do you transduce every CVC stick?

[VentdependenT]

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Not that I see all of their experience, but I bet they don't. At least by policy they aren't supposed to do it any other way.

Sad, I agree, but if it was my wife with the speared carotid that they did their one or two old fashioned attempts on, I don't know how I would feel, when there is a technology that might help protect against some of the complications of a procedure.

A tough philosophical question.

Do any of your residents graduate with trans-arterial ax blocks or plumb-bob supra-clavicular blocks, rather than US guided, in this day and age, and should they?

Do residents learn to do blind stellate ganglion or blind celiac plexus blocks any more (like I did), now that we have imaging that makes it a better, safer procedure?

Good questions, all.

Never had an issue after hitting carotid with finder needle. never sunk the 18g into carotid. I think blind ax block is ridiculous. seen a few seizures in surgicenter with this.

 

[Bostonredsox]

Do Residents place 1-2 IJ lines without live/dynamic U/S before graduating? What a shame to never have placed an internal Jugular line without u/s.

I would assume as a gas resident yes. As an IM resident? No. Attendings and admins don't want there to be carotid sticks so every IJ is done with US. They don't care that you might later be ate place without US, they just don't want a carotid stick on their watch. I however am one of the few that put in trams venous pacers and I was taught by one of the old time cards attendings who would not let me use the US to place the jugular sheath. It was 22ga finder then 18ga. I'm comfortable with it. But I don't think a single other of my co-IM residents have done this except one who is going cardio next year and worked with the same cards attending here.

That said, in my own practice I will probably never do this. I am very comfortable with anatomical/landmark based subclavians. I don't think I would ever place a blind IJ if I didn't have an US, I would just stick the chest. I could, but SC is just an easier line to place by feel in my opinion. Plus if I drop the lung with my blind SC, I can personally fix the situation pretty quickly. If I blow up a carotid on a blind stick, well I can't fix that.

 

[45408]

Surgery resident here, and we never place IJs without U/S.


How exactly do you guys do your "poor man's CVP"? put a length of IV tubing on there and watch how high it rises? let it fill horizontally then make it a standing column?

 

[pgg]

How exactly do you guys do your "poor man's CVP"? put a length of IV tubing on there and watch how high it rises? let it fill horizontally then make it a standing column?

Yes. Needle --> angiocath into vessel --> tubing to angiocath. Or, needle --> wire --> angiocath over wire --> wire out --> tubing to angiocath. Let tubing fill, hold it vertical.

If it's venous, it'll drain back into the patient. If it keeps filling (pulsatile or not) it's arterial. If it doesn't drain, either the angiocath is kinked or outside the vessel.

Then wire back in through angiocath --> angiocath out --> dilator over wire, etc etc.

 

[nlax30]

IM resident here and we have to use live US on all IJs. There may be a couple of us who have done a couple blind IJs but it would've been when we were off service doing something like a gas elective and doing lines in the OR.

I've only transduced one so far, a SC stuck by someone else I was trying to help determine if arterial or not. Haven't had to do it on an IJ yet as so far I've gotten clear confirmation from a longitudinal US view or short axis scanning the vessel.

Can't remember where I saw it, but remember seeing an article about ECG line verification involving clipping a tele/ECH lead on the end of the guidewire and looking for activity while advancing..... seemed overly cumbersome and haven't seen or heard of anyone doing that.

 

[Mman]

My point is that if you are using the US, visualize the wire in the vein. I can deal with the 3 seconds it takes to rotate the probe and find the wire. And yes, its ALL about the pretty picture.

I do find the wire in the vein. It's in short axis. No need to go long axis. I'm not printing a picture of the wire in the vein so I don't need to make it a pretty picture. I just need to convince myself before I dilate that I'm dilating into a vein.

 

[Idiopathic]

I do find the wire in the vein. It's in short axis. No need to go long axis. I'm not printing a picture of the wire in the vein so I don't need to make it a pretty picture. I just need to convince myself before I dilate that I'm dilating into a vein.

having seen wires that are in the vein in short axis also be in the artery in short axis i cannot recommen enough that people turn the probe 90 degrees to find the vein in long axis. it always makes me feel better and its really the only way short of TEE to verify that your wire STAYS in the vein. it is my observation that most lines that end up in the carotid started in the IJ

 

[ASA6]

graduating resident here. I have never done a transarterial ax block, or a supraclavicular without us. I have done about 5 ij's without the ultrasound, but only because I insisted on it with a few attendings. I later found out its policy that they must be done with ultrasound, so I was grateful to those attendings that broke the rules for my education. My standard approach when I do lines without an attending is live ultrasound, then follow the wire in short axis view down to the clavical. if I have any doubt I put the angiocath over the wire, poor mans cvp, then rewire.

