Tips and Tricks

[Ronin786]

The ACCRAC podcast by Wolpaw out of Hopkins has a good episode on tricks and tips for line placement.

http://accrac.com/episode-18-tips-and-tricks-for-line-placement/

Some of the things are pretty basic that any anesthesiologist should know, but he has a few interesting pointers.

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[Hoya11]

Reviving this thread:

Any tips on IV line/arterial line/monitoring line management/organization? Had a STAT trauma case with 3 PIVs + arterial line, arms tucked and patient prone. IVs were taped securely and ran along the arms. Midway through the case, 2/3 IVs crapped out (16-18G in hands), had a tough time accessing/troubleshooting the lines.

I dont think it would be unreasonable to halt the surgeons and go under the drapes (or re-drape) and untuck the arms and fix the IVs to your satisfaction. Maybe even place new ones while you have the arms back out. You can also try placing a new IV in the foot. Last resort is you flip him and do a SC > Femoral.

 

[IlDestriero]

I guess I was thinking ACs may infiltrate and go undetected, especially with the patient prone and the arms tucked. Made me hesistant to place one with good hand/arm veins.



The IVs worked very well for the ex-lap. Surgeons placed the fem CVC after closing. In retrospect, I should have pushed harder to hook up a line to the CVC--not sure why I didn't. Probably took the patient's stability for granted (decompensated after flipping prone and opening the neck/spine). I'm sure the IV lines got kinked somewhere on tucking so am trying to think of ways to mitigate that. Had the IV/lines taped, looped, and running along the arms towards the head without too much tension. I'm thinking maybe the IV tubing got too warm under the drapes and started to kink up.





It was a great case for me to see as a resident. The patient actually did well during the ex-lap and didn't look too shocky, but per Murphy's law spinal shock started to show itself when we went prone, neck was open, and IV lines started to crap out.



Yeah, I should have taken the extra 5 seconds to hook it up in retrospect, no doubt.



Yep. We did what we could. The patient was under-resuscitated with one working IV and two that ran like 24-G's but not much we could do at that point other than to stop the surgery and untuck the arms to troubleshoot, or try to get a foot IV. It never got to that point as we could still run our stuff through the 18G. Spent as much time adjusting/troubleshooting the IVs as I could afford to, but the patient was pretty much unstable throughout the second part of the case. Definitely wasn't a "feel-good" case for me, but the patient got the resuscitation needed in the ICU (IVs worked wonderfully after untucking).

Stop the case for the 3 minutes needed to hook an IV up to the central line.
I run the lines outside all the tucking crap not inside when possible.
It's usually easy to just put a line in the foot.


--
Il Destriero

 

[Mman]

Stop the case for the 3 minutes needed to hook an IV up to the central line.
I run the lines outside all the tucking crap not inside when possible.
It's usually easy to just put a line in the foot.


--
Il Destriero

I usually try to hook up at least an extension to any line I can't access from positioning even if don't plan on using it just in case. So if a patient comes with 3 IVs and we are tucking arms and going prone and I only think I need one, I'll still put extensions on the other 2 that I can access during the case if needed. If the patient had a femoral line that I wasn't going to use, I'd similarly try to throw an extension on it so I could get to it during case.

 

[Iso4ane]

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

Jet ventilator. You can't get enough pressure/flow with an ambubag or the machine circuit. Exhalation is passive, once you get the lungs inflated, even if you can't intubate/ventilate from above, a full pair of lungs will still exhale passively through the upper airway. But the extremely low pressure/flow you get with the ambubag/circuit through an angiocath won't get much into the lungs since the low resistance path is up and out. You need to use the jet ventilator. IMO the whole angiocath + 3cc syringe + ETT connector is mystic MacGyverish lore dogma and should die. If you ever get a chance to do a cadaver lab try it both ways. Low pressure/flow through an angiocath Doesn't Work.

I suppose if you sealed the mouth/nose while ambubaging an angiocath you might get a tiny amount of O2 into the lungs and that's better than nothing, but you're far better off just using the jet ventilator on the machine.

Definitely the jet ventilator, the one I have at my institution has a Luer lock so no 3cc syringe needed. I tested this myself, even at 15 LPM the flows feel measly thorough the angiocath. Now, its been a while and I can't remember if the flush valve improves things, but then again if I have to manually actuate it, I'll just use the jet ventilator.

