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On Monday, I'll be doing the 2nd part of the central line series--this one on placement tips. In anticipation, I had to release this video on central line micro-skills (microskills). These are the steps of the Seldinger technique to which you need to devote deliberate practice time. Thanks to Jeremy Faust for the filming help.

 

Read this Review of Vascular Complications of CVC Placement

(J Cardiothoracic and Vascular Anesthesia 2014;28(2):358)

When to Confirm

I prefer to confirm all non-crash introducers and especially HD caths prior to dilation. There are times I will place a triple lumen and then confirm the line after insertion (do the latter at your own risk)

Confirming Venous Placement (Choose at least 1)

* Observation of the intravascular pressure waveform using an electronic transducer and pressure tubing

* Determination of the of the intravascular pressure using sterile tubing as a venous manometer

* Analysis of the PO2 of a blood specimen drawn from the needle/catheter compared to simultaneously drawn arterial blood (this is stupid!)

* Bubble Test-when saline is rapidly injected through the catheter, there is opacification of the echocardiographic view of the right heart structures.

* Using real-time fluoroscopic or echocardiographic confirmation of venous catheterization (e.g., visualizing the guide wire or catheter within the superior vena cava)

* Using a contrast study to opacify the venous structures.

Less Desirable

* Guidewire Visualization in the Vein

The Methods in Depth

Pressure Transduction

Easiest way to do this is use the casing of the wire was packaged in--this tip thanks to my friend Taku Taira, MD.

How to Use Wire Casing to Transduce Pressure

[cite source='pubmed']19377052[/cite]

[cite source='pubmed']9412883[/cite]

Numerous other studies cited here: (J Cardiothoracic and Vascular Anesthesia 2014;28(2):358)

Study specifically on using tube transduction (Anesth Analg 2009;109:130)

Or if doing IJ, Just use the Catheter-Over-Needle from the Get-go (but I will lose all respect for you)

thankfully Reub provided the study showing the needle technique is superior [cite source='doi']10.1097/CCM.0000000000001167[/cite]

Or Using a Commercial Device

Compass Single Use Manometers with or without guidewire slot

Bubble Test, Flush Test, Rapid Atrial Swirl Sign (RASS)

Inject 10 ml of saline and observe Right Atrium/Right Ventricle

* [cite source='doi']doi:10.1016/j.ajem.2014.10.010[/cite]

* [cite source='pubmed']24552526[/cite]

* [cite source='pubmed']25624649[/cite]

* [cite source='pubmed']17006130[/cite]

* [cite source='pubmed']19829102[/cite]

* [cite source='pubmed']23242559[/cite]

* Should appear in <2 seconds for properly placed neck line [cite source='pubmed']25550065[/cite]

* Saline Flush and Pneumo Exclusion obviates immediate chest radiography [cite source='pubmed']26112633[/cite]

* For Hemodialysis Caths (Kidney International Reports 2017;2:952

* Crit Care Med 2017;45(7):1192

* SR DOI 10.1097/CCM.0000000000002188

* Ultrasound to Detect Central Venous Catheter Placement Associated Complications: A Multicenter Diagnostic Accuracy Study. Anesthesiology. 2020 Jan 21. doi: 10.1097/ALN.0000000000003126.

 

Equipment to have Bedside

* VL

* Suction

* New Same-Sized Empty ETT

* Additional ETTs

* Syringe

* Tube Exchanger (Cook CAE19 for ETT 7 or larger; CAE15 for ETT 5-6.5)

* BronchPort

* Tons of lube

* Bougie or Glidescope Stylet depending on your VL choice

* SGA and Scalpel

* ETCO2 with Waveform

* BVM

* If you have one available, a Bronchoscope is a wonderful bonus esp. if it can fit an Aintree catheter

A Video from AirwayOnDemand

Literature

* [cite source='pubmed']19299792[/cite]

* Please Use VL if it is available [PMID: 26111264]

*

Now on to the Wee...

Today I get to talk Status Epilepticus with Tom Bleck.

Tom Bleck is a neurointensivist from Rush Medical College in Chicago, where he is a professor of neurological sciences, neurosurgery, medicine, and anesthesiology. Dr. Bleck is board certified in internal medicine, with subspecialty certification in critical care medicine; neurology, with subspecialty certification in vascular neurology; clinical neurophysiology; and neurocritical care. He was the founding president of the Neurocritical Care Society.

