A-line and Craniotomy

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bentrider

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Pt is scheduled for parietal-occipital craniotomy for hemispheric cystic mass. Position is prone. Surgeon requests no A-line. Is an A-line standard of care for this case?
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bentrider said:
Pt is scheduled for parietal-occipital craniotomy for hemispheric cystic mass. Position is prone. Surgeon requests no A-line. Is an A-line standard of care for this case?
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Dude....

NOT HIS CALL.

Work up your patient and then decide.

There is no standard of care for a-lines except for bypass.
 
Tell him you request no craniotomy.


If the patient would benefit from it, stand your ground. If the patient wakes up blind (for example), and you are in court, the surgeon will tell the jury, "well I thought we could maybe do it with no art-line, but it's ultimately the anesthesiologist's call. I don't know why he chose not to, and now my patient is blind."
 
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bentrider said:
Pt is scheduled for parietal-occipital craniotomy for hemispheric cystic mass. Position is prone. Surgeon requests no A-line. Is an A-line standard of care for this case?
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Seems like a very bizarre request from a neurosurgeon. Did you ask him why? I do arterial lines for intra-dural procedures and case-by-case for extra-dural. The posterior fossa contains too many potential sites of hemodynamic instability, plus you won't have access to any arterial site short of a posterior tibial artery. Just not worth it.
 
would you do the case with no art line? i doubt i could be persuaded to, but its ultimately up to you. if i understand correctly, this is a big mass, probably some sinus involvement, possibility to take on air...that alone is enough for me to demand an art line.
 
Agree w/ sevoflurane's comment. Ultimately your call for the aline, but buy-in from the surgeon is helpful for customer service. Why does he not want one placed? Unless the tumor is right at the cortical surface, away from the dural sinuses, and the surgeon is fast and skilled; I place alines. I look at the imaging, especially MRI, to predict the approach and how much brain the surgeon is going to resect. A prone intracranial procedure makes me wonder whether they are going into the posterior fossa, and I definitely will use an aline for these procedures. Post op posterior fossa bleeding or swelling can significantly affect ventilation, and an aline is going to enable the nurses get blood gases more easily. Discussing post op management might be a selling point for the surgeon. I've often read postings that say something like, "I've never regretted placing an aline, but I've often regretted not doing it." That is my own experience also. Good luck, sounds like a potentially challenging surgeon to work with.
 
gtb said:
Agree w/ sevoflurane's comment. Ultimately your call for the aline, but buy-in from the surgeon is helpful for customer service. Why does he not want one placed? Unless the tumor is right at the cortical surface, away from the dural sinuses, and the surgeon is fast and skilled; I place alines. I look at the imaging, especially MRI, to predict the approach and how much brain the surgeon is going to resect. A prone intracranial procedure makes me wonder whether they are going into the posterior fossa, and I definitely will use an aline for these procedures. Post op posterior fossa bleeding or swelling can significantly affect ventilation, and an aline is going to enable the nurses get blood gases more easily. Discussing post op management might be a selling point for the surgeon. I've often read postings that say something like, "I've never regretted placing an aline, but I've often regretted not doing it." That is my own experience also. Good luck, sounds like a potentially challenging surgeon to work with.
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i say this all the time
 
Agree with the above comments. Prone posterior fossa crani with large mass absolutely indicates a-line IMO. All reward, no risk, negligible time cost. Did this surgeon say why they didn't want one?

My biggest concern after this request would be about the surgeon's overall clinical judgement outside of operative neurosurgery. This is a sign of one of two things, arrogance or ignorance. Both are dangerous.
 
Hawaiian Bruin said:
My biggest concern after this request would be about the surgeon's overall clinical judgement outside of operative neurosurgery. This is a sign of one of two things, arrogance or ignorance. Both are dangerous.
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Well said HB.

👍
 
Hawaiian Bruin said:
Agree with the above comments. Prone posterior fossa crani with large mass absolutely indicates a-line IMO. All reward, no risk, negligible time cost. Did this surgeon say why they didn't want one?

My biggest concern after this request would be about the surgeon's overall clinical judgement outside of operative neurosurgery. This is a sign of one of two things, arrogance or ignorance. Both are dangerous.
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Amen to that.
No way would I do that case without an a-line.

Reminds me of the time a neurosurgeon who was brand new at our hospital told me that I was going to extubate over a bougie at the end of the case. Right. Needless to say, my attending loved that. And we most definitely did not extubate over a bougie.

