IO for difficult IV access?

[nimbus]

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85yo vasculopath coming to the burn OR yesterday. I take over the case from a colleague before the pt rolls and he tells me he was planning on sticking the EJ because the pt has no access and bilateral UE burns to just above the elbow.

No need to stick the EJ unnecessarily.

Tourniquet the axilla and slap the U/S on. Get a picture very similar to this one from emed. The basilic is the big vein on the right. The brachial veins (venae comitantes of the brachial artery) can be seen. These are typically smaller and the risk of arterial puncture is higher.

My pt has an even bigger, fatter basilic vein. Nice. Prep out, dump a bunch of lido above the vein.

Go to kit is a 20g 15cm argon arterial line. Has a nice micropuncture style needle and soft tipped guidewire.

Done in 5-10 minutes. Surgeon preps the line into the field. The pt now has a reliable "midline" and he won't have to be stuck repeatedly during his hospital stay for IVs and he won't have to deal with potential complications from a PICC because IR and IV team here doesn't do midlines.

Nice solution. But why not put in a central line? I suppose one could argue a 15cm catheter near the axilla is a central line and not a midline. Depends how high you are on the arm.

Agree with you about an EJ. For me EJ’s are almost always the wrong answer unless it’s an outpatient with poor iv access. I wouldn’t even consider it in a burn patient.

 

[vector2]

Nice solution. But why not put in a central line? I suppose one could argue a 15cm catheter near the axilla is a central line and not a midline. Depends how high you are on the arm.

Agree with you about an EJ. For me EJ’s are almost always the wrong answer unless it’s an outpatient with poor iv access. I wouldn’t even consider it in a burn patient.

I think you could make a reasonable argument to put a central line into a burn pt who may have to return to the OR for more grafting and will likely require IV meds and fluids for awhile, but I lean more towards the minimalist solution if two methods will both work. He had 10-19% partial/full thickness burns of the arms, but he was hemodynamically stable, on room air, and not receiving parkland levels of fluid. There was just no need in this situation to fully gown up, stick a big needle in his neck, and assume the (albeit very minimal) risks of CVL placement.

 

[MirrorTodd]

Gave my attending a good laugh when I suggested an IO for a recent pt based on this thread. (They knew I was joking).

 

[IMGASMD]

Gave my attending a good laugh when I suggested an IO for a recent pt based on this thread. (They knew I was joking).

GTFOH would have been any of my attendings response.

 

[MirrorTodd]

GTFOH would have been any of my attendings response.

Their look said exactly that. Lol

As far as the IO stuff goes, we practiced sternal IO’s on each other as medics and ya it hurt...a lot but it didn’t hurt worse than a muscle cramp or anything. Hell I’ve even got the video on YouTube.

 

[IMGASMD]

Their look said exactly that.

Yes I totally saw it in my head with “that look” couldn’t convey it. I imaging you saw it too.

 

[MoMoGesiologist]

Their look said exactly that. Lol

As far as the IO stuff goes, we practiced sternal IO’s on each other as medics and ya it hurt...a lot but it didn’t hurt worse than a muscle cramp or anything. Hell I’ve even got the video on YouTube.

For sternal IOs, from my understanding, it's a special type of IO kit (not the same needle used in tibia or humerus)

 

[anbuitachi]

Their look said exactly that. Lol

As far as the IO stuff goes, we practiced sternal IO’s on each other as medics and ya it hurt...a lot but it didn’t hurt worse than a muscle cramp or anything. Hell I’ve even got the video on YouTube.

you let each other put sternal IOs in each other? wow

 

[AKMD_1984]

Im surprised no one mentioned femoral access. I typically use a double lumen CVL kit for femoral. I am not a big fan of blind stick with femoral, so I do use the ultrasound.
If the patient is high risk or will be admitted, then I try U.S. guided IJ. If outpatient, I really push for femoral line to be D/C'd as soon as possible to avoid any risk of infection that occurs with prolonged time the line is in place.

