CVL placement landmarks?

[traumaguy8]

What are the landmarks for a subclavian cvl insertion? I help md's put them in all the time in my unit but when they are in the zone, they dont really explain it too well. What do you all use to keep from hitting a lung?

[Creamsoda, ASN, RN]

Im not sure I understand your question. We as nurses cant to anything to keep a doc inserting a central line from hitting a lung. The doc inserts them. You just gotta hope its a competent doc. After the line is in, then we get a chest x-ray to confirm placement to ensure there is no pneumo and its in far enough. I

[PICNICRN, BSN, RN]

We have a bedside US/doppler that the docs will use. I think this is a new thing over the past few years, they used to just use their landmarks and put them in. I think I've only seen a pneumo about two times in my career from a CVL placement.

[Happy Halothane]

What are the landmarks for a subclavian cvl insertion? I help md's put them in all the time in my unit but when they are in the zone, they dont really explain it too well. What do you all use to keep from hitting a lung?

SCV line insertions are traditionally a blind procedure, using anatomical landmarks for guidance. Fluoro or Doppler can be used, but in the interest of time, not commonly used. A skilled clinician should be able to have the dressing on within 5 minutes of prepping.

Landmarks...if you use the infraclavicular approach, the pt should be head-down, turned away from insertion site. The SCV runs parallel and just deep of the middle 3rd of the clavicle. You can place your thumb where the clavicle bends slightly posteriorly (costoclavicular ligament), and your index finger in the suprasternal notch.

You insert 1cm below the clavicular midpoint, and advance towards the suprasternal notch....keeping close to the posterior clavicle.

Complications beyond a pneumothorax: hemothorax, air embolism, catheter embolism, infection, dysrhythmias...among a few. "Dropping" a lung is possible, but unusual with practiced technique.

On one of the slow days....ask one of your intensivists to map the landmarks on a patient (hopefully sedated).

[traumaguy8]

Youre right..that is confusing. let me explain. When i said i help the doctors, i ment by getting the drugs they order, the cvl kit, anything else they might need during the procedure, and holding the pt still if they are moving. This question is for CRNA's who I thought were able to place cvls under their scope of practice. the doctors i have asked have never really given me a solid answer about the landmarks they use...sorry for the confusion!

[sleeperer1]

http://apps.med.buffalo.edu/procedures/centralvenous.asp?p=6

[traumaguy8]

Thanks Happy! That sounds like something that would take a lot of practice. unfortunatly on my unit, we have a lot of 2nd year residents trying to place lines in pts with +3-4 edema, and lungs are dropped way too often.

[CerebralCRNA]

The doc inserts them.

My, my, my...... how can this statement be made in a CRNA forum....

CRNAs place them as well.

[traumaguy8]

My, my, my...... how can this statement be made in a CRNA forum....

CRNAs place them as well.

I thought so...

[NRSKarenRN, BSN, RN]

working nights, assisted many doctors and crna's inserting central lines on resp/telemetry unit, helping to position pt + setup equipment:

england:

the insertion of central venous catheters using the landmark technique

february 2004

1.1. central venous catheters (cvc's) are inserted for a number of reasons

including haemodynamic monitoring, intravenous delivery of drugs (e.g.

inotropes and chemotherapy) and blood products, haemodialysis, total

parenteral nutrition, cardiac pacemaker placement and management of

perioperative fluids. central venous catheterisation may be required for

patients undergoing cancer treatment, dialysis, or coronary or other major

surgery and for those admitted to intensive care units (itu's), high

dependency units (hdu's) or accident and emergency departments. it is

estimated that approximately 5000 cvc's are inserted annually across the

lth trust.

1.2. cvc's are inserted in a wide range of clinical settings by a diverse group of clinicians including radiologists, anaesthetists, nephrologists, oncologists, surgeons, cardiologists, general physicians and paediatricians. in the usa and increasingly in the uk, nurse specialists are also undertaking cvc procedures. the range of settings in which cvc's are inserted across the trust includes operating theatres, emergency rooms, nephrology, oncologyand general wards, radiology departments, itu's and hdu's.

1.3. an audit of practice in 2002 highlighted a number of deficiencies in practice.

this document lays out basic guidelines for the practice of cvc insertion by the landmark technique to which all practitioners should adhere.

www.leedsteachinghospitals.com/sites/emibank/clinicians/guidelines/documents/centralvenouslines.pdf

infraclavicular approach: central venous line placement

central line insertion: r internal jugular vein rudolf cardinal ...

anatomical drawings: central line insertion skills in cooperation with arrow ...

[NRSKarenRN, BSN, RN]

My, my, my...... how can this statement be made in a CRNA forum....

CRNAs place them as well.

Member is from Canada where they do not have CRNA's practicing yet...just starting first program.

[vaccrn]

Im not sure I understand your question. We as nurses cant to anything to keep a doc inserting a central line from hitting a lung. The doc inserts them. You just gotta hope its a competent doc. After the line is in, then we get a chest x-ray to confirm placement to ensure there is no pneumo and its in far enough. I

Creamsoda,

CRNAs can, and do, a lot to keep a doc from hitting a lung. They can insert the line themselves. CRNAs routinely insert central lines (I did 2 today - 1 subclavian, 1 IJ). Happyhalothane did a great job outlining the landmarks (posted below).