SCCMPod-576: Central Line Innovation: Rethinking a Procedure Stuck in Time

Announcer: This episode is sponsored by the BD CentroVena One Insertion System. Central line placement is routine, but complexity continues to define this critical procedure. CentroVena One is designed to simplify the procedure by integrating the guide wire, needle, syringe, and catheter into one streamlined system, helping reduce the risks created by complexity.

Finally, a simpler central line. To learn more about CentroVena One, visit bd.com\sccm, bd.com/SCCM.

Dr. Enfield: Hello, and welcome to the Society of Critical Care Medicine's podcast. I'm your host, Kyle Enfield. Today, I'm speaking with Dr. Adnan Javed about innovation in central venous access and how emerging technologies may help improve safety, consistency, and procedural performance during central line insertion in critically ill patients. Dr. Javed is an attending physician specializing in cardiovascular critical care at Orlando Regional Medical Center within Orlando Health. He's board certified in emergency medicine and anesthesiology critical care medicine and holds additional certification in critical care echocardiography. His clinical and research background includes focuses in improving outcomes in critically ill patients, particularly those with sepsis and septic shock.

Welcome to the podcast, Adnan. And before we start, do you have any disclosures you'd like to report?

Dr. Javed: Yes. So I do have a consulting arrangement with BD, which is a medical device company making the product that we're talking about today.

Dr. Enfield: Thank you for sharing that. You have a broad background and specialize now in cardiovascular critical care. But if training both in emergency medicine and anesthesia critical care, those traditions, you know, have some different approaches with how they approach central lines.

I wonder if you think that training in different specialties has shaped the way you think about what we're doing with central line insertion, as well as what we're doing wrong with central line insertion at the at the bedside.

Dr. Javed: Yeah, absolutely. I trained in emergency medicine. That's where I first learned that skill set placing central lines.

And then I did two years of private practice after that. And then I went back for fellowship. So there are I mean, in general, I think the the approaches that I learned during my training were quite similar.

But there were some nuances that were unique to each setting. And in the emergency department, the focus, you know, traditionally is on speed and on getting access as quickly as possible in sometimes a relatively austere environment with, you know, less than ideal circumstances, whether it's space, whether it's sterility. So the focus really, I remember as an intern or as a trainee in emergency medicine was is that these things have to go in fast because you have a crashing patient, you know, generally that's coming in undifferentiated and there's really not a lot of time.

And while, you know, we learned good sterile technique, the focus was really on getting access quickly, because oftentimes that would be the only access we would have. And in the intensive care setting, those types of priorities are still there. Things have to be done quickly.

Patients can be crashing, access may have been lost, but there's a little bit more control in terms of time and and the sterility of the environment and the environment itself and also the level of assistance you may have in doing those types of procedures. But, you know, the pitfalls of central line placement, the complications and the things that can go wrong are pretty much similar across the board.

Dr. Enfield: So we're here talking about innovation. Why do you think that we haven't seen more innovation in the placement of central lines over that 70 year period? And how do you think current practices and practice demands is shaping the evolution of technologies as we go into the future?

Dr. Javed: So I think that there's a few different parts to this. I would say that there was a point of major innovation in central line placement, and that was probably when ultrasound guidance arrived in the late 90s, 2000s. And, you know, those of us who trained, you know, after 2010 or so, I think ultrasound was was pretty much used 100% of the time we were taught using ultrasound.

And so that introduced a an extra layer of safety. And, you know, you could argue innovation on what is essentially a pretty, pretty old procedure that I think solved a lot of the problems that you had prior to the introduction of ultrasound. So that that might be one reason where there's some degree of stagnation.

It's like, well, we've introduced ultrasound, so things are pretty good. You know, we've we've overcome the pitfalls of blind blind approaches and things are pretty good. And I think that kind of has resulted in this sort of complacency with, well, if it's good enough, you know, it's good enough and there's no reason to fix something that isn't broken.

I think that sort of creates this circular scenario where it's like, well, this is how I've been doing it and this is how we train all our trainees. And it's almost like a rite of passage in emergency or critical care. Really a lot of multiple specialties in terms of in terms of your training is that, well, yes, there's a lot of steps.

There's a lot of potential pitfalls here. But part of training is that you become, you know, facile with this technique. And I think there's just a general sort of, well, this is how it is.

