invasive lines - page 2

I work at very large teaching, level one trauma center and there are a few practices that I have questioned in regards to lines. First one is, two Mac or cordis (introducter) lines inserted into the same IJ during liver... Read More

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    Quote from MLB55
    I work at very large teaching, level one trauma center and there are a few practices that I have questioned in regards to lines.

    First one is, two Mac or cordis (introducter) lines inserted into the same IJ during liver cases. I understand the rationale for big access in these cases as they require tons of transfusions. My concern is two 9 fr catheters in one vessel, does any one else see this as a problem. I asked an anesthesia resident and he said because it's easier to do 2 sticks on One prepped site rather than cleaning another... Seems more of a convenience than anything. He also rationalized it as the vessels can expand to accommodate this.

    Second, I've seen anesthesia residents and even fellows change art lines over wires to the long femoral arterial lines in a radial artery! Again my concern is that burden on a smaller vessel to hold a catheter that probably almost reaches the elbow. I asked one resident if this was "ok" and his response was probably not.

    What do you think?
    We get similar patients all the time. Usually anesthesia uses a triple lumen and a Cordis. If you've ever looked at the vessel with a catheter in it after placed with US there is actually quite a bit of room. We don't seem to see more stenosis with these patients. Multiple catheters seems to be a bigger risk factor. The risk of sticking both sides and dropping both lungs in surgery would be higher.

    As for the art line, if these are the same catheters that we use, they don't have a bigger diameter, they are just longer. The artery gets larger the farther up you go. The theory is that the artery is spasming around the tip and by using a longer catheter you can bypass this. You have to look for diminished flow in the hand (pale or cold hand in the radial distribution). I've only seen this once with the longer catheters. Seen it a couple of times with the regular catheters.

    All in all nothing that unusual there.

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    I also work in a large center that also has a high volume liver transplant service. In these OR cases, our anesthesia team typically places a MAC on the IJ, a couple large bore peripheral IV's, and a RIC ( in the arm knowing that these are very bloody OR cases that result in large EBL's and multiple transfusions.

    That said, placing two central catheters in the same IJ site is acceptable. As an ICU NP, I have placed a triple lumen CVC and a Trialysis catheter (Power-Trialysis* Short-Term Dialysis Catheter | Dialysis Catheters | Bard Access Systems) in the same IJ site. As Core0 stated, the IJ is typically a large vessel and can accomodate two lines through its diameter. In this age of ultrasound guided line placements, you could actually tell during placement if you can do this just by looking at the size of the IJ on the axial view with the ultrasound probe.

    There are many factors taken into consideration when we place lines. Dialysis catheters (such as Trialysis) works well in the Right IJ location best and is preferred especially for patients on CRRT. In the few cases I've placed double lines in the same site, the other IJ site is unusable (clotted, subjected to intervention, etc.), SC sites are contraindicated due to coagulopathy, and femoral sites are not ideal due to a large pannus that could subject the line to infection.

    As far as arterial lines, I have placed long femoral catheters in the radial site in a previous setting I worked in. They tend to last longer and same as in Core0's experience, have not seen adverse effects from its long length that would not have happened in the regular length arterial catheter. Our arterial catheters are all Gauge 20's regardless of length if that makes a difference. However, current policy where I work now requires that we only place the short catheters in the radial site. A lot of time, policies are created based on case reports of adverse effects. I would have to dig up the literature on it.

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