My go to if I actually need an A-line for some reason is the femoral double prep. Open both trays, one sterile field, needle into artery, wire, fem art line, second needle into femoral vein for femoral CVC. Only adds about 30-60 seconds to my line time.
Yep. I've placed one a line in the past 2 years and it was for exactly that scenario. Don't see the point otherwise.
Seems reasonable.
I can only assume that you work in academics, or are on the lower end of pph if working community. I don't mean any disrespect by that. I do mean that if I had to place an a-line in every patient I had on pressors I'd never get anything done. Hell, I don't put central lines in 90% of the patients I have on pressors. They can go to the unit on peripheral norepi.
If that's your practice, that's fine. But I'm unconvinced that arterial lines decrease extravasation risk. Any evidence for that?
Most often in the unit if they're on low dose levo I never place a central line or a-line. I just let them coast with peripheral pressors. I use art lines mostly for ARDS and frequent need of ABG. Otherwise, I'll place them for high risk intubations prior to induction (group 1 pHTN, severe aortic stenosis), dissections, cardiogenic shock if I have them on an infusion of nipride or cleviprex, and some multipressor shock. But I don't think that any pressor is an indication for an art line, though I am a firm believer in "less is more."
I'm assuming you were inferring limb ischemia = extrav? I don't think that was the intent of the post. I think they were simply stating that downtitraing pressors decreases the chance of limb ischemia.
You had me until you decided to throw those of us who ARE WELL TRAINED under the bus by demanding that to put in a central line without ultrasound is malpractice. I HOPE you are just referring to IJs. I've probably put a few hundred lines in (EM/Critical Care) and the vast majority were no-ultrasound subclavians. Sometimes, they were in crashing patients and so we were infusing the things that matter less than 120 seconds after the package was cracked while the nurse was looking for the vascular ultrasound in the back of the supply room.... or we were waiting for the thing to boot up... or we were looking for a probe cover....
Yes. 100% my go-to. Speed and consistency of landmarks make it totally safe sans u/s, IMO - plus ultrasound gives you ****ty images in even thin patients let alone bog-standard Amurican' BMI patients....
YMMV based on your site as regards if you really NEED the skill of doing a rapid line (trauma center?) but you definitely cannot do an u/s guided femoral as fast as an experienced pit doc can whap in a subclavian, and yes I'm still doing it sterilely which means I get central delivery right into the heart (ok, the SVC) of life saving meds (let's see your IO do that) it isn't gonna get infected as readily as your femoral and/or I'm not gonna have to just rely on the Intensivist to fix my mess and convert the line later.
Ah, that makes more sense.
Yes. I do blind subclavians myself with no ultrasound. Trained that way. I don’t know why it was that way. I imagine because we were a super busy trauma center. So ijs off limits generally due to c collars. So fem lines and subclavians were the go to. All trauma icu patients got those as the old way was that femoral lines were dirty and frankly SCs are most comfortable for patients.
Is there literature showing a mortality benefit for using a manual blood pressure cuff? 😉
Working in a critical access hospital. Trying to use an arterial line would make my life infinitely harder due to nursing issues...
When I work in those settings I only place when transferring and I think it’s helpful.
I think it’s probably got to be hands on. You bring the beer, I’ll bring the tubing, and we’ll zero it together.
My problem is they never go to the unit so I get bugged about putting in the CVL because they've been on peripheral levo for 18 hours. I just go ahead and do them. I like doing lines still. Gives me 5 mins of not signing EKGs/transfer forms or answering stupid questions.
Central lines intubation reductions and chest tubes I still enjoy 10+ years out. Lps, lacs and I and ds I can do without.
Reductions are so fun. It’s nice to actually feel like you actually accomplish something.
One of the two greatest moments of my medical career was when I reduced my neighbor's shoulder, in my kitchen, using the Cunningham method.
It's a long story that's better told in person. Maybe I'll hit you up when I'm in FLA next month.
Really? I'm willing to be convinced by evidence, so please educate me.
I thought systolic was the pressure needed to occlude a peripheral artery...
Would you avoid all of these newly accredited programs?
Yep.
Absolutely avoid
Did my first one in prob 10 years recently: morbidly obese pt with sepsis. Groins were infected, neck had a ton of redundant folds, really had no other option. He was so big I had to hub the needle with about an inch of indentation before the flash but it worked out OK.
Lakeland Regional is the nation's busiest ED (single facility). They see 220,000 patients per year.
Yep.
Good for you. I’d have given up before it was at that point and run whatever peripheral tbh
Had 2 good U/S guided IV’s, but these were his infusions prior to transfer to an academic mothership: insulin (sugar>1000), Precedex (got tubed), norepi, bicarb, LR.
On a manual BP cuff yes. Automatic BP cuffs use oscillation to measure the MAP. Basically they occlude the artery and release pressure, as pressure in the vessel increases (with decreased occlusion) there are pressure oscillations against the arterial wall which increase in amplitude up to a maximum point and then decrease again. The maximal point of oscillatory amplitude is the MAP. Then the BP cuff will derive systolic and diastolic from that depending on how the manufacturer sets its algorithm. Only MAP is measured on an automatic BP cuff.
Learn something new every day
