Nephro critical care

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How many of you all put arterial lines in pts on pressors ? My partners tend to get by with cuff pressures claiming that people stay on pressors longer when arterial lines are in place. I on the other hand place art lines on all ICU pt who's SBP drops below 90 or MAP <65 mmhg . Other folks will stay with cuff pressures even if the pt is on 0.2/mcg/kg/min of Levophed. My worry is that nurses react slowly to cuff pressures and they don't titrate the pressors aggressively or give boluses if they don't see the ticking arterial line pulsations.

I hate the Arrows but love the Argons in which you use seldinger technique . I like the spurt of blood with the Argons and then the argon catheters have 2 wings that I can suture through and the Aline stays in place for a week. We get a lot of problems with arrows placed in the OR they never stitch them in and they invariably peter out in 24 hrs.

It seems like arterial lines pay very poorly so many attendings get by without them in private practice. At our big Mother ship everybody gets an arterial line but its done by RT. At my smaller satellite I have do all of them.
 
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jdh71

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I tend to put in arterial lines in on patients that need pressors, mostly because I don't think I can always trust many cuff pressures in my patient population, but if I think I'm getting a good cuff pressure and I believe it, then I see no need for one. I think if I had to personally put them all in I'd probably put in less. I am unaware of any data that suggests patients do better with them in though.
 
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1) do I believe the cuff pressure
2) do I expect minute to minute variation
3) are you perfusing the kidneys
4) what dose of vasopressor are you on (under 0.05 makes me less concerned)
5) is the patient in need of more than a couple abgs in the next 24-48 hours

If I ever have 2 of the above, I definitely do it. One and I strongly consider it.

I don't buy the "on pressors longer" thing - that seems like a crappy justification to be lazy.
 

sluggs

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For a patient improving on low dose levophed, I usually hold off; if pressor requirements increase or I'm adding a second pressor I usually put one in
 
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fakin' the funk

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Agree with most above.

Also, having a real-time BP for the nurses to act on can be a major, major downside. (Same thing for particularly vigilant family members.) Nurses can get super aggressive with rapidly up or downtitrating whatever they're titrating and cause major roller coaster swings in BP. Sometimes it is better just to have them have q15 data points.
 
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Nephro critical care

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1) do I believe the cuff pressure
2) do I expect minute to minute variation
3) are you perfusing the kidneys
4) what dose of vasopressor are you on (under 0.05 makes me less concerned)
5) is the patient in need of more than a couple abgs in the next 24-48 hours

If I ever have 2 of the above, I definitely do it. One and I strongly consider it.

I don't buy the "on pressors longer" thing - that seems like a crappy justification to be lazy.
I feel cuff pressures become unreliable in critically ill patients especially when u add a tube and propofol in the mix. I throw in the arterial line soon after intubation in all critically ill intubated pts . Everyone drops his pressure after propofol /fentanyl . Some will have a hypertensive response immediately after intubation but invariably after a while they will drop. And if you are doing q15 BP checks these drops will likely be missed.
 
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TimesNewRoman

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I feel cuff pressures become unreliable in critically ill patients especially when u add a tube and propofol in the mix. I throw in the arterial line soon after intubation in all critically ill intubated pts . Everyone drops his pressure after propofol /fentanyl . Some will have a hypertensive response immediately after intubation but invariably after a while they will drop. And if you are doing q15 BP checks these drops will likely be missed.
Eh. I don't put an a-line in all tubed patients. I go to q2-3m NIBPs then if BP stable at 15-20 mins, I don't do it. But yours certainly isn't an unreasonable practice.
 

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If the pressor is on a peripheral line (meaning I expect it to be short term), and I have a reliable and stable BP, possibly with a conscious unintubated patient, I may wait with the A-line. If it's on a central line, in a sick unstable patient, with increasing pressor requirements, the earlier that a-line goes in the better. In between those two scenarios, it's a matter of risks vs benefits.

I have never regretted putting in an a-line, especially if not technically challenging. Not placing A-lines in patients on non-trivial doses of pressors borders malpractice (it's sheer laziness and/or greed).
 
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engineeredout

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Also something to be said about being able to easily draw labs/blood gasses in a progressively edematous/peripherally constricted patient
 

FFP

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Also something to be said about being able to easily draw labs/blood gasses in a progressively edematous/peripherally constricted patient
... instead of using the central line (which should be a no-no, except for emergencies).
 