Here are the questions we discussed:

Initial Treatment

RAMPART [cite source='pubmed']21967361[/cite] showed us that 10 mg IM Midazolam was at least as good as 4 mg IV Lorazepam

If we have an IV, why are we not using IV midazolam over IV Lorazepam?

When is Status Refractory?

* "Status should be considered refractory after the failure of the first agent that should have worked"

* "If you fail lorazepam, you should move to general anesthesia"

* "The longer you seize, the tougher it will be to break"

When should you say that the seizure is unlikely to end? At 5 minutes, you have an 80% or greater chance that you will continue seizing

See Josh Farkas' view on the rapid sequence termination

So if they fail lorazepam (midazolam?), we should consider intubation and general anesthesia.

Which Paralytic?

Sux vs. Roc

Which agent is best for General Anesthesia?

High Dose Midazolam (Neurology 2014;82:359)

– loading dose: 0.2 mg/kg

– maintenance: 0.1 -­ 2.0 mg/kg/hr

Propofol

may be bad (Prasad A et al Epilepsia 2001;?42:380-­386)

Conventional AEDs

Which one and when?

* Fosphenytoin

* Valproic Acid

* Levetiracetam (Keppra)

* Lacosamide

Dr. Bleck recommends one of the latter two. Levetiracetam at a dose of 1 gm, may repeat 1-2 times or Lacosamide 200-300 mg.

Still Refractory

* Ketamine for Status [cite source='pubmed']23758557[/cite] and this article. Reasonable Starting Dose 3-5 mg/kg.

* Hypothermia

* Inhaled General Anesthesia-AnaConDa with Iso or Desflurane

* This Review Article Discusses Super-Refractory Status Management

EEGs

When should a patient get continuous EEGs?

What if you don't have access

EEG Interpretation for Dummies

* EEG should be the opposite of your EKG (Vfib is good)

* Reactive is better than non-reactive

What if we can't get one?

NitWitticism: Being in burst suppression will prevent you from seizing. Pts can seize through burst. May need to be made flatline EEG.

Etiology

Consider Autoimmune Encephalitis, especially Anti-NMDA Encephalitis (Neurology 2015 vol. 85 no. 18 1604-1613)

Consider Tox

* INH

* Tricyclics

* Theophylline

* Cocaine

* Alcohol/Benzo withdrawal

* Organophosphates

More from Tom on Status

* Rossetti and Bleck in ICM

* Tom Bleck's Slides from SMACC on SE

*

Update:

* Listen to Podcast 160 for the Actual Panel Discussion

Consider Joining the RLA if you want to commit to Resuscitation

* Resuscitation Leadership Academy

Does SIRS Suck?

* Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis (DOI: 10.1056/NEJMoa1415236)

* The Falsely Reported Death of SIRS [cite source='doi']10.1056/NEJMoa1415236[/cite]

We are Complicit

* Please read my post, We are Complicit, to understand why this Table 2 from SSC will make life miserable for all ED docs:

Table 2 from the 2012 SSC Guidelines

Sepsis Collaborative Triage Screen

* Here you go

More Recent Evidence on the Benefit of Lactate for Prognosis

* doi:10.1136/emermed-2013-203541

* doi:10.1136/emermed-2014-204305

Peripheral Pressors

* A discussion on peripheral pressors on EMCrit

* Paul Mayo's Article from LIJ

Additional Posts of Interest

* 2012 SSC Guideline Post

* Lessons from the NYC STOP Sepsis Collaborative

* ARISE has Arisen

 Now on to the Podcast...

John was one of the most wonderful people I knew in medicine. He was kind. He was an amazing doc; strong and confident in what he believed was right, but the consistent trait noticed by all who met him in the FOAM world was his rare humility. John was just lovely, with an acerbic wit that kept me in tears whenever I was around him. He was trying to better the trauma care of Northern Ireland, hopefully his work will be continued and his amazing contributions remembered. My thoughts are with John's family. He left us far too soon, and I miss him so.

