Cardiac: how long should it take...

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Chloroform4Life said:
How many of you use through and through for A line from the get go?
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All I did in residency. Since, I have used the arrow kit with guidewire. I think learning to do it with a wire is the way to go because I still convert to that technique when the wire in the arrow kit won't go, which isn't uncommon in the heart and vascular rooms.
 
kazuma said:
I agree with Sevo, 15-20 min but not including acquiring images. I don't do hearts now but I used to time myself as a resident with the help of an anesthesia tech, my attending in the lounge until I called him to help with images. I was sick of waiting for the CT surgeons taking their sweet time and blaming it on us taking an hour to do our lines so I'd time myself.
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15-20 minutes as a resident??? If true, that is extremely impressive. I wasn't under 30 minutes until about 6 months into private practice
 
sethco said:
15-20 minutes as a resident??? If true, that is extremely impressive. I wasn't under 30 minutes until about 6 months into private practice
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With the attending in the lounge nonetheless.
 
sethco said:
I'm not one to critique others practice, but seriously WTF?!?!??
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Easier access for initiating IABP post pump? Though that should be pretty rare and I agree does not warrant routine fem A line for every case.
 
Hawaiian Bruin said:
30 min is chloraprep on skin. So line(s) and tee should be in by 25 min after room time at the most.

I ultrasound every a-line. It adds no time and usually saves time. I have a tegaderm over the hockey stick probe ready to go before pt rolls in. Prep on the arm is the ultrasound medium. I walk up to the prepped arm, put probe down very proximal in the forearm, boom lido, boom line. I don't feel for a pulse- no need to. So it adds exactly zero time to do this. First pass success is nearly 100%. Note that I consider a radial a-line a clean procedure, so I'm not using sterile gloves or a whole sterile us sheath.

Putting the line high up prevents kinking issues, USG avoids tortuosities, plaques etc.

Edit: I should add that I do this with a-lines only in the heart room, where the echo machine is in there already with the hockey stick probe on it.
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I do the same with radial arterial lines. I don't use sterile gloves. However, for brachial lines, when I am using the 20g x 6 in kits, I will chloraprep and put on sterile gloves. My theory is if I am actually touching the guide wire and it is a long catheter, I probably should be sterile
 
changeofheart2016 said:
First yr resident here, im inclining toward 1hr mark.

What happens when the pts pressure tanks afetr induction, like a majority of pts, especially during a period of no surgical stimulation, and youre in the middle of ur cordis with sterile gloves on? Who pushes pressors?
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This usually isn't a problem because I don't give a massive opioid dose during induction, unlike what I use to do during residency/fellowship.

However, before I gown and glove, I hand a syringe of phenylephrine and epinephrine to the nurse. I will pay attention to the vitals while doing my lines and if I need a bump (very rare), I will ask the nurse to push a cc or two
 
How long should it take? It won't take long for you to find out for yourself because the surgeon will let you know one way or another. If he's in the room sitting on a stool tapping his feet staring directly at you and you still got a gown on, that is a clue
 
urge said:
Why so slow?

It shouldn't take more than 8 min.

1 min for the a line, 2 min for induction and tube, and 5 min for the central line.
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I'm getting old.😉 As long as you can accomplish those tasks in less than 30 minutes there won't be an issue. Most of my colleagues can do the lines and TEE in under 35 -40 minutes which is respectable. The heart surgeons expect you to move along with these mundane tasks so unless you are having a very difficult time (which happens on occasion) there is an expectation of proficiency.
 
sethco said:
I do the same with radial arterial lines. I don't use sterile gloves. However, for brachial lines, when I am using the 20g x 6 in kits, I will chloraprep and put on sterile gloves. My theory is if I am actually touching the guide wire and it is a long catheter, I probably should be sterile
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Agree.
 
