Placing a cordis and TLC with one needle pass.

[92122]

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I have recently seen a person place a cordis and TLC through the same hole in the skin. At the time, they were attempting to "double stick" the neck, but were unable to get good venous return for the second wire. They proceeded to do the following:

1. Place cordis in the usual fashion.

2. Place second wire through cordis.

3. Remove cordis and dilator.

4. Sew a purse string around the two wires.

5. Placed cordis and TLC via their respective wires. Mind you, the "nick" was more like a gash, but...

6. Tightened purse string suture and staunched the flow from the wound.

I had never seen such an approach before, and while it would be worrisome for some patients, it's apparently a technique that has a long history in this area for allowing the placement of two lines where only one seemed possible.

Any comments?

 

[caligas]

I see no need to do this with the availability of the MAC cath by Arrow. It has a volume line a drip line and a swan port. One stick, one wire, one catheter.

 

[92122]

Triple lumen catheters can accompany the patient to the cardiac step down unit. A MAC would have to be removed and a tlc wired into place. TLCs are also left in while in the CTICU after the PAC and cordis are removed.

 

[Idiopathic]

seems like you are quintupling your risk to avoid downsizing a line in PACU or the ICU. I typically like the double stuck neck but this seems like an idea fraught with potential downside (huge skin nick, will likely bleed; very large venotomy - does this increase risk for future clot or venous stenosis?). In short, two lines, two holes.

 

[Idiopathic]

and why do they need central lines to go to step down? not like a liver transplant.

 

[92122]

Some of these patients have the need for dopamine, etc. while in the ICU. In some cases, the PAC is out and the patient begins to have issues. Development of tamponade physiology has been seen several days out.

Another argument for leaving the TLC in place is to allow for blood draws. Obviously, these can be done without them and nobody would argue for a TLC to accomplish this task, but if they're there...

I have never performed this technique, although I regularly double-stick the neck.

 

[92122]

"very large venotomy - does this increase risk for future clot or venous stenosis"

Good point. However, they've never had issues of this type. Some patients have come for redo-sternotomies and there wasn't anything overtly abnormal about their IJ on surface U/S.

 

[periopdoc]

One of my partners likes to say

You can do the wrong thing 100 times and get away with it. Pretty soon you will start to think that you are pretty good at it and, despite what the book says, it is in fact quite safe. This doesn't make it safe or the right thing to do.

Another discussion here recently probably deserves the same response.



- pod

 

[Idiopathic]

Some of these patients have the need for dopamine, etc. while in the ICU. In some cases, the PAC is out and the patient begins to have issues. Development of tamponade physiology has been seen several days out.

Another argument for leaving the TLC in place is to allow for blood draws. Obviously, these can be done without them and nobody would argue for a TLC to accomplish this task, but if they're there...

I have never performed this technique, although I regularly double-stick the neck.

in the ICU they keep their line. when they go to stepdown, the line comes out. they shouldnt need inotropres or pressors and be headed to stepdown. i only see it in our liver transplabt patients, where their lines will get downsized before they go to the floor and the increased risk that comes with that procedure.

 

[ecCA1]

.

 

[urge]

I have recently seen a person place a cordis and TLC through the same hole in the skin. At the time, they were attempting to "double stick" the neck, but were unable to get good venous return for the second wire. They proceeded to do the following:

1. Place cordis in the usual fashion.

2. Place second wire through cordis.

3. Remove cordis and dilator.

4. Sew a purse string around the two wires.

5. Placed cordis and TLC via their respective wires. Mind you, the "nick" was more like a gash, but...

6. Tightened purse string suture and staunched the flow from the wound.

I had never seen such an approach before, and while it would be worrisome for some patients, it's apparently a technique that has a long history in this area for allowing the placement of two lines where only one seemed possible.

Any comments?

Sounds awful. Why not just a regular double stick?

I have placed 3 lines in the same IJ. Three different sticks: 1 mac, 1 introducer, and 1 retrograde jugular bulb.

The approach you mention sounds like a big mess.

 

[Bostonredsox]

this is probably not right either....but the CTS patients I get in MICU come out of the OR with a right IJ cordis. Swan through the cordis. Neo/epi/insulin/nitro all run through the side port on the cordis. they never come with 2 lines.

not sure on the compatability of all that stuff but as they all come out like that and all seem to do fine I presume they are all compatabile. They usually have 1-3 peripheral 18s as well for antibiotics, general IVF and whatever else they're on.

they usually have a left rad art line, 2 mediastinal chest tubes, varying amounts of pleural chest tubes, foley. one time I had one come out with the typical right IJ cordis and a left subclav TLC, but its uncommon.

