Weekend Case

[dannyboy1]

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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?

That was a case from internship hospital . As an aside I did my internship in a truly ****ty community hospital. Pt was a 26 y/o pregnant woman with severe preeclampsia for urgent c/s. Done under GA. I don’t know why she needed a line but one was placed in the OR. Pt became more unstable as time went on so they started transfusing in the OR. I was on ICU rotation and they bring her up with HR in the 180’s and profoundly hypotensive. We started chest compressions about 5 minutes after she arrived but never got her back. Autopsy showed massive hemothorax with TLC in the right pleural space. Before anyone starts asking about TEE or cvp waveform I should mention that the “anesthesiologist” was one of those who barely spoke English.... again, a true ****hole of a community hospital. Want some more central line disaster stories? I had a case in residency where the ER resident put in a 9fr cordis for “brisk lower GI bleed”. Problem is he put it in the carotid. To compound matters he then proceeded to take it out. Somehow they managed to intubate him and it was off to the OR for emergent neck exploration. Guy was otherwise healthy and hemodynamically stable. He also had veins like garden hoses on both arms on which 14 gauges could have been easily placed. Oh yeah, the brisk GI bleed turned out to be hemeroids....
Another disaster case. Resident was placing the 9fr introducer in the RIJ for a cardiac case. Went a bit too far with the dilator through the IJ and into the pulmonary artery. Pt dead in 30 seconds.
the point I am making is that central line placement carries the potential for disaster especially in inexperienced hands. I will place a cvl if I think that I need it to keep the patient alive and stable throughout the case and pacu stay. If some ICU nurse needs it for her “protocol” then she is welcome to ask her ICU staff to place one.....

 

[deleted171991]

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"

You don't need to measure a CVP. You take a foot-long piece of tubing, you connect it to the needle BEFORE dilating, and you hold it up.

Regarding the vertebral artery stick: people don't realize that, in the short-axis approach. the needle could be anywhere, not necessarily where they think. The only way to know where the needle is exactly is to look around with the ultrasound probe while not moving the needle. It's the famous Indian anecdote about the blind men and the elephant (i.e. one plane is not enough!):

A group of blind men heard that a strange animal, called an elephant, had been brought to the town, but none of them were aware of its shape and form. Out of curiosity, they said: "We must inspect and know it by touch, of which we are capable". So, they sought it out, and when they found it they groped about it. In the case of the first person, whose hand landed on the trunk, said "This being is like a thick snake". For another one whose hand reached its ear, it seemed like a kind of fan. As for another person, whose hand was upon its leg, said, the elephant is a pillar like a tree-trunk. The blind man who placed his hand upon its side said the elephant, "is a wall". Another who felt its tail, described it as a rope. The last felt its tusk, stating the elephant is that which is hard, smooth and like a spear.

And that's why one shouldn't stick the neck at the base of the triangle, where the vertebral artery lies closely. What you see on the ultrasound screen may not be what you stick.

 

[nimbus]

That was a case from internship hospital . As an aside I did my internship in a truly ****ty community hospital. Pt was a 26 y/o pregnant woman with severe preeclampsia for urgent c/s. Done under GA. I don’t know why she needed a line but one was placed in the OR. Pt became more unstable as time went on so they started transfusing in the OR. I was on ICU rotation and they bring her up with HR in the 180’s and profoundly hypotensive. We started chest compressions about 5 minutes after she arrived but never got her back. Autopsy showed massive hemothorax with TLC in the right pleural space. Before anyone starts asking about TEE or cvp waveform I should mention that the “anesthesiologist” was one of those who barely spoke English.... again, a true ****hole of a community hospital. Want some more central line disaster stories? I had a case in residency where the ER resident put in a 9fr cordis for “brisk lower GI bleed”. Problem is he put it in the carotid. To compound matters he then proceeded to take it out. Somehow they managed to intubate him and it was off to the OR for emergent neck exploration. Guy was otherwise healthy and hemodynamically stable. He also had veins like garden hoses on both arms on which 14 gauges could have been easily placed. Oh yeah, the brisk GI bleed turned out to be hemeroids....
Another disaster case. Resident was placing the 9fr introducer in the RIJ for a cardiac case. Went a bit too far with the dilator through the IJ and into the pulmonary artery. Pt dead in 30 seconds.
the point I am making is that central line placement carries the potential for disaster especially in inexperienced hands. I will place a cvl if I think that I need it to keep the patient alive and stable throughout the case and pacu stay. If some ICU nurse needs it for her “protocol” then she is welcome to ask her ICU staff to place one.....

“Lines don’t kill people. People kill people.”

 

[chocomorsel]

How does a dilator make it all the way to the pulmonary artery? I need a visual. It’s too short and stiff.
Ok.. so somehow going thru the posterior wall of the SVC? Would have to require a pretty stiff angle. As in directing the needle to the patient’s back.
Well... I guess anything can happen.

