RIJ CVL Trouble Shooting and TEE

Stillwater45

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    Hey guys,
    I was reading a few threads from earlier that mentioned the use of TEE to confirm placement of RIJ Cordis in the heart room. I have a few questions about this:

    Are you confirming wire placement during the line placement or just seeing the SWAN afterwards?

    How do you use the TEE and stay sterile while placing line? Or which view to you have the Probe at if you just have it place when you are placing the line?



    Also as an aside... how far do you thread your wire at baseline? And what is your strategy if you "bounce the wire" at 18 cm vs. 22 cm ect. I have been placing lots of TLC's during my ICU month on vasculopathic Pts and "bouncing" way more wires than I remember in the past.


    Thanks - CA3 here trying to explore some trouble shooting strategies
     

    sevoflurane

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      Hey guys,
      I was reading a few threads from earlier that mentioned the use of TEE to confirm placement of RIJ Cordis in the heart room. I have a few questions about this:

      Are you confirming wire placement during the line placement or just seeing the SWAN afterwards?

      How do you use the TEE and stay sterile while placing line? Or which view to you have the Probe at if you just have it place when you are placing the line?



      Also as an aside... how far do you thread your wire at baseline? And what is your strategy if you "bounce the wire" at 18 cm vs. 22 cm ect. I have been placing lots of TLC's during my ICU month on vasculopathic Pts and "bouncing" way more wires than I remember in the past.


      Thanks - CA3 here trying to explore some trouble shooting strategies

      A-line, Tube, then:

      ME ascending aorta SAX

      TEE01.jpg


      300px-ME_asc_aortic_SAX.svg.png


      Gown and glove.

      USD for IJ placement. Float swan, and see the catheter enter the RVOT and main PA on TEE.

      I don't use TEE for an IJ stick, USD is more than enough. Confirmatory when floating the swan.

      I place the wire deep enough to be able to seldinger whatever catheter I'm placing.

      Not sure what "bouncing" means.
       

      periopdoc

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        AnnCardAnaesth_2009_12_2_174_53439_u3.jpg


        TEE06.jpg


        Bicaval view.

        Get the image you want and set the handle of the transducer down.

        Prep, drape, gown glove.

        Thread wire and watch it pass from SVC to RA to IVC/RV.

        Occasionally, you will need to rotate the probe slightly to get the view lined up after you have set the transducer handle down. This can be accomplished by grasping the probe through the drape and twisting. Just be sure your handle is secure and won't fall off of whatever you set it on.

        Wire does not need to be threaded into IVC/RV and should be pulled back into RA or SVC if it goes into the RV.

        PAC placement I tend to use this view instead of the ME AV SAX that Sevo uses although I use that view to confirm where the tip went.

        TEE02.jpg


        - pod
         
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        sevoflurane

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          Yep. PODs answer is right on if you are trouble shooting and want to see the wire in the SVC/RA. :thumbup:

          My go to view is the one described, just cuz I like to know where the tip is and @ what depth. I leave it there until the drapes come down.
           

          Stillwater45

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            Thanks guys! That is very helpful re: TEE. At our institution we have a ritual that includes Aline, Induction, Cordis, TEE - we seldom if ever stray from that routine

            So when I say "bouncing" the wire im talking about a scenario where your wire threads freely without resistance until it gets to anywhere >15 cm. It exits the needle (5-7cm) without a problem but then meets resistance after it has threaded smoothly for 15-25cm. Differential would include clot, stenosis, natural bouncing traversing cavo-atrial junction or bifurcation with subclavian.

            The question is..... what is your threshold pulling the trigger and threading the catheter vs resticking?
             

            Hawaiian Bruin

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              The bouncing you're talking about is either something intrinsic to the vein, i.e. flap, valve etc., or you're bouncing off tricuspid or RV.

              If I'm sure I'm in the vessel but meeting distal resistance with the wire, I'll take the angiocath that comes in the kit and thread it over the wire into the vessel, then remove the wire. Ensure appropriate venous return, then reinsert the wire. This often will get the J-tip past whatever structure was causing the problem.
               

