Preop lines

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Reveler

Reveler

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Who’s doing preop lines? Just a-lines or central lines too? Does it speed things up for first starts? Do preop nurses or anesthesia techs help with setup? Mild sedation for central lines, etc.?

We have a few cardiac attendings who came from private practice and they’re always advocating for preop lines even though our preop nurses hate it and our workflow isn’t setup to be efficient in that way. For those supervising bigger cases in PP, do preop lines allow for greater efficiency in the daily workflow?
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Why not admit them and line them up on the floor the night before? Why not make a do it yourself central line kit the patient can use at home before they come into the hospital? Honestly if these are the kind of things people are suggesting there are bigger issues with workflow. Maybe start with the turnover times. I'm sorry my a line and central line take 30 minutes and are a necessary part of the procedure, later surgeon nerd.
 
Reveler said:
Who’s doing preop lines? Just a-lines or central lines too? Does it speed things up for first starts? Do preop nurses or anesthesia techs help with setup? Mild sedation for central lines, etc.?

We have a few cardiac attendings who came from private practice and they’re always advocating for preop lines even though our preop nurses hate it and our workflow isn’t setup to be efficient in that way. For those supervising bigger cases in PP, do preop lines allow for greater efficiency in the daily workflow?
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I think pre-op a-lines are fine as long as you can explain to the pre-op nurses that inserting an arterial line is not, in fact, major surgery, and that they can continue on asking the pt the 25 inane questions on their checklist while you work.

OTOH, pre-op cordis or MAC placement for cardiac surgery (even with some sedation) is a goddamned pain in the ass and I wish nothing but sadness upon whomever first came up with that idea to speed workflow.
 
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vector2 said:
I think pre-op a-lines are fine as long as you can explain to the pre-op nurses that inserting an arterial line is not, in fact, major surgery, and that they can continue on asking the pt the 25 inane questions on their checklist while you work.

OTOH, pre-op cordis or MAC placement for cardiac surgery (even with some sedation) is a goddamned pain in the ass and I wish nothing but sadness upon whomever first came up with that idea to speed workflow.
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Honestly i think all of this is stupid and creates a good deal of patient discomfort for no real reason. There are so many other areas of OR inefficiency, this shouldn't be the way we try to shave a few minutes.
 
In residency, the culture was to do all alines in preop holding. Then I quickly realized how stupid that was when I joined my group. Can’t even imagine routinely doing central lines in holding.

The expectation needs to be that preop lines are simply part of the procedure and should be done in the OR. For patient safety, comfort, and expediency. Those surgeons need to get over themselves and get with the program.
 
vector2 said:
OTOH, pre-op cordis or MAC placement for cardiac surgery (even with some sedation) is a goddamned pain in the ass and I wish nothing but sadness upon whomever first came up with that idea to speed workflow.
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Unfortunately this is still quite common in my geographic area, Passed on several PP jobs where this was the norm. Why would I come to the hospital at 6am to torture an awake patient in pre-op, just so some prima-donna can get out at 2:00 in stead of 2:30. Do it in the OR. The patient wins because they’re asleep and don’t have to experience it and I win because I get another 2 units for my time.
 
A difficult central line/MAC or a line 'delays' a case wherever they're done. There's even a name for that...an anesthesia delay. But crappy targets, difficult vein harvests, adhesions, friable tissue...that's all just part of a tough case....
 
We do a lot of awake a-lines in pre-op. There are often room delays for one reason or another, so we have time on our hands. A lot of our patients who get a-lines have a reason to have them before induction anyway, so whether they're done in the room or pre-op, they're getting them before going to sleep. When residents first start with us, they "can't believe we do it," but after they've done a few, with good patient preparation, effective local anesthesia, and the attention to technique required for a patient who is staring at you the whole time, they realize it's not much of a fuss, and a good technique to learn.
 
cchoukal said:
We do a lot of awake a-lines in pre-op. There are often room delays for one reason or another, so we have time on our hands. A lot of our patients who get a-lines have a reason to have them before induction anyway, so whether they're done in the room or pre-op, they're getting them before going to sleep. When residents first start with us, they "can't believe we do it," but after they've done a few, with good patient preparation, effective local anesthesia, and the attention to technique required for a patient who is staring at you the whole time, they realize it's not much of a fuss, and a good technique to learn.
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Understood if the patient is a train wreck. This doesn't apply to community hospitals. Besides a patient who is having a carotid endarterectomy and has had a recent stroke, someone with active ischemia or raging CAD, or severe cardiomyopathy or valvulopathy, they don't need it pre-induction. I would say in PP 10-20% of a lines are preinduction and I would probably be overstating it at that.
 