 

[BLADEMDA]

Are these basic skills no longer being taught in residency?

1. Landmark based central line via IJ
2. Landmark based Transarterial Axillary block
3. Nerve Stimulator only Interscalene block
4. Nerve Stimulator only Femoral block


I assume most Residents will finish their program without ever doing items 1-4. I still think those items are a valuable skill set especially 2-4 for outpatient surgicenters.

 

[BLADEMDA]

http://forums.studentdoctor.net/showthread.php?t=968579&highlight=zero+room

I get it that the world of anesthesia has moved on to u/s for everything. Still, many surgicenters don't have an u/s machine so NOT being able to do a basic nerve block without an expensive piece of equipment could be a potential problem.

 

[BobBarker]

I have done all of the 4. Only the trans arterial once, the rest several times. All at the VA. Current CA2.

 

[OB1🤙]

I have never done a transarterial axillary block, but was trained on the other three techniques you mention in residency.

 

[Arch Guillotti]

I think it's stupid to even think about doing a transarterial axillary block. The last time one got done at my place the patient seized.

 

[fakin' the funk]

Are these basic skills no longer being taught in residency?

1. Landmark based central line via IJ - done
2. Landmark based Transarterial Axillary block - paresthesia, done
3. Nerve Stimulator only Interscalene block - done
4. Nerve Stimulator only Femoral block - done

The problem with these "basic skills" is that they're friggin basic

 

[periopdoc]

Are these basic skills no longer being taught in residency?

1. Landmark based central line via IJ
2. Landmark based Transarterial Axillary block
3. Nerve Stimulator only Interscalene block
4. Nerve Stimulator only Femoral block

.

Officially I did not perform any of the above during residency or fellowship.

This includes two months at Virginia Mason where I was well liked and even recruited for their regional fellowship, but still not allowed to do stim guided blocks except for lumbar plexus.

I did bail out an attending (who shall remain un-named) twice when I placed IJs blindly on her draped patients halfway through a case after her suboptimal access was recognized. These were true ninja situations where I "just happened to drop by" part way through the cases, and disappeared as quickly as possible afterwards. There were some attendings you had to keep an eye out for.

I jumped at every chance to place subclavians as a resident and stole every single subclavian during fellowship so that I would have at least one blind technique that I felt comfortable with.

I will do stim guided ISB if I have to, but I am not comfortable with them. I insist on U/S for IJs.

Not proud of it, but realistic. I know my limits.

This would have been the first weakness in my training that I would have addressed had I joined your group. In my current group, I have the luxury of sticking with what I know.

-pod

 

[Idiopathic]

i dont understand why it would be considered a weakness to perform a prcoedure safely and with the least chance of traumatic complication?

 

[sevoflurane]

http://www.ncbi.nlm.nih.gov/pubmed/8608066

Funny how far we've come and how far away we are from what used to be. 🙄

Given usd, transarterial axillary block is a bit dirty. It's still good to know (although through and through is not my method to a blind axillary).

I believe there is a question or two that circulates some of the board material which addresses transarterial axillary block specifically.

Everyone should know how to do blind techniques... peripheral nerve blocks as well as CVLs and A-lines (the next to go).

What happens when 2 of your USD machines are down and you have 2 ortho rooms and a minor trauma room to start... say the block room is packed?

How about the stand alone surgery centers as someone mentioned above?

I'm 100% on board for USD, but I try not to be reliant on it. The outgoing residents should have some familiarity with these techniques. The old school methods are fun to learn.

I'm afraid the art of landmark based approaches might becoming lost. What does a diaphramgn stim mean and where should your neelde tip be? How will you reposition your needle based on that information? Not that academic when you have an USD machine, but acadamic nonetheless.

Just playing devils advocate here. 🙂

 

[sevoflurane]

The problem with these "basic skills" is that they're friggin basic

I disagree.

How often do you "feel" for the brachial plexus?

IMO, USD is a little more mindless... but it's my go to technique because it's better.

 

[MTGas2B]

If I'm using TEE and placing a central line I drop the probe, get the bicaval view, and my first picture is the right atrium with a wire floating in it.

