Care of central lines placed intraop

[deleted126335]

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[militarymd]

we don't have one, but we had the same thing that you described happen a little while back except the person (who just happened to be a locum tenems fmg) put the triple lumen into the carotid and sent the patient up to the ward with the line in the carotid.

I got a call a few days later when the patient started having TIA's when they started tpn through it.

 

[rsgillmd]

Question regarding post op responsibility for care of central lines. No documented policy in our institution. We place them intraop, make sure post op film is good, leaving post op care to surgery or medical service. Had an incident where a line was placed properly, but improperly cared for afterwards. Phone call was along the lines of "do you know what happened with YOUR line that YOU placed?" Am curious what written policy is in your institutions?

The phone call sounds like another case of people not wanting to take responsibility for their actions. As far as I'm concerned, once you make sure the post-op film is good and transfer care of the patient, it becomes the receiving team's responsibility.

We had a case recently where ER placed a triple lumen, and started a vasopressor after prelim X-ray report said it was good. Pt. came up to the OR for a procedure. The triple lumen, along with the peripheral IVs, was used during the case. Postop a huge pleural effusion was found and review of preop X-ray suggested the triple lumen was not in place (rumor). Thank goodness the blood they gave was through the peripheral IV and not the triple lumen.

I'm being vague because a) this case will be dicussed in PI and b) I don't know all the details. I know what the conclusion is likely going to be: if you use a central line that wasn't placed by you, confirm it in some manner (ex: aspiration of blood, transduce a CVP, etc.). I can't speak for what was actually done in the OR -- for all I know it was confirmed on entry to the OR and came out sometime intraop. The presence of the pleural effusion is a fact. The reading of the initial x-ray is a rumor.

We have no written policy as of yet that I know of. However, after this case there probably will be one.

 

[Planktonmd]

I have one advice here:
If you place a central line in the OR the best thing you can do for the patient is remove that central line in recovery if possible.
If you don't have a central line then you don't get central line complications.
If they don't truly need it, take it out.

 

[coprolalia]

We routinely place PICCs now in our institution. Except for cardiac patients (which get an introducer). And, it'd be a hard sell to pull a central line after a case is over for a variety of (mostly political) reasons. Chances are if you are going to pull it after, you probably didn't really need it in the first place.

-copro

 

[deleted126335]

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[deleted126335]

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[rsgillmd]

The case that occurred was an 8.5 Fr introducer properly placed without incident, patient went to ICU for a few days, then to floor. Disconnect of IV tubing with expected consequences.

They sent a patient with an introducer to the floor? That's the ICU's fault. I'm surprised you're even getting a phone call.

Any patient that is stable enough to leave an ICU does not need an introducer. We always either change it to a TLC, or pull the central line itself.

 

[Planktonmd]

Chances are if you are going to pull it after, you probably didn't really need it in the first place.

-copro

Correct! most of the times we place central lines that we don't need.
If the central line is needed post op for TPN or certain meds then a PICC placed electively is a better choice.

 

[dhb]

PICC?

thx

 

[coprolalia]

PICC?

Peripherally Inserted Central Catheter. They're the bomb. Can stay in for weeks... even months... if cared for properly.

-copro

 

[jetproppilot]

Question regarding post op responsibility for care of central lines. No documented policy in our institution. We place them intraop, make sure post op film is good, leaving post op care to surgery or medical service. Had an incident where a line was placed properly, but improperly cared for afterwards. Phone call was along the lines of "do you know what happened with YOUR line that YOU placed?" Am curious what written policy is in your institutions?

What happened to the line?

 

[deleted126335]

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[coprolalia]

Case 1. patient with introducer transferred to floor, exsanguinated when IV tubing disconnected.

Case 2. Triple lumen placed by anesthesiologist in OR. Left in place for 4 weeks, line sepsis.

Both completely inexcusable. This is why anesthesiologists need to remember that they are doctors and follow-up on their patients instead of beating a hasty retreat at 3:00 PM along with the CRNA's.

You know the old joke, right? "Why is there such a high death rate among anesthesiologists? Because they get run over by radiologists in the parking lot while running to their cars."

I think that if you put that line in, you own it. And, unless you trust that someone to whom you're transferring care, you better make sure it's managed properly. I'm sure the courts would likely agree.

OWN IT!

-copro

 

[deleted126335]

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[Planktonmd]

1
The attitude that "you placed it, you own it" is why most of us write for central line to be d/c'd within 48-72 hours.

Exactly, or even sooner if you can.