This is what you've got to learn. And you've got to learn how to manage these steps in this procedure and become good enough to where you're not having those complications. So I think it's multifaceted.

There's just a status quo that's developed that I think we've just sort of become comfortable with the procedural complexity. And I think that there hasn't really been much of a drive to improve on that, especially after ultrasound.

Dr. Enfield: So I think that's an important point to point out that, you know, we do have this fairly complex procedure that feels like a rite of passage. And ultrasound changed the safety profile a lot, being one of those people that bridge between the areas of not having ultrasound and then having ultrasound. I know that our first pass access improved dramatically with the use of ultrasound.

And so the safety really went up. But at the same time, I see that our patients are becoming increasingly complex. There's more coagulopathy.

Obesity is increasing. There's a lot more that we are seeing in the form of cancer-related complications, as well as, you know, cardiovascular risk. And I wonder if, in your mind, the risk calculus for this procedure has changed in comparison to what we now consider the gold standard.

And if it really makes sense for us to be thinking of it as the gold standard compared to 2010, as you mentioned, where our patients were a little bit different.

Dr. Javed: Yeah, absolutely. I think that's exactly right. You know, my in my current position, so you know, I do, I do cardiovascular intensive care.

And I can speak a little bit to my experience with central lines and particularly a all in one central line kit, which is, you know, part of what we're talking about today. Yeah, our patients, you know, these are ECMO patients, and they're anticoagulated. They're frequently, you know, super therapeutic in terms of their anticoagulation, or they have multiple other reasons for coagulopathy.

We have a lot of impala patients now, the use of mechanical circulatory support has exponentially risen in the current age of AMI, cardiogenic shock. And, you know, so you have multiple, multiple things going on now that you probably didn't have as much of 10-15 years ago, coagulopathy, hemolysis, thrombocytopenia, and then, you know, of course, increasing rates of obesity. So the complexity has is significantly greater than what I think the original, you know, procedure was designed for.

And so not only is that an area to improve on, or where we have to be conscious of the fact that okay, yeah, you know, it's a great technique. And once you learn it, the traditional central line that is once you learn it, that's part of your rite of passage, and you get good at it, and then you can handle any situation, but patients have become much more sick, and they've got multiple other devices. And just there's a lot more going on, I think, than there used to be.

And I think it also impacts the types, the type of approach that we're using, you know, and I would say, since I've been out of training, and in my own personal use, the use of ultrasound guided subclavian has has increased substantially as well. In fact, that is my go to line, a lot of the fellows that I work with now, there's a great interest in doing ultrasound guided subclavian. So you're almost seeing a resurgence of subclavian access.

And that in itself, you know, you have non compressible site, there's additional complexity there, but it's a great option. And if you have technology now that can improve the first pass success of that while minimizing complications, that's another great area for us to improve what we're doing.

Dr. Enfield: So thinking about that, you know, I think there's two areas that we under appreciate in critical care. And I hear this from our fellows, when I talk to them, sometimes, there is still procedural variability, even in what is kind of a routine practice about how people approach lines, both in the decision of where to put lines and how they approach the actual process of the celldinger technique. But I think there's also this cognitive dimension that we under appreciate, because with management of more unstable patients, coordinating the team, coordinating someone to be there, be present when we're inserting the line so that we have that person observing what we're doing, the handling of equipment, all of these things are happening simultaneously.

And so in addition to variation in procedural performance, that is a factor of training, we also have this cognitive load that interacts with that. And it makes the whole process a little bit more complicated. I wonder if that's your experience as well, or and how you approach the interplay between the cognitive load of managing the patient and the procedural components.

Dr. Javed: Yeah, I think that's a really great point. The cognitive load, and I think we're all becoming more aware of these things that it's not just about, okay, are we able to do these procedures quickly, but if you are able to reduce the cognitive and physical clutter that is involved in doing a procedure like that is as routine as a central line as commonly performed as a central line, then those eliminating those individual steps, you know, has a huge, huge benefit every manual step that you do, whether it's picking up a tool or component of the kit, and then you're having to hand something off or introduce these types of steps. Not only we're going to talk a little bit about, you know, this breaching potential breaches in the sterile field, but you're reducing those steps.

