Tips and Tricks

[MirrorTodd]

Don't need gloves when you're only inserting the tip

Hey now, that's how I got the clap.

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[dchz]

I used to only use arrow catheter in residency. Would get it 85% of the time first stick no issues threading, but every now and then you can’t thread for whatever reason.
I’ve started doing angiocath through and through, first time success rate Easily over 90%. Almost never have issues threading, and if so just make minor adjustments with the catheter changing the angle, twisting, whatever. Almost never have to stick the vessel again. Now I think through and through is the only way. But to each their own.

What % of your pt population is >70 years old, BMI >30?

I inject my own meds for blocks. You don’t need three hands. Leave the syringe on the patient. Get your image and needle where you want it. Once you’re in the right spot pick up the syringe and inject. Usually don’t even need a hand on the needle to keep it in view. Try it. You’ll figure out how to adjust the needle and inject much easier than you’d think it’d be.

I just prefer being self sufficient and i don’t like it when a nurse continues to press if a patient is having pain with injection. Who here doesn’t like having more control?

If the pt has pain half way through injecting, the control you need is of the ultrasound and needle tip, not whether the nurse stops fast enough when you ask them to stop.

Don't need gloves when you're only inserting the tip

That's what I tried to tell her...

 

[dchz]

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.

It doesn't matter which method you choose as long as you visualize the tip in relation to the vessel 100% of the time.

The people that argue about in plane and out of plane either don't understand this concept or don't have the technical skills to demonstrate this concept.

That being said, it's usually easier for a beginner to visualize the tip in plane, but its much harder to visualize the tip and the vessel in plane because you give up lateral resolution.

 

[deleted697127]

If the pt has pain half way through injecting, the control you need is of the ultrasound and needle tip, not whether the nurse stops fast enough when you ask them to stop.

Plus it’s the first mL that the patient usually reacts. Most of the time i stop and ask and they say “just feels like pressure” but if it is is tingling down the arm, ill readjust the tip.

Definitely can still control the ultrasound and tip. The needles not going anywhere when you inject. That’s why catheters work.

Plus it’s the first mL that the patient usually reacts. Most of the time i stop and ask and they say “just feels like pressure” but if it is is tingling down the arm, ill readjust the tip.

 

[pjl]

No lube on the probe - chloraprep. You have approximately 15 seconds to place the line

Chloroprep WILL degrade the probe over time, don’t do this. Probes are 6-10k to replace.

I definitely used to think this was a great trick.

 

[abolt18]

Chloroprep WILL degrade the probe over time, don’t do this. Probes are 6-10k to replace.

I definitely used to think this was a great trick.

We usually just stretch a tegaderm over the probe to keep the chloraprep off of it. Easier cleanup too. Gel comes off when you toss the tegaderm. Then you just disinfect with your cleaning wipes rather than have to wipe off all the gel.

 

[dhb]

Chloroprep WILL degrade the probe over time, don’t do this. Probes are 6-10k to replace.

I definitely used to think this was a great trick.

What happens to the probe? As far as i can remember I've always used an alcoholic solution as interface without noticing any damage to the probe.

 

[dchz]

Definitely can still control the ultrasound and tip. The needles not going anywhere when you inject. That’s why catheters work.

Plus it’s the first mL that the patient usually reacts. Most of the time i stop and ask and they say “just feels like pressure” but if it is is tingling down the arm, ill readjust the tip.

Sounds like you didn't control the tip and blaming the nurse bro....

I'm all about being self sufficient, but stopping the injection in time in case they have pain is not a good reason to have the syringe in your hand. You're clearly sacrificing needle control by having the syringe in your hand at that point e.g. tingling down the arm means your tip is too deep.

 

[deleted697127]

Sounds like you didn't control the tip and blaming the nurse bro....

I'm all about being self sufficient, but stopping the injection in time in case they have pain is not a good reason to have the syringe in your hand. You're clearly sacrificing needle control by having the syringe in your hand at that point e.g. tingling down the arm means your tip is too deep.

You mad bro? When did i say i was blaming the nurse for anything? I only use the nurse for time out. If the patient even flinches i like backing off and readjusting. Are you trying to tell me you’ve never had a patient react to an injection? Why so triggered by this?

 

[dchz]

When did i say i was blaming the nurse for anything?

i don’t like it when a nurse continues to press if a patient is having pain with injection.

