Tips and Tricks

[Noyac]

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Jet ventilator. You can't get enough pressure/flow with an ambubag or the machine circuit. Exhalation is passive, once you get the lungs inflated, even if you can't intubate/ventilate from above, a full pair of lungs will still exhale passively through the upper airway. But the extremely low pressure/flow you get with the ambubag/circuit through an angiocath won't get much into the lungs since the low resistance path is up and out. You need to use the jet ventilator. IMO the whole angiocath + 3cc syringe + ETT connector is mystic MacGyverish lore dogma and should die. If you ever get a chance to do a cadaver lab try it both ways. Low pressure/flow through an angiocath Doesn't Work.

I suppose if you sealed the mouth/nose while ambubaging an angiocath you might get a tiny amount of O2 into the lungs and that's better than nothing, but you're far better off just using the jet ventilator on the machine.

While I agree that the jet ventilator is better with this technique I will disagree that the angio hooked up to the circuit is dogma. If you look at my photo below you can see that the circuit pressure is at 40cmH2O which is enough to passively ventilate the lungs in order to buy time.

 

[Noyac]

Don't know if this one has been mentioned before, possibly even by me.
If you get a wet tap, inject the 10cc of saline from the epidural tray intrathecally. Cut's PDPH rates down.

 

[Noyac]

Another picture to show how well the angio via the cricothyroid cartilage can work. I punctured the circuit bag with a 14 g angio and occluded the circuit. You can see that the bag is well inflated and it only took a few seconds to inflate.

 

[OB1🤙]

Don't know if this one has been mentioned before, possibly even by me.
If you get a wet tap, inject the 10cc of saline from the epidural tray intrathecally. Cut's PDPH rates down.

Or, in the right situation, just thread the catheter intrathecal and use it very very very very carefully.

Also probably reduces the pdph rate.

 

[deleted171991]

Or, in the right situation, just thread the catheter intrathecal and use it very very very very carefully.

Also probably reduces the pdph rate.

And simplifies the answer on the oral boards.

 

[Noyac]

FOB tips.
If you want to practice your FOB skills while sitting in a longer case you can arrange a maze with rolls of tape in the top drawer of your anesthesia machine. Them close the drawer leaving a small space to pass the FOB thru the side hole and see if you can drive it through the maze. You will need to secured the tape rolls down. See pics.

 

[Vaporized]

When you going to replace those aestivas ?

 

[narcusprince]

Here is a trick I use. Try a deep extubation with 1/2 inhalational agent and a little propofol running in the background IE 50/mcg/kg/min. With them spontaneously breathing and take the LMA or tube out. Shortens the emergence time because the propofol is being redistributed and the inhlational agent is being blown off.

 

[pjl]

FOB tips.
If you want to practice your FOB skills while sitting in a longer case you can arrange a maze with rolls of tape in the top drawer of your anesthesia machine. Them close the drawer leaving a small space to pass the FOB thru the side hole and see if you can drive it through the maze. You will need to secured the tape rolls down. See pics.

Also a great way to entertain a medical student when they get annoying. I normally use a 3 mL syringe as the "goal"

 

[Noyac]

Another trick.
Pull your LMA's while still inflated. It pulls any secretions up and away from the cords.

 

[pjl]

On OB with crazy squirmy lady that refuses to sit still:
Do epidural lateral. Then they can only move in two directions (forward/back) instead of 4. Plus it is harder for them to make even those movements.

 

[deleted171991]

Another trick.
Pull your LMA's while still inflated. It pulls any secretions up and away from the cords.

I thought that's how you're supposed to do it.

 

[Noyac]

On OB with crazy squirmy lady that refuses to sit still:
Do epidural lateral. Then they can only move in two directions (forward/back) instead of 4. Plus it is harder for them to make even those movements.

Or do a spinal so they get comfy and then follow with epidural. It's like doing a CSE just in a different order.

 

[Noyac]

I thought that's how you're supposed to do it.

Me too but I sometimes see newer grads deflate first.

 

[Spinach Dip]

Another trick.
Pull your LMA's while still inflated. It pulls any secretions up and away from the cords.

I thought that's how you're supposed to do it.

Wait... Someone's actually bothering to inflate and deflate those things?

 

[deleted171991]

Wait... Someone's actually bothering to inflate and deflate those things?

Yes. Plastic surgeons. 😀

 

[Noyac]

Wait... Someone's actually bothering to inflate and deflate those things?

Correction. Remember to inflate your LMA when pulling it.

 

[deleted171991]

Correction. Remember to inflate your LMA when pulling it.

I am not certified for that.

 

[gclax30]

Anyone have a solution for this: Trying to keep the A-line transducer at a consistent patient level while the surgeon requests the table up-down-up-down-up some more-higher-good, stop-ok table lower... I've tried fastening it to the tube tree w/ tape but it's too flimsy, just falls off. I suppose I could just tape it to the bed, but was hoping for something a little more ninja-esque from the great minds on this forum. 😉

 

[deleted171991]

I am no ninja, but you need better tape. 😉

With a good tape, you can tape the transducer to anything, such as the patient's arm (over some protective gauze). I also used to shove it under the patient's foam head rest.

