Tips and Tricks

[OB1🤙]

Everyone has their own little semi-secret tricks. Let's hear what yours are. Maybe this thread will suck, and maybe it'll be great. We'll see.

I'll throw 2 out there.

1) Your pt has very crappy veins, and you need a reasonable IV? Got an ultrasound, found a nice juicy target but it's pretty deep?

The Arrow a-line kit is your friend. You can enter the vein at a pretty steep angle, thread the built-in wire, and voila, 20g IV. Because it's kink-resistant, it'll stay good despite the angle.

2) Have trouble masking, and don't have qualified help? Set your machine to pressure control ventilation, dial the pressure to something reasonable (I use 15), rate about 10. Turn vent on. Now use both hands to hold the mask, and the machine does the "bagging" for you.

Bonus: If the reason you're having trouble is a bushy beard, pop a big Tegaderm over the beard and cut a hole over the mouth. Seal will be much, much better.

Let's hear some more.

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[Noyac]

Aww ****, where did you learn the Tegaderm trick? I've mentioned it here before ( yrs ago) but never heard of anyone else that knew it.

My basic trick that I don't see my partners do is to hit the pt with 20-40mg of propofol 5 minutes before extubation. It seems to me like most people would be doing this.

 

[kazuma]

Nasal intubation- slide a red rubber catheter over the tip of the nasal RAE, it helps guide the tube down with less trauma/bleeding. Just pull the tip up and out if the mouth and pop it off the ETT which now positioned in the back of the pharynx, ready to be advanced through the cords.

 

[OB1🤙]

Learned the Tegaderm trick in residency.

Kazuma- I like. Another nasal intubation trick- cut a nasal airway lengthwise, insert after lubing inside and out. Prior serial dilation is optional. The nasal ETT now has an expandable atraumatic conduit to the pharynx.

 

[kazuma]

Nice, I like that idea, I'll have to try that. It reminds me if the trick to assist og tubeinsertion. You take the connector Off an extra ETT and slide it down into the esophagus after lubing inside and out and it works as a conduit for those flimsy og tubes if your struggling in a difficult pt. You just leave the ETT in place until you're ready to pull it at the end if the case.

I like the propofol emergence Noyac, especially in PEDs and teens, seems to smooth things out.

Keep the tricks coming, I love MacGuyver stuff like this. The PS+rate bagging trick is great, I can't wait to try that out.


Another way to deal with beards especially in obese pts is to ask them how much the facial hair means to them and let them know you may difficulty ventilating them. I had my cardiac attending tell that to a pt the other day and he agreed to let the tech shave his beard off before he shaved his chest and legs for the vein harvest.

 

[OB1🤙]

kazuma- PC, not PS. I give paralytic along with induction agent 100% of the time, so PS wouldn't get me far.

Another Arrow catheter "trick" that for some reason doesn't get widespread traction- if the wire won't thread after entering the artery, just go through and through and take out the needle. Now deploy the wire fully beyond the bare needle. Functions as would a regular standalone wire, and no need to open a separate wire (or cut the wire out of the assembly). Withdraw catheter until flow, insert wire+needle into artery, thread.

 

[BobBarker]

Use toddler mask to mask ventilate through the nostrils.

 

[dhb]

Magnesium for pacu pain
Calcium for hypotension (almost never use pressors for routine cases)

 

[napman]

after loosing couple of IV's which went SC after US guided peripheral vein cannulations, I decided to use femoral arterial kit for US IV placement. It works great (and patient has a PICC line now). If for some reson patient neads a larger bore IV than 20g I go direct to IJ with a central line

I use ETT which comes with intubating LMA for nasal intubations. It is much less traumatic and is flexable. BUT REMEMBER TO TELL THE CRNA NOT TO TROUGH THE TUBE AFTER USE

I always use Parker flex tip for all my glidescopes and flexable fiberotics as it is less trumatic and dose not hinge on to any tracheal rings down the line

PC for mask ventilation is a great idea, I have been using and teaching this technique for a long time. It is much better than a nurse squeezing a bag with peak pressures of 30-40 cm

Everyone has their own little semi-secret tricks. Let's hear what yours are. Maybe this thread will suck, and maybe it'll be great. We'll see.