I normally take ~15-25 minutes. I checked my time from Thursday, when I had a medical student do the a line and central line and was at 38 minutes. That was by far the slowest one in 6 months.
My average time is 22 minutes from in room to TEE probe in esophagus based on my report from EMR I just ran. I am bad at TEE comparatively, so I spend a lot of time on that. But just poking a couple needles into patients and slipping a tube into their trachea is quick. I have lots of motivated help.

My process:
-Show up 30 minutes prior to case
-Draw up drugs after chart review, select ETT size. No other set up needed, including drips (that is what techs and nurses are for)
-Talk to patient
-Revise plan if needed, change setup as needed
-Go get donut when I realize I showed up too early (only do this step if I have 4 minutes, I actually time it out and see if I have enough time)
-Get patient, giving 1-3 mg versed when cart unlocks
-Get patient to room 2 minutes later
-Walk up, click buttons on chart while room staff asks patient if they can move over (crossing fingers they say no so we can save 5 minutes), then place mask with O2 running at 10L gently on face, assess mental status and give more versed as needed.
-Walk over, put on gloves for A line while "team" is placing monitors.
-Remind them to hit the BP button which they forget 75+% of the time
-place A line. I usually the pick 20 gauge needle for this, and switch to arrow if I dont get it first pass. The arm is in position and prepped for me while I was getting oxygen out before.
-Walk to head of bed after catheter in vein (nurses/techs can put dressing on and secure)
-Wait 1 minute for them to draw labs off A line
-Give fentanyl/induction agent
-Mask
-Intubate
-Check breath sounds, turn on vent, set iso at 1
(foley is placed during intubation/induction)
-Wash hands, perform timeout, get on gloves. (tech ties me up while nurse puts T-burg and starts prep)
-Put on gown, tech secures gown, then walks over to line they have set up and flushed with saline, gets ready to hand me stuff.
-Use U/S for line which 2nd scrub hands me. (use the probe off TEE, foot pedal is set up, patient data typed in by anesthesia tech)
-After line in I go swap gloves to non-bloody ones
-Grab TEE probe that anesthesia tech is handing me, place in mouth.

Done.

All this said, our surgeon does not care at all how long I take, he just sits in his office scoping out the news after officially showing up prior to heading to room.

Sent from my iPad using SDN mobile app
 
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Obviously you need good help to be efficient as above, which I have, and is pretty freaking cheap.
I feel bad for those who have hospitals that dont value nurses and techs.


Sent from my iPad using SDN mobile app
 
pjl -

You'll PM me when your group is hiring for cardiac, won't you?

Our place is such a clusterfu*k...it's a bit of a detour from the topic, but as an illustration, one of our TEE machines will only record images on VHS, floppy disk, or hard disk. Instead of people coming in/staying to help, the opposite happens when the patient comes into the OR. There is literally no help.
 
bigdan said:
pjl -

You'll PM me when your group is hiring for cardiac, won't you?

Our place is such a clusterfu*k...it's a bit of a detour from the topic, but as an illustration, one of our TEE machines will only record images on VHS, floppy disk, or hard disk. Instead of people coming in/staying to help, the opposite happens when the patient comes into the OR. There is literally no help.
Click to expand...

You and urge in the same group? +pity+

j/k Bigdan... that sounds painful.

pjl said:
I normally take ~15-25 minutes. I checked my time from Thursday, when I had a medical student do the a line and central line and was at 38 minutes. That was by far the slowest one in 6 months.
My average time is 22 minutes from in room to TEE probe in esophagus based on my report from EMR I just ran. I am bad at TEE comparatively, so I spend a lot of time on that. But just poking a couple needles into patients and slipping a tube into their trachea is quick. I have lots of motivated help.

