Cardiac: how long should it take...

[caligas]

Once patient is on the table how long should it take a private practice cardiac anesthesiologist to do the following in a routine heart case? (they have an anesthesia tech to help, otherwise they are on their own. Its all done in the o.r. in whatever order, and things go smoothly)

-place one art line
-induce and intubate
-place neck line/lines, and swan
-place tee probe

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[urge]

Once patient is on the table how long should it take a private practice cardiac anesthesiologist to do the following in a routine heart case? (they have an anesthesia tech to help, otherwise they are on their own. Its all done in the o.r. in whatever order, and things go smoothly)

-place one art line
-induce and intubate
-place neck line/lines, and swan
-place tee probe

30 to 40 min is not unreasonable.

 

[OB1🤙]

If pt is in the room at 7, prep should start by 730 at the latest.

 

[sevoflurane]

Routinely 15-20 minutes for all the above. Add a minute or two for a double stick.

This is necessary as I also need another 2-3 minutes to aquire 2D and 3D images if I'm doing a mitral valve repair vs replace. The CT surgeon will go over my mitral exam with me b4 scrubbing in. Speed is of the essence as the entire case can be and often is as short as 3 hrs- in room to out of room.

 

[sevoflurane]

I always have an anesthesia tech. Sometimes two. It's a dance, and we all know it very well.

 

[urge]

Routinely 15-20 minutes for all the above. Add a minute or two for a double stick.

 

[dhb]

What about putting the patient on the table, positioning etc.. if you count 5min for the aline 3min to intubate and 5min for the cvl, yeah thats 15 min but its all the small stuff that eats time

 

[sevoflurane]

Do you secure your aline? Do you prep the neck? Put them in tburg? Do you put monitors on? Open your CVL tray and prep it? I don't.

Can't help you if you are taking 30-40 minutes.
We track times. That is slow as molasses if you hit the 40 mark.

 

[sevoflurane]

5 minutes for an Aline? Really?
OMG.

 

[urge]

We track times. That is slow as molasses if you hit the 40 mark.

So do we. That's why I'm very comfortable saying it is .

 

[deleted126335]

Depends on how much help. Doc plus Crna or doc only? Tech to help with central line?


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[kazuma]

I agree with Sevo, 15-20 min but not including acquiring images. I don't do hearts now but I used to time myself as a resident with the help of an anesthesia tech, my attending in the lounge until I called him to help with images. I was sick of waiting for the CT surgeons taking their sweet time and blaming it on us taking an hour to do our lines so I'd time myself.

 

[urge]

This is necessary as I also need another 2-3 minutes to aquire 2D and 3D images if I'm doing a mitral valve repair vs replace.

Replacement is still a consideration where you are at?

 

[Ignatius J]

My take is "be quick, but do not hurry".

Although with experience your time will go down and there should be no dilly-dallying, mistakes happen when you're trying to get things going in a hurry.

Taking your time and doing it right may mean the difference between a four hour and ten minute OR time and a four hour and twenty minute OR time. Who gives a ****? The surgeon with his altered time warp?

Probably why I don't do much cardiac. I always thought "Man, these people need some Valium".

 

[urge]

I agree with Sevo, 15-20 min but not including acquiring images. I don't do hearts now but I used to time myself as a resident with the help of an anesthesia tech, my attending in the lounge until I called him to help with images. I was sick of waiting for the CT surgeons taking their sweet time and blaming it on us taking an hour to do our lines so I'd time myself.

Another

The bull is going number 2 a lot in this thread.

 

[Ignatius J]

5 minutes for an Aline? Really?
OMG.

I take anywhere from 5 seconds to 20 minutes putting in an a-line. I've seen even the hottest of a-line hot shots strut up to a vasculopath and be humbled.

 

[Random Anesthesiologist]

We put Alines in preop for the most part.

 

[sevoflurane]

I take anywhere from 5 seconds to 20 minutes putting in an a-line. I've seen even the hottest of a-line hot shots strut up to a vasculopath and be humbled.

Agree completely. We are talking about cases without such obstacles. Everyone will have hiccups based on patient protoplasm. USDG Aline's really make things easier if you get in a bind. I have a very low threshold to use it as it is always right there. However, it is one extra step.

 

[caligas]

Another

The bull is going number 2 a lot in this thread.

You aren't doing the SDN conversion: 20 minutes converts to 40 minutes in reality. But I'm the one who asked, so I get what I get.

 

[urge]

I take anywhere from 5 seconds to 20 minutes putting in an a-line. I've seen even the hottest of a-line hot shots strut up to a vasculopath and be humbled.

Very true. If you aren't humbled occasionally you are doing only easy cases.