You're also freeing up your bandwidth to focus on the other stuff that's going on patient's physiology while you're doing these procedures, ultrasound visualization, you know, so there's a lot of bandwidth that's freed to focus on other aspects of the procedure and the patient.

Dr. Enfield: I think one of the things that I think about in our ICUs these days is we hear a lot about trying to get to a zero CLABSI rate. And I think, you know, CLABSI has become the real focus of how we approach our central line insertions. And that was really driven by the Michigan Keystone Project, which, you know, arguably didn't totally show zero CLABSIs, but marked reduction of CLABSIs.

But it was really built upon this ability that sort of assemble a whole team to insert those lines with someone observing, having the kits put together for the provider. So it was a huge success, but it didn't focus as much on sort of the short-term safety of the insertion and insertion related complications, including malposition and failed access attempts. And I wonder how we begin to also incorporate the short-term complications in a model of risk reduction within our ICUs around central line insertions.

Absolutely.

Dr. Javed: And I think this gets back to the fact that our patients are getting more and more complex things like coagulopathies have a huge, huge impact. And as you add more steps to the procedure, you know, we're talking about, you know, at least 15 steps with our contemporary current baseline, you know, and you have a needle introduction, then guide wire, then removal of the needle, then dilation, you know, the rates of whether it's arterial cannulation, arterial puncture, you know, placement failure, you know, hematomas, you're increasing that exponentially with every introduction of an additional step. And so that's another huge target for improvement. And I think the basis for why we should approach this in a different way.

Dr. Enfield: So in your mind, what does innovation look like in the central line arena? And what are our next steps to moving forward in a process that's over 70 years old, but still ripe for improvement?

Dr. Javed: So I think, you know, I think it looks like reducing the number of steps, you know, that's probably the first thing reducing the number of steps without drastically changing the way we do things. So, of course, you know, retaining the use of ultrasound so that, you know, providers can continue focusing on vessel identification and not having to rely simply on landmarks. I think it looks like creating kits that are simplified.

Okay, so reducing the number of components that are available in the tray, reducing the amount of help that is that you need a second operator, okay, and reducing the amount of prep time that goes into preparing for the procedure. But I think primarily probably the biggest focus really should be on reducing the number of steps, particularly between cannulation, guidewire placement, dilation, and then advancement of the catheter. And so if you can eliminate a number of those steps to where you are not having to exchange one component for another over a guidewire, and you sort of have an all-in-one system with a, you know, perhaps a peel-away catheter or peel-away needle, and you don't have to remove things and then risk losing vessel, okay, risk guidewire embolization, and then finally eliminating the step for making the skin nick where you either make the incision too big or too small. And this is a frequent problem for everybody.

It doesn't matter where you're at in training or experience. Those are huge, huge gains, I think, in the realm of central line technology.

Dr. Enfield: Where are we in that process? Where do you think the technology is right now? And where do you think the next steps in innovation are going to come from?

Dr. Javed: So we have, there's not a whole lot of options. You know, my experience is up until a few months ago, I was doing central lines routinely, sort of using the traditional catheter kits we have in my entire experience. You know, I started medical school in 2010 and learned central lines at that time and throughout residency, fellowship, and up until now, so we're talking about 16 years later, really the kits are the same.

And there's really not been a lot of innovation or changes. But I did recently use the Centrovino 1 kit, which has a basically an all-in-one system where the guide wire is attached with the needle, attached with a syringe, and essentially comes with a self-dilating triple lumen catheter already attached and has a mechanism by which the guide wire can be clipped onto the drape. So that essentially an all-in-one system that eliminates most of the common complications associated with central line placement and eliminates the need for exchanging a dilator, or first the needle and then into a dilator, and then finally a catheter over that same guide wire has essentially cut the number of steps by 30%.

And I think that as these types of kits are rolled out, then there need to be some head-to-head studies, you know, comparing. Probably something prospective would be, I think, really interesting to see whether we reduce complication rates and perhaps infection rates as well.

Dr. Enfield: As you transition to a different catheter kit, you know, that always comes with some motor learning. What was the motor learning process for you of switching to a somewhat different technique? And how did you overcome that motor learning problem?

