How to Prevent and Manage Malpositioned Central Lines

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central Line, central line complications, Central line insertion, central line placement, central lines, Central Venous Catheter, central venous catheters, Featured, femoral lines, HPC Updates, IJ lines, internal jugular line, subclavian line
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Malpositioned central venous catheters occurs in about 7% of central line placements. A malpositioned central line is any central venous catheter where the tip is located anywhere other than the superior vena cava (SVC) for internal jugular lines or subclavian…
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Procedural Competency in Academic Emergency Medicine Attending Physicians

Joseph Esherick, M.D., FAAFP, FHM
More Articles – ACLS, advanced airway, Airway management, Central line insertion, central line placement, central lines, chest tube placement, cricothyroidotomy, difficult airway, difficult airway management, Endotracheal Intubation, Featured, HPC Updates, Intubation, Lumbar Puncture, Paracentesis, paracentesis, Procedural Sedation, Simulation Based Training, Simulation-based procedural training, Thoracentesis, Tube Thoracostomy
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A recent article summarizes a cross-sectional survey aimed at determining the processes in place to assess the procedural competency of academic emergency medicine attendings.[i] The survey was sent to the 39 ACGME-accredited Emergency Medicine programs in the U.S. and had…
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Periprocedural Bleeding Risk for Thrombocytopenia, Coagulopathy, Antiplatelets and Anticoagulation

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Anticoagulation, antiplatelets, central lines, Chest tube, chest tubes, coagulopathy, Featured Procedure, HPC Updates, Lumbar Puncture, Paracentesis, procedures, Thoracentesis
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This blog summarizes the 2019 Society of Interventional Radiology (SIR) for Periprocedural Management of Image-guided Procedures with regards to thrombocytopenia, coagulopathies, antiplatelets and anticoagulation.  The SIR guidelines are summarized as follows: Anticoagulation with heparin, LMWH, fondaparinux, argatroban, warfarin, DOAC, clopidogrel, ticagrelor…
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Recommendations for Invasive Hospital Procedures in Patients with Cirrhosis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – acute kidney injury, Arterial Line, Arterial line insertion, Arterial line placement, Arterial Lines, Central Line, Central line insertion, central line placement, central lines, Central Venous Catheter, central venous catheters, Chest tube, chest tube placement, Cirrhosis, Featured, hospital procedures, HPC Updates, Paracentesis, paracentesis, Procedures in Cirrhotic Patients, Radial Artery Catheterization, Sepsis, Small-bore chest tube, Spontaneous bacterial peritonitis, Thoracentesis, thrombocytopenia, transexamic acid, Tube Thoracostomy, ultrasound-guided arterial lines, Ultrasound-Guided Central Line Insertion, Ultrasound-Guided Paracentesis, Ultrasound-guided radial artery line placement, Ultrasound-Guided Thoracentesis
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This blog aims to summarize the data available on how to safely perform invasive hospital procedures in patients with cirrhosis. Unfortunately, no prospective randomized controlled trials have been conducted to inform the practice of procedural medicine in cirrhotic patients. Therefore,…
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Tips for Management and Bedside Procedures in Critically Ill Patients with COVID Pneumonia

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Acute respiratory distress syndrome, advanced airway, Airway management, ARDS, Arterial Line, Arterial line insertion, Arterial line placement, Arterial Lines, asystole, Cardiac Arrest, cardiac arrest survival, Central Line, Central line insertion, central line placement, central lines, Central Venous Catheter, central venous catheters, COVID, CPR, difficult airway, difficult airway management, Difficult Intubation, emergent intubation, Endotracheal Intubation, Featured, Glidescope Intubation, hospital procedures, hospital procedures course, HPC Conference, HPC Updates, ICU, Intubation, Mechanical Ventilation, PEA, preoxygenation, prone positioning, pulseless electrical activity, Radial Artery Catheterization, respiratory failure, Simulation Based Training, Simulation-based procedural training, ultrasound-guided arterial lines, Ultrasound-Guided Central Line Insertion, video laryngoscopy, Videolaryngoscopy
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The SARS-COV-2 pandemic started in January 2020 and has decimated the majority of U.S. hospitals for the past 18 months. The impact of COVID-19 has not only affected available hospital beds, but has limited the ability of hospitals to perform…
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Management of Vasopressor Extravasation Injuries

Joseph Esherick, M.D., FAAFP, FHM
More Articles – central lines, extravasation injuries, Featured, HPC Updates, norepinephrine, phenylephrine, vasopressors
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Peripheral vasopressor infusions are generally safe at low-moderate doses and for short durations, but you must watch the patient carefully for extravasation that can cause serious tissue injury. Traditionally, central lines were placed for administration of vasopressor infusions at any rate. We…
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Does the Location of the Central Line Tip Make a Difference?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – central lines, central venous catheters, Featured, HPC Updates
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Based on several studies, central line malposition occurs between 3.3-6.7% of the time.1  The historical recommendation is that malpositioned central lines should not be used for long periods of time, if at all.  The basis for these recommendations is based…
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The subclavian vein may be the preferred location over IJ and Femoral Locations for Central Line Placement

Joseph Esherick, M.D., FAAFP, FHM
More Articles – central line complications, central line placement, central lines, Featured Procedure, HPC Updates
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Where to place a central venous catheter is a decision driven mainly by individual preference. The limited evidence available has not established any site as superior; the subclavian position has been reported as being less infection-prone, but more likely to cause…
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Where Should I Place My Central Line?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – central lines, central venous catheters, DVTS, Featured, femoral lines, HPC Updates, IJ lines, Pneumothorax, subclavian line
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The internal jugular or subclavian veins have fewer combined mechanical or infectious complications for central venous catheter insertions compared with femoral vein CVC placements.  Numerous organizations have proposed guidelines or central line bundles that have advocated preferential use of the…
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Bleeding Risk of Central Line Insertion in Coagulopathic Patients

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line insertion, central lines, Central Venous Catheter, Featured, HPC Updates, thrombocytopenia
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The evidence base for the safety of ultrasound-guided central line placement with thrombocytopenia or in patients with a bleeding diathesis is not robust.  Nevertheless, based on the data available most procedural experts feels that an ultrasound-guided central venous catheter insertion…
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The subclavian vein may be the preferred location over IJ and Femoral Locations for Central Line Placement

Joseph Esherick, M.D., FAAFP, FHM
More Articles – central line complications, central line placement, central lines, HPC Updates
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Where to place a central venous catheter is a decision driven mainly by individual preference. The limited evidence available has not established any site as superior; the subclavian position has been reported as being less infection-prone, but more likely to cause…
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Summary of Sepsis and Septic Shock Treatment in 2017

Joseph Esherick, M.D., FAAFP, FHM
More Articles – ARDS, Arterial Lines, central lines, hemodynamic monitoring, HPC Updates, Mechanical Ventilation, Sepsis, Septic Shock, vasopressors
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Definitions Presumed source with SIRS criteria = infection Infection with life-threatening organ dysfunction = sepsis Sepsis refractory to intravenous fluid challenge = septic shock Treatment of sepsis or septic shock Draw blood cultures x 2 Analyze any fluid that may…
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Antimicrobial impregnated caps decrease the rate of catheter-related bloodstream infections

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Catheter-related bloodstream infections, central line associated bloodstream infections, central lines, central venous catheters, Device-related infections, HPC Updates, Vascular access
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The goal of zero device-related infections is what CMS desires for all hospitals, but is not a realistic goal.  Nevertheless, we can do everything in our power to minimize central line-associated bloodstream infections (CLABSIs).  We now can appreciate that the…
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