Invasive Line Placement: Central Line, Arterial Line, and Peripheral IV Placement
John P. Gaillard
Casey D. Bryant
Jonathan T. Jaffe
1. An 83-year-old man with chronic obstructive pulmonary disease (COPD) (FEV1 50% of predicted) presents to the Emergency Department with progressive dyspnea and wheezing. His vital signs are temperature 37.1°C, BP 132/74 mm Hg, HR 94 bpm, respirations 22/min, and SpO2 92% on 4 L/min O2 via nasal cannula. Due to the inability to place a peripheral IV, you place a central line in the patient’s left subclavian vein. A postprocedure chest x-ray shows a pattern consistent with COPD and a small right-sided pleural effusion. The following ultrasound image (Figure 74.1) is obtained from the left chest.
Based on Figure 74.1, which of the following is indicated?
A. Immediate needle decompression of the left chest
B. Bronchodilators and steroids
C. Left-sided tube thoracostomy
D. Right-sided tube thoracostomy
1. Correct Answer: B. Bronchodilators and steroids
Rationale: Figure 74.1 shows a lung point sign: the point at which the lung (visceral pleura) begins to separate from the chest wall (parietal pleura). Initially thought to be pathognomonic for pneumothorax, a lung point sign can also be seen in patients with blebs from COPD or other disease processes in which the lung is adherent to the chest wall (e.g., asbestosis). This is confirmed by the presence of a lung pulse, that is, movement of the heart transmitted to and sensed at the pleural space, which can be seen on the right side of the image. The patient in this question is having a COPD exacerbation, so choice B is correct. Based on the vital signs, the patient is not in extremis, so choice A is incorrect. In a stable patient with COPD, you should obtain further imaging (computed tomography [CT] scan) before placing a chest tube, so choice C is incorrect. A small pleural effusion is not likely to cause significant dyspnea, so choice D is incorrect.
1. Aziz SG, Patel BB, Ie SR, Rubio ER. The lung point sign, not pathognomonic of a pneumothorax. Ultrasound Q. 2016;32(3):277-279.
2. Based on the ultrasound images shown in Figure 74.2, which of the following locations is the preferred puncture site for a right femoral arterial line?
A. RED arrow
B. PURPLE arrow
C. GREEN arrow
D. BLUE arrow
2. Correct Answer: A. RED arrow
Rationale: Figure 74.8A shows a longitudinal view of the common femoral artery and its bifurcation into the superficial femoral artery and the deep femoral artery. Figure 74.8B shows a transverse view of the superficial femoral artery, the deep femoral artery, and the common femoral vein at the junction with the greater saphenous vein. The ideal location for femoral artery puncture is in the common femoral artery proximal to the bifurcation (choice A). This area is usually above the middle third of the femoral head (not pictured here). Puncture into the superficial femoral artery (choices B and C) increases the likelihood of unsuccessful cannula placement and increases the incidence of retroperitoneal bleeding and pseudoaneurysms. Choice D is the femoral vein. See Figure 74.8 for additional details.
1. Turi ZG. Ending “poke until you get a gusher”: part II-the evidence based approach to vascular access revisited. Catheter Cardiovasc Interv. 2017;89(7):1185-1192.
3. Which of the ultrasounds shown in Figure 74.3 best identifies the internal jugular vein?
A. Figure 74.3A
B. Figure 74.3B
C. Figure 74.3C
D. Figure 74.3D
3. Correct Answer: B. Figure 74.3B
Rationale: Figure 74.3B shows pulsed-wave Doppler tracing of a vein, evidenced by the flow away from the probe during systole and diastole at a relatively slow velocity. Figure 74.3A shows pulsed-wave Doppler of an artery, evidenced by flow only during systole at a relatively faster velocity. Figure 74.3C shows M-mode without a corresponding B-mode image. M-mode alone is not used to identify a specific vessel. Since there is no B-mode image with the M-mode tracing, it would be difficult to differentiate an artery from a vein. Figure 74.3D shows color Doppler with flow going away and coming toward the probe. Based on this limited information, it would be difficult to differentiate the artery from the vein, although real-time visualization may help identify the appropriate vessel.
1. Troianos CA, Hartman GS, Glas KE, et al. Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2011;24:1291-1318.
4. Based on Figure 74.4, which of the following is the best course of action regarding central venous catheter placement?
A. This is an acceptable site to place a central venous catheter.
B. Going proximal to this site is recommended.
C. Going distal to this site is recommended.
D. Finding an alternative vessel is recommended.
4. Correct Answer: D. Finding an alternative vessel is recommended.
Rationale: Figure 74.4 shows a thrombus within the internal jugular vein. Whenever a thrombus is visualized on ultrasound, it is recommended to find an alternative vessel for central line placement, so choice D is correct. Central line placement in this vessel would increase the risk of dislodging part or all of the thrombus, leading to a pulmonary embolism.
1. Saugel B, Scheeren TWL, Teboul JL. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care. 2017;21(1):225.
2. Silverberg MJ, Kory P. Intensive care ultrasound: II. Central vascular access and venous diagnostic ultrasound. Ann Am Thorac Soc. 2013;10(5):549-556.
5. A nurse asks you for assistance with obtaining peripheral IV access on a patient in the intensive care unit who was admitted with endocarditis associated with intravenous drug abuse. During the course of the procedure, you obtain the ultrasound shown in Figure 74.5 without getting blood return into the catheter.
Which of the following is the next best step?