 

[Monty Python]

Our transducer assembly has wings with slots which allows it to hang (essentially secure) on the tube tree.

 

[BobBarker]

Either thread a tourniquet through the wings and tie it to a tree or use a 20cc syringe as a spacer to allow you to clamp the triple transducer holder to the tree. I used the former most of the time and the later only if using multiple transducers.

 

[polar403]

Roll up some blue towels and tape the transducer to the roll. Lay next to the patient's shoulder or head.

 

[Endee]

I had this exact problem yesterday, except the patient was prone in Mayfield pins and I couldn't think of a good way to do it. So I ended up just moving it up and down the IV pole every few minutes 🙁

 

[stonemd]

1 year old for BMT, adenoids, surgeon requests labs drawn after induction of anesthesia.
Often difficult to aspirated volume of blood from a peripheral IV.

After mask induction, place 22g catheter at antecubital fossa.
REMOVE tourniquet and attach syring to IV catheter
Intermittent squeeze of forearm will increase vein size allowing you to aspirated required volume of blood.

 

[Ignatius J]

Alright dudes, give me your tips and trips for getting a wire to thread on subclavian and IJ central lines.

It's driving me crazy.

 

[G0S2]

Alright dudes, give me your tips and trips for getting a wire to thread on subclavian and IJ central lines.

It's driving me crazy.

I try one more time with the straight end of wire and then either 1- ask for US or 2- move to another location. For all my hearts I prep the R neck and left side of chest so I can just move the drapes over and place a subclavian if I'm flailing on IJ.

 

[sevoflurane]

Scan, scan, scan..... It takes 5- 10 seconds. If you are new... scan longer, much longer... Not cuz you're gonna hit big red, but because the extra time will get you to the 5-10 sec. mark. Also, long axis can help... and start up high before things get twisty. 😏

 

[BobBarker]

Do more, get better??

 

[gclax30]

On the subject of difficult line placement- tricks for floating the PAC? The only trick I know of is putting the bed in reverse T-berg. Some say go with the HR, some say go fast, no faster!

 

[Gimlet]

On the subject of difficult line placement- tricks for floating the PAC? The only trick I know of is putting the bed in reverse T-berg. Some say go with the HR, some say go fast, no faster!

Just wait til the chest is open...it'll float right in. I don't waste OR time trying to float swans more than 2 or 3 tries since I figured this out. Just leave it in the RV someplace where it isn't causing too much ectopy and float it while the surgeon is taking down the LIMA or cannulating.

For the wires, with an IJ make sure you drop your syringe all the way down to line up with the tragus (while aspirating) to maximize chances of not hitting resistance.

 

[OB1🤙]

Reverse T and airplane toward the patient's right if having trouble. Also torque the catheter counterclockwise as you advance. I advance with each heartbeat, and do so quickly.

If trying to float or refloat a swan and the chest is open, here's my own patented maneuver- have the surgeon pinch the IVC while you advance. Nowhere to go but through the tricuspid now...

 

[Ignatius J]

Just wait til the chest is open...it'll float right in. I don't waste OR time trying to float swans more than 2 or 3 tries since I figured this out. Just leave it in the RV someplace where it isn't causing too much ectopy and float it while the surgeon is taking down the LIMA or cannulating.

For the wires, with an IJ make sure you drop your syringe all the way down to line up with the tragus (while aspirating) to maximize chances of not hitting resistance.

I pretty much do that. I prefer doing subclavians, as they're lower infection risks and more comfortable for patients. But I also have a lot more trouble getting wires to go with subclavians. I typically prep in the IJ on the side I am going on as I can just get the U/S, keep the IJ in the sterile field, and keep the patient as is for a quick transition.

I've heard people say that they prefer a particular side for subclavians. One attending I worked with in residency would go on the right primarily. I've heard of aiming more cephalad under the clavicle and then rotating back medially when you get the flash. And of course the rotating the bevel, flipping the wire around, etc.

Anyone ever heard of a bad outcome for using the non-looped backside of the wire? I see some guys do this all the time and others who would feint at the notion of it.

Anyways, thanks for the tips guys. Any little tricks of the trade that helps y'all out are greatly appreciated as I develop and hone my skills in PP.

 

[deleted87051]

If trying to float or refloat a swan and the chest is open, here's my own patented maneuver- have the surgeon pinch the IVC while you advance. Nowhere to go but through the tricuspid now...

It can also go in the coronary sinus, especially if it is big.

Along those lines, if you have TEE down, you can guide the swan using modified bicaval and RV inflow-outflow views.