My process:
-Show up 30 minutes prior to case
-Draw up drugs after chart review, select ETT size. No other set up needed, including drips (that is what techs and nurses are for)
-Talk to patient
-Revise plan if needed, change setup as needed
-Go get donut when I realize I showed up too early (only do this step if I have 4 minutes, I actually time it out and see if I have enough time)
-Get patient, giving 1-3 mg versed when cart unlocks
-Get patient to room 2 minutes later
-Walk up, click buttons on chart while room staff asks patient if they can move over (crossing fingers they say no so we can save 5 minutes), then place mask with O2 running at 10L gently on face, assess mental status and give more versed as needed.
-Walk over, put on gloves for A line while "team" is placing monitors.
-Remind them to hit the BP button which they forget 75+% of the time
-place A line. I usually the pick 20 gauge needle for this, and switch to arrow if I dont get it first pass. The arm is in position and prepped for me while I was getting oxygen out before.
-Walk to head of bed after catheter in vein (nurses/techs can put dressing on and secure)
-Wait 1 minute for them to draw labs off A line
-Give fentanyl/induction agent
-Mask
-Intubate
-Check breath sounds, turn on vent, set iso at 1
(foley is placed during intubation/induction)
-Wash hands, perform timeout, get on gloves. (tech ties me up while nurse puts T-burg and starts prep)
-Put on gown, tech secures gown, then walks over to line they have set up and flushed with saline, gets ready to hand me stuff.
-Use U/S for line which 2nd scrub hands me. (use the probe off TEE, foot pedal is set up, patient data typed in by anesthesia tech)
-After line in I go swap gloves to non-bloody ones
-Grab TEE probe that anesthesia tech is handing me, place in mouth.

Done.

All this said, our surgeon does not care at all how long I take, he just sits in his office scoping out the news after officially showing up prior to heading to room.

Sent from my iPad using SDN mobile app
Click to expand...

This is more like it.

But hey... it may be some sort of worm hole time continuum.

I rarely do cabgs any more. Mostly valves, so I don't have the luxury of mammary dissection as bypass is just around the corner and I like to get a full echo exam B4 the roller pumps start spinning. I'm constantly moving in order to achieve this goal.

The team I work with is an integral part of this.

Sounds like pjl has this figured out. 👍
 
25-30 minutes for me. I do place monitors on myself and I place the TEE probe once the pt is intubated, before I place the cordis. I do float a swan for all the Pts where I'm at.


Sent from my iPhone using SDN mobile app
 
Direct Laryngoscopy said:
I do float a swan for all the Pts where I'm at.


Sent from my iPhone using SDN mobile app
Click to expand...

Seems like horrible overkill unless you have pulm htn, bad right heart, or LVEF < 25-30%


At my place we have a resident and staff 1 on 1 for cardiac. Both of us do everything (bring in pt, monitors, set up a-line and CVL kits, bring in TEE machine, etc). Our fastest start data collection -> probe in mouth times have been somewhere like 22-25 min with an experienced CA-2/CA-3. Average is 35-40 min. I honestly can't imagine anyone is much faster than 30-35 unless they have an RN/tech doing all the grunt work.
 
sethco said:
I'm not one to critique others practice, but seriously WTF?!?!??
Click to expand...

He is probably one of the most well-known CV surgeons in the world so he could do whatever he wanted.

I was just a peon resident trying not to get kicked out of the OR. Like I am going to say anything.
 
vector2 said:
Seems like horrible overkill unless you have pulm htn, bad right heart, or LVEF < 25-30%


At my place we have a resident and staff 1 on 1 for cardiac. Both of us do everything (bring in pt, monitors, set up a-line and CVL kits, bring in TEE machine, etc). Our fastest start data collection -> probe in mouth times have been somewhere like 22-25 min with an experienced CA-2/CA-3. Average is 35-40 min. I honestly can't imagine anyone is much faster than 30-35 unless they have an RN/tech doing all the grunt work.
Click to expand...

I see it in private practice where in the middle of the night the nurses can just rattle off some numbers to the surgeon when they call from the ICU. Not saying that makes it okay, but that is what it is used for where I see it placed routinely.
 
Hawaiian Bruin said:
Why?
Click to expand...

