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Ya cuz that’s what I do. Some old folks with bad hearts can develop apnea with very little- also saves time as you are pre-oxygenating.Explain, please
Ya cuz that’s what I do. Some old folks with bad hearts can develop apnea with very little- also saves time as you are pre-oxygenating.Explain, please
Waddup! Just checking on you awesome folks here. A lot less clinical these days… but the anesthesia landscape continues to change, so it merits discussion.HEY! Been a minute. Glad to see you here.
This sounds terribly inefficient.
I think he just meant that an art line takes zero minutes in the OR if it's already in.How so? Everyone knows their roll and moves efficiently around one another. The smooth operators in the group can usually get a-line, induce/tube, intro+swan in about 20 minutes.
Apparently a certain NE academic hospital had a disconnected aline during transfer from preop to room and it took some time to noticeI will never again do lines in pre-op on awake patients.
Patients hate it, i hate it… little to gain.
Mount Sinai in Florida used to do that.
Not a fan. Little upside, lots of downsides.
My surgeons tried that line when they first arrived. I made a point of showing them it makes little to no difference, if you know what you’re doing.I will never again do lines in pre-op on awake patients.
Patients hate it, i hate it… little to gain.
Mount Sinai in Florida used to do that.
Not a fan. Little upside, lots of downsides.
But it takes me about two minutes to place in the OR. Or 10-15 to carry all that crap to pre-op, where I have to place it in a closet while the family stares at me. Then convince the pre-op nurses nothing will happen.I think he just meant that an art line takes zero minutes in the OR if it's already in.
I think he just meant that an art line takes zero minutes in the OR if it's already in.
But it takes me about two minutes to place in the OR. Or 10-15 to carry all that crap to pre-op, where I have to place it in a closet while the family stares at me. Then convince the pre-op nurses nothing will happen.
I’m not saying one way is right, but each way has its place based on the circumstances of an institution.
One time I was placing it in pre-op. Patients son was a cardiologist, unknown to me. Watching me do my thing, said “isn’t this supposed to be a sterile procedure”. Of course I didn’t have sterile gloves on.
But they just had a 20g PIV placed by a nurse without sedation. Why do I need to give any for a 20G radial line that I'm gonna place with local and even *less* effort than the nurse?I think we all could benefit from stepping back for a second and wondering where this awake a line stuff comes from. It’s a many decades old practice from a time when anesthesia was less sophisticated and patients were getting unstable because anesthesia providers didn’t really know what they were doing like we do today.
Of course there are patients that are tenuous enough that I’ll place an a line with minimal or zero sedation. But they are pretty uncommon. The vast vast majority of patients will tolerate a heavy sedation.
I encourage you to leave your comfort zone and experiment a little if you don’t feel confident that you can render a hemodynamically stable, spontaneously breathing, normocarbic general anesthesia for line placement. Whether it’s just the a line or all the lines plus a pericardiocentesis
Ours also. There's a tray set out with local drawn up in a syringe, prep materials, ultrasound, a line cart with more supplies. No family in the prep area. Couldn't be easier.Our holding area already has an ultrasound and the nurses make the pressure bag setup. It's trivially easy to put it in in 95% of patients.
Hypercarbia is only causing major instability for a few select severe comorbidities.Agreed on 3 of 4 points.
I disagree re 2. It is unsafe... if one does enough of that nonsense for essentially a 20g IV, a patient will crump...
Ive seen it a couple times a year...
Hypoxia, and worse hypercabia in a bad heart and they can fall apart in front of you...
For anyone interested in some of our Tavis the co2 can climb to 70s, and PAs can jump to 70 80s too with that...
I will never again do lines in pre-op on awake patients.
Patients hate it, i hate it… little to gain.
Mount Sinai in Florida used to do that.
Not a fan. Little upside, lots of downsides.
I am specifically talking about central lines, but I also don’t do a-lines in pre-op. Nothing is gained in my workflow to do them in pre-op. Haven’t done a pre-op aline in over 15 years.I prefer in OR preinduction art lines, but my workflow usually entails preop awake art lines. I’m pretty specific in where I deposit my lido, both subs and periarterailly, and I’ve pretty much never had a complaint.
I believe all my partners do their art lines post induction/intubation except on the rare occasion (critical left main disease, for example). I'm the anomaly who does them all awake.I think we all could benefit from stepping back for a second and wondering where this awake a line stuff comes from. It’s a many decades old practice from a time when anesthesia was less sophisticated and patients were getting unstable because anesthesia providers didn’t really know what they were doing like we do today.
Of course there are patients that are tenuous enough that I’ll place an a line with minimal or zero sedation. But they are pretty uncommon. The vast vast majority of patients will tolerate a heavy sedation.
I encourage you to leave your comfort zone and experiment a little if you don’t feel confident that you can render a hemodynamically stable, spontaneously breathing, normocarbic general anesthesia for line placement. Whether it’s just the a line or all the lines plus a pericardiocentesis
Mitral valve case, known RV issues/Pulm HTN, or severely reduced LVEF. Or if the surgeon requests it. TEE in everyone.How many of you are routinely floating swans for routine cases? I feel like they offer little intra-op with TEE onboard but some intensivists like it for post op.
I may place one for EF < 30%.
EveryHow many of you are routinely floating swans for routine cases? I feel like they offer little intra-op with TEE onboard but some intensivists like it for post op.
I may place one for EF < 30%.