 

[deleted697127]

Yea i don’t like that. That’s why I inject myself. So i stop when i want to stop or if there were resistance. What’s your point?

 

[pjl]

What happens to the probe? As far as i can remember I've always used an alcoholic solution as interface without noticing any damage to the probe.

It gets little tiny holes, they normally start near the edges. Eventually when you keep using it to stretch the life they will cover a lot of it and degrade the picture. It took a few years. Then when you are buying a new one the rep will tell you about the chloroprep issue.

I suspect it is worse if you don’t adequately get all the chloroprep off shortly after use.

We normally do the tegaderm or a glove now, and I use whatever type of wipe they have. After getting the new probes and not doing the chloroprep trick our probes still look great 7 years later.

 

[okayplayer]

I use a probe cover, even for single shot blocks. Easier to stay sterile, protects the probe. Not a big fan of the pseudo sterility of using the tegaderm over the probe (and futzing with it all).

 

[DrZzZz]

All this talk of tegaderms and probe covers... Does anyone out there not cover the probe at all? Chloraprep the skin, needle doesn't touch the probe when you're inserting it. I've always felt a lot of people take sterility for nerve blocks way too far. I see them as less invasive than a peripheral IV, where you're actually leaving a device behind in the skin.

 

[pjl]

All this talk of tegaderms and probe covers... Does anyone out there not cover the probe at all? Chloraprep the skin, needle doesn't touch the probe when you're inserting it. I've always felt a lot of people take sterility for nerve blocks way too far. I see them as less invasive than a peripheral IV, where you're actually leaving a device behind in the skin.

I know lots of people that do nothing for the probe. Their justification is that the probe is not very close to the insertion site. I tend to agree.
I do feel somewhat bad about using that approach though, based on the giant drapes and covers and all that I trained with, so use the tegaderm to help me sleep. Those guys have done thousands of blocks without infections.

 

[abolt18]

I use a probe cover, even for single shot blocks. Easier to stay sterile, protects the probe. Not a big fan of the pseudo sterility of using the tegaderm over the probe (and futzing with it all).

I claim no sterility with the tegaderm. It's to keep the PROBE clean. Placing the tegaderm has potential to have air bubbles which requires smoothing out the bubbles. My ultrasound is not even touching the insertion site of the needle after I've prepped.

 

[MirrorTodd]

All this talk of tegaderms and probe covers... Does anyone out there not cover the probe at all? Chloraprep the skin, needle doesn't touch the probe when you're inserting it. I've always felt a lot of people take sterility for nerve blocks way too far. I see them as less invasive than a peripheral IV, where you're actually leaving a device behind in the skin.

We don't unless placing catheter.

 

[DrZzZz]

We don't unless placing catheter.

Catheters are certainly another story. But I haven't placed one since residency.

 

[vector2]

I **** you not, one of our regional staff uses regular gloves, no tegaderm, slathers everything in purell and goes to town. As far as I’ve heard our SSIs aren’t out of whack.

 

[Twiggidy]

I **** you not, one of our regional staff uses regular gloves, no tegaderm, slathers everything in purell and goes to town. As far as I’ve heard our SSIs aren’t out of whack.

It is kind of crazy right? I feel like more than anything it’s just for optics.

Although I will say, some sort of sterile technique will keep you out of the blame game if there ever is a surgical site, graft, or hardware infection. People love to blame anesthesia

 

[deleted162650]

Single shot block: regular Non-sterile nitrile exam gloves, bare probe with a dab of gel (non-sterile out of the squeeze bottle), probe on patient - obtain image, swipe needle insertion site with chloroprep (if no prep stick nearby then alcohol pad), poke, inject, done.

 

[deleted162650]

No idea why people think an SSNB needs to be more sterile than an indwelling IV??

 

[okayplayer]

Equally sterile as an IV.

 

[epidural man]

We cover the probe for optics. I thought it was a JC requirement.

 

[IMGASMD]

We cover the probe for optics. I thought it was a JC requirement.

We “drape” for TAP just to get the nurses off our backs.

 

[dhb]

Gloves? Are you touching the patient?

Lol dudes not wearing gloves but they still put the hat on the patient

I'm that kind of dude
@dchz why are you so obsessed with seeing the needle all the time? In a lot of steep blocks i'm seeing more of a shade than the needle

 

[abolt18]

Gloves? Are you touching the patient?

