Ultrasound for everything
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What will you do in an emergency at the OP hospital when a pt needs an IJ and there is no IJ kit available? 🙂
We're way beyond the era in which a hospital in the USA isn't going to have ultrasound available.
I suppose if there is not appropriate equipment in the facility to do something, then the defense could make the argument that the local standard of care is to do the procedure without the equipment, and the plaintiff could make the argument that the procedure shouldn't have been happening at a facility that was supplied so negligently and inadequately. But a jury would never hear that argument because it'd be settled with a check early on.
No, that's still horse****. I'm sure they can find an "expert" to testify to that effect, but defense would find experts that refute testimony. A blood pressure cuff going q3 min, plus evoked potential monitoring are adequate for monitoring pressure and nerve function. An arterial line is not a therapeutic intervention, just another monitor.
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Its standard of care.
If there isnt one readily available. You calculate the risk/benefit of landmark vs not placing one at all or delaying care while you wait for one. Then you proceed with landmark.
Its entirely defensible and justifiable.
Its not defensible if one is available and you dont use it. Unless you can argue that you have no experience/training in ultrasound. Pretty hard to argue that these days though
I’m sorry but there’s no such thing as an emergency IJ. Quite frankly if there an “emergency” the “safest” vessel to blindly stick is the groin.
I see the point you’re trying to make. “What are going to do in a situation where an ultrasound isn’t available?” There answer is there’s no situation that requires emergency central access or arterial line insertion. It’s not in any ACLS/BLS protocol. Emergency heart or AAA? Yes, that’s why I said any cardiac/vascular OR should have dedicated machine that isn’t being taken to start pre-op IVs
Do you have to save the image in some manner for billing?
Arch Guillotti
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put one in. its an emergency?
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this is nonsense.
The old ones will get repurposed. Anticipated completion date 2027-2028ish
They've been working with the Columbia Heartsource program for the last 18 months or so, which has actually been quite good. In contrast to other consultants who show up, look around, write a report, cash a check, and leave, these guys have been involved week to month the entire time, with recurring site visits, participation in M&Ms, screening (and vetoing) surgeon applicants, etc. I think a big part of why it's working well is that administration is more or less listening to them and doing what they advise.
One new surgeon started earlier this year, and brought along a partner. They are excellent. Actively recruiting another. A couple of the troublesome recurring locums were not renewed. The realistic end goal given our location and market is 3 surgeons and 600-700 hearts per year. They've hired some PAs and intensivists as well. (One awkward conversation about a year ago went along the lines of them saying Heeeeyyyy it'd be really nice to recruit an intensivist or two who were anesthesiologists with CT and critical care training, that'd be a great fit for the new ICU model. And it took all of my poise and professionalism not to shout back YOU DUMB MOFOS JUST DROVE A GREAT ONE AWAY.)
Anyway, it's not all roses, but the CT surgery program is looking up.
I don’t know. I feel like I’ve done more than a few emergent IJ CVCs, usually in cases where you don’t expect it (e.g., aortic laceration on a robotic case). Good luck getting to the groin while the surgeons are trying to filet the chest and abdomen open while someone’s doing CPR. Patient was morbidly obese, so PIV access and emergent arterial line insertion was difficult even with ultrasound. Pre-existing IV access was insufficient for massive resuscitation. Neck was full of subcutaneous emphysema due to suboptimal trocar placement/insufflation, so US was useless as everything got reflected back to the probe. Wasn’t my case, but colleagues couldn’t see the IJ under US and were mostly unfamiliar with landmark-based approach since we always had US machines available. I did heavy trauma at a previous institution so was able to place one quickly for that patient who ultimately didn’t make it, but the IJ access helped us run the Belmont and temporized the hemodynamics for some time (aortic injury was too catastrophic).
There are certainly other cases where I’ve placed one urgently. Peri-induction hypotension in a patient with early tamponade who couldn’t tolerate awake central access (ICU delirium). Surgeon in room, induced, hypotension, drapes up quickly, cut. No time or space for ultrasound with the drapes up. Again, landmark-based IJ was the only feasible option in that setting. I had good peripheral access, so the patient did fine. Similar situation in a trauma pt (GSW chest) who came to us straight from the ED with a tube and peripherals. Drapes go up quickly, surgeons working in the chest, no room for the US.
There’s a time and place for it. Otherwise, 99.5% of the time, I use US for everything. Not many reasons not to use it, although I do fear the newer batch of graduates have already lost this skillset.
All good reasons and rationale. Very defensible.
Agree. Its a technique that residents should learn. Combining both osnangood technique to teach resid
This is getting off the topic, but I can't help but chime in. Everyone where I'm at cycles BP cuff q1m for induction. If you can't tell what the bp is going to do or worry the patient can't handle the swings, then maybe you should put in that a-line first. Am I the weirdo?
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It's quite the opposite, it is rare to NOT have an US when I need one. My original concern was that is not the case in PP land for the new grads.
One could argue, if it's an emergency, and no US, maybe the person with limited experience doing by landmark, a-line or CVC, should NOT be the one doing it.