 

[dA pilot]

I think that if you put that line in, you own it. And, unless you trust that someone to whom you're transferring care, you better make sure it's managed properly. I'm sure the courts would likely agree.

OWN IT!

-copro

Medicine is about transfer of care. No one is in the hospital 24/7. When you drop a critical patient in the ICU, you expect the staff there to take care of the patient because you go home, same as a central line.

 

[Arch Guillotti]

I have never written for a central line to be discharged other than when I was on an ICU rotation. I checked the chest xray when I was the PACU resident or rarely switched out a cordis for a TLC if necessary.

 

[seinfeld]

Peripherally Inserted Central Catheter. They're the bomb. Can stay in for weeks... even months... if cared for properly.

-copro

I am seeing increased number of upper extremity DVTs associated with PICC, of course i work in an ICU where the risk factors abound. The way they are used in the hospital (constantly drawing blood, attaching and detaching infusions) makes them have similar suspect for infection in the febrile pt.

Where i trained the cental line was the surgeons responsibility postop. It was never assumed that a central line was the property of the anesthesia team. We rarely used them intraop only if going to an ICU post op, and all our ICU were staffed 24/7 in house by residents.

As far as a 9 french anything on the floor thats not ideal. But remember a well placed 14g in the AC can cause significant blood loss if left uncapped. This whole thing sounds like nurses trying to blame someone else for poor patient care.

 

[mille125]

we don't have one, but we had the same thing that you described happen a little while back except the person (who just happened to be a locum tenems fmg) put the triple lumen into the carotid and sent the patient up to the ward with the line in the carotid.

I got a call a few days later when the patient started having TIA's when they started tpn through it.

holy ****....did you need to get a vascular consult...good thing it wasnt a cordis

 

[mille125]

We routinely place PICCs now in our institution. Except for cardiac patients (which get an introducer). And, it'd be a hard sell to pull a central line after a case is over for a variety of (mostly political) reasons. Chances are if you are going to pull it after, you probably didn't really need it in the first place.

-copro

i agree with coprolalia...typically if you need it intra-op, you are going to need it postop...it would be hard to pull a lot of these lines...

 

[mille125]

They sent a patient with an introducer to the floor? That's the ICU's fault. I'm surprised you're even getting a phone call.

Any patient that is stable enough to leave an ICU does not need an introducer. We always either change it to a TLC, or pull the central line itself.

agreed...they had no right to call you ....this sounds like stupidity on their part

 

[mille125]

Both completely inexcusable. This is why anesthesiologists need to remember that they are doctors and follow-up on their patients instead of beating a hasty retreat at 3:00 PM along with the CRNA's.

You know the old joke, right? "Why is there such a high death rate among anesthesiologists? Because they get run over by radiologists in the parking lot while running to their cars."

I think that if you put that line in, you own it. And, unless you trust that someone to whom you're transferring care, you better make sure it's managed properly. I'm sure the courts would likely agree.

OWN IT!

-copro

So you are saying that if these two cases happened to one of your patients, you would take responsibility for it (own it as you say)???? Also, you would have continued to round on patient two for a whole 4 weeks postop just because they had a central line.

 

[jetproppilot]

Both completely inexcusable. This is why anesthesiologists need to remember that they are doctors and follow-up on their patients instead of beating a hasty retreat at 3:00 PM along with the CRNA's.

You know the old joke, right? "Why is there such a high death rate among anesthesiologists? Because they get run over by radiologists in the parking lot while running to their cars."

I think that if you put that line in, you own it. And, unless you trust that someone to whom you're transferring care, you better make sure it's managed properly. I'm sure the courts would likely agree.

OWN IT!

-copro

Sorry, Bro, I humbly disagree.

S hit happens.

If I had to follow up on every central line I placed it'd be a part time job!

In the hospital I'm at, theres things that happen..some good, some bad.

THE BAD:

1)We place ALL central lines in the hospital. No need for posting rebuttals...I agree with your rebuttal. I'm just posting reality at my hospital. And since my gig is such a good one for the area I'm in, its a sword I swallow....remember resident colleagues....WANNA GEOGRAPHICALLY limit yourself? NEED TO live in ONE certain area? I respect that. I'm currently living that scenerio. Hence my swallowing the sword...

