procedures for hospitalists working at nights

[James ij]

I am about to start moonlighting nights at this place. They said I dont need to do any procedures.
Just wondering how often do hospitalists get the help they needed when working at nights. Is IR always available to do central lines?

For those doing it now, do you automatically know all the procedures, or do you consult for help? What happens when the specialists are not available?

How available are the ER doctors to help out procedures? Do they like this kind of thing?

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[cbrons]

I have a somewhat related question - is it possible to become proficient in these procedures during IM residency?

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[Crayola227]

I have a somewhat related question - is it possible to become proficient in these procedures during IM residency?

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Absolutely. An IM program that is ICU heavy and with no fellows. There you can get a lot of intubation and lines, arterial puncture. Also paracentesis, if you're lucky thoracentesis although admittedly that's going more and more to IR. Chest tubes even.

Also seeing more u/s being used bedside for billing.

This would be more in a community program than large academic center so there's the trade off. Although some academic programs have no issue. It's sorta program dependent. People will mention it's also up to how aggressive you are in seeking out the opportunity but I think that's bollocks. The reality of any program you're in can always trump your individual enthusiasm.

 

[group_theory]

I am about to start moonlighting nights at this place. They said I dont need to do any procedures.
Just wondering how often do hospitalists get the help they needed when working at nights. Is IR always available to do central lines?

For those doing it now, do you automatically know all the procedures, or do you consult for help? What happens when the specialists are not available?

How available are the ER doctors to help out procedures? Do they like this kind of thing?

Really depends on the culture of the hospital where you are working.

Who does the lines/procedures there? Surgery? ICU doc? Anesthesia? ER?

Would IR come in the middle of the night for a line - unlikely

Would ER come do the line - depends on the hospital culture, but what if the ED is busy and full? Your "procedure" will be on the backburner

Would the ICU doc do the procedure? Depending on how sick your patient is, compare to how busy/sick the ICU is. However keep in mind (according to Leapfrog), the majority of hospitals in the US don't even have 8 hr of intensivisit coverage/day ... would you have someone in the ICU for night (or would it be you?)

Would anesthesia or surgery do it? Depends on the hospital/culture and whether they are in house. What if the surgeon is in surgery with anesthesia there at night?

Most likely no one will be coming in from home (whether IR/Pulm CCM/Surgery/Anesthesia) to do a procedure for you on your patient unless it is life threatening/emergency.

Again, I would ask the hospital where you are moonlighting ... who does the procedure if it needs to be done. And if the answer is "ER or surgery or ICU" then ask how likely or easily can that request be done. Remember, you are asking another service, which is likely also busy, to do you a favor for your patient.

 

[Crayola227]

Really depends on the culture of the hospital where you are working.

Who does the lines/procedures there? Surgery? ICU doc? Anesthesia? ER?

Would IR come in the middle of the night for a line - unlikely

Would ER come do the line - depends on the hospital culture, but what if the ED is busy and full? Your "procedure" will be on the backburner

Would the ICU doc do the procedure? Depending on how sick your patient is, compare to how busy/sick the ICU is. However keep in mind (according to Leapfrog), the majority of hospitals in the US don't even have 8 hr of intensivisit coverage/day ... would you have someone in the ICU for night (or would it be you?)

Would anesthesia or surgery do it? Depends on the hospital/culture and whether they are in house. What if the surgeon is in surgery with anesthesia there at night?

Most likely no one will be coming in from home (whether IR/Pulm CCM/Surgery/Anesthesia) to do a procedure for you on your patient unless it is life threatening/emergency.

Again, I would ask the hospital where you are moonlighting ... who does the procedure if it needs to be done. And if the answer is "ER or surgery or ICU" then ask how likely or easily can that request be done. Remember, you are asking another service, which is likely also busy, to do you a favor for your patient.

I agree with all of this, except I don't know how much a "favor" it is as it just problematic for the reasons you gave. Fellows are salaried, my understanding is that if an attending does the procedure for you like the examples you gave, that they are able to bill the procedure. This was pointed out to me for why all sorts of things are a PITA with fellows and that specialists tend to be more pleasant after finishing. I think too this is where I hear that some community programs residents can complain about private hospitalists not attached to the teaching service "steal" procedures.

