invasive lines

Specialties MICU

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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?

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Yeah, that sounds pretty shady.

A Cordis is HUGE. Two in the same IJ is just asking for trouble in my opinion. Liver patients are usually the ones getting them, and their coagulopathy would have me concerned about them bleeding around two large catheters like that.

A Cordis might be convenient, but if you don't have another access already, they should be putting in a triple lumen instead. Push for that. If you connect the blood tubing directly into a triple lumen's port instead of using connectors, you can pressure bag blood in at a wicked fast rate, typically in under 5 minutes, so a Cordis doesn't give you that much of an advantage unless they're bleeding out their eyeballs for hours on end. I've never seen a real benefit to someone getting a unit of blood in 60 seconds versus 5 minutes.

I've never seen any of our fellows put a fem kit into a radial artery, not to mention how much longer the wire is and the risks that might involve.

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The two cordis' are for the OR. We would pull one of them once they got to the unit. I've heard of livers getting 91 liters of blood/fluid during a case. So the benefit of two major lines could be needed, I just think they should be different sites.

Speaking of which, trauma from Ed after being run over by our transit train got two cordis' in each fem... Plus a triple lumen in the subclavian. He got at least 75 units of products in his first 24 hrs.

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The two cordis' are for the OR. We would pull one of them once they got to the unit. I've heard of livers getting 91 liters of blood/fluid during a case. So the benefit of two major lines could be needed, I just think they should be different sites.

Speaking of which, trauma from Ed after being run over by our transit train got two cordis' in each fem... Plus a triple lumen in the subclavian. He got at least 75 units of products in his first 24 hrs.

Oh, I thought you meant they were bringing them up from the ED with two Cordis' in the same site and leaving them like that for days. Traumas bleeding out is different than a liver failure/GI bleed. I think the most units of blood I've ever given in a 12 hour shift is 20, so that's doable with one Cordis or a good solid triple lumen.

In a trauma, I suppose if you're going to go through the whole sterile procedure of doing a line and it's either a dead patient or two good lines to dump blood products in, that's a different case. Might not be the ideal scenario, but it's like in PALS where if you've got an infant that needs AED pads it's either throw adult pads on A/P if you have nothing smaller, or have a dead baby. Gotta do what you gotta do.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

How can they be in the same vessel? If one is in the EJ and the other is in the IJ it should be fine. The long a lines...my question is why would they do that???? If you could get it to thread it should be fine and it might be in far but it wouldn't be near the elbow.

Many times anesthesia places the lines where they can access them due to the draping and positioning of the patient in the OR.

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They are directly superior/inferior of each other. They are indeed in the same vessel.

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Specializes in CVICU.

Yeah, seen this done with RSC triples and split-caths just inferior to them in temp dialysis pts

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Two double lumen cordis for every liver transplant.

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In the same vessel?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
They are directly superior/inferior of each other. They are indeed in the same vessel.

Yes they are....sort of.....eventually they dump into the subclavian....and yes they can take the volume.

The internal jugular vein collects blood from the brain, the outside of the face and the neck. It runs down the inside of the neck outside the internal and common carotid arteries and unites with the subclavian vein to form the innominate vein.

The external jugular vein collects most of the blood from the outside of the skull and the deep parts of the face. It lies outside the sternocleidomastoid muscle, passes down the neck and joins the subclavian vein.

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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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Specializes in ACNP-BC, Adult Critical Care, Cardiology.

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 (http://spinalist.debunk-it.org/RIC%206.pdf) 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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