Academic dogma

[GassmanMD]

As a current CA1, I find it really interesting to learn about the tricks my attendings will not teach me. For example, a past thread about extubating a bucking patient really fascinated me. There was also an awesome thread started by jet years ago about his top ten. In it, he listed some things like sterile art lines and LR not mixing with PRBCs as academic dogma. Here is a link, it's worth revisiting: http://forums.studentdoctor.net/threads/jets-top-ten.907043/

I love this kind of stuff!! What else are they not teaching us in residency?

---

Members don't see this ad.

 

[urge]

You don't have to do central lines sterilely either.... they work just fine despite all those Enterococcus faecalis on them.

 

[countingdays]

You don't have to do central lines sterilely either.... they work just fine despite all those Enterococcus faecalis on them.

Totally. Starting Levophed is just as easy as doing a sterile prep.

 

[deleted171991]

You don't have to do central lines sterilely either.... they work just fine despite all those Enterococcus faecalis on them.

Why should we do A-lines in a sterile fashion, when we don't do peripheral IVs?

 

[dhb]

Totally. Starting Levophed is just as easy as doing a sterile prep.

Do you think your sterile prep is really sterile?

 

[lane]

Why should we do A-lines in a sterile fashion, when we don't do peripheral IVs?

Because nursing protocols demand PIVs be replaced every 3 days to prevent any infections, but those arterial lines may be there for, like, 4 days. And that extra day totally increases the likelihood of infection. Until we get more nursing protocols to protect the patients we should definitely use sterile prep

 

[Sonny Crocket]

Now this is an interesting thread. How sterile are you guys with peripheral nerve blocks? Has there been any documented cases of infection after a single shot block? I do the whole sterile thing so I can document it but I really wonder sometimes. Why we are so sterile with single shots and not PIVs.

 

[BobBarker]

I clean the skin with a chlorprep and don't touch the needle with my single shot blocks. That's about it.

 

[BuzzPhreed]

I once saw a vascular surgeon put an a-line in with his bare hands. I also saw a pulm/cc doc fully gowned and gloved for an a-line.

The key is to not touch the insertion point or the catheter. I've put plenty of a-lines in with sterile gloves and a good chlorhex wash. Use an ultrasound. And don't let anything touch the spot where you're gonna put the needle. And don't touch the catheter itself. If you do these things it won't get infected. Also don't suture it in.

 

[Sonny Crocket]

You putting condoms or tegaderm on the ultrasound for a single shot?

 

[scudrunner]

Line infections have been studied- central lines benefit from sterile technique, a-lines do not. It's befuddling that some go to such lengths to basically put in an IV.

 

[Dwindlin]

I once saw a vascular surgeon put an a-line in with his bare hands. I also saw a pulm/cc doc fully gowned and gloved for an a-line.

The key is to not touch the insertion point or the catheter. I've put plenty of a-lines in with sterile gloves and a good chlorhex wash. Use an ultrasound. And don't let anything touch the spot where you're gonna put the needle. And don't touch the catheter itself. If you do these things it won't get infected. Also don't suture it in.

Disagree with the bolded. Otherwise I learned similarly, chloraprep and sterile gloves (because we don't routinely do u/s).

 

[HollATme]

The ICU nurses are all about having those lines sutured. I can understand the rationale.

In the OR, you won't be suturing those a-lines. benzoin, tegaderm, tape.

 

[BuzzPhreed]

Also don't suture it in.

Disagree with the bolded. Otherwise I learned similarly, chloraprep and sterile gloves (because we don't routinely do u/s).

In my opinion suturing exponentially increases your chances for it getting infected.

Learn to use an ultrasound. What inevitably turns into a painful and prolonged procedure in some patients futzing around trying to get it will routinely and reproducibly take you less than 30 seconds with practice. Place it a little more proximal too (proximal part of the distal third of the radius). If you benzoin it and put a good tegaderm on the suture is irrelevant. So is that stupid armboard.

 

[jwk]

The ICU nurses are all about having those lines sutured. I can understand the rationale.

