Venous Catheter Line Complications

Just a line, just a line. How many people get a consult for, it's, we just need a line. So, uh, so this is a, a real case, a 13 year old presented to the peed service with hemolytic uremic syndrome. It's very proud of myself for getting a hematologic slide on there. Uh, and then, you know, it's posted by your partner who was on call last night. You're the Sal. You're just back from seeing a trauma. They brought the patient back to the OR before you can get by to see the parents. You say hi to them in the OR. Tell them it's all gonna be OK. And then, you know, you go and you review the chart. The PS note says to OR in the a.m. for vas cath for peritoneal dialysis. What does that mean? Intern consented for a vas cath. NICU gets a, you got a potential ECMO coming in. The patient's asleep. What do you do? Do you put in a temporary dialysis catheter in the right IJ? Do you put in a peritoneal dialysis catheter? Do you call the PES team? Do you call the intern who consented the patient? Like, what do you do? So, what I did is we called the team, the primary team. And they said, no, we want a vast calf. So we put in a right IJ Pas cath. Turns out nephrology, apparently everybody was debating this. They really wanted a peritoneal dialysis catheter, but we did this for a couple of days because usually we do peritoneal dialysis for HUS cause we questioned that. And then 2 days later we were back putting in a peritoneal dialysis catheter. OK, it's an incredibly common issue for us, or has been, and we've tried all sorts of things to mitigate that about what is the right catheter before you get to the recovery room, have you put the right catheter in? Yeah, at the Cleveland Clinic there are issues with line placement all the time and so now there's like an actual, anytime that a patient's getting a line. There's a separate form that they have to fill out where they specify exactly what type of line that they want, how many lumens, uh, all of that. We also have that form and just last week when I was the SA, which for those of you who aren't familiar, stands for surgeon of the Week. It's not an award. Yeah, I know it's not an award. I had to call the service to say we have 3 diff this, you know, the pre-op information says 3 different things. What do you actually want? Yeah, we have a very similar mechanism with the line request form that has to be filled out. Specifically though, one of the things is who's the attending responsible and what's the number. So when you, we've used that multiple times, so it's a nephrology service, we're not calling peds, we're not, we're calling the nephrology attending. Um, but, and we actually won't book the case until it's that line is actually in the patient's chart. We, we have it scanned in and a, uh, physical copy of it, so it has to match. Yeah, so we actually have a, uh, an order set in our, we have an order for it in Epic. This is a paper version of it that I put up there, and at the bottom is this latest revision. Has who is the uh the resident and the attending, you know, and everybody responsible for that patient with their contact information so we can get it right away because I know for us this is a really It's a pain in the rear problem that everybody has. And what I'm trying to emphasize is that it's just all about communication because there's so many combinations and permutations of the just a line. And does your form say what we also have them say what line, every line that was there in the past. So we, we have that on our thing, so we know what's available. We, we don't have them putting every line there, but we can get that pretty easily out of Epic, um. So here's, here's another case. Uh, this is a pretty active 16 year old that has sickle cell but has complications of his sickle cell and is on a transfusion protocol. This kid probably today, and I actually don't know if he's gotten one, would probably get a bone marrow transplant in our hospital for his sickle cell. Uh, but it has a history of multiple lines. MRV shows again, again, like my hematology slides. I got the sickle cells. Um, this MRI is supposed to be the next slide. Um, well, basically the whole upper system is an MRV that's with the both subclavians and both IJs clotted off. There's reconstitution of the superior vena cava with the azyous, which is what you usually see in these kids. That usually, that stuff usually doesn't clot off. So what do you do? Would anyone here, uh, do a saphenous vein cutdown? I would, yeah, because there are some people that would, you can do a broviac or a, you know, a cuff central venous catheter in the femoral with the saphenous vein cut down even though they're active. You, you could do that. Yep, there's, that's popping up some there too. It's just because Todd would do it. People are jumping on the bandwagon. That's probably, that's how people don't, there's a, so just two weeks ago I had a similar case and we have a really great IR guy. And we went to the IR suite, brought the whole OR team there, and did, uh, managed to get above and, and, uh, took a long time, but eventually got a wire then a catheter. Hold on, hold on, hold on. Oh, sorry. Yeah, the, the, we got, we're gonna, well, I, I know what you're gonna say. You're, you're given the answer. Oh, so 9%. So see, Max started talking and then all of a sudden people want to poke the heart. So, uh Yeah, so I'm going to go. So this is what we did, um, uh, and this is actually a video we presented a few years ago with, uh, Kurt Koontz, uh, who's in Tennessee, and Matt Clifton, who's basically what you can do is, and what we did is under thoracoscopic guidance, we put a needle in the Right neck and went along the course of the superior vena cava and you can see it scarred down up in the superior mediastinum, but just track along the mediastinum and get into the superior vena cava right where it reconstitutes with the azygous vein and then get a