I'll throw 2 out there.

1) Your pt has very crappy veins, and you need a reasonable IV? Got an ultrasound, found a nice juicy target but it's pretty deep?

The Arrow a-line kit is your friend. You can enter the vein at a pretty steep angle, thread the built-in wire, and voila, 20g IV. Because it's kink-resistant, it'll stay good despite the angle.

2) Have trouble masking, and don't have qualified help? Set your machine to pressure control ventilation, dial the pressure to something reasonable (I use 15), rate about 10. Turn vent on. Now use both hands to hold the mask, and the machine does the "bagging" for you.

Bonus: If the reason you're having trouble is a bushy beard, pop a big Tegaderm over the beard and cut a hole over the mouth. Seal will be much, much better.

Let's hear some more.

 

[BobBarker]

Need another IV preferably a big one but no appropriate veins?

Apply the esmarch bandage in a reverse fashion as to the way when doing a bier block to drive the blood into the hand. This will dilate the present veins and make them 16g worthy.

 

[deleted126335]

Use toddler mask to mask ventilate through the nostrils.

Infant mask over trach stoma.

 

[ArMed]

When attempting an a-line, everyone always puts their feeler pointer finger perpendicular to the radial artery. Not quite sure why, you have way finer touch reception at the fingerTIP. Try putting your feeler finger parallel to the artery. The position is goofy at first, but just line up the PMI with the middle of the finger tip, and you will never miss again.

 

[sevoflurane]

Another Arrow catheter "trick" that for some reason doesn't get widespread traction- if the wire won't thread after entering the artery, just go through and through and take out the needle. Now deploy the wire fully beyond the bare needle. Functions as would a regular standalone wire, and no need to open a separate wire (or cut the wire out of the assembly). Withdraw catheter until flow, insert wire+needle into artery, thread.

I'm thorugh and through every single time.






Some of my partners are now switching to this technique from the get go.

.021 g wire. Lots of "feel" doing it this way. I love the "eclipse" gloves for feel- very thin.

 

[BobBarker]

Everyone probably knows but 3cc syringe to 14g angiocath with small ett connector to go to circuit for quick cric

 

[Sublimazing]

Instead of forcing your patient to sniff, bathe, and swallow oxymetazoline in preop before a nasal tube...wait until after induction while masking...have two cotton tip applicators (qtips) ready with oxymetazoline (or cocaine if you're pro) and pass them through the nares before paralytic is passed...this will

1. Apply the vasoconstrictor much more thoroughly (do a in and out and twirling motion)
2. Allow you to push out any solid debris
3. Allow you to determine which nares has better patency...pass all the way past turbinates
4. Doesn't cost anywhere near an NPA

Hooray!

 

[BobBarker]

Oral ketamine. Put some of the concentrated ketamine in apple juice. More effective than oral versed and kids actually like apple juice.

 

[napman]

Low dose succinylcholine 0.3 -0.5mg/kg for floor intubations if difficult intubation is not aticipated, just makes your life easy and return to spontanious ventilation is quick in case you miss it. I also use Delayed sequence intubation technique for these floor intubations
http://emcrit.org/podcasts/dsi/
http://www.ncbi.nlm.nih.gov/pubmed/14576536

 

[Noyac]

When attempting an a-line, everyone always puts their feeler pointer finger perpendicular to the radial artery. Not quite sure why, you have way finer touch reception at the fingerTIP. Try putting your feeler finger parallel to the artery. The position is goofy at first, but just line up the PMI with the middle of the finger tip, and you will never miss again.