 

[urge]

You aren't doing the SDN conversion: 20 minutes converts to 40 minutes in reality. But I'm the one who asked, so I get what I get.

I bet if we go visit it will probably be closer to an hr.

 

[Chloroform4Life]

If I feel a big pounding pulse, chloraprep, arrow kit, hook up, tegaderm. 30 secs- 1 minute. Most patients are like this if you put A-line in before induction.

If I barely feel anything, use U/S, may use through and through technique with guide wire. 1-10 minutes depending on difficulty. May have to abandon radial and go for femoral, which will take more time.

Induction, intubation, tape job- about 3 minutes

IJ CVL are typically pretty easy with U/S. 2-5 minutes. Swan takes 1 minute if no difficulty. If difficult, can wait to float later.

Inserting TEE takes less than a minute typically.

So 20 minutes total is not unreasonable, unless difficulty arises, which happens about 10-20% of cases.

 

[urge]

If I feel a big pounding pulse, chloraprep, arrow kit, hook up, tegaderm. 30 secs- 1 minute. Most patients are like this if you put A-line in before induction.

If I barely feel anything, use U/S, may use through and through technique with guide wire. 1-10 minutes depending on difficulty. May have to abandon radial and go for femoral, which will take more time.

Induction, intubation, tape job- about 3 minutes

IJ CVL are typically pretty easy with U/S. 2-5 minutes. Swan takes 1 minute if no difficulty. If difficult, can wait to float later.

Inserting TEE takes less than a minute typically.

So 20 minutes total is not unreasonable, unless difficulty arises, which happens about 10-20% of cases.

 

[Ignatius J]

If I feel a big pounding pulse, chloraprep, arrow kit, hook up, tegaderm. 30 secs- 1 minute. Most patients are like this if you put A-line in before induction.

If I barely feel anything, use U/S, may use through and through technique with guide wire. 1-10 minutes depending on difficulty. May have to abandon radial and go for femoral, which will take more time.

Induction, intubation, tape job- about 3 minutes

IJ CVL are typically pretty easy with U/S. 2-5 minutes. Swan takes 1 minute if no difficulty. If difficult, can wait to float later.

Inserting TEE takes less than a minute typically.

So 20 minutes total is not unreasonable, unless difficulty arises, which happens about 10-20% of cases.

We had a surgeon who put in a femoral for every single pump case he had. He did it just before incision.

It was very interesting. Coming off pump and even through ICU transport, there was sometimes a 20 mmHG difference in the mean arterial pressure between femoral and radial.

Anyone have a preference for site?

 

[Chloroform4Life]

The key is to have everything set up beforehand so you job is minimized once patient gets in room.

Then again, there are those among us who haven't figured out to be efficient yet.

 

[urge]

5 minutes for an Aline? Really?
OMG.

Well, the evidence points out that it takes well over 1 minute with the arm already secured in place, prepped, numbed, gloves on, catheter in hand to just connecting the line, not even a tegaderm on. Never mind finishing the actual work. And that is with someone pulling the wire out for you!

And of course a gigantic patient with an artery that could well fit a 16 IV.




Wonder who made that video?

 

[caligas]

maybe we all need to do some time trials and report back?

In the situation described, it takes me 30 minutes. This includes a double stick. This is an honest, timed number and includes all the setup and positioning and taping time, etc. Im not fast but I know I'm not slow.

 

[urge]

maybe we all need to do some time trials and report back?

In the situation described, it takes me 30 minutes. This includes a double stick. This is an honest, timed number and includes all the setup and positioning and taping time, etc. Im not fast but I know I'm not slow.

I have been doing this stuff for years. Half an hour is the norm about 85% of the time.

That is in room time to central line tegaderm on.

 

[sethco]

My goal is from the time I enter the room with the patient to prep time is <25 minutes. This time includes induction, arterial line, double lumen and cordis central lines, PAC, and quick TEE interpretation of pertinents for the surgery (i.e. Regurgitation etiology/severity, annulus size, RWMAs, global function, and any surprises). I do more in depth TEE stuff and back charting after drapes go up. Sometimes, it may be take a couple minutes longer for preinduction arterial lines or difficult vascular access/intubation, but like HB 30 minutes is usual for people that regularly do hearts. However, I think a better measure is my room time to surgical incision. If I can get this in 40-45 minutes, then everybody has their **** together that day

Some of the hospitals I work at there is minimal Anesthesia tech help, if any at all. Having an experienced OR nurse circulating certainly did help, though.

 

[sethco]

Routinely 15-20 minutes for all the above. Add a minute or two for a double stick.