 

[group_theory]

I agree with all of this, except I don't know how much a "favor" it is as it just problematic for the reasons you gave. Fellows are salaried, my understanding is that if an attending does the procedure for you like the examples you gave, that they are able to bill the procedure. This was pointed out to me for why all sorts of things are a PITA with fellows and that specialists tend to be more pleasant after finishing. I think too this is where I hear that some community programs residents can complain about private hospitalists not attached to the teaching service "steal" procedures.

I'm not waking up and coming in from home in the middle of the night to do a procedure on a patient I don't know, who isn't sick enough to be transferred to my unit, for 2.5 RVU (CPT 36556)

 

[rokshana]

Remember, you are asking another service, which is likely also busy, to do you a favor for your patient.

not necessarily a "favor" but part of their job requirement...as you said, depends on the hospital culture, but some places hospitalist are not credentialed for many procedures and are done by anesthesia or surgery (who are in-house , IR is rarely in house in the middle of the night), but then again, most procedures other than a central line or intubation (which means they are going to the ICU s/p a rapid response or code anyway) need to be done at night.

there is a difference between "do not need" and "not required" to do procedures...check with the hospital which one it is...

 

[Vigileo]

I have a somewhat related question - is it possible to become proficient in these procedures during IM residency?

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I'm at an academic, university program in the Midwest and I am comfortable doing CVCs, VasCaths, paracentesis, thoracentesis, arterial lines, LPs. We are routinely expected to do them, particular when on one of our 5-6 ICU months. I don't routinely intubate without someone standing over my shoulder (most often pulmonary fellows but also ER/anesthesia on occasion). I also don't feel comfortable doing subclavian lines, but IJ and femoral are fine. So yes, it's definitely possible. Just currently de-emphasized in a number of residencies.


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[chessknt]

Hospitals with the resources to properly utilize hospitalists always de-emphasize these procedures because hospitalists are slower (done less frequently) than other specialties and it ruins their workflow which decreases overall efficiency in terms of getting people out of the ER/hospital and meeting quality measures. Its the same reason ER wont do it unless someone is going to die without the line--ruins their workflow which is critical to the hospital. RVU billing for bedside procedures is pretty subpar also unless you can churn it quickly (eg do a central line in 10 minutes or a diagnostic para in 5); you wont get any extra RVUs for a complicated line that takes 4x that.

 

[Siggy]

I have a somewhat related question - is it possible to become proficient in these procedures during IM residency?

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I'm a 2nd year at a unopposed community program and I've gotten numerous intubations (I feel comfortable deciding to intubate and feel comfortable giving a first and second shot... I need more difficult airways though), central line placements (mostly IJs and I feel comfortable with IJs), and paracentesis.

It depends both on your program and how aggressive you are. If I'm in the ICU seeing one of my patients and I hear the intensivist needs to intubate a patient, I'll ask if I can give it a shot even if it's not one of my patients. Same with the ED. The vast majority of the ICU and ED attendings at my hospital like to teach and if they see a resident around prior to a procedure, they'll ask if we want to take a shot at it first.


Obviously it becomes harder to snipe procedures if you're competing with other programs for procedures (i.e. EM residents are generally going to get the first shot in the ED).

 

[Siggy]

Hospitals with the resources to properly utilize hospitalists always de-emphasize these procedures because hospitalists are slower (done less frequently) than other specialties and it ruins their workflow which decreases overall efficiency in terms of getting people out of the ER/hospital and meeting quality measures. Its the same reason ER wont do it unless someone is going to die without the line--ruins their workflow which is critical to the hospital. RVU billing for bedside procedures is pretty subpar also unless you can churn it quickly (eg do a central line in 10 minutes or a diagnostic para in 5); you wont get any extra RVUs for a complicated line that takes 4x that.

All the more reason to get the most experience with procedures in residency. Heck, if you can have US mark your spot for paras, then it really shouldn't take longer than 5 minutes to throw a Yueh in and let the nurse run the bottles. Go, write procedure note, remove needle. Bandaid. Back to work.


Also, if you're using the kits and not a Yueh, then you don't know what you're missing.

 

[poopybutt]

I have a somewhat related question - is it possible to become proficient in these procedures during IM residency?

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I'm at a large academic residency program who expects us to be competent in ultrasound guided procedures early on in intern year. I have done lots of A-lines, central lines including big dialysis ones or the cooling lines, one chest tube, more paracentesis than I can count, no intubations. I had a lot of interest in doing procedures early on in residency.. Now they just seem to be a time suck, but I feel comfortable with any procedure I need to do emergently overnight without supervision.