Reveler said:
Who’s doing preop lines? Just a-lines or central lines too? Does it speed things up for first starts? Do preop nurses or anesthesia techs help with setup? Mild sedation for central lines, etc.?

We have a few cardiac attendings who came from private practice and they’re always advocating for preop lines even though our preop nurses hate it and our workflow isn’t setup to be efficient in that way. For those supervising bigger cases in PP, do preop lines allow for greater efficiency in the daily workflow?
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I have honestly no idea what this thread is about (which lines? In preop? Why? Which cases? Who the hell thought of this?) but the idea that doing an awake central line in preop as standard for whatever case somehow saves time vs asleep in the OR is so insane as to prompt professional investigation.

Doing a preinduction art line can happen in the OR in 2 minutes, literally the only extra step vs periinduction vs postinduction is that you have to draw up 1ml lidocaine. Jfc.
 
cchoukal said:
We do a lot of awake a-lines in pre-op. There are often room delays for one reason or another, so we have time on our hands. A lot of our patients who get a-lines have a reason to have them before induction anyway, so whether they're done in the room or pre-op, they're getting them before going to sleep. When residents first start with us, they "can't believe we do it," but after they've done a few, with good patient preparation, effective local anesthesia, and the attention to technique required for a patient who is staring at you the whole time, they realize it's not much of a fuss, and a good technique to learn.
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I still don't see what the time savings is. An art line takes 2 minutes and all the stuff is there in the OR.
 
fakin' the funk said:
I still don't see what the time savings is. An art line takes 2 minutes and all the stuff is there in the OR.
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I residency service did them in preop during room turn over. Nowadays I do them in the OR.


Many years ago, we had a cardiologist who would insert PA catheters in preop holding for the patients he referred for cardiac surgery. It was a money thing. He stopped 15-20 years ago. With decreasing reimbursements, it probably stopped being worthwhile for him to get up early.
 
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I’m sure some here are faster, but I can get a pt in the room, induce/a-line/introducer/float Swan, in 16-18 minutes, when I’m really hopping (20 minutes, if I’m not).

If I can wait 4-6 hours for the surgeon to get their job done, they can wait the 10-15 mins (time ON TOP of induction) for me to get mine done.

I can SEDATE a pt more adequately in the OR (if they need a-line pre induction, and are anxious/uncooperative). I can POSITION better in the OR (armboard for arm/ease of adjusting bed). I have better LIGHTING in the OR. Also, I don’t have to send an anesthesia tech or nurse running a lot further for equipment (and wasting my time) for items kept in the OR but NOT in pre-op holding.

I pride myself on being quick/efficient, but I’m not gonna torture anxious patients in pre-op with awake IJ placements and a-line sticks, just to kiss a surgeon’s azz.

It’s an imposition on the patient, the staff, AND myself. Seeing as how it routinely takes 10-15 minutes to get the surgeon over to the OR, anyway (it’s not like THEY are trying to be efficient, and scrubbing as soon as I finish and the pt is being prepped), and THEY don’t feel obligated to close the skin (which they could do much more quickly than their first assist or PA) to save EVERYONE ELSE time at the end of the case, then I certainly don’t feel obligated to work in substandard conditions over in pre-op holding, to feed their ego...
 
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I do virtually all my art lines awake with lignocaine. Haven't done an awake CVC since I was in ICU. art lines add less than 30 seconds to induction if you've got it planned...

Shuffle them over to bed --> feel pulse --> inject lignocaine --> position them properly/do a time-out while placing monitors --> place art line while assistant runs the auto-BP and holds the mask for pre-O2 --> switch position with assistant, zero the line, check everyone's happy, induce.

I've seen someone get needle-sticked by an art line needle left on the bed from pre-op. I don't see the time-saving.
 
DirtDocMD said:
I’m sure some here are faster, but I can get a pt in the room, induce/a-line/introducer/float Swan, in 16-18 minutes, when I’m really hopping (20 minutes, if I’m not).

If I can wait 4-6 hours for the surgeon to get their job done, they can wait the 10-15 mins (time ON TOP of induction) for me to get mine done.

