Weekend Case

[vector2]

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Decrease preload less venous return. Increase after load, more intrathoracic Pressure.

PEEP actually has a differential afterload effect depending on whether we're referring to the RV or LV. In a spontaneously ventilating person, the LV has to overcome the intrinsic -5 cm H2O of pressure in the thorax before it can begin ejecting (think of this like a suction cup that's applied to the outside wall of the ventricle). When PPV is applied, the LV no longer has to deal with the negative transmural pressure that's resisting ventricular contraction, and thus afterload is reduced. PPV is beneficial for LV failure because as you said, it decreases preload and also because it decreases LV afterload.

 

[deleted171991]

Decrease preload less venous return. Increase after load, more intrathoracic Pressure.

So would it help or hurt this patient? (trick question, like my previous one) 🙂

P.S.
Arrgh, @vector2, you destroyed my socratic teaching. 😛

Btw, that was exactly my point: it depends, whether it's the LV or the RV one is referring to and wants to help. That's why intubation, PPV and PEEP are bad for the RV and good for the LV (usually). In this patient, PPV, invasive or not, would be a good thing. The minimum this guy requires is a CPAP mask.

 

[MirrorTodd]

So the boards answer would be delay the case, optimize medically as best we can, have an strong heart to heart with fam that he is likely going to die?

 

[shepardsun]

Don't have a lot to add, just love reading these types of threads. Some of the highest yield learning I can get. Wish they were more frequent.

 

[bigdan]

I see the guy as septic already. The new(ish) sepsis definitions were created so that people DIDN’T say “The heart rate is only 80, so he’s not septic”. The “CHF exacerbation” is more likely septic cardiomyopathy in a guy with known heart disease. He’s 90. He hasn’t mounted anything in 30 years - there’s no way I’d wait for him to mount a fever or leukocytosis before taking action.

1. Ensure standard care, including panculture and Abx. If he re-infected on Cefepime, consider that treatment failure and start something else.
2. Talk with Ortho about presumptive urgency; in my mind he’s already in need of source control so I don’t give a ton of push back if they want to go soon/now. If we’re at the rural hospital without meaningful 24/7 postop care, would discuss transfer. If not already done, ensure Ortho is sure pt & family want everything done.
3. Talk w/pt and family about realistic risk issues, including intraop/postop death, etc.
4. Bedside TTE if aforementioned echo isn’t recent.
5. Art line, ETT. CVC as Ortho gets to work. Inotropes and pressors as needed. Gentle diuresis if needed.
6. Try to extubate at the end.

 

[MoMoGesiologist]

The guy is on the general care floor and his vitals are fine. If OP went to bedside and saw the pt and they look ok, then that is the most sensitive indicator of how he’s goin to do IMO.

While he may need aline, central line, vent, dialysis line, etc, I feel like if he’s on the floor looking ok, then everything we do in the OR should only be temporary and be reversed at the end and we can get him back to how he came in, especially if the case is just a knee scope (not to say it doesn’t sound like patient still needs a lot of optimization). Personally I don’t like to escalate prophylactically if I don’t have to. That’s not to say this patient may not crump in the OR, but if he’s lookin fine on the floor, then there’s a reasonable chance he can get through this procedure and go back to the floor.

As an aside, Why line up and put on a vent and dialysis machine and send to the ICU a 90yo with too many medical problems who hasn’t left the hospital/SNF in the last month? I know it’s dumb/pointless to ask in our healthcare system, but is that really a reasonable outcome? Does anyone see this man actually going home?

 

[IlDestriero]

My note would acknowledge that I recognize that he’s in CHF, has a very guarded status with real likelihood of dying under anesthesia or immediately after, that this was discussed with the family, patient, and surgeon, and that the surgeon declared it an emergency that can’t wait for optimizing issues. It’s not a get out of jail free card but it does make it clear that you understood what was going on, discussed the big risks, and needed to proceed immediately. Surgeons are often quick to push marginal patients as urgent, and suddenly bump them to tomorrow when you ask for “Emergent” to be added to the surgical consent and or note. They’re also quick to back down from weekend BS off-site procedures for the same reason. I’m happy to call in the second call team for this horse ****e MRI, if you say it’s an emergency that can’t wait.
As for the case. Gentle cardiac approach, blocks, AL, CL, pressors du jour, try to extubate so he doesn’t linger intubated for the rest of his life.