In the OR, you won't be suturing those a-lines. benzoin, tegaderm, tape.

I understand the rationale behind suturing an A-line, but if the nurses would just leave the damn thing alone when the patient gets to the ICU, it wouldn't get pulled out accidentally in the first place. We never suture ours in. They're rarely in for more than a day or two at our place. If they need one longer than that, the intensivist is going to change it out anyway.

 

[OB1🤙]

http://journals.lww.com/anesthesia-..._Dogmas_and_Shibboleths___Barriers_to.31.aspx

 

[Dwindlin]

In my opinion suturing exponentially increases your chances for it getting infected.

Learn to use an ultrasound. What inevitably turns into a painful and prolonged procedure in some patients futzing around trying to get it will routinely and reproducibly take you less than 30 seconds with practice. Place it a little more proximal too (proximal part of the distal third of the radius). If you benzoin it and put a good tegaderm on the suture is irrelevant. So is that stupid armboard.

I know how to use it and I am getting more comfortable, it just isn't the culture here (plus the one in our SICU is a piece of trash). The dressings on all our lines get changed every couple days. If they aren't sewn it they come out or fail at an alarming rate. It's easier to sew them in, and while my numbers are too small to matter I can tell you none of my trauma/ICU attendings have ever seen an a-line infection. So unless specifically told otherwise (or evidence says otherwise) I'll likely keep on sewing them in, it takes 10 seconds to thrown a single stitch.


Sent from my iPad using Tapatalk

 

[Dwindlin]

I understand the rationale behind suturing an A-line, but if the nurses would just leave the damn thing alone when the patient gets to the ICU, it wouldn't get pulled out accidentally in the first place. We never suture ours in. They're rarely in for more than a day or two at our place. If they need one longer than that, the intensivist is going to change it out anyway.

We don't routinely change out a-lines here. Central lines every 5 damn days, but only time we muck with the a-lines is if they go bad (except the mandated dressing changes by nursing).


Sent from my iPad using Tapatalk

 

[OB1🤙]

I:
Don't suture a-lines.
Use ultrasound for a-lines (it's sitting there in the heart room anyway), I use a tegaderm on the pre-gelled probe because otherwise the nurses think it's icky), the wet chloraprep on the skin is as good as gel between the Teggie and the skin. I usually go as far proximal in the forearm as I can before the artery dives deep, and find a good target with minimum calcium or plaque (it's amazing once you start ultrasounding the radial artery just how diseased this vessel can be in so many folks). I don't use sterile gloves for a-lines.
Don't test ventilate before I give the roc (and I almost never use sux, because myalgias truly suck).
Do use chloraprep for PNBs, with a Tegaderm over the probe, I don't use sterile gloves for these either.
Do use a full body drape for CVCs since the NWCs have come after us for this. Usually put on the regular drape that comes in the kit backwards so that it covers more of the table by the head, then use a three-quarter sheet to cover the body down to the toes. I don't think this practice is worth a damn in reducing infection, but I'll jump through the hoop since the extra drape doesn't come out of my salary.
Use Normosol or Plasmalyte, so I don't worry about mixing LR and blood, but if you're running it fast, I agree there's minimal concern.

 

[BuzzPhreed]

I know how to use it and I am getting more comfortable, it just isn't the culture here (plus the one in our SICU is a piece of trash).

This sounds like a cultural/institutional problem.

The dressings on all our lines get changed every couple days.

Why? Why would anyone mess with a perfectly well-dressed and occluded sterile dressing if there is no problem?

If they aren't sewn it they come out or fail at an alarming rate.

This sounds like a two prong problem. First, you have a nursing issue. Someone needs to teach them to be more careful. Second you are probably placing them too distally which increases the risk of it getting kinked or dislodged (think about what happens when you put it closer to a fulcrum point, in this case the wrist). If you put it more proximal this will occur less frequently. The reason why you're not doing that now is because it's more difficult to palpate and slightly deeper more proximally. If you use an ultrasound you have a better chance of obviating both of these problems.