              Bostonredsox

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                why do you need the tee at all? I floated one in the MICU the other night, US->IJ-> place sheath. --> float swan, watch wave forms and pressures on thr monitor. If you are getting CVP->RV->PA pressures in proper sequence, where the hell else could your catheter be? In my case once I had wedged, measured, deflated and taped in place, I shot a plain film. But arent all ORs equipped with C-arms? would imagine you could just swing it over the bed, step on the flouro and see your tip in the PA no?

                Granted I know all of the heart patients get pre and post TEE's for LV function and such so if you can also see your catheter I guess that kills two birds with one stone.
                 

                pie944

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                  why do you need the tee at all? I floated one in the MICU the other night, US->IJ-> place sheath. --> float swan, watch wave forms and pressures on thr monitor. If you are getting CVP->RV->PA pressures in proper sequence, where the hell else could your catheter be? In my case once I had wedged, measured, deflated and taped in place, I shot a plain film. But arent all ORs equipped with C-arms? would imagine you could just swing it over the bed, step on the flouro and see your tip in the PA no?

                  Granted I know all of the heart patients get pre and post TEE's for LV function and such so if you can also see your catheter I guess that kills two birds with one stone.

                  That sequence doesn't always happen so easily, for example in individuals with right sided heart pathology. The TEE can be a helpful guide as to why that proper sequence is not occurring.
                   

                  periopdoc

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                    I would guess that 95% of my CVL/PAC placements have been without any kind of guidance except ultrasound of the neck and waveform. TEE is not necessary, but if you are going to use it anyway, why not use it for that extra confirmation. If the tip of the wire is floating around in the RA/RV/IVC, then I feel just a bit more comfortable threading the dilator.

                    I would guess that I have used TEE to troubleshoot a half dozen or so PAC's that wouldn't thread with the routine techniques, including a couple for partners that couldn't get PACs into the pulmonary circulation.

                    I did a PAC placement with fluoro once. It was nice. However, the vast majority of OR's do not have a C-arm that you can just grab. You have to have a x-ray tech bring one. Assuming it isn't being used already by the ortho or spine or urology folks, it might show up in 10-15 min, and then you have to fuss with getting it into place. If the TEE probe is already there, you can save time if you know how to use it.

                    My usual sequence. A-line prior to OR or immediately prior to induction. Induction, laryngoscopy, intubate and pass TEE probe with same laryngoscopy/ PAC/CVL.

                    - pod
                     

                    periopdoc

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                      If you are getting CVP->RV->PA pressures in proper sequence, where the hell else could your catheter be?

                      Of course, but it is still nice to see if the tip is in the main PA, the right PA, or the left etc.

                      Aaaaand, what do you do if your waveform instead goes CVP->RV->CVP after multiple attempts? What if it goes CVP--> CVP-->CVP. What if it goes CVP->RV->some superfunky waveform-->PA? These are all cases that I have seen.

                      First one is due to high PA pressures and pulm regurg "pushing" your catheter away from the PA. Second one was due to tricuspid pathology that would not let the PA pass the tricuspid valve. Both where resolved with TEE guidance and a couple of tricks.

                      The third was just the weirdest thing I ever saw. When we opened the chest, there was a segment of the PAC laying outside the RV. The balloon was tested prior to insertion, but I suspect it was damaged in some way and did not actually inflate after the resident inserted it. It passed ok into the RV then penetrated and re-entered it. It was a minimally invasive and the only other thing we noted was just a little more blood than usual during the repair so we went ahead and opened the chest.

                      Oh yeah, we didn't watch the last one with TEE or we would likely have seen that the balloon was not inflated.

                      - pod
                       

                      Bostonredsox

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                        Yeah I suppose your responses are all obvious. I guess I have just been fortunate in that my swans have all been easygoing. Although the one I did the other night was a resp failure that was stumping everyone. Diuresed like crazy no better. Intubated and hypercapnea fixed, ventilated for a few days still no better. finally I came on and put a swan in and had a wedge of 60. I said no f'n way. deflated, rewedged, sure as **** 60. PA systolic almost 100. Houston we had an answer lol. I am going to do a CTsurg month or 2 towards graduation time so I can put a few in every day, rack up 30-40 of them and get comfortable with TEEs. I just dont get to do enough in general MICU to get proffiecient. Atleast I don't do enough to really run into trouble and have to learn how to troubleshoot them.
                         
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