No TEE, long axis view of the wire with u/s.

I encourage my residents to be comfortable with both seldinger and modified seldinger. With modified I will have them do sterile tubing manometry.

I usually make a point to hook up a CVP transducer when I place a central line. I have seen a straight forward short access live u/s view, ectopy, and a static manometry column end up with a TLC in the carotid. I'd rather know in the first few minutes after it happened than the next day when they stroke.

 

[fakin' the funk]

How often do you "feel" for the brachial plexus?

Not sure what you mean. Identify and palpate surface landmarks? These days, always. But when I was first learning regional it was 100% ultrasound and I had a bad case of stare-at-the-screen-and-forget-the-patient syndrome.

Ultrasound is absolutely more mindless because you simply don't have to know the anatomy all that well in order to do an effective block. You have to know your basics but the technique relies a lot more on 3-d geometry and manual dexterity.

 

[pgg]

I've seen/done exactly one transarterial ax block. During a humanitarian trip in central America, no u/s and no nerve stim. Super easy. I'm sure I could do another one quick and easy, but have no intention of ever doing so.

 

[BLADEMDA]

I've seen/done exactly one transarterial ax block. During a humanitarian trip in central America, no u/s and no nerve stim. Super easy. I'm sure I could do another one quick and easy, but have no intention of ever doing so.

I'm wondering what % of outpatient surgicenters across the USA have u/s machines? 50%? This means there still thousands of Anesthesiologists doing "blind" transarterial axillary blocks, ISB, Femoral blocks, every single day. I know this for a fact.

In my geographical region alone more nerve blocks are still performed the old way (no U/S) than with u/s.
But, my practice changed dramatically in 2011 and these days in my practice we do 95% under u/s guidance.

 

[Dejavu]

Are these basic skills no longer being taught in residency?

1. Landmark based central line via IJ
2. Landmark based Transarterial Axillary block
3. Nerve Stimulator only Interscalene block
4. Nerve Stimulator only Femoral block


I assume most Residents will finish their program without ever doing items 1-4. I still think those items are a valuable skill set especially 2-4 for outpatient surgicenters.

Me, I do occasional teaching of #2 if resident wants to (I am probably the only one in the whole place though), a number of #3's and a whole bunch of #4 to our residents (like 30-40, I would guess, maybe more, probably our primary way, for now)

 

[sevoflurane]

Not sure what you mean. Identify and palpate surface landmarks? These days, always. But when I was first learning regional it was 100% ultrasound and I had a bad case of stare-at-the-screen-and-forget-the-patient syndrome.

Ultrasound is absolutely more mindless because you simply don't have to know the anatomy all that well in order to do an effective block. You have to know your basics but the technique relies a lot more on 3-d geometry and manual dexterity.

I mean actually feeling the b. plexus. Try it out on a skinny patient. Sometimes you can feel the trunks.

But yeah... once you learn how to do USD, blocks are easy.

 

[sevoflurane]

I've seen/done exactly one transarterial ax block. During a humanitarian trip in central America, no u/s and no nerve stim. Super easy. I'm sure I could do another one quick and easy, but have no intention of ever doing so.

Good job pgg. These are the situations where that knowledge comes in handy.

How about when deployed? Are you (or somebody/medic) blocking our troops in the field?

How about natural disasters? Haiti, Katrina, etc?

No USD= No block? A lot of children in Haiti had amputations under ketamine alone. The ORs down there were terrible. No oxygen. Regional anesthesia was huge during that crisis. Not everyone had the luxury of USD.

 

[pgg]

How about when deployed? Are you (or somebody/medic) blocking our troops in the field?

We have u/s and nerve stims just about everywhere. There generally aren't physicians out in the field, and the medics of course don't do anything regional. They carry morphine autoinjectors, although those are sort of falling out of favor, being replaced with fentanyl lollipops and ketamine. If it was up to me they'd only use ketamine.

We're very aggressive with regional anesthesia in the ORs though. Typically after the extremity procedure is done, whatever it is (washout, fasciotomy, amputation, ex-fix), we'll place single shot vs continuous PNBs or epidurals. Coags permitting of course, but they usually are, even in the guys who get massive transfusions. We do the blocks asleep, then extubate. Satisfying work, to see a new amputee who just got a massive transfusion, awake and extubated, pain free and able to talk with his friends before flying out. The general comes over and does the Purple Heart ceremony in the ICU with the unit. Takes the edge off the injury and loss. Regional is key.