 

[Arantius]

I guess I was thinking ACs may infiltrate and go undetected, especially with the patient prone and the arms tucked. Made me hesistant to place one with good hand/arm veins.



The IVs worked very well for the ex-lap. Surgeons placed the fem CVC after closing. In retrospect, I should have pushed harder to hook up a line to the CVC--not sure why I didn't. Probably took the patient's stability for granted (decompensated after flipping prone and opening the neck/spine). I'm sure the IV lines got kinked somewhere on tucking so am trying to think of ways to mitigate that. Had the IV/lines taped, looped, and running along the arms towards the head without too much tension. I'm thinking maybe the IV tubing got too warm under the drapes and started to kink up.





It was a great case for me to see as a resident. The patient actually did well during the ex-lap and didn't look too shocky, but per Murphy's law spinal shock started to show itself when we went prone, neck was open, and IV lines started to crap out.



Yeah, I should have taken the extra 5 seconds to hook it up in retrospect, no doubt.



Yep. We did what we could. The patient was under-resuscitated with one working IV and two that ran like 24-G's but not much we could do at that point other than to stop the surgery and untuck the arms to troubleshoot, or try to get a foot IV. It never got to that point as we could still run our stuff through the 18G. Spent as much time adjusting/troubleshooting the IVs as I could afford to, but the patient was pretty much unstable throughout the second part of the case. Definitely wasn't a "feel-good" case for me, but the patient got the resuscitation needed in the ICU (IVs worked wonderfully after untucking).

A trick I learned and use ALL THE TIME now is to cut holes in the white sheet material the nurses use to wrap around the arms after they have made the "tuck" and thread your IV tubing through it very proximal to the insertion site of the IV. to do this you usually have to disconnect and reconnect the tubing at some point to thread through the hole. This way the maximum amount of IV tubing is outside the "tuck" and accessible right under the drape so you can get to the tubing to inspect for kinks during the case.

 

[Arantius]

Peds trick: have succinylcholine drawn up and connected to a 25 G needle and in the event of laryngospasm during inhalational induction inject the dose into the large veins under the tongue- very close to larynx and easy target.

 

[sevoflurane]

Serious trauma patient that comes up to the OR with a triple lumen...

Not enough. Fix it before the drapes go down.

 

[Mman]

Peds trick: have succinylcholine drawn up and connected to a 25 G needle and in the event of laryngospasm during inhalational induction inject the dose into the large veins under the tongue- very close to larynx and easy target.

While I find that to be intriguing, what's the benefit compared to just sticking it IM? IM succinylcholine breaks laryngospasm in about 5-10 seconds and if I'm that far down the algorithm of things to do probably not going to want to take the mask off and try to hit a vein under the tongue with a dainty needle as you'd usually rather just continuing bagging while the succinylcholine is going in.

 

[Libertas]

While I find that to be intriguing, what's the benefit compared to just sticking it IM? IM succinylcholine breaks laryngospasm in about 5-10 seconds and if I'm that far down the algorithm of things to do probably not going to want to take the mask off and try to hit a vein under the tongue with a dainty needle as you'd usually rather just continuing bagging while the succinylcholine is going in.

Some people advocate doing a submental injection through the soft tissue. Shrug.

 

[anesthesiadoc]

Peds trick: have succinylcholine drawn up and connected to a 25 G needle and in the event of laryngospasm during inhalational induction inject the dose into the large veins under the tongue- very close to larynx and easy target.

Same thing for atropine. I never give Emergent/laryngospasm sux without also giving atropine in a kid (preferably give the atropine first as it buys you time before your airway problem becomes a bradycardia/cardiac output problem)


Sent from my iPhone using SDN mobile

 

[narcusprince]

Suggamadex....

 

[Arantius]

While I find that to be intriguing, what's the benefit compared to just sticking it IM? IM succinylcholine breaks laryngospasm in about 5-10 seconds and if I'm that far down the algorithm of things to do probably not going to want to take the mask off and try to hit a vein under the tongue with a dainty needle as you'd usually rather just continuing bagging while the succinylcholine is going in.