I can SEDATE a pt more adequately in the OR (if they need a-line pre induction, and are anxious/uncooperative). I can POSITION better in the OR (armboard for arm/ease of adjusting bed). I have better LIGHTING in the OR. Also, I don’t have to send an anesthesia tech or nurse running a lot further for equipment (and wasting my time) for items kept in the OR but NOT in pre-op holding.

I pride myself on being quick/efficient, but I’m not gonna torture anxious patients in pre-op with awake IJ placements and a-line sticks, just to kiss a surgeon’s azz.

It’s an imposition on the patient, the staff, AND myself. Seeing as how it routinely takes 10-15 minutes to get the surgeon over to the OR, anyway (it’s not like THEY are trying to be efficient, and scrubbing as soon as I finish and the pt is being prepped), and THEY don’t feel obligated to close the skin (which they could do much more quickly than their first assist or PA) to save EVERYONE ELSE time at the end of the case, then I certainly don’t feel obligated to work in substandard conditions over in pre-op holding, to feed their ego...
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Good luck telling that to administration when they've had problems with CT surg coverage for years and the group finally providing coverage demands lines at 630 so they can cut at 7.
 
vector2 said:
Good luck telling that to administration when they've had problems with CT surg coverage for years and the group finally providing coverage demands lines at 630 so they can cut at 7.
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Seems like the admin in your hospital ought to learn how to place the lines themselves and come in at 6 am to do them
 
Personally I see a lot of utility in pre-induction art lines. In the OR or in holding, I really don’t care… But it takes the same amount of time awake or asleep, with good local anesthetic it should be virtually painless (certainly not “torturing the patient), and if the patient is sick enough to justify an art line for whatever reason, I like having that monitor when I’m pushing propofol and switching to positive pressure ventilation.

Awake central lines, I can’t stand. Even with good local anesthesia, the dilation step is generally somewhat uncomfortable for the patient (even more so with introducers). As someone who has done probably between 5000 and 10000 central lines, I also still find that sticking the IJ on a spontaneously ventilating patient who is moving and talking can sometimes be challenging (not always, but for folks with very small and collapsible veins). At my shop we do awake R IJ transvenous pacers for MAC TAVRs, and it’s just generally a pain in the azz… Moreover, awake central lines are rarely necessary. I’ll push just about any med through a peripheral IV for a few minutes until we can get to sleep and obtain central access
 
I have done art lines both before OR in preop and after induction. I greatly prefer placing in preop. I’m very efficient so I’m usually ready far ahead of the room. I use this time to do the line. Lots of lidocaine, US guide for first pass success on an awake bounding artery. Patients are usually fascinated by the US and many don’t even realize I’m done! It certainly isn’t torture lol
 
fakin' the funk said:
I still don't see what the time savings is. An art line takes 2 minutes and all the stuff is there in the OR.
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Well, like I said, we usually do it this way when there's a room delay and we're waiting. It may only be 2 minutes or 5 minutes (or longer, since it's often a resident doing it), but it's free time since we can't go in the room yet anyway. We stock all the equipment in pre-op, so that isn't a factor.
 
There’s zero reason to do any pre-OR lines aside from an IV. It reeks of nothing more than the appearance of doing something. Unless you’re CCF with a separate team doing preop lines for your cardiac surgery factory it’s not more efficient, and even then, I see no reason to put the patient thru an awake Introducer/PAC. And I’ve done more than my share of systemic pulm htn and bad RVs.
 
The only reason to routinely place central lines in preop is to meet a metric and/or placate a surgeon at the expense of torturing the patient. So you're knowingly doing something that's worse for the patient because some external actor told you to and your department won't/can't stand up for doing the right thing. End of story.
 
Hork Bajir said:
Personally I see a lot of utility in pre-induction art lines. In the OR or in holding, I really don’t care… But it takes the same amount of time awake or asleep, with good local anesthetic it should be virtually painless (certainly not “torturing the patient), and if the patient is sick enough to justify an art line for whatever reason, I like having that monitor when I’m pushing propofol and switching to positive pressure ventilation.