 

[MoMoGesiologist]

Re central access: is it reasonable to push pressors and inotropes peripherally and if at the end of the case it becomes obvious patient will require long term pressors, then place a central line?

 

[bigdan]

Re: the central line, of course it’s reasonable to go with the PIV-only option, but I’ve always hate the optics of the ICU or PACU hand-off that says: “Yes, we knew this 90 y/o had a depressed EF, sepsis, renal failure and dropping platelets. We got away with this peripheral, which has his NEpi running through it. And he’ll need his Vanco again soon.”

 

[deleted875186]

All these ICU bound people will probably get a central line eventually. Many of my attendings always prefer PIVs, but I think it adds some comfort knowing there’s a line in in case things get hairy.

 

[chocomorsel]

The guy is already septic. He's old, frail, cachectic and cannot mount an immune response. I agree with @bigdan.
As soon as you induce this guy, unless you just use roc alone, his pressure is likely going to tank. Especially with addition of positive pressure. PEEP would be helpful for his lung congestion but detrimental for his BP. So I wouldn't go crazy with it.
I don't agree that this guy looks OK. He's teetering on the brink of going south quickly.
This guy is in complete heart block with a pacemaker but "not pacemaker dependent" with a HR in the 80's? That makes absolutely no sense to me. These patients are bradycardic and hence the pacemaker. I haven't seen complete heart block with a rate in the 80's that is NOT due to a pacemaker. Hopefully that pacer is also an ICD.
He needs diureses as likely his creatinine is up due to congestion like someone has said. However, with his sepsis, some of that could be due to a prerenal etiology. A lot of Lasix along with some Norepi is in the works.
The INR could be due to sepsis or congestion hepatopathy which as it's been said may or may not mean much. Certainly no spinal.
He may not come off the vent easily at the end of this. ICU bed most likely. Once they start mucking around in the knee sepsis will worsen before it improves
I would diurese and give him time to respond before the OR. Hopefully a day. In the meantime make sure he's on proper antibiotics so switch up to something stronger.

Just seeing this today as was on the beach yesterday.

Edit: It's possible for sepsis to be driving the HR in this complete heart block patient who is "not pacemaker dependent". However, I think it's the pacemaker.

 

[shepardsun]

All these ICU bound people will probably get a central line eventually. Many of my attendings always prefer PIVs, but I think it adds some comfort knowing there’s a line in in case things get hairy.

At the risk of derailing the thread a little bit, what is with the seeming hesitation (beyond the obvious risks inherent to placement) of a lot of people these days with placing intra-op central lines? The only time I do them as a resident is on pump cases, which means I do maybe 10-15 a year, which is fine for learning the technique on the "chip shots" but has left me not very confident in troubleshooting the tougher ones, let alone the fact that I have never (and will likely finish residency without having) placed a subclavian or femoral. Even our major traumas seem to get away with a couple of large bore IVs.

 

[chocomorsel]

At the risk of derailing the thread a little bit, what is with the seeming hesitation (beyond the obvious risks inherent to placement) of a lot of people these days with placing intra-op central lines? The only time I do them as a resident is on pump cases, which means I do maybe 10-15 a year, which is fine for learning the technique on the "chip shots" but has left me not very confident in troubleshooting the tougher ones, let alone the fact that I have never (and will likely finish residency without having) placed a subclavian or femoral. Even our major traumas seem to get away with a couple of large bore IVs.

I finished residency with less than 40 central lines. I learned to trouble shoot them in Private Practice. Have put in hundreds since I graduated although this year that number dropped since I was teaching residents instead. I have done probably about 5 to 10 subclavians in my life. They are challenging for me.

Femoral lines are very easy. They can be a little challenging on the fat patients. You gotta get a hold of the pannnus and put some power into it.

