Tips and Tricks

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MirrorTodd said:
Still gotta learn how to do it without ultrasound and that technique has been gold for me. Speaking about ultrasound though...are lines done easier in plane or out of plane? I find in plane far easier, but that probably is just cause we do all our blocks in plane.
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There’s truth in that statement. You definitely don’t want to hold up a case because you don’t have an ultrasound available.

I do my lines out of plane. It just works best for me. Our vascular surgeons and cardiologist do the same. The times I see the cardiologist go in plane. is just when they’re taking pictures for their billing.
 
MirrorTodd said:
Speaking about ultrasound though...are lines done easier in plane or out of plane? I find in plane far easier, but that probably is just cause we do all our blocks in plane.
Click to expand...

The “right” way is the way that works best for you and allows you to get the line in as quickly and safely as possible. I go in-plane for a-lines and PIVs. Outta-plane for IJs. Haven’t placed a fem line since residency.
 
Twiggidy said:
Use an ultrasound.....your success rate on first attempt will skyrocket
Click to expand...

I feel shame everytime I use it. But my success rate is 100% and it takes me about 20 seconds with not 1 spill of blood. So ofc i still do a blind try every case.

SaltyDog said:
The “right” way is the way that works best for you and allows you to get the line in as quickly and safely as possible. I go in-plane for a-lines and PIVs. Outta-plane for IJs. Haven’t placed a fem line since residency.
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dude the vein isn't even gonna fit on 1 plane, it's not as straight as the artery (but still straighter elton john, amiright?)
 
dchz said:
I feel shame everytime I use it. But my success rate is 100% and it takes me about 20 seconds with not 1 spill of blood. So ofc i still do a blind try every case.
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I trained at a place that really tried the push the old school "you don't know what you're doing if you use ultrasound" machisimo. I admittedly bought into myself. It's 2020. More shame will come to you with wrist and neck hematomas vs taking the extra minute to throw some lube on the probe (that's what he/she said) and get the line in faster and safer. Plus, if you're really wanting to nickel and dime your earnings, bill for the picture.

Personally, I feel like ultrasound guided techniques make you look more skilled and advanced than the person down the hall thumping their chest doing blind sticks.
 
Don't think I've ever had even mild trouble putting an a-line preop with ultrasound. With a tad lidocaine and the fact that you aren't jabbing in and out on the difficult ones, it is completely painless without sedation, tolerated no worse than an easy IV stick, efficient, and no surgeon breathing down your neck or a colleague now down on the foot or something ridiculous after some misses in the OR.

I do it out of plane, very slow minimal needle advancement, constant scanning to find the needle tip after each small advancement, and some wrist action to put the needle tip dead center in the artery before the next small advancement. Advance a few times in the artery, no wires necessary, slide the catheter off, and done.

Bonus. Surgeon loves you when you enter the room and tell him a-line already in place. Sometimes their jaw even drops and their eyes light up like an excited puppy.

Second bonus, you'll become "the guy" to get when others are struggling.
 
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A friend of mine taught me this one:

Say you've been asked to place an IJ CVC and you haven't done one before? You could look really stupid in front of your attending if you ask for help, so instead you just insert it blind and dilate anyway. This way you've got almost a 100% chance of quickly and cleanly inserting one of either a working CVC, arterial line, or chest drain. People will comment on how slick you are.

Actual one (for very junior staff only). For the super anxious patient who absolutely requires a benzo, but the attending won't let you because reasons...

Assess in holding bay --> insert IV cannula and have a set of obs prior to entry to OR --> As soon as their butt hits the table attach a line --> Push opioid --> Clamp line --> Flush dead space with ~50mg lignocaine --> Chase with ~10-50mg Propofol --> By this time their head should be coming down to the pillow --> Re-position and pre-O2 while your lackey attaches monitoring --> Induce with 1/3 of the dose of Propofol you would have used if you hadn't rapidly medicated them the second they entered the room.

Or just use Midazolam.
 
