> I regard rapid vascular access as a core skill. IJ,
> subclavian, femoral
> (closed and open) and cut down should all be part of the
> armamentarium.
>
I was hoping to get through this thread without having to agree with Rowley.
> Fair enough, but it doesn't answer the question. I can't
> remember the last time I needed to put in an 'emergency' neck
> line or do a cut down.
Last one I had was yesterday. We get a fair amount of septic shock and
haematemesis in the elderly here. Part of the reason for putting them in is
that the patient is going to a medical ward- I can handle a patient on
clinical assessment while standing at the bedside. Leave them on a medical
ward with nurses and occasional review by an SHO and they need more invasive
monitoring.
I also believe that if you are to give drugs during a cardiac arrest, it
makes sense to give them centrally.
I agree that in general, however, there are few cases where you need one
because you can't get any other access. The cut down at the groin is used
only in that circumstance and it's been a couple of years since I've used
one of them (however, it's also a very easy technique, so deskilling isn't
an issue).
> Sometimes there just isn't enough of
> a need for a procedure to gain or even maintain the skill in
> doing it. This is an increasing problem in many departments
> I suspect. As staff numbers are increased to deal with the
> 'minor & major' workload there are less resus cases to go
> round and so exposure to critical care interventions is
> diluted for both trainer and trainee.
Looking at our figures (and leaving aside the cardiac arrests), I'd reckon
that maybe 1 in a thousand patients need central lines, plus the same number
or maybe a few more in whom a central line can be justified, but the need is
debatable. I think that's sufficient to support a consultant on call from
home and coming in for all patients needing central lines (i.e. being called
in at an early stage based on physiological parameters). It may not be
enough in a consultant delivered service. Having said that, I went through a
couple of years as a trainee in departments where A and E didn't put in
central lines at all, but when I got back to it, I didn't seem to have lost
the skill.
> Andy I'm not Ga
> Ga yet, I hope tell me if I'm wrong though.
I can confirm that last time I met Danny he wasn't Ga Ga yet. That was a few
years ago, though.
> On the rare occasion I do a central line...
> 1. In medical patients, found jugular no easier than
> suclavian or femoral.
> Unless very fat and sometimes femoral is difficult in these.
However, it has a lower rate of haemo or pneumothorax than subclavian; and
if you mess up it's compressible. Femoral has a high infection rate is of
arguable use with abdominal trauma, abdominal compartment syndrome or in
cardiac arrest; and can be unreliable for pressure monitoring.
> - I personally believe subclavian lines are easier to dress
> and nurse. I
> certainly very often stuffed up the dressing on the neck...
I agree. They are also more comfortable in the awake patient and have a
lower infection rate. They have a higher incidence of major complications,
and are harder to pass a Swan or pacing wire through if you want to do that,
though.
Matt Dunn
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