post induction CVL insertion

[maceramsay]

Hi
I am being told by the medical director/administrator that I must get a CXR after inserting an internal jugular CVL post induction before I can use it. I have only recently moved to this rural Australian hospital. My normal practice is to place the CVL post induction using Ultrasound guidance with the head midline and feel the guidewire down. I usually look for evidence of atrial stimulation to check I'm in the RA. I aspirate venous blood after removing the guidewire. I then measure the distance to the sternomanubrial junction using the marks on the guidewire then position the catheter to that length.
I used to do cardiac anaesthesia as well as Intensive CAre and have placed at least 1500 catheters this way. They get a post op CXR.
Does anybody do an on-table CXR before using an Internal jugular CVL place post induction?
thanks
Mace

[jafo1964]

Mace
your practice is consistent with recommended scientific evidence
I dont think the process can be made any safer
USG guidance, measured catheter length and aspiration should suffice
I wonder how an CXR is going to further aid confirmation of placement. CXR may reveal a pneumothorax if it develops secondary to pleural injury, which is why we use a USG to minimize it.
CXR in post-op period will suffice, unless you are going to IPPV the patient with large volume controlled ventilation and you want to avoid any chance of tension pneumothorax

a piece of advice
if your boss wants it that way and the facility is available why not get it done
it may not be necessary but it can do no harm
the only thing you will lose is a few minutes and a bit of scientific ego

regs

[Bicarb]

we don't make use of x-rays right after insertion since we do the alpha-card ecg check to see if it's in place. cheap, no radiation exposure and easy to do...

[yogenbhatt1]

Alpha Card ECG check.
New for me. No more in ICU running and management.
Can you explain a bit more?
May be easier learning a new thing from you.
Regards

[jafo1964]

"A card" is the trade name for INTRA- ARTERIAL ECG GUIDANCE for proper positioning of CVC catheter tip at the confluence of SVC with the RA
You can google the Braun products and the catalogue should show up
Proper positioning of catheter tip is of paramount importance when there is a likelihood of air embolism. Aspiration of the embolised air will be possible only if the catheter tip is optimally placed

But Xray chest shows you pneumothorax which a ACARD cannot show. Pneumothorax can occur when the advancing needle touches the apical pleura or the lung itself. This has an incidence of 10% with SCL vein and about 3 -5 % with IJV insertion. Is more common in COPD patients.
Needle touching the pleura followed by IPPV during anaesthesia can produce significant pneumothorax or rarely potentially fatal tension Pneumothorax.
ACARD cannot detect this and this undoubtedly will require a Xray chest in the post op period although it can be delayed by a bit


regs

[yogenbhatt1]

Hi,
Thanks for the prompt reply. The name was new to me, but I knew that you will reply soon.
better to show your ignorance once and learn something new.
Thanks again,
With Regards.
Yogen Bhatt