Don't know that theres really a difference, just a trick a very seasoned peds gas guy showed me...

 

[pgg]

While I find that to be intriguing, what's the benefit compared to just sticking it IM? IM succinylcholine breaks laryngospasm in about 5-10 seconds and if I'm that far down the algorithm of things to do probably not going to want to take the mask off and try to hit a vein under the tongue with a dainty needle as you'd usually rather just continuing bagging while the succinylcholine is going in.

Supposedly faster action, and you're not aiming for a vein, just doing a pseudo-IM injection in an area where uptake is presumed to be faster. Had a peds attending who talked about doing it this way. Have never done it myself. Not sure I want to add blood to the mouth of a problem airway, but I guess a 22 or 24 g hole isn't likely to bleed very much.

 

[Mman]

Supposedly faster action, and you're not aiming for a vein, just doing a pseudo-IM injection in an area where uptake is presumed to be faster. Had a peds attending who talked about doing it this way. Have never done it myself. Not sure I want to add blood to the mouth of a problem airway, but I guess a 22 or 24 g hole isn't likely to bleed very much.

The only part of it that worries me is the time to take the mask off the patient and pry their mouth open to find the spot to inject. By the time I'm reaching for the succinylcholine I'm probably providing some vigorous positive pressure to try to squeeze as many molecules of O2 as possible past those cords. Giving up on that for the 5-10 seconds it would take just seems like it isn't the best idea. I'm sure it works fine, though.

 

[deleted162650]

The jet ventilator talk reminds me of one of my favorite tricks. For any case that needs a shoulder roll (thyroids, etc.) place a deflated pressure bag on the table right at shoulder level before the pt moves onto the bed - I'll usually cover it with a pillow case or flat gel pad so you don't really see it. Then connect the jet vent luer lock to the pressure bag. Induce and tube as usual. Then when they are ready to place a shoulder roll and everyone is getting ready to lift the pt up just reach over and squeeze the jet vent lever. BOOM, instant shoulder roll - and it's infinitely adjustable.

 

[IlDestriero]

If a kid is in laryngospasm, like the little punk was today, I treat the problem they have, not the one they might get if I don't fix that problem in a timely manner.
Sublingual works faster, though it's likely academic. They get it in the delt. There was some article that compared quad to delt to sublingual. It went as you'd expect. I can't believe people get promoted publishing that crap. Mine will show intracardiac is the fastest of all...
Probably on a porcine model.
Love all that bacon.


--
Il Destriero

 

[sanityonleave]

Great thread! I love reading the tips.

I've started using the PCV two-handed mask quite a bit this month -- doing mostly vascular and our "OR of the future" hybrid angio suites have a really awkward layout from an anesthetic POV when the room is flipped to angio the legs -- you end up having to squeeze the bag with your left hand (and the machine is at the patient's waist) and hold the mask with your right. I've started just setting the vent and using two hands. It's awesome!

A few T&Ts from a CA-2 (obviously not a ton of experience so take it with a grain of salt):

1) Agree with the continuous epidural technique. Our institution is mostly intermittent and an attending showed me continuous and it was life changing. Especially for challenging epidurals it has cut my time down at least 50%. I use glass syringes with saline and a tiny bubble in the end of the syringe. Right hand on the syringe applying pressure, left hand on the shaft of the needle (not the wings) "feeding" the needle in like you would a catheter. I've probably done 75ish each way and I can say the continuous technique is far superior in my hands. YMMV.

2) For PACs, if you get to ~50cm and still haven't hit RV (aka you're headed south down the IVC), drop the balloon and pull back slowly. I've had several PACs flop through the TV on their return trip through the RA while pulling back - then put the balloon up and advance.