I have had few MICU pts of my own doing that have needed more than one TLC. usually shock pts in status EP on bicarb drips as its compatable with nothing nor is the fosphenytoin. for them they get an IJ and if I need more toss in a subclav on the other side. have never double stuck the IJ, don't see any reason to put that big a hole in anyone's jugular.

 

[TrustMe]

Sounds like a bad idea to me.

 

[GoldnLead]

I have recently seen a person place a cordis and TLC through the same hole in the skin. At the time, they were attempting to "double stick" the neck, but were unable to get good venous return for the second wire. They proceeded to do the following:

1. Place cordis in the usual fashion.

2. Place second wire through cordis.

3. Remove cordis and dilator.

4. Sew a purse string around the two wires.

5. Placed cordis and TLC via their respective wires. Mind you, the "nick" was more like a gash, but...

6. Tightened purse string suture and staunched the flow from the wound.

I had never seen such an approach before, and while it would be worrisome for some patients, it's apparently a technique that has a long history in this area for allowing the placement of two lines where only one seemed possible.

Any comments?

Can be done as a salvage maneuver. My boss, who has about 30 years of placing lines and is slick with them has explained it to me and I've had to do it once.

Sometimes you just can't get the second wire in; we do double sticks for our cardiac cases with the patient awake, which makes it tougher especially if they're dry (they're spontaneously ventilating and on US you can see the IJ collapse completely upon inspiration). It is a bit bloodier and the catheters are in close proximity to each other, but it can be done safely.

 

[OB1🤙]

we do double sticks for our cardiac cases with the patient awake.

Note to self: don't get cardiac surgery at your hospital. That's just cruel, man.

 

[Bostonredsox]

Note to self: don't get cardiac surgery at your hospital. That's just cruel, man.

/nod. Why wouldn't you tube them first and place your lines when they're asleep. Seems like cruel and unusual punishment to me.

 

[GoldnLead]

/nod. Why wouldn't you tube them first and place your lines when they're asleep. Seems like cruel and unusual punishment to me.

In a way, I agree, but they all get enough versed so that they're amnestic.

We do it cause we cannot intubate with the surgeon in house. This is PP. No offense intended, but we can't dick around like in academics. The surgeons (who do numerous cases and thus bring in revenue to the hospital) want to walk in the door, do a 10 second time out and start cutting ASAP. We can easily do 2 virgin AVRs before 11AM this way.

 

[Arch Guillotti]

TLC's aren't too bad to place awake.

 

[OB1🤙]

In a way, I agree, but they all get enough versed so that they're amnestic.

We do it cause we cannot intubate with the surgeon in house. This is PP. No offense intended, but we can't dick around like in academics. The surgeons (who do numerous cases and thus bring in revenue to the hospital) want to walk in the door, do a 10 second time out and start cutting ASAP. We can easily do 2 virgin AVRs before 11AM this way.

You do what you gotta do for your surgeons. For me though, it doesn't pass the Yo Momma test. That is, if it was Yo Momma getting her AVR, would you rather they do her line asleep or awake?

In PP a double stick central line/swan is a 5 minute procedure. Your surgeons really can't be bothered to end their day by 11:10 instead of 11:00 in the name of patient comfort?

 

[GoldnLead]

You do what you gotta do for your surgeons. For me though, it doesn't pass the Yo Momma test. That is, if it was Yo Momma getting her AVR, would you rather they do her line asleep or awake?

In PP a double stick central line/swan is a 5 minute procedure. Your surgeons really can't be bothered to end their day by 11:10 instead of 11:00 in the name of patient comfort?

I agree with you, but alas, my hands are tied. Gotta keep the powers that be happy.
😉

 

[IveGotTwins]

I don't understand how doing them in that order would increase your efficiency. I've done a fair share of awake/awake-ish central lines in ICU and I felt that the patient squirming and saying "ow/ay" made me slower because I might have to stop to say "you're doing great, almost done" or reposition them because they moved. Does someone do them in pre-op holding before rolling back?

I also don't understand the statement that you can't intubate with the surgeon in house.

 

[B-Bone]

I'm in a similar situation as GoldnLead. I show up at about 6:15 for a 7:30 start, review the history, interview the patient and place an art line. If I get this stuff done by about 7:00, I'll place my CVP (9 Fr cordis) awake in preop or in the OR. We can't induce until the surgeon is on the premises. He calls from his cell phone in the parking lot precisely at 7:30 (+/- two minutes). I get the line in, all the monitors on, and am preoxygenating by 7:30 and push the drugs when I hear the phone ring. By the time he's changed and in the OR, the patient is prepped, draped and ready to cut. Half the time, my prebypass TEE is done before he's in the OR. It doesn't sound like a preinduction line would save that much time, but it makes the day a hell of a lot smoother. For subsequent cases, one of my partners sometimes places art line/CVP while I'm taking first patient to the ICU and I can be in the OR with my next one within 10 minutes of getting back from upstairs. Like I said: smooth.