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[cbrons]

I'm at a large academic residency program who expects us to be competent in ultrasound guided procedures early on in intern year. I have done lots of A-lines, central lines including big dialysis ones or the cooling lines, one chest tube, more paracentesis than I can count, no intubations. I had a lot of interest in doing procedures early on in residency.. Now they just seem to be a time suck, but I feel comfortable with any procedure I need to do emergently overnight without supervision.


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How do you get intubatios? Or is that just not really possible in IM?

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[Crayola227]

How do you get intubatios? Or is that just not really possible in IM?

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it is possible you get them on the floor when a patient crumps and gets a code blue and needs to be tubed before transfer to the ICU

you also get them in the ICU when patients fail extubation, or otherwise need it

also, whenever you carry the code pager

it's definitely a "right place right time" sort of thing

also, on however many ED rotations you do you might get some, especially at a program that doesn't have an EM residency

hell, I got one my first month of internship

 

[chessknt]

At a large academic center I have only gotten tubes in the ICU when the fellow was off. Very very rare here--I may be only one of 2-3 people in my entire residency to even get an attempt, let alone success, at intubation.

If procedural competence is your focus with no intent for fellowship go to a community program with no fellows or EM/anesthesia residents.

 

[Siggy]

Another option if you're looking for tubes is to do a month on anesthesiology

 

[IMreshopeful]

I was pretty enthusiastic about procedures and did quite a few as a resident but no intubations.

Now I'm a cardiology fellow and we have far more advanced procedures which we have to train in....so now the learning curve is back to baseline

 

[badasshairday]

It is rearly unfortunate to see bedside procedures fall from the skillset of a general internist. IR generally provides procedural support during normal business hours, then tends to be on call for emergencies like gi bleeders, trauma, strokes, cold legs. Otherwise, like most specialists that take home call, they are not coming in for non-emergency things like central lines, paras, thoras, which most expect is in the skillset of almost all docs especially hospitalists.

Understandably it makes sense for a hospitalist to send basic bedside procedures to IR because it allows them to continue their work flow and those procedures are very quick to complete in IR so everyone is happy. But nights and weekends it is like pulling teeth unless we are already in the hospital for a real emergency and can as add on a basic procedure with the IR team in house.

I find it surprising when I get consults for paracentesis/thoracentesis over the weekend on patients with massive ascites. It is a lost learning opportunity for IM residents and no gain for radiology residents as we already get to do a billion of these.

 

[rokshana]

It is rearly unfortunate to see bedside procedures fall from the skillset of a general internist. IR generally provides procedural support during normal business hours, then tends to be on call for emergencies like gi bleeders, trauma, strokes, cold legs. Otherwise, like most specialists that take home call, they are not coming in for non-emergency things like central lines, paras, thoras, which most expect is in the skillset of almost all docs especially hospitalists.

Understandably it makes sense for a hospitalist to send basic bedside procedures to IR because it allows them to continue their work flow and those procedures are very quick to complete in IR so everyone is happy. But nights and weekends it is like pulling teeth unless we are already in the hospital for a real emergency and can as add on a basic procedure with the IR team in house.

I find it surprising when I get consults for paracentesis/thoracentesis over the weekend on patients with massive ascites. It is a lost learning opportunity for IM residents and no gain for radiology residents as we already get to do a billion of these.

yes, but since IR and radiology have decided to take on these as things that should come in their scope of practice, they have to expect that they will be called on to do them at other, maybe inconvenient, times...the learning "opportunity" should come during the regular day with people to supervise the procedure (but then the radiology residents wouldn't get to have a "billion" of these...you shouldn't be surprised that the consult would come to those that are experienced in the procedure...

 

[badasshairday]

yes, but since IR and radiology have decided to take on these as things that should come in their scope of practice, they have to expect that they will be called on to do them at other, maybe inconvenient, times...the learning "opportunity" should come during the regular day with people to supervise the procedure (but then the radiology residents wouldn't get to have a "billion" of these...you shouldn't be surprised that the consult would come to those that are experienced in the procedure...

Not arguing with you, but we didn't ask for paras and thoras. Just saying that some procedures such as para and routine central line placement should be in the basic skill set of all docs, especially hospitalists. I will gladly come in and take care of a difficult central line for someone who needs dialysis 2 days ago and you have attempted unsuccessfully to place a temp HD line. But routine lines and therapeutic paras need to be in the skill set of general IM, imo.

