XXXVI. Bad Carotid - Bad Heart
XXXVII. Bad Head - Bad Lungs
XXXVIII. Procedures
A. A-Lines
1. The A-Line is generally place in the arm
that will be coming toward the anesthesia
machine after the patient in finaly
positioned. If the A-Line ends up being
remote from the anesthesia machine, be
very sure to tape the hidden stop cocks so
that they don't come open during the case.
2. Different attendings have different
guidelines for the degree of sterile
technique to be employed during A-line
placement. These differences may include the
use of sterile drapes and sterile gloves. I
utilize the wrapping that comes around the
sterile goves as a sterile field upon
which I place the Arrow kit and an 18g
needle for skin puncture. I also put the
Tegaderm dressing on this field. I do not
necessarily use a sterile drap on the
average patient's wrist. If I do employ a
sterile drape, I utilize the "1020"
plastic eye drape.
3. The more time that is spent positioning
the hand for A-line placement, the easier
and more predictably the line will go in.
I prefer to use a rolled up hand towel
over the blue foam supporter for wrist
dorsiflexion. Ideally, the patient is on
the O.R. table and the wrist is anchored to
the arm board. If the patient is on a
gurney, then a long IV board with a rolled
towel is a good combination. An
alternative is a employ a patient tray
table for supporting the hand. The thumb
is taped down along with the fingers
rather than seperately abducted. Betadine
is used for antisepsis. If the patient is
awake, lidocaine is instilled SQ over the
pulse and then deeply injected on either
side of the artery. While the local is
setting up, I spread out the goves and
needles as described above. Adequate time
for lidocaine to work is important for
painless line placement. This is very
important in the aneurysm patient who has
to have an A-line placed preoperatively.
4. For me, the procedure is much easier to do
if I do it sitting down. Successful line
placement is much more likely if you are
sitting comfortably rather than in an
arkward stoop. The extra time spent
getting a chair is made up for in a quick
placement. Also the chances of infection
or trauma to the artery rise in proportion
to the number of stabs made so make your
first attempt count. The needle
advancement is smoother if the arm is
coming across me rather than angled
directly at me.
5. The things most likely to make placement
difficult are having the B/P cuff on the
same arm as the A-line placement and
having the blood pressure to low for easy
placement.
6. The skin is broken with the 18g needle.
This allows a smoother action of the
catheter and allows palpation of a click
when the artery wall is penetrated. Once
the needle of the Arrow kit is through the
break in the skin, it is helpfull to
determine where the needle tip is in
relation to the artery. This is done by
lifting up the tip of the Arrow so that
the palpating finger of the left hand
feels the needle and pulse at the same
time. This permits accurate aiming of the
Arrow. I prefer to slowly advance the
needle in a continuous fashion till
flashback occurs. The instructions that
come with the Arrow recommend quick short
advancements. I do use abrupt needle
advancement is in the patient with scant
subcutaneous tissue. These arteries
simply slide out of the way when using
gradual advancement. This type of
placement will more often result in through
and through needle placement.
7. Ideally, a good flashback occurs. The
angle of the needle with the skin is then
lowered prior to advancing the guide wire.
I prefer to transfer the needle to my left
hand prior to lowering the angle. After
lowering, the guidewire is advanced with
my right hand. The needle is slightly
advanced with my right hand and the
catheter is advanced with my left hand.
8. If no flashback occurs on advancement of
the needle, one of two things has probably
occured. The needle has gone to one side
of the artery or the needle has transfixed
the artery. It is quite possible to go
through both walls of the artery with no
blood appearing in the chamber of the
Arrow kit. Transfixtion can be easily
evaluated. The catheter is left in place
and the needle is removed. If there is
blood in the tip of the needle, then
transfixtion has probably occured. Of
course, even if no blood is present, then
it still may have occured. I recommend
backing the catheter out with a slow
twisting motion till blood spurts out. A
hand towel strategically placed prior to
this step will prevent a mess from
occuring. Blood merely dribbling out is
not the endpoint most likely to result in
placement, a pulsitile flow is more desir-
able. The catheter may be advanced
into the artery, a twisting motion may be
helpful. The guide wire in the Arrow kit
may be used by extending the wire out the
end of the needle and re-inserting it into
the catheter. This must be done with due
concern for shearing of the catheter. The
new Arrow kits allow the complete removal of
the guide wire from the catheter. Backing
the catheter out with the needle in it
rarely seems to work.
9. If the needle has missed and gone to one side
of the artery, it is important to palpate the
artery near the needle and determine to
which side of the artery the needle has
gone. This information is used to improve
the aim. The needle and catheter are
backed out as a unit till you are certain
that the tip of the needle is above the
artery. Often times, this requires going
all the way to the skin with the needle
tip as the artery can be very superficial.
The needle is then re-aimed using the
information obtained above. Merely
palpating the artery again without using
the information gained on the first pass
of the needle will merely result in another
blind stick, so you are likely to get the
same result as the first pass.
10. Brief flashbacks sometimes occur on
advancement of the needle. A small amount
of blood enters the chamber but it quickly
stops advancing. Usually this means
transfixion or near transfixion has
occured. I recommend proceeding with the
transfixion protocol above. Push the
needle and catheter through the artery
with no further attempt to locate the
lumen. Then remove the needle and back the
catheter out till blood is forcefully
spurting out.