 

[deleted162650]

If the wire won't thread on your central lines try rolling the needle over 180 degrees so the bevel faces into the lumen and not up against the anterior vessel wall. Also try holding the wire coil so the curve goes towards midline and not out laterally. This helps direct the wire to stay in the central circulation and not track out the right subclavian

 

[deleted641888]

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[deleted87051]

Reviving this thread:

Any tips on IV line/arterial line/monitoring line management/organization? Had a STAT trauma case with 3 PIVs + arterial line, arms tucked and patient prone. IVs were taped securely and ran along the arms. Midway through the case, 2/3 IVs crapped out (16-18G in hands), had a tough time accessing/troubleshooting the lines.

Central lines don't crap out.

 

[deleted641888]

.

 

[Mman]

Reviving this thread:

Any tips on IV line/arterial line/monitoring line management/organization? Had a STAT trauma case with 3 PIVs + arterial line, arms tucked and patient prone. IVs were taped securely and ran along the arms. Midway through the case, 2/3 IVs crapped out (16-18G in hands), had a tough time accessing/troubleshooting the lines.

I'm curious, what sort of "STAT trauma" case was positioned prone? Was it a crani?

 

[Ezekiel2517]

Reviving this thread:

Any tips on IV line/arterial line/monitoring line management/organization? Had a STAT trauma case with 3 PIVs + arterial line, arms tucked and patient prone. IVs were taped securely and ran along the arms. Midway through the case, 2/3 IVs crapped out (16-18G in hands), had a tough time accessing/troubleshooting the lines.

First thing I do when I get a trauma coming up from ED is sort out the lines. Bc they're usually a fukn mess and access is the pts life. If needed I will actually disconnect all their lines and have my own fluid/product lines ready to attach. This simple thing and just transferring the pt from the gurney to the OR table without losing or confusing your lines is actually an important part of the case

 

[deleted171991]

Reviving this thread:

Any tips on IV line/arterial line/monitoring line management/organization? Had a STAT trauma case with 3 PIVs + arterial line, arms tucked and patient prone. IVs were taped securely and ran along the arms. Midway through the case, 2/3 IVs crapped out (16-18G in hands), had a tough time accessing/troubleshooting the lines.

Try to place all IVs above the antecubital fold. Much less infiltration and positional dependence. They have been reportedly used successfully even for vasopressor administration, for days.

The fewer joint areas you have between your IV and the trunk, the lower the chances of positional problems. A tucked hand is probably the worse place for an IV.

Also, learn to place antecubital RICs with high-flow infusion sets, or replace existing small gauge IVs with them (faster/easier than central lines).

 

[pjl]

Those RICs are awesome.

Interestingly, they are really freaking annoying to buy. The minimum number we can get is 50 and they are expensive enough that we are just forced to do without. Would use maybe 2 a year. Cant even get a stinking rep to give us a few "samples."


Sent from my iPad using SDN mobile app

 

[deleted641888]

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[deleted171991]

It was s/p highway MVC, new quadriplegic with dropping pressures. Gen surg did an ex-lap (clean) and then spine came in to fillet the back open for decompression/stabilization.

Ouch, spinal shock. Working IVs and volume are of essence.

 

[Mman]

It was s/p highway MVC, new quadriplegic with dropping pressures. Gen surg did an ex-lap (clean) and then spine came in to fillet the back open for decompression/stabilization.

didn't have time to mess with the IV access when the arms were out for the x-lap? That's what I like to do. I can either put new peripheral lines in under the drapes while the surgeons or working or stick an IJ line in if there aren't good peripherals. Either way should've been able to lock down the IV access prior to flipping prone.

Just my 2 cents. And with spinal shock I'd learn towards a CVP simply because of the likelihood of needing > 24 hours of vasopressors in the ICU afterwards.

 

[deleted171991]

didn't have time to mess with the IV access when the arms were out for the x-lap? That's what I like to do. I can either put new peripheral lines in under the drapes while the surgeons or working or stick an IJ line in if there aren't good peripherals. Either way should've been able to lock down the IV access prior to flipping prone.

Just my 2 cents. And with spinal shock I'd learn towards a CVP simply because of the likelihood of needing > 24 hours of vasopressors in the ICU afterwards.

I wouldn't put in an IJ in a neck injury patient.

Also, ex-lap in spinal shock must have been fun.

 

[deleted162650]

Pts is very likely to need pressors due to the spinal shock/vasodilation. Attending was a dufus for not using the in situ central line.

 

[deleted171991]

Pts is very likely to need pressors due to the spinal shock/vasodilation. Attending was a dufus for not using the in situ central line.

Spinal shock responds better to fluids than pressors; most patients need both.

 

[deleted641888]

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[Mman]

I wouldn't put in an IJ in a neck injury patient.

I have no qualms using an U/S to place an IJ in an asleep patient with a cervical injury. You move the patient's neck more in a c-collar sliding them from the stretcher to the OR table and back and then flipping them prone later than you do placing a probe on their neck and sticking. And in an unstable patient having an x-lap (which they must be if they are also in spinal shock), I could do an IJ safer and faster than any other approach.