Newtwo said:
no offense but i think many people would say you just havent done enough then.
i can think of 2 scenarios just this week that wouldnt be so easy.

every procedure will humble even the best every now and again. alines probably the most common
Click to expand...
I agree i've had some real tough alines even with ultrasound so to say you just need an echo and 20sec is unrealistic.
 
woopedazz said:
A friend of mine taught me this one:

Say you've been asked to place an IJ CVC and you haven't done one before? You could look really stupid in front of your attending if you ask for help, so instead you just insert it blind and dilate anyway. This way you've got almost a 100% chance of quickly and cleanly inserting one of either a working CVC, arterial line, or chest drain. People will comment on how slick you are.

Actual one (for very junior staff only). For the super anxious patient who absolutely requires a benzo, but the attending won't let you because reasons...

Assess in holding bay --> insert IV cannula and have a set of obs prior to entry to OR --> As soon as their butt hits the table attach a line --> Push opioid --> Clamp line --> Flush dead space with ~50mg lignocaine --> Chase with ~10-50mg Propofol --> By this time their head should be coming down to the pillow --> Re-position and pre-O2 while your lackey attaches monitoring --> Induce with 1/3 of the dose of Propofol you would have used if you hadn't rapidly medicated them the second they entered the room.

Or just use Midazolam.
Click to expand...

When I make a line, I infuse the line with 1/kg of lido and fent. Sometimes a little versed for the squirrely young ones. As soon as patient is near me, I attach the line and let it flush in. I have my prop and paralytic already on the line so if there's a small clot in the iv I push a little prop to clear it out. Then I can preoxygenate while the nurse positions and places monitors.
 
Newtwo said:
no offense but i think many people would say you just havent done enough then.
i can think of 2 scenarios just this week that wouldnt be so easy.

every procedure will humble even the best every now and again. alines probably the most common
Click to expand...
No offense taken. Ok, not every single one took 20 seconds, but if there's a visible lumen and needle echogenicity, I honestly don't remember a major struggle. I don't put in as many as cardiac, but I've done very many.

We all have strengths and weaknesses. The reason I'll hold myself against just about anybody with ultrasound is I'm the first to admit I'm average at best on a good day at a-lines without it. I got tired of screwing up the start of a case. I began embracing ultrasound for nerve blocks close to 15 years ago way ahead of the curve before everyone else, and have helped teach courses on its use.
 
Twiggidy said:
I trained at a place that really tried the push the old school "you don't know what you're doing if you use ultrasound" machisimo. I admittedly bought into myself. It's 2020. More shame will come to you with wrist and neck hematomas vs taking the extra minute to throw some lube on the probe (that's what he/she said) and get the line in faster and safer. Plus, if you're really wanting to nickel and dime your earnings, bill for the picture.

Personally, I feel like ultrasound guided techniques make you look more skilled and advanced than the person down the hall thumping their chest doing blind sticks.
Click to expand...
I think most of my faculty have embraced the idea that it's totally reasonable to take a shot blind if it's a good pulse but zero shame in using ultrasound from the beginning or switching to it early. Except 1 attending. I have 1 attending who will blind stick 20 times before using the ultrasound. You fail 1 arm, even with ultrasound and have to switch arms? They'll go to the other arm and start sticking by palpation only. It's crazy. They'd rather spend over an hour trying to get an arterial line than just grab an ultrasound early.
 
woopedazz said:
A friend of mine taught me this one:

Say you've been asked to place an IJ CVC and you haven't done one before? You could look really stupid in front of your attending if you ask for help, so instead you just insert it blind and dilate anyway. This way you've got almost a 100% chance of quickly and cleanly inserting one of either a working CVC, arterial line, or chest drain.
Click to expand...

I’ve seen a few too many ‘accidental’ arterial line. Is that a CVC? Nope that’s an arterial line now. Is that a chest tube? Nope, that’s an arterial line. Is that an arterial line? Nope that an IV.
 
abolt18 said:
I think most of my faculty have embraced the idea that it's totally reasonable to take a shot blind if it's a good pulse but zero shame in using ultrasound from the beginning or switching to it early. Except 1 attending. I have 1 attending who will blind stick 20 times before using the ultrasound. You fail 1 arm, even with ultrasound and have to switch arms? They'll go to the other arm and start sticking by palpation only. It's crazy. They'd rather spend over an hour trying to get an arterial line than just grab an ultrasound early.
Click to expand...
Thats really bad tbh, and hopefully will die out this decade.
Ive certainly seen that too...