I'm that kind of dude
@dchz why are you so obsessed with seeing the needle all the time? In a lot of steep blocks i'm seeing more of a shade than the needle

Yes, whenever I do a block I touch the patient, by anchoring my hand that is holding the ultrasound, and more often than not, also anchoring the hand holding the needle.

 

[zyovka]

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/Resident Web Site Articles/Post Dural Puncture HA/injectionof IT NS reduces the severity of PDPH 2001.pdf

This link doesn't work. Sorry

 

[Lidolover]

I have switched to in plane ultrasound-guided aline, PIVS and IJs cvc placement.
actually a new study recently published, showed that in plane approach for radial Alines is way more successful. Try

 

[deleted875186]

I have switched to in plane ultrasound-guided aline, PIVS and IJs cvc placement.
actually a new study recently published, showed that in plane approach for radial Alines is way more successful. Try

Ultrasound art line is 100% with US, how could they show any difference?

 

[Lidolover]

Ultrasound art line is 100% with US, how could they show any difference?

They compared in plane with out of plane approach and all primary and secondary outcomes they had set were better with in plane approach. As simple as that...

 

[nimbus]

They compared in plane with out of plane approach and all primary and secondary outcomes they had set were better with in plane approach. As simple as that...

Link?

 

[Choo]

I have switched to in plane ultrasound-guided aline, PIVS and IJs cvc placement.
actually a new study recently published, showed that in plane approach for radial Alines is way more successful. Try

Other than collapsibility, how do you know your probe didn’t drift half a millimeter as you place your needle to skin, and now you are attempting to cannula the the carotid? Out of plane is simple enough.

 

[Hork Bajir]

If you must go in plane for an IJ, I would suggest oblique angle of the probe on the neck such that you’re visualizing an oblique slice of the IJ, the carotid, and the entire needle throughout it’s trajectory (which will end up being medially directed... Which is fine as long as you’re keeping the whole needle in view).

IMHO out of plane is faster and easier, but do whatever works best for you.

 

[MirrorTodd]

Other than collapsibility, how do you know your probe didn’t drift half a millimeter as you place your needle to skin, and now you are attempting to cannula the the carotid? Out of plane is simple enough.

I mean come on....you got HUGE problems if you can't tell the difference between the carotid and IJ.

 

[deleted875186]

I have switched to in plane ultrasound-guided aline, PIVS and IJs cvc placement.
actually a new study recently published, showed that in plane approach for radial Alines is way more successful. Try

Ultrasound-guided radial arterial cannulation: long axis/in-plane versus short axis/out-of-plane approaches? - PubMed

Arterial cannulation with ultrasound (US) guidance increases the success rate and reduces complications. US-guided vascular access has two main approaches: long axis in-plane (LA-IP) and short axis out-of-plane (SA-OOP) approaches. The purpose of this study was to compare performance time and...

pubmed.ncbi.nlm.nih.gov

Is this the study? They had 50%first attempt success rate in the short axis group, which seems surprisingly low. The overall time to cannulation was 47 seconds in the short axis group, which doesn’t seem to jive with 50% first pass success rate. I bet they had a few people that were very good at cannulation, and 50% that were very bad or inexperienced and skewed the numbers.

 

[ethilo]

Here's a silly little tip that works well:
You hook up and IV, unclamp everything and it doesn't run (clot at the tip). Take a section of IV tubing and wrap it really tightly and fast 3 or 4 times around your finger then let it all go. The pressure in the line pops the clot or without a flush!

On the same line, let's say you let an iv bag run out and there's air in the line after you put a fresh bag on. Wrap the tubing tightly around your finger working the air back up the line into the drip chamber, starting the wrap at the meniscus of the fluid in the line. Doesn't work if the air got past a one way valve in the tubing though.

 

[abolt18]

I mean come on....you got HUGE problems if you can't tell the difference between the carotid and IJ.

They're talking after you switch to a longitudinal view of the vessels so you can only see one vessel and it's in plane with the US. You have to be very deliberate and I'd argue you could triple check you're on the vein by panning over to the artery and back to the vein numerous times before the first stick.

