Access issues

[B-Bone]

Here's a recent case I had:

48M with long hx brittle DM1, ESRD on HD x 14 years, smoker. Presents for CABG after positive stress test and cath showing 3 vessel CAD not amenable to stents. On exam in pre-op, noted to have old (non-functional) AV fistulas in bilateral forearms as well as bilateral upper arms. Non-Functioning AV graft still in place at left femoral site and current-use AV graft in right femoral. No identifiable IJ, subclavian, or femoral veins on either side by US (all thrombosed) with venous drainage apparently provided by multiple tiny collateral veins. Does have a 16g PIV in his right biceps/shoulder area. What's your access plan, and what concerns do you have about any access you do get?

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[Maverikk]

Good case, good to think of it step by step. Do you need central access? Yes, I'm not going in there when I may end up with multiple pressors through a 16.
Waste of time to try a thrombosed vessel. Consult IR for translumbar IVC catheter, which can be later used for HD, not ideal but neither is the patient

 

[Libertas]

That is super tough. How about some venograms to figure out where any remaining patent veins are hiding?

 

[WholeLottaGame7]

How bad is the CAD? How likely do you think you'll need to be giving lots of high-dose pressors before going on? Most of the time it's not a problem getting on bypass, it's coming off. You could probably get away with going on with decent PIV access and have the surgeon place an atrial line for central access for coming off.

If the IJs and subclavians are all thrombosed, though, I wonder where that 16 in the shoulder is draining?

 

[nimbus]

Assuming it's an on pump CABG, you need to be able to moniter CVP to ensure you are getting adequate venous drainage during CPB. Tough problem. The surgeon could directly cannulate the SVC or the RA after sternotomy.

 

[OB1🤙]

First step would be to look around with ultrasound to see how other veins look. I'd also scan the vein the the 16g is in, and if accommodating, consider upsizing it to a RIC. That'd be your volume line. Find another PIV somewhere as a backup.

Would also look to see if the EJ is patent, you could consider either a piv or a cvc of some kind there, though if the subclavian is occluded it may be a no go.

It's possible the subclavians are occluded relatively distally, and you can find a supraclavicular subclavian with ultrasound. This is a great line, and under-utilized.

If all the fails, for pressors, I'd actually think about an IO. Not optimal necessarily, but if it's a cabg with preserved EF you probably won't be on pressors for very long after surgery, so it may suffice for the purposes of the case.

Tough case.

 

[Maverikk]

I would want central access far before the sternum is cracked, this is not someone I would want to induce without the ability to massively resuscitate.

 

[nimbus]

I would want central access far before the sternum is cracked, this is not someone I would want to induce without the ability to massively resuscitate.

Interesting. We typically induce with an Aline and place central lines and PA caths after induction.

 

[B-Bone]

Great thoughts. Here's how it went down:
Patient had severe 3 vessel disease, but no significant left main disease. EF normal with no significant valvular abnormalities. Plan was for off-pump CABG. I would actually have been comfortable inducing without an a-line, but I did place a right axillary a-line in pre-op. After induction, I checked the right and left neck wth US, and found no viable veins. Largest vein I could see was about 10-20% the size of the carotid and immediately behind it . No subclavian/axillary vein visible on US. Surgeon attempts blind subclavian, gets flow, but unable to pass wire. I restick at a different angle; same result. Back to the neck, I try to get a wire in a tiny EJ, but cannot get wire past 5-6 cm. To the groin. I am not willing to touch the right side given that it's his functioning dialysis access (AV graft). On the left is an old, non-functioning AV graft and no vein on US.

At this point, I decide to call a vascular surgeon for his opinion. He can't find anything with US, and proceeds to stick blindly above the inguinal ligament, somehow getting into the iliac vein (hopefully not through a loop of bowel) with a micropuncture kit and places an introducer.

Regarding questions above:
-the existing 16 g PIV was draining into a series of small collateral veins around the arm/shoulder/neck
-I did consider having the surgeon place access after sternotomy. He's an older surgeon who has done this in the past.
-vascular surgeon had access to his office's records showing that he had completely thrombosed all significant upper extremity veins with old dialysis access and relied completely on collaterals and suffered from functional SVC syndrome.

More questions:
-what effects, if any, will the presence of AV grafts or AV fistulas (functional or otherwise) have on nearby arterial and venous lines? Flow rates? Pressures? Blood gases?

 

[rp218]

This patient chooses to smoke...
Is that okay?