 

[VentdependenT]

freakin awesome

 

[sevoflurane]

+1

Great experience pgg. Thanks for taking care of our own dude.👍

 

[Mman]

having seen wires that are in the vein in short axis also be in the artery in short axis i cannot recommen enough that people turn the probe 90 degrees to find the vein in long axis. it always makes me feel better and its really the only way short of TEE to verify that your wire STAYS in the vein. it is my observation that most lines that end up in the carotid started in the IJ

You are referring to people that take one quick 2D image in short axis of the vein. What you should do is just scan up and down the neck and see the wire remaining in the vein in short axis. It's the exact same information you get from a long axis scan of the vein, but quicker and easier.

 

[Idiopathic]

You are referring to people that take one quick 2D image in short axis of the vein. What you should do is just scan up and down the neck and see the wire remaining in the vein in short axis. It's the exact same information you get from a long axis scan of the vein, but quicker and easier.

seriously both ways take about 5 seconds, i like seeing the wire longitudinally in the vessel, as long as you do more than watch the needle enter the vessel, its probably fine. it never ceases to amaze me how many inexperienced proceduralists refuse to accept that their catheter/wire is outside the vessel/inside another vessel because they "saw the needle enter the vein"

 

[Mman]

seriously both ways take about 5 seconds, i like seeing the wire longitudinally in the vessel, as long as you do more than watch the needle enter the vessel, its probably fine. it never ceases to amaze me how many inexperienced proceduralists refuse to accept that their catheter/wire is outside the vessel/inside another vessel because they "saw the needle enter the vein"

I find it's faster to go up and down the neck for about 2 seconds than it is to tweak the U/S to get the wire perfectly in plane in the vein for about 10 or 20 seconds.

I should note that while I use high quality Sonosite S-Nerves for nerve blocks, I'm using relatively less impressive Site-Rite's for CVP placement and they aren't as high resolution and the pictures aren't as pretty. Lining up the wire just right is a waste of time on those IMHO.

But mostly I just want to make the point to any novices that seeing the wire in long axis does not provide additional info. It's the movement of the probe that gives you a 3D image and gives you information. I can show people a long axis view of a wire in the carotid and they won't be able to tell the difference. To me the benefit of short axis (in addition to saving a little time) is that you can see the wire in the vein and see the artery at the same time. A long axis view of the wire means you can't see the artery.

 

[BLADEMDA]

seriously both ways take about 5 seconds, i like seeing the wire longitudinally in the vessel, as long as you do more than watch the needle enter the vessel, its probably fine. it never ceases to amaze me how many inexperienced proceduralists refuse to accept that their catheter/wire is outside the vessel/inside another vessel because they "saw the needle enter the vein"

Agree. Always keep some doubt in your mind. Never get cocky. It's like an ETT. Unless I see ETCO2 (good trace) on the screen I'm not happy.

Still, I've poked the Carotid back in the day more than a few times. The wire NEVER passes down the carotid as smoothly as a vein. Yes, It does pass but never as smooth as butter.

So, look all you want but if you have any doubt then do a poor man's CVP or transduce the angiocath. You can never be too careful if you have struggled getting that wire into place and conditions are suboptimal.

No matter how good you think you are at this procedure the fact remains that **** happens. You must be on guard for that 1:1,000 complication.

 

[Bostonredsox]

Just for you blade.

Early Hemorrhagic shock pt last night, variceal bleed. Prepped chest for quick subclav, couldn't get it. Moved to neck, called for US...oops, not on the floor and im gowned and gloved. Thought to myself, man I should probably do a fem. then I said...

F that.

Palpated carotid, stuck the 22Ga from the TLC kit 2cm or so lateral to pulse. Boom. Purple non pulsatile blood. Stuck 18ga in behind it and threw in wire. Nurse got there with US like 10 sec later, stuck it on for quick panning short axis view and a long axis view. Clearly in vein. Dilated and through in catheter.

My attending read my procedure note this am and sent me a text......"welcome to the old school club"

Think I'm gonna do that periodically on non coagulopathic non urgent IJs so I can develop the skill.

 

[periopdoc]

I am amazed that anesthesiologists who can consistently drive a needle within a couple of mm of a nerve with U/S can still bone up a routine U/S guided IJ placement in a big vein, but it does happen. Of course I am also amazed that we are arguing whether it is worth ten seconds to confirm that we aren't going to kill the patient (or cause major morbidity) with the next step of our procedure.

