Swan

[PpfSuxTube]

Weird q sorry...

For cardiac folk, for easy cases.

To speed up anesthesia start up...

Anyone just float the Swan to cvp, then let the surgeons start, and float it to PA later in the case?


We're short on AAs right now and the OR nurses are very slow with the Swan connections and pressure lines. Sometimes they contaminate the whole setup. I have 0 control over which help I get daily. Often it's a new person.


So, if I do it myself later in the case when I have downtime, would that be feasible?

Or can anyone see this causing issues?

Fwiw... busy cardiac centre but good supply of patients for cabg with normal LV normal valves that sail through, easy cases like this I'm targeting. Our institution mandates Swan for every case so I can't and won't fight that

---

Members don't see this ad.

 

[2buckchuck]

I’ve done this. It’s harder once the drapes are up cause it’s buried under the ether screen etc but doable. Easiest if you can float before the drapes go up. Also let’s you use TEE to assist if you want (if you are routinely using TEE).

 

[thinkorswim]

I’ve done it in certain situations. The Swan will lose some of its natural curvature which can make advancing it technically more challenging.

How much time would you realistically be saving? Like 5 minutes at most?

 

[ryanjmy]

Fwiw... busy cardiac centre but good supply of patients for cabg with normal LV normal valves that sail through, easy cases like this I'm targeting. Our institution mandates Swan for every case so I can't and won't fight that

 

[PpfSuxTube]

Do you not put a Swan?why not?
Don't you get paid for it? It's about a 5 min process

 

[medicine2wallstreet]

Why not put a swan in? Because putting a swan in is a pain in the ass and it can cause arrhythmias that I ain't trying to deal with. And it's mostly a trash number generator. Severe reduced EF and severe valve stuff only real reason to put one in. Nerds won't admit it but especially for standard CABGs the only important number is keeping the systolic 120 or less. Not dumb pa pressures.

I'm a resident and we have plenty of attendings that want me to park it at 20cm and then us float later. Mostly because they don't want to deal with it in pre-op. It can be done for sure. Pain in the ass to deal once in OR in my opinion as there's plenty of other stuff going that has my attention. Probably a larger audience for the arrhythmias which I would dislike.

 

[ryanjmy]

Do you not put a Swan?why not?
Don't you get paid for it? It's about a 5 min process

I probably put it in 10% of pump cases. Risks/Benefits

Doesn't affect my pay. Wouldn't change my practice if it did. I think you get 1 extra unit for putting in a swan vs cvl.

 

[thinkorswim]

Why not put a swan in? Because putting a swan in is a pain in the ass and it can cause arrhythmias that I ain't trying to deal with. And it's mostly a trash number generator. Severe reduced EF and severe valve stuff only real reason to put one in. Nerds won't admit it but especially for standard CABGs the only important number is keeping the systolic 120 or less. Not dumb pa pressures.

I'm a resident and we have plenty of attendings that want me to park it at 20cm and then us float later. Mostly because they don't want to deal with it in pre-op. It can be done for sure. Pain in the ass to deal once in OR in my opinion as there's plenty of other stuff going that has my attention. Probably a larger audience for the arrhythmias which I would dislike.

If you’re regularly inducing arrhythmias while floating a PA catheter then you’re doing something wrong.

You should probably stick to the easy stuff, like OB.

 

[pgg]

If it doesn't float easily, I'll quit trying and get back to it later. I've got other more important stuff to do than position a monitor I don't really need, so no rush. Sometimes TEE helps to float it.

If I'm taking off a unit or two of ANH blood, sometimes I'll just connect it sterilely and float it later, because the PA catheter really slows the bloodletting through the introducer.


Our surgeons want them for postop management. Whether or not it's useful to them or the intensivists isn't really something I'm emotionally invested in. It's a fast easy thing to do and we get paid more for it. I'm happy to put them in. There are other hills I'd choose to die on first, if I was in a dying mood.

 

[Beeftenderloin]

Why not put a swan in? Because putting a swan in is a pain in the ass and it can cause arrhythmias that I ain't trying to deal with. And it's mostly a trash number generator. Severe reduced EF and severe valve stuff only real reason to put one in. Nerds won't admit it but especially for standard CABGs the only important number is keeping the systolic 120 or less. Not dumb pa pressures.

