorax, you do not want to rely on pressure measured outside thoracic cavity or infuse vasoactive or hypertonic solutions like TPN elsewhere than the desired site. There may be situations where you cannot wait or cannot do a check X-ray (for example perioperative period). In these situations as long as one is able to aspirate blood in all the lumens and there is a convincing pressure trace with appropriate pressures, I do not see any reason to start using the line without an x-ray. If these criteria are not met, I would have a high suspicion and hope a check X-ray was done at the earliest. Regarding line tips migrating to the jugular veins, pressure on the jugulars would cause distortion of the wave form and pressure.

We recently had a patient who sustained head injury and admitted under the neurosurgeons. On the third day patient had features of acute abdomen. Patient also had left sided pleural effusion. Differential diagnosis including pancreatitis were considered. Before using the central line inserted through the femoral route, the registrar tried to aspirate the line only to get some clear fluid. The line was not used and another access was secured. On reviewing the abdominal X-ray, it was found that the line was coiled in the same side (left) iliac fossa. Patient also had some 3 litre fluid in her pleural space which was of the same colour wh8ch was aspirated out. This patient had received all drugs including Mannitol and fluid through the line inserted in the femoral region for three days. All she needed was removal of the line and throracocentesis!