3) Central line wire won't go -- I had this happen to me for the first time the other day. Stuck with thin-wall, visualized in vein with u/s but wire got hung up. I assumed I was out of the vein (through and through or whatever) and took wire out but could still aspirate. Wire still won't pass. I pulled out and went ~1cm north, stuck again, again easy vein access, same story - but I noticed the wire was getting hung up ~15cm (so it was out of the bevel of the needle, not like it was getting stuck at the end of the needle and I wasn't intravenous). The RN scrubbed with me (we have a dedicated group of CCRNs who scrub all our lines / PACs / etc and prep / hand us stuff... I know, I'm spoiled) told me to try threading the 18g long angiocath (used for manometry) over the wire, which I did and then was able to advance the wire past the stenosis I was hitting. Later w/ ultrasound I scanned way down and pointed the probe intrathoracic and you could see some stenosis of the IJ proximally that I think was causing my wire to kink. Apparently it's a trick she's employed several times over the years when you have a wire in the vein but it won't advance past a certain point. We later floated a PAC on the patient and the PAC also required some finagling to get through that same spot. Weird.

4) For u/s guided PIVs, alines, etc: don't take the needle out of the catheter when you get a flash -- as a matter of fact, I never even look for flash on my u/s guided lines -- look at the monitor the whole time. The only time I see the flash is when I look down at the end. I do short axis out-of-plane approach and "follow" the tip of my needle in the vein until I've hubbed the whole thing - with the needle still in situ (as opposed to a regular PIV where you thread the catheter off the needle after advancing a few mm). The only time I don't do this is if the vein takes a big bend or bifurcates making it anatomically too challenging to keep following it under u/s. Definitely increased my success rate. Also for u/s guided alines don't just poke through-and-through, follow the artery a-la an u/s guided PIV. It helps for really bad vasculopaths (increases the success rate of the wire threading as opposed to through-and-through) and it's good practice for PIVs.



Here's a question for those with a lot more experience than me:

Is anyone using the arrow long a-line kits to access the basilic vein above the AC fossa in patients with poor peripheral access? It's often big and juicy in patients with otherwise poor access but unless they're rail-thin it's too deep for regular angiocaths (you can sometimes hit it but there so little catheter in the vein it's super high risk to infiltrate). I feel like with the arrow it's a poor man's midline (especially since getting a PICC on the weekends is like pulling teeth - and forget about it overnight). If anyone's doing this, are you doing it sterile or semi-sterile or just clean like a regular IV? How long are you leaving these in? Any issues with median nerve hits?

Thanks again for the thread - keep 'em coming!

 

[deleted9493]

Great thread! I love reading the tips.

I've started using the PCV two-handed mask quite a bit this month -- doing mostly vascular and our "OR of the future" hybrid angio suites have a really awkward layout from an anesthetic POV when the room is flipped to angio the legs -- you end up having to squeeze the bag with your left hand (and the machine is at the patient's waist) and hold the mask with your right. I've started just setting the vent and using two hands. It's awesome!

A few T&Ts from a CA-2 (obviously not a ton of experience so take it with a grain of salt):

1) Agree with the continuous epidural technique. Our institution is mostly intermittent and an attending showed me continuous and it was life changing. Especially for challenging epidurals it has cut my time down at least 50%. I use glass syringes with saline and a tiny bubble in the end of the syringe. Right hand on the syringe applying pressure, left hand on the shaft of the needle (not the wings) "feeding" the needle in like you would a catheter. I've probably done 75ish each way and I can say the continuous technique is far superior in my hands. YMMV.

2) For PACs, if you get to ~50cm and still haven't hit RV (aka you're headed south down the IVC), drop the balloon and pull back slowly. I've had several PACs flop through the TV on their return trip through the RA while pulling back - then put the balloon up and advance.

3) Central line wire won't go -- I had this happen to me for the first time the other day. Stuck with thin-wall, visualized in vein with u/s but wire got hung up. I assumed I was out of the vein (through and through or whatever) and took wire out but could still aspirate. Wire still won't pass. I pulled out and went ~1cm north, stuck again, again easy vein access, same story - but I noticed the wire was getting hung up ~15cm (so it was out of the bevel of the needle, not like it was getting stuck at the end of the needle and I wasn't intravenous). The RN scrubbed with me (we have a dedicated group of CCRNs who scrub all our lines / PACs / etc and prep / hand us stuff... I know, I'm spoiled) told me to try threading the 18g long angiocath (used for manometry) over the wire, which I did and then was able to advance the wire past the stenosis I was hitting. Later w/ ultrasound I scanned way down and pointed the probe intrathoracic and you could see some stenosis of the IJ proximally that I think was causing my wire to kink. Apparently it's a trick she's employed several times over the years when you have a wire in the vein but it won't advance past a certain point. We later floated a PAC on the patient and the PAC also required some finagling to get through that same spot. Weird.