- a more elegant alternate to this technique
is to go all the way through the artery,
then to connect the transducer tubing
before begining to withdraw. When a good
wave form is seen on the monitor, the
catheter can be advanced as above. This
method saves a lot of blood spillage.
11. If the flashback occurs while withdrawing
the Arrow needle and catheter, push the
assembly back thru the artery and then
proceed as for transfixion.
12. It is usually not necessary to go through
the skin in more than one spot. If an
advancement is not successful, redirect
the needle using the same entrance point.
13. In the event a hematoma forms and the
pulse is lost, apply pressure and then
proceed to place the A-line on the other side.
14. It is important to clear the line of air
prior to flushing the line into the patient.
This is performed by attaching a 10 cc syringe
to a stopcock in the line, then turning the
stopcock handle toward the patient to flush
the line into the syringe first. The flush
solution in the syringe should be discarded
to make room for the next step. Then, turn
the stopcock handle back toward the trans-
ducer and use the syringe to draw back until
there is blood in the syringe. As long as all
connectionns were made in a sterile fasion,
the blood may be pushed back into the patient
(without the air). The line may now be safely
flushed with the heparinized saline normally.
15. I have seen anesthesia caregivers
succesfully thread a catheter when the
guidewire would not advance. The blood
flow back up the Arrow was vigourous and
yet the guide wire would not go. The
catheter was advanced off the needle
without using the guidewire. A twirling
motion was applied to the catheter as it
was advanced.
16. Axillary artery: In some instances, the
axillary may be the preferred artery. An
example is deep hypothermic arrest. A through
and through technique is best. After a
generous skin wheal of local anesthetic,
use the left hand to immoblize the artery
and place an IV thru both walls of the
artery. Remove the needle and withdraw the
catherter till blood spurts out. Then pass
a guide wire. If a small (.021 in) wire is
used, it is possible for the catheter to
fold at its junction with the artery.
The catheter may appear to thread
but will not go interarterial. To test for
this possibility, pull back on the guide
wire after the catherter is in a small
way. If folding has occured, the wire will
be very difficult to remove. Also be sure
about the compatibility of the guide wire
and the catheter. After the catheter is
in place, any flushing of the catheter
must be done very carefully. It is
possible to flush clots and air in a
retrograde fashion into the cerebral
circulation and cause a CVA.
17. Using the Doppler to locate the artery.
18. Dr Moyses Mandel's search and penetrate
technique.
B. Long Arm CVP's
1. Always have two kits in the room as it is
easy to lose sterility.
2. Don't remove the long catheter until the
IV and introducer are in place. The
catheter will unwind and contaminate
itself.
3. Optimize the EKG size on the monitor.
4. Sequence of veins in the order of preference.
a. The basilic vein (medial) on the arm coming
toward the anesthesia machine is the
first choice. If this is not adequate,
look at the same vein on the opposite
arm. The "Vein of Bloom" located on
the posterior aspect of the medial arm
will also feed into the basilic. This
vein can even be utilized from a point
below the elbow and still reach the
heart. The next choice is the cephalic
vein in the appropriate arms.
b. The arterialized venous blood often
appears to spurt out when the
tourniquet is still applied. Remove
the tourniquet before deciding that
you are intra-arterial. The side-port
on the introducer can be used to tell
if you are intra-arterial by holding
the end about 10 cm above the chest. If
the blood still comes spurting out, it is
probably not venous as CVP is seldom much
greater than 10 cm water. However,
don't let blood come back into the
sideport unless you have to.
5. Turn the patient's head toward the arm
being catheterized. Massage the axilla to
help pass a catheter stuck there. The J-
wire should be less than completely advanced
when threading the catheter. If the cephalic
vainis used, the catheter may get hung up
as it goes over the top of the shoulder.
Applying traction on the arm and
depressing the shoulder may aid in passage
of the catheter into the central
circulation.
6. The IV catheter is thin walled to allow
passage of the .035 guidewire. The walls
are easily penetrated when resheathing the
needle into the catheter. If a regular 18g
IV is used, great force will be needed for
passage of the guidewire but it will fit.
Move the whole IV catheter back and forth
to acheive movement of the guidewire.
7. You may not always be able to draw blood back
thru the cathether.
8. The catheter goes in further with arm
abduction.
9. Pull the catheter out at the end of the case.
10. Need an example of a CXR with the cath in
the correct position.
C. Lighted stylet
1. Make sure the light is at the very end of
the ET tube, beyond even the Murphy eye.
Bend the ET tube to 90 degrees at about 2
inches from the end.
2. The stylet should be very well lubricated.
Make sure that you are able to remove the
stylet prior to inserting the ET tube into
the patient. Also lubricate the ET tube.
3. The left hand grasps the tongue in this
technique. A wooden tongue blade is used
to push the tongue up allowing you to
grasp the tongue with some gauze.
4. Stay in the midline when you introduce the
ET tube. Darken the room. When you see
light going down the trachea all the way
to the suprasternal notch, you know you
are in the correct spot. Push the ET tube
off the stylet. This will require a great
deal of force. There is not much feel
involved in this maneuver.
5. Seeing the light in the midline is not
enough. The light must shine down into the
trachea.
D. Mini-med operation
1. Avoiding bubbles and resetting the volumes
2. What to do when all the alarms go off.
3. Getting air out when the air alarm goes
off.
Neurologic Monitoring