I'm a resident and we have plenty of attendings that want me to park it at 20cm and then us float later. Mostly because they don't want to deal with it in pre-op. It can be done for sure. Pain in the ass to deal once in OR in my opinion as there's plenty of other stuff going that has my attention. Probably a larger audience for the arrhythmias which I would dislike.

Why would the SBP need to be under 120 for a straightforward CABG? If there’s any data to support that, I’d love to see it. Maybe for some serious aortic work in a patient with horrible quality tissue, or a surgeon that doesn’t trust there ability to tie suture, but that’s about it.

 

[crash2500]

Why would the SBP need to be under 120 for a straightforward CABG? If there’s any data to support that, I’d love to see it. Maybe for some serious aortic work in a patient with horrible quality tissue, or a surgeon that doesn’t trust there ability to tie suture, but that’s about it.

Seriously, @medicine2wallstreet showing how clueless he really is once again...

 

[medicine2wallstreet]

No heart surgeon will get spooked about a SBP of 120 or less for a CABG. Pressure starts to get above that then it becomes actionable. Just because it's not a valve surgery doesn't mean that the coronary sites aren't still fragile. I've had plenty of urgent experiences with surgeons wanting to cool off the blood pressure. If the blood pressure is 120 or less I have never heard a word about it from perfusion or CT surgeon or ICU nurses. It isn't in some book I've read. It's just my personal opinion from experience. I don't care if y'all call me stupid. I'm just being honest.

In regards to the arrhythmias it is a known thing that occurs with PA catheters. It's not like there's some savant way to jam a line thru the heart. It's invasive and I would prefer to not use one unless those things I addressed earlier.

 

[pgg]

I'm a resident and we have plenty of attendings that want me to park it at 20cm and then us float later. Mostly because they don't want to deal with it in pre-op.

Wait

You're taking the time to put your lines in in pre-op (which I think is ridiculous but I'll leave that for another time) ... but you're not finishing the associated tasks?

I understand that as a resident, you're at the mercy of the dumb things your attendings tell you to do, but it doesn't make any sense to endure the hassle of putting in pre-induction central lines and torturing awake patients if you're not even going to get the whole thing done anyway.

 

[pgg]

Also I find it odd that you're electively, unnecessarily putting introducers into awake patients but it's the ectopy from the PA catheter that gets you anxious about that process.

From your posts it appears you've drawn some oddly firm conclusions about anesthesia practice despite still being a resident (a July CA-3?) I'm not trying to be mean but there's a wide world out there and one academic practice doesn't represent everything. I especially wouldn't take the barking of an academic cardiac surgeon at an anesthesia resident too too seriously ... those guys are high strung to begin with and having a new trainee on the other side of the curtain every 30 days breeds a degree of micromanagement that you just don't see elsewhere.

 

[medicine2wallstreet]

I realize my experience doesn't represent everything. Wherever I go to practice I'll absorb what they do and adapt accordingly. Just relax. I have told you my opinion. My opinion is not dogma and I'm not trying to get anyone to agree.

 

[pgg]

I realize my experience doesn't represent everything. Wherever I go to practice I'll absorb what they do and adapt accordingly. Just relax. I have told you my opinion. My opinion is not dogma and I'm not trying to get anyone to agree.

I think everyone here is pretty relaxed.

Relaxed, bemused ...

You're getting pretty consistent feedback here from a number of people. Take it for what you paid for it. Do with it what you will.

 

[Beeftenderloin]

Nerds won't admit it but especially for standard CABGs the only important number is keeping the systolic 120 or less.

I realize my experience doesn't represent everything. Wherever I go to practice I'll absorb what they do and adapt accordingly. Just relax. I have told you my opinion. My opinion is not dogma and I'm not trying to get anyone to agree.

That’s quite the turn around in less than an hours time. Going from definitively stating 120 SBP is the only number that matters unless you’re a “nerd”, too saying you were just sharing your opinion, but only once challenged by people with more experience. It makes your lack thereof, particularly in this domain, glaringly obvious.

 

[DesiredMemberName?]

Wait

You're taking the time to put your lines in in pre-op (which I think is ridiculous but I'll leave that for another time) ... but you're not finishing the associated tasks?

I understand that as a resident, you're at the mercy of the dumb things your attendings tell you to do, but it doesn't make any sense to endure the hassle of putting in pre-induction central lines and torturing awake patients if you're not even going to get the whole thing done anyway.

I can totally see how the attending could get frustrated with this very coachable resident as they flail around trying to “jam a line through the heart.”