Awake central lines, I can’t stand. Even with good local anesthesia, the dilation step is generally somewhat uncomfortable for the patient (even more so with introducers). As someone who has done probably between 5000 and 10000 central lines, I also still find that sticking the IJ on a spontaneously ventilating patient who is moving and talking can sometimes be challenging (not always, but for folks with very small and collapsible veins). At my shop we do awake R IJ transvenous pacers for MAC TAVRs, and it’s just generally a pain in the azz… Moreover, awake central lines are rarely necessary. I’ll push just about any med through a peripheral IV for a few minutes until we can get to sleep and obtain central access
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This.

Awake spontaneously breathing central lines are more difficult and higher risk than asleep, paralyzed, PPV, and with a good amount of tberg that would make most awake patients uncomfortable. In my hands, they’re much easier and faster asleep.


Also agree that preinduction Aline is useful in tenuous patients. Even for stable patients, we always did preinduction Aline’s for hearts.
 
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My current job makes it a nightmare to try to do even a simple pre-op aline. So I'm doing everything in the OR. Don't think doing them in holding speeds things up.

In residency for cardiac we did them in pre-op holding with some versed/fent sedation and then almost immediately took them to the OR. Didnt really understand the exact reason for it...
 
The whole idea is fuking stupid. Doing arterial lines or central lines in the holding area is both ergonomically more difficult and time consuming than placing it under anesthesia is a wide open OR. Better sterile technique for the CVC as well. Pre/Post induction A-lines depends on the case, but its not a time saver. Also assuming you're placing them before first-starts, YOU have to come in even earlier than before (30-45 minutes early) that you are not compensated for. Why in the world would you do that?

Only thing in the pre-op should be a PIV to push fentanyl and midaz thru when they get in the door.
Urzuz said:
The only procedures I’ll do in preop are a peripheral nerve block or a PIV (if the nurses are having trouble). Everything else gets done in the OR.
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This is the way
 
Robotic Wis-Hipple said:
There’s zero reason to do any pre-OR lines aside from an IV. It reeks of nothing more than the appearance of doing something. Unless you’re CCF with a separate team doing preop lines for your cardiac surgery factory it’s not more efficient, and even then, I see no reason to put the patient thru an awake Introducer/PAC. And I’ve done more than my share of systemic pulm htn and bad RVs.
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No separate pre-op line team at CCF, sounds luxurious. CRNAs will do each other's second-start PIV/art lines in holding area while first case is still finishing up. Residents/Fellows are left scrambling to get their own lines done between 1st/2nd case transition, in holding area if possible, otherwise we'll do awake PIV/brachial art lines in OR on awake patient.
 
Where I trained, we did preop a-lines for TAVRs and that was about it being done awake. Where I practice, we do almost all of the a-lines and central lines in preop. I thought it was going to be terrible, but honestly, it's nowhere near the hassle that a lot of you are making it out to be. We have good techs that assist with the central lines. And save for the dramatic patients that act like they're dying when the BP cuff cycles, patients tolerate it just fine with some local, fentanyl, +/- versed. I do find both to be easier to do asleep, but not to a clinically significant level. For our practice, it does make life easier for us to do them in preop.
 
DrZzZz said:
Where I trained, we did preop a-lines for TAVRs and that was about it being done awake. Where I practice, we do almost all of the a-lines and central lines in preop. I thought it was going to be terrible, but honestly, it's nowhere near the hassle that a lot of you are making it out to be. We have good techs that assist with the central lines. And save for the dramatic patients that act like they're dying when the BP cuff cycles, patients tolerate it just fine with some local, fentanyl, +/- versed. I do find both to be easier to do asleep, but not to a clinically significant level. For our practice, it does make life easier for us to do them in preop.
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Why the f do people do that? It drives me nuts when people whine about the bp cuff. You had it in preop, in your primarys office, on the floor etc. Wtf is the point of whining??
 
GassYous said:
Why the f do people do that? It drives me nuts when people whine about the bp cuff. You had it in preop, in your primarys office, on the floor etc. Wtf is the point of whining??
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It's an early indicator that patient is going to be a pain in the ass through postop
 
So long as you give some versed or sedation I don’t see the issue, a triple lumen or art line is not really painful. Definitely would not want a MAC or swan awake though.
 
BlueRug said:
I've seen more "delays" from difficult foley placement requiring cysto than anything else. Seems like preop foley should be on the list.

Why not preop ETT as well?
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its funny you say this, but europe has induction rooms where you do place preop ETT and then bring them into the OR
 
BlueRug said:
I've seen more "delays" from difficult foley placement requiring cysto than anything else. Seems like preop foley should be on the list.