Wouldn't be my choice, but the CT surgeons prefer it so all the hemodynamic parameters can be referred to when they're at home.

I floated swans approx 15% of the time in fellowship, so this is a change. But the guys who bring the business have the most say.......


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I don't know why so many people are thinking this is unbelievable. There are several people here saying it can be done and I agree because I've done it. I have nothing to gain by making **** up here. The people on SDN that know me in real life could tell you that I'm pretty quick and efficient and have no trouble keeping up with our busy lines and fast surgeons.

A couple of my heart staff were impatient and if you were fumbling around they'd talk over so I made sure I was quick and efficient. I specifically remember one case, it was an add on and the surgeon was making a big deal about how we needed to have a quick turnover so we wouldn't be there all night. I got all my drips ready while on pump in the previous case and we got the patient in the room on a 45 min turnover which was impressive for the slow nurses/techs at my program. I had the circulator time me as I wanted to refute the surgeons bs about us taking an hour to do our lines. Don't get me wrong, some people did take that long but I never did, 45 min was the max that I remember.

I intubated the pt, did a straight forward a-line, double stick (cordis, 2x lumen and a swan), and placed the probe in 20min. We then sat there and waited 60 minutes for them to prep and for the surgeon to show up. My attending was present in that case, but it wasn't uncommon for my chair to give us a lot of autonomy if he/she trusted us and we felt comfortable. I wanted to be able to do straightforward CABG/valves in PP if I needed to and that was the goal I had achieved- doing straightforward cardiac cases with my attending as a consultant to confirm my echo findings, thats it. It was a great experience and I really appreciated the autonomy.

Ultrasound really makes things easy, especially A-lines in vasculopaths or central lines. The things that take the longest are prepping, setup, suturing and dressing and if you have good help with all that there's no reason why anyone can't achieve these numbers.
 
kazuma said:
The things that take the longest are prepping, setup, suturing and dressing and if you have good help with all that there's no reason why anyone can't achieve these numbers.
Click to expand...
This: if you are just doing the sticks and leaving everything else to a tech/nurse then yes of course 20min is reasonable. I've just never had that kind of help.
 
Not interested in a pissing match over how fast it can be done. Cutting time down usually requires a good bit of help and teamwork, for example everything is prepped for me to just stick a needle and catheter in and then move on to next step. In emergency cases where I can do that, yes I can be ready in 15-20 min. Less in a true splash and cut emergency where you place lines as the chest is being opened.

I prefer to take my time. It usually takes me 30 -45 min from the time the patient hits the OR to do the following.

1) Wait for patient to move over to OR bed and get positioned. Wait some more. Wait a little more.

2) A little Midaz in the IV and lidocaine to the wrist while nurses apply monitors.

3) A-line. 2 to 20 min. Typically 3-5. I apply Tegaderm and first piece of tape. Nurses finish.

4) Induce and intubate. Tape tube. Lube and tape eyes.

5) Place TEE probe and acquire view of right atrium. (To confirm CVL wires in right atrium before dilating)

6) Double stick IJ for CVL and cordis. Like Sevo, I place both wires then both catheters then suture both.

7) Float PA Catheter in every patient (per ICU and CT surgeon request)

8) Grab critical TEE measurements for case.

30 min of a-line takes typical 3-5 min, 45 if it takes 20 min.

One of my surgeons wants me to place a femoral a-line for every CABG in addition to the radial. I place it after the patient is prepped and draped and this adds another 5 min or so.



-pod
 
BLADEMDA said:
12 minutes total for the above plus 8-9 minutes to do the TEE (basic exam). If you miss the a-line the U/S should be in the room so you can use it for the second or third attempt. This would add about 5 minutes to the procedure time when utilized.
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😆🤣
Honestly guys. Such BS. I know you see the world in Matrix-style Bullet Time...
 