After a few passes of them not listening and causing all kinds of arrhythmias, it probably would make sense to 1) spare the patient and 2) have someone else try to teach him proper technique after the patient is asleep.

 

[Iso4ane]

Arrhythmia's happen yes, but if you're fast it doesn't matter. Placing a Swan in to 20cm is nearly half to 3/4 of the work already.

 

[medicine2wallstreet]

I answered the guys question and because I'm a resident this has deteriorated into the classic resident is dumb attending is smart experience of residency.

One of my CT attendings was floating under US guidance in the room yesterday and caused v tach. I certainly didn't think he was dumb. Arrhythmias happen unless you're the best there is like everyone on here.

 

[vector2]

I answered the guys question and because I'm a resident this has deteriorated into the classic resident is dumb attending is smart experience of residency.

One of my CT attendings was floating under US guidance in the room yesterday and caused v tach. I certainly didn't think he was dumb. Arrhythmias happen unless you're the best there is like everyone on here.

You must be an absolute joy to work with

 

[pgg]

I answered the guys question and because I'm a resident this has deteriorated into the classic resident is dumb attending is smart experience of residency.

That wasn't my experience in residency.

And it's not the usual experience of residents on this forum.

If this kind of interaction is classic to you, maybe give that some thought.

One of my CT attendings was floating under US guidance in the room yesterday and caused v tach. I certainly didn't think he was dumb. Arrhythmias happen unless you're the best there is like everyone on here.

Everyone here is handsome (or pretty), and witty too.

 

[lane]

I just had the pleasure of reading a clearance note from an academic ivory tower dweller that recommended a CV anesthesiologist float a swan… for a tongue biopsy.

 

[PpfSuxTube]

the classic resident is dumb attending is smart experience of residency.

i think a classic selection bias is more likely...
Relax dude...

You trying so hard to be something you don't need to...

 

[psychbender]

I just had the pleasure of reading a clearance note from an academic ivory tower dweller that recommended a CV anesthesiologist float a swan… for a tongue biopsy.

Interesting way to get a biopsy, but ok.

 

[psychbender]

I'll push back slightly on the idea that placing introducers and PACs in awake patients is torture. Honestly, the most painful thing is on my end, trying to talk the ICU nurse through getting the transducers all hooked up, and how to get them on the screen (when placing them in the unit). The patient is just a little uncomfortable under the drapes, but it's otherwise not really much more stimulating than doing an ISB without sedation, which many here do.

At one of my old places, we routinely placed the CVC and PAC in the OR pre-induction, largely because "that's how we've always done it here." I think the actual rationale was that we didn't have any real help, aside from maybe getting the perfusionist to push pressors through the PIV while we're sterile, if they were needed when placing the line after induction. 🤷‍♂️

 

[nimbus]

I'll push back slightly on the idea that placing introducers and PACs in awake patients is torture. Honestly, the most painful thing is on my end, trying to talk the ICU nurse through getting the transducers all hooked up, and how to get them on the screen (when placing them in the unit). The patient is just a little uncomfortable under the drapes, but it's otherwise not really much more stimulating than doing an ISB without sedation, which many here do.

At one of my old places, we routinely placed the CVC and PAC in the OR pre-induction, largely because "that's how we've always done it here." I think the actual rationale was that we didn't have any real help, aside from maybe getting the perfusionist to push pressors through the PIV while we're sterile, if they were needed when placing the line after induction. 🤷‍♂️

9fr introducer is a lot bigger than a 22g Pajunk. Put me to sleep first.

 

[pgg]

I'll push back slightly on the idea that placing introducers and PACs in awake patients is torture. Honestly, the most painful thing is on my end, trying to talk the ICU nurse through getting the transducers all hooked up, and how to get them on the screen (when placing them in the unit). The patient is just a little uncomfortable under the drapes, but it's otherwise not really much more stimulating than doing an ISB without sedation, which many here do.

At one of my old places, we routinely placed the CVC and PAC in the OR pre-induction, largely because "that's how we've always done it here." I think the actual rationale was that we didn't have any real help, aside from maybe getting the perfusionist to push pressors through the PIV while we're sterile, if they were needed when placing the line after induction. 🤷‍♂️

In the grand scheme of ICU barbarism I guess placing an awake introducer doesn't rank too far up there.

I've worked a couple places where the culture was to line up the hearts in preop. It seemed somewhere between pointless and mean to me. Also, lines in non-OR locations are logistically irritating at best - patients on hospital beds and not OR tables, lighting, help. It needlessly adds a small but nonzero level of technical difficulty.