It's easier to sew them in, and while my numbers are too small to matter I can tell you none of my trauma/ICU attendings have ever seen an a-line infection. So unless specifically told otherwise (or evidence says otherwise) I'll likely keep on sewing them in, it takes 10 seconds to thrown a single stitch.

Change is hard. I know. Just be open minded. I've been putting in a-lines going on 11 years. There's really no reason to create two more holes (entrance and exit point of the suture) into a patient if its dressed properly. The only infections I've seen with a-lines is when someone sutures it it. Trust me when I tell you that if you do it my why you really don't need a suture. You certainly don't need to change the dressing every two days either unless there is a problem with it.

I've also learned a thing or two since I started residency and continue to learn. Most importantly I recognize an opportunity when someone shows me or tells me about something that works better. And side by side with that the fact that I still don't know everything. This thread is about dogma after all.

 

[Dwindlin]

The dressing changes are an infection control mandate. Everything is taken down, cleaned with chloroprep, and redressed. We have absolute no control over this and as such it will likely not change. So, we can either replace them every couple days when they get pulled or repositioned inadvertently and fail, or we toss in a stitch. This policy is for any invasive line, not just a-lines.


Sent from my iPad using Tapatalk

 

[BuzzPhreed]

The dressing changes are an infection control mandate. Everything is taken down, cleaned with chloroprep, and redressed. We have absolute no control over this and as such it will likely not change. So, we can either replace them every couple days when they get pulled or repositioned inadvertently and fail, or we toss in a stitch. This policy is for any invasive line, not just a-lines.

You have to be a lot more careful with your aseptic technique when suturing in an a-line. You probably need a fenestrated drape, etc. Not worth the effort. I am not aware of any problems with the a-lines I put in. Some of them stay in for days (or longer).

 

[deleted171991]

Now this is an interesting thread. How sterile are you guys with peripheral nerve blocks? Has there been any documented cases of infection after a single shot block? I do the whole sterile thing so I can document it but I really wonder sometimes. Why we are so sterile with single shots and not PIVs.

It's similar to an intramuscular injection, so I don't really see why the big fuss.

Regarding the A-lines: I have always treated them the same as PIVs. No sutures.

CVCs are a different story. I would scrub and gown for them and use the kit drape.

I still attempt ventilating before muscle relaxant, unless it's a morbidly obese patient. It just gives me piece of mind, and the opportunity to exercise my mask ventilation skills.

I use sux for intubation (fast private surgeons), but I tend to use about 0.8 mg/kg or less (I rarely need RSI where I work). Very rare complaints of myalgia.

I avoid using LR with blood transfusions. It might not be a problem at high flows of LR, but I definitely used to see specks that resembled tiny clots.

 

[deleted171991]

You putting condoms or tegaderm on the ultrasound for a single shot?

When I was a resident, one of my regional attendings was doing the tegaderm plus disinfection of skin with alcohol, and used clean gloves. Others were playing the condom game with chloroprep and sterile gloves. Never had an infection with either technique. Glorified IM injections...

 

[somedumbDO]

In my opinion suturing exponentially increases your chances for it getting infected.

Learn to use an ultrasound. What inevitably turns into a painful and prolonged procedure in some patients futzing around trying to get it will routinely and reproducibly take you less than 30 seconds with practice. Place it a little more proximal too (proximal part of the distal third of the radius). If you benzoin it and put a good tegaderm on the suture is irrelevant. So is that stupid armboard.

agreed, Unless it's a kid. Arm board is good. I only use u/s if I think its gonna be rough 3kg kid, vasculopathy, super fatty ect

 

[Mman]

I only use u/s for radial art line if I'm struggling. And I'm a massive proponent of U/S and use it for blocks and central lines on a daily basis. But an a-line takes all of 5-10 seconds > 90% of the time. If I place 1000 radial a-lines, it'll take me more total time to use the U/S for every one than to save it for only the 25-50 that I need it on.

