Whippe Procedure and Arterial Lines.

[Iso4ane]

How often are you NOT placing an arterial line for a Whipple. I have a surgeon who suggests that it’s not indicated just because it’s a Whipple, and although I could be persuaded, these patients rarely come in with just pancreatic cancer. It’s not like this surgeon is a whiz at them either but I like to hear the thoughts of others here.

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[GassYous]

In residency we placed a lines for all cranis, give all sorts of medications, hyperventilate and used all kinds of ridiculous drips. Now that I work with fast, efficient surgeons I basically never do any of these things.

However, I would place an a line for every whipple. I don't care what the surgeon says and if he sucks that's an even bigger indication. It's a huge whack on a sick patient (even if they didn't have other comorbidities) and too many important things around there to not do it.

 

[abolt18]

How often are you NOT placing an arterial line for a Whipple. I have a surgeon who suggests that it’s not indicated just because it’s a Whipple, and although I could be persuaded, these patients rarely come in with just pancreatic cancer. It’s not like this surgeon is a whiz at them either but I like to hear the thoughts of others here.

What's his concern? That you'll take an extra few minutes before his many-hours-long operation? Are you not having sometimes significant blood loss, fluid loss (eternally open belly), and eventually profound hyperglycemia?

 

[Hork Bajir]

If they’ve had chemo and radiation, which is becoming more common with the newest protocols, art line 100% of the time. The combo of chemo and XRT turns the tissues into wet Kleenex, destroys all of the dissection planes, plus these folks often had only borderline resectable disease to begin with. I’d also look at the CT scan... Tumor encasing the celiac, abutting the portal vein, etc? You won’t win any awards for not placing an art line.

That being said, you don’t necessarily need an art line for every whipple if you have a good surgeon. If you’re going to spare the a line, be sure that your surgeon is willing to leave an arm untucked (or make it clear up front that you reserve the right to untuck an arm midway thru the procedure if they get into trouble).

 

[Airway]

How often are you NOT placing an arterial line for a Whipple. I have a surgeon who suggests that it’s not indicated just because it’s a Whipple, and although I could be persuaded, these patients rarely come in with just pancreatic cancer. It’s not like this surgeon is a whiz at them either but I like to hear the thoughts of others here.

The chair of surgery (pancreatobiliary surgeon) at University of Wisconsin wrote a paper saying you should place an arterial line for all Whipple's.

Serious answer: If no radiation, healthy ( arbitrary 6 mets and decent Hgb), low likelihood of venous injury (imaging and discussion w surgeon) I could see my self not routinely putting in an arterial line. Especially if non invasive continuous bp monitoring was available (and relatively inexpensive).

 

[deleted162650]

I’d tell him:

One of the rules of general surgery is “Don’t f*** with the pancreas.” If you’re going to f*** with the pancreas, I’m going to f***ing put in an A-line.

 

[Ronin786]

On this topic, any diplomatic ways you guys deal with dickbag surgeons that give **** about arterial line placement?

(outside of finding a new job sans dickbag surgeons)

 

[turnupthegas]

I'd place it. It takes a minute to do and lord knows I hate doing when the drapes are up.

"It shouldn't be that long", "I don't expect a lot of bleeding", "Do they really need that line?" - Okay, buddy. I've heard it all before. The surgeons that say stuff like this need whatever you're doing the most.

On this topic, any diplomatic ways you guys deal with dickbag surgeons that give **** about arterial line placement?

(outside of finding a new job sans dickbag surgeons)

"Thanks for your input, I think the patient needs it and it impacts my care. Later nerd."

 

[coffeebythelake]

How often are you NOT placing an arterial line for a Whipple. I have a surgeon who suggests that it’s not indicated just because it’s a Whipple, and although I could be persuaded, these patients rarely come in with just pancreatic cancer. It’s not like this surgeon is a whiz at them either but I like to hear the thoughts of others here.

Why is a surgeon saying any of this. If you want to put in an art line then do so. It takes 2 minutes to do.

 

[2Fast2Des]

Why is a surgeon saying any of this. If you want to put in an art line then do so. It takes 2 minutes to do.

Exactly! I don't need a surgeon permission for an art line, they're not placing it or helping to place it so they can get to work on prepping the pt and foley while I'm doing the line if they feel it will slow them down for the marathon case. And I'm not going to suffer or work in the blind based on what they "feel."