I am also negatively disposed to the concept because it's usually done because some jerkoff of a surgeon whined and cowed some weak anesthesiology department into doing preop lines to shave 15 minutes off his OR time. I mean there's no good reason an anesthesiologist would choose to routinely do awake vs asleep central lines, so someone else conjured and imposed that habit.

 

[vector2]

I'll push back slightly on the idea that placing introducers and PACs in awake patients is torture. Honestly, the most painful thing is on my end, trying to talk the ICU nurse through getting the transducers all hooked up, and how to get them on the screen (when placing them in the unit). The patient is just a little uncomfortable under the drapes, but it's otherwise not really much more stimulating than doing an ISB without sedation, which many here do.

At one of my old places, we routinely placed the CVC and PAC in the OR pre-induction, largely because "that's how we've always done it here." I think the actual rationale was that we didn't have any real help, aside from maybe getting the perfusionist to push pressors through the PIV while we're sterile, if they were needed when placing the line after induction. 🤷‍♂️

I've had to do awake lines/swans for 5 years and I still hate it. I think you're right in that the majority of pts can tolerate it ok, but yowsers, the stress increase from the ones who don't more than makes up for any decrease from the ones who do.

At least we do ours "awake" in the OR so there are some advantages, but the whole thing (including the fact I work with trainees) has led me down the unfortunate path of essentially doing general with an unprotected airway whenever the pts hemodynamics will tolerate.

 

[psychbender]

9fr introducer is a lot bigger than a 22g Pajunk. Put me to sleep first.

With lido at the skin, it's not that noticeable, at least by what patents at that time told me (have had awake ISB myself, but not awake 9MAC). I do lines post-induction now, unless I'm wearing my ICU hat.

 

[psychbender]

In the grand scheme of ICU barbarism I guess placing an awake introducer doesn't rank too far up there.

I've worked a couple places where the culture was to line up the hearts in preop. It seemed somewhere between pointless and mean to me. Also, lines in non-OR locations are logistically irritating at best - patients on hospital beds and not OR tables, lighting, help. It needlessly adds a small but nonzero level of technical difficulty.

I am also negatively disposed to the concept because it's usually done because some jerkoff of a surgeon whined and cowed some weak anesthesiology department into doing preop lines to shave 15 minutes off his OR time. I mean there's no good reason an anesthesiologist would choose to routinely do awake vs asleep central lines, so someone else conjured and imposed that habit.

Lining hearts in preop and lining hearts awake in the OR are a little different, and addresses some of your concerns (table, lighting, help). In the grand scheme of things though, I completely agree, it does not add to the safety of the procedure, and pre-induction lines don't increase OR efficiency (with the bulk of the time being surgeon-****-around-time). Lines in preop/ holding are a special kind of hell, and anyone forced to do them should have all the proper support and equipment, AND get paid extra for the bull****.

 

[nimbus]

With lido at the skin, it's not that noticeable, at least by what patents at that time told me (have had awake ISB myself, but not awake 9MAC). I do lines post-induction now, unless I'm wearing my ICU hat.

We always do them asleep in the OR. I don’t like to make the skin nick too big because it can sometimes cause bleeding at the insertion site. For that reason, I sometimes find myself pushing pretty hard to get the dilator and introducer assembly through and into the vessel. Seems like it would hurt. Maybe it would be fine with a little versed and ketamine on board. I never push that hard on a block needle.

 

[Beeftenderloin]

We always do them asleep in the OR. I don’t like to make the skin nick too big because it can sometimes cause bleeding at the insertion site. For that reason, I sometimes find myself pushing pretty hard to get the dilator and introducer assembly through and into the vessel. Seems like it would hurt. Maybe it would be fine with a little versed and ketamine on board. I never push that hard on a block needle.

I practice similarly. But the other day I had a guy with some of the thickest/toughest skin I’ve seen in a while. I think I had to go back 4-5 times with that crappy little scalpel in the kit trying to make my incision bigger, but not too big. Still really had to force it in. Their BP response under GA suggested it would have been quite uncomfortable awake.

 

[medicine2wallstreet]

Sounds like a slow central line! I only ever make one cut with my lines. Horizontal with blade away from the carotid and in alignment with neck folds to minimize scarring, take it down deep. Done.