Regards,
RP

 

[ZzzPlz]

This patient chooses to smoke...
Is that okay?

Regards,
RP

Definitely not ok

 

[jwk]

This patient chooses to smoke...
Is that okay?

Regards,
RP

As the saying goes, "you just can't kill some people".

 

[nimbus]

As the saying goes, "you just can't kill some people".

He will die soon. His life expectancy is less than 5 years.

We've had a couple of similar patients, frequent flyers, who ended up getting brachial or subclavian artery to right atrial grafts for hemodialysis access. When those fail they die.

 

[nimbus]

Great thoughts. Here's how it went down:
Patient had severe 3 vessel disease, but no significant left main disease. EF normal with no significant valvular abnormalities. Plan was for off-pump CABG. I would actually have been comfortable inducing without an a-line, but I did place a right axillary a-line in pre-op. After induction, I checked the right and left neck wth US, and found no viable veins. Largest vein I could see was about 10-20% the size of the carotid and immediately behind it . No subclavian/axillary vein visible on US. Surgeon attempts blind subclavian, gets flow, but unable to pass wire. I restick at a different angle; same result. Back to the neck, I try to get a wire in a tiny EJ, but cannot get wire past 5-6 cm. To the groin. I am not willing to touch the right side given that it's his functioning dialysis access (AV graft). On the left is an old, non-functioning AV graft and no vein on US.

At this point, I decide to call a vascular surgeon for his opinion. He can't find anything with US, and proceeds to stick blindly above the inguinal ligament, somehow getting into the iliac vein (hopefully not through a loop of bowel) with a micropuncture kit and places an introducer.

Regarding questions above:
-the existing 16 g PIV was draining into a series of small collateral veins around the arm/shoulder/neck
-I did consider having the surgeon place access after sternotomy. He's an older surgeon who has done this in the past.
-vascular surgeon had access to his office's records showing that he had completely thrombosed all significant upper extremity veins with old dialysis access and relied completely on collaterals and suffered from functional SVC syndrome.

More questions:
-what effects, if any, will the presence of AV grafts or AV fistulas (functional or otherwise) have on nearby arterial and venous lines? Flow rates? Pressures? Blood gases?

I think you would have some functional left to right shunting, arterialization of venous blood, and possibly low SVR.

 

[sevoflurane]

Had a patient like this a while back. Came up with a 20G in the AC and another small peripheral somewhere else.
Everything else was either thrombosed or massively re-routed with inability to pass wires for access.
Ultimately, I placed a wire through the 20G AC and converted to a RIC which flowed like a big cordis. Case went well, although I knew I'd be hosed if I lost the RIC and had encountered major bleeding.
The unfortunate part is that RICs can trash ACs for future use. If that patient had to come back for something, it potentially would be a pretty big headache for the anesthesia provider.
Conversion of a 20G AC to a RIC is a viable option in these patients- just something to think about.

 

[leaverus]

this really isn't that difficult a situation. the guy is high risk no matter what. if you can't get access you can't access - cancel and manage medically until he dies of whichever issue decides to kill him first. otherwise, get as much access as you can where you can, make sure your paperwork is in order and hope for the best. or pass the case off to a hated colleague.

 

[ZzzPlz]

this really isn't that difficult a situation. the guy is high risk no matter what. if you can't get access you can't access - cancel and manage medically until he dies of whichever issue decides to kill him first. otherwise, get as much access as you can where you can, make sure your paperwork is in order and hope for the best. or pass the case off to a hated colleague.

Agree but enjoyed reading the above approaches

 

[OB1🤙]

Or you could do what some drug addicts do and cannulate the dorsal vein of the penis...

 

[McPoyle]

I've not, yet, had to change a PIV to anything bigger? What exactly are you upsizing to? Is it essentially just using a wire and sliding in whatever size catheter you can make fit? Are you ending up with a midline/peripheral catheter?

 

[repititionition]

Or you could do what some drug addicts do and cannulate the dorsal vein of the penis...

I was encouraged to do this for a rugged old street rat, longtime IVDU who admittedly did know his veins well. Came in with pneumonia, volume depleted, and I was fishing around for a ****ty 20 in his thumb just to get fluids started when he made "the offer". I declined, got the 20 in the thumb, and got enough fluids in that we had other, ahem, options.

 

[Ronin786]

Or you could do what some drug addicts do and cannulate the dorsal vein of the penis...