 

[Southpaw]

1) next case tell him you need a central line or a 2nd aline as backup in case the first fails. Smile/wink.

2) start politely suggesting where he needs to place retractors or clamps once the belly is open.

put your friggin’ line in and take the necessary few minutes to care for the patient to your happiness level so he can putz around for the next however many hours.

 

[sevoflurane]

On this topic, any diplomatic ways you guys deal with dickbag surgeons that give **** about arterial line placement?

(outside of finding a new job sans dickbag surgeons)

I don’t deal with that ****. Ever.
Have a strong anesthesia department and if a surgeon thinks he can dictate anything I do for the sake of patient care... they go to the principles office which is followed up by always getting the slowest and oldest member of our group.

 

[GassYous]

On this topic, any diplomatic ways you guys deal with dickbag surgeons that give **** about arterial line placement?

(outside of finding a new job sans dickbag surgeons)

Nah cause my surgeons aren't dumb enough to do that

 

[gaspasser127]

In the words of one of my older attendings: “I don’t give a f*** what the surgeon thinks. You’re the anesthesiologist. You dictate the anesthetic management of that case, not her.”

Her = chair of surgery at our institution at that time.

As I finish out residency I’m starting to have much more appreciation for attendings who don’t take crap from surgeons, nurses, CRNAs, etc. but are still kind, humble, and knowledgeable people. The pushovers are the ones who get promoted within the department or in academic leadership but aren’t necessarily the best clinically. They just do whatever it takes to appease nurses and surgeons.

 

[GassYous]

In the words of one of my older attendings: “I don’t give a f*** what the surgeon thinks. You’re the anesthesiologist. You dictate the anesthetic management of that case, not her.”

Her = chair of surgery at our institution at that time.

As I finish out residency I’m starting to have much more appreciation for attendings who don’t take crap from surgeons, nurses, CRNAs, etc. but are still kind, humble, and knowledgeable people. The pushovers are the ones who get promoted within the department or in academic leadership but aren’t necessarily the best clinically. They just do whatever it takes to appease nurses and surgeons.

So true! I was one of those don't take **** people as a resident and some people didn't like that. The ones who were suck ups that played politics well were the golden boys. A number of those guys decided to stay and I'm sure they will slurp their way up the ranks.

 

[Katheudontas parateroumen]

These are the reasons why when people say "dealing with surgeons" is a negative. I think it's fine if they ask why, but if i give them an answer, that better be the end of it. I usually place a central line in these patients as well... or do you guys just roll with 2 good PIV? I can see not placing a central if they are "otherwise healthy". But it's nice to know for a big case i have a reliable line and one for pressors as needed.

 

[Hork Bajir]

As nice as it might feel to tell certain surgeons to go pound sand, at the end of the day a mutually respectful relationship is much more productive (and professionally fulfilling) than an adversarial one. I know I’m largely preaching to the choir here, but in order to be respected you need to demonstrate knowledge, skills, efficiency, and flexibility to your surgeons. There will come a day when that surgeon makes a hole in the portal vein and the case goes south... Your behavior, demeanor, and resuscitation of the patient (assuming you keep your cool and do a good job) will win you more credibility with the surgeon than any chest-beating about an arterial line ever could. That’s one of the reasons I like doing cardiac and other “big” cases: much easier to demonstrate your worth and earn respect than when all the surgeon seems you doing is popping LMAs into an ASA1 all day, in which case I couldn’t blame the surgeon for thinking we’re interchangeable technicians.

 

[2Fast2Des]

These are the reasons why when people say "dealing with surgeons" is a negative. I think it's fine if they ask why, but if i give them an answer, that better be the end of it. I usually place a central line in these patients as well... or do you guys just roll with 2 good PIV? I can see not placing a central if they are "otherwise healthy". But it's nice to know for a big case i have a reliable line and one for pressors as needed.

In residency all we did was 2 large IV + Art line, that's all you need unless anticipating worse that needs a CVL

 

[GassYous]

These are the reasons why when people say "dealing with surgeons" is a negative. I think it's fine if they ask why, but if i give them an answer, that better be the end of it. I usually place a central line in these patients as well... or do you guys just roll with 2 good PIV? I can see not placing a central if they are "otherwise healthy". But it's nice to know for a big case i have a reliable line and one for pressors as needed.

I'm happy with 2 big ivs and the arms out but I wouldn't fault anyone for placing a line.

 

[deleted697535]

Why is a surgeon saying any of this. If you want to put in an art line then do so. It takes 2 minutes to do.