Where I trained we never placed awake CVPs or even awake a-lines. I thought they were barbaric. I give most patients 2 mg versed, 50 mcg fentanyl and maybe 1-2 cc propofol (just before the dilator) and most people don't even notice. Smooth.

 

[IveGotTwins]

I suppose I understand not inducing until the surgeon is on site. In that case getting the lines done prior to induction would save significant amounts of time. Now what I don't understand is the surgical consent and marking. These surgeons who want to gown-glove-cut in
such quick succession must have some subordinate checking the consent and marking the patient prior to rolling back, correct? Or is that more academic tom-foolery I can look forward to leaving behind?

 

[Idiopathic]

I suppose I understand not inducing until the surgeon is on site. In that case getting the lines done prior to induction would save significant amounts of time. Now what I don't understand is the surgical consent and marking. These surgeons who want to gown-glove-cut in
such quick succession must have some subordinate checking the consent and marking the patient prior to rolling back, correct? Or is that more academic tom-foolery I can look forward to leaving behind?

they can be consented in clinic

edit:and as long as you dont operate on the wrong patient, i suppose marking doesnt matter

 

[Bostonredsox]

TLC's aren't too bad to place awake.

I've put in many many TLCs awake with just a little shot of fentanyl and some local. That doesn't mean they are pleasant. Especially dual catheters in the IJ with a much bigger skin incision and dilatation. Was just saying, if they are about to get induced to start sx, can the lines wait till after they're in sleepy land.

I now understand from further posts as to why they are done in the order he has been doing them. Just numb em up good I guess.

 

[Arch Guillotti]

I've put in many many TLCs awake with just a little shot of fentanyl and some local. That doesn't mean they are pleasant. Especially dual catheters in the IJ with a much bigger skin incision and dilatation. Was just saying, if they are about to get induced to start sx, can the lines wait till after they're in sleepy land.

I now understand from further posts as to why they are done in the order he has been doing them. Just numb em up good I guess.

Just depends on local culture I guess. I think all the ones I did in residency were asleep. Now most of them are awake.

 

[IveGotTwins]

Do the surgeons explain to their patients that the reason these are done awake is because they don't want to be at the hospital 15-30 min earlier? Can't they be "on site" and round/paperwork/cogitate while the patient is induced and then gets the 9f harpoon in the neck? Just seems unnecessary but if its done all over the place then it must not be as crazy as it sounds.

 

[TrustMe]

Do the surgeons explain to their patients that the reason these are done awake is because they don't want to be at the hospital 15-30 min earlier? Can't they be "on site" and round/paperwork/cogitate while the patient is induced and then gets the 9f harpoon in the neck? Just seems unnecessary but if its done all over the place then it must not be as crazy as it sounds.

Many different ways. Where I trained we usually did a-line awake/sedated in the OR, followed by induction/intubation, followed by venous lines/PAC.
I rotated at a hospital that did all lines for cardiac cases in pre-op holding with sedation and local, went to OR, went to sleep, cut the skin.
Where I am now, they do a-line in pre-op holding, go to OR, induce/intubate, place venous lines/PAC.
Friend at another place, all lines for all cases are done in pre-op holding (although they have awesome nurses that sedate the patient, prep the neck/chest, drape the patient, open the kit, turn on and drape the U/S, then page you. She walks in, puts on gown/gloves (already opened and waiting), grabs already covered U/S probe and sticks needle in the neck.)

So yes, many different ways to do the same thing. A little midazolam goes a long way in them not remembering how unpleasant of an experience it was.

 

[GoldnLead]

Just seems unnecessary but if its done all over the place then it must not be as crazy as it sounds.

You're right, it's not. On interviewing the patients post op in CCU, no one's said to me (gee doc, those needles you stuck in my neck/chest really hurt.
They get more than enough versed +/- fent to be amnestic.


Again, it's important to realize that if you join a PP group, sometimes you'll have to do things their way, and unless it's negligent or detrimental to patient care, it's not a huge issue.

 

[BobBarker]

We place all of our lines in holding, too. I also drop on OG and suction contents then remove it for my TEE prep. I have the nurse put the foley in and clip the chest hair at this time as well. I then tape the eyes shut and proceed to the OR.