Ive no doubt the day will come maybe in 15-20 years time when every anesthesia machine will have a glidescope built in, plus an uss
 
Newtwo said:
no offense but i think many people would say you just havent done enough then.
i can think of 2 scenarios just this week that wouldnt be so easy.

every procedure will humble even the best every now and again. alines probably the most common
Click to expand...

US doesn't make every aline take 20 seconds, but it will absolutely tell you artery size and whether it's even worth jabbing a wrist 5 times and getting no success before you 1) get the US machine 2) figure out that radial was crap to begin with and 3) move up the arm. I don't feel any less of an anesthesiologist for using US for every aline, and I totally understand you weren't saying that to begin with. yes, definitely, alines can be humbling.
 
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abolt18 said:
I think most of my faculty have embraced the idea that it's totally reasonable to take a shot blind if it's a good pulse but zero shame in using ultrasound from the beginning or switching to it early. Except 1 attending. I have 1 attending who will blind stick 20 times before using the ultrasound. You fail 1 arm, even with ultrasound and have to switch arms? They'll go to the other arm and start sticking by palpation only. It's crazy. They'd rather spend over an hour trying to get an arterial line than just grab an ultrasound early.
Click to expand...
Every single resident I trained with is thinking of the exact same attending right now! haha
 
I used to only use arrow catheter in residency. Would get it 85% of the time first stick no issues threading, but every now and then you can’t thread for whatever reason.
I’ve started doing angiocath through and through, first time success rate Easily over 90%. Almost never have issues threading, and if so just make minor adjustments with the catheter changing the angle, twisting, whatever. Almost never have to stick the vessel again. Now I think through and through is the only way. But to each their own.
 
surgndoc said:
I used to only use arrow catheter in residency. Would get it 85% of the time first stick no issues threading, but every now and then you can’t thread for whatever reason.
I’ve started doing angiocath through and through, first time success rate Easily over 90%. Almost never have issues threading, and if so just make minor adjustments with the catheter changing the angle, twisting, whatever. Almost never have to stick the vessel again. Now I think through and through is the only way. But to each their own.
Click to expand...

Agree. Arrow kit - great success up to 85%. But we need 99%.
 
Anybody have any tricks on how to pull your ET tube out 1cm or two when in the prone position with head in the PRONEVIEW and a great tape job?

Someone should study the inverse relationship between length of training and depth of ETT placement. Working with a brand new CA-1 (what...3 weeks in the OR now?) and after we flipped the patient prone, had reason to suspect right main stem placement. It was confirmed with bronchoscopy. Now what?
 
Pull hard...or cut the tape.
epidural man said:
Anybody have any tricks on how to pull your ET tube out 1cm or two when in the prone position with head in the PRONEVIEW and a great tape job?

Someone should study the inverse relationship between length of training and depth of ETT placement. Working with a brand new CA-1 (what...3 weeks in the OR now?) and after we flipped the patient prone, had reason to suspect right main stem placement. It was confirmed with bronchoscopy. Now what?
Click to expand...
 
epidural man said:
Anybody have any tricks on how to pull your ET tube out 1cm or two when in the prone position with head in the PRONEVIEW and a great tape job?

Someone should study the inverse relationship between length of training and depth of ETT placement. Working with a brand new CA-1 (what...3 weeks in the OR now?) and after we flipped the patient prone, had reason to suspect right main stem placement. It was confirmed with bronchoscopy. Now what?
Click to expand...

Im not trying to be a dick but a great tape job wouldn’t have mainstemmed. I have definitely had issues with flipped obese patients where i have had to flip back and retape. It likely happens to everyone despite our best intentions. Recognizing the problem early and fixing it before the case starts is essential, even if it means delaying a few minutes to reprep. I side with defending attendings for retaping tubes for prone cases as much as it used to annoy my coresidents. Tape and flip is the most important part of these cases. You can kill someone if you screw it up and that literally does happen. If your sats are 100 supine and they drop to low 90s after the flip, fix it before it becomes a problem and you find yourself dangerously limping through a case.
 
epidural man said:
Anybody have any tricks on how to pull your ET tube out 1cm or two when in the prone position with head in the PRONEVIEW and a great tape job?