Or the time the vascular surgeon wouldn't get over the fact that we needed an a-line before induction for his Tenckhoff placement. PASP >60, EF < 15%.

The surgeons don't get to decide.
 
Hawaiian Bruin said:
My biggest concern after this request would be about the surgeon's overall clinical judgement outside of operative neurosurgery. This is a sign of one of two things, arrogance or ignorance. Both are dangerous.
Click to expand...

Right on! It's one thing to say that you probably don't need an A line or central line because of X,Y,Z. It's quite another to make a request for no Aline. Did he at least explain why?
If I'm on the fence about lines, I'll ask the surgeon for input. Not "does he need one" (the answer would almost always be no), but EBL expectations, duration, positioning, post op plans and goals, etc. Than I make the decision. They don't get veto power. Just like intubating GI patients. They don't think you need to intubate anyone, but it's not their call, unless they want to do it themselves with a pre op Valium.
Lining is no joke in some of the really messed up scoliosis kids or former 6+ months in the NICU disasters. You need to know what is needed and what's not. Most surgeons get that.
 
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Hawaiian Bruin said:
Agree with the above comments. Prone posterior fossa crani with large mass absolutely indicates a-line IMO. All reward, no risk, negligible time cost. Did this surgeon say why they didn't want one?

My biggest concern after this request would be about the surgeon's overall clinical judgement outside of operative neurosurgery. This is a sign of one of two things, arrogance or ignorance. Both are dangerous.
Click to expand...

Is this NSG serious?

Reasons for A-line:
1. ABGs (easier from A-line than from PIVs)
2. electrolyte determination - CSW/DI/SIADH
3. H/H determination during case - dural sinus? vascular tumor? carotid nick?
4. beat-to-beat monitoring of blood pressure - trigeminal-vagal reflex, massive blood loss
5. ANY kind of pulmonary/cardiovascular disease would warrant one in this particular case
...I could go on......

Reasons NOT for a-line
1. Patient has no arteries
2. Not doing craniotomy.
3. Surgeon is joking.......
 
This is joke, right?

If not, I'm really curious as to why he doesn't want you to use one.
 
As previously stated, I would be scared about his overall clinical judgement. If they open the dura, pt. gets a-line in my room. We had a neurosurgeon that would ask for a 9Fr. MAC line if we were planning on putting in a central line for the case. He was also one of the neurointensivists, so he liked them for the pt's in the NSU post-operatively. I happily obliged, mainly because that is my favorite line for volume resuscitation.
 
bentrider said:
Pt is scheduled for parietal-occipital craniotomy for hemispheric cystic mass. Position is prone. Surgeon requests no A-line. Is an A-line standard of care for this case?
Click to expand...

I guess I am a little confused by this scenario. Your profile says you are an attending physician yet you are asking a basic question that any upper level anesthesia resident should be able to answer. You have also started a thread about whether or not it is safe to perform an epidural with a modestly marginal platelet count.

We can all stand to learn a few things here but maybe if you give some more detail with your posts we could be more helpful.

I would do the case without an arterial line.





If it was impossible to place one. Otherwise I would put it in like everyone else.
 
Arch Guillotti said:
I guess I am a little confused by this scenario. Your profile says you are an attending physician yet you are asking a basic question that any upper level anesthesia resident should be able to answer. You have also started a thread about whether or not it is safe to perform an epidural with a modestly marginal platelet count.

We can all stand to learn a few things here but maybe if you give some more detail with your posts we could be more helpful.

I would do the case without an arterial line.


If it was impossible to place one. Otherwise I would put it in like everyone else.
Click to expand...

I think you are on to something here Watson!
 
fakin' the funk said:
Surgeons do not appreciate that, in optimal circumstances, an A-line placement is no more complicated than an IV placement.
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Is that so? Have you never seen or read about a complication from an A line? Some facilities are even recommending using US for A line placement these days as if the US will help prevent complications. I find this to be total BS as I have never seen a complication but it goes to show that there must be some people out there that can manage to traumatized the artery pretty well.

But I don't understand why you quoted my post on this. I was complimenting Arch on his detective skills. I think he may have outed an imposter.
 
That is how I felt when I first read both of his threads. Kinda weird, but who knows.... Good discussions stemmed from them.
 