Dr. Javed: Yeah. So for me, speaking to my experience personally, placing the Centrovino kit. So this was done, you know, in a patient who was on VA ECMO, had an impella with platelets that were well below 20,000 coagulopathic, you know, high-risk patient.

And basically when the kit was made available and we had vendors come in, I said, you know, look, if you have one with you, let me try and place one because it's really difficult for me to understand it without actually doing the procedure. And so I took the risk and I went ahead and placed one of these in an ultrasound-guided subclavian approach with an infraclavicular view. That's just how I do my ultrasound-guided subclavians.

And the real challenge, the muscle memory is really no different because the steps are the same. You are obtaining an ultrasound view that you like, fanning through, looking at the vessel course. In the case of the subclavian, which is a very tortuous vessel, it, you know, very quickly changes based on where you're looking at.

The approach was the same. And the feel of a finder needle, because it's really the same size finder needle, you still kind of are holding suction on the syringe as you go in, in that same exact fashion as you normally would. Really not a whole lot of difference.

And I think the only place where it changes is that once you're in, rather than now having to, you know, meticulously hold the needle without it moving and unscrewing the syringe and then getting guide wire in, that part's already done for you. And so it was a very, very, you know, surprisingly simple step from getting blood flow into the syringe. The syringe pops off and the wire is already in there and just goes in.

And after that, it was really bizarre, pleasantly bizarre for me to then say, okay, so I don't need a knife. There's no dilator. I'm just literally just going to advance this triple lumen catheter into where we're at.

And so that was, you know, pretty amazing. No real difference in the muscle memory, the feel of your hand as you're going in and what you're doing with it. It's just eliminating basically all the next major steps.

I think there's a huge potential for this to translate very well for anybody that's been doing central lines, you know, for any amount of time into this new way of doing it.

Dr. Enfield: So that all sounds great. And I think a lot of us would appreciate, you know, fewer steps, but there's going to be a lot of our audience who are perfectly skeptical of new devices. What do we know right now about this device as far as data?

And where do you think companies are going to acquire new data or new trials to show either superior or to your non-inferiority of their devices?

Dr. Javed: Yeah, you know, to your point, I mean, I was extremely skeptical. And I think most of us who are good clinicians remain healthily skeptical of any of these types of new devices, especially when, you know, you come very fast on with the procedure and you do it with minimal complications because you're good at it. There's no current head to head trials, to my knowledge, with the Centrovino one versus traditional central lines.

But I know that in their internally studied simulations, we know that these are designed to reduce procedural steps by at least 30% investment studied a 50% reduction in average insertion time, a zero guidewire kinking that they've observed in simulations. And I think that in terms of high quality evidence, I think that's needed. And I think something prospective where you do a head to head trial or non-inferiority, maybe file a study and then go to a head to head trial, I think would be very useful for all of us.

But I think the potential is there, you know, coming from a skeptic.

Dr. Enfield: So I know that one of the other arguments that's going to be raised as we roll out new devices and emerging approaches is going to be the training points. It was common as ultrasound guidance came on that our older attendings would opine that our residents are going to be less capable moving forward. What do you say about that when it comes to these integrated systems?

And do you think there's a role for teaching an approach that has more steps versus an approach that has fewer steps as far as our educational paradigms?

Dr. Javed: Yeah, I think that's a really, really good question. And maybe gets back a little bit to the philosophy of medical education. Because the first thing I would say is that this is not a new debate.

As you mentioned, when ultrasound was introduced, this was a debate. We can draw some parallels to the world of airway management when we went from direct laryngoscopy to video assisted, that there was a big feeling on the part of educators that there's a skill that's being lost in terms of airway management when you have video assisted. And, you know, I think that's a really, really big debate.

But I think at the end of the day, you have to think about, you know, two or three different things. One is that what are we doing for the patients? And patient care is first and foremost.

So while there may be a set of skills that gets lost as a better technology is introduced, at the end of the day, if the complication rates, okay, if the procedural difficulty is reduced, I think if I were a patient, then that would make, you know, complete sense to me that if there's a better way of doing something, then that's what we should be teaching. With that said, I don't know that this is necessarily, you know, about to take over as the initial learning pathway for central line placement. I think they're still important to learn the concept of using the ultrasound, using the finder needle, which those steps are preserved, no matter what type of central line kit you use.