 

[deleted171991]

“Lines don’t kill people. People kill people.”

I had never realized we have a Second Amendment right to placing central lines.

 

[Hoya11]

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.

But who is to say that the insult to the RV from PPV is not more hemodynamically significant than this seemingly academic advantage to the LV?

 

[deleted171991]

But who is to say that the insult to the RV from PPV is not more hemodynamically significant than this seemingly academic advantage to the LV?

A question I always ask myself in a cardiac patient, before just blindly intubating somebody.

 

[Planktonmd]

Doesnt cover everything

It does!
I have done AKAs with femoral + sciatic blocks. If you are not going to use any sedation at all then add a lateral cutaneous block.

 

[Planktonmd]

How does a dilator make it all the way to the pulmonary artery? I need a visual. It’s too short and stiff.
Ok.. so somehow going thru the posterior wall of the SVC? Would have to require a pretty stiff angle. As in directing the needle to the patient’s back.
Well... I guess anything can happen.

I am having trouble visualizing this as well!
Did he actually insert the dilator through the SVC, right atrium, right ventricle, tricuspid, and ended in the pulmonary artery? That must be a very long dilator!

 

[coffeebythelake]

It does!
I have done AKAs with femoral + sciatic blocks. If you are not going to use any sedation at all then add a lateral cutaneous block.

The literature, anatomy textbooks and many regional anesthesiologists would say otherwise. Sci fem does not provide a reliable block for this type of surgery

 

[Planktonmd]

The literature, anatomy textbooks and many regional anesthesiologists would say otherwise. Sci fem does not provide a reliable block for this type of surgery

OK...😀

 

[epidural man]

You don't need to measure a CVP. You take a foot-long piece of tubing, you connect it to the needle BEFORE dilating, and you hold it up.

Regarding the vertebral artery stick: people don't realize that, in the short-axis approach. the needle could be anywhere, not necessarily where they think. The only way to know where the needle is exactly is to look around with the ultrasound probe while not moving the needle. It's the famous Indian anecdote about the blind men and the elephant (i.e. one plane is not enough!):

And that's why one shouldn't stick the neck at the base of the triangle, where the vertebral artery lies closely. What you see on the ultrasound screen may not be what you stick.

That's why it would be better if everyone would start using an oblique view, with in-plane needle advancement. However, it does take a little more ultrasound guidance skill.

 

[epidural man]

You're called by Ortho for a washout of infected knee hardware. They warn you the guy is a little sick. You review the record...

90 yo M with a PMHx of CHF (EF 25%), AFib, and 3rd degree AV block (all presumed due to amyloidosis) and COPD. He was admitted to an OSH a month ago for infected knee hardware and underwent arthroscopy x 3 and grew out pseudomonas. Went to SNF on cefepime, but redeveloped infected knee and got admitted to your hospital. He now has fluid overload with pulmonary edema and effusions, AKI with a creatinine of 3 (baseline 1-ish), an INR of 2.2 (not on anticoagulants and LFTs are NL), and plts of 90K.

What's your move?

Defer pending optimization of his CHF? Will he get septic in the meantime?

Nerve blocks and a strap of leather to bite down on?

Retrograde wire?

Plan:

ENT to trach
GI to place peg
Call the SNF for long term management of intubated patient.
Then, call in sick.

 

[Twiggidy]

Okay, so at the bedside, he is elderly, cachectic, and asleep. Arouses with difficulty, says, "Son, can we do this on monday or Tuesday?"

VS:
Afebrile.
HR 80s, regular; he has a dual-chamber pacer, but does not appear to be pacer dependent. BP 100/50. He is not diaphoretic.
His extremities are warm, but cap refill sluggish. There is no pitting.
He has a wet cough and brings up pink, frothy sputum. He has crackles at both bases.
His knee is swollen and hot, but not red.

His INR is now down to 1.8, WBC 11.

I think my plan would also depend on length of case. Are these ortho residents or private practice orthos? The nugget above shows that while he isn't great, he's not terrible either, but pretty bad. I would want to put an LMA in this old dude to give him at least a chance but that wet cough has me thinking otherwise so I would ETT him but do as little else as possibly drug-wise to increase chances of extubation (minimal relaxation if any and minimal narcs). In the right ICU he could be ok after the case but in the wrong one he could also find himself with a trach/peg.

Have a discussion with the patient/family beforehand about possibility of extended ICU intubation because quite honestly that's the real issue of the case. He will get intubated, he'll likely get septic, and he will be intubated in the ICU likely on pressors. If his lungs weren't wet and you could run him light on an LMA that would give him a better shot.