This is necessary as I also need another 2-3 minutes to aquire 2D and 3D images if I'm doing a mitral valve repair vs replace. The CT surgeon will go over my mitral exam with me b4 scrubbing in. Speed is of the essence as the entire case can be and often is as short as 3 hrs- in room to out of room.

It only takes you an extra 1-2 minutes for the second stick? I would say mine is more like 3 minutes between stick, guide wire, dilation, catheter, and suture. Pretty impressive if you can do that in one minute

 

[sevoflurane]

Well, the evidence points out that it takes well over 1 minute with the arm already secured in place, prepped, numbed, gloves on, catheter in hand to just connecting the line, not even a tegaderm on. Never mind finishing the actual work.

An of course a gigantic patient with an artery that could well fit a 16 IV.




Wonder who made that video?

Ohhh urge... You just don't change do you.
Such a whinner.

Took a bit longer than usual yes. But you are correct it took me a little over a minute. Congrats... You got me! I've mentioned before that this was a bit longer than usual.

But here is where you might be able to improve your time technique. I don't prep it, I don't secure it in place, the tubing is passed to me as soon as I'm in and then I hand it over. All the prep work before I sit down and all the "finishing the actual work" part is done as I move to the head of the table and induce.

40 minute is slow for a routine case my old friend.

I've mentioned that in order to achieve these times, you need everyone on board staying three steps ahead of you.

Don't get your feelings hurt for crying out loud.

 

[sevoflurane]

It only takes you an extra 1-2 minutes for the second stick? I would say mine is more like 3 minutes between stick, guide wire, dilation, catheter, and suture. Pretty impressive if you can do that in one minute

That's what it feels like. I stick then wire, then stick again and place the second wire. Same goes for dilation and catheter placent. Do them in tandem. Could take a bit longer I guess. My times aren't very much longer with a double stick.

 

[urge]

Ohhh urge... You just don't change do you.
Such a whinner.

Took a bit longer than usual yes. But you are correct it took me a little over a minute. Congrats... You got me! I've mentioned before that this was a bit longer than usual.

But here is where you might be able to improve your time technique. I don't prep it, I don't secure it in place, the tubing is passed to me as soon as I'm in and then I hand it over. All the prep work before I sit down and all the "finishing the actual work" part is done as I move to the head of the table and induce.

40 minute is slow for a routine case my old friend.

I've mentioned that in order to achieve these times, you need everyone on board staying three steps ahead of you.

Don't get your feelings hurt for crying out loud.

40 min is not particularly fast, but I said that it was not unreasonable, not fast.

Like Ignatius said, 10 extra minutes is not a huge deal at the end of the day.

It is pretty clear to me that the patient in the video had been already a good 10 or 15 min in the OR before you got to put the a line. Just positioning a pt on a bed takes 10 min.

15 to 20 min is just not realistic.

I have a hyperacute olfactory sense.

 

[Chloroform4Life]

Once patient is on the table how long should it take a private practice cardiac anesthesiologist to do the following in a routine heart case? (they have an anesthesia tech to help, otherwise they are on their own. Its all done in the o.r. in whatever order, and things go smoothly)

-place one art line
-induce and intubate
-place neck line/lines, and swan
-place tee probe

Initial question by OP was how long it would take to do these procedures, not how long it would take from in room to prep.

At my institution, they do an extensive time out when patient gets in room and that takes almost 5 minutes as the nurse read through their massive checklist.

 

[sevoflurane]

40 min is not particularly fast, but I said that it was not unreasonable, not fast.

Like Ignatius said, 10 extra minutes is not a huge deal at the end of the day.

It is pretty clear to me that the patient in the video had been already a good 10 or 15 min in the OR before you got to put the a line. Just positioning a pt on a bed takes 10 min.

15 to 20 min is just not realistic.

I have a hyperacute olfactory sense.

Positioning a patient on a table takes 10 minutes? Get your nose checked dude.

That would drive me nutz.

 

[psychbender]

I don't have a tech or other assistance (the perfusionist usually drops the probe in the sterile sleeve, and opens the PA kit when I ask, though), and I routinely take 30-40 minutes from in room to TEE insertion. The surgeons are elsewhere until called that I'm inducing. I never hear them complain about my times, but do hear some grumbles about one of my partners who routinely takes well over an hour to do all of the same.

 

[urge]

Positioning a patient on a table takes 10 minutes? Get your nose checked dude.

That would drive net nutz.

About a quarter of these patients cannot even move themselves.

Then come the blankets, the ekg pads, the bp cuff, the pulse ox, nasal cannula, connecting the iv and giving some sedation, then securing the arm for the a line....

10 min are gone at least.

I starting to believe you do have a warped sense of time or reality.

 

[sevoflurane]

About a quarter of these patients cannot even move themselves.