I have had a complication from an a-line that resulted in a trip to the OR for the pt. However, I still place them for many cases and for monitoring in the ICU without hesitation. It was a pt. with a h/o ventral hernia repair now with suspected infected mesh. He had a questionable heart and surgeon said case would be long (known slow surgeon) so we placed an a-line. Two attempts (one by the jr. resident and then by me). Slides right in with good wave form. Proceeds to work for the next 8 hours in the OR without problem. Take pt. to ICU and head to call room. Couple hrs. later get a call that a pt. in the ICU has a cold hand and vascular surgeon wants to head to the OR. Go to check it out and it is our pt. from earlier. Come to find out pt. had no dopplerable ulnar pulse from the take-off of the brachial down to the hand and must have formed a clot around the a-line. Of course a-line had been removed already. Quick thrombectomy and hand was warm again.

Raises the question of who around here does an Allen's test before an a-line?? My guess is few to none. What is the evidence that it is an effective test for determining collateral flow to the hand?
 
TrustMe said:
I have had a complication from an a-line that resulted in a trip to the OR for the pt. However, I still place them for many cases and for monitoring in the ICU without hesitation. It was a pt. with a h/o ventral hernia repair now with suspected infected mesh. He had a questionable heart and surgeon said case would be long (known slow surgeon) so we placed an a-line. Two attempts (one by the jr. resident and then by me). Slides right in with good wave form. Proceeds to work for the next 8 hours in the OR without problem. Take pt. to ICU and head to call room. Couple hrs. later get a call that a pt. in the ICU has a cold hand and vascular surgeon wants to head to the OR. Go to check it out and it is our pt. from earlier. Come to find out pt. had no dopplerable ulnar pulse from the take-off of the brachial down to the hand and must have formed a clot around the a-line. Of course a-line had been removed already. Quick thrombectomy and hand was warm again.

Raises the question of who around here does an Allen's test before an a-line?? My guess is few to none. What is the evidence that it is an effective test for determining collateral flow to the hand?
Click to expand...

It is my understanding that an Allen's test is neither a sensitive or specific test. Maybe this individual had a coagulation disorder. I've never had a problem with them beyond dampening. I probably place somewhere btw/ 5-10 a week. Many of these patients are vasculopaths. This is not to say it is a risk free procedure.
 
TrustMe said:
I have had a complication from an a-line that resulted in a trip to the OR for the pt. However, I still place them for many cases and for monitoring in the ICU without hesitation. It was a pt. with a h/o ventral hernia repair now with suspected infected mesh. He had a questionable heart and surgeon said case would be long (known slow surgeon) so we placed an a-line. Two attempts (one by the jr. resident and then by me). Slides right in with good wave form. Proceeds to work for the next 8 hours in the OR without problem. Take pt. to ICU and head to call room. Couple hrs. later get a call that a pt. in the ICU has a cold hand and vascular surgeon wants to head to the OR. Go to check it out and it is our pt. from earlier. Come to find out pt. had no dopplerable ulnar pulse from the take-off of the brachial down to the hand and must have formed a clot around the a-line. Of course a-line had been removed already. Quick thrombectomy and hand was warm again.

Raises the question of who around here does an Allen's test before an a-line?? My guess is few to none. What is the evidence that it is an effective test for determining collateral flow to the hand?
Click to expand...

Allen test, not that I would ever do one, is for those who have no doppler U/S, as in poor regions in Africa.... It's ancient medicine. If you are a physician who has doubts about collateral flow, then use the doppler to check for collateral flow....
 
TrustMe said:
I have had a complication from an a-line that resulted in a trip to the OR for the pt. However, I still place them for many cases and for monitoring in the ICU without hesitation. It was a pt. with a h/o ventral hernia repair now with suspected infected mesh. He had a questionable heart and surgeon said case would be long (known slow surgeon) so we placed an a-line. Two attempts (one by the jr. resident and then by me). Slides right in with good wave form. Proceeds to work for the next 8 hours in the OR without problem. Take pt. to ICU and head to call room. Couple hrs. later get a call that a pt. in the ICU has a cold hand and vascular surgeon wants to head to the OR. Go to check it out and it is our pt. from earlier. Come to find out pt. had no dopplerable ulnar pulse from the take-off of the brachial down to the hand and must have formed a clot around the a-line. Of course a-line had been removed already. Quick thrombectomy and hand was warm again.

Raises the question of who around here does an Allen's test before an a-line?? My guess is few to none. What is the evidence that it is an effective test for determining collateral flow to the hand?
Click to expand...