Why not preop ETT as well?
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You don’t have some poor SA that used to be a urologist in another country that everyone calls when they have a tough foley who sprinkles fairy dust on a 14F coude and magically gets it in? I thought every hospital had one of these.
 
Do you people not sedate before your lines?

I'm a big fan of preop lines. I don't have a bunch of people walking all around me to place a foley, try to position the patient, move the chest strap, etc. I don't have a surgeon (literally, this happens) tapping his foot loudly in the corner. We have a dedicated block/line area where all of my supplies are. I position the patient how I want to and move at whatever pace I desire. The patient is adequately sedated with versed, localized and we go. 90% of my arterial lines are done preop. I only do CVL or cordis preop if it's a cardiac case, and those people are getting like 4-6+ versed and are very comfortable. None of them even remember the procedure when I check on them the next day.
 
Mehd School said:
Do you people not sedate before your lines?

I'm a big fan of preop lines. I don't have a bunch of people walking all around me to place a foley, try to position the patient, move the chest strap, etc. I don't have a surgeon (literally, this happens) tapping his foot loudly in the corner. We have a dedicated block/line area where all of my supplies are. I position the patient how I want to and move at whatever pace I desire. The patient is adequately sedated with versed, localized and we go. 90% of my arterial lines are done preop. I only do CVL or cordis preop if it's a cardiac case, and those people are getting like 4-6+ versed and are very comfortable. None of them even remember the procedure when I check on them the next day.
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I don't have any of those things happening to me in the or?
 
GassYous said:
I don't have any of those things happening to me in the or?
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I do, and I always have. A metric at my hospital, and many others is time from patient entering the OR to cut. When the patient moves over to the OR table it's a mad dash. I have had a nurse tell me she refused to place a foley with the patient in trendelenburg while I was placing a very difficult central line and was told that my team was slowing her down. One of many examples of the buffoonery I can avoid if I do the lines on my time.
 
Mehd School said:
I do, and I always have. A metric at my hospital, and many others is time from patient entering the OR to cut. When the patient moves over to the OR table it's a mad dash. I have had a nurse tell me she refused to place a foley with the patient in trendelenburg while I was placing a very difficult central line and was told that my team was slowing her down. One of many examples of the buffoonery I can avoid if I do the lines on my time.
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Hearing stories like this makes me so grateful for my practice environment.
 
Mehd School said:
I do, and I always have. A metric at my hospital, and many others is time from patient entering the OR to cut. When the patient moves over to the OR table it's a mad dash. I have had a nurse tell me she refused to place a foley with the patient in trendelenburg while I was placing a very difficult central line and was told that my team was slowing her down. One of many examples of the buffoonery I can avoid if I do the lines on my time.
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Sounds like your anesthesia department needs to grow a pair. This is ridiculous and stupid. Maybe we should also collect metrics on how much stupid surgery goofing off takes place.
 
Where I trained we had this asinine process of doing lines and spinal drains the day prior to TAAA repairs. Absolutely haste that practice. Why expose a patient to risk of complication or infection for a line they don’t need at the moment?

Doing lines in preop seems unnecessary, though with production pressures can see how this would be the natural outcome.
 
McPoyle said:
Where I trained we had this asinine process of doing lines and spinal drains the day prior to TAAA repairs. Absolutely haste that practice. Why expose a patient to risk of complication or infection for a line they don’t need at the moment?

Doing lines in preop seems unnecessary, though with production pressures can see how this would be the natural outcome.
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Re lumbar drain. That actually makes sense. And done probably because a bloody tap would delay the surgery.
 
Mehd School said:
I do, and I always have. A metric at my hospital, and many others is time from patient entering the OR to cut. When the patient moves over to the OR table it's a mad dash. I have had a nurse tell me she refused to place a foley with the patient in trendelenburg while I was placing a very difficult central line and was told that my team was slowing her down. One of many examples of the buffoonery I can avoid if I do the lines on my time.
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Tell her to wait? You're a doctor homeboy
 
GassYous said:
Tell her to wait? You're a doctor homeboy
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Of course. I don't know if you have travelers in your shop yet, but my experience so far is that they could give a **** about local culture or respect. They're on to the next in 3 weeks.

Or alternatively I could deal with none of this and place lines in the comfort of my line/block area with a sedated patient.
 
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