 

[dhb]

Central lines every 5 damn days

No rational for this it's crazy and puts the patient at more risk for complications

 

[Dwindlin]

No rational for this it's crazy and puts the patient at more risk for complications

Yup. We're aware and said as much to the committee. I did misspeak somewhat, Cordis comes out or exchanged after 5 days. Triple/quad lumens are every 7.


Sent from my iPhone using Tapatalk

 

[Desperateapplicant]

Why should we do A-lines in a sterile fashion, when we don't do peripheral IVs?

I think it applies only when a wire is used.

 

[epidural man]

As a current CA1, I find it really interesting to learn about the tricks my attendings will not teach me. For example, a past thread about extubating a bucking patient really fascinated me. There was also an awesome thread started by jet years ago about his top ten. In it, he listed some things like sterile art lines and LR not mixing with PRBCs as academic dogma. Here is a link, it's worth revisiting: http://forums.studentdoctor.net/threads/jets-top-ten.907043/

I love this kind of stuff!! What else are they not teaching us in residency?

First off, academia dogma becomes dogma because academia does the research and find the answers. They also are usually the ones reviewing the cases of the private practice guys, so they start to see what goes wrong - even with small numbers - and change their practices and write the guidelines based on this.

Second, you can't compare practices, so that sets up a problem. For example, Dr Gamble, who writes some chapters in Chestnut - and an expert on pre-eclampsia - has written that severe eclampsia patients deserve a-lines preoperatively. However, when I rotated through his private practice job as a resident, he said he never places them. To paraphrase him, he said "why would I place an a-line for the 2 to 3 blood pressures I am going to record during the case?" His point - pp surgeons are FAST, and they can do a c/s in 15-20 minutes. At our hospital, we need a-lines. There is going to be more than 2-3 cycles of the BP cuff for our cases.

Finally, pp guys are cocky. They think that since they have NEVER had a cardiac arrest with a bupivicaine block that they are somehow immune to this extremely low incidence event - as if it has something to do with how wonderful their hands are. This type of thinking fosters the idea the academic guys don't know what they are talking about. But again, the academics often see a broader picture. In addition, they tend to believe science more than dogma.

So what is the science behind a-lines and infections? I am going to help you out. Read these articles and decide how you will practice.

 

[periopdoc]

They also are usually the ones reviewing the cases of the private practice guys,

so they start to see what goes wrong - even with small numbers - and change their practices and write the guidelines based on this.

They see what happens when trainees are caring for patients and write guidelines based on this. Trainees do stupid things like touching the sterile portion of the a-line catheter with their non-sterile hand as they are inserting it. (personally witnessed this when I was a fellow).

Second, you can't compare practices... pp surgeons are FAST.

Exactly. This is antithetical to your philosophy that, because our numbers are too small to see what goes wrong, we can't adequately deduce what is and isn't appropriate for our individual practice. I would argue that it is harder for the academic guy with no private experience to figure out what is appropriate for us than for us, with some historical academic exposure, to figure out which of the guidelines may be more appropriate for an academic setting and less appropriate for our setting.

Finally, pp guys are cocky... But again, the academics often see a broader picture. In addition, they tend to believe science more than dogma.

Some doctors are cocky. Academic types just as much as private types. Generally the private guys have a lot more experience to back up any cockiness they might express and the more cautious private guys are more willing to look for ways to work around their concerns than just cancel cases in hopes that the patients become somebody elses problem.

Except for certain subtypes of cases (transplants/ complex congenital) that aren't done in my practice, I saw vastly more cases, more types of cases, and more complicated cases in sicker patients in the first three years of private practice than I did during my residency and fellowship, and I came from a big, busy program with a huge variety of cases.

Yes, occasionally the docs here may be more reluctant to immediately buy into new landmark scientific findings that contradict intuition or years of personal experience. Sometimes our concerns turn out to be well justified (cough Poldermans cough).

So what is the science behind a-lines and infections? I am going to help you out. Read these articles and decide how you will practice.