THE GOOD:

1) I place a line and kinda forget about it. Post op CXR is a given on all central lines. If theres a problem I'll get a phone call pretty soon.

2) Post op line care is delegated to whatever service is handling the patient.


ASIDE: I've been doing this gig for twelve years now. Its hard for me to fathom how cannulation of the carotid artery goes unnoticed by the anesthesia attending.

WANNA KNOW WHY I KNOW THAT?

I know that because a few years ago I inadvertently cannulated the carotid artery with a central line.😱

Yep.

Read that again.

I'm not proud of it.

One of the most painful telephone calls I've ever made:

"Yeah, hey Jack? Bill. Listen....your CABG patient Mister Jones? Gott'em in Holding and I put the central line in the carotid."

Jay: (flusters for a cuppla seconds) "Are you sure?"

(When I opened a port to flush it, blood gushed out, obviously from a NON VENOUS ETIOLOGY.)

"Uhhh, yeah Dude. I'm sure."

Haffta say Jack the Heart Surgeon handled it well.

We went to the back, put the dude to sleep, Jack-the-Heart-Surgeon fixed my error, did the Dudes heart surgery, then went home.

BUT WAIT.....it gets better....

this 70s dude who I cannulated the carotid on's....

SON WAS A LAWYER.😱

I spoke with the son before the surgery.

And after the surgery.

Thankfully nothing bad happened to his Dad.

PLEASE HEAR MY WORD OF ADVICE HERE:

I was a fan of those syringe-needle set-ups where you can thread a wire thru the plunger of the syringe without disconnecting anything before this happened.

Despite the proprietary coolness of not disconnecting this kinda cool invention, PLEASE DISCONNECT THE SYRINGE FROM THE NEEDLE before threading a wire.

It should be obvious then.

 

[mille125]

Sorry, Bro, I humbly disagree.

S hit happens.

If I had to follow up on every central line I placed it'd be a part time job!

In the hospital I'm at, theres things that happen..some good, some bad.

THE BAD:

1)We place ALL central lines in the hospital. No need for posting rebuttals...I agree with your rebuttal. I'm just posting reality at my hospital. And since my gig is such a good one for the area I'm in, its a sword I swallow....remember resident colleagues....WANNA GEOGRAPHICALLY limit yourself? NEED TO live in ONE certain area? I respect that. I'm currently living that scenerio. Hence my swallowing the sword...

THE GOOD:

1) I place a line and kinda forget about it. Post op CXR is a given on all central lines. If theres a problem I'll get a phone call pretty soon.

2) Post op line care is delegated to whatever service is handling the patient.


ASIDE: I've been doing this gig for twelve years now. Its hard for me to fathom how cannulation of the carotid artery goes unnoticed by the anesthesia attending.

WANNA KNOW WHY I KNOW THAT? geez this forum is so revealing sometimes I mind as well give you dudes my Schwab account number and tell you to WITHDRAW AT WILL

I know that because a few years ago I inadvertently cannulated the carotid artery with a central line.😱

Yep.

Read that s hit again.

I'm not proud of it.

One of the most painful telephone calls I've ever made:

"Yeah, hey Jay? Bill. Listen....your CABG patient Mister Jones? Gott'em in Holding and I put the central line in the carotid."

Jay: (flusters for a cuppla seconds) "Are you sure?"

(When I opened a port to flush it, blood gushed out, obviously from a NON VENOUS ETIOLOGY.)

"Uhhh, yeah Dude. I'm sure."

Haffta say Jay the Heart Surgeon handled it well.

We went to the back, put the dude to sleep, Jay-the-Heart-Surgeon fixed my error, did the Dudes heart surgery, then went home.

BUT WAIT.....it gets better....

this 70s dude who I cannulated the carotid on's....

SON WAS A LAWYER.😱

I spoke with the son before the surgery.

And after the surgery.

Thankfully nothing bad happened to his Dad.

And no lawsuit originated.

PLEASE HEAR MY WORD OF ADVICE HERE:

I was a fan of those syringe-needle set-ups where you can thread a wire thru the plunger of the syringe without disconnecting anything before this happened.

Despite the proprietary coolness of not disconnecting this kinda cool invention, PLEASE DISCONNECT THE SYRINGE FROM THE NEEDLE before threading a wire.

It should be obvious then.