For some reason, some anesthesiologists just feel uncomfortable with placing lines awake, and do that to get through induction, then place the line. I don't get it either. If I want the line for patient factors, it's going in pre-induction (either in holding or in the room, depending on setup). Hell, most times I want one for surgical factors, I still place it pre- induction
cittykat
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Some training programs teach q1min BPs during induction, then q3min after they prove stable. UCSF comes to mind. Maybe that’s where you are? Seems like a reasonable low risk practice. Sometimes patients you don’t expect will hit the basement.
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I am a big fan of pre-induction art lines.
cittykat
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I’m a fan of that and a preinduction low dose norepi infusion in tenuous patients. Makes the Epic record much prettier.
Nothing makes EMR prettier by cycle the cuff, push prop and roc, intubate and tape the tube, before the next BP. It might be useful for CA-0 to see what happens when you induce and intubate, but any advanced resident should be able to deal with it empirically. Do they also run a pre-induction levophed infusion for everyone? Maybe I'm lazy, but I don't have time for that.
Well you may want the line for high risk potential surgical bleeding. Doesnt mean the patient is unstable at the start.
Wouldn't subject a patient (and myself) to enduring an awake central line
I rarely use U/S for art lines, but will use it if I am doing awake or suspect they are a terrible vasculopath or if I struggled without. I get >99% of them quickly and easily without it when I start without it (but that also eliminates all the suspected/known difficult ones I don't try on).
I use it for almost all CVPs which are almost always IJs.
I use it for almost all CVPs which are almost always IJs.
A Vscan is $5k and doesn't require a subscription model like the butterfly. Given almost everyone here has CME or other dept funds which could very likely be used to buy one, there's not really a good excuse for not having US available.
I still have an old piece of sht butterfly (used ones are maybe $1000-1500?) and it's more than adequate for arterial access.
I still have an old piece of sht butterfly (used ones are maybe $1000-1500?) and it's more than adequate for arterial access.
yes.
cittykat
Full Member
An arterial line?
I prefer gentle and generous local (ultrasound guided, naturally) plus some encouraging words.
I try to never give old people benzos unless it's for a cataract.
yeah. so long as it’s a patient not teetering on the edge i sedate pretty hard and it’s come to a point where i may as well place the ett so they don’t desat. I do this knowing good well that most of these patients also probably just recently had a Cath in the wrist and probably got little to no sedation with a bigger arterial sheath.
Personally I feel like if they’re not groaning and moving I’m more successful
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I think most of the time they prefer the BP/MAP in a certain area to minimize bleeding or maintaining a certain SPP and YMMV if you believe in that sort of thing. I’m not opposed to an art line for tight BP control
I think it’s one of these things where since more and more people use U/S it’s a faster placement and less case delays and complications as opposed to the old days where people would miss and cause hematomas etc again YMMV on if that’s the case
You're advocating that we should teach and allow residents to perform non-ultrasound guided IJ cannulation? That's a hot take. Even as someone who is willing to take on some extra risk for trainee education (I do almost 100% subclavian lines for my CVCs (~100-150/year) almost solely for resident education, though I think there are some benefits), I think if you had a carotid stick and a complication it would be indefensible.
Now sure, there are a few edge cases where being able to do a landmark IJ would be great - I'm not going to argue that. But no one is graduating training now with that skill set, since there's no need or space to acquire it except for these super marginal edge cases. As a result, no matter that there may be some utility to the skill set, it's not going to continue to exist. Even someone who trained with you and did - maybe 2-4 if they're lucky? - they're not going to reach for that technique in a critical situation.
At least at my institution I'm just trying to keep subclavian line skills from going the way of the dodo. I had a new-ish attending graduated from a relatively prestigious program tell me a few months ago they weren't comfortable sticking the left IJ - we're not talking about a high level of skill here for the average anesthesia trainee.
This is a bit like arguing there are a few situations where the light wand is the superior intubating technique. Sure, but with the advent of VL etc the actual use case is so rare nobody is going to learn the skill - and you certainly shouldn't encourage people to reach for a skill they don't know how to use in an emergency.
As ultrasound continues to become smaller, better, more portable and more ubiquitous my bias is that arguments for doing any line without ultrasound (excepting small IVs and that solely for convenience) will become negligible.
One last thing for the trainees reading - don't underestimate the power of scrubbing into the surgical field to do groin/subclavian access when needed. Obviously this requires someone else to be at the head helping, but I've often found that while the surgeons are occupied with a mess they (or someone else) has made in the belly/chest I can scrub in and get a line in the field while they're working.
Its pretty easy to teach. Mainly just teaches how to choose the needle insertion point using palpation while the attending visualizes with the ultrasound (can turn it away from the resident)
Dont actually need to insert the large needle, or can use a small finder needle as well.
Or you can palpate first, pick a insertion point and then use ultrasound to confirm. For teaching purposes
Once the needle is inserted (ultrasound or landmark), the rest of the process is the same.
Basically learn both techniques simultaneously
Why be 90% successful when you can be 99.9% successful with an ultrasound for arterial lines? Many people are fat with a palpable pulse but one that is more deep and more difficult to pinpoint.
If you are concerned about residents needing the skill, perhaps recommend them to try a few without just so they know how.
