invasive lines

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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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  3. 11 Comments so far...

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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.
  6. 0
    Quote from MLB55
    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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    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.
  9. 0
    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?
  12. 0
    Quote from MLB55
    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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