 

[deleted697535]

(so many people forget to turn the head properly),

Can you elaborate on this? How do you 'turn the head properly'?

 

[deleted697535]

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.

I think the key word here is fool!
If a resident or junior staffman is going to the trouble to perform manometry etc, and knows how to interpret it, they might also be able to use the USS sufficiently well to put the damn needle into the IJV. They aint no fool.

But the guy who does 1 or 2 per year, and inevitably has to do it on a collapsed patient, well he should be transducing, and sending VBG and praying to the almighty vein god that he's in cause hes dilating that carotid or subclavian artery and you better believe that! I've seen it on basically a replica of this exact patient. A regional fellow harpooned the carotid on me 4 years back, and was ready to give the ancef thru it. Luck of god i stopped him when i saw the blood pulse back up into the bag

I used to transduce my lines when i was a young padawan and i believe everyone who is either new to the game, or only dabbles in lines should do that too. But if you're doing 50 to 100 per year like a good cardiac shop, and use dynamic USS it doenst add anything 99% of the time...

There is that very rare poke that you're just not sure about (im thinking particularly femoral here), then id transduce that

 

[deleted697535]

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?

Why would someone put a line into the lungs and not know it in the first place? Likely junior, tired, crapped out patient, poor skill, no awareness. This person doenst know to aspirate more than they know how to dynamically scan using USS.

You only get these skills after having good teachers, and good luck. Good luck in that you didnt kill someone in your trial and error phase of learning

 

[vector2]

I am having trouble visualizing this as well!
Did he actually insert the dilator through the SVC, right atrium, right ventricle, tricuspid, and ended in the pulmonary artery? That must be a very long dilator!

The SVC and the proximal right PA by anatomic relationship have about 3 millimeters separating them at the level of the ascending aorta

Posterior is toward the top of the image, anterior is toward the bottom of the image, lateral right, medial is left, so it would certainly require a bizarre wire kink/dilator angle to punch through posterolaterally at this level

 

[Twiggidy]

The SVC and the proximal right PA by anatomic relationship have about 3 millimeters separating them at the level of the ascending aorta

Posterior is toward the top of the image, anterior is toward the bottom of the image, lateral right, medial is left, so it would certainly require a bizarre wire kink/dilator angle to punch through posterolaterally at this level

I'm late to this portion of the conversation but the CVP dilator should NEVER be inserted far enough to even come close to the major heart vessels. The dilator is meant more than anything to dilate the skin/fat. That's for the triple lumen. Even for the 9F you push through enough to get dilator/catheter complex past the skin and fat and then you thread as if inserting an IV. If dilators are in SVCs you're doing all sorts of wrong, even in the biggest fattest neck patient.

 

[deleted171991]

Can you elaborate on this? How do you 'turn the head properly'?

In the landmark technique, one was supposed to see the two heads of the SCM, and insert the needle at the apex of the triangle formed by them. If one cannot see/feel the SCM, the head is not turned enough. Typically, by turning the head, the carotid would get into a more medial and less anterior position.

The rookie mistake is to just go wherever one sees the IJ lateral to the carotid on the US, even closer to the clavicle (the base of the triangle). That's how bad things happen.

 

[deleted697535]

In the landmark technique, one was supposed to see the two heads of the SCM, and insert the needle at the apex of the triangle formed by them. If one cannot see/feel the SCM, the head is not turned enough. Typically, by turning the head, the carotid would get into a more medial and less anterior position.

That's just not true. In fact it's the opposite and has been verified in a few trials using MRI bja afaik. Turning the head tends to pull the carotid so it is almost exactly posterior to the ijv. now you're in tiger land.


The head should only be slightly turned away or should stay midline.

I'm not sure why landmark technique is being used to make a hybrid of USS technique. They're not the same. Weve all seen enough strange anatomy on uss to know the difference. Just last week a dude straight up did not have a right ijv. Or if he did it was a quarter the size of the carotid and tortuous as could be... with landmark wed be still there trying to find it.

 

[fakin' the funk]

If this guy can lay flat, oxygenate on a simple mask, and stay still with just a Bair Hugger and your voice, you do a femoral block and the surgeon supplements with local as needed. Dunzo.

If not, he needs a day or two to diurese, maybe thora's, ?steroids, continue abx, etc etc. Possibly in ICU. This is more about you telling the hospitalist about the needed endpoints prior to surgery than you doing it yourself.

 

[fakin' the funk]

Seriously, why would anybody even consider doing this case? This guy's infection is chronic. WBC of 11, HR of 80, BP of 100/50, this ain't sepsis yet (despite the AMS). Fix the heart, especially an amyloid heart with a lot of diastolic dysfunction (not just systolic).

The guy in multiorgan failure (shock) and a known infection doesn't have sepsis?