And I would argue that that's actually really the more difficult part for a trainee is learning the technique of using an ultrasound probe with one hand while finding the blood vessel and cannulating it with the other. And so I think the most difficult steps are really unchanged. The part that actually takes the mechanical skill in terms of finding blood vessel and cannulating it, that's not really going to go away.

And I think if you can do that, then you can arguably use any kind of central line kit, whether it's an all in one kit or the other kit, I would say that you have to find a balance there.

Dr. Enfield: So let's talk about the other elephant in the room when it comes to new devices, and that's institutional adoption. What do you see as the real barriers beyond just the cost of getting new central venous catheters being used in both academic and non-academic settings?

Dr. Javed: Well, I think probably the big one would be, you know, like we've alluded to, is proving that this is better. You know, and I think that until there's some degree of robust prospective, you know, comparison between what we're already using and what's new, you're not really going to see that that's going to be a barrier. And I think just like with prior technologies, whether, you know, it was ultrasound adoption, that took a while, but that's become the standard of care.

And, you know, those types of things continue to evolve. So I think that until you see high quality evidence, until people start doing these and realizing that, hey, we're actually demonstrating reduced complication rates, reduced collapses and higher first pass success. And especially as the landscape of intensive care changes, you know, more and more we have people who are speaking generally, but more and more you have, you have trainees or people who are coming into intensive care positions or working in the ICU with less and less training and you introduce a method of doing something that has a lower complication rate.

And you're demonstrating that, then I think that institutional barrier starts to go away.

Dr. Enfield: So I can only imagine in addition to our institutional barriers, if we got all the intensivists in our combined medical centers together, there would be a lot of talk about how expert level performance requires flexibility, not rigid workflows. What's your response to that?

Dr. Javed: Well, I think I agree. I mean, flexibility is important. And so you have to, again, it's a balance.

You know, if flexibility means being able to use any central line kit, I agree. And I think we should still be teaching the traditional steps involved in central line placement. And I don't think that those go away with an all-in-one kit necessarily.

On the other hand, you know, being able to use a variety of different kits is important. You don't know what situation you might find yourself in where a kit is not available. And having a good basis for using any type of kit, I think is important.

But at the same time, if you have a way of doing something that demonstrably reduces complication rates, results in less bleeding, especially in your more complicated patients, then I think it's hard to argue against that.

Dr. Enfield: So if you were to advise a medical director of an ICU that's really looking at their internal central line practices, what would you advise them to do? And what approach would you suggest to them as they think about revisions to what they're doing in their ICUs?

Dr. Javed: So as far as I think, you know, the different types of kits being available or different technologies, I think, you know, my experience as, and I'm not a medical director, having gone through various levels of training and two different specialties, I think you make things available, you know, and that that's how I came upon the kit. We have a product that's available. Let's try it.

We have excellent medical directors who are open to new technologies. And this isn't the first time I think most people have experienced working somewhere where they say, Hey, hey guys, we're going to try, we're going to try this new vendor for this central line kit. It's arranged a little bit differently, you know, give some feedback on how you like the way that things are arranged or what comes in the kit.

You know, this is a very commonplace discussion that I've experienced. And, you know, so we try out new kits, we see what we like, whether it's dialysis, catheters or central line kits or introducers. So I think this is basically part of that same flow is that, Hey, there's a new product here.

Let's give it a shot. Let's try it. Get the feedback from your on the ground players who are placing these.

And I think, you know, a good medical directors, good institutions will take that feedback and we need more robust evidence. And you measure that, you measure that and you show that there is an improvement or not.

Dr. Enfield: And what do you hope for in the next 10 years? If you were to envision the future of central line insertion in a well-resourced ICU in the future, what do you think that procedure looks like? What do you think is still there?

And what do you think we've stopped doing?

Dr. Javed: The basic overall central line, I don't think is necessarily going to go away. I do think that I see innovation in the realm of making more all-in-one kits or at least reducing the number of steps, because some of it is just once you use an all-in-one kit, you know, you just wonder like, why wasn't this built sooner? And why are we still doing central lines the way we were doing?

That was my first impression. And I think where you see it expanding is to other types of catheters. You know, I don't have to tell anybody who's placed dialysis catheters or introducers, the number of problems that happen with dilators, especially as your kits get bigger and the amount of damage you can cause when you're having to stick someone multiple times or you're having issues with dilation.