Of course, there is a little higher risk of infection, but for outpatient surgery, its easier because if I need to anesthetize the patient through the mask with nitrous/sevo, I find it hard to mask the patient as well as do the line. Too many hands near the face/neck.
Last week, my 67 year old craniotomy patient with ESRD, alcoholism, arrived without any IV access, I tried PIV multiple times - patient was already bruised everywhere from IV access, then did a left subclavian triple lumen emergently while my CRNA masked the patient. The neurosurgeon wrote an email to the administration while I was doing the line because he was very upset as to how the patient made it to the OR without reliable access.

Im glad I did CVL for that patient instead of our usual protocol of 2 PIVs, because I couldnt even get one PIV. The technique with axillary torniquet seems worthwhile and I will try.

Again, the site, location, size of catheter will really depend on type of surgery and patient's characteristics.

IO to me seems barbaric. Maybe truly emergent conditions in pediatric surgery...otherwise, no.

 

[pgg]

you let each other put sternal IOs in each other? wow

Yeah, that's a special kind of ridiculous.

 

[deleted697535]

Agree with you about an EJ. For me EJ’s are almost always the wrong answer unless it’s an outpatient with poor iv access. I wouldn’t even consider it in a burn patient.

You're ok with a line in a stinky armpit but not with a line in the ej??

Ej is an excellent option in many cases esp when the whole body is under drapes as it almost always is mid OR. Great for ivdu's too. Great in a hurry. Just great full stop. No need uss, guidewire etc.

What's wrong with it?

As for an earlier claim of done in 5 to 10 mins that's just not possible or repeatable in any of the 8 places I've worked. Well done if thats actually how long it took you to solo find all the equip needed but Sometimes it takes 20 mins alone to evefind an ultrasound.

Maybe it took you 10 mins in total but someone else spent another 10 or 15 getting things ready.

Ej takes literally 12 seconds. Every time.

Nice solution. But why not put in a central line? I suppose one could argue a 15cm catheter near the axilla is a central line and not a midline. Depends how high you are on the arm.

Agree with you about an EJ. For me EJ’s are almost always the wrong answer unless it’s an outpatient with poor iv access. I wouldn’t even consider it in a burn patient.

 

[nimbus]

You're ok with a line in a stinky armpit but not with a line in the ej??

Ej is an excellent option in many cases esp when the whole body is under drapes as it almost always is mid OR. Great for ivdu's too. Great in a hurry. Just great full stop. No need uss, guidewire etc.

What's wrong with it?

As for an earlier claim of done in 5 to 10 mins that's just not possible or repeatable in any of the 8 places I've worked. Well done if thats actually how long it took you to solo find all the equip needed but Sometimes it takes 20 mins alone to evefind an ultrasound.

Maybe it took you 10 mins in total but someone else spent another 10 or 15 getting things ready.

Ej takes literally 12 seconds. Every time.

I have anesthesia techs....they get everything for me. It literally takes 1-2min to get an ultrasound. We must work in very different places. I’ve never had to put in an armpit line so not sure where you got that. I have put in EJs and while they are easy to place, they frequently don’t flow well and occlude unless I have the head turned just so. As for IVDAs, most of mine have already scarred down their EJs. Just for perspective, when I start a heart, I place a radial Aline, induce and intubate, double stick the IJ for a central line and float a PA catheter, and place a femoral A-line. The whole thing usually takes 25-30min. So if it takes 20min to place 1 central line, you are not being efficient.

 

[Arch Guillotti]

I have anesthesia techs....they get everything for me. It literally takes 1-2min to get an ultrasound. We must work in very different places. I’ve never had to put in an armpit line so not sure where you got that. I have put in EJs and while they are easy to place, they frequently don’t flow well and occlude unless I have the head turned just so. As for IVDAs, most of mine have already scarred down their EJs. Just for perspective, when I start a heart, I place a radial Aline, induce and intubate, double stick the IJ for a central line and float a PA catheter, and place a femoral A-line. The whole thing usually takes 25-30min. So if it takes 20min to place 1 central line, you are not being efficient.