In other words a hospitalist probably shouldn't expect someone to come in and do a central line for them for the 2 am admit. The ED might have messed that up for not sending them up with a line, but now you are going to have to do it if needed or wait til 6 or 7am. This is akin to me not calling you for my liver tumor ablation admitted for obs who has hypertension 180/100 at 2 am since I should be able to take care of that myself.

 

[deleted547339]

Not arguing with you, but we didn't ask for paras and thoras. Just saying that some procedures such as para and routine central line placement should be in the basic skill set of all docs, especially hospitalists. I will gladly come in and take care of a difficult central line for someone who needs dialysis 2 days ago and you have attempted unsuccessfully to place a temp HD line. But routine lines and therapeutic paras need to be in the skill set of general IM, imo.

In other words a hospitalist probably shouldn't expect someone to come in and do a central line for them for the 2 am admit. The ED might have messed that up for not sending them up with a line, but now you are going to have to do it if needed or wait til 6 or 7am. This is akin to me not calling you for my liver tumor ablation admitted for obs who has hypertension 180/100 at 2 am since I should be able to take care of that myself.

Wait......you (as a radiologist) admit your own patients!?

 

[badasshairday]

Wait......you (as a radiologist) admit your own patients!?

Haha. Rarely. Usually when we admit it is our interventional oncology patients after procedures. As you know, IR procedures are minimally invasive so it is usually 23 hours obs at most. We also admit our elective aneurysm coiling patients with neuroICU consult, but we are primary. IR is changing. We even run a clinic

 

[deleted547339]

Haha. Rarely. Usually when we admit it is our interventional oncology patients after procedures. As you know, IR procedures are minimally invasive so it is usually 23 hours obs at most. We also admit our elective aneurysm coiling patients with neuroICU consult, but we are primary. IR is changing. We even run a clinic

The times, they are a'changin'

 

[rokshana]

Not arguing with you, but we didn't ask for paras and thoras. Just saying that some procedures such as para and routine central line placement should be in the basic skill set of all docs, especially hospitalists. I will gladly come in and take care of a difficult central line for someone who needs dialysis 2 days ago and you have attempted unsuccessfully to place a temp HD line. But routine lines and therapeutic paras need to be in the skill set of general IM, imo.

In other words a hospitalist probably shouldn't expect someone to come in and do a central line for them for the 2 am admit. The ED might have messed that up for not sending them up with a line, but now you are going to have to do it if needed or wait til 6 or 7am. This is akin to me not calling you for my liver tumor ablation admitted for obs who has hypertension 180/100 at 2 am since I should be able to take care of that myself.

Not sure where a HD line is done by any Hospitalist ( even as a resident that was done by the nephrology fellows or vascular)... Interesting that you feel it should be a part of the skill set of the Hospitalist when the acgme doesn't require them to complete a residency or the abim consider them necessary to sit for the boards.
In small rural hospitals I can see where it would be necessary for the Hospitalist to do everything but at larger places particularly academic centers (at least the places I have been) the hospitalists aren't even credentialed to do them...
And that's great that you admit your obs pts... Where I have been they are usually admitted to the Hospitalist service after the procedure for obs...

 

[gutonc]

Not sure where a HD line is done by any Hospitalist ( even as a resident that was done by the nephrology fellows or vascular)... Interesting that you feel it should be a part of the skill set of the Hospitalist when the acgme doesn't require them to complete a residency or the abim consider them necessary to sit for the boards.
In small rural hospitals I can see where it would be necessary for the Hospitalist to do everything but at larger places particularly academic centers (at least the places I have been) the hospitalists aren't even credentialed to do them...
And that's great that you admit your obs pts... Where I have been they are usually admitted to the Hospitalist service after the procedure for obs...

A couple of the hospitals that I rotate at have hospitalists that will do procedures like dialysis lines. But they're not required to do so as part of the job, they can if they want to.

 

[badasshairday]

You are right. A HD line may be a bit much. But a para on massive ascites and a routine central lines for venous access I think are reasonable skills to have. And intubating. Not saying everyone has these skills, but these are skills to strive for for anyone working in the inpatient setting (including myself regarding airway).

 

[deleted547339]

You are right. A HD line may be a bit much. But a para on massive ascites and a routine central lines for venous access I think are reasonable skills to have. And intubating. Not saying everyone has these skills, but these are skills to strive for for anyone working in the inpatient setting (including myself regarding airway).