4) For u/s guided PIVs, alines, etc: don't take the needle out of the catheter when you get a flash -- as a matter of fact, I never even look for flash on my u/s guided lines -- look at the monitor the whole time. The only time I see the flash is when I look down at the end. I do short axis out-of-plane approach and "follow" the tip of my needle in the vein until I've hubbed the whole thing - with the needle still in situ (as opposed to a regular PIV where you thread the catheter off the needle after advancing a few mm). The only time I don't do this is if the vein takes a big bend or bifurcates making it anatomically too challenging to keep following it under u/s. Definitely increased my success rate. Also for u/s guided alines don't just poke through-and-through, follow the artery a-la an u/s guided PIV. It helps for really bad vasculopaths (increases the success rate of the wire threading as opposed to through-and-through) and it's good practice for PIVs.



Here's a question for those with a lot more experience than me:

Is anyone using the arrow long a-line kits to access the basilic vein above the AC fossa in patients with poor peripheral access? It's often big and juicy in patients with otherwise poor access but unless they're rail-thin it's too deep for regular angiocaths (you can sometimes hit it but there so little catheter in the vein it's super high risk to infiltrate). I feel like with the arrow it's a poor man's midline (especially since getting a PICC on the weekends is like pulling teeth - and forget about it overnight). If anyone's doing this, are you doing it sterile or semi-sterile or just clean like a regular IV? How long are you leaving these in? Any issues with median nerve hits?

Thanks again for the thread - keep 'em coming!

I am not familiar with the long arrow arterial line kits but I have done this with Cook kits before. I have a high degree of confience if I see a good target on ultrasound and will therefore towel the site off, put a probe cover on and don sterile gloves.

If I don't see anything on U/S, am typically placing something centrally under sterile prep. If no U/S, treat like an infant and go where known veins are anatomically with slow advancement approach, using the smallest angiocath that is appropriate for case at hand and site on the body.

 

[deleted162650]

A gem from residency: Always suction your farts.

 

[nimbus]

2) For PACs, if you get to ~50cm and still haven't hit RV (aka you're headed south down the IVC), drop the balloon and pull back slowly. I've had several PACs flop through the TV on their return trip through the RA while pulling back - then put the balloon up and advance.




Here's a question for those with a lot more experience than me:

Is anyone using the arrow long a-line kits to access the basilic vein above the AC fossa in patients with poor peripheral access? It's often big and juicy in patients with otherwise poor access but unless they're rail-thin it's too deep for regular angiocaths (you can sometimes hit it but there so little catheter in the vein it's super high risk to infiltrate). I feel like with the arrow it's a poor man's midline (especially since getting a PICC on the weekends is like pulling teeth - and forget about it overnight). If anyone's doing this, are you doing it sterile or semi-sterile or just clean like a regular IV? How long are you leaving these in? Any issues with median nerve hits?

Thanks again for the thread - keep 'em coming!

You don't need to go all the way to 50cm. Float a few PA catheters under TEE guidance (teapot modified bicaval view) and you will see that you cross the tricuspid valve around 30 cm for most patients.

And yes I use the 20g 6" arrow for poor mans midline several times a year. We use those kits for brachial Aline's so I noticed the vein was always next to the artery and could be accessed with the same kit. I use the chloraprep and drape that comes with the kit. Sterile gloves too. I use ultrasound and try not to go through the nerve. Honestly I don't know how long they stay in.

 

[nimbus]

A gem from residency: Always suction your farts.

Another gem from residency: if the OR is 52deg and you freezing your a** off, shove the bair hugger down your pants for awhile to warm up.

 

[Maverikk]

Thoracic epidurals: use the hanging drop technique. Instead of letting it hang where advancement/patient movement can drop the drop add a three way stopcock, fill it up with the lidocaine from the kit with the drop is facing caudad. It eliminates the uncertain LOR in the thoracic ligamentum flavum, the whole drop gets sucked in, way less uncertainty with this; after I was shown this the success rate for me went up

 

[stonemd]

Great thread! I love reading the tips.