The trend these days I guess is to not do as many central lines as we’ve done in the past which kind of sucks with residents.

 

[MirrorTodd]

I'm sure my numbers will change when I do my heart months, but I've only ever put in subclavians. They seem fairly straightforward.

 

[deleted126335]

Central Line sepsis is a metric that hospitals get tagged for. No central line...no central line sepsis. Problem solved.

 

[IMGASMD]

I'm sure my numbers will change when I do my heart months, but I've only ever put in subclavians. They seem fairly straightforward.

Definitely not the norm here.

 

[T-burglar]

The hesitation to place central lines in academics is that attendings don’t want to deal with teaching the procedure. Now that I’m on my own in an MD only private setting I place WAY more CVCs.

Ultrasound and some clinical judgment makes this a very quick benign procedure that significantly increases the safety of a complicated anesthetic/surgery . If I was having a big operation I would rather have a small hole in my jugular than a couple peripherals.

 

[deleted875186]

The hesitation to place central lines in academics is that attendings don’t want to deal with teaching the procedure. Now that I’m on my own in an MD only private setting I place WAY more CVCs.

Ultrasound and some clinical judgment makes this a very quick benign procedure that significantly increases the safety of a complicated anesthetic/surgery . If I was having a big operation I would rather have a small hole in my jugular than a couple peripherals.

I get this impression. Attendings would prefer not to teach a procedure, and don’t want to slow down the room.

 

[abolt18]

I finished residency with less than 40 central lines. I learned to trouble shoot them in Private Practice. Have put in hundreds since I graduated although this year that number dropped since I was teaching residents instead. I have done probably about 5 to 10 subclavians in my life. They are challenging for me.

Femoral lines are very easy. They can be a little challenging on the fat patients. You gotta get a hold of the pannnus and put some power into it.

The trend these days I guess is to not do as many central lines as we’ve done in the past which kind of sucks with residents.

Less than 40? I've done that many in my CA1 year! ~10 as a 4th year medical student, and 5-10 as an intern.

 

[chocomorsel]

Less than 40? I've done that many in my CA1 year! ~10 as a 4th year medical student, and 5-10 as an intern.

Good for you. Want a cookie?
Point of my post was to encourage someone. It’s not the end of the world if they don’t do 100 by graduation.

 

[abolt18]

Good for you. Want a cookie?
Point of my post was to encourage someone. It’s not the end of the world if they don’t do 100 by graduation.

Sorry, my intention was not for gloating, rather to express my significant surprise!

 

[chocomorsel]

Sorry, my intention was not for gloating, rather to express my significant surprise!

Sorry I misunderstood. We had a very weak cardiac program. And the ICU had drama. Surgical and ER run so we got treated poorly.

 

[deleted875186]

Sorry I misunderstood. We had a very weak cardiac program. And the ICU had drama. Surgical and ER run so we got treated poorly.

We do a lot of cardiac, but still outside of that we don’t do many central lines. I’d say one CVC per case, and we do three months of cardiac, and a few more in ICU. So probably I will graduate with around 100. Vast majority being IJs, probably less than 10 each subclavian and femorals. All with US except for the subclavian. I get the impression my experience is similar to many graduating residents.

 

[deleted171991]

Central Line sepsis is a metric that hospitals get tagged for. No central line...no central line sepsis. Problem solved.

Not only tagged, but fined, millions of dollars.

 

[Echo33]

Re: the central line, of course it’s reasonable to go with the PIV-only option, but I’ve always hate the optics of the ICU or PACU hand-off that says: “Yes, we knew this 90 y/o had a depressed EF, sepsis, renal failure and dropping platelets. We got away with this peripheral, which has his NEpi running through it. And he’ll need his Vanco again soon.”

Nothing bothers me more than really sick patients leaving the OR to the ICU with peripherals. I think it’s very poor form, especially with a vasoactive med running? 😡

I also don’t understand the shift away from central lines. Don’t most hospitals have aggressive line removal policies these days? I’m not an ICU doc, but how can a patient who is already septic and sick be presumed to have “central line sepsis” when the line is being placed to help save the patients life? Are people seriously allowing these policies to influence away from decision that should be common sense?

