Learning curve for bedside procedures

[premed8888]

new resident here in surgery. Yesterday was my first experience in bedside femoral vein lines and it was not fun. My paranoia of hitting the artery resulted in me having my junior stick it. Granted the patient has a plt level of 7.. just wanted to ask more senior ppl how long it took them to just do it naturally. There isn't a good way to practice it without doing it on people at our place and I can't have an u/s at home to practice looking at the anatomy

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[operaman]

Everyone sticks an artery just like everyone will put a dobhoff tube in a lung. The key is not to dilate the artery and not to put feeds in the lung. That said, there's nothing wrong with handing it off if you aren't comfortable; there will definitely be more chances in the future. There's also a lot of transferrable skill to be gained from similar procedures. Other ultrasound guided work will get you more comfortable using it and your next fem line won't seem that different from all the others.

 

[NotAProgDirector]

To be fair, it's probably not a good idea to have your program have you put your first line in a patient with a platelet count of 7. One could argue that you were smart to let someone with more experience do that one.

If you're going to learn how to fly, best to start on a sunny day.

 

[BoardingDoc]

just wanted to ask more senior ppl how long it took them to just do it naturally.

It took about 5 CVLs before I felt comfortable placing them on my own. It took maybe 20 before I felt comfortable handling aberrant anatomy, ****ty veins, actively crashing, placing them in patients who probably have a total of 1L of fluid in their entire body etc etc etc.

My first CVL took absolutely forever and I was not slick. You'll be fine. If your residency does sim lines, I'd take advantage. The mannequins all suck so that part isn't helpful. What is helpful is knowing exactly where everything you need in the kit is, and exactly what order you're doing things in.

Golden rules: Don't dilate an artery. Take out the wire.

 

[link2swim06]

Probably would make more sense to do it under US if you have plt of 7 (and have an experienced operator do it). But just my opinion.

And it's not the end of the world if you puncture to femoral artery. I mean....if you put in a femoral a-line, thats kinda the point.

 

[Bobblehead]

Sometimes the IJ is a better option than a femoral with that low of a platelet count as well. It's probably beyond you to recommend that this early in your training but there's a lot less soft tissue to go through in the neck and cause bleeding. As long as you're careful you can use the actual catheter to help tamponade the tract and encourage the platelet plug to form by limiting how aggressively you dilate the tract.

It's good you had someone else there. I'm not sure it's reasonable to take that type of challenging scenario and dump it on someone in their first month of residency.

 

[Apollyon]

Sometimes the IJ is a better option than a femoral with that low of a platelet count as well. It's probably beyond you to recommend that this early in your training but there's a lot less soft tissue to go through in the neck and cause bleeding. As long as you're careful you can use the actual catheter to help tamponade the tract and encourage the platelet plug to form by limiting how aggressively you dilate the tract.

It's good you had someone else there. I'm not sure it's reasonable to take that type of challenging scenario and dump it on someone in their first month of residency.

Wait - are you saying, in event of a carotid puncture, to leave the catheter in? More than one surgeon has told me to pull it immediately if that happens - to NOT leave it in to tamponade it.

If there's new research, clearly, I'm not up to date on it.

 

[Bobblehead]

I believe you misinterpreted my statement. To further elaborate, when you visualize an IJ under US you will frequently find that it is only slightly below the skin surface (1-2cm or less) and therefore you need to traverse less soft tissue than for a femoral vein puncture where you may need to traverse 4-5cm of soft tissue. Under those circumstances you can often get to the IJ more readily under US visualization or guide someone to the vein more easily if you're not driving the needle yourself. Once you have cannulated the IJ, fed the wire and removed the introducer needle you can often limit the amount of bleeding/oozing around the catheter by not advancing the dilator more than minimally to dilate the top layers of the epidermis and instead using the actual catheter as a pseudo-dilator. This works as the dilator is a larger bore than the catheter that follow it. This approach works better in the IJ position than femoral because you do not necessarily need to dig all that deep before the catheter enters the actual vein.

With regards to the complication of an arterial puncture it depends on whether you've punctured, dilated or cannulated the vessel. In this particular instance with a low platelet count I would favor leaving an asymptomatic arterially placed TLC in place and consulting vascular surgery for a vascular closure device. Before that point in time I've never seen equipment left in place (introducer needle, wire, dilator) as none of it could be reliably secured during patient transport to the cath lab, OR, etc. not to mention that the hole you've left in the artery to that point is usually smaller (except for the dilator if you've dilated the actual vessel by accident). There are risks to both immediate removal with direct pressure and delayed removal with surgical closure. I believe there's sufficient literature that backs up delayed removal with vascular surgery consultation:.

Guilbert MC, Elkouri S, Bracco D, et al. Arterial trauma during central venous catheter insertion: case series, review and proposed algorithm. J Vasc Surg. 2008;48(4):918-925; discussion 925.