Where was the a line? If it was radial, how did the ulnar clot at the brachial? I've seen dead legs, dead hands and several needing thrombectomies. Do enough and you'll see the complications. Allen's test is worthless. BTW it's now the modified Allen since the modern test is longer than the original.
 
It was radial. From my understanding talking to the vascular fellow they thought that the ulnar was probably chronically occluded and that the pt. had no ulnar flow to begin with. The hand was most likely fully supplied by the radial/collaterals and a small clot formed around or just distal to the a-line and compromised the hand. The pt. was otherwise sick enough that once the hand was warm and pink again they didn't further assess the ulnar or collaterals.
 
sevoflurane said:
Dude....

NOT HIS CALL.

Work up your patient and then decide.

There is no standard of care for a-lines except for bypass.
Click to expand...

I'm in agreement with this.

There are risks and morbidities associated with everything we do...if the benefits outweigh the risks in your educated opinion...you place the A-Line...it's your butt on the line if you don't and it was needed...not the surgeon's...just saying
 
I realize that I am a little late to chime in on this, but really... this is a question?

Glad I don't work in your institution.

- pod
 
Arch Guillotti said:
I guess I am a little confused by this scenario. Your profile says you are an attending physician yet you are asking a basic question that any upper level anesthesia resident should be able to answer. You have also started a thread about whether or not it is safe to perform an epidural with a modestly marginal platelet count.

We can all stand to learn a few things here but maybe if you give some more detail with your posts we could be more helpful.
Click to expand...

but wait, that's not all

bentrider said:
Does anyone know if IV Tylenol is any better than PO Tylenol?
Click to expand...

and

bentrider said:
What monitoring is required for preoperative nerve blocks in a holding area administered with sedation? Thanks.
Click to expand...

-pod
 
fakin' the funk said:
Surgeons do not appreciate that, in optimal circumstances, an A-line placement is no more complicated than an IV placement.
Click to expand...

Maybe the placement isn't, but as you have seen people mention, the potential complications are much greater. There is badness that awaits in the dark closets of a-lines. I think they are rare, but I have seen a few that are not pretty (psuedo-anuerysms, clots, infections.)

by the way, infected a-lines are a lot more common than people think. Recent data shows this...very surprising actually since everyone always says - AH HELL, I've never seen an infected a-line.

Bio-patch is $3.50 - maybe worth putting them on a-lines if it is going to be in for a long time.

I think most surgeons say no a-line because of the perceived time to put them in - and honestly, they have a point...I have seen a-lines take a long long time to be placed. (Not by me of course, all my a-lines reverse time since I do them so fast)
 
epidural man said:
by the way, infected a-lines are a lot more common than people think. Recent data shows this...very surprising actually since everyone always says - AH HELL, I've never seen an infected aline.
Click to expand...

does the data show any complications from the infected aline or did they just show that you can growth **** off the catheter when removed. All alines can come back culture positive if checked but very few will have sequela.
 
Ketafol20 said:
does the data show any complications from the infected aline or did they just show that you can growth **** off the catheter when removed. All alines can come back culture positive if checked but very few will have sequela.
Click to expand...


Why thank you very much for asking!

Actually, both colonization and infection have been looked at. Surprisingly, there are prospective studies (a large one in 2008 and another in 2010) that show that infection rates for a-lines are just as much as central lines - yet they don't get near the attention that central lines do for whatever reason.

Anyway, rather than attach the articles, here is a verbage from a very recent editorial on the subject - the first paragraph anyway. You can look up the rest if you are interested.


Critical Care Medicine
Issue: Volume 39(6), June 2011, pp 1573-1574

Arterial catheters: “They don't get no respect”*
Rupp, Mark E. MD
Author Information
Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
The author has not disclosed any potential conflicts of interest.
Peripheral arterial catheters are widely used in critically ill patients for continuous monitoring of the blood pressure and for convenient vascular access to obtain blood for testing. Unfortunately, many clinicians have not recognized the substantial risk of infection that is associated with the use of arterial catheters. In a systematic review of 14 prospective studies that included 4,366 arterial catheters and 21,397 catheter days of observation, Maki et al (1) noted a rate of bloodstream infection of 1.7 per 1,000 arterial catheter days (95% confidence interval, 1.2–2.3). Indeed, this is comparable to the risk of bloodstream infection associated with short-term, nonmedicated central venous catheters (1). Despite this substantial risk, recent national programs to prevent intravascular catheter-associated bloodstream infections in critical care units have largely ignored the role of arterial catheters (2, 3).
 
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