Surely you aren't suggesting that I modify my arterial line practice (limited almost exclusively to radial arterial lines placed in a controlled OR setting) based on these two papers that blend data from all types of arterial lines, including femoral arterial lines placed in the ER, to come up with a their conclusions.

- pod

 

[periopdoc]

IMHO a-line colonization is more a result of the frequency of post-placement manipulation than a result of contamination during initial placement.

This could be studied very easily.

- pod

 

[BuzzPhreed]

Place the aline more distally in the wrist. Recleanse it with an antiseptic once more before you dress it. Keep the sterile dressing on it. Don't suture it. Don't futz with it. Pull it out as soon as it's no longer needed.

Problem solved.

 

[periopdoc]

I find that they are more susceptible to damping out post-bypass the further distal I go. I also reclean it before I dress it. No suture.

- pod

 

[BuzzPhreed]

I find that they are more susceptible to damping out post-bypass the further distal I go. I also reclean it before I dress it. No suture.

- pod

Sorry, I meant proximally. Yes, distally = greater fail rate.

 

[epidural man]

They see what happens when trainees are caring for patients and write guidelines based on this. Trainees do stupid things like touching the sterile portion of the a-line catheter with their non-sterile hand as they are inserting it. (personally witnessed this when I was a fellow).




Exactly. This is antithetical to your philosophy that, because our numbers are too small to see what goes wrong, we can't adequately deduce what is and isn't appropriate for our individual practice. I would argue that it is harder for the academic guy with no private experience to figure out what is appropriate for us than for us, with some historical academic exposure, to figure out which of the guidelines may be more appropriate for an academic setting and less appropriate for our setting.

Some doctors are cocky. Academic types just as much as private types. Generally the private guys have a lot more experience to back up any cockiness they might express and the more cautious private guys are more willing to look for ways to work around their concerns than just cancel cases in hopes that the patients become somebody elses problem.

Except for certain subtypes of cases (transplants/ complex congenital) that aren't done in my practice, I saw vastly more cases, more types of cases, and more complicated cases in sicker patients in the first three years of private practice than I did during my residency and fellowship, and I came from a big, busy program with a huge variety of cases.

Yes, occasionally the docs here may be more reluctant to immediately buy into new landmark scientific findings that contradict intuition or years of personal experience. Sometimes our concerns turn out to be well justified (cough Poldermans cough).



Surely you aren't suggesting that I modify my arterial line practice (limited almost exclusively to radial arterial lines placed in a controlled OR setting) based on these two papers that blend data from all types of arterial lines, including femoral arterial lines placed in the ER, to come up with a their conclusions.

- pod

Can we agree that you can't compare pp to academia then? I would agree that most studies come from academic centers anyway. Unfortunately, we have no data from pp for most things and likely never will. And by the way, good job on picking up my thesis because I didn't even know I had one.

Let me pose an example...for many years, most academic pain physicians have abandoned using particulate steroid in the neck (for certainl procedures) because if the tiny needle from a transforaminal steroid is placed in an important artery, and particulate steroid is injected, the result can be castostrophic. However, when I ask pp guys, many say they still do it and they don't believe the risk is as great as has been touted by academia. This could certainly be true, but most of the cases of paralysis and death have come from pp. I just heard about a guy in NYC that killed 3 patients before his license was revoked. Does that make pp guys cowboys? Who knows? What should a physician do? Believe the pp doc who says,"Ive never had a problem so there must not be a problem" or believe the academic guy who says "you are screwed if you practice that way?"

As far as the line infections, yes I would hope you modify your arterial line practices based on available data - or perform a study that shows it doesn't make a difference. A biopatch is $4 and takes no time and will be the easiest thing you do all day. I'm not sure what the beef is - or why people want to protect a-lines so badly from the idea that they may become infected at some point and perhaps at a rate higher than previously described. The papers argue they are an infection risk, just like all other lines placed. So...if you place an arterial line in a controlled OR setting - and you place a sublcavian central line in a controlled OR setting, the risk of both those lines becoming a source of infection is likely similar if left in the same amount of time.