Yeah tell him go **** himself. Is that indicated?

 

[deleted875186]

100% art line. Risk of serious bleeding. Risk of surgeon or more likely assistant pushing on a largely vessel and hemodynamic effects. Plus always a possibility of case going

I don’t put in a CVC unless there’s access issues or anticipated need postop.

100% thoracic epidural.

 

[Iso4ane]

Yeah, I pretty much always to an arterial line, but the surgeon says it every time, and I just tell her cause I want to.

 

[zizzer]

In residency many of our surgeons would try to manage the anesthetic plan. At my new job on the other side of the country, none of them care what I do and seem grateful that I'm managing all the nonsurgery stuff for them. There have been two exceptions, and both of those surgeons used to work at the place I did residency lol

I do arterial line and CVC for most Whipples, but if I had to choose only one I would choose the arterial line.

 

[Urzuz]

Arterial line every time for a Whipple. They are around big vessels. Low risk, takes a minute to do, and adds a very useful monitor for a several hour case.

On this topic, any diplomatic ways you guys deal with dickbag surgeons that give **** about arterial line placement?

(outside of finding a new job sans dickbag surgeons)

Don't debate them on it, and don't be wishy washy and start to doubt yourself - just say that you need it to keep the patient safe and do it.

What kind of a practice do you work in? Most surgeons in the real world outside of academics are actually reasonable people that are grateful if you take good care of their patients. That being said, it helps if 1) you have a good relationship with them (which helps if you are in a physician only group and do your own cases, since you end up shooting the **** with them for hours on end most days so you develop a rapport with them), and 2) you don't take years to put an arterial line in. Use an ultrasound if you need to - it is a much bigger sign of weakness to take ten minutes repeatedly stabbing a patient's wrist and trying to wire it in, etc, than it is to use an ultrasound and put it in in less than 30 seconds.

 

[Ronin786]

As nice as it might feel to tell certain surgeons to go pound sand, at the end of the day a mutually respectful relationship is much more productive (and professionally fulfilling) than an adversarial one. I know I’m largely preaching to the choir here, but in order to be respected you need to demonstrate knowledge, skills, efficiency, and flexibility to your surgeons. There will come a day when that surgeon makes a hole in the portal vein and the case goes south... Your behavior, demeanor, and resuscitation of the patient (assuming you keep your cool and do a good job) will win you more credibility with the surgeon than any chest-beating about an arterial line ever could. That’s one of the reasons I like doing cardiac and other “big” cases: much easier to demonstrate your worth and earn respect than when all the surgeon seems you doing is popping LMAs into an ASA1 all day, in which case I couldn’t blame the surgeon for thinking we’re interchangeable technicians.

I don’t deal with that ****. Ever.
Have a strong anesthesia department and if a surgeon thinks he can dictate anything I do for the sake of patient care... they go to the principles office which is followed up by always getting the slowest and oldest member of our group.

I do agree. Strong anesthesia department is the key to eliminating a lot of malcontent when it comes to the job. Unfortunately, some departments have made a name for themselves sitting in their offices and signing charts or being generally not good which perpetuates a culture where the surgical staff dictates more of what goes on in the OR. Makes it hard for anybody who actually does care.

 

[IlDestriero]

I don’t deal with that ****. Ever.
Have a strong anesthesia department and if a surgeon thinks he can dictate anything I do for the sake of patient care... they go to the principles office which is followed up by always getting the slowest and oldest member of our group.

We used to have a couple aging super slow, super talkative, super obstructionist anesthesiologists at my shop. They were good physicians and really cared about the patients, but they didn’t care at all how long anything took, and were extremely conservative. The last maybe 5 years of their careers they were part time, mostly protected from super crazy cases, and often did out of OR cases, or were the float.
Anytime someone got a little mouthy about turnover time while we were setting up 6 drips, lines, etc., “do we really need an epidural?”, or whatever, I’d say, “don’t make me switch rooms with ‘Joe’. ” They got the message. I said that a few years ago to the chief of surgery and he said, “Well, that won’t happen.” I thought that was hilarious.
Fortunately pretty much all of the surgeons let us do what we think we need to do or maybe ask why we are doing a central line or whatever. Sometimes it’s the PICU requesting it for longer term reliable access. Occasionally they get uptight about transfusions, so that must be tracked for USNews rankings or something.