 

[MirrorTodd]

They're talking after you switch to a longitudinal view of the vessels so you can only see one vessel and it's in plane with the US. You have to be very deliberate and I'd argue you could triple check you're on the vein by panning over to the artery and back to the vein numerous times before the first stick.

I know and maybe I'm Dunning-krugering this, but you should still be able to tell the difference.

 

[abolt18]

I know and maybe I'm Dunning-krugering this, but you should still be able to tell the difference.

Not always crystal clear in this view, which is precisely why when the probe is transverse, you use anatomical relationships to help differentiate them (carotid usually and trachea always being medial to the vein), compressibility and pulsatility of one over the other. When only 1 is in view when the probe is longitudinal, you no longer have those distinguishing features ON SCREEN with the target.

 

[Hork Bajir]

Do enough lines on patients with high CVP, hyperdynamic circulation, greater than moderate TR, and not textbook anatomy (short fat neck, deep small vessels with scattershot collaterals, scarring from prior lines, etc) and you’ll find yourself questioning whether that vein is 100% a vein. It’s easy to tell vein from artery until it’s not. Highlights the importance of being comfortable with multiple techniques/methods so that you have a bag of tricks to pull from when you or your colleague is struggling.

 

[venacontracta]

Any tips on getting better with the Arrow a-line kit? I am having issues not being able to thread the catheter after smoothly passing the wire, either blind or after advancing the whole system a few mm into the vessel under US. I prefer angiocath and a separate wire but the Arrows are much better stocked at a new hospital.

 

[Simba1711]

Any tips on getting better with the Arrow a-line kit? I am having issues not being able to thread the catheter after smoothly passing the wire, either blind or after advancing the whole system a few mm into the vessel under US. I prefer angiocath and a separate wire but the Arrows are much better stocked at a new hospital.

I’m curious too. I’ve had this happen to me a few times as well and find that the wire is kinked after I remove the arrow catheter and or a hematoma forms.

 

[Urzuz]

Any tips on getting better with the Arrow a-line kit? I am having issues not being able to thread the catheter after smoothly passing the wire, either blind or after advancing the whole system a few mm into the vessel under US. I prefer angiocath and a separate wire but the Arrows are much better stocked at a new hospital.

Loosen up the catheter before poking. Sometimes they are fairly stuck on and tough to slip off straight out of the kit.

Make sure the wire threads in smoothly. If there is any resistance whatsoever, you aren't in the vessel cleanly and need to either advance/withdraw the needle before trying again.

If the wire advances smoothly, drop the angle of the entire apparatus to maybe 15-20 degrees in relation to the wrist.

Before advancing the catheter off, advance the entire apparatus (needle and all) ever so slightly (<<0.5 cm) -- this trick I found kind of weird at first, but one of my most senior attendings in residency taught it to me and it works marvelously.

Slide catheter off, sometimes I employ a spiral/twisting motion of the catheter while threading since it seems to go in easier.

I’m curious too. I’ve had this happen to me a few times as well and find that the wire is kinked after I remove the arrow catheter and or a hematoma forms.

If there is a kink in the wire when you take it out, you weren't fully in the artery, even if your flash was textbook. Again, if there is a kink, you would have felt some degree of resistance when advancing the wire, in which case you should withdraw the wire and reposition the needle (advance, withdraw, potentially even change the angle of entry).

 

[MirrorTodd]

I've gotten facile with just using a plain 18g or 20g angiocath, no wire. Start low angle, 10-20 degrees, advance until flash, rotate device 180 degrees (im getting to the point of not even needing to do that), advance little more just like an IV, then slide that sucker on in.

 

[venacontracta]

Urzuz, thanks for all the input.

I've gotten facile with just using a plain 18g or 20g angiocath, no wire. Start low angle, 10-20 degrees, advance until flash, rotate device 180 degrees (im getting to the point of not even needing to do that), advance little more just like an IV, then slide that sucker on in.

Sounds slick. I think I'll try this too.

If you're doing this and the catheter doesn't slide on in, what's your next move? Advance a bit more? Transfix, pull the needle out, and have a wire ready?

Have you had any reliability problems leaving a regular angiocath as your a-line rather than something designed to be an a-line?

I was taught that the white Arrow catheter is stiffer and less likely to kink and as such discouraged from leaving the pink angiocath as an a-line, being told that if using an angiocath to access the vessel, I should wire it out for an Arrow catheter. I haven't experimented to see whether this is true.