Two things - a CVL and a dialysis line are the same. If you're competent with ultrasound, you can do both. It's literally just one extra dilator. Just a little extra blood.

As far as intubations, I strongly disagree. I think this isn't something someone should "try to get good at." You either need to do several hundred of these, or none. I've yet to meet an internist who received adequate training in intubation to be competent to perform unsupervised intubations while in residency. This is one of the few ways you can kill a patient. Someone who has done a couple dozen and thinks that he is decent will kill people. Yes, 90%+ of intubations are fairly easy, but the bad ones can get real bad real quick, and if you're not physically and mentally prepared to use all of your adjunct airway devices and, ultimately, willing and able to perform a surgical airway you shouldn't be intubating unsupervised.

 

[PlutoBoy]

Two things - a CVL and a dialysis line are the same. If you're competent with ultrasound, you can do both. It's literally just one extra dilator. Just a little extra blood.

As far as intubations, I strongly disagree. I think this isn't something someone should "try to get good at." You either need to do several hundred of these, or none. I've yet to meet an internist who received adequate training in intubation to be competent to perform unsupervised intubations while in residency. This is one of the few ways you can kill a patient. Someone who has done a couple dozen and thinks that he is decent will kill people. Yes, 90%+ of intubations are fairly easy, but the bad ones can get real bad real quick, and if you're not physically and mentally prepared to use all of your adjunct airway devices and, ultimately, willing and able to perform a surgical airway you shouldn't be intubating unsupervised.

Way more scary to put those huge cathteters in though

Hospital medicine should be its own residency or a fellowship. It has little in common with general IM.

I think hospitalists should be able to do paracentesis and central lines. You don't really need to do intubations or arterial lines if you are not running the ICU.

It is a plus if you can do thoracentesis but I understand why these are a little more scary (having said that, one of my patients was recently admitted to a large tertiary care center in town and had bilateral CT guided thoracentesis... Sounds like a bit too much... I guess it pays more to use the scanner than the US).

When I worked as a hospitalist I didn't sweat calling anesthesia for intubations. I'd have a hard time calling them to place a central line though. I did "let the residents have a shot" at the lines if you know what I mean.

 

[gutonc]

Two things - a CVL and a dialysis line are the same. If you're competent with ultrasound, you can do both. It's literally just one extra dilator. Just a little extra blood.

I keep wondering about why people are freaking out about dropping a Quinton/Niagara but have no issues with a triple lumen. Same location, same technique, a little more bleeding risk, but whatever. I put HD caths in acute leukemics for leukopheresis with WBC of 200K and plts of 15K without difficulty when I was a resident. Usually supervised by the first-year ICU fellow (admittedly never did them on the floor) who had often done about 10% more lines than I had.

 

[badasshairday]

Two things - a CVL and a dialysis line are the same. If you're competent with ultrasound, you can do both. It's literally just one extra dilator. Just a little extra blood.

As far as intubations, I strongly disagree. I think this isn't something someone should "try to get good at." You either need to do several hundred of these, or none. I've yet to meet an internist who received adequate training in intubation to be competent to perform unsupervised intubations while in residency. This is one of the few ways you can kill a patient. Someone who has done a couple dozen and thinks that he is decent will kill people. Yes, 90%+ of intubations are fairly easy, but the bad ones can get real bad real quick, and if you're not physically and mentally prepared to use all of your adjunct airway devices and, ultimately, willing and able to perform a surgical airway you shouldn't be intubating unsupervised.

I agree to an extent.

Yes temp HD line is the same concept except larger bore and dilation needed. Because of that, I can understand the reservation against doing them for a hospitalist if they don't have as much experience with doing them. At best it is similar to central line with dilater and more blood, bUT the worst case is putting that dilator in too far and causing venous injury and hemothorax. With that said, nephrology, MICU, and SICU put those in at my hospital if they need it in a pinch before we place a permanent catheter if we are super busy.

I don't mean to be cavalier about intubation at all. I meant it as more of a last ditch effort rather than a regular thing to do.

 

[cbrons]

Can you do anesthesiology rotations as a categorical im resident?

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[leviathan]

Worst case for hemodialysis cath would actually be dilating the subclavian artery and causing massive hemothorax and cardiac arrest, or dilating a carotid and causing a stroke etc. As an internist I'm comfortable putting in vascaths but I can understand the reservation of others who aren't comfortable with ultrasound technique or confirmation of placement (vessel ultrasound is not foolproof for this).