Then come the blankets, the ekg pads, the bp cuff, the pulse ox, nasal cannula, connecting the iv and giving some sedation, then securing the arm for the a line....

10 min are gone at least.

I starting to believe you do have a warped sense of time or reality.

There you go. You are doing all the work that my techs do. I help get the patient moved to the bed and then right to the a-line. While I sit down and put on gloves my tech does the prepping.

Meanwhile, the rest of the room is putting on monitors and pre oxygenating.

BIG difference.

 

[urge]

That's what it feels like. I stick then wire, then stick again and place the second wire. Same goes for dilation and catheter placent. Do them in tandem. Could take a bit longer I guess. My times aren't very much longer with a double stick.

There we go.

"what it feels like"...

The clock on the wall does not care what you feel.

 

[sevoflurane]

There we go.

"what it feels like"...

The clock on the wall does not care what you feel.

I know what my end times are. We document them. Stop crying Urge. Modify your routine and I bet you can get there... but puhhhlease stop your whining. It gets old.

 

[OB1🤙]

30 min is chloraprep on skin. So line(s) and tee should be in by 25 min after room time at the most.

I ultrasound every a-line. It adds no time and usually saves time. I have a tegaderm over the hockey stick probe ready to go before pt rolls in. Prep on the arm is the ultrasound medium. I walk up to the prepped arm, put probe down very proximal in the forearm, boom lido, boom line. I don't feel for a pulse- no need to. So it adds exactly zero time to do this. First pass success is nearly 100%. Note that I consider a radial a-line a clean procedure, so I'm not using sterile gloves or a whole sterile us sheath.

Putting the line high up prevents kinking issues, USG avoids tortuosities, plaques etc.

Edit: I should add that I do this with a-lines only in the heart room, where the echo machine is in there already with the hockey stick probe on it.

 

[Chloroform4Life]

How many of you use through and through for A line from the get go?

 

[urge]

I know what my end times are. We document them. Stop crying Urge. Modify your routine and I bet you can get there... but puhhhlease stop your whining. It gets old.

Let's just agree to disagree. I'll multiply your times by 3. You can feel free to divide my times by 3 so you can understand them better.

 

[changeofheart2016]

First yr resident here, im inclining toward 1hr mark.

What happens when the pts pressure tanks afetr induction, like a majority of pts, especially during a period of no surgical stimulation, and youre in the middle of ur cordis with sterile gloves on? Who pushes pressors?

 

[BLADEMDA]

Once patient is on the table how long should it take a private practice cardiac anesthesiologist to do the following in a routine heart case? (they have an anesthesia tech to help, otherwise they are on their own. Its all done in the o.r. in whatever order, and things go smoothly)

-place one art line
-induce and intubate
-place neck line/lines, and swan
-place tee probe

12 minutes total for the above plus 8-9 minutes to do the TEE (basic exam). If you miss the a-line the U/S should be in the room so you can use it for the second or third attempt. This would add about 5 minutes to the procedure time when utilized.

 

[BLADEMDA]

First yr resident here, im inclining toward 1hr mark.

What happens when the pts pressure tanks afetr induction, like a majority of pts, especially during a period of no surgical stimulation, and youre in the middle of ur cordis with sterile gloves on? Who pushes pressors?

There should be a Nurse in the room who can give the ephedrine or Phenylephrine IV. In my case I have a midlevel provider so it's not an issue.

 

[OB1🤙]

First yr resident here, im inclining toward 1hr mark.

What happens when the pts pressure tanks afetr induction, like a majority of pts, especially during a period of no surgical stimulation, and youre in the middle of ur cordis with sterile gloves on? Who pushes pressors?

First of all, learn conduct your induction so the patient doesn't need rescuing. But I leave a syringe of norepi 8mcg/ml (phenylephrine is fine too) in line with the IV running reasonably, leave the syringe accessible near the periphery of the drape, and ask the circulator to give a cc if the pressure sags.

This is necessary maybe 5% of the time, but it's always available. I don't scrub for the line until I'm satisfied with hemodynamics.

 

[OB1🤙]

I use Arrows, and only go through and through when the wire won't thread easily.

 

[Chloroform4Life]

First yr resident here, im inclining toward 1hr mark.

What happens when the pts pressure tanks afetr induction, like a majority of pts, especially during a period of no surgical stimulation, and youre in the middle of ur cordis with sterile gloves on? Who pushes pressors?

You don't need much anesthesia in this time period. Use combination of nitrous/gas with total mac of 0.5-0.7 and you shouldn't get much hypotension even in pt with low EF.

 

[urge]

12 minutes total for the above

Why so slow?

It shouldn't take more than 8 min.

1 min for the a line, 2 min for induction and tube, and 5 min for the central line.