wolfpackMD

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Do you guys routinely topicalize with lidocaine prior to placing awake A-Lines?

I’ve had attendings tell me different things but in my mind - if I’m using ultrasound, im most likely going to get it in the first stick and so why torture the patient with lidocaine infiltration? (I’ve gotten lidocaine before a finger lac stitch once and it hurt like a B****!) We don’t topicalize for placing 20G IVs so why are A-Lines different?
 

nolagas

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Do you guys routinely topicalize with lidocaine prior to placing awake A-Lines?

I’ve had attendings tell me different things but in my mind - if I’m using ultrasound, im most likely going to get it in the first stick and so why torture the patient with lidocaine infiltration? (I’ve gotten lidocaine before a finger lac stitch once and it hurt like a B****!) We don’t topicalize for placing 20G IVs so why are A-Lines different?
I topicalize for both A-lines and 20G IVs.
 

Mman

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I use a TB syringe with lido for awake art lines. I also usually do the same for peripheral IVs if I'm getting called in to start it, though that might just be because I'd rather have them squirm with the lidocaine than squirm right when I'm getting into an iffy vein. Radial artery is significantly deeper than most an IV on the back of the hand and it can't hurt to help avoid some vasospasm.
 

DrOwnage

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If it hurts that much when you're putting in the lidocaine, you're doing it wrong. I've seen people go back and forth, side to side, and deep. You just need a good skin wheel since the artery is shallow. I had an attending tell me once to inject local under ultrasound and get local around the side of the artery. I was like why....? Since I've been getting a good skin wheel like when during a peripheral IV, people have not complained one bit.
 

ethilo

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Warm lido burns less. Dentist trick. They frequently keep vials in a warmer in the office. Also smaller gauge needle.
 

Ronin786

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I had somebody try an ABG on me for ****s and giggles. It hurts. And it stings for quite a while afterwards and that was with the tiny ABG syringe. Always use local.
 
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eikenhein

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I aways inject local for awake art lines.
For 20g piv I dont do it routinely, unless pt is one of those finicky ones that moves with any poke. For these pt I think it reduces their movement for the actual stick
 
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ragnathor

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A perpendicular insertion of the needle used for local is less painful than a more parallel approach.

Also you only need a small wheal the size of the insertion or slightly larger. No need for these nickel size or larger wheals I see sometimes.
 
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Twiggidy

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Do you guys routinely topicalize with lidocaine prior to placing awake A-Lines?

I’ve had attendings tell me different things but in my mind - if I’m using ultrasound, im most likely going to get it in the first stick and so why torture the patient with lidocaine infiltration? (I’ve gotten lidocaine before a finger lac stitch once and it hurt like a B****!) We don’t topicalize for placing 20G IVs so why are A-Lines different?
I'll say it like this......a good amount of nurses, especially OB nurses, put in 18G IVs without local

You're not a nurse, you're an anesthesiologist......give some ANESTHESIA, prior to the large needle stick. If you're questioning local you must've never accidentally stuck yourself with an 18G or large needle

if you don't think they can handle the needle of the local then give a smidge of propofol or midaz to take the edge off
 
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Twiggidy

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A perpendicular insertion of the needle used for local is less painful than a more parallel approach.

Also you only need a small wheal the size of the insertion or slightly larger. No need for these nickel size or larger wheals I see sometimes.
3cc of 1% liocaine over the radial artery......they won't feel a thing.

i also feel like when people use local, especially proceduralist, they don't use enough. Numb. The. Area.
 

dhb

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I'll say it like this......a good amount of nurses, especially OB nurses, put in 18G IVs without local

You're not a nurse, you're an anesthesiologist......give some ANESTHESIA, prior to the large needle stick. If you're questioning local you must've never accidentally stuck yourself with an 18G or large needle

if you don't think they can handle the needle of the local then give a smidge of propofol or midaz to take the edge off
I only do local for 14g.
Done plenty of 16g with no local and patients jump less than with a 22g.
 

nimbus

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When you donate blood they use 14g needles in the AC and no local

I’ve done that too. A steel needle is much smoother than any IV catheter that I’ve had. The sensation of the plastic catheter “dragging” through the skin is what makes IV’s worse. Anyway I use local with a 30g needle for all awake IV’s and Aline’s.
 
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Laryngophed

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POKE AND A BURN COMING IN!
One of my more crass attendings in residency always said “big prick with a needle” in reference to me. ‍♂
 

dhb

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If patients were screaming and thrashing i wouldn't do it of course but in my experience a 16g is not worse than a 20g. A subcue of lido is not pleasant either.
*in my patient population: i don't have to dig through 1 inch of fat to get to a vein
 
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I think it depends a lot on the patient and the location. In the AC I’m much less likely to use local. In the hand, or wrist, or for patients I think will move and complain, I use local even for a 20G IV.

I’ve donated blood many times, and I too think the needle is overal less painful than an IV catheter.
 
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Twiggidy

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When you donate blood they use 14g needles in the AC and no local
Right.....which is why people run to donate blood. There’s nothing enjoyable about being stuck with a 14g needle. If it’s not such a big deal then why do we I’ve local for epidural/spinals

Guys. Stop torturing your patients.
 