 

[IMGASMD]

Are people seriously allowing these policies to influence away from decision that should be common sense?

Hahahhahahahah..... you work in the US right?

 

[coffeebythelake]

Nothing bothers me more than really sick patients leaving the OR to the ICU with peripherals. I think it’s very poor form, especially with a vasoactive med running? 😡

I also don’t understand the shift away from central lines. Don’t most hospitals have aggressive line removal policies these days? I’m not an ICU doc, but how can a patient who is already septic and sick be presumed to have “central line sepsis” when the line is being placed to help save the patients life? Are people seriously allowing these policies to influence away from decision that should be common sense?

i think if someone needs a central line they need a central line.
they exist for a reason. and besides, central line sepsis is a function of technique sterility and how long the line is in place.
this would be if you have crappy peripherals, or if the patient needs high dose pressors
because you know what's worse than being dinged for central line sepsis?
having the patient die. or having levophed extravasate from a peripheral IV.

 

[MoMoGesiologist]

Nothing bothers me more than really sick patients leaving the OR to the ICU with peripherals. I think it’s very poor form, especially with a vasoactive med running? 😡

I also don’t understand the shift away from central lines. Don’t most hospitals have aggressive line removal policies these days? I’m not an ICU doc, but how can a patient who is already septic and sick be presumed to have “central line sepsis” when the line is being placed to help save the patients life? Are people seriously allowing these policies to influence away from decision that should be common sense?

Agree with you in general. But for people who are going to be on pressors less than a day and are expected to turn around quick, I personally think it’s better to just run things peripherally. Why put in a central line if it’s not going to be needed in 12 hours?

 

[Echo33]

Hahahhahahahah..... you work in the US right?

Yes. There’s no policy that prohibits central line placements in our OR under any circumstance. Our hospital also has an aggressive line removal policy. Our CLABSI rates are extremely low because The central lines are removed (new one is placed if needed) so quickly.

 

[Echo33]

Agree with you in general. But for people who are going to be on pressors less than a day and are expected to turn around quick, I personally think it’s better to just run things peripherally. Why put in a central line if it’s not going to be needed in 12 hours?

True. By no means am I putting them in every ICU patient. But I’ve seen enough really suboptimal peripheral access leave the OR only to have the patient deteriorate overnight and need a line placed by the ICU. “They were only on a small dose of norepi when we left”. But then before you know it the patient is in a fib, needs amigo gtt, bleeds, now needs blood, hypotensive, nurse starts cranking up the levo through the 18G and piggybacking 2 other meds through the 20. Before you know it comments are being made about them coming out on pressers without a line.

Certainly goes both ways. Patient in need of emergency surgery makes it through the ER and ICU with additional drugs through peripherals along the way, with the mindset “he’s going to the OR so anesthesia will give us a central line”

 

[nimbus]

Agree with you in general. But for people who are going to be on pressors less than a day and are expected to turn around quick, I personally think it’s better to just run things peripherally. Why put in a central line if it’s not going to be needed in 12 hours?

Because they need it for 12 hours. It can be pulled when they don’t need it any more. Sometimes they need it a lot longer than predicted.

 

[bigdan]

I’m not complaining about PIV use in the patient that had an unexpected refractory SVR from the vasodilatory effects of the anesthetic; you gotta do what you gotta do.

In the case posted by the OP, the patient arrived septic with dysfunction in at least 4 organ systems and history of CHB. I’m not the best anesthesiologist on this site, but if you KNOW you can get through the intraoperative case without a pressor and/or KNOW you won’t need the central line, you’re an especially fantastic anesthesiologist. A personal frustration of mine is receiving a patient that is clearly unwell or not “routine” postop for ICU care, and having the OR anesthesia team tell me “We got away with an 18 and a 20”. Thieves “get away” with robbery. We’re taking care of patients. I’m never sure what to think: a) the OR team didn’t have time to place a line due to urgency of care, b) line not placed because severity of condition wasn’t recognized, c) the lazy fu@ks said “the can do it in the unit if they need it.

