Tuesday, July 31, 2012

The "Peripheral" IJ

Some patients just have no IV access – no superficial peripherals, no deep peripherals, no external jugular veins.  In a critical emergency, this is the perfect time for an intraosseous line.  But, what about the situation where IV access is simply necessary, but not urgent?  Placing a central line is the last thing we're interested in doing – draping, opening a costly central line kit, billing for an expensive procedure, exposing them to risks of over-the-wire techniques in the central circulation.

This technique, described formally here by folks from Highland Hospital, involves placing a standard, peripheral catheter into the internal jugular vein under ultrasound guidance.  While I think this is a fantastic idea – much faster and less expensive than a full multi-lumen central line set-up – I wouldn't characterize it as "risk-free", either.  The nine cases in this year-long review all demonstrated a lack of complications, but more data would help refine the procedural risks.


"The ultrasound-guided 'peripheral IJ': internal jugular vein catheterization using a standard intravenous catheter."

9 comments:

  1. It is baffling why the authors would think this is a good idea. The time in placing a central line is taken up by 2 things:
    sterility & securing

    If you ignore these two, of course you can place a single lumen central line in a few seconds longer than it takes to place an IV cath like they did in this study.

    However not taking the time to be sterile then exposes the patient to a 2nd stick in the ICU or the potential for increased infection from rewiring the non-full sterile IV catheter.

    Central line infection rates are measured in 1000/line/days. A hundred-fold greater number of patients would still not dub this practice safe. We need to be increasing our sterility practices to exactly what we do in the ICU, not look for ways to be lazy at the expense of our patients.

    Will step off my soapbox now.

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  2. I think their argument is one of resource utilization in the Emergency Department - full sterile draping for a central line vs. local sterile technique. In a patient who doesn't necessarily need a central line for any reason other than reliable access, perhaps the patient gets a PICC the next day on the floor?

    If you look at the disposition of many patients in their case series, a significant number were discharged after treatment completed. I can think of several patient types - sicklers, diabetic gastroparesis - who are difficult access and it would be a waste of a ~$600 triple lumen.

    I don't think they're describing it as an ideal alternative - only that it might have a limited role.

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    1. I don't disagree with that tack, problem is the ones we thought we were going to send home and then wind up admitting. And let's compare apples to apples, a single lumen set (which is what should be inserted for a non-critically ill patient) costs $40. It is the addition of all of the sterility and anesthetizing items in a central line tray rather than a set that leads to costs similar to what you quoted.

      I know I am grumpy about this, but it seems to me what we gain by this technique is just another path to being half-butted. This is the old emergency medicine of getting done just what we need to in order to get the patient out of our dept and let the folks upstairs worry about the rest.

      You mention the PICC Line the next day, but that is probably what we should be placing in these situations. Not a formal picc, but a mid-line. I think what we need are some cheap and easy kits that allow seldinger placement of mid-length catheters in the vessels of the upper arm for the ED. Find me a inexpensive kit with a thin introducer needle, a wire, and a 10 cm catheter and I will never need to place anything in the central vessels unless the patient needs pressors. The RIC sets are great for this, but rather expensive.

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  3. I've had tempting thoughts about this, never dared.

    Could we make an analogy with IO placement? While there had been concerns about osteomyelitis, etc., in practice there are few complications, perhaps owing to the brief periods of time the devices are left in situ. Similarly, I don't think I would be too worried about the risk if infection if it's left in place for less than a day, let alone just for an ED visit.

    Interesting!

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  4. wow, someone actually did this 'study' - I missed my opportunity. I've placed a few of the long 18 gauges (64 mm) into the IJ for pts that I plan on being able to discharge after treatment.

    I definitely think this line has utility, both in terms of speed and resource utilization. Perhaps I'm thinking about this wrong but the risk of infection should essentially be equivalent to the length of the foreign body, ie catheter - the vein that it's in is not relevant, all veins are created equal; unless perhaps the distance to the heart has a role, which seems a bit ludicrous that that could appreciably alter the rate of infection.

    Could almost make the argument that perhaps the 64 mm angiocath would have lower rate of infection, and in patient that doesn't need multiple lumens or long term access, this would be a better choice - now THAT would be a good study.

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  5. this has come up before. http://emupdates.com/2009/11/26/peripheral-line-in-central-vein/

    I suspect that placing a small catheter in a central vein in a semi-sterile fashion confers less risk to the patient for all relevant endpoints than a formal, full sterile central line. but we don't know this, yet, and it's difficult to be either beyond the standard of care or not meeting the standard of care, depending on your perspective. crossing fingers for larger studies.

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  6. If the goal is some sort of basic access to bridge to placement of a PICC during banker's hours, then I think an IO is a simple/safe/easy option. It's certainly easier to place than a PIJ (or a midline, or a central line) and we know a lot more about the adverse effects -- it seems like all we know about PIJs right now is that the risk of badness is somewhere less than 33%.

    While round-the-clock availability of PICC placement may be be nice -- save the patient the initial stick -- it's probably not feasible, and IO's are cheap, easy & safe and might be operationally preferable.

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  7. While I'm as big a fan of IO as the next, I find it hard to advocate for their use in the non-critically ill. It would certainly make the sickle cell patient with no access avoid your hospital during their next pain crisis, however (which shouldn't be a goal we aspire to in EM).

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    1. I think there is a small subset of patients who are impossible to get IV access yet need it now. For them, I think IO beats central line.

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