The benefit of scanning SAX is that you can follow the vein further into the chest (looking under the clavicle). In SAX you can usually see the IJ and subclavian veins merge into the innominate vein and sometimes identify the wire there. LAX is better for folks who can't do a 3d reconstruction in their mind, but MMan is right. LAX does not give you more info, in fact it gives you less info than a series of SAX images. If your goal is patient safety, scanning in SAX is sufficient. If your goal is to communicate to someone reviewing the chart, then both SAX and LAX images (or a series of SAX images) are necessary to give them the most info.

I scan in both SAX and LAX for my wire placement. We do a double IJ stick for all hearts and I attempt to have everything lined up perfectly so that both wires appear in the same LAX view. No, having both wires perfectly placed doesn't make a hill of beans difference, but it is all about honing the technique so that you are in control of exactly where the wire goes so that on the tough ones your margin of safety is increased.

- pod

 

[Idiopathic]

I am amazed that anesthesiologists who can consistently drive a needle within a couple of mm of a nerve with U/S can still bone up a routine U/S guided IJ placement in a big vein, but it does happen. Of course I am also amazed that we are arguing whether it is worth ten seconds to confirm that we aren't going to kill the patient (or cause major morbidity) with the next step of our procedure.

The benefit of scanning SAX is that you can follow the vein further into the chest (looking under the clavicle). In SAX you can usually see the IJ and subclavian veins merge into the innominate vein and sometimes identify the wire there. LAX is better for folks who can't do a 3d reconstruction in their mind, but MMan is right. LAX does not give you more info, in fact it gives you less info than a series of SAX images. If your goal is patient safety, scanning in SAX is sufficient. If your goal is to communicate to someone reviewing the chart, then both SAX and LAX images (or a series of SAX images) are necessary to give them the most info.

I scan in both SAX and LAX for my wire placement. We do a double IJ stick for all hearts and I attempt to have everything lined up perfectly so that both wires appear in the same LAX view. No, having both wires perfectly placed doesn't make a hill of beans difference, but it is all about honing the technique so that you are in control of exactly where the wire goes so that on the tough ones your margin of safety is increased.

- pod

its all about what you are really worried about. i am not concerned that my wire is leaving the IJ some 10 cm after the insertion site, Im concerned that it either is through and through or up against the wall of the vessel, neither of which would be optimal. i scan the SAX view and turn LAX because it shows me what I want to know. I think to argue either way is more valuable is silly. There needs to be some real time assessment of the wire in the vessel if you already have US prepped and are using it. with an uncomplicated stick, I would not sit there and wait for US with a wire in a vessel, there are other ways to reasure yourself that you are in the vessel (and the apppropriate vessel)

 

[psychbender]

Are these basic skills no longer being taught in residency?

1. Landmark based central line via IJ
2. Landmark based Transarterial Axillary block
3. Nerve Stimulator only Interscalene block
4. Nerve Stimulator only Femoral block


I assume most Residents will finish their program without ever doing items 1-4. I still think those items are a valuable skill set especially 2-4 for outpatient surgicenters.

Only ever did number 1, but a whole lot of them. At my home program, they were done almost exclusively under real-time ultrasound. At one of the hospitals we go for hearts, its about 50/50, depending on attending and whether or not there was a recent incident. At the place where I just finised doing some CT electives, it was almost exclusively landmark (probably used U/S for <6 lines out of 150+). We used a 21ga 1 3/4" needle (or it may have been a 23-ga) as a finder, then threaded a 25ga wire through the needle. Needle out, 18-ga angiocath over wire, first wire out, then standard wire, then dilator/MAC. Staff was usually doing the initial TEE while I was placing the line (I would stand at the pt's left shoulder, staff at the head with TEE probe), and confirmed wire in SVC. If no TEE, then we sometimes did the tubing to gravity confirmation. After that rotation, I am actually faster and nearly as comfortable doing the landmark technique as doing it under live U/S.

As for nerve-stim only Regional, aside from LPs, I had never done a purely stim block until last month, when I decided to do all of my sciatic's via Labatt's approach, just for fun. My program has gone entirely to ultrasound (very rarely, U/S plus stim), and we now also do ultrasound for other blocks such as LPs and PVBs.

 

[Jay K]

No.