AGAIN, hard for me to see how a clinician could miss a cannulated artery, to the point of sending it to the floor, since I've done it.

i can see how it is done...the practitioner didnt care...sad but true

 

[usnavdoc]

So you are saying that if these two cases happened to one of your patients, you would take responsibility for it (own it as you say)???? Also, you would have continued to round on patient two for a whole 4 weeks postop just because they had a central line.

He is just spouting some senseless surgical doctrine. No one is going to follow a CVL for the life of the line. That care is transferable to the surgeon or intensivist taking care of the patient. Ridiculous to even consider. Now an epidural is slightly different. But not a CVL or Art line. Remember we are consultants for the perioperative period. We do not own the patient therefor we do not own the line as you say.

In terms of inadvertently cannulating an artery we generally use gravity transduction as an additional measure prior to dilation. Only takes a sec or two.

 

[jetproppilot]

In terms of inadvertently cannulating an artery we generally use gravity transduction as an additional measure prior to dilation. Only takes a sec or two.

YESSIR, DUDE.

"YESSIR."👍

 

[coprolalia]

Medicine is about transfer of care. No one is in the hospital 24/7. When you drop a critical patient in the ICU, you expect the staff there to take care of the patient because you go home, same as a central line.

So you are saying that if these two cases happened to one of your patients, you would take responsibility for it (own it as you say)???? Also, you would have continued to round on patient two for a whole 4 weeks postop just because they had a central line.

No, no, no. That's not what I'm saying at all. Don't misquote/overinterpret/put words in my mouth.

What I'm saying (and, I know because I've done it too... glass houses... throwing stones...) is that you need to follow-up on your patients. How many times have you failed to go back and see a critical patient 24 hours later?

This is very easy. You see the patient the next day, you drop a note in the chart, and part of that note says "central access should continue to be monitored and discontinued at earliest feasible time. If not feasible, line site should be discontinued or changed on XX/XX/20XX." CYA.

What happens (again, been there done that) is that you drop a central line in with no documentation (except what's on the anesthesia record) and then you send the patient off to some remote area of the geriatric ward never to see or hear about them again... until Haywood Jablome, Esq. sends you a subpoena.

I hope no one is advocating that we don't follow-up on our patients. That's part of our expected and required standard of care. IF you don't follow-up on your patients, you've failed in your fiduciary responsibility. And, that is grounds for malpractice. That doesn't mean you need to go see them everyday for four weeks ( 🙄 ).

-copro

 

[coprolalia]

He is just spouting some senseless surgical doctrine.

Sad that we don't take responsibility for what we do to the patient sometimes. That's what I'm talking about. Easy to stick a line in and then forget it, isn't it?

No one is going to follow a CVL for the life of the line. ... Ridiculous to even consider. ... We do not own the patient therefor we do not own the line as you say.

Never meant to imply (nor do I think I ever said) that you should follow a CVP line for the entire time it's in. But, if you do a procedure, you're responsible for it. And, Mr. Judge Joe Brown may see it differently than you do, especially if you fail to appropriately follow-up and/or document transfer of care.

-copro

 

[Planktonmd]

I hope no one is advocating that we don't follow-up on our patients. That's part of our expected and required standard of care. IF you don't follow-up on your patients, you've failed in your fiduciary responsibility. And, that is grounds for malpractice. That doesn't mean you need to go see them everyday for four weeks ( 🙄 ).

-copro

Dude, are you a lawyer?? 🙂

 

[usnavdoc]

Sad that we don't take responsibility for what we do to the patient sometimes. That's what I'm talking about. Easy to stick a line in and then forget it, isn't it?



Never meant to imply (nor do I think I ever said) that you should follow a CVP line for the entire time it's in. But, if you do a procedure, you're responsible for it. And, Mr. Judge Joe Brown may see it differently than you do, especially if you fail to appropriately follow-up and/or document transfer of care.

-copro

I see where you are coming from, but I just feel that as we sign a patient out of PACU or in the ICU we are turning care over to surgical/ICU team. We always have direct communication with the recieving resident/PA and it is stated in our turnover notes.

 

[Arch Guillotti]

This is very easy. You see the patient the next day, you drop a note in the chart, and part of that note says "central access should continue to be monitored and discontinued at earliest feasible time. If not feasible, line site should be discontinued or changed on XX/XX/20XX." CYA.

Had I done the above I would have been laughed out of residency.

 

[radslooking]

we don't have one, but we had the same thing that you described happen a little while back except the person (who just happened to be a locum tenems fmg) put the triple lumen into the carotid and sent the patient up to the ward with the line in the carotid.