I've started using the PCV two-handed mask quite a bit this month -- doing mostly vascular and our "OR of the future" hybrid angio suites have a really awkward layout from an anesthetic POV when the room is flipped to angio the legs -- you end up having to squeeze the bag with your left hand (and the machine is at the patient's waist) and hold the mask with your right. I've started just setting the vent and using two hands. It's awesome!

A few T&Ts from a CA-2 (obviously not a ton of experience so take it with a grain of salt):

1) Agree with the continuous epidural technique. Our institution is mostly intermittent and an attending showed me continuous and it was life changing. Especially for challenging epidurals it has cut my time down at least 50%. I use glass syringes with saline and a tiny bubble in the end of the syringe. Right hand on the syringe applying pressure, left hand on the shaft of the needle (not the wings) "feeding" the needle in like you would a catheter. I've probably done 75ish each way and I can say the continuous technique is far superior in my hands. YMMV.

2) For PACs, if you get to ~50cm and still haven't hit RV (aka you're headed south down the IVC), drop the balloon and pull back slowly. I've had several PACs flop through the TV on their return trip through the RA while pulling back - then put the balloon up and advance.

3) Central line wire won't go -- I had this happen to me for the first time the other day. Stuck with thin-wall, visualized in vein with u/s but wire got hung up. I assumed I was out of the vein (through and through or whatever) and took wire out but could still aspirate. Wire still won't pass. I pulled out and went ~1cm north, stuck again, again easy vein access, same story - but I noticed the wire was getting hung up ~15cm (so it was out of the bevel of the needle, not like it was getting stuck at the end of the needle and I wasn't intravenous). The RN scrubbed with me (we have a dedicated group of CCRNs who scrub all our lines / PACs / etc and prep / hand us stuff... I know, I'm spoiled) told me to try threading the 18g long angiocath (used for manometry) over the wire, which I did and then was able to advance the wire past the stenosis I was hitting. Later w/ ultrasound I scanned way down and pointed the probe intrathoracic and you could see some stenosis of the IJ proximally that I think was causing my wire to kink. Apparently it's a trick she's employed several times over the years when you have a wire in the vein but it won't advance past a certain point. We later floated a PAC on the patient and the PAC also required some finagling to get through that same spot. Weird.

4) For u/s guided PIVs, alines, etc: don't take the needle out of the catheter when you get a flash -- as a matter of fact, I never even look for flash on my u/s guided lines -- look at the monitor the whole time. The only time I see the flash is when I look down at the end. I do short axis out-of-plane approach and "follow" the tip of my needle in the vein until I've hubbed the whole thing - with the needle still in situ (as opposed to a regular PIV where you thread the catheter off the needle after advancing a few mm). The only time I don't do this is if the vein takes a big bend or bifurcates making it anatomically too challenging to keep following it under u/s. Definitely increased my success rate. Also for u/s guided alines don't just poke through-and-through, follow the artery a-la an u/s guided PIV. It helps for really bad vasculopaths (increases the success rate of the wire threading as opposed to through-and-through) and it's good practice for PIVs.



Here's a question for those with a lot more experience than me:

Is anyone using the arrow long a-line kits to access the basilic vein above the AC fossa in patients with poor peripheral access? It's often big and juicy in patients with otherwise poor access but unless they're rail-thin it's too deep for regular angiocaths (you can sometimes hit it but there so little catheter in the vein it's super high risk to infiltrate). I feel like with the arrow it's a poor man's midline (especially since getting a PICC on the weekends is like pulling teeth - and forget about it overnight). If anyone's doing this, are you doing it sterile or semi-sterile or just clean like a regular IV? How long are you leaving these in? Any issues with median nerve hits?

Thanks again for the thread - keep 'em coming!

 

[stonemd]

been doing this for a while
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1923181

I use tegaderm/opsite over probe
non sterile gloves, no drape, 10cm 20g arrow cath with integral wire
I work in op so cath in <24h
Try to see the median nerve to make sure you don't hit it
Do most in awake patients

 

[BobBarker]

Yes, that is a good tip to use the arrow art line kit for your US guided deep IVs. I used to do it all of the time. A 20g in a big vein works great.

