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THE UNIT: The Official Newsletter of the ACEP Critical Care Section - Fall 2016

 Update from ACEP16, IJ vs. Subclavian

 

Scientific Assembly Wrap-Up and the Coming Year --A call for authorship

Joseph Tonna 2016It was great to see everyone at ACEP16 Scientific Assembly this year. Our section graduated to a larger room this year, based on being so packed in years past, and on consistent growth. The meeting started off with the year’s business, including introductions. It was surprising to me this year that so many of our attendees were fellows in critical care or new faculty, in contrast somewhat to years past—when so many attendees were residents and medical students looking to find a fellowship in critical care. Many worried about what the future held, whether board certification could be achieved, whether they would be accepted into clinical training programs, and whether they could ‘hack it’ as intensivists. It was wonderful to be at the meeting and see that so many had done just that.

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Internal Jugular Central Lines: The Safest Approach

Any time a medical provider places a central venous catheter, complications are possible. It is therefore imperative that providers do everything within their power to decrease the morbidity and mortality associated with this vital procedure. Without a doubt, the ultrasound-guided internal jugular (IJ) central line is the best choice in a majority of clinical scenarios. Those who favor subclavian lines will inevitably point to the lower rate of infection with subclavian catheters compared to IJ catheters. [1] However, multiple studies have proven that with the proper sterile technique and use of a checklist to ensure high fidelity to best practices, the rate of central line associated bloodstream infections can be vanishingly small. [2-4] When bloodstream infection rates are diminished by adherence to standards of practice, the main argument for subclavian catheterization is rendered moot.

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Interview with Michael Reade, DPhil, FCICM

FromReade MC, Eastwood GM, Bellomo R, et al. Effect of dexmedetomidine added to standard care on ventilator-free time in patients with agitated delirium. JAMA. 2016;315(14):1–9.

Joe: What do you think is the role of dexmedetomidine in the non-intubated, ICU patient with agitated delirium? Should we repeat the study for that group? 

Dr. Reade: I can see the theoretical argument, especially as dexmedetomidine can be continued after extubation, as was the case in approximately 10% of people randomized to receive dexmedetomidine in our study. We had originally planned also to study patients who were not intubated at the time of randomization, but the sponsoring company would not fund that part of the proposal. Given what we have now found, yes, I think studying such patients would be very wise. I’m reluctant to recommend just going ahead & treating such patients, however, especially a less monitored environment than is the case in the ICU, as we really need to assess the risk vs. benefit in such patients.

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Internal Jugular vs Subclavian Temporary Central Lines... In Today’s ICU, Which is Actually Superior?

The debate between achieving temporary central venous access via the subclavian or internal jugular (IJ) approaches has waxed and waned. While blind subclavian and IJ approaches for years were the basis of medicine training, with the advent of point-of-care (POC) bedside ultrasound, the known complications of arterial puncture decreased during IJ approaches, making the procedure safer. For this reason, many have argued that the relatively stable risk of traumatic needle pneumothorax from blind subclavian lines is greater than the risk now of complication from ultrasound guided IJ lines. Whether the infection rates are comparable, or even the procedural complication rates, is up for debate. Here two authors argue opposing sides of IJ vs Subclavian in the modern critical care era.

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Subclavian Central Lines: Reduced Infection and Thrombosis Risk

While central line insertion is necessary for many critically ill patients in the emergency department and ICU alike, placement of central lines is also associated with a high rate of complications, including mechanical complications, thrombosis, and infection. Appropriate selection of the subclavian, internal jugular (IJ) or femoral site, along with training in safe technique and use of checklists, are important to mitigate the risks of this common procedure. Recent data suggest that for many patients, the subclavian approach is the safest.

Over the last ten years, the wide adoption of ultrasound guidance has dramatically changed the risk associated with IJ central line placements, improving the safety and reducing mechanical complications.1 However, not all patients are candidates for IJ lines, such as patients in cervical collars, those with obese necks, and some neurosurgical patients. Additionally, despite the short-term safety of the ultrasound-guided IJ line placement, questions remain regarding the longer term effects of IJ catheterization.  

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