Hawaiian Bruin said:
You guys gotta wean your surgeons off the swans, man.
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Not logistical for the guys that do hearts in my practice, IMO. I think it comes down to whether the intensivist is in house or not. When the surgeon gets a call in the middle of the night, they want numbers. Those numbers could mean the difference between getting up and going in for a case or just going back to bed.
 
Ignatius J said:
Not logistical for the guys that do hearts in my practice, IMO. I think it comes down to whether the intensivist is in house or not. When the surgeon gets a call in the middle of the night, they want numbers. Those numbers could mean the difference between getting up and going in for a case or just going back to bed.
Click to expand...
What about arterial pulse contour analysis? You already have an a-line. No increased risk. No need for double stick.

http://www.sciencedirect.com/science/article/pii/S1053077007002236

http://www.sciencedirect.com/science/article/pii/S0003497502040596

http://www.sciencedirect.com/science/article/pii/S1053077099902161
 
All of the above is exactly why I don't do cardiac. Timing yourself for your lines? Are these the OR Olympics? Heaven forbid the mighty surgeon wait an extra ten minutes. Because, you know, we NEVER wait for them.
 
I can do it in 7 minutes. Taping the eyes after finishing preop interview saves me 30 seconds. I save another 30 seconds by inducing from a drained 50ml saline bag that I have filled with my induction meds. I have my 3rd anesthesia tech open the piggyback after I stick the radial. Number 2 is connecting the tubing to the a line. I just leave the wire in the artery and let her handle the rest. Number one holds cricoid and mask ventilates if number 3 opens the piggyback to early.
 
soorg said:
All of the above is exactly why I don't do cardiac. Timing yourself for your lines? Are these the OR Olympics? Heaven forbid the mighty surgeon wait an extra ten minutes. Because, you know, we NEVER wait for them.
Click to expand...

There was a case at my shop last week which was a five box thorascopic maze. Excellent surgeon so my staff felt content with a-line and two nicely flowing 16g's. Procedure going fine until BP suddenly tanks. Surgeon notifies us there is a hole in the main PA (required full sternotomy and crash bypass). Moral is, being able to quickly place a cordis (or IV-> RIC line) has more utility than just anesthesia ready time bragging rights and pleasing impatient surgeons.
 
caligas said:
Once patient is on the table how long should it take a private practice cardiac anesthesiologist to do the following in a routine heart case? (they have an anesthesia tech to help, otherwise they are on their own. Its all done in the o.r. in whatever order, and things go smoothly)

-place one art line
-induce and intubate
-place neck line/lines, and swan
-place tee probe
Click to expand...

I can't tell you how long it'd take me because I haven't done a pump case in years, not since residency. But I'm T-minus 82 days from doing a whole bunch of them. I'm so excited for fellowship even reading dorky threads about how many minutes to start lines has me checking the calendar and counting days.

/ nothing else to add
 
pgg said:
I can't tell you how long it'd take me because I haven't done a pump case in years, not since residency. But I'm T-minus 82 days from doing a whole bunch of them. I'm so excited for fellowship even reading dorky threads about how many minutes to start lines has me checking the calendar and counting days.

/ nothing else to add
Click to expand...

You're going back to do a cv fellowship after pp?

How long have you been in pp and why?
 
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soorg said:
All of the above is exactly why I don't do cardiac. Timing yourself for your lines? Are these the OR Olympics? Heaven forbid the mighty surgeon wait an extra ten minutes. Because, you know, we NEVER wait for them.
Click to expand...

It's an interesting culture. And it seems like that is the rule rather than the exception in any heart room. I just don't get it either.
 
I have been considering doing cardiac myself, but this kind of culture, coupled with some hugely oversized surgical egos, make me wonder if I would ever be happier in a cardiac room than in the ICU.
 
FFP said:
I have been considering doing cardiac myself, but this kind of culture, coupled with some hugely oversized surgical egos, make me wonder if I would ever be happier in a cardiac room than in the ICU.
Click to expand...