Someone should study the inverse relationship between length of training and depth of ETT placement. Working with a brand new CA-1 (what...3 weeks in the OR now?) and after we flipped the patient prone, had reason to suspect right main stem placement. It was confirmed with bronchoscopy. Now what?
Click to expand...


If it’s only 1cm just pull it without retaping. It will stay there. It won’t “migrate” back in, at least with my tape jobs.
 
SnapperRocks said:
Im not trying to be a dick but a great tape job wouldn’t have mainstemmed. I have definitely had issues with flipped obese patients where i have had to flip back and retape. It likely happens to everyone despite our best intentions. Recognizing the problem early and fixing it before the case starts is essential, even if it means delaying a few minutes to reprep. I side with defending attendings for retaping tubes for prone cases as much as it used to annoy my coresidents. Tape and flip is the most important part of these cases. You can kill someone if you screw it up and that literally does happen. If your sats are 100 supine and they drop to low 90s after the flip, fix it before it becomes a problem and you find yourself dangerously limping through a case.
Click to expand...
So if I jam the tube in too far, but do a great tape job, it won't be mainstreamed?
 
nimbus said:
If it’s only 1cm just pull it without retaping. It will stay there. It won’t “migrate” back in, at least with my tape jobs.
Click to expand...
We did this - got the Murphy Eye to sit just above the carina - and let him spontaneously breath - hoping that would get something into the other lung.

After the flip prone, the patient was persistently tachycardic - so I had the resident run through the DDx and EVENTUALY got them to a possible mainstem inbutabion - took a look with the fiberoptic. Other than the high HR, patient had normal peak pressures and no decrease in saturations with about 40-50% FiO2. It was a short case and I was happy to just let him have a lung unventilated for an hour. That seemed safer than cutting the tape, repositioning, risk LOOSING an airway.
 
SnapperRocks said:
Im not trying to be a dick but a great tape job wouldn’t have mainstemmed. I have definitely had issues with flipped obese patients where i have had to flip back and retape. It likely happens to everyone despite our best intentions. Recognizing the problem early and fixing it before the case starts is essential, even if it means delaying a few minutes to reprep. I side with defending attendings for retaping tubes for prone cases as much as it used to annoy my coresidents. Tape and flip is the most important part of these cases. You can kill someone if you screw it up and that literally does happen. If your sats are 100 supine and they drop to low 90s after the flip, fix it before it becomes a problem and you find yourself dangerously limping through a case.
Click to expand...
Classic ITE question, a well taped tube can advance with neck flexion and pull back with neck extension. If neck was well extended when taped and is now flexed significantly in prone, it could definitely advance the tube enough to cause a problem. I also agree that it's reasonable to flip to fix if it can't easily be adjusted.

Or you could be an idiot like myself and prone a patient WITHOUT taping in the tube (whoops!). C-spine injury so he was in pins, thankfully making it easy to tape. Before everyone loses their minds, I agree that this was totally idiotic and never should have happened.

Now that that is behind us, I'll describe a few events that led to it. Took forever to get fem art line (can't remember why upper extremities weren't an option), guy had crappy heart (EF15-20%), AICD, vertebral artery dissection and numerous c-spine fractures after a fall. Had all the other health problems you expect (CKD, DM, AFib, etc.). Immediately after an asleep fiberoptic intubation, my attending starts telling me to do stuff (that does not involve taping in the airway) so I do those things, assuming that my attending is taping the tube -- this is a very common practice here, attendings usually say things like "go put in your IV and I'll tape the tube."

Anyway, the neurosurgeon puts the head in pins and takes the head for the flip so I never returned to the head personally after putting the tube in.
 
epidural man said:
We did this - got the Murphy Eye to sit just above the carina - and let him spontaneously breath - hoping that would get something into the other lung.

After the flip prone, the patient was persistently tachycardic - so I had the resident run through the DDx and EVENTUALY got them to a possible mainstem inbutabion - took a look with the fiberoptic. Other than the high HR, patient had normal peak pressures and no decrease in saturations with about 40-50% FiO2. It was a short case and I was happy to just let him have a lung unventilated for an hour. That seemed safer than cutting the tape, repositioning, risk LOOSING an airway.
Click to expand...