 

[turnupthegas]

I wonder if surgeons have a "dealing with a difficult anesthesiologist" on their oral boards.....

 

[DoctwoB]

I wonder if surgeons have a "dealing with a difficult anesthesiologist" on their oral boards.....

Haha, doesn't come up on our side as much. Probably because we're typically asking for something for ours/patient convenience and you're asking for something at least ostensibly for patient safety, and thats not a "board" answer, even if in the real world we make reasonable trade offs based on risk/benefit/convenience. I can't remember the last time I asked anesthesia for a general or a line and they insisted on MAC or going lineless.

Personally I butt out of anesthesia decisions and usually come into the room when the patient is asleep. It really helps to work with the same docs over time, so I know if they tell me person X should be a general and not a MAC or something along those lines. I know they have a reason for it. The only thing that really grinds my gears is the anesthesiologist who clearly doesn't take the patient into account and insists on doing things a certain (overly intrusive) way every time, like the doc who insisted every robotic prostate needed an A-line (and usually took 20 min to place one).

 

[zizzer]

Yup, my physician-only group at an academic center has a much better relationship with the surgeons than my residency attendings did (who have a medical direction model).

 

[Iso4ane]

Just an update, as I only started the case for a colleague. I went back and took a look. The Whipple was a NINE hour robo Whipple.

I know technically long surgery in of itself is not a indication, but I wish I could tell the surgeon, that they are my indication for an arterial line.

 

[Airway]

I do agree. Strong anesthesia department is the key to eliminating a lot of malcontent when it comes to the job. Unfortunately, some departments have made a name for themselves sitting in their offices and signing charts or being generally not good which perpetuates a culture where the surgical staff dictates more of what goes on in the OR. Makes it hard for anybody who actually does care.

I can't emphasize how important this is. The worst things I've ever been around are incompetent weak leaders

 

[fakin' the funk]

Some of our HPB surgeons do uncomplicated Whipples in 4-5 hours with 100ml blood loss.
Does anyone think that procedure mandates an arterial line? Obviously not. None of us should be so dogmatic as what I've seen in this thread. I get it, if your surgeon routinely takes 8 hours, brings you cardiac cripples, and gets into the PV more often then not, then sure - but that's abnormal, and if this person is giving you guff about monitoring just tell them to sit outside until they're summoned.

 

[fakin' the funk]

I’d tell him:

One of the rules of general surgery is “Don’t f*** with the pancreas.” If you’re going to f*** with the pancreas, I’m going to f***ing put in an A-line.

☝️ Disagree

 

[Iso4ane]

Some of our HPB surgeons do uncomplicated Whipples in 4-5 hours with 100ml blood loss.
Does anyone think that procedure mandates an arterial line? Obviously not. None of us should be so dogmatic as what I've seen in this thread. I get it, if your surgeon routinely takes 8 hours, brings you cardiac cripples, and gets into the PV more often then not, then sure - but that's abnormal, and if this person is giving you guff about monitoring just tell them to sit outside until they're summoned.

Open Whipple or Laparoscopic/Robotic Whipples?

 

[DrOwnage]

Benefits of the A line outweighs the risks in these procedures. Unless its a 50 year old completely healthy dude/chick I'm putting in an a line. Use ultrasound for every a line. From the time I put the needle in the skin it takes about 20 seconds until the catheter is in, plus a couple of minutes to secure. Usually done before the prep has its 3 minutes to dry. The complication rate is 2.7 per 10,000 for 20 gauge catheters. Put in the A line.

 

[nimbus]

Open Whipple or Laparoscopic/Robotic Whipples?

I’ve never done a robotic Whipple. Are they less bloody than open?

In the old days we did a lot of open radical prostatectomies. Depending on the surgeon, it was not uncommon to lose 500-1500 ml blood in a hurry. Nowadays, blood loss is negligible with robotic prostatectomies.

 

[GassYous]

I’ve never done a robotic Whipple. Are they less bloody than open?

In the old days we did a lot of open radical prostatectomies. Depending on the surgeon, it was not uncommon to lose 500-1500 ml blood in a hurry. Nowadays, blood loss is negligible with robotic prostatectomies.

Yes

 

[kidthor]

I have a surgeon who suggests that it’s not indicated just because it’s a Whipple

I don't get it? Why is this something they even bring up?

 

[Iso4ane]

I don't get it? Why is this something they even bring up?

They don’t like the five minute delay for their 8hour case.