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FFP

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There are places where nurses draw daily labs from central lines. The problem with that is that every single time a port is manipulated, in a non-sterile fashion, there is an increase in the infection risk, especially because some nurses don't flush the port properly after use (that applies even more to a-lines - how many times do you find dried blood in the side port?). There is probably no better culture medium for bacteria than blood, especially the kind that is biofilm.
 

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Just put the arterial line. the threshold should be pretty low for arterial lines in my opinion. they are easy to place, and have many benefits with few downsides. Also find it infuriating when patient comes from the ICU on pressors going to the OR but with no arterial line, but has a central line.. if you are putting in a central line for pressors, probably should put an arterial line unless you think the hypotension is unlikely to last.
 

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Just put the arterial line. the threshold should be pretty low for arterial lines in my opinion. they are easy to place, and have many benefits with few downsides. Also find it infuriating when patient comes from the ICU on pressors going to the OR but with no arterial line, but has a central line.. if you are putting in a central line for pressors, probably should put an arterial line unless you think the hypotension is unlikely to last.
In which case the intensivist should also educate himself/herself about pressor administration through peripheral IVs. We put in way too many central lines (and not enough arterial lines). If the hypotension won't last more than 48 hours (e.g. urosepsis pre- and post-cysto) and one has a good 18G peripheral IV, there is probably little need for a central line (especially if phenylephrine is enough).

There will come a time in our professional lives when we will look down with contempt upon this barbaric practice of giving pressors only through central lines. That will coincide with the time when ICU nurses will spend their time mostly at bedside.
 
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TimesNewRoman

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In which case the intensivist should also educate himself/herself about pressor administration through peripheral IVs. We put in way too many central lines (and not enough arterial lines). If the hypotension won't last more than 48 hours (e.g. urosepsis pre- and post-cysto) and one has a good 18G peripheral IV, there is probably little need for a central line (especially if phenylephrine is enough).

There will come a time in our professional lives when we will look down with contempt upon this barbaric practice of giving pressors only through central lines. That will coincide with the time when ICU nurses will spend their time mostly at bedside.
Ehhh...I think you're overstating the case. A good 18 GA can blow at 3AM when you're at home. There's not a lot of harm in putting in an IJ and taking it out 72 hours later. Also, why are you using neo for a patient with sepsis?
 

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Ehhh...I think you're overstating the case. A good 18 GA can blow at 3AM when you're at home. There's not a lot of harm in putting in an IJ and taking it out 72 hours later. Also, why are you using neo for a patient with sepsis?
Because the IV can blow while I am sleeping at 3 AM without the patient needing plastic surgery by the time the nurse notices. And I try not to put in central lines unless they are really needed (meaning that the patient has failed peripheral neo, or I expect him to).

Pulmcrit - An alternative viewpoint on phenylephrine infusions
 
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Nephro critical care

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I throw the central line in during the day if I get any whiff the patient will need pressors. And throw the arterial line in as well so I know the nurse won't miss the hypotension for 15-30 minutes at night. Levophed is ordered as well PRN to keep MAP > 65. I find that lot fewer patients have AKI in the morning from 3 AM hypotension.
Night shift nurses sometimes do weird things. Observe night nurses and you will see contact isolations routinely ignored etc.
And drawing from central lines ?? That is probably going to be an inaccurate draw. All patients will have a sodium of 150, K of 2.8 and HCO3 of 15 , Hgb of 6.7 and WBC of 3 from the 75% blood/25 % saline mixture.
 

TimesNewRoman

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Because the IV can blow while I am sleeping at 3 AM without the patient needing plastic surgery by the time the nurse notices. And I try not to put in central lines unless they are really needed (meaning that the patient has failed peripheral neo, or I expect him to).

Pulmcrit - An alternative viewpoint on phenylephrine infusions
I'm not saying neo is a bad drug, it's not. But the guidelines aren't unclear. Standard of care is certainly levo, and without compelling evidence to deviate from that norm, it seems like an unnecessary medical-legal risk.

Also, I'm not concerned about the 18 blowing and the arm falling off so much as the 18 blowing and not being able to get another good IV.
 
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I suspect it varies considerably from place to place but where I did residency they way overused a-lines and central lines. Sure they are fun to put in and handy to have but they can have serious complications. I saw one young woman lose her leg to a femoral a-line that was not needed. I saw multiple fatal complications from unneeded central lines. Somehow the folks there acted like these fatalities didn't count because they were "Unusual" More than once I took a patient from the ICU to the OR and got told to put in a triple lumen 'cause they couldn't get an IV..usually sent them back with the Crabbygas triple lumen, 3 PIV's.
 