 

[pgg]

Sounds like a slow central line! I only ever make one cut with my lines. Horizontal with blade away from the carotid and in alignment with neck folds to minimize scarring, take it down deep. Done.

Jesus Christ are you now really throwing shade and explaining skin nick technique to people who've done 1000s more of these than you?

 

[PpfSuxTube]

Jesus Christ are you now really throwing shade and explaining skin nick technique to people who've done 1000s more of these than you?

I love this Wallstreet guy... he's so much entertainment...

"Well in my experience bla bla bla..."
N=5 all bread and butter cases, staff nearby

 

[GassYous]

Jesus Christ are you now really throwing shade and explaining skin nick technique to people who've done 1000s more of these than you?

Mmm I think I've only done a few hundred

 

[pgg]

Mmm I think I've only done a few hundred

Yeah come to think of it I guess I'm well under 1000 too.

Call it poetic license

 

[medicine2wallstreet]

It is funny to me how the default number is always 1000 from attendings. Epidurals, central lines, a lines. It's always 1000.

I do love to entertain.

 

[pgg]

It is funny to me how the default number is always 1000 from attendings. Epidurals, central lines, a lines. It's always 1000.

I do love to entertain.

It's a nice round number that's probably accurate for most procedures after 15+ years of working.

Bump to 10000 if you're Blade.

 

[Iso4ane]

It's a nice round number that's probably accurate for most procedures after 15+ years of working.

Bump to 10000 if you're Blade.

I would argue that it takes a few dozen central lines to be somewhat okay at central lines. And the. A few dozen more to be competent. But even on lines past 100, there is always something to learn, because you already mastered all the other stuff.

 

[Maz777]

Jesus Christ are you now really throwing shade and explaining skin nick technique to people who've done 1000s more of these than you?

New-age residents. They are the experts. Us attendings are old, out-of-touch dinosaurs.

 

[nimbus]

New-age residents. They are the experts. Us attendings are old, out-of-touch dinosaurs.

Even dinosaurs can get by if we have VL, ultrasound, and sugammadex

 

[Maz777]

Even dinosaurs can get by if we have VL, ultrasound, and sugammadex

What are those new-age contraptions you speak of? I'll stick to my blind intubations, landmark techniques, and neostigmine thank you very much. Unless one of these fancy, new-age residents can sit me down during one of my "education" days, give me a lecture about how to use them, maybe I will reconsider. Oh wait, I don't get days off for education anymore. Woe is me.

 

[Robotic Wis-Hipple]

Sounds like a slow central line! I only ever make one cut with my lines. Horizontal with blade away from the carotid and in alignment with neck folds to minimize scarring, take it down deep. Done.

Lol. For the first 5-6 posts from this joker I thought they were the embodiment of;

”Better to remain silent and be thought a fool than to speak and remove all doubt,”

But now? This can’t be real. There’s no way this troll isn’t doing this on purpose.

 

[vector2]

Lol. For the first 5-6 posts from this joker I thought they were the embodiment of;

”Better to remain silent and be thought a fool than to speak and remove all doubt,”

But now? This can’t be real. There’s no way this troll isn’t doing this on purpose.

Dude is like the Everest of Mount Stupid

 

[medicine2wallstreet]

Did a double IJ stick yesterday on call. I used the blade 3 times. For two sticks! Where's ol buddy who uses it 5 times on 1 stick.

 

[Beeftenderloin]

Did a double IJ stick yesterday on call. I used the blade 3 times. For two sticks! Where's ol buddy who uses it 5 times on 1 stick.

I’m comfortable enough in my skillset that I’m more than happy to self flagellate from time to time and share my experience with the tricky ones. But since you clearly need it, PM your address so I can send you a gold star. My toddler loves them.

 

[tdub878]

Why not put a swan in? Because putting a swan in is a pain in the ass and it can cause arrhythmias that I ain't trying to deal with. And it's mostly a trash number generator. Severe reduced EF and severe valve stuff only real reason to put one in. Nerds won't admit it but especially for standard CABGs the only important number is keeping the systolic 120 or less. Not dumb pa pressures.

I'm a resident and we have plenty of attendings that want me to park it at 20cm and then us float later. Mostly because they don't want to deal with it in pre-op. It can be done for sure. Pain in the ass to deal once in OR in my opinion as there's plenty of other stuff going that has my attention. Probably a larger audience for the arrhythmias which I would dislike.

Ridiculous. Some many errors here. Need a few more years of residency.

 

[T-burglar]

I put swans in everyone .