 

[Mman]

arterial lines I place have roughly the same infection rate as peripheral IVs. In fact, it's probably lower because the peripheral IVs stay in longer on average. That and the fact that IVs are routinely used to access and give meds through where as arterial lines are in a high pressure system and aren't having meds given through them.

As for PP vs academics, of course there aren't studies coming from PP. Those docs are too busy actually taking care of patients and don't have an army of residents and fellows to do their research for them.

I'm in PP. I review plenty of disasters from academic land that are being litigated. Not all expert witnesses are academicians. Some are actually working doctors.

 

[BLADEMDA]

I open a pair of sterile gloves and use a Chloraprep for Arterial lines. Honestly, it isn't a big deal and I want to lead by example for the CRNAs who don't always use the best technique when placing an arterial line.

We all have the 15-20 seconds to open a pair of sterile gloves and use a Chloraprep stick.

 

[nimbus]

I find that they are more susceptible to damping out post-bypass the further distal I go. I also reclean it before I dress it. No suture.

- pod

Like this....

Why we do femoral+radial. 40 min later they were equal.

 

[urge]

Like this....View attachment 179311

Why we do femoral+radial. 40 min later they were equal.

Your patient doesn't have a chance.

 

[periopdoc]

Can we agree that you can't compare pp to academia then?

I think it is difficult for the academic to do the comparison. It is fairly easy for the private practice guy to look at the data and see if it applies to his personal situation. We understand many of the pitfalls of being/ working with trainees and why you may do things a certain way when working with trainees that isn't necessary when working solo.

In no way do I intend to denigrate the academic. The data he generates is extremely important and useful, but it does have to be individualized before it is applied.

but most of the cases of paralysis and death have come from pp. I just heard about a guy in NYC that killed 3 patients before his license was revoked. Does that make pp guys cowboys? Who knows? What should a physician do? Believe the pp doc who says,"Ive never had a problem so there must not be a problem" or believe the academic guy who says "you are screwed if you practice that way?"

Not a pain guy here and really couldn't comment on the controversy except generically. There are vastly more injections performed by PP pain docs and para-professionals than academics, and it is expected that there would be more total complications in private practice. Nothing meaningful can be inferred from the fact that there is more morbidity and mortality in PP. Now if the rate of complications is higher in PP then you are starting to make a case.

There was a prominent academic guy in Rotterdam who falsified research data on beta blockade before he was fired. Some have theorized that this resulted in more than 10,000 excess deaths (how is this guy not in jail?) A prominent academic guy in Boston falsified research data on multimodal pain treatment before he was jailed. Does that make academics fraudsters? Obviously no more so than some random dude in NY killing 3 patients makes private practice guys cowboys.

What should a physician do? I would never trust the guy who says "I have never had a problem..." If the rate of complications is low, you can get away with doing the wrong thing 100 times... Doesn't make it right or safe.

Neither would I trust the academic who says "your patient is screwed if you practice that way" I would look at the academic data and where it came from and see if it makes sense and is applicable to my personal situation.

As far as the line infections, yes I would hope you modify your arterial line practices based on available data

How are the two studies that you presented, which mix data from femoral arterial lines placed in the ER with data from arterial lines placed in other settings, in any way applicable to my practice other than as a potential bellwether?

I'm not sure what the beef is - or why people want to protect a-lines so badly from the idea that they may become infected at some point and perhaps at a rate higher than previously described.

It's not that we want to "protect" a-lines. It is just that experience doesn't support the idea that a-lines become infected as frequently as central lines or that the sequelae are as severe. We want good data to support that claim before we completely throw out our experience.

You have some academic types saying we have to treat every a-line just like a central line and you have nurses with a clipboards just waiting for another guideline to enforce. There is simply no reason for me to go to the added expense of time, sterile gloves, drape, biopatch etc for an arterial line placed solely for the duration of the case for monitoring or sampling.