 

[Neopolymath]

What's his concern? That you'll take an extra few minutes before his many-hours-long operation? Are you not having sometimes significant blood loss, fluid loss (eternally open belly), and eventually profound hyperglycemia?

Isn't that basically the mindset all whiny, and usually also mediocre to boot, surgeons have where you are from?

 

[Lecithin5]

99 percent of the time my aline is in and secure (I almost always use ultrasound) before the foley is in and secure. So the surgeon should chill out.

 

[Hork Bajir]

“I could have had the arterial line done in the time it’s taken for us to have this conversation”

 

[MDanesth]

I trained at a place where we did a lot of Whipples. We did not routinely use A-lines. Patient comorbidities would dictate A-line versus not. I would say it was 50/50.

 

[AnesRunner]

It's very dependent on the quality of the surgeon and the patients they choose to operate on. Bad surgeons operate on people they probably should not operate on and suffer the consequences intraoperatively and postoperatively (but never seem to learn). Meanwhile, there is the rare HPB surgeon who is quick, technically good, and knows when to say patients are not surgical candidates.

 

[Iso4ane]

It's very dependent on the quality of the surgeon and the patients they choose to operate on. Bad surgeons operate on people they probably should not operate on and suffer the consequences intraoperatively and postoperatively (but never seem to learn). Meanwhile, there is the rare HPB surgeon who is quick, technically good, and knows when to say patients are not surgical candidates.

Yeah, I’ve noticed this recently, still trying to figure out how much of a surgeons perceived skill is attributed to careful patient selection (which in of itself is a skill), vs actual procedural skills.

 

[anbuitachi]

100% arterial line. whipple takes about 12 hours here. arterial lines help with electrolyte and fluid management, and resuscitation. also makes glucose checks easier.

 

[Aether2000]

The art line is not for the surgeon, it is for you. Put in whatever you need regardless of the surgeon's protestations.

 

[Twiggidy]

“I could have had the arterial line done in the time it’s taken for us to have this conversation”

This

 

[zizzer]

So yesterday, I had to rush up to the ICU to bring a patient down for a hemicraniectomy for ischemic stroke that converted to hemorrhagic stroke who just developed a blown pupil and had midline shift. This surgeon gave me trouble over an arterial line I placed a couple months ago for a spine case in a patient with cardiac issues. Today he wanted to get started without an arterial line too despite it being his fault that he pushed this case to a second round case so he could do an elective spine case. I promised him it would take 2 minutes because the anesthesia tech had already set everything up. The US died right in the middle of the procedure and it took 3, so he was a little crabby. Anyhow, the recent aspirin combined with tPA the prior day resulted in about a liter of blood loss and the patient being in hemorrhagic shock with me struggling to keep MAP >50 for a bit. Surgeon was completely losing his mind at how much bleeding there was and screamed, "I need the blood pressure way down!" I said, "It's 87/31." Anyway, after a liter of blood loss in an already anemic patient, things got under control and the nurses and his PA were making fun of how he always loses his **** with bleeding. Everybody told me good job and standing my ground to place an arterial line.

 

[vector2]

So yesterday, I had to rush up to the ICU to bring a patient down for a hemicraniectomy for ischemic stroke that converted to hemorrhagic stroke who just developed a blown pupil and had midline shift. This surgeon gave me trouble over an arterial line I placed a couple months ago for a spine case in a patient with cardiac issues. Today he wanted to get started without an arterial line too despite it being his fault that he pushed this case to a second round case so he could do an elective spine case. I promised him it would take 2 minutes because the anesthesia tech had already set everything up. The US died right in the middle of the procedure and it took 3, so he was a little crabby. Anyhow, the recent aspirin combined with tPA the prior day resulted in about a liter of blood loss and the patient being in hemorrhagic shock with me struggling to keep MAP >50 for a bit. Surgeon was completely losing his mind at how much bleeding there was and screamed, "I need the blood pressure way down!" I said, "It's 87/31." Anyway, after a liter of blood loss in an already anemic patient, things got under control and the nurses and his PA were making fun of how he always loses his **** with bleeding. Everybody told me good job and standing my ground to place an arterial line.

For these kind of emergent cranis we set up the room in such a fashion so that post-intubation we can immediately turn the bed about 120 so the surgeon can start prepping- but we still have the patient’s arm facing us and accessible to work on 2nd IV and aline. Your patient does need an a-line, but what they need more is their skull flap off and a blood transfusion.