I got a call a few days later when the patient started having TIA's when they started tpn through it.

😱

 

[radslooking]

No, no, no. That's not what I'm saying at all. Don't misquote/overinterpret/put words in my mouth.

What I'm saying (and, I know because I've done it too... glass houses... throwing stones...) is that you need to follow-up on your patients. How many times have you failed to go back and see a critical patient 24 hours later?

This is very easy. You see the patient the next day, you drop a note in the chart, and part of that note says "central access should continue to be monitored and discontinued at earliest feasible time. If not feasible, line site should be discontinued or changed on XX/XX/20XX." CYA.

What happens (again, been there done that) is that you drop a central line in with no documentation (except what's on the anesthesia record) and then you send the patient off to some remote area of the geriatric ward never to see or hear about them again... until Haywood Jablome, Esq. sends you a subpoena.

I hope no one is advocating that we don't follow-up on our patients. That's part of our expected and required standard of care. IF you don't follow-up on your patients, you've failed in your fiduciary responsibility. And, that is grounds for malpractice. That doesn't mean you need to go see them everyday for four weeks ( 🙄 ).

-copro

it would be nice but unexpected to see anesthesia write a note like that in the charts. any medical or surgical team worth their salt will take care of the line just fine, however. mostly they're just happy and grateful you placed the line for them. I don't know any team that would expect you to follow that line or write a note.

 

[radslooking]

I am seeing increased number of upper extremity DVTs associated with PICC, of course i work in an ICU where the risk factors abound. The way they are used in the hospital (constantly drawing blood, attaching and detaching infusions) makes them have similar suspect for infection in the febrile pt.

Where i trained the cental line was the surgeons responsibility postop. It was never assumed that a central line was the property of the anesthesia team. We rarely used them intraop only if going to an ICU post op, and all our ICU were staffed 24/7 in house by residents.

As far as a 9 french anything on the floor thats not ideal. But remember a well placed 14g in the AC can cause significant blood loss if left uncapped. This whole thing sounds like nurses trying to blame someone else for poor patient care.

at an institution i was working at, i was seeing a lot of those too.(UE DVT) more than could be explained by chance. my anecdotal opinion is that it was associated with a specific brand of catheter. i believe it was powerpicc, but could be mistaken.

on a side note, i was aghast when we had a huge increase in thoracentesis ptx's with a new thoracentesis catheter, but instead of going back to the old catheter's the institution decided we just needed more training on the new ones. wondered if they signed a good contract with the company....hmm......

 

[radslooking]

i should know this but i don't. what is the proper procedure if you cannulate the carotid artery? keep it in place?

 

[Arch Guillotti]

we don't have one, but we had the same thing that you described happen a little while back except the person (who just happened to be a locum tenems fmg) put the triple lumen into the carotid and sent the patient up to the ward with the line in the carotid.

Did this turkey do a case with this line in place?

Wow, that is bad.

 

[9french]

i should know this but i don't. what is the proper procedure if you cannulate the carotid artery? keep it in place?

Depends on what you cannulate it with. If you hit it with your seeker or angiocath, just pull it out and hold a few minutes of pressure. If you dilate the carotid, you should let one of your surgical colleagues know what happenned in case it needs surgical repair, then pull it out and hold pressure, but this time for a good 30 minutes.

What gets controversial is what to do if the SC artery is dilated. Some surgeons would suggest only pulling it in the O.R., and immediately follow up with an angiogram, while others believe it can be pulled at bedside and watched.

I've personally done near 500 central lines and never dilated an artery. I owe that solely to the fact that I always tranduce before dilating. An easy trick is to hook up a 70 cm piece of sterile tranducer tubing once the angiocath is in the vessel. You then allow the tubing to fill with blood and hold it up. If blood rises, you are in an artery, if it falls, you are in a vein. If you use the steel needle as opposed to the angiocath, you can place the wire through the needle, remove the steel needle, then place the 20g angiocath back over the wire to transduce. This whole process adds less than a minute onto the procedure and can prevent a disasterous complication.

 

[deleted126335]

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[Gern Blansten]

An easy trick is to hook up a 70 cm piece of sterile tranducer tubing once the angiocath is in the vessel. You then allow the tubing to fill with and hold it up. If rises, you are in an artery, if it falls, you are in a vein. If you use the steel needle as opposed to the angiocath, you can place the wire through the needle, remove the steel needle, then place the 20g angiocath back over the wire to transduce. This whole process adds less than a minute onto the procedure and can prevent a disasterous complication.