I mean, those are huge problems. And so I foresee that as there's more and more use of all-in-one kits, you'll see the tide change a little bit. I think some of that skepticism will go away because it's just that much more efficient.

Dr. Enfield: So we started this conversation and are kind of ending it on this idea that we have a lot of commonly performed procedures in critical care. Many of them haven't really gotten significant redesign or innovation in decades. So how would you like intensivists to start thinking about what they do day to day?

And how do we start questioning what is normal and start bringing innovation back into our ICUs? Again, getting back to the idea of what's good for the patient is what's going to be best for our outcomes.

Dr. Javed: I think part of the difficulty with central lines, and I think changing that paradigm is that, you know, it's a routine procedure. And I think inherently it's difficult for us to sometimes think about why do small changes make such a big difference. Number one, recognizing that that's a thing, you know, small incremental improvements do matter.

And when you're doing high volume procedures like central lines, like everybody's doing these, you know, whether it's your nurse practitioner out in the community ICU, or whether it's an attending physician, you know, doing it on an ECMO patient, or you have residents that are learning. I mean, it's a high volume procedure. And when you have such a high volume procedure, small changes, small improvements really matter.

They can make massive system wide safety gains. And I think that's really overcoming that complacency where if you realize that there's a small incremental improvement, removing a couple steps here reduces the risk of a collapse, reduces the risk of a guidewire kinking, and then the downstream effects of those types of things. Like, I mean, a guidewire kinking is a big deal because once your guidewire kinks, then that's where you're really at risk of cannulating the wrong vessel or causing a pneumothorax or doing, you know, other type of tissue damage.

I think once you realize that across like hundreds of thousands of central lines, those little changes matter. That's where I think the fun stuff is with improving what we're doing. And I think we do need it as intensivists.

We should pay more attention to everyday procedures. I mean, just because we're familiar with it doesn't mean that it's necessarily safe. We're kind of stuck in this bubble, but if you were an outsider looking in, you'd say, well, of course, why wouldn't this industry be trying to do things in a better, more updated way?

And I think we really have to think about that.

Dr. Enfield: So you really touched on in a way that Peter Pronovost did when he's approached CLABSI thinking about the impact that his interventions had and how doing things the same old way doesn't always lead to the best outcomes and how innovation can occur. I think as we wrap up today, I wonder if there's anything that we didn't touch on that you wish we had touched on.

Dr. Javed: I think we touched on everything, but I think what I would sort of leave with is that, you know, for me personally, being skeptical of any, any new central line kit or really any anything new, probably the biggest impact on me personally placing this in the type of patient that I was placing it in is the reduction in bleeding and how much safer I felt using a kit that self dilates with no need to exchange a needle for a dilator over a guidewire, especially as in a, in an ultrasound guidance equavian.

So I think if there was one thing that impacted me the most from this whole experience was that there was no bleeding, which is pretty, pretty amazing when you're placing a central line in a coagulopathic patient with platelets less than 20.

Dr. Enfield: That's a great place to end both with the idea that there is definitely going to be something in the future that's going to help all of our patients and the mindset that we should question everything that we do and ask ourselves is really this the best way to approach patient care. This will conclude another episode of the Society of Critical Care Medicine's podcast. If you're listening on your favorite podcast app and you like what you heard, consider rating and leaving a review.

For this Society of Critical Care Medicine podcast, I'm Kyle Enfield.

Announcer: This episode is sponsored by the BD CentroVino1 Insertion System. Central line placement is routine, but complexity continues to define this critical procedure. CentroVino1 is designed to simplify the procedure by integrating the guide wire, needle, syringe, and catheter into one streamlined system, helping reduce the risks created by complexity. Finally, a simpler central line. To learn more about CentroVino1, visit bd.com\sccm, bd.com/SCCM.
  
Always consult the product's current Instructions for Use (IFU) and adhere to your facility's policies, procedures, and clinical practice guidelines before using any product.

Kyle B. Enfield, MD, is an Associate Professor of Medicine in the Division of Pulmonary and Critical Care at the University of Virginia. He received his undergraduate degree from the University of Oklahoma.

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