Narcotic administration in cardiac surgery cases

[sevoflurane]

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.

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[sevoflurane]

HEY! Been a minute. Glad to see you here.

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.
Hope everyone is doing well. ✌🏽

 

[Beeftenderloin]

This sounds terribly inefficient.

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.

 

[pgg]

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.

I think he just meant that an art line takes zero minutes in the OR if it's already in.

 

[kb1900]

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.

Apparently a certain NE academic hospital had a disconnected aline during transfer from preop to room and it took some time to notice
“Yada yada”
They don’t do holding Alines anymore

 

[Bertelman]

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.

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.

Wanna save time? I can find safer ways to shave 5 min off a case. How about having your PA scrubbed & on standby as they drape the patient? Don’t make me call them.

Our practice has adapted along the way. Used to do awake neck lines- got pretty good at titrating 1 versed, 50-100 fent to maintain respys but be unresponsive. There’s a dozen ways to do this, as this thread shows.

 

[Bertelman]

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.

 

[Beeftenderloin]

I think he just meant that an art line takes zero minutes in the OR if it's already in.

Oooh, inefficient for the surgeon… but far less convenient for me. Our dept. shut down that practice long before I joined. All effort on our end to save surgeon 2 minutes in the room, no thanks. All art lines happen in OR.

 

[anaesthetic]

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.

Agree. I’ve done it both ways and usually depends on the hospital culture. I will say giving local and giving enough local is a skill in and of itself. I have no preference either way as they almost never take long to do, although having techs to grab stuff and all the equipment available in the OR when it is a tough line is nice.

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).

 

[PpfSuxTube]

An aline in the holding area doesn't save much time most of the time but it does alert me to potential difficult aline where the radial has been the cath site recently and they've trashed it for example...

So while I've abandoned placing aline in the holding area for many of the same reasons mentioned above I do like to palpate it, and I'll even freeze it up if I have some lido drawn up

I do brachials any chance or excuse I get, so this is one thing I've noticed...

I dislike radials honestly

 

[T-burglar]

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

 

[gunnershow]

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.

 

[pgg]

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.

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.

Honestly it's easier than putting all that stuff out on a stand in the OR where there are sterile fields nearby and a tiny armboard and I have to walk around the bed or climb over the circuit to get to the arm.

This thread does a good job of showing how different circumstances are at different hospitals.

 

[T-burglar]

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...

Hypercarbia is only causing major instability for a few select severe comorbidities.

You either have an unusual patient population or you're misdiagnosing the cause of the arrests in your facility.

And refer these cases to quality committee if you have one.

 

[Iso4ane]

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 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.

 

[sevoflurane]

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 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.

 

[abolt18]

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

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.

Patients don't even flinch or squirm because I am heavy with the local, including around the artery, guided by ultrasound.

I may give them 1-2mg midazolam or 50mcg fentanyl for it, but usually nothing. I just chat with them about their life and interests. It's very much no big deal and only takes me a couple minutes.

 

[DirtDocMD]

No pre-op a-lines/central lines for me. Too much hassle dragging stuff over to pre-op-holding/poor lighting/my azz up against a wall/family staring.

Get in the OR, do my thing, with good lighting and positioning. May do a-line pre-induction if serious disease/aortic stenosis. Otherwise, sleep the patient, do my business. Takes 17-18 minutes for bed transfer/monitors/a-line/PA, if everything going super smooth, 20-22 if the nurse helping the tech and myself is slow handing us the swan/flushing lines/etc.

Don’t know why I bother, since my surgeons are so slow, but keeps me in practice for our trauma cases..

 

[sevoflurane]

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%.

 

[abolt18]

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%.

Mitral valve case, known RV issues/Pulm HTN, or severely reduced LVEF. Or if the surgeon requests it. TEE in everyone.

My older partners are the opposite. TEE only for valves and swan in everybody.

 

[pgg]

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%.

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.

 

[Bertelman]

Same.

 

[psychbender]

Workflow comes down to whatever the norm at your institution has been. Where I am now, the techs have my line supplies, drawn up local, USD all laid out and ready for an art line in the holding bay (which has plenty of room to maneuver). I end up seeing the patient well before the OR nurse is done setting up, so once I've consented the patient, I can place my art line, go to the bathroom, and shoot the **** before they show up. It would actually be more difficult to do it in the OR, with the USD being moved around, finding an unused mayo stand, etc. If we decided to move to that workflow, however, we'd change the layout, and it's be fine.

I still don't get why sedate for lines (or blocks), though. It's a tiny needle, no worse than the IV already started, and we actually use local. Unless I have someone I need to scrape off the ceiling, a-lines in holding are with local and some small talk (which let's my autistic ass practice with interacting with a human). I used to sedate in the OR for pre-induction CVC and PAC, when that was the practice at one place I worked. But ever since CCM fellowship, I don't. Local and kind words are sufficient for a CVC, trialysis catheter, PAC, thoracentesis, small bore/seldinger technique chest tube, paracentesis, etc. I haven't sedated for any of those in years, and patients are fine. Honestly, we put this expectation of an unconscious and unreactive patient for any little procedure on ourselves.

 

[Robotic Wis-Hipple]

I’m a minimalist for the most part.