 

[PlutoBoy]

Can you do anesthesiology rotations as a categorical im resident?

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Yes

 

[Siggy]

Not sure where a HD line is done by any Hospitalist ( even as a resident that was done by the nephrology fellows or vascular)... Interesting that you feel it should be a part of the skill set of the Hospitalist when the acgme doesn't require them to complete a residency or the abim consider them necessary to sit for the boards.
In small rural hospitals I can see where it would be necessary for the Hospitalist to do everything but at larger places particularly academic centers (at least the places I have been) the hospitalists aren't even credentialed to do them...
And that's great that you admit your obs pts... Where I have been they are usually admitted to the Hospitalist service after the procedure for obs...

I've done a couple dialysis lines. For non-tunneled caths, it's essentially the same as a central line, except with a second much larger dialator.

 

[irwarrior]

I have seen a handful of catastrophic large bore central venous catheters placed. The catheter or dilator can rarely perforate the SVC/right atrium and result in hemothorax/pericardial tamponade. There have also been a handful of inadvertent placements of lines in the carotid artery and subclavian artery. Luckily these are few and far between. I do think that there is a certain amount of experience and training needed prior to large bore central venous catheters.

As far as IR admitting, this is becoming more prevalent in practice but certainly not universal.

 

[sluggs]

I finished IM in 2010 at a university program (20/class plus prelims; very busy and a VA). On floors we did all our own LPs, Para and Thoras (not US guided, as first but then we used US for para/thora). We would do 6-8 weeks ICU per year (you could sneak in more as an elective, may not have been ACGME kosher) and we would do a lot of cvl and hd cats and art lines (had > 150 total lines). CX tubes and intubations were usually the fellow, but they would teach us (supervised only unless emergency/code/no help) and let us develop skills. When I started my CCM fellowship I felt comfortable with all of the above except intubation and bronch. It took 8 weeks of anesthesia, plus a difficult airway class plus a lot of reading about airway pharmacology, plus a bronch rotation plus 50 more ICU or ER or code airways, before I felt highly skilled to "go solo" and it was not until after my first year of ccm practice that I really had confidence enough not to be a bit afraid!
Very appreciative for the training I got

 

[deleted547339]

vessel ultrasound is not foolproof for this

That entirely depends on your technique. I see a lot of people (probably most) use US wrong for lines...

 

[leviathan]

That entirely depends on your technique. I see a lot of people (probably most) use US wrong for lines...

Even with proper technique you can miss an arterial cannulation, especially if you've gone through a vein into an artery not easily visualized like the innominate or proximal subclavian. You'll see the wire in the IJ but miss it tracking into the artery downstream. Unless you were referring to using agitated saline and doing a subcostal echo, but that's why I specifically said vessel ultrasound. The only definitive way before dilating is measuring the pressures or maybe using agitated saline.

Overall a low risk event, though there was a study that showed when an artery was entered under ultrasound guidance, they still thought they were in a vein 20% of the time (based off color, pulsatility).

 

[drfunktacular]

Reading this thread is making me even happier to be a rheumatologist


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[CatFactorial]

Even with proper technique you can miss an arterial cannulation, especially if you've gone through a vein into an artery not easily visualized like the innominate or proximal subclavian. You'll see the wire in the IJ but miss it tracking into the artery downstream. Unless you were referring to using agitated saline and doing a subcostal echo, but that's why I specifically said vessel ultrasound. The only definitive way before dilating is measuring the pressures or maybe using agitated saline.

Overall a low risk event, though there was a study that showed when an artery was entered under ultrasound guidance, they still thought they were in a vein 20% of the time (based off color, pulsatility).

Due to crazy delirium (patient's)/incompetence (mine) I placed a finder needle in this dude's carotid. Thankfully his pressure was OK and the jet of bright red blood made me stop and hold pressure. However for the SBP <= 80 folks where arterial/venous flow can be difficult to distinguish, it can be scary. Color Doppler is your friend but even then not foolproof.

 

[Siggy]

Even with proper technique you can miss an arterial cannulation, especially if you've gone through a vein into an artery not easily visualized like the innominate or proximal subclavian. You'll see the wire in the IJ but miss it tracking into the artery downstream. Unless you were referring to using agitated saline and doing a subcostal echo, but that's why I specifically said vessel ultrasound. The only definitive way before dilating is measuring the pressures or maybe using agitated saline.