That is how most people at our place do it. Hard to go wrong with that technique.

 

[seinfeld]

That is how most people at our place do it. Hard to go wrong with that technique.

Agree, this is how i do it all the time. I never rely on blood color or pulse as i have had patients who were in shock have dark arterial blood and pts with mod-severe TR with pulsating blood in the IJ

 

[fval28]

Depends on what you cannulate it with. If you hit it with your seeker or angiocath, just pull it out and hold a few minutes of pressure. If you dilate the carotid, you should let one of your surgical colleagues know what happenned in case it needs surgical repair, then pull it out and hold pressure, but this time for a good 30 minutes.

What gets controversial is what to do if the SC artery is dilated. Some surgeons would suggest only pulling it in the O.R., and immediately follow up with an angiogram, while others believe it can be pulled at bedside and watched.

I've personally done near 500 central lines and never dilated an artery. I owe that solely to the fact that I always tranduce before dilating. An easy trick is to hook up a 70 cm piece of sterile tranducer tubing once the angiocath is in the vessel. You then allow the tubing to fill with blood and hold it up. If blood rises, you are in an artery, if it falls, you are in a vein. If you use the steel needle as opposed to the angiocath, you can place the wire through the needle, remove the steel needle, then place the 20g angiocath back over the wire to transduce. This whole process adds less than a minute onto the procedure and can prevent a disasterous complication.

just a question, why not just hook the sterile tubing up to the steel needle and check for pulsatile flow-- why the xtra step of placing the angiocath?

thanks

 

[usnavdoc]

Depends on what you cannulate it with. If you hit it with your seeker or angiocath, just pull it out and hold a few minutes of pressure. If you dilate the carotid, you should let one of your surgical colleagues know what happenned in case it needs surgical repair, then pull it out and hold pressure, but this time for a good 30 minutes.

What gets controversial is what to do if the SC artery is dilated. Some surgeons would suggest only pulling it in the O.R., and immediately follow up with an angiogram, while others believe it can be pulled at bedside and watched.

I've personally done near 500 central lines and never dilated an artery. I owe that solely to the fact that I always tranduce before dilating. An easy trick is to hook up a 70 cm piece of sterile tranducer tubing once the angiocath is in the vessel. You then allow the tubing to fill with blood and hold it up. If blood rises, you are in an artery, if it falls, you are in a vein. If you use the steel needle as opposed to the angiocath, you can place the wire through the needle, remove the steel needle, then place the 20g angiocath back over the wire to transduce. This whole process adds less than a minute onto the procedure and can prevent a disasterous complication.

70cm? lol are you like across the room J/k you can use the standard extension set

 

[jwk]

If you dilate the carotid, you should let one of your surgical colleagues know what happenned in case it needs surgical repair, then pull it out and hold pressure, but this time for a good 30 minutes.

What gets controversial is what to do if the SC artery is dilated. Some surgeons would suggest only pulling it in the O.R., and immediately follow up with an angiogram, while others believe it can be pulled at bedside and watched.

Respectfully yet vehemently disagree.

Leave the damn thing in - no exceptions. A cordis/dilator in the carotid = surgical exploration. With a catheter that big, you're making a hole, not pushing fibers to the side. And in the neck, there just ain't no place for blood to go.

I've seen this twice - once during training at Emory around 1980, which prompted a lovely and embarassing presentation at the M&M conference for the resident involved. The universal thought from the attendings (inlcuding Steinhaus, Hug, Kaplan, et al) was leave it in and get it explored. That's what they did.

I also saw it in PP about 10 years ago. The new attending put in the introducer. As they were turning to pick up the swan, I happened to walk by, and in my calmest and coolest voice whispered "the bubble in the sideport of your introducer is pulsating". We hooked the sideport lumen to the transducer that was sitting there ready, and you know the rest. I told her my Emory M&M story - she called the surgeon and asked what to do. He told her to "pull it, hold pressure on it for 20 minutes, and send them to the ICU with a sandbag on the side of their neck".

