The ICU Point-of-View series: Central line placement

We’re pleased to introduce a new educational series.

Bedside procedures are common in the ICU, and teaching them typically relies on one-on-one instruction by skilled users. This model is great, but inefficient, since it requires constant repetition of the same teaching points; it’s also inconsistent, since many of the supervisors have only recently learned the procedure themselves (the “see one, do one, teach one” model). A better way would be to have learners watch a standardized video that demonstrates the procedure in detail. Once viewed, “see one” is out of the way, and learners can be supervised for their first attempts with an emphasis on actual supervision (rather than on de novo teaching).

That’s the premise of our ICU Point-of-View series. These are procedural tutorials, recorded from the perspective of a GoPro camera mounted to my head. They depict an entire procedure from the user’s perspective, performed on live (consenting and anonymized) patients, and narrated in detail.

For our first procedure, we’ll address central line placement. Please see the video below, as well as the short “focus” videos that discuss important components of the procedure in isolation; most importantly, make sure you view the “line following” focus, which highlights one of the key skills for any ultrasound-guided procedure.

A few points:

1. The emphasis here is on the actual steps of the procedure. We won’t be discussing on camera many of the cognitive points, such as procedural indications and contraindications, site selection, potential complications, and so on. Perhaps we’ll cover those in a separate text post; this is purely a psychomotor tutorial.
2. I’m grateful to the many mentors whose time was instrumental in teaching me most of the concepts you see here. Special thanks in particular to the PA residency crew at Johns Hopkins, and to their special procedure team, particularly the immortal Dave Lichtman.
3. Like the rest of this site, these tutorials are meant to be educational, but not definitive. Don’t mimic anything you see that runs contrary to your own understanding of the standard of care; discuss with your seniors, consult your local policies, and check with a textbook. At the end of the day, I live on the internet; what do I know?

Narrated walkthrough: Right IJ central line placement

Supplemental videos

FOCUS: Dynamic needle guidance using ultrasound

FOCUS: Seldinger technique overview

FOCUS: Needle and syringe selection

FOCUS: Three useful ways to grip a syringe