If you are concerned about residents needing the skill, perhaps recommend them to try a few without just so they know how.
I think starting with an ultrasound routinely vs not probably changes your success rate from 99.9% to 99.91% successful. I struggle to think of a significant complication I have had in a patient that could have been avoided by starting with an ultrasound (that I did not start with) nor an art line I would have gotten placed with an ultrasound that I did not by not starting with it.
I use ultrasound for nearly every central line and nearly every nerve block, but I really don't think it adds much for the overwhelming majority of art lines either in terms of success rate or complication rate.
I might agree with that, but I'm talking about first-attempt success. I agree that missing isn't a big deal, but it's at least more of a problem than a missed IV usually and I'm sure we can agree it's undesirable at the least. I'm skeptical that you are 99.9% successful on your first try by palpation if that's what you're claiming. If you are, then I'm very impressed, especially if you're dealing with vascular surgery patients, obese patients, and acute ill patients daily.
If you're not 99.9% on your first try without ultrasound, then there's also the efficiency argument for ultrasound. With proper anesthesia tech support, the ultrasound doesn't add any time to the procedure and reduces time attempting procedure because of higher first-attempt success rate.
i mean i think it just depends on the availability of the us
our hospital was 400 beds and had 2 ultrasound machines, one was this huge dinosaur that took 3 minutes to turn on, and you had to find it (usually in heart room) and wheel it over and change all the settings
the other was the block ultrasound in a different part of the hospital used for day surgery where i would have to take an elevator down to get it, elevator it up to the main OR, and then return it.
if i had an appropriate us available i wouldnt hesitate, but that wasnt the reality for that hospital, maybe things have changed i havent been in that setting in about 5 years, but I doubt its changed much
That's why I think it's good for residents to be familiar with how to place them by palpation, but I wouldn't fault anybody for doing 100% of them with ultrasound because there are many places with much better support than what you described. I've never had to wait for an ultrasound. When I request an arterial line, the ultrasound is brought with it and handed to me with the needle when I sit down. The procedure takes 30 seconds of my time because they do the prep and securing.
Data would suggest otherwise
Ultrasound allows you to perfectly line up the needlepoint with the center of the artery. Direct palpation alone simply cant do that to the same degree.
--you cant palpate and insert the needle into the same location simultaneously. Your finger will always be proximal or you have to palpate and then remove to insert. You can with ultrasound
-palpation relies on strong pulses. Not so with US
-tissue moves with needle insertion and the artery can shift
-can easily pass through the medial or lateral wall with palpation technique
Just no way for manual palpation to be as accurate unless the user has poor US skills or the US is very old
I am not talking about first pass success because that isn't a relevant metric for any meaningful outcome. This isn't laryngoscopy where a failed first pass attempt is an esophageal intubation. I measure success by successful cannulation (in a reasonable time) and avoidance of long term complication. Passing a 20 g needle near the artery and missing it does not cause a meaningful complication.
Sure, but none of that is clinically relevant.
Additional punctures and trauma to the artery certainly is clinically relevant
to what measure would you consider it clinically relevant? Amputation rate? Hematoma requiring intervention? Permanent nerve palsy? Like what actually measured bad outcome are you hoping to prevent?
I mean I've seen patients with approximately 40 skin punctures up their forearm as somebody went to town for an hour trying to get an art line. That's insane. But one poke hole through the skin that redirected 2 or 3 times and took 7 seconds? Give me a break.
Another problem with ultrasound for newbies and learners is not paying attention to where their inital stick is; I’ve seen people cannulate the artery mid-forearm or mid-bicep.
I'm not trying to denigrate anybody who wants to use an ultrasound all the time. I use ultrasound a ton in my daily practice. But when we try to talk about clinically meaningful outcomes for things we do, start with things like 30 day morbidity/mortality, MACE, hospital LOS, PONV rates, postop narcotic requirements, etc. and go from there. If one person took 6 seconds more than someone else to do something or whether a needle went back and forth once or three times is probably not meaningfully different to the patient in any way.
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All of them.
Embolization, thrombosis, infection, limb ischemia, neuropathy. Increasing the incidence of a low probability event is still increasing it and unjustifiable if the reason for it is being too lazy to wheel the ultrasound in the room
All of them clearly correlate with the number of puncture attempts. Yup. Probably needed 40 puncture attempts because they didnt use ultrasound.
One poke with 2-3 redirect attempts is just a nice way of "spray and pray".
1) Dissection
2) Pseudoaneurysm
I’ve seen each and that was enough for me to use an ultrasound almost always especially if it’s available. Can it still happen? Sure but certainly less likely. I personally feel if the vascular surgeon uses it for all their access (including AVF which you can actually see) and they’re the ones mainly dealing with the complications, I feel like using an ultrasound is doing both the patient and them a favor. We and some proceduralist can tend to treat art lines like they’re benign things. I don’t think they are
what is your NNT? I've probably put in roughly 10,000 art lines without an ultrasound and never had one with a serious complication. That's 0. I've put in maybe another 500-1000 with an ultrasound.
cittykat
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That is because they are internal medicine trained.