Honestly, tachycardia alone would put a mainstem intubation WAY down on my list. I'd sooner assume the patient was under-anesthetized. If peak pressures were normal and oxygenation appeared adequate, it would take me a long time to consider a mainstem'd tube based solely on tachycardia.
 
abolt18 said:
Honestly, tachycardia alone would put a mainstem intubation WAY down on my list. I'd sooner assume the patient was under-anesthetized. If peak pressures were normal and oxygenation appeared adequate, it would take me a long time to consider a mainstem'd tube based solely on tachycardia.
Click to expand...
Well we ran through the list. It was way down on that list - but I had a high index of suspicion since as I have hinted, she seemed to put the tube super deep after intubation. Hence my theory that depth of tube placement is inversely proportionate to years in training.
I can’t tell you how many times I have said the words “ put the ballon just past the chords - watching very closely - then STOP!” But it never seems to matter.
People need to make their bed and lie in it several times before wisdom sinks in.

smart people learn from their mistakes. Wise people learn from other people’s mistake.
I find residents aren’t wise. I tried to be but doubt I was. I’m smart now because I’ve made MANY mistakes.
 
epidural man said:
Well we ran through the list. It was way down on that list - but I had a high index of suspicion since as I have hinted, she seemed to put the tube super deep after intubation. Hence my theory that depth of tube placement is inversely proportionate to years in training.
I can’t tell you how many times I have said the words “ put the ballon just past the chords - watching very closely - then STOP!” But it never seems to matter.
People need to make their bed and lie in it several times before wisdom sinks in.

smart people learn from their mistakes. Wise people learn from other people’s mistake.
I find residents aren’t wise. I tried to be but doubt I was. I’m smart now because I’ve made MANY mistakes.
Click to expand...
Fair enough!
 
By the way, I love the idea of putting an ETT in the esophagus to facilitate OG placement.

I’m anxious to try it but have had great success recently.
Had to place a dobhoff yesterday. That wasn’t easy.
 
abolt18 said:
Classic ITE question, a well taped tube can advance with neck flexion and pull back with neck extension. If neck was well extended when taped and is now flexed significantly in prone, it could definitely advance the tube enough to cause a problem. I also agree that it's reasonable to flip to fix if it can't easily be adjusted.

Or you could be an idiot like myself and prone a patient WITHOUT taping in the tube (whoops!). C-spine injury so he was in pins, thankfully making it easy to tape. Before everyone loses their minds, I agree that this was totally idiotic and never should have happened.

Now that that is behind us, I'll describe a few events that led to it. Took forever to get fem art line (can't remember why upper extremities weren't an option), guy had crappy heart (EF15-20%), AICD, vertebral artery dissection and numerous c-spine fractures after a fall. Had all the other health problems you expect (CKD, DM, AFib, etc.). Immediately after an asleep fiberoptic intubation, my attending starts telling me to do stuff (that does not involve taping in the airway) so I do those things, assuming that my attending is taping the tube -- this is a very common practice here, attendings usually say things like "go put in your IV and I'll tape the tube."

Anyway, the neurosurgeon puts the head in pins and takes the head for the flip so I never returned to the head personally after putting the tube in.
Click to expand...

I agree that head positioning can change tube depth, but to epidural mans point of placing just past the cords...You are working with 11cm on average between cords and carina.
 
Back to tips.
Here's my dead man walking anesthesia:
Propofol amount subject to clinical evalution range 20-200mg, lido on the epiglottis, cords and trachea let rest for 2min, intubate and leave patient in SV with sevo.
This is what i do for most gastroenterology cases that need intubation. No messing around with narcotics and muscle relaxant.
If the patient can't tolerate this then you shouldn't have put him out to start with.
(Don't know if this works in super high BMI patients since we don't encounter those very often)
 
epidural man said:
Well we ran through the list. It was way down on that list - but I had a high index of suspicion since as I have hinted, she seemed to put the tube super deep after intubation. Hence my theory that depth of tube placement is inversely proportionate to years in training.
I can’t tell you how many times I have said the words “ put the ballon just past the chords - watching very closely - then STOP!” But it never seems to matter.
People need to make their bed and lie in it several times before wisdom sinks in.

smart people learn from their mistakes. Wise people learn from other people’s mistake.
I find residents aren’t wise. I tried to be but doubt I was. I’m smart now because I’ve made MANY mistakes.
Click to expand...

