If you’re not good enough at Ultrasound, that’s not an excuse to punish your patients with radiation. Get out there, ultrasound some hearts, lungs, IVCS and let us know how you feel about it. He got his wrist pain from over-aggressive high-fives. Hello US podcast listeners Welcome to the second US podcast little itty bitty We’re gonna tal about US guided subClavian lines today This came up recently in my university when we were looking at our complication rates of central lines. We thought about actually moving subclavian as down the list or off the list of preferred sites because we were having some pneumothoraces when placing subclavian lines. Some people brought up the point that this is a good line a nice clean line, its more comfortable for patients and when our residents get out of training, if they haven’t placed enough subclavian lines, and they do have to place one, they are going to have higher complication rates. because they don’t have the experience. So, we thought about, well, will US make a difference? How can we decrease the PTX rates and still give our residents the training and still be able to use this line. If you’d asked me this question a few years ago, I’d have told you – No, that’s crazy. You have a great landmark there, just place the line, don’t wasted your time with US here. But, I’ve been burned by the literature before, and I was burned by the literature this time. Matt’s inner monologe: So that “burned the literature” quote was kinda an inside story that needs a little explaining. During residency, we had a trauma surgeon who wanted to do something… …uhhhh, kinda not supported by the evidence. some thing….malpracticey… We knew it was wrong, and someone pointed out to him “uh, I wonder if we could do it this way,” it would seem that the most current literature would suggest this is a much better way of getting this done. and his response was classic “well I’ve been burned by literature before so I stick with my experience now” And this quote was all at the same time, hilarious, sad and very instructive for me in the youth of my training in how I didn’t want to practice. So there you go, now you’re in on this inside quote- joke. Matt: In 2011, in Critical Care Medicine, there was a great study on this, what they did is they randomized over 400 patients to landmark versus US guided when placing a subclavian line. I don’t like to normally call the landmark technique the “blind” technique… because I think it’s more appropriate name, but it is landmark. You get the nice clavicle, a good landmark, So, how much of a difference would US make for this line. A pretty big difference in their study. This was a nice big randomized study and they found the success rates went from 87.5% to 100% with US guidance. The PTX rates (which we really worry about), went from 5% to 0%. No are you ever going to really get to 0% complication rate for a procedure, absolutely note, but in their study of over 400 patients, they did get there. So, this did seem to be statistically significantly better then the landmark technique in complication rates and every outcome measure that they actually measured. So this is a pretty convincing study. There’ve been a few other small studies, but this is the one, the really nice big one that answers the question best for us. So, how do you do this, first you want to find an unsuspecting tech in the ED You’re going to want to take their sweater off, instead of leaving it on like I did here but I’m going to image through the sweater to show you the technique. So you’re going to go to your normal landmarks, find the clavicle, find the subclavian vein just underneath it, you saw it here, you don’t see it anymore as I’m scanning out laterally, I see the subclavian artery, I’m compressing the vein, as I slowly scan more medially – you see the vein appear agin. here it is. Once you have it in short axis (again there’s the clavicle shadow), you’re going to place the line. If you’re doing it in short axis, you’re going to want to follow the needle tip. That is by far the most important thing. Fan or slide the probe to follow the needle tip. And see it the whole time. If you don’t follow the needle tip and see it the whole time, you may as well not use US. You may as well do it blindly. If you’re not going to see the tip you’re going to get pneumothoraces if you don’t watch the tip the whole time. I want to stress that because it’s the mistake that I see most often of new users of US when placing lines. Here’s a couple pictures of long-axis subclavian placement. YOu can see in the bottom left hand corner the nice long subclavian and the pleural line just behind it. This is a nice picture to show you how close the lung is. This is why we get PTX when we place subclavian lines, because we’ve got a needle pretty close to the lung, we can pop it pretty easily. For a vein that’s large like this, and you can get the probe, needle and the vein the whole thing lined up like this this can be a nice option going in the long instead of short. For peripheral veins, I think the short axis is generally easier especially for new learners than the long axis because it’s hard to get all three lined up and you don’t always have a straight peripheral vein all too often that you can us. For this, the long axis is really a nice approach. Here you see some more pictures you see the guide wire in the bottom left hand corner and you can actually see the catheter as you thread it in, it’s just nice confirmation to see you’re in where you think you are. Here’s an image showing the lung highlighted in green. It’s so close so you have to see the needle tip the whole time. Here’s a video you see the needle tip appear just above the vein and as you’re slowly fanning and sliding with the placement you see it puncture into the vein. So hopefully that was helpful. that’s how to place an US-guided subclavian line very short. the complications are going to be the same as your normal central line placement the rates of complications aren’t the same, I’ve shown you the literature on that. So thanks for watching and give us another topic you want hear an US podcast little itty bitty on. So our little itty bitty editor’s note: So there are actually two approaches to the subclavian vein under US gudiance. This was the infraclavicular approach which was studied in the paper I mentioned. The other approach is the supraclavicular approach. Mike has actually published on this approach, and he’s going to tell you about it in another little itty-bitty. shortly. Meanwhile, if you really wish you could just have us show you this technique in person well guess what – you can.