Post-induction A-line for the vast majority.
150mcgs fentanyl or so for incision/sternotomy. If pressure is high during line placement they get 100mcgs.

Precedex gtt

Last 100mcgs of fentanyl at end of case if I have it otherwise 1-2mg dilaudid for the road. The rare drinker or “social” drug user may get 500mcgs fentanyl total in addition to the dilaudid but I haven’t given more than 500mcgs of fentanyl since training.

Most early extubate. In training we tried to extubate many in the OR but in my practice I don’t do that. Prove you’re not bleeding, tube comes out in 2-6hrs.

 

[Beeftenderloin]

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%.

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.

 

[psychbender]

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.

When I'm in the ICU, I ****ing love it when they come up without a PAC, as then I don't have those guys trying to mismanage the patient to literally treat a single number. An ambulatory, normotensive, peeing, warm, well-oxygenated patient does not need to be confined to a bed, bolused with milrinone, and upped to high-flow NC for a single low mixed venous oxygen checked right after he completed his third lap around the ICU, feeling great.

 

[Twiggidy]

I think midazolam is the most overused drug we have. Except maybe dexmedetomidine.

100% agree with this

 

[Twiggidy]

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.

And you should’ve responded to him “No.” That’s not to say it’s ok to spit on an A line

 

[Bertelman]

I think I said it’s clean, not sterile.

 

[Twiggidy]

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

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.

Now we have ultrasounds almost everywhere and the new generation is much more skilled with its use so we can get lines in much faster. This is why I have no problem putting someone who isn’t a frail or sickly heart to sleep before their A line.

 

[Twiggidy]

We also PA catheter just about every heart, much to my chagrin, but it’s for the surgeons/nurses in the ICU to manage patients. I’m grown tired of lecturing them on if they really need it especially for healthier patients. The surgeons are the ones getting called left and right so it’s a favor to help them out

 

[DrN2O]

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.

Intra-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.

 

[pgg]

Intra-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.

C'mon

Do you pull your a-lines before taking them to PACU or ICU for fear that some helpful nurse can get to the stopcock?

Intra-arterial anything is extremely dangerous, but that's not a great reason to avoid putting them in preop.

We once had a RN hook up a spinal drain to wall suction. At some point you've got to trust the people around you to not be complete idiots.

 

[sevoflurane]

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.

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.

 

[woopedazz]

1500mcg induction crew represent

 

[Bertelman]

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.

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.

But everyone gets a double stick, too.

 

[drmwvr]

Don't know why there's so much resistance to pre-op a lines, especially by folks that do awake neck lines. Of course a little sedation is involved which isn't a bad idea anyway for someone about to have a saw run through their chest and most probably done themselves the favor of watching a few videos on the subject. I give them anxiolysis no matter if I do the a line in the OR or not. And the family chills as soon as the patient does from sedation as well, most times so there's that...one more way to skin the cat...

 

[Robotic Wis-Hipple]

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.

Aside from the fact the vigileo/flotrac is complete and utter made up garbage data wtf is it for when you have a CCO?

 

[Maverikk]

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.

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?

 

[pgg]

I used to work at a place that routinely did the double stick, one for an introducer and one for a triple lumen.

Typically they'd pull the introducer very soon after surgery, and then they'd have the triple lumen for a few days.

I put a 9 Fr MAC in everyone and that's it. Room for a PA catheter and plenty of additional access.

 

[Bertelman]

We used to do doubles stick for frequent Amio infusions post-op. Our director was hot for that.

Now, I do them because we keep central lines until close to discharge. Our post-ops go upstairs to a separate unit. I’m not terribly keen on a 9Fr hose in someone’s neck with the quality of nursing we have up there.

Brought a patient down from the floor for surgery this morning. Looking for a nurse to get report. Oops! They were never assigned a nurse at shift change. Guess nothing bad happened.

 

[PpfSuxTube]

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?

Never done a liver TX. What size were those cannulae and how quick could ye go on? It was for massive bleed I assume?

 

[T-burglar]

The double stick is so you can bill insurance for two central lines

 

[sevoflurane]

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?

Patient comfort. Remove 7 fr. double or introducer after a day or so if all is stable.

 

[cchoukal]

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:

1. 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

 

[nimbus]

For whatever it's worth, the CDC has said since 2011 that arterial lines should be done under sterile conditions:

1. 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?

 

[cchoukal]

I’ve read that before but how is an arterial line different from an IV?

They are different in the sense that a national regulatory body with the gravitas to represent a standard of care says they are different. The truth is irrelevant. At my last shop, we started bundling our kits with a small, fenestrated drape. Can't say how often people used them, though.

 

[Potatoman1800]

Category 1B evidence doesn't change my practice.

And yep, no reasons for double sticks except for the old timers that wanted the full units (Now its just MAC plus introducer) or for anticipated massive resuscitation.

 

[DesiredMemberName?]

For whatever it's worth, the CDC has said since 2011 that arterial lines should be done under sterile conditions:

1. 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’s still ok if I tear off the finger of the glove to better palpate the pulse, though, right?

 

[Dantrolene FC]

I’ve read that before but how is an arterial line different from an IV?

It depends on if you use the kit or the quick cath.

The quick cath doesn’t require sentirle gloves because you never touch anything that goes into the body.

With the kit, you’re touching the wire that’s going to enter the vessel.