Very true and when feeling for the artery try to feel the artery as a tube in the wrist and up the forearm some. In other words, don't just feel for the pulse,but rather feel the artery along its course. You will become much more successful with your first attempt if you can mentally see the course of the artery. And then as you get even better at this you will be able to place one in code situations when there is pulse. Works well for peds as well.

 

[Noyac]

Low dose succinylcholine 0.3 -0.5mg/kg for floor intubations if difficult intubation is not aticipated, just makes your life easy and return to spontanious ventilation is quick in case you miss it. I also use Delayed sequence intubation technique for these floor intubations
http://emcrit.org/podcasts/dsi/
http://www.ncbi.nlm.nih.gov/pubmed/14576536

Totally agree. When I get called for ICU intubations I believe they struggle mostly from lack of relaxant. The first thing I do is paralyze.

 

[twoliter]

I haven't tried this one personally, but I heard it in lecture recently. If you are having trouble mask ventilating, insert a nasal trumpet and use the ETT connector from a 6 or 6.5 tube to connect to the circuit, seal the mouth and contralateral nostril and bag ventilate through the nasal trumpet.

 

[bostonblaz]

Nasal airway is the least traumatic and best oral airway. Blaz

 

[deleted162650]

I haven't tried this one personally, but I heard it in lecture recently. If you are having trouble mask ventilating, insert a nasal trumpet and use the ETT connector from a 6 or 6.5 tube to connect to the circuit, seal the mouth and contralateral nostril and bag ventilate through the nasal trumpet.

Or better yet, if you're having that much trouble just put an LMA in till you're ready to tube em.

Another LMA trick: if you have to ventilate through an uncuffed trach, put an LMA in and clamp it with a kelly. Upper airway is now sealed and you won't lose all your positive pressure up through the glottis

This one has been mentioned in the past (PGG I think): for Pre-oxygenating pts with Santa beards or those that are extremely claustrophobic and won't tolerate the mask, remove the mask, put the elbow of the circuit in their mouth, and have them breathe like a snorkel.

On labor deck today, so here's my epidural trick: Our arrow epidural kits come totally dry (no saline or local). Instead of hassling with multiple vials of saline, lido, etc, I just squirt 15-20mL's of our infusion solution into the kit (1/8th% bupi w/ 2mcg/mL fent). Use 3-5cc of that for skin local, 3-5 more for LOR fluid, 2.5-3cc for spinal dose of CSE via 26g Gertie Marx, thread cath, and then 3-5cc through the epidural cath. Done and done. Pt is comfy before the tape is on and the BP stays remarkably stable.

 

[ASA6]

Aww ****, where did you learn the Tegaderm trick? I've mentioned it here before ( yrs ago) but never heard of anyone else that knew it.

Ill give credit where its due....I got this trick from you, and in fact I used it yesterday! Had a guy with a great big bushy beard and no teeth with a terrible heart. Broke out the big tegaderm with a whole and awe'd the hell out of everyone in the room. Thanks dude!

 

[Reciprocity79]

Everyone probably knows but 3cc syringe to 14g angiocath with small ett connector to go to circuit for quick cric

You can also place an ETT into a 20cc syringe and inflate the cuff if it's all you have handy.

 

[sleepallday]

Here's one I was showed just a few days ago. I induced a patient and placed an LMA. The patient then starts to hiccup. Nothing to disruptive but it was still pretty annoying. One of the old-timer partners walks into my room, notices the hiccuping patient, and says let me show you something. He grabs a flexible oral catheter and places it through the nose into the nasopharynx. And the patient stops hiccuping!! Just like that!! He claims it works every time.

 

[pgg]

Next time someone I know has a bad case of hiccups, I'm going to go after him with a flexible catheter.

I learned the tegaderm-on-the-beard trick when I was a resident, but I can't remember who taught it to me. It might have been Noyac (via SDN not in person).