You can also get a blood gas.
Another option is building a poor man's mamometer using the angiocath in the kit and the tubing for the guide wire. https://www.acep.org/Clinical---Pra...ade--Central-Venous-Line-Confirmation-Tricks/

 

[Vigileo]

You can also get a blood gas.
Another option is building a poor man's mamometer using the angiocath in the kit and the tubing for the guide wire. https://www.acep.org/Clinical---Pra...ade--Central-Venous-Line-Confirmation-Tricks/

I like this method as a resident. I utilize this as well as using ultrasound in multiple planes to help confirm wire placement, so essentially I'm trying to double check myself. Additionally, you don't necessarily need to use the angiocath for this. You can use the introducer needle after accessing the vessel and directly connect it to a longer piece of IV tubing, which they include in our CVC bundles. You just can't move the needle, so some prefer the angiocath.

 

[deleted547339]

Guys. It's not that hard. Just identify your needle tip. That's something most people don't do correctly. That is the problem with 99% of these issues.

 

[leviathan]

Guys. It's not that hard. Just identify your needle tip. That's something most people don't do correctly. That is the problem with 99% of these issues.

I agree if you do proper technique (which I've seen very few people do) either long axis or short axis following the needle tip the entire way in, then you substantially lower the risk. That said, even if you identify the neelde tip, many arterial cannulations happen after dropping the probe, as many inadvertently advance the needle into an artery before they start to put the wire in.

I agree it's 'not that hard' and that the risk is very low, but the fact that we do so many successful line placements can make us forget and be cavalier with how potentially serious the complications can be. Even in the most experienced and competent hands, the risk is never zero. Whether you want to confirm placement depends on how much risk you want to accept.

 

[deleted547339]

You can also literally hook it up to an a-line tracing on the monitor.

The "pros" imho (cardiac trained anesthesiologists) use a combo of the above: u/S visualization of needle tip, u/s confirmation of wire, and manometry.

That's what I do in any non-emergent situation now.

I find adding manometry tedious. I feel like it's an extra manipulation that's unnecessary.

Serious question: how many times in your career have you been certain it was in the vein, then had blood pour out of the top of your manometer?

 

[SouthernSurgeon]

I find adding manometry tedious. I feel like it's an extra manipulation that's unnecessary.

Serious question: how many times in your career have you been certain it was in the vein, then had blood pour out of the top of your manometer?

I personally haven't, but I know a very good anesthesiologist who has and that's more than enough for me.

But personal experience is a weak metric to rely on. There's a lot of complications in procedural medicine that I haven't personally experienced...doesn't mean I don't take the best steps I can to avoid them.

A lot of safety checks are "tedious". But employing those, to borrow from the tired/cliched airline industry analogy, tedious safety checks are how you drive error rates from say 1/1000 to 1/100000.

In the case of manometry - it adds less than a minute to the procedure and I can't think of what quantifiable risk one additional seldinger exchange adds to it.

I think it's laziness and hubris not to use it. Like I said, the people with far more experience than me that I learned from do it every time.

 

[leviathan]

In the one study I read it was about 0.8% of events were arterial cannulations, but when they did happen, it was mistaken for venous 20 % of the time before they used tubing to measure the pressures. It's a rare event that you might never even see in your career, but if it did happen it'd be hard to defend it.

 

[Apollyon]

I personally haven't, but I know a very good anesthesiologist who has and that's more than enough for me.

But personal experience is a weak metric to rely on. There's a lot of complications in procedural medicine that I haven't personally experienced...doesn't mean I don't take the best steps I can to avoid them.

A lot of safety checks are "tedious". But employing them is, to borrow from the tired/cliched airline industry analogy, tedious safety checks are how you drive error rates from say 1/1000 to 1/100000.

In the case of manometry - it adds less than a minute to the procedure and I can't think of what quantifiable risk one additional seldinger exchange adds to it.

I think it's laziness and hubris not to use it. Like I said, the people with far more experience than me that I learned from do it every time.

Yeah, you describe the "fallacy of anecdote" - "I've never seen it, so it doesn't exist". Exactly - take another's failure as your own. I don't need to have it happen to me, to put the fear of God into me.

 

[rfv123]

I'm a cardiac anesthesiologist and I transduce every line every time.

 

[smartparts]

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