Shah PM, Babu SC, Goyal A, Mateo RB, Madden RE. Arterial misplacement of large-caliber cannulas during jugular vein catheterization: Case for surgical management. J Am Coll Surg. 2004;198:939–44.

 

[qxrt]

Wait - are you saying, in event of a carotid puncture, to leave the catheter in? More than one surgeon has told me to pull it immediately if that happens - to NOT leave it in to tamponade it.

If there's new research, clearly, I'm not up to date on it.

If you just stuck a small gauge needle in it, take it out and hold pressure. If you dilate/catheterize it, leave the catheter in and call vascular surgery. It gives the vascular surgeon more options to manage the arterial injury that way. If you take an arterial catheter out, it f***s things up for them.

Most important thing to understand when doing venous lines is know the ultrasound anatomy. It's easy when you completely understand what you're looking at. When your knowledge is just half-assed, you can make silly mistakes that could have been easily avoided. When I was a medicine intern, I was given no formal didactics on central line placement aside from a brief bedside demonstration and had very little idea of what I was looking at in the neck outside of "floppy round thing is jugular, circle thing is carotid." Now that I'm a senior radiology resident going into IR, it boggles my mind how little formal education there is for medical residents in understanding these things, even as they are expected to stick needles and catheters in them. Hell, at our institution we got nephrologists who got a lock on doing ultrasound guided renal biopsies, even as they barely know what they're looking at outside the kidney ("What's that?" <--pointing at the spleen).

 

[j4pac]

To be fair, it's probably not a good idea to have your program have you put your first line in a patient with a platelet count of 7. One could argue that you were smart to let someone with more experience do that one.

If you're going to learn how to fly, best to start on a sunny day.

Clearly a program that doesn't care about it's patients. That horrible patient care.

 

[Apollyon]

If you just stuck a small gauge needle in it, take it out and hold pressure. If you dilate/catheterize it, leave the catheter in and call vascular surgery. It gives the vascular surgeon more options to manage the arterial injury that way. If you take an arterial catheter out, it f***s things up for them.

See, that is what has changed - 11 years ago, as a senior resident, I had my attending insist on using the ultrasound - with which he had minimal experience. Even under US, I put the catheter in the IC. When I called vascular, and told them I left in the catheter, the first thing I was told was to pull it.

I'll just do my best not to stick the artery!

 

[Siggy]

Probably would make more sense to do it under US if you have plt of 7 (and have an experienced operator do it). But just my opinion.

And it's not the end of the world if you puncture to femoral artery. I mean....if you put in a femoral a-line, thats kinda the point.

Platelet of 7 and I'm giving serious thought to pulling out a micropuncture kit.

 

[wakeboard023]

new resident here in surgery. Yesterday was my first experience in bedside femoral vein lines and it was not fun. My paranoia of hitting the artery resulted in me having my junior stick it. Granted the patient has a plt level of 7.. just wanted to ask more senior ppl how long it took them to just do it naturally. There isn't a good way to practice it without doing it on people at our place and I can't have an u/s at home to practice looking at the anatomy

I had a senior who gave me an unused kit to practice with at home. Honestly, just repeating the process and knowing the order that I was going in helped me focus on the anatomy without the stress of unfamiliarity. Took me about three lines to feel comfortable, but then it was a lot easier

Also, watching YouTube videos actually help lol

 

[AdmiralChz]

In 2017, asking a brand new intern to perform a blind femoral CVL placement with a platelet level of 7K isn't setting said intern up for success. Even if it were ultrasound-guided, probably poor form unless maybe someone scrubbed in with you to go through the steps... probably still a bad idea.

But that's already been said by other people. I would also contribute that many of us have felt almost the same way, and in most cases with much better circumstances with you. You are in residency to learn these bedside procedures and no one is expecting you to be an expert by just reading about them. You will gain confidence as you do more, trust me. Remember this experience, though, years down the road - and don't put the intern you are supervising in this position.

Never, EVER be afraid to ask assistance for a procedure. It's true for interns, residents, fellows and even junior attendings. An extra set of hands can be extremely valuable in a pinch!

 

[Iso4ane]

I had a senior who gave me an unused kit to practice with at home. Honestly, just repeating the process and knowing the order that I was going in helped me focus on the anatomy without the stress of unfamiliarity. Took me about three lines to feel comfortable, but then it was a lot easier

Also, watching YouTube videos actually help lol

This is bigger than most people realize. Different institutions have different and many of them are somewhat custom built. Know what is and isn't in your kit is extremely helpful. You also need to setup a system for yourself. For the most part the major steps are the same; but everyone has their own little idiosyncrasies when it comes to placing lines. (For example when I flush a triple lumen, I always go brown, white, blue in that order; small thing, but when I am dead tired/or in a rush and start flushing lines I never has to second guess myself.)