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August 11, 2012

Answers from Haney on SCUS

Jeopardy! host Alex Trebek
Haney Mallemat responds to my response to his great screencast on placing subclavian central lines with US:

1) Doppler - This is a great point. Although most commercial point-of-care machines now have pulse wave Doppler, some older machines may not. My response?...get a new machine ;) , or use color Doppler which should work just fine. The only problem is when the vessels are very close and one vessel creates alterations of flow and color in the other vessel. To a person with a moderate amount of ultrasound experience this may not be a problem, but when I've taught folks with little to no U/S experience I find they have trouble with the color distinction. This is why I choose pulse wave Doppler; it allows you to put the interesting area in the middle of the sample volume (that thing that looks like an equals sign) and you get accurate information without the other "noise". Just a preference.

2) PTX in SC - True, the risk of PTX may be overblown and ultrasound might be like medical school (i.e., the more you know/see, the more paranoid you get…) However, I am a firm believer in that if I have the ability (and time) to do a procedure "un"blinded "and see anatomy, I will (and this logic goes for the puny, little radial arterial line too; I always try to use U/S). I'll will also play devil's advocate and ask, "should trainee's ditch the blind subclavian approach for U/S"? No, I think that would be a HUGE mistake as this line should be mastered blindly. The addition of ultrasound is just another trick up my sleeve that makes procedures safer and increases success when others can't get the line.  

3) Ultrasound Saves Time - I don't think that U/S adds time; I feel that's a perception and the U/S studies don't support that notion. 100% agree with you that U/S gets the line done sooner because it's done one time. I think people that argue against ultrasound are in the "generational" gap and don't want to learn something with a moderate learning curve. It might be cool if they just said that but I find it hard to believe (and argue) against people who state that they can do central lines WITHOUT U/S faster and with the same complications as U/S….the data doesn't support that. If true, however, those people should do a study and publish…that paper would be a "game changer"  

4) Femoral Lines - I'll insert your points with my comments in parenthesis:
Seth:Femoral lines are terrible in codes (Well...maybe not terrible, but not my first choice)
Seth: The vein collapses during hypotension, making it hard to find and harder to cannulate (Yes, I agree)
Seth: It can appear arterial (by palpation or US) as chest compressions push both ways (Yes, I agree)
Seth: Landmarks & anatomy are unreliable (Yes, I agree)
Seth: I'm not saying to never use place a femoral line, but if you do I really think you should absolutely use ultrasound (Yes, I agree. Always w/ ultrasound)
I personally wouldn't place an U/S guided IJ or SC during a code. My personal preferences in descending order are 1)IO 2)Fem w/ U/S 3)Blind Subclavian 4)Blind supraclavicular (one of my favorite procedures)

5) No Neck? - That left IJ is actually the subclavian I placed. We had to come anterior because the needle was not long enough and we went perpendicularly into the skin. The dialysis line was placed by IR during business hours. 

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