An hour later there is a call from another anesthesiologist stating they were one their way from the ICU with a patient with a rapidly expanding neck hematoma and to find an empty OR. Of course it was the same patient. HUMONGOUS hematoma. Major puckering by all involved. After a few minutes we headed down the can't intubate-can't ventilate scenario and literally pushed a general surgeon into the room and said "trach him now or the patient will die". The trachea was deviated WAY over to the left side of the neck. Lo and behold, about the time we got the trach in and everybody unpuckered a little, the vascular surgeon (the one that said pull it) shows up, wants to know what the big deal is, and opens the guys neck. A good 500cc or more came out of that hematoma, along with several BIG squirts from the carotid before he got a clamp on it. This experience of course made a MAJOR impression in my psyche.

Leave it in - explore it. End of story.

 

[mille125]

Respectfully yet vehemently disagree.

Leave the damn thing in - no exceptions. A cordis/dilator in the carotid = surgical exploration. With a catheter that big, you're making a hole, not pushing fibers to the side. And in the neck, there just ain't no place for blood to go.

I've seen this twice - once during training at Emory around 1980, which prompted a lovely and embarassing presentation at the M&M conference for the resident involved. The universal thought from the attendings (inlcuding Steinhaus, Hug, Kaplan, et al) was leave it in and get it explored. That's what they did.

I also saw it in PP about 10 years ago. The new attending put in the introducer. As they were turning to pick up the swan, I happened to walk by, and in my calmest and coolest voice whispered "the bubble in the sideport of your introducer is pulsating". We hooked the sideport lumen to the transducer that was sitting there ready, and you know the rest. I told her my Emory M&M story - she called the surgeon and asked what to do. He told her to "pull it, hold pressure on it for 20 minutes, and send them to the ICU with a sandbag on the side of their neck".

An hour later there is a call from another anesthesiologist stating they were one their way from the ICU with a patient with a rapidly expanding neck hematoma and to find an empty OR. Of course it was the same patient. HUMONGOUS hematoma. Major puckering by all involved. After a few minutes we headed down the can't intubate-can't ventilate scenario and literally pushed a general surgeon into the room and said "trach him now or the patient will die". The trachea was deviated WAY over to the left side of the neck. Lo and behold, about the time we got the trach in and everybody unpuckered a little, the vascular surgeon (the one that said pull it) shows up, wants to know what the big deal is, and opens the guys neck. A good 500cc or more came out of that hematoma, along with several BIG squirts from the carotid before he got a clamp on it. This experience of course made a MAJOR impression in my psyche.

Leave it in - explore it. End of story.

i absolutely agree. I personally havent had the above experience (but why would anyone want to go down this pathway).

 

[GasEmDee]

WOW. Awesome story. How could one ever forget that??

What do you guys think about ultrasound-guided line placements?

Respectfully yet vehemently disagree.

Leave the damn thing in - no exceptions. A cordis/dilator in the carotid = surgical exploration. With a catheter that big, you're making a hole, not pushing fibers to the side. And in the neck, there just ain't no place for blood to go.

I've seen this twice - once during training at Emory around 1980, which prompted a lovely and embarassing presentation at the M&M conference for the resident involved. The universal thought from the attendings (inlcuding Steinhaus, Hug, Kaplan, et al) was leave it in and get it explored. That's what they did.

I also saw it in PP about 10 years ago. The new attending put in the introducer. As they were turning to pick up the swan, I happened to walk by, and in my calmest and coolest voice whispered "the bubble in the sideport of your introducer is pulsating". We hooked the sideport lumen to the transducer that was sitting there ready, and you know the rest. I told her my Emory M&M story - she called the surgeon and asked what to do. He told her to "pull it, hold pressure on it for 20 minutes, and send them to the ICU with a sandbag on the side of their neck".

An hour later there is a call from another anesthesiologist stating they were one their way from the ICU with a patient with a rapidly expanding neck hematoma and to find an empty OR. Of course it was the same patient. HUMONGOUS hematoma. Major puckering by all involved. After a few minutes we headed down the can't intubate-can't ventilate scenario and literally pushed a general surgeon into the room and said "trach him now or the patient will die". The trachea was deviated WAY over to the left side of the neck. Lo and behold, about the time we got the trach in and everybody unpuckered a little, the vascular surgeon (the one that said pull it) shows up, wants to know what the big deal is, and opens the guys neck. A good 500cc or more came out of that hematoma, along with several BIG squirts from the carotid before he got a clamp on it. This experience of course made a MAJOR impression in my psyche.

Leave it in - explore it. End of story.