Relatively low side effect profile as well:
http://www.ncbi.nlm.nih.gov/pubmed/7073051

 

[Ignatius J]

How about a brachial central line? Could you have placed it over the 16G?

 

[pgg]

Or you could do what some drug addicts do and cannulate the dorsal vein of the penis...

Tourniquet goes where?

 

[chocomorsel]

Relatively low side effect profile as well:
http://www.ncbi.nlm.nih.gov/pubmed/7073051

Ahh, this article is talking about injecting and infusing fluid in the corpora carvenosa. Not even in the vein. Guess all the spongy tissue absorbs it and distributes it to the body. Apparently it causes a temporary erection which disappears after the infusion stops.
Wow, you learn something new every day.

 

[Random Anesthesiologist]

Tourniquet goes where?

Nurse, can you please hold this firmly?

I mean the other guy, thanks.

 

[wickedskillz]

How about IO lines? The ER people seem to be pretty adept at using them, and it seems like they use them essentially in lieau of central venous access when the situation calls for it

 

[Noyac]

If that patient had to come back for something, it potentially would be a pretty big headache for the anesthesia provider.

Hey man, WTF?
You went to DOCTOR school, not provider school.

 

[sevoflurane]

 

[Laryngophed]

First the dorsal vein, and now this? Things are getting testis I mean testy in here.


And for some reason, my simple CA1 brain can't come up with the un-acronymed RIC. Anyone care to drop some knowledge on me?

 

[Urzuz]

And for some reason, my simple CA1 brain can't come up with the un-acronymed RIC. Anyone care to drop some knowledge on me?

Rapid Infusion Catheter.

 

[Laryngophed]

Rapid Infusion Catheter.

Thanks. I don't think I've ever used one of those. Interesting, and fairly simple concept. Thanks again.

 

[RxBoy]

this really isn't that difficult a situation. the guy is high risk no matter what. if you can't get access you can't access - cancel and manage medically until he dies of whichever issue decides to kill him first. otherwise, get as much access as you can where you can, make sure your paperwork is in order and hope for the best. or pass the case off to a hated colleague.

Ding, ding, ding, ding. We have a winner.

Although the ending does not result in the heroic anesthesiologist saving the damsel in distress, this is by far the best answer.

The more private I become, the bigger the picture gets. Lets break this down...

You have a severely diseased patient who has severely diseased arteries everywhere in his visible body. You do the 5000 dollar workup because he had some chest pain after eating a very spicy burrito. After all ur stress tests, and angiograms, you make the earth shattering discovery that the arteries in his heart happen to be diseased as well. Suprise!

No STEMI (which would of been an entirely different story), no urgency, but we have to fix this incidental CAD diagnosis quick. Lets rush for open heart surgery. Lets do this despite tne studies proving ZERO mortality benefit . If only the patient was lucky and had only 2 diseased vessels. He could of got some stents and added just as much of a mortality benefit... ZERO. To make matters worse, the CT surgeon makes even a bolder move... Off pump CABG. Something that has went the way of the dinosaur because of its unproven benefit.

So what does work? Medical management (BB, ASA, ACE, ect)... Yes, the good drugs. They have a proven mortality benefit.

Someone up there was looking out for this guy, made it really really hard to get his case going. Almost impossible. But the doctors were victorious. Now we can reward the patient with a trach, peg, and an icu bed.

Anyways I digress..

Me personally:
1) postpone or cancel. Push for medical management. If CT surgeon still pushing.... or this is urgent/emergency... We go to #2
2) Do what the OP eventually does. Id save myself a mess and get a vessel expert involved. Them vascular guys know a thing or 2 about venous access when all our tricks are exhausted. No central access, no case.

 

[fakin' the funk]

Here's a recent case I had:

48M with long hx brittle DM1, ESRD on HD x 14 years, smoker. Presents for CABG after positive stress test and cath showing 3 vessel CAD not amenable to stents. On exam in pre-op, noted to have old (non-functional) AV fistulas in bilateral forearms as well as bilateral upper arms. Non-Functioning AV graft still in place at left femoral site and current-use AV graft in right femoral. No identifiable IJ, subclavian, or femoral veins on either side by US (all thrombosed) with venous drainage apparently provided by multiple tiny collateral veins. Does have a 16g PIV in his right biceps/shoulder area. What's your access plan, and what concerns do you have about any access you do get?

What a disaster

Go to sleep

Bit of a guess - surgeon does axillary/subclavian cutdown or direct cannulation