 

[Simba1711]

anybody have any tips for keeping lines and cables organized during cardiac cases. Always have spaghetti transporting my patient at the end of the case.

 

[Mman]

anybody have any tips for keeping lines and cables organized during cardiac cases. Always have spaghetti transporting my patient at the end of the case.

Airway on top

IVs in the middle

monitors on the bottom


Beyond that you can always take all your infusions coming off the IV pumps and put little ties or tape around the tubing when they leave the pump and when they get to the CVP port they are going into and make essentially a big braided rope of IV tubing. What I do is fold about an 8 inch piece of tape up on itself lengthwise and then use it as a tie to tie the lines together. If you just tape it, becomes much harder to undo if needed.

 

[Noyac]

Along the lines of Mg for smooth muscle and visceral pain, and B-blockers in PACU for pain I thought of another trick. Glyco for urologic Pain. Seems to help with urethral and ureteral Pain.

 

[WholeLottaGame7]

Airway on top

IVs in the middle

monitors on the bottom


Beyond that you can always take all your infusions coming off the IV pumps and put little ties or tape around the tubing when they leave the pump and when they get to the CVP port they are going into and make essentially a big braided rope of IV tubing. What I do is fold about an 8 inch piece of tape up on itself lengthwise and then use it as a tie to tie the lines together. If you just tape it, becomes much harder to undo if needed.

We are kindred spirits, you and I. This is coming from someone who obsessively tried different methods of organizing during residency/fellowship.

The only thing that worked better than the folded tape ties was at the VA where the perfusionists would cut up the velcro strips that came with their tubing and gave it to us. Those were the days...

 

[deleted162650]

Tape works fine on the IV lines to keep them bundled. Just take 3" long pieces of 1" plastic tape and fold it in 1/2 around the lines. Doing it this way keeps it very easy to tear open and separate the lines. Don't use silk and wrap it around the lines unless you really want to irritate the ICU nurses.

98% of problems in the OR can be solved with tape.

 

[Ronin786]

Tourniquets also work well.

 

[partydoc]

Tape works fine on the IV lines to keep them bundled. Just take 3" long pieces of 1" plastic tape and fold it in 1/2 around the lines. Doing it this way keeps it very easy to tear open and separate the lines. Don't use silk and wrap it around the lines unless you really want to irritate the ICU nurses.

98% of problems in the OR can be solved with tape.

I really enjoy pissing off some of my ICU nurses

 

[Noyac]

I really enjoy pissing off some of my ICU nurses

Passive aggressive at all?

 

[partydoc]

Passive aggressive at all?

No, I'm actually quite active aggressive about it these days

 

[Iso4ane]

There was a regional tip (an image) posted somewhere on the forums about how to hold the needle and syringe with one hand so you can inject the medication yourself. So someone post and image again if they have it, or do something similar .

 

[Dejavu]

There is a case report of an arm board falling of during surgery with an arm attached. Patient’s arm hung for a few hours with armboard still attached. Brachial plexus injury.

Years ago, when placing arm boards, it was mandatory to check that the underside catch actually caught. You check this by lifting the end of the board. If it falls on your toes, the underside didn’t catch. Sticky arm boards do this a lot. If you cannot lift the end, the board is properly placed.

Nobody has ever heard about this in a modern OR, but do it for a while and see how many boards are improperly placed and could fall off if bumped during a case.

 

[gasblaster]

There was a regional tip (an image) posted somewhere on the forums about how to hold the needle and syringe with one hand so you can inject the medication yourself. So someone post and image again if they have it, or do something similar .

Would also be interested in this.

 

[Ronin786]

There was a regional tip (an image) posted somewhere on the forums about how to hold the needle and syringe with one hand so you can inject the medication yourself. So someone post and image again if they have it, or do something similar .

Would also be interested in this.

Here's the post in question:
Block teams

View attachment 225713 View attachment 225714

 

[deleted697535]

Thoracic epidurals: use the hanging drop technique. Instead of letting it hang where advancement/patient movement can drop the drop add a three way stopcock, fill it up with the lidocaine from the kit with the drop is facing caudad. It eliminates the uncertain LOR in the thoracic ligamentum flavum, the whole drop gets sucked in, way less uncertainty with this; after I was shown this the success rate for me went up

Have you a picture of this?