If you want to send condolences to John's Family, please contact Rob Mac Sweeney--Tweet (@CritCareReviews)

Please see these words from John's friends in the FOAM World:

* The St. Emlyn's folks

* Michelle from the LitFL Crew

* Cliff from resus.me

A few months ago, John came and visited us at Stony Brook to give EM Critical Care Grand Rounds. He was easily the speaker of the year. He gave an amazing lecture on how he ran his unit (along with his 5 amazing colleagues). The audio quality of the recording was crap (my fault, not John's). We had plans to rerecord it as a podcast, but that can't happen now, so I hope you love listening to John in any form possible, as I know I do:

How John Ran His Unit

When not in the field as a road-racing doc, John was an Anesthesia-Intensivist at Craigavon Area Hospital. He worked in a ten bed unit, only eight of which could have mechanically ventilated patients and yet...

The unit has

* CO2 Dialysis with Novalung

* One of the first centers in the UK to offer REBOA (done by the intensivists)

* Tele-Critical Care

* TEE

Central Lines

* Remove all peripheral ivs

* Remove all resus placed lines

* Place all resus lines 5x ports in left sub clav sunk to 20cm. 10% of them sit in the right atrium; they've had no problem with cardiac erosion. John felt this is a relic of the past.

* Place all CRRT lines r subclav sunk to 20 cm (intra-arial)

* They get CVP off prox port

* Most dangerous drug in the distal

* Subclav is the Line of Champions

* 800-1000 lines per year, no infections in the past year. Pneumothorax rate 0.8% in the last 300 lines tracked

Sepsis

* All get arterial line

* Serial Lactates

* All get a central line

* Fresh PIVs

* Norepi or epi

* Max fluid load of ~2 liters and then need a good reason to give anymore

* No etomidate; They use ketamine, it is open shelf

* No Inodilator (b/c they run their patients extremely dry)

* Phenylephrine and Metaraminol are banned to prevent lazy resuscitation

* No cardiac output monitors until they are not random number generators--they use TTE and TEE

* They don't see ARDS (You need to listen to the Podcast)

* No standing maintenance fluids

InoPressors

Not in the lecture,

Today we have a brief discussion on the new hottie in the respiratory care world, High-Flow Nasal Cannulae

Check Out Critical Care Horizons

Critical Care Horizons published its first articles this week, with a further article due out in the next few days.

How do these Bad Boys Work?

* Best Review by Ward et al.

* Review from an RT Journal

* LitFL CCC Entry

* Josh Farkas has a great post on sole use of high-flow NC

Gastric rupture following nasopharyngeal catheter oxygen delivery-a report of two cases

Some of the Devices: Optiflow, Vapotherm

THRIVE

The THRIVE Study

Miguel-Montanes Study

* The Study in CCM

PREOXYFLOW

* The PREOXYFLOW Study

and the response from the FOAM World

PulmCrit

The Bottom Line Review

FLORALI

The FLORALI Study

The FLORALI Editorial

and the response from the FOAM World

The Bottom Line Review

ICMWK

PulmCCM

ESICM

PulmCrit

EMNerd

Update:

* This trial demonstrates that in poor mental status, Nasal Facemask rather than Full Facemask led to better outcomes (Crit Care. 2013; 17(6): R300)

* John Greenwood, editor of the CCProject, adds this great comment:

Hey Scott,

Great summary and review as always. I've seen a worrisome trend of people citing FLORALI to justify HFNC as a reasonable strategy for pts with hypoxic RF rather than (in my opinion) what should probably be a tool used as bridge during intubation planning. Consider adding this study (http://www.ncbi.nlm.nih.gov/pubmed/25691263) to your pack.

Just out of curiosity,

Today I am joined by James Miner, MD; chief of emergency medicine at Hennepin and an amazing, prolific researcher on procedural sedation.

 

Some of Jim's Procedural Sedation Studies

* [cite source='pubmed']25441247[/cite]

* [cite source='pubmed']23701339[/cite]

* [cite source='pubmed']20624140[/cite]

* [cite source='pubmed']19845550[/cite]

* [cite source='pubmed']16997421[/cite]

* [cite source='pubmed']15692132[/cite]

Some of the Points on Jim's Method for Short Procedures in Stable Patients

* Pre-procedural analgesia rather than peri-procedural

* He uses preoxygenation and ETCO2

* In stable patietnts, he gives 1-1.5 mg/kg of propofol up front

* 30-90 sec retrograde amnesia

* Can do painful things as propofol is coming on, but not coming off

Are there patients who will need different dosing?