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I topicalize with a wheel and then push it around into the skin/subq tissue (buys me some time for the lido to kick in and to get it deeper/periarterial). Usually no pain during Aline placement and it gives me some room if I want to change my target
 

ragnathor

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3cc of 1% liocaine over the radial artery......they won't feel a thing.

i also feel like when people use local, especially proceduralist, they don't use enough. Numb. The. Area.
I would agree to disagree. I use 0.5cc in the skin and another 0.5-1cc deeper depending on how chunky the arm is. For blocks, maybe 1cc total. Epidural I use a bit more maybe 1.5-2cc. Pain procedures (22g needle) 0.3cc on the skin. Anecdotally I feel patients experience much less discomfort on initial LA injection.

I will say a-line is a bit different as I feel it needs good numbing on the skin and subcuatenous, especially if you feel you may need to redirect some. Ultimately 1.5cc probably doesn't feel much different than 3cc since it goes in quick, and I'd agree better to use too much LA then not enough!
 
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Radial Art Lines are exceedingly painful. Localize generously if you do it awake which I always do. Dont skimp because if you do undoubtedly, you will have to come out and put more local in very few people can tolerate an art line awake without serious wincing.
 
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Newtwo

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Why is this even a question? Of course local! Add some bicarb and keep the lido warm as already said and it doesn't hurt much at all. Check what the pka of the soln of lido you use is too. The more acidic the more it hurts

We like to pretend were not surgeons. So then dont be a neanderthal. Give some local. And some midaz if you have another small iv

Theres lots of research on this. Anyone that thinks local hurts more than the iv itself is not correct.

I dont think it's even ethical to do a study placing art lines without local
 
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pgg

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Maybe this was mentioned up thread already and I didn't see it.

If you're doing awake a-lines, use ultrasound. Every time. Make your first stick your only stick. First pass, only pass. Minimal redirection. No matter how awesome you are, use ultrasound.

And of course, use local.
 

nimbus

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Maybe this was mentioned up thread already and I didn't see it.

If you're doing awake a-lines, use ultrasound. Every time. Make your first stick your only stick. First pass, only pass. Minimal redirection. No matter how awesome you are, use ultrasound.

And of course, use local.

Agree on all your points which are true for asleep Aline’s too. Also if the artery looks crappy on ultrasound, you can find a better artery (opposite side, brachial or femoral) before you ever stick the patient.
 

Noyac

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Disclaimer, I haven’t read any of the replies here so if anyone has mentioned this already then disregard.

The key to good topicalization is hitting the artery on the first attempt. Once you start probing around things start to get uncomfortable.
I typically make a good skin wheel and then drive the local needle right under the skin about a cm cephalad making a larger wheel of local superficial to the artery. Then I will sometimes go medial or lateral to the artery and deep so that the local might spread around and under the artery. I never give so much that I can’t feel the artery. I’m not talking about the pulse, I’m talking about the artery. You just be able to feel the artery. Except those of you routinely using the US. You probably don’t k know what I talking about and I can’t help.

But the key to painless A line placement is to hit the artery first pass without redirecting.

Oops, it looks like pgg already said this. I just disagree with the US part.
 
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Twiggidy

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Agree on all your points which are true for asleep Aline’s too. Also if the artery looks crappy on ultrasound, you can find a better artery (opposite side, brachial or femoral) before you ever stick the patient.
I agree with this. I was taught by old school guys who didn't know how to use an ultrasound machine. This lead to me thinking I could do the same in practice. I can do an U/S A-line so much faster now that I put about 90% or more of my patients to sleep before A-lines, even the hearts. But if they're awake, I give some local because i'm not a mean person.
 

pgg

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Disclaimer, I haven’t read any of the replies here so if anyone has mentioned this already then disregard.

The key to good topicalization is hitting the artery on the first attempt. Once you start probing around things start to get uncomfortable.
I typically make a good skin wheel and then drive the local needle right under the skin about a cm cephalad making a larger wheel of local superficial to the artery. Then I will sometimes go medial or lateral to the artery and deep so that the local might spread around and under the artery. I never give so much that I can’t feel the artery. I’m not talking about the pulse, I’m talking about the artery. You just be able to feel the artery. Except those of you routinely using the US. You probably don’t k know what I talking about and I can’t help.

But the key to painless A line placement is to hit the artery first pass without redirecting.

Oops, it looks like pgg already said this. I just disagree with the US part.
I learned to do blocks, central lines, and arterial lines before ultrasound became ubiquitous and I got good at them. I can feel the artery in some patients but by no means all (some thick or edematous wrists just can't be felt).

Years later I did a fellowship where the standard accepted approach for awake a-lines was to stick by feel, and if you had trouble after a couple attempts, to grab the ultrasound.

These days I just go for ultrasound on the first attempt. There's no reason not to. If it's a heart, the machine is right there next to the table gel'd up and waiting for the central line. Even if it's not primed already, it doesn't take long to turn on.

I watch experienced people go for landmark/feel attempts and most of the time they get it, but sometimes they don't and I just wonder why.

As @nimbus pointed out, sometimes you'll see a nasty, calcified, plaque-encrusted artery and you won't bother sticking it at all, because you'll know to go more proximal.

Few things look as slick as a wire-less arterial stick, one pass, flash, spin 180, advance, thread, done ... but while I respect and admire style, I'd rather make my landmark 90% first pass success rate 99% with ultrasound. If it was my wrist, I'd wonder why the hell the person needling my arm wouldn't bother to use the device that nearly guaranteed a quick single attempt success.
 
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