 

[deleted697535]

I dont think it would be unreasonable to halt the surgeons and go under the drapes (or re-drape) and untuck the arms and fix the IVs to your satisfaction. Maybe even place new ones while you have the arms back out. You can also try placing a new IV in the foot. Last resort is you flip him and do a SC > Femoral.

Don't let em tuck!! Unless they really have to.
Seriously it should be included in the WHO list of topics to discuss. Arms in or out. It's really important. I change my practice based on that. No pumps on tucked arms. And much lower threshold for art line. Or else I'd put a bp cuff on each arm.
I am not crawling under the drapes again like a fool because some dimwit surgical resident said 'arms tucked' at the start for no reason

 

[deleted162650]

Another gem from residency: if the OR is 52deg and you freezing your a** off, shove the bair hugger down your pants for awhile to warm up.

We have those Bair Hugger gowns where patients can get “pre-warmed” in preop holding by the little mini Bair Huggers. This morning my patient’s wife asked him what the hose was running to his gown. Without skipping a beat he said “That’s my catheter.”

 

[Psai]

We have those Bair Hugger gowns where patients can get “pre-warmed” in preop holding by the little mini Bair Huggers. This morning my patient’s wife asked him what the hose was running to his gown. Without skipping a beat he said “That’s my catheter.”

What a champ.

 

[MirrorTodd]

Bumping because this thread is gold.
My A-line technique: Pretend it's an IV. Grab an 18g or 20g angiocath, start low (like 15 degrees), insert until flash, rotate bevel 180 degrees, lower angle and advance a smidge, then slide off catheter into artery. My hit % has gone up significantly since doing a-lines this way and my squirrley a-lines that have a disappearing tracing seem to have improved significantly as well. Rarely do I need to go through and through with a wire. I'll even start super low, like 5-10 degrees and advance it that way without needing to lower the angle.

 

[deleted697535]

Bumping because this thread is gold.
My A-line technique: Pretend it's an IV. Grab an 18g or 20g angiocath, start low (like 15 degrees), insert until flash, rotate bevel 180 degrees, lower angle and advance a smidge, then slide off catheter into artery. My hit % has gone up significantly since doing a-lines this way and my squirrley a-lines that have a disappearing tracing seem to have improved significantly as well. Rarely do I need to go through and through with a wire. I'll even start super low, like 5-10 degrees and advance it that way without needing to lower the angle.

try adding 200mcg nitro to your lido for alines/pivs and watch your successes increase exponentially again!
i actually think you could hammer a nail into a radial artery after 'nitrocaine' and still get an aline trace from it

 

[2Fast2Des]

try adding 200mcg nitro to your lido for alines/pivs and watch your successes increase exponentially again!
i actually think you could hammer a nail into a radial artery after 'nitrocaine' and still get an aline trace from it

Nice! I will have to try that. Problem is our nitro comes in vials so would have to waste a giant vial for such a small dose...

 

[zizzer]

The green ekg lead is the ground lead, so its position doesn't matter. Save yourself a lot of reaching and place it on the arm or something easily accessible.

 

[deleted162650]

The green ekg lead is the ground lead, so its position doesn't matter. Save yourself a lot of reaching and place it on the arm or something easily accessible.

Forehead

 

[Twiggidy]

Bumping because this thread is gold.
My A-line technique: Pretend it's an IV. Grab an 18g or 20g angiocath, start low (like 15 degrees), insert until flash, rotate bevel 180 degrees, lower angle and advance a smidge, then slide off catheter into artery. My hit % has gone up significantly since doing a-lines this way and my squirrley a-lines that have a disappearing tracing seem to have improved significantly as well. Rarely do I need to go through and through with a wire. I'll even start super low, like 5-10 degrees and advance it that way without needing to lower the angle.

Use an ultrasound.....your success rate on first attempt will skyrocket

 

[MirrorTodd]

Use an ultrasound.....your success rate on first attempt will skyrocket

Still gotta learn how to do it without ultrasound and that technique has been gold for me. Speaking about ultrasound though...are lines done easier in plane or out of plane? I find in plane far easier, but that probably is just cause we do all our blocks in plane.