 

[periopdoc]

At our institution we transduce all central lines with a T-Piece connected between the steel needle and the syringe. Line it up, pop the needle in, look at your screen for an appropriate pressure and waveform then go to town. Appropriate can be quite variable if you have a lot of pulmonary HTN and tricuspid regurg.

As far as U/S guidance, I have mixed emotions. It is so easy and ubiquitous that i worry that our residents will be unable to place IJ lines without U/S guidance. While it is not foolproof, we can always find a bigger fool, it is remarkably safe. Here is my technique.

Get a short axis view of the Carotid and IJ. Verify with compression that what you think is venous is actually venous. Place the tip of your needle on the center of the IJ, you should see a bright dot right on the surface at the middle of the vein. Turn your probe 90 degrees to obtain a long axis view of the vein. Watch the tip of your needle pierce the IJ and advance a short distance. Verify with manometry and thread your wire. With practice this takes 2-3 minutes from the time you set the probe on the patient until you are threading your line over the wire.

Oh and if you use one of those syringes that allows you to thread the wire through it and you don't have a T-Piece, there is a blunt tipped needle in the central line kit that you can connect into your manometer and push into the back of the syringe to get the tracing/ pressure check.

Of course when you are halfway through operating on that 200 kg beached whale and some lovely gyn resident decides to adjust the warming blanket and grabs ahold of and pulls the last possible peripheral IV left on this decrepit soul of a patient, you better be able to place that central line at arms length, with anatomical landmarks and the basic extension tubing transducer technique described above. Been there done that.

pod

 

[mille125]

Both completely inexcusable. This is why anesthesiologists need to remember that they are doctors and follow-up on their patients instead of beating a hasty retreat at 3:00 PM along with the CRNA's.

You know the old joke, right? "Why is there such a high death rate among anesthesiologists? Because they get run over by radiologists in the parking lot while running to their cars."

I think that if you put that line in, you own it. And, unless you trust that someone to whom you're transferring care, you better make sure it's managed properly. I'm sure the courts would likely agree.

OWN IT!
-copro

I dont believe that i misquoted or misinterpretted you. This is what you said.........

 

[coprolalia]

I dont believe that i misquoted or misinterpretted you. This is what you said.........

If you don't appropriately document transfer of care including the discontinuation date, I think the first lawyer who sues (and wins) for a central line infection is going to change a lot of your guy's opinion on the matter. I know how sloppy the follow-up can be on these lines. I'm guilty of it myself. I'm trying to do better.

-copro

 

[9french]

Respectfully yet vehemently disagree.

Leave the damn thing in - no exceptions. A cordis/dilator in the carotid = surgical exploration. With a catheter that big, you're making a hole, not pushing fibers to the side. And in the neck, there just ain't no place for blood to go.

I've seen this twice - once during training at Emory around 1980, which prompted a lovely and embarassing presentation at the M&M conference for the resident involved. The universal thought from the attendings (inlcuding Steinhaus, Hug, Kaplan, et al) was leave it in and get it explored. That's what they did.

I also saw it in PP about 10 years ago. The new attending put in the introducer. As they were turning to pick up the swan, I happened to walk by, and in my calmest and coolest voice whispered "the bubble in the sideport of your introducer is pulsating". We hooked the sideport lumen to the transducer that was sitting there ready, and you know the rest. I told her my Emory M&M story - she called the surgeon and asked what to do. He told her to "pull it, hold pressure on it for 20 minutes, and send them to the ICU with a sandbag on the side of their neck".

An hour later there is a call from another anesthesiologist stating they were one their way from the ICU with a patient with a rapidly expanding neck hematoma and to find an empty OR. Of course it was the same patient. HUMONGOUS hematoma. Major puckering by all involved. After a few minutes we headed down the can't intubate-can't ventilate scenario and literally pushed a general surgeon into the room and said "trach him now or the patient will die". The trachea was deviated WAY over to the left side of the neck. Lo and behold, about the time we got the trach in and everybody unpuckered a little, the vascular surgeon (the one that said pull it) shows up, wants to know what the big deal is, and opens the guys neck. A good 500cc or more came out of that hematoma, along with several BIG squirts from the carotid before he got a clamp on it. This experience of course made a MAJOR impression in my psyche.

Leave it in - explore it. End of story.

Thanks for the story. I have not had to deal with an arterial dilation, yet, so it is good to hear from someone who has seen the consequence. It seems your vascular surgeon was under the same impression I was. I wonder if there is any evidence-based guidelines as to what to do?