So you suspected it was deep upon intubation, prior to the flip. But you let the patient be flipped like that? I get it if you've got a senior resident and they are being a dingus, let them struggle and learn (within reason of not harming the patient), but a brand new CA-1? They need a lot more hand holding and I certainly wouldn't allow a patient to be flipped if I had any concerns about the tube.
 
epidural man said:
Anybody have any tricks on how to pull your ET tube out 1cm or two when in the prone position with head in the PRONEVIEW and a great tape job?

Someone should study the inverse relationship between length of training and depth of ETT placement. Working with a brand new CA-1 (what...3 weeks in the OR now?) and after we flipped the patient prone, had reason to suspect right main stem placement. It was confirmed with bronchoscopy. Now what?
Click to expand...

What about putting in a nasal tube for these cases?
 
DrZzZz said:
So you suspected it was deep upon intubation, prior to the flip. But you let the patient be flipped like that? I get it if you've got a senior resident and they are being a dingus, let them struggle and learn (within reason of not harming the patient), but a brand new CA-1? They need a lot more hand holding and I certainly wouldn't allow a patient to be flipped if I had any concerns about the tube.
Click to expand...
No I didn't suspect it at all before the flip. I just thought they put the tube deeper than what I would have done - but not deep enough that I thought needed intervention. Why would I let a mainstemmed patient get flipped?

Anyway, after running through the list - not coming up with something - it dawned on me that it was possible that a mainstem happened.
 
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SnapperRocks said:
I agree that head positioning can change tube depth, but to epidural mans point of placing just past the cords...You are working with 11cm on average between cords and carina.
Click to expand...
Yes, but are really working with 11cm minus the length of the endotracheal tube tip to just proximal to the balloon, leaving you in the area of 3-4cm or so of play (as a guess without a tube currently in front of me), so it's not very much when factoring in movement and maybe a tad deep tube.
 
epidural man said:
No I didn't suspect it at all before the flip. I just thought they put the tube deeper than what I would have done - but not deep enough that I thought needed intervention. Why would I let a mainstemmed patient get flipped?

Anyway, after running through the list - not coming up with something - it dawned on me that it was possible that a mainstem happened.
Click to expand...

Fair enough. We both agree flipping a patient with a possible mainstemmed tube is a bad plan. Just interpreted it that way from what you wrote. Sort of like you let it happen as a teaching point. Glad I misunderstood!
 
Twiggidy said:
I trained at a place that really tried the push the old school "you don't know what you're doing if you use ultrasound" machisimo. I admittedly bought into myself. It's 2020. More shame will come to you with wrist and neck hematomas vs taking the extra minute to throw some lube on the probe (that's what he/she said) and get the line in faster and safer. Plus, if you're really wanting to nickel and dime your earnings, bill for the picture.

Personally, I feel like ultrasound guided techniques make you look more skilled and advanced than the person down the hall thumping their chest doing blind sticks.
Click to expand...

No lube on the probe - chloraprep. You have approximately 15 seconds to place the line 😀
 
0kazak1 said:
There was a regional tip (an image) posted somewhere on the forums about how to hold the needle and syringe with one hand so you can inject the medication yourself. So someone post and image again if they have it, or do something similar .
Click to expand...

Put a 30ml syringe on a Tuohy, easy
 
fakin' the funk said:
Put a 30ml syringe on a Tuohy, easy
Click to expand...

I inject my own meds for blocks. You don’t need three hands. Leave the syringe on the patient. Get your image and needle where you want it. Once you’re in the right spot pick up the syringe and inject. Usually don’t even need a hand on the needle to keep it in view. Try it. You’ll figure out how to adjust the needle and inject much easier than you’d think it’d be.

I just prefer being self sufficient and i don’t like it when a nurse continues to press if a patient is having pain with injection. Who here doesn’t like having more control?
 
rps20171121_122401.jpg
 
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