For longer-term lines, I actually do use sterile gloves etc. However, the data you presented don't speak to the question of whether technique has anything to do with colonization rates or CRBI. For all we know the complications in these studies arose due to frequency of sampling post-placement and the technique of placement had no effect the colonization/ CRBI rate whatsoever. Clearly it is contaminated data because it mixes femoral a-lines placed in the ER in less than ideal conditions with other types of lines.

So...if you place an arterial line in a controlled OR setting - and you place a sublcavian central line in a controlled OR setting, the risk of both those lines becoming a source of infection is likely similar if left in the same amount of time.

At best, your studies provide indirect evidence that this may be true. This is remarkably irrelevant to the real question of whether my choice of technique can effect the ultimate rates of colonization of, and CRBI due to, arterial lines. Observing nurses in the ICU, and their techniques for sampling a-lines, I am highly skeptical that the critical problem in most a-line colonization is found during the placement.


- pod

 

[periopdoc]

Like this....View attachment 179311

Why we do femoral+radial. 40 min later they were equal.

Yup. Your patient is still ischemic BTW (air in the coronary?). Of course you could just go really proximal and place a brachial line. Oh god let's not have that debate again.

- pod

 

[nimbus]

Yup. Your patient is still ischemic BTW (air in the coronary?). Of course you could just go really proximal and place a brachial line. Oh god let's not have that debate again.

- pod

Good catch! It was ascending aorta graft. RCA did not have enough length and kinked when heart was full. RV failure and IW hypokinesis. Had to go back on cpb and put svg to RCA.

Sometimes we do brachial. But we never use single radial for pump cases.

 

[BLADEMDA]

POD,

You are too good an anesthesiologist not to put on sterile gloves and use a cholraprep stick. While the evidence for doing so may be weak the inconvenience to your practice is minimal at best. I was reluctant at first to make the switch from non sterile to sterile gloves but these days that is how I roll.

 

[epidural man]

I think it is difficult for the academic to do the comparison. It is fairly easy for the private practice guy to look at the data and see if it applies to his personal situation. We understand many of the pitfalls of being/ working with trainees and why you may do things a certain way when working with trainees that isn't necessary when working solo.

In no way do I intend to denigrate the academic. The data he generates is extremely important and useful, but it does have to be individualized before it is applied.





Not a pain guy here and really couldn't comment on the controversy except generically. There are vastly more injections performed by PP pain docs and para-professionals than academics, and it is expected that there would be more total complications in private practice. Nothing meaningful can be inferred from the fact that there is more morbidity and mortality in PP. Now if the rate of complications is higher in PP then you are starting to make a case.

There was a prominent academic guy in Rotterdam who falsified research data on beta blockade before he was fired. Some have theorized that this resulted in more than 10,000 excess deaths (how is this guy not in jail?) A prominent academic guy in Boston falsified research data on multimodal pain treatment before he was jailed. Does that make academics fraudsters? Obviously no more so than some random dude in NY killing 3 patients makes private practice guys cowboys.

What should a physician do? I would never trust the guy who says "I have never had a problem..." If the rate of complications is low, you can get away with doing the wrong thing 100 times... Doesn't make it right or safe.

Neither would I trust the academic who says "your patient is screwed if you practice that way" I would look at the academic data and where it came from and see if it makes sense and is applicable to my personal situation.



How are the two studies that you presented, which mix data from femoral arterial lines placed in the ER with data from arterial lines placed in other settings, in any way applicable to my practice other than as a potential bellwether?




It's not that we want to "protect" a-lines. It is just that experience doesn't support the idea that a-lines become infected as frequently as central lines or that the sequelae are as severe. We want good data to support that claim before we completely throw out our experience.

You have some academic types saying we have to treat every a-line just like a central line and you have nurses with a clipboards just waiting for another guideline to enforce. There is simply no reason for me to go to the added expense of time, sterile gloves, drape, biopatch etc for an arterial line placed solely for the duration of the case for monitoring or sampling.