guide wire and then just, it's just another line. Um, that you can, uh, dilate up. One of the keys is that you need a longer needle than comes in the kit, so we use a spinal needle. We did not do it with IR, but uh, you know, I guess you could do it with IR. We just did it under thoracoscopic guidance, um, and it worked really well. It worked well enough that this kid actually kept that line for about a year or two, and then something happened to it. I forget what it was, and we came back and we did it again, and it was sort of just the same thing over again, so. Didn't Marcus, I think Marcus Jarbo reported doing this essentially we're using IR, using radiographic guidance or ultrasound guidance as opposed to thoracoscopic guidance, but it's it's the same sort of thing, and my guess is that you can probably just, as far as I know, you can just keep doing this. We've done, you know, maybe half a dozen of these when they've come up, but it's not, uh, again, it's a, it's a pretty straightforward technique once you're doing it. Everybody gets a little nervous, but it's pretty straightforward, so in Birmingham. As I recall, um, yeah, in our case, what we did actually, the, the clot went in the upper atrium, and so we had to get into the distal atrium, then we balloon dilated the clot to make a channel. That wasn't just going to thrombosis right away. That's why we had the whole OR team standing there cheering. I think I was scrubbed in passing, passing things to him, so a little bit different. So, uh, next case, a 5 year old needs just a single limb and cuff CVL for treatment of ALL. How do you approach this? And what I don't, I actually don't have on here is subclavian using ultrasound, and there's some folks that are using ultrasound for subclavian sticks, which we're not doing yet. I think it's a different approach. It's a supra, the supraclavicular approach. The, the new in, in the papers on that, the pneumothorax rate is still higher than the IJ, um, and then there's some mixed data about higher in fact. There used to be some, some data that you get a higher infection rate with an IJ stick, although that's, that's very mixed data, and that doesn't really pan out in a lot. So most people are gonna do a right IJ stick using ultrasound, and that's what we would do. Uh, currently, um, but you know, there's, there's a lot of papers out there about, you know, what is the, you know, the intravascular complications based on sight, uh, subclavian, you get a little more, uh. Pneumothorax IJ question whether you get more infection, but the bottom line is it's really not a whole lot of difference in all the, in all the, uh, different, uh, routes that you go, and many of the final recommendations I'll say, you know, basically right IJ ultrasound or you could do a a or, or you could, or ultrasound, I should say IJ ultrasound guided or. A subclavian stick. So I, uh, it was Sean Saint Peter's paper out of Kansas City that convinced me years ago to switch to this when they showed that using ultrasound guidance and an IJ had, had better outcomes. Um, I don't remember, oh. There it is, uh, so, uh, that, yeah, and then the other person, Carolina Milan, is a pediatric surgeon in Argentina who came to spend some time with me and actually she taught me a ton more than I could ever teach her, and one of those is how young I could go with percutaneous sticks. Um, I was always a little hesitant to do this in the, in the newborns. Uh, I did cut downs and, uh, since she came now, I even do them in that age as well. Yeah, I mean, we, we do percutaneous sticks in almost everybody. The tiny little micro premiums we still do a, a cut down on. But actually in that, I didn't even cover that and it was in those kids, I don't ligate the jugular vein. I just poke it with a needle and then thread, thread a catheter through it so you don't ligate it. So hopefully you can get it. But the other thing, the other trick that someone taught me, I think it was Oliver sold this, this idea of a micropuncture needle. Do, do you have that as well? We do. OK, we do have the micropuncture needles. OK. So you have a 16 year old trauma patient and he's a central line for pressers. You place the line in the right subclavian using landmarks, and that arrow is pointing to your catheter. So what do you do? People here in the room. Between the last two. Who would, um, try again at the same site, who would go somewhere else, so who would try at the same site. I would probably try. It depends. If it, if you put a big dilator in there, then you might have a hematoma. Right, and that's a, that's, you know, that's my point. I'd try again at the same site, but I wouldn't persist very long. Um, I'd go to the other side, is what I, is what I would do. But again, you know, this is one of those things that, you know, you want to look with fluoroscopy too, because you don't wanna have, you know, you don't want to end up with a hemothorax on one side and a, uh, and a pneumothorax on the other. Sorry, we have a ton of questions that, um, we'll answer, but, uh. Uh, Faiza Haidar, who has been coming on to these events for about 8 or 7 years, uh, she actually, she's in Bahrain, and she said that they do external jugular, uh, access back to the original thing. Does anyone here use that as their primary site, EJ, if it's there and big. I did for years. He used to. I get a lot of used to. Yeah, I used to, so, so Mark Rowe taught me how to do that when I was in, I was in Pittsburgh for a year doing a critical care fellowship. He, that was like his primary go to, and he talked about it and how you could, you know, but there were all these tricks he had, and, and they, it's not as easy as you think to get to the junction of the EJ and the IJ. Things can get hung up and stuck and go the wrong way. Yeah, you can use the facial vein, actually, yeah, facial vein cutdowns. We used to use to do those too. That's what I used to do too. All right, next. OK, so.