How many of you are routinely floating swans for routine cases? I feel like they offer little intra-op with TEE onboard but some intensivists like it for post op.
I may place one for EF < 30%.
We currently have two surgeons. One wants a PAC on every single case more complicated than a sternal wire removal. The other is fine with just a SLIC down the introducer if it's a CABG with normal LV systolic function. Maybe if we're doing something like removal of an atrial myxoma or ASD closure in an otherwise healthy patient, he'd be ok if we skipped the PAC.How many of you are routinely floating swans for routine cases? I feel like they offer little intra-op with TEE onboard but some intensivists like it for post op.
I may place one for EF < 30%.
100% agree with thisI think midazolam is the most overused drug we have. Except maybe dexmedetomidine.
And you should’ve responded to him “No.” That’s not to say it’s ok to spit on an A lineOne time I was placing it in pre-op. Patients son was a cardiologist, unknown to me. Watching me do my thing, said “isn’t this supposed to be a sterile procedure”. Of course I didn’t have sterile gloves on.
Much of it is habit from the “old” days of ultrasound not being readily available, anesthesiologists not being capable with ultrasound, or a combination of both. With all those factors you just couldn’t induce a heart without an A line because it could take forever to blindly place the line.I think we all could benefit from stepping back for a second and wondering where this awake a line stuff comes from. It’s a many decades old practice from a time when anesthesia was less sophisticated and patients were getting unstable because anesthesia providers didn’t really know what they were doing like we do today.
Of course there are patients that are tenuous enough that I’ll place an a line with minimal or zero sedation. But they are pretty uncommon. The vast vast majority of patients will tolerate a heavy sedation.
I encourage you to leave your comfort zone and experiment a little if you don’t feel confident that you can render a hemodynamically stable, spontaneously breathing, normocarbic general anesthesia for line placement. Whether it’s just the a line or all the lines plus a pericardiocentesis
But they just had a 20g PIV placed by a nurse without sedation. Why do I need to give any for a 20G radial line that I'm gonna place with local and even *less* effort than the nurse?
Our holding area already has an ultrasound and the nurses make the pressure bag setup. It's trivially easy to put it in in 95% of patients.
C'monIntra-arterial zofran burns like nothing else. Wonder how I know? Happens once, I will never put an a-line in again where some helpful preop nurse can get to the stopcock.
Every
Single
Case
Our surgeons want them for postop management in the ICU. Not a hill I care to die on. Takes a couple minutes, bills a few units, on to the next task.
Yeah, I had one surgeon who would let us get away with no swan, but then if his partner was on call, we had to place it anyways.That is what we did at our first job.
Every case.
Thankfully not at this one.
Single vessel cabg ef 60%. Nope.
Simple P2 flail everything else normal? Nope.
We double stick w 7fr double lumen plus triple for uncomplicated cases. Complicated does get an introducer and swan.
If the surgeon or ICU doesn’t want it, I can get behind not having the tricuspid vale open and close with a foreign object in it 5000 times an hour..
Thx for the responses.
Aside from the fact the vigileo/flotrac is complete and utter made up garbage data wtf is it for when you have a CCO?I work in a big name health system that, despite being a 501c3, generates some billions in revenue. Since this service line is a strong contributor we get the worlds most well resourced (see wasteful) cardiac set-up. Every pump case gets a CCO swan, TEE, flotrac with CI/CO/SVR/SVV, cerebral ox and rapid infuser/warmer primed.
What’s the point of the double stick? I see it mentioned a lot but have never practiced at an institution that did it. It was always introduced +/- PA for all hearts.That is what we did at our first job.
Every case.
Thankfully not at this one.
Single vessel cabg ef 60%. Nope.
Simple P2 flail everything else normal? Nope.
We double stick w 7fr double lumen plus triple for uncomplicated cases. Complicated does get an introducer and swan.
If the surgeon or ICU doesn’t want it, I can get behind not having the tricuspid vale open and close with a foreign object in it 5000 times an hour..
Thx for the responses.
Never done a liver TX. What size were those cannulae and how quick could ye go on? It was for massive bleed I assume?Only the liver txp which got a rij and a lij (in case we had to go into VV bypass, out liver surgeons were not that good). Is this what you mean by double stick in case you have to put in an introducer?
Patient comfort. Remove 7 fr. double or introducer after a day or so if all is stable.What’s the point of the double stick? I see it mentioned a lot but have never practiced at an institution that did it. It was always introduced +/- PA for all hearts.
Only the liver txp which got a rij and a lij (in case we had to go into VV bypass, out liver surgeons were not that good). Is this what you mean by double stick in case you have to put in an introducer?
For whatever it's worth, the CDC has said since 2011 that arterial lines should be done under sterile conditions:I think technically an arterial line is a clean procedure, although most of us tend to do it as sterile as possible (takes near zero effort to put on sterile gloves and drape out).
For whatever it's worth, the CDC has said since 2011 that arterial lines should be done under sterile conditions:
- A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion [47, 158, 159]. Category IB
I’ve read that before but how is an arterial line different from an IV?
It’s still ok if I tear off the finger of the glove to better palpate the pulse, though, right?For whatever it's worth, the CDC has said since 2011 that arterial lines should be done under sterile conditions:
- A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion [47, 158, 159]. Category IB
It depends on if you use the kit or the quick cath.I’ve read that before but how is an arterial line different from an IV?