Do you put in 2 central lines and 2 art lines for every heart?

 

[Twiggidy]

Do you put in 2 central lines and 2 art lines for every heart?

2 CVP where I am. Intro for the PA and. 3 lumen for infusions. The surgeons want a PA for post op and it’s them managing the patient so whatevs

1 only do radials but if it fails I or is being weird I ask the surgeons to put in a femoral

 

[nimbus]

Do you put in 2 central lines and 2 art lines for every heart?

Almost every heart. This has been discussed before.

 

[vector2]

Almost every heart. This has been discussed before.

The double lumen Arrow MAC line has totally obviated the need for double sticking the neck. Only problem is that post op the pt loses reliable access when the cordis is ready to be pulled, whereas with a double stick you can leave the TLC in if need be.

 

[psychbender]

The double lumen Arrow MAC line has totally obviated the need for double sticking the neck. Only problem is that post op the pt loses reliable access when the cordis is ready to be pulled, whereas with a double stick you can leave the TLC in if need be.

Wire exchange the introducer for a triple or quad lumen if you think you'll still need central access, but not a volume line. Usually, one little stitch at the insertion point downsizes the hole nicely, so it doesn't bleed with the smaller catheter. That was the standard POD1 or 2 job of the surgery resident on Transplant for livers.

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[Twiggidy]

The double lumen Arrow MAC line has totally obviated the need for double sticking the neck. Only problem is that post op the pt loses reliable access when the cordis is ready to be pulled, whereas with a double stick you can leave the TLC in if need be.

Yep. That’s pretty much our situation.

 

[Twiggidy]

Wire exchange the introducer for a triple or quad lumen if you think you'll still need central access, but not a volume line. Usually, one little stitch at the insertion point downsizes the hole nicely, so it doesn't bleed with the smaller catheter. That was the standard POD1 or 2 job of the surgery resident on Transplant for livers.

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The thing is why go through all the fuss when you have the ability to just place both lines in the OR. It could be a private practice thing since there aren’t residents around to do this plus it just adds a procedure to the patient.

 

[nimbus]

Wire exchange the introducer for a triple or quad lumen if you think you'll still need central access, but not a volume line. Usually, one little stitch at the insertion point downsizes the hole nicely, so it doesn't bleed with the smaller catheter. That was the standard POD1 or 2 job of the surgery resident on Transplant for livers.

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I’ve downsized cordis’s as you describe before. Usually in the OR because we decided not to send patient to the ICU. For our hearts, the ICU nurses d/c the swan and cordis, usually on POD 1 and the patients keep the central line.

 

[anbuitachi]

Why not just run the infusions thru the ports on the PA catheter? We usually run the infusions in the proximal ports.

 

[Twiggidy]

Why not just run the infusions thru the ports on the PA catheter? We usually run the infusions in the proximal ports.

For some reason our institution has the PA that only has the CVP and PA port. I remember in residency we had the PA that has that 3rd port.

Again, all this stuff for the hearts is for the most part for post op and they’re not managed by us, but we just do the ICU a favor. In reality, for a “healthy” heart and a good surgeon, you really only need a good IV and a triple lumen.

 

[vector2]

Wire exchange the introducer for a triple or quad lumen if you think you'll still need central access, but not a volume line. Usually, one little stitch at the insertion point downsizes the hole nicely, so it doesn't bleed with the smaller catheter. That was the standard POD1 or 2 job of the surgery resident on Transplant for livers.

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Not that I really ever have to place lines for cardiac pts in the ICU, but I've always found wire exchange to be kind of dirty no matter how much I try to prep out the line and the introducer hub beforehand. I usually will just place a fresh 20cm LIJ TLC on the handful of occasions I'm asked to help out.

I'm probably just overreacting though cause it doesnt look like infection rates are different

The microbiological and clinical outcome of guide wire exchanged versus newly inserted antimicrobial surface treated central venous catheters