Two of the most common bedside procedures in the ICU are placement of central venous catheters (for reliable venous access) and arterial catheters (for hemodynamic monitoring). Since both devices are often placed for management of shock, it stands to reason that if you need one, you’ll often need the other.
Placing sterile vascular lines can take a fair amount of time, and it may seem like placing a pair of them would take twice as long. However, in reality most of that time—at least for a skilled operator—is spent positioning the patient, finding and preparing equipment, and establishing the sterile field… not actually inserting the lines. (Hypothetically, if you could assemble a dozen vessels in one place, like a vascular assembly line, you could cannulate them all pretty darned quick.)
This means that if you’re planning to place both central and arterial lines, the clever way to do it is to prepare a single sterile field, set up a single kit, and use that shared setup (reusing the common pieces of equipment) for both procedures.
How? Here are a few of the logistical and anatomic approaches that tend to work well.
The IJ/subclavian and radial combo
The internal jugular is probably the most common site for ultrasound-guided central lines in most centers, while the radial is the default arterial site. Combine them as follows:
- Open a central line kit. In addition to your central line supplies, drop in a radial arterial catheter. You’ll need an extra dressing as well.
- Whichever IJ you’re using, position the ipsilateral arm (e.g. the right arm for the right IJ). You can do this in various ways, but the essential thing is to hold it in supination so the volar surface remains accessible; I just run a loop of tape from the thumb side of the thenar eminence to the bed. Expose the wrist, confirm the vessel’s patency (by palpation or ultrasound), and perhaps clean the skin.
- Cover the patient with a full-length drape (thus hiding the arm) and insert your IJ line.
- Once finished with the IJ, palpate through the drape to find your arm, lift the drape away from the patient, and use scissors or a scalpel to carefully cut a small fenestration. Position this over the target vessel and prep the skin. (Even if you cleaned it before, I would not presume it to still be aseptic.)
- Insert the radial line, reusing the lidocaine, sutures, ultrasound, and other accessories from the central line.
- Dress both sites and break down the field.
This works equally well with a subclavian line, and is generally a good setup for slow, thoughtful cannulation.
What about for more emergent lines? In many cases, the classic “crash” line—such as in a cardiac arrest patient with no access—can simply be handled by an intraosseous catheter. However, some patients, such as those needing massive transfusion, may still benefit from an expeditious central line. Crashing patients may also need an arterial line to guide their resuscitation, and for the sickest, you’ll want one in a large, central artery; if you’re placing that, you might as well place a venous line nearby.
These can be done in a sterile manner if you have time, but can also be placed “dirty,” using a partial or wholly non-sterile technique, with the understanding that they’ll need to come out as soon as the patient is stable. Consider:
The double femoral lines
Dubbed the “dirty double” by Josh Farkas, this uses simultaneous, ipsilateral femoral lines. It is fairly conducive to blind (non-ultrasound-guided) placement, even for users generally accustomed to relying on sonography.
- Prepare one femoral site, either fully sterile or with just a cursory skin prep. (Even the sickest patients can usually wait a couple seconds while you run a chlorhexadine swab over the skin, which dramatically decolonizes the site compared to puncturing a completely unprepared surface.)
- Insert either the central or arterial line; you can start with either. If placing it blind, you may inadvertently puncture the wrong vessel anyway (i.e. the artery when you were looking for vein, or vice versa). Suture this in place, or it may get inadvertently pulled while you’re fussing around subsequently. If necessary, this line can be used immediately while you keep working.
- Insert the second line adjacent. If going blind, use the position of the first as a landmark; if using ultrasound, you’ll need to work around the other cannula.
- Cover both lines with the same dressing.
- An alternative: place both wires first, then insert each cannula. This leaves you with more working room (the REANIMATE ECMO folks like this approach). However, in a sick patient you may want to use the first line as soon as it’s available, and a wire won’t help you there.
- Another alternative: prepare both sides of the groin and put one line in each location. This obviates bumping into the first line as you place the second, but you’ll have to manage (and dress) two sites; it tends to take a little longer.
Not enough choices for you? Here’s one final option for simultaneous lines.
The dual chest lines
This is a somewhat advanced approach and doesn’t always pan out as elegantly as you’d like. However, it can be a nice option when you want two central, supradiaphragmatic catheters.
- Prepare for and insert a subclavian line, either blind or with ultrasound.
- Insert an axillary arterial line on the same side.
- Alternately, insert a brachial rather than axillary A-line.
The problem with this is that you’ll often need to reposition the patient for the second portion; axillary (or brachial) lines are usually placed with the arm abducted and/or externally rotated. You can try to do this in advance, but it may distort the anatomy and your working position for the venous line.
Cannulating the proximal axillary/subclavian artery adjacent to the venous line (a “transpectoral” approach) can be done and is described in the literature, but is usually a little scary: the vessel is quite deep and hard to compress, and you end up with an incredibly central arterial line, sometimes terminating in the aortic arch. It can work, but buyer beware.
When placing multiple lines, it’s almost always preferable to do them as a combined procedure. A bit of caution is needed to ensure that both remain sterile, and in general the “more sterile” line should be placed first (usually the central line). With a thoughtful approach, however, it becomes a fast, efficient process that makes intelligent use of your most valuable resource: time.