 

[dannyboy1]

I’m not complaining about PIV use in the patient that had an unexpected refractory SVR from the vasodilatory effects of the anesthetic; you gotta do what you gotta do.

In the case posted by the OP, the patient arrived septic with dysfunction in at least 4 organ systems and history of CHB. I’m not the best anesthesiologist on this site, but if you KNOW you can get through the intraoperative case without a pressor and/or KNOW you won’t need the central line, you’re an especially fantastic anesthesiologist. A personal frustration of mine is receiving a patient that is clearly unwell or not “routine” postop for ICU care, and having the OR anesthesia team tell me “We got away with an 18 and a 20”. Thieves “get away” with robbery. We’re taking care of patients. I’m never sure what to think: a) the OR team didn’t have time to place a line due to urgency of care, b) line not placed because severity of condition wasn’t recognized, c) the lazy fu@ks said “the can do it in the unit if they need it.

There is nothing magical about a central line. So long as the PIV is well placed/running well you can give whatever you want through there. I have done massive transfusion protocols with 2 big peripherals and things went just fine. In fact the rate limiting step was how fast we could get the product from the blood bank.....

 

[deleted171991]

There is nothing magical about a central line. So long as the PIV is well placed/running well you can give whatever you want through there. I have done massive transfusion protocols with 2 big peripherals and things went just fine. In fact the rate limiting step was how fast we could get the product from the blood bank.....

You do realize you are "teaching" a critical care AND cardiac anesthesiologist, trained and practicing at some of the best places in this country, don't you? Also, any anesthesiologist worth her salt knows the Hagen-Poiseulle equation and its applications for massive transfusion. 😉

Respectfully, if a patient needs levo or high dose neo when leaving the OR, the patient should get a central line. It's that simple. The anesthesiologist is basically signing off the patient to another service, so one should optimize the patient appropriately for the transfer; it's simple courtesy (and good patient care).

The ICU is not the OR. It's the intensivist who should decide that the patient can get away with a pressor on a peripheral in the ICU, because he's the one who knows whether his nurses can function with that (especially in places without peripheral levo protocols).

Also, it's the intensivist who actually has the experience to correctly judge whether a patient will turn around in 12-24 hours; anesthesiologists rarely follow their former patients for days, to learn from them.

 

[Robotic Wis-Hipple]

The hesitation to place central lines in academics is that attendings don’t want to deal with teaching the procedure. Now that I’m on my own in an MD only private setting I place WAY more CVCs.

Ultrasound and some clinical judgment makes this a very quick benign procedure that significantly increases the safety of a complicated anesthetic/surgery . If I was having a big operation I would rather have a small hole in my jugular than a couple peripherals.

I agree. We do these all day prone or arm tucked cases as ERAS/TIVA. Give me a central line in that all day.

 

[Robotic Wis-Hipple]

A personal frustration of mine is receiving a patient that is clearly unwell or not “routine” postop for ICU care, and having the OR anesthesia team tell me “We got away with an 18 and a 20”. Thieves “get away” with robbery. We’re taking care of patients. I’m never sure what to think: a) the OR team didn’t have time to place a line due to urgency of care, b) line not placed because severity of condition wasn’t recognized, c) the lazy fu@ks said “the can do it in the unit if they need it.

For every 1 of those I drop off in the ICU I get a minimum of 5 from a unit with a 20/22ga PIV in the “hard stick” patient that was “scheduled for surgery anyway”....... But I agree with everything you said.

 

[deleted126335]

I’m not complaining about PIV use in the patient that had an unexpected refractory SVR from the vasodilatory effects of the anesthetic; you gotta do what you gotta do.