 

[MirrorTodd]

Urzuz, thanks for all the input.



Sounds slick. I think I'll try this too.

If you're doing this and the catheter doesn't slide on in, what's your next move? Advance a bit more? Transfix, pull the needle out, and have a wire ready?

Have you had any reliability problems leaving a regular angiocath as your a-line rather than something designed to be an a-line?

I was taught that the white Arrow catheter is stiffer and less likely to kink and as such discouraged from leaving the pink angiocath as an a-line, being told that if using an angiocath to access the vessel, I should wire it out for an Arrow catheter. I haven't experimented to see whether this is true.

No reliability issues, if anything they seem to run better. I've found I often have issues with the arrows if the wrist gets bent at all during positioning or something, either i can't draw blood well enough or the waveform looks like crap.
If i can't advance initially, I'll advance needle a little bit more. Or just go through and through and use a wire. It kinda depends on if I think I went far enough in or not the first time I found blood.

 

[deleted697127]

No reliability issues, if anything they seem to run better. I've found I often have issues with the arrows if the wrist gets bent at all during positioning or something, either i can't draw blood well enough or the waveform looks like crap.
If i can't advance initially, I'll advance needle a little bit more. Or just go through and through and use a wire. It kinda depends on if I think I went far enough in or not the first time I found blood.

Take the catheters off the needle for an angiocath and an arrow. The arrow is a stiffer catheter. If your catheter has issues with the wrist being bent, it’s likely the placement rather than the catheter. Plan out where you want the catheter to end up. We’re often taught to start distal but if you get it in too distal, then the catheter can end up at a funky angle.

You can also run into an issue if you come at too steep of an angle and the vessel is a little deep under the skin. When your approach Is too steep and the vessel is 1.5cm into thick forearm, you can kink the catheter when you drop your angle.

If the catheter doesn’t go in smoothly, it may give you trouble during the case. May be better to just start over. We’ve all had catheters in that felt a little off, kind of worked for a bit, and turned into more of a headache than it was worth.

Take a peak at one of your more OCD seniors or cardiac fellows and see where and how they place their lines and how they secure them. If you notice someone taped an IV or Art line and the way they did it looks badass and secure, try to emulate that. It doesn’t always work out perfectly, but one of the reasons why art lines are my favorite procedure is there are so many different ways to do it.

If you’re working with an attending you know is good at them or regional, don’t be afraid to ask them to watch you and Have them give you tips. After you have done enough procedures to do them safely, attending’s tend to let you do them on your own until you’re obviously effing it up. But feedback can be surprisingly helpful even as a ca3. Ask your coresidents what they do or have seen that has been interesting. It definitely can be fun experimenting. You should be comfortable doing them by palpation and ultrasound.

 

[OB1🤙]

If you're in the vessel with the Arrow but your wire won't advance, drop your angle to something shallower and keep trying. Oftentimes it just means you're up against the back wall of the artery. Once you get the tip pointed in the same axis as the course of the artery, the wire will go. Sometimes that even means a little "sideways" angulation to follow any tortuosities.

This assumes you haven't dissected the vessel. With ultrasound, it is apparent whether the vessel is dissected and you should abort that site, or if you just need to line things up better.

If it still doesn't work, then go through and through.

The Arrow is kink-resistant. Angiocaths are not. Pull a couple out of your drawer and try and kink them. The difference is obvious.

 

[woopedazz]

I'm not sure if I agree with all of these tips being useful for this particular scenario. Specifically where the wire is 100% in, even under US guidance, but there is difficulty threading the cannula.

I reckon an additional advancement of the needle once the wire is successfully threaded could be the underlying problem OP is having? So I wouldn't be advocating for more of it. But i might be completely wrong.

If the wire is in, and you put it in relatively flat, and there was 0 resistance... i would be hesitant to advance the needle any further after the fact. Youre risking penetrating the far wall (or any wall really) and then the cannula cannot thread over the needle's tip.

Arrows are kink resistant, as stated above, and also strong. The guidewire being in the correct spot is sufficient for the cannula to thread even with the needle withdrawn.

Next time you run in to issues threading the cannula I'd suggest trying to withdraw the needle 5mm and then threading the cannula firmly over the wire while twisting.

Of course this is only true if the wire is 100% in the right spot in the first place.