You should also go ahead and do a regional fellowship, so that you can block a joint in 2 seconds.

I kid.
 
I track times in all cases from Ortho to Uro to Cards, as do our nurses. If there is ever a question of delay, I can account for whether or not I am responsible and why.

This is extremely rare and my induction times average 3-5 min, but I still keep track. Pretty simple when you can put a time stamp on the record so easily.

About the only cases where I actually can be responsible for slowing things down is pedi tonsil/ BMT days. It's the only row that routinely keeps up with me.
 
Chloroform4Life said:
You're going back to do a cv fellowship after pp?

How long have you been in pp and why?
Click to expand...
I'm an unusual case. I'm still active duty Navy.

It took a few years for the Navy to perceive a need to train more CT anesthesiologists, and I had to get their OK (i.e. funding) to go. I've been wanting to go for a while.

I'll still get paid by the Navy, have those benefits, accrue retirement credit, etc so there's effectively no opportunity cost for me. In essence it's a free year away from the Navy to be a fellow at a civilian hospital.

It'd sure be harder to leave a PP group where I was a partner, or on the partner track, to go make $70K for a mid-career year.
 
vector2 said:
There was a case at my shop last week which was a five box thorascopic maze. Excellent surgeon so my staff felt content with a-line and two nicely flowing 16g's. Procedure going fine until BP suddenly tanks. Surgeon notifies us there is a hole in the main PA (required full sternotomy and crash bypass). Moral is, being able to quickly place a cordis (or IV-> RIC line) has more utility than just anesthesia ready time bragging rights and pleasing impatient surgeons.
Click to expand...

With 2 good 16's, do you really need the cordis? Focus on resuscitation?
 
pgg said:
I'm an unusual case. I'm still active duty Navy.

It took a few years for the Navy to perceive a need to train more CT anesthesiologists, and I had to get their OK (i.e. funding) to go. I've been wanting to go for a while.

I'll still get paid by the Navy, have those benefits, accrue retirement credit, etc so there's effectively no opportunity cost for me. In essence it's a free year away from the Navy to be a fellow at a civilian hospital.

It'd sure be harder to leave a PP group where I was a partner, or on the partner track, to go make $70K for a mid-career year.
Click to expand...

This is exactly what I did, only for $50K/year and I am so glad I did. I'm a much happier individual. Congratulations, you will have a great year.
 
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FWIW

Real case example today. In room 07:21 induction, all lines in, and echo done 07:49.

Art line took 4 min. Induction 2 min. Lines and echo took 17 min exact.

-pod
 
caligas said:
With 2 good 16's, do you really need the cordis? Focus on resuscitation?
Click to expand...

We obviously had someone hanging blood ASAP, but the arms were tucked so we wouldn't have been able to get directly to the catheters to hook up a belmont/rapid infuser (i.e. regular IV extension tubing is gonna be your rate limiting factor if you try to piggy back on that). The surgeon was able to intermittently put a finger in the PA hole while calling for help from another surgeon, but if she was rapidly exsanguinating the only way you'd be able to keep up is with a belmont hooked to a trialysis/12fr TLC/RIC/cordis/double lumen MAC etc. Not to mention we needed central access for pressors/vasoactive meds for both going on and coming off pump.
 
periopdoc said:
FWIW

Real case example today. In room 07:21 induction, all lines in, and echo done 07:49.

Art line took 4 min. Induction 2 min. Lines and echo took 17 min exact.

-pod
Click to expand...

Honest question, did the patient benefit from 7:49 as opposed to 7:59?
 
Ignatius J said:
Honest question, did the patient benefit from 7:49 as opposed to 7:59?
Click to expand...

It's really more for our own benefit than the patient's. After doing things for awhile everything becomes routine. I think a lot of people who do cardiac are looking for more challenge. Timing ourselves, refining technique, streamlining the process are all ways to keep things interesting and fun. And when it's necessary to do things quickly and efficiently, it's good to have practiced.
 
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