In the case posted by the OP, the patient arrived septic with dysfunction in at least 4 organ systems and history of CHB. I’m not the best anesthesiologist on this site, but if you KNOW you can get through the intraoperative case without a pressor and/or KNOW you won’t need the central line, you’re an especially fantastic anesthesiologist. A personal frustration of mine is receiving a patient that is clearly unwell or not “routine” postop for ICU care, and having the OR anesthesia team tell me “We got away with an 18 and a 20”. Thieves “get away” with robbery. We’re taking care of patients. I’m never sure what to think: a) the OR team didn’t have time to place a line due to urgency of care, b) line not placed because severity of condition wasn’t recognized, c) the lazy fu@ks said “the can do it in the unit if they need it.

Usually c. But there is a "d". Absence of defined "ownership" for appropriate care of post op central lines. I have seen several lines (including my own) that were placed properly in the OR, but improperly cared for postoperatively resulting in patient harm. Everybody runs from it and eyes fall upon the person who placed the line. Does your institution have a specific written policy that addresses this issue? I tried to institute one. Unsuccessfully. What I do now is write an order to d/c any line I put in in 72 hours. This requires specific countermanding by another physician or it being ignored. Both of which I hope will provide me some cover in the event of a complication not related to insertion.

 

[deleted171991]

Usually c. But there is a "d". Absence of defined "ownership" for appropriate care of post op central lines. I have seen several lines (including my own) that were placed properly in the OR, but improperly cared for postoperatively resulting in patient harm. Everybody runs from it and eyes fall upon the person who placed the line. Does your institution have a specific written policy that addresses this issue? I tried to institute one. Unsuccessfully. What I do now is write an order to d/c any line I put in in 72 hours. This requires specific countermanding by another physician or it being ignored. Both of which I hope will provide me some cover in the event of a complication not related to insertion.

Blaming the person who placed the line is bad policy. It's Medicine and Nursing 101 that line care belongs to whichever service the patient is currently on. If they are not comfortable with it, they can remove it.

When I get a line from the OR, I do two things: I ask whoever placed the line whether it was sterile and there were any issues, and I get a CXR. Beyond that, it's on me and the ICU nurses, unless the complication is clearly related to line placement (e.g. they nicked the vertebral artery).

 

[Robotic Wis-Hipple]

Blaming the person who placed the line is bad policy. It's Medicine and Nursing 101 that line care belongs to whichever service the patient is currently on. If they are not comfortable with it, they can remove it.

When I get a line from the OR, I do two things: I ask whoever placed the line whether it was sterile and there were any issues, and I get a CXR. Beyond that, it's on me and the ICU nurses, unless the complication is clearly related to line placement (e.g. they nicked the vertebral artery).

How many people are getting into the vertebral for you to specifically mention that?!

 

[deleted171991]

How many people are getting into the vertebral for you to specifically mention that?!

I've only seen one case. But many people don't realize how close the vertebral artery is to the IJ vein, especially when they use ultrasound and stick the vein at the base of the triangle. Those of us who trained on anatomic landmarks tend to go at the apex reflexively.

 

[Robotic Wis-Hipple]

I've only seen one case. But many people don't realize how close the vertebral artery is to the IJ vein, especially when they use ultrasound and stick the vein at the base of the triangle. Those of us who trained on anatomic landmarks tend to go at the apex reflexively.

I would argue it’s the blind fanning style that gets into that. Or maybe the hesitant, missed with blind technique unfamiliar with US user that did that. It’s not close by US, it’s in the wrong direction if using US (most would focus on the IJ with carotid medial in field of view), and the point of US is to follow your needle tip (though we all likely get lazy at times when we see a giant IJ as wide as our US field and don’t truly follow needle tip into lumen).

 

[deleted171991]

I would argue it’s the blind fanning style that gets into that. Or maybe the hesitant, missed with blind technique unfamiliar with US user that did that. It’s not close by US, it’s in the wrong direction if using US (most would focus on the IJ with carotid medial in field of view), and the point of US is to follow your needle tip (though we all likely get lazy at times when we see a giant IJ as wide as our US field and don’t truly follow needle tip into lumen).