* The elderly may need less, especially if they have opioids on board

* Volume depleted patients will need less

* Thin patients will need more, obese patients will need less (if we dose by actual weight)

* (IBW + 1/3 of remaining weight) may be the better way to dose with the 1.5 mg/kg

The biggest mistakes

* People ignore how long it takes for the propofol to kick in, need to wait 60 sec before a 2nd dose

Cardioversion

* Jim (and I) uses Etomidate

Nasal CPAP for Procedural Sedation

* [cite source='pubmed']25455053[/cite]

Alfentanil for Procedural Sedation

Stay Tuned

Update

An article demonstrating that supplemental oxygen impairs pulse ox detection of hypoventilation (Chest 2004;126:552)

And an article on Fasting (Ann Emerg Med. 2014;63(2):247-58. PMID: 24438649)

Now on to the podcast...

 

Reanimate San Diego

Holy crap, response for this conference has been amazing! Not many doc spots left--bunch of nurse spots still available.

ReanimateConference.com

 

Developing EM Conference in Cuba

Joe, Zack, and I (The EDECMO Podcast Guys) will be speaking on the topic of Resuscitation Heavy, Resource Light Cardiac Arrest Management: the Anti-ECMO

From the Organizers:

Don’t miss the chance to attend one of 2015’s most significant Emergency Medicine conferences.

Developing EM 2105, will be held in Havana, Cuba between September 13th and 17th.

The DevelopingEM 2015 is being held with the express invitation from the Cuban Government and growing support from the USA. The conference has a  global  program  that  in 2014 brought  together delegates from over 17 countries in 2014. The 2015 faculty are the best names globally in emergency medicine, the 4 day  conference  includes  an  academic  program,  optional  sessions  and  a  truly  extraordinary  social program.

The program includes  topics  such as  Adult  Emergency Medicine  and  Critical  Care,  Paediatrics,  Trauma medicine,  Global  EM  and  EM  in  Cuba.  We  have several  optional  workshops  available  including  a stellar pre-conference ultrasound workshop hosted by our partners at Ultrasound Podcast, topic specific sessions from the world’s leading EM guys on Cardiac Arrest Management, Lifelong Learning and the NAEMSP Medical Direction course. We have also worked with our  Cuban colleagues to offer site visits to medical institutions in  Havana  and  also  with  our  regional  partners  to coordinate satellite workshops around the Caribbean.   The plenary  will  once  again  offer simultaneous bilingual translation

The program and faculty for 2015 are simply the best in the business, for more information go to www.developingem.com

Register Now

The Resuscitation Crisis Manual

Go to emcrit.org/rcm

to see the initial round of author assignments

more details to follow after SMACC

Can't believe we made it this far...and it's all thanks to the emcritters!

Rob Orman's ERCast for Episode 150

http://traffic.libsyn.com/ercast/Weingart_on_the_state_of_things.output.mp3

or listen at ERCast

note: this is not EMCrit Podcast 150, scroll down to play episode 150

Evolution of Sepsis Care

From EGDT to GNYHA to the Triumvirate of Good Care

Fluids in Sepsis

IVC Ultrasound for Non-Invasive Sepsis Protocol

hear the definitive word from Jean-Francois Lanctôt in an upcoming episode

Asthma Rx

Severe Asthma

Check out the 3MG Trial there

SCAPE

Sympathetic-surge Crashing Acute Pulmonary Edema

Standard nitro mix is 200 mcg/ml, so draw up 4 ml and give 2 ml the first minute and 2 ml the second minute.

VERIFY YOUR HOSPITAL’S MIX BEFORE USING THESE RECS

ECMO

EMCrit EDECMO Podcast

Check out the REANIMATE Conference to learn ECPR

See the EDECMO Site

PROPPR Trial Episode

So Good

Intubation Checklist

Soon to be updated, the EMCrit Intubation Checklist Page is a compilation of so many things that go into good airway management

Combat Aviation

The airline industry helps anesthesia, the Combat Aviation World should guide EM/CCM

Come here to put your hat in the ring for the Resus Crisis Manual

Do the Current CT Contrast Agents Really Cause Serious Kidney Issues

See those 2 blog posts here

Severe Accidental Hypothermia

Here is the accidental hypothermia episode, but use the...

Use the Xmas Tree to Luer Adapter (Made by Cook)

Cric Page

This EMCrit Cric Page has EVERYTHING!

Preox Page

All things EMCrit Preoxygenation

Videos from George Kovacs and Nick Sowers

What did I miss? Comment below:

Now on to the Podcast...