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I am cautious about femoral a lines having had a bad complication after a nurse pulled the catheter out without holding sufficient pressure in a patient on anticoagulants. The pt had a bad femoral hematoma. She thankfully did well in the end.
However I am pretty chill about radial arterial lines on which by using US and exactly pinpointing where to stick above the radial my success is >99%. I have about 70 radials for this year alone 1-2 a shift. Unfortunately it's such a poorly paid procedure.
 
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Just put the arterial line. the threshold should be pretty low for arterial lines in my opinion. they are easy to place, and have many benefits with few downsides. Also find it infuriating when patient comes from the ICU on pressors going to the OR but with no arterial line, but has a central line.. if you are putting in a central line for pressors, probably should put an arterial line unless you think the hypotension is unlikely to last.
I could live with this. It is the patient on high dose pressors with intraabdominal badness who comes to the OR with the pressors going through a 20 gauge and maybe a 22 gauge on the other side (sometimes without a foley in)that grind my gears. Particularly the ones who have critically ill for many hours or perhaps days before imaging caused me to be involved (somehow it is always close to midnight for a scan performed before 3pm and often with a read time before 5pm).
 
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TimesNewRoman

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I suspect it varies considerably from place to place but where I did residency they way overused a-lines and central lines. Sure they are fun to put in and handy to have but they can have serious complications. I saw one young woman lose her leg to a femoral a-line that was not needed. I saw multiple fatal complications from unneeded central lines. Somehow the folks there acted like these fatalities didn't count because they were "Unusual" More than once I took a patient from the ICU to the OR and got told to put in a triple lumen 'cause they couldn't get an IV..usually sent them back with the Crabbygas triple lumen, 3 PIV's.
If you're seeing "multiple fatal complications" from central lines, your institution has bigger problems. I've seen a few complications from cvls, but never fatal.
 
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If you're seeing "multiple fatal complications" from central lines, your institution has bigger problems. I've seen a few complications from cvls, but never fatal.
Agree. If using ultrasound guidance and doing primarily IJs complication rate should be very low. SC has a small ( 1%) risk of PTX that's kind of unavoidable. But in current times you shouldn't have a PTX with IJ and if you only keep the IJ as long as needed and it is handled properly CLABSI rates should be exceedingly low.
While some institutions look down on femorals I also have a very good track record on femorals as I place them under U/S and get them out within 48 hrs. Femoral central lines can be tricky as the artery can be right over the vein but using ultrasound and sticking medially you can angle and sneak in under the artery. You can't lose a leg if you went cleanly into the vein.
 

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Oh I suppose there is a certain amount of recall bias. You do remember the things that go bad. And yes one place I worked had real problems. Over the year's I have seen IJ into vert artery that was at autopsy sc into aorta that survived thoracotomy with CPR in progress retained guidewire- autopsy just to name a few memorable ones. My point was lines should not be placed without really good reasons
 
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Fox800

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I'd be curious about the hive mind's thoughts on the peripheral IJ. I've done it a handful of times in the ED for patients that just need access in a timely manner (but don't need an IO right now) and ultrasound-guided peripheral IVs weren't working. The catheter is the exact same length as what we'd put in a peripheral vein, so, it shouldn't be inherently "dirty" just because it's in the IJ vs the EJ.

I'm placing these with as sterile of a technique as I can: sterile gloves, sterile ultrasound probe and jelly, ChloraPrep over the neck, someone hands me the ultrasound catheter and the Tegaderm in sterile fashion.

The Easy IJ: Another Option for Difficult IV Access in Stable Patients? - R.E.B.E.L. EM - Emergency Medicine Blog
More on the Easy IJ - R.E.B.E.L. EM - Emergency Medicine Blog
http://www.emergencyultrasoundteaching.com/assets/articles/vascaccess_2012_Teismann_JEM.pdf
 

FFP

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I'd be curious about the hive mind's thoughts on the peripheral IJ. I've done it a handful of times in the ED for patients that just need access in a timely manner (but don't need an IO right now) and ultrasound-guided peripheral IVs weren't working. The catheter is the exact same length as what we'd put in a peripheral vein, so, it shouldn't be inherently "dirty" just because it's in the IJ vs the EJ.

I'm placing these with as sterile of a technique as I can: sterile gloves, sterile ultrasound probe and jelly, ChloraPrep over the neck, someone hands me the ultrasound catheter and the Tegaderm in sterile fashion.