 

[Mman]

As much as my sensibilities make me want to avoid awake CVPs in patients for comfort reasons, it's not that bad and I find that you get a lot more space to work with when doing it awake and not having to get things like the ETT and circuit out of the way. Several times a year I'll have to do an awake IJ in a patient with no IV access so I can't sedate them and when it's all said and done the vast majority report that it wasn't terribly uncomfortable. 5 mls of 1% lidocaine goes a long way when putting an 8 Fr double lumen catheter in. Doing them awake in cardiac patients with a peripheral IV you can use for sedation is even easier.

 

[OB1🤙]

If the patient has nothing to compare it to they won't complain about it. They just figure that's the way it always is, and they deal with it.

And no, it's not like you're waterboarding them or anything, but I bring the point up again- if it was your elderly mother going for surgery, you'd rather the line be done asleep in the OR, rather than after a bunch of midaz/fent in holding, wouldn't you?

You can do ortho cases safely with a PCA and no regional too. Doesn't mean it's the most comfortable way for the patient.

Anyway, I understand that you play the hand you're dealt, and you do what you gotta do in your individual situations. I'm just glad my cardiac surgeons have enough respect for the patient to prioritize their comfort and let me take an extra five minutes to do it asleep.

 

[bigeyedfish]

they can be consented in clinic

edit:and as long as you dont operate on the wrong patient, i suppose marking doesnt matter

What about h and p update? At my institution we can't roll to the or unless the history taken in clinic is updated that morning by the staff surgeon.

 

[pgg]

We place all of our lines in holding, too. I also drop on OG and suction contents then remove it for my TEE prep. I have the nurse put the foley in and clip the chest hair at this time as well. I then tape the eyes shut and proceed to the OR.

One of our OB nurses gives the hard sell of a pre-spinal Foley to every scheduled c-section, in the privacy of the preop area. She makes it sound like there will be 27 guys standing around leering in the OR if she gets the spinal first.

But god help me if I ask her to start a 2nd IV.

People are funny.

 

[Mman]

If the patient has nothing to compare it to they won't complain about it. They just figure that's the way it always is, and they deal with it.

And no, it's not like you're waterboarding them or anything, but I bring the point up again- if it was your elderly mother going for surgery, you'd rather the line be done asleep in the OR, rather than after a bunch of midaz/fent in holding, wouldn't you?

You can do ortho cases safely with a PCA and no regional too. Doesn't mean it's the most comfortable way for the patient.

Anyway, I understand that you play the hand you're dealt, and you do what you gotta do in your individual situations. I'm just glad my cardiac surgeons have enough respect for the patient to prioritize their comfort and let me take an extra five minutes to do it asleep.

If you sedate them appropriately and use enough local, the vast majority of patients are unaware you did anything to them. They don't even know you started, let alone finished, or that there is anything sticking out of their neck. To compare it to doing an ortho case with a PCA and no regional is quite inappropriate.

 

[92122]

I would like to comment on a few issues being discussed here:

1. Awake central line placement. Where I trained for residency and fellowship, this was done exceedingly rarely. Elswhere, (e.g. MGH) PACs are placed in pre-op holding on a regular basis. In my current practice, we do the same thing as the guys up in Boston: awake lines in most patients (if done solo).

Our situation may be a bit different than HB's in that we are often doing the lines without any other physician/nurse assistance. I may well have an anesthesia tech standing by to hand me things, but I cannot have an unstable, newly induced patient who requires my adjusting their meds while simultaneously working on their lines.

As others have said, the vast majority of patients will tolerate neck line placement if reasonably sedated and generous amounts of local are given.

2. The double-stick I asked about to start the thread is actually pretty easy, as I found out recently. The purse strings really do need to be done properly, and there may well need to be some attention paid to the posterior region (underneath the catheters) as it is hard to encircle the area with just one attempt.

Despite the fact that it is a larger venotomy site, the people here have done them for decades without any significant complications. Of course, one better be sure they're in the IJ so U/S recordings for medicolegal purposes is mandatory (for me, at least). If you need to get a doublestick, this is the way to do it if the second wire cannot be passed.

 

[OB1🤙]

I work in a busy PP solo MD environment, there is just a tech to help. I don't see how this makes a difference as far as asleep or awake.

I am not saying it's wrong to do these awake. I just don't think it's optimal, in my own personal opinion.

Unless I'm going to stay with the patient after the line, I also prefer not to give a bunch of benzo/narc to a cardiac patient and then leave them with an RN after the procedure.

I do load a syringe (usually neo) on a running iv and leave it under the drape in an area where I can give a bump without breaking scrub. I have to give med a very small minority of the time.

Anyway, this is all dealer's choice, and I'm just stating my preference, both for my practice and what I would want for myself/my family.

 

[Jay K]

My XP

Residency - rare

PP - the norm, although it continues to change depending on the surgical group

It is what it is.

You adapt or you move on.