 

[deleted162650]

I was taught the tegaderm trick in residency as well. I have had it fail with a big ZZ top style beard as air leaked out under the tegaderm the beard was so bushy. Maybe next time I'll just wrap the whole head in Ioban.

 

[deleted162650]

Also gotta give Noy credit for one of my favorites: 400ish mcg phenylepherine into the IV bag for C/S under SAB = train track vitals and way less nausea

 

[sevoflurane]

Coming towards the end of your case and you wanna get that heme outta your hotline stat?

Grab a 30cc syringe, and purge it. Really nice for when you are keeping your fluids to a minimum (pneumonectomy/CABG). This way you can purge your line and clamp your fluids immediately.

I also like to keep things neat... Don't unwind the hotline unless you absolutely have to.

 

[sevoflurane]

Also gotta give Noy credit for one of my favorites: 400ish mcg phenylepherine into the IV bag for C/S under SAB = train track vitals and way less nausea

Noy is worth his weight in gold. Super chill, super smart, super nice.... and one very talented athlete.

Carry on.

 

[dhb]

Low dose succinylcholine 0.3 -0.5mg/kg for floor intubations if difficult intubation is not aticipated, just makes your life easy and return to spontanious ventilation is quick in case you miss it. I also use Delayed sequence intubation technique for these floor intubations
http://emcrit.org/podcasts/dsi/
http://www.ncbi.nlm.nih.gov/pubmed/14576536

Not really low dose: sux ED95 is 0.4mg/kg

 

[pgg]

Also gotta give Noy credit for one of my favorites: 400ish mcg phenylepherine into the IV bag for C/S under SAB = train track vitals and way less nausea

I got that from him too. Very nice.

 

[Laryngophed]

I got that from him too. Very nice.

Ha! I saw a resident at my home program do that once. Now I wonder if they read SDN too.

 

[Noyac]

I never really thought about how I may have influenced people here. Usually just trying to participate but I understand that I have some experience as well. I guess, in a way I have helped in the training of a few. Nice to know.

 

[Noyac]

Sevo, I can easily say the same about you my friend.

 

[deleted162650]

I never really thought about how I may have influenced people here. Usually just trying to participate but I understand that I have some experience as well. I guess, in a way I have helped in the training of a few. Nice to know.

I like to think that about 50% of my anesthetic education came from SDN, and I trained at a great program.

 

[BobBarker]

Here is a good one I forgot to mention:

Having trouble oxygenating during single lung ventilation? Take some regular suction tubing and hook it up to the oxygen spigot then take one of the long suction catheters that came with the DLT and affix it to the opposite end and tape up all of the suction holes. Stick the catheter into the unventilated lung side and put your o2 flows at 2l. A little flow by apneic oxygenation. Much better than the cpap because it is essentially free and does not distend the lung/hurt surgical conditions. Works great.

 

[OB1🤙]

Here is a good one I forgot to mention:

Having trouble oxygenating during single lung ventilation? Take some regular suction tubing and hook it up to the oxygen spigot then take one of the long suction catheters that came with the DLT and affix it to the opposite end and tape up all of the suction holes. Stick the catheter into the unventilated lung side and put your o2 flows at 2l. A little flow by apneic oxygenation. Much better than the cpap because it is essentially free and does not distend the lung/hurt surgical conditions. Works great.

Love it. Going to have to try that one.

 

[OB1🤙]

I like to think that about 50% of my anesthetic education came from SDN, and I trained at a great program.

I totally agree.

 

[BobBarker]

Yes, it is a winner. I do it all the time with great results.

 

[Sublimazing]

Introduce yourself to the patient using a colleague's name...Wear the ID badge of one of the janitorial staff...and then sign the charts with fabricated alias linked to your offshore bank account

That way, when the lawyers show up, they'll be looking for 3 people, none of which are you!

 

[Lightwand]

For patients with "trauma face" or those who chose to apply lotion liberally pre-op, a dab of isoflurane on a 2x2 will instantly degrease the face and allow you to tape the tube without 700 layers of tape that are stuck to each other, but not actually sticking to the patient.