The Easy IJ: Another Option for Difficult IV Access in Stable Patients? - R.E.B.E.L. EM - Emergency Medicine Blog
More on the Easy IJ - R.E.B.E.L. EM - Emergency Medicine Blog
http://www.emergencyultrasoundteaching.com/assets/articles/vascaccess_2012_Teismann_JEM.pdf
Useless, except for emergency IV access?

It's not a central line, but that doesn't mean that it could not be used for pressors. I just don't see it lasting for days. Plus I can see a lot of medico-legal problems if the patient gets CLABSI or endocarditis from one of these. "Doctor, were you too lazy to insert a proper central line with full barrier precautions?"

I haven't seen one yet. Am I wrong?
 
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Nephro critical care

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EJ maybe be OK in an emergency. But at least for me EJs are harder for me to place then a central line. I have seen an ED provider and a critical care NP try to place an EJs and flail around for 15-20 minutes. The IM attending physician then asked me to try the EJ . The patient had no IV access and needed abs for next 2-3 days. . I tried once realized I was just going to be mucking around as well and the pt was likely going to end up with some bad complications. Donned full barrier precautions and in 15 minutes : there you go sir here's an IJ and you can keep it in till for the next week or till whenever the patient gets discharged.
Get the line in you are most comfortable with and placed most times. For me in CC that's IJ > Fem > SC >>>> peripheral/EJ.
 

TimesNewRoman

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EJ maybe be OK in an emergency. But at least for me EJs are harder for me to place then a central line. I have seen an ED provider and a critical care NP try to place an EJs and flail around for 15-20 minutes. The IM attending physician then asked me to try the EJ . The patient had no IV access and needed abs for next 2-3 days. . I tried once realized I was just going to be mucking around as well and the pt was likely going to end up with some bad complications. Donned full barrier precautions and in 15 minutes : there you go sir here's an IJ and you can keep it in till for the next week or till whenever the patient gets discharged.
Get the line in you are most comfortable with and placed most times. For me in CC that's IJ > Fem > SC >>>> peripheral/EJ.
Sounds like you need to do more SC.
 

FFP

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EJ maybe be OK in an emergency. But at least for me EJs are harder for me to place then a central line. I have seen an ED provider and a critical care NP try to place an EJs and flail around for 15-20 minutes. The IM attending physician then asked me to try the EJ . The patient had no IV access and needed abs for next 2-3 days. . I tried once realized I was just going to be mucking around as well and the pt was likely going to end up with some bad complications. Donned full barrier precautions and in 15 minutes : there you go sir here's an IJ and you can keep it in till for the next week or till whenever the patient gets discharged.
Get the line in you are most comfortable with and placed most times. For me in CC that's IJ > Fem > SC >>>> peripheral/EJ.
I think @Fox800 was talking about a regular peripheral IV catheter inserted in the IJ under ultrasound guidance, in a somewhat sterile fashion. A so-called "easy/peripheral IJ". Not EJ.
 
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Nephro critical care

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I think @Fox800 was talking about a regular peripheral IV catheter inserted in the IJ under ultrasound guidance, in a somewhat sterile fashion. A so-called "easy/peripheral IJ". Not EJ.
Sorry my mistake. I thought EJ. I wouldn't touch the IJ without full barrier precautions even in a 911 situation. The femoral vein is the site for access which can be placed cleanly but not in a sterile fashion and taken out in few hours.
 
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jdh71

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Who knew everyone was a bad doctor for their current practices??!!

Not me. At least until this thread. :heckyeah:

themoreyouknow.jpg
 
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alpinism

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EJ maybe be OK in an emergency. But at least for me EJs are harder for me to place then a central line. I have seen an ED provider and a critical care NP try to place an EJs and flail around for 15-20 minutes. The IM attending physician then asked me to try the EJ . The patient had no IV access and needed abs for next 2-3 days. . I tried once realized I was just going to be mucking around as well and the pt was likely going to end up with some bad complications. Donned full barrier precautions and in 15 minutes : there you go sir here's an IJ and you can keep it in till for the next week or till whenever the patient gets discharged.
Get the line in you are most comfortable with and placed most times. For me in CC that's IJ > Fem > SC >>>> peripheral/EJ.
EJs take all of 30 seconds in the right patient.

The key is that they actually have to have a good one visible when sitting upright.

The problem arises when people try to place them in patients with small or tortuous neck veins that collapse with every breath.
 
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