Many people don't have the skills to follow the needle tip at all times. Also, truth be told, if going at the apex towards a big and superficial IJ (in many patients), one doesn't really need continuous ultrasound. One just needs to go in the right direction. That's why I was able to place 50+ IJ lines without any complications, and without ultrasound, during my residency.

I still teach the landmark technique WITH ultrasound. In my view, that's the safest for people who don't know a lot of neck anatomy (99% of us). The former reinforces the correct positioning (so many people forget to turn the head properly), place to stick the neck (apex of the triangle), and general direction one should go (toward the ipsilateral nipple); the latter verifies them in real time.

 

[dannyboy1]

How many people are getting into the vertebral for you to specifically mention that?!

I’ve seen it as well. Had to be repaired by vascular surgery. Residents can stick a needle into all sorts of places...
Central lines can be risky. Every institution has horror stories. I’ve also seen a death in a young person 2/2 improperly placed TLC ( it was in the pleural space and they kept on transfusing through it). Point is, central cannulation is not a benign procedure. I use it when I need to but my threshold to place one is pretty high...

 

[T-burglar]

I’ve seen it as well. Had to be repaired by vascular surgery. Residents can stick a needle into all sorts of places...
Central lines can be risky. Every institution has horror stories. I’ve also seen a death in a young person 2/2 improperly placed TLC ( it was in the pleural space and they kept on transfusing through it). Point is, central cannulation is not a benign procedure. I use it when I need to but my threshold to place one is pretty high...

You know what would have prevented that? Adherence to good technique and transducing the damn line. It drives me crazy the current trend of "getting away" with not placing a CVC and also not transducing the line when you actually do place one because "CVP is useless"

 

[abolt18]

I’ve seen it as well. Had to be repaired by vascular surgery. Residents can stick a needle into all sorts of places...
Central lines can be risky. Every institution has horror stories. I’ve also seen a death in a young person 2/2 improperly placed TLC ( it was in the pleural space and they kept on transfusing through it). Point is, central cannulation is not a benign procedure. I use it when I need to but my threshold to place one is pretty high...

We had a patient come to us from OSH with a RIJ trialysis catheter that they had been using for days... It happened to be in the right innominate artery leading to a sternotomy and open repair.

(I've only seen pictures, was not personally involved in the case)

 

[narcotics999]

You know what would have prevented that? Adherence to good technique and transducing the damn line. It drives me crazy the current trend of "getting away" with not placing a CVC and also not transducing the line when you actually do place one because "CVP is useless"

Tranducing does not help with pleural perforartion.

Insertion into veterbral artery is not excusable though. How can one miss the big hose and go for the tiny one? Vetebral is a damned ARTERY, smaller, much lateral and lower.

 

[Xerxes1729]

You know what would have prevented that? Adherence to good technique and transducing the damn line. It drives me crazy the current trend of "getting away" with not placing a CVC and also not transducing the line when you actually do place one because "CVP is useless"

An anesthesia attending in med school taught me to do that on my rotation. I'm in EM now, but I still do it. You can even do quick qualitative manometry with some sterile IV tubing, or the plastic sheathe that the wire comes in, while you're putting it in.

 

[Robotic Wis-Hipple]

An anesthesia attending in med school taught me to do that on my rotation. I'm in EM now, but I still do it. You can even do quick qualitative manometry with some sterile IV tubing, or the plastic sheathe that the wire comes in, while you're putting it in.

Manometry/transducing is literally the only foolproof way to confirm you’re venous with the exception of seeing wire in the RA on TEE. Using surface US or not.

 

[T-burglar]

Tranducing does not help with pleural perforartion.

Insertion into veterbral artery is not excusable though. How can one miss the big hose and go for the tiny one? Vetebral is a damned ARTERY, smaller, much lateral and lower.

Yeah but it helps with proper placement, so you don’t dump blood products into the chest instead of the circulation

 

[chocomorsel]

Yeah but it helps with proper placement, so you don’t dump blood products into the chest instead of the circulation

When in the thorax/lungs/pleural space, there should be no blood return. Why would someone put in a line, that doesn’t return blood, and still presume it’s in the SVC and go ahead and use it?