 

[BobBarker]

Here is another one from the same guy who taught me the o2 flowby trick.

The originator of this method is quite a bit of a peacock, always showing off his feathers. And this goes right with that type of personality. But he is good at what he does.

Our epidural trays come with a 20cc plastic syringe. He puts 5cc of LOR saline in it. He engages the tuohy in flavum then affixes the 20cc syringe to it. Then he takes one hand and pushes the plunger of the syringe with his palm alone. The needle advances to the epidural space and then once LOR is obtained the plunger moves forward but the needle advances no further.

I think @BLADEMDA needs to try this one.

 

[Noyac]

Here is another one from the same guy who taught me the o2 flowby trick.

The originator of this method is quite a bit of a peacock, always showing off his feathers. And this goes right with that type of personality. But he is good at what he does.

Our epidural trays come with a 20cc plastic syringe. He puts 5cc of LOR saline in it. He engages the tuohy in flavum then affixes the 20cc syringe to it. Then he takes one hand and pushes the plunger of the syringe with his palm alone. The needle advances to the epidural space and then once LOR is obtained the plunger moves forward but the needle advances no further.

I think @BLADEMDA needs to try this one.

On this one I would add one of my favorite things but is probably done by many here already. When you get that LOR and are ready to advance the catheter push 5cc of that same saline into the epidural space. It seems to make threading the catheter go more smoothly with less intravascular incidents. I started doing this when I switched to CSE's. I noticed that every once in a while there was some resistance to advancing but I never remembered that happening before doing CSE's. Then I figured it out, I was bolusing all my local thru the Touhy back then and it spread the space out some therefore allowing for easier catheter placement.

 

[napman]

Use recrutement manuvers and add PEEP of 5-6 to dependent lung before starting one lung ventilation, this prevents hypoxia 95% of times

 

[WholeLottaGame7]

Here is another one from the same guy who taught me the o2 flowby trick.

The originator of this method is quite a bit of a peacock, always showing off his feathers. And this goes right with that type of personality. But he is good at what he does.

Our epidural trays come with a 20cc plastic syringe. He puts 5cc of LOR saline in it. He engages the tuohy in flavum then affixes the 20cc syringe to it. Then he takes one hand and pushes the plunger of the syringe with his palm alone. The needle advances to the epidural space and then once LOR is obtained the plunger moves forward but the needle advances no further.

I think @BLADEMDA needs to try this one.

I had an attending teach me this, with the premise that you'd have a lower risk of wet tap because the syringe acts as a shock absorber and stops the needle when you got LOR. Proceeded to wet tap the first patient I tried it on, despite going slowly and smoothly.

Could have been that I would have wet-tapped her regardless and I got unlucky, but that was the end of that experiment. It was basically just adding a cool factor, which for me was not worth wet-tapping that chick.

I have also used the suction catheter/O2 trick to great success, definitely second that one.

 

[Noyac]

Here's one from my residency.

If you get a wet-tap, inject the entire 10cc of NS that comes in the kit intrathecally. Come out and place epidural at another level. The incidence of PDPH after this will decrease hugely.

http://ape.med.miami.edu/Doc/Reside...f IT NS reduces the severity of PDPH 2001.pdf

 

[sethco]

I was wondering if anybody worries about the possibility of an airway fire if you are insufflating O2 into the operative lung? Do you tell the surgeon not to use electrocautery?

 

[epidural man]

Also gotta give Noy credit for one of my favorites: 400ish mcg phenylepherine into the IV bag for C/S under SAB = train track vitals and way less nausea

Check this out...

 

[dhb]

Use recrutement manuvers and add PEEP of 5-6 to dependent lung before starting one lung ventilation, this prevents hypoxia 95% of times

I also ventilate the lungs with a a low FiO2 before OLV to help hypoxic vasocontriction in the non ventilated lung