For longer-term lines, I actually do use sterile gloves etc. However, the data you presented don't speak to the question of whether technique has anything to do with colonization rates or CRBI. For all we know the complications in these studies arose due to frequency of sampling post-placement and the technique of placement had no effect the colonization/ CRBI rate whatsoever. Clearly it is contaminated data because it mixes femoral a-lines placed in the ER in less than ideal conditions with other types of lines.





At best, your studies provide indirect evidence that this may be true. This is remarkably irrelevant to the real question of whether my choice of technique can effect the ultimate rates of colonization of, and CRBI due to, arterial lines. Observing nurses in the ICU, and their techniques for sampling a-lines, I am highly skeptical that the critical problem in most a-line colonization is found during the placement.


- pod

Pod,

If what you say is true - tell me why that is. What is it that is so special about a radial catheter that keeps it from colonizing at a rate much less than ANY OTHER catheter placed through the body's protective layer - the skin?

 

[deleted171991]

Pod,

If what you say is true - tell me why that is. What is it that is so special about a radial catheter that keeps it from colonizing at a rate much less than ANY OTHER catheter placed through the body's protective layer - the skin?

According to your logic, we should insert all peripheral IVs in a sterile fashion.

 

[urge]

It is not uncommon for some of our patients to have the same a line for 3 or 4 weeks. I see no point in not taking maximum precaution to protect those patients.

That's why my first post in this thread was very sarcastic. Instead of aiming to improve care, the spirit of this thread is about aiming for mediocrity.

 

[urge]

But we never use single radial for pump cases.

Pretty much all of our patients with "normallish" function get done with a radial only. It's pretty rare over here for a radial not to work well in a patient that came from home.

 

[periopdoc]

If what you say is true - tell me why that is. What is it that is so special about a radial catheter that keeps it from colonizing at a rate much less than ANY OTHER catheter placed through the body's protective layer - the skin?

I never claimed that a-lines "colonize at a rate much less than ANY OTHER catheter..." Experience suggests that the infectious complication rates from radial a-lines are lower than the rates seen with central lines (CVLs) and I suspect that colonization rates for radial a-lines are more affected by ICU care than they are by the presence or absence of full sterile barrier precautions when the line is placed.

Why would you think that the colonization and CRBI rates for radial catheters would be similar to that of femoral catheters? If you don't think that they are similar, why would you use data that mixes outcomes from both types of catheters and try to apply it to radial catheters?

As for the why... We know from CVL data that we can rank colonization and CRBI rates by site; Femoral > IJ > Subclavian > PICC (arguably), with PIV's having the lowest rates of CRBI's. Further, the sequelae of PIV associated infectious complications are typically less severe than the sequelae associated with infectious complications of CVLs and PICCs. It is reasonable to assume that arterial catheters sites will have a similar distribution of infectious complication rates and severity.

I believe that the colonization and CRBI rates for peripherally placed arterial lines are similar to the colonization and CRBI rates for peripherally placed IVs. I believe that the colonization and CRBI rates of centrally placed arterial lines (femoral) is similar to that of CVLs.

The studies you listed aren't very helpful in sorting this out as they mix peripherally and centrally placed arterial lines and they do not control for the environment in which the line was placed.

Of course, the real question is whether full sterile barrier precautions reduce the incidence of infectious complications of peripherally inserted arterial catheters. If colonization and CRBI rates are independent of placement technique, then the studies you presented are interesting but ultimately unhelpful in improving outcomes.

- pod

 

[periopdoc]

You are too good an anesthesiologist not to put on sterile gloves and use a cholraprep stick. While the evidence for doing so may be weak the inconvenience to your practice is minimal at best. I was reluctant at first to make the switch from non sterile to sterile gloves but these days that is how I roll.

If I am sending a patient to the ICU with the line, then I actually do use sterile gloves, and chloroprep and I rewipe the site with a chloroprep after placement and before placing the Tegaderm. I don't use a biopatch.

For cases where I will be pulling the arterial line in PACU (a-line placed for intraoperative monitoring or labs only) I still use chloraprep, but skip the sterile gloves. This is probably overkill for a simple peripheral line.

- pod