PICC lines (peripherally inserted central catheter) are often seen as a lower risk alternative to central lines for patients with difficulty iv access, however this is a myth and piccs are not without risk including:
Higher risk of upper extremity dvt (2.55 or and account for 35% of all ue dvt)
Similar risk of infection! Meta analysis and systematic reviews show no sig diff in clabsi!
Other complications include thrombophlebitis,and dysfx and malpositioning greater for PICC than central line
Don’t place, or leave in place, peripherally inserted central catheters for patient or provider convenience.
Peripherally inserted central catheters (or “PICCs”) are commonly used devices in contemporary medical practice that are associated with two costly and potentially lethal health care-acquired complications: central-line associated bloodstream infection (CLABSI) and venous thromboembolism (VTE). Given the clinical and economic consequences of these complications, placement of PICCs should be limited to acceptable indications (long-term intravenous antibiotics, total parenteral nutrition, chemotherapy and frequent blood draws). PICCs should be promptly removed when acceptable indications for their use ends.
So next time someone recommends a PICC over a central line, think about the indications and necessity!
The Awake Fiberoptic Intubation – The DN Technique
Educate patient what to expect and what they should do
This education gives you understanding of any language and/or comprehension barriers
D/W surgery team reason for awake fiberoptic (difficult airway, neuro, etc)
Glycopyrrolate 0.2mg when patient enter room – essential to dry secretions and absorb topical local
50 fentanyl prn for corporation up to 200mcg, slowly after patient demonstrates understanding
4-5cc Xylocaine (2%) jelly swish and swallow (numbs oropharynx)
5% Xylocaine spray (in atomizer), hold nose and have patient take deep breaths, on each inspiration spray oropharynx… confirm that “Xylocaine mist” is inhaled…. continue until mist comes out mouth at the end 0f inhalation. Repeat for 3 breaths, then pause.
note: if mist comes out too soon patient is breath holding -> reeducate
repeat this process 5x
Tip: put nasal airway in mouth and spray thru while inhaling
Optional Transtracheal Block:
find cricothyroid membrane and topicalize with local
fill a 5cc syringe with 5% xyolocaine, load onto a 20g needle with catheter
insert needle into cricothyroid membrane aspirating continuously until you get air bubbles
if blood, back off and reinsert, same goes for if you hit cartilage
once air aspirated (bubbles), pull out needle (leaving catheter) and then inject 5cc
Patient is expected to cough and this helps spread local (note if patient does not react strongly to this, and you had previously performed atomize technique per above, then likely adequate block!)
At this point, patient is adequately anesthetized and one can proceed with the awake fiberoptic, through use of a mouthpiece of choice.
A few further notes:
If reason for awake fiberoptic is neurologic in nature (myelopathy), perform neuro exam with team before and after intubation
Versed can interfere with patient cooperation
Watch for local toxicity, if patient begins shaking, consider versed +/- propofol
watch for hematomas in transtracheal blocks
Consider having screen positioned for patient to watch intubation, can reduce trauma of experience.
Carcinoid Tumors and Anesthesia: Notes from TrueLearn
Carcinoid Tumors: Slow growing, benign, small intestine tumors that can metastasize
Hormonal secreting tumors -> cause cutaneous flushing of head neck and thorax, bronchoconstriction, hypotenion, diarrhea, heart disease
Carcinoid Crisis: triggered by physical/chemical such as histamin release, serotonin, bradykinin
Other triggers include: chemo, tumor necrosis, or succinycholine induced fasciculations!
Anesthestic management: avoid histamine release (succ, atracurium, thiopental, morphine, vancomycin); Desflurane good for patients with liver metastasis as low hepatic metabolism (0.02%); Also the use of NE, epi, Dopamine and isoproternol a/w carcinoid crisis
Carcinoid Heart Disease seen in 60% of patients with carcinoid ->right side: tricuspid and pulmonic valves (plaque like deposits on valves) with TR as most common finding; 50% of carcinoid deaths are from cardiac involvement
So Carcinoid Triad = flushing, diarrhea and cardiac involvement
Management I/O And Peri-Op:
Carcinoid tumors secrete variety of substances (serotonin, catecholamines, histamine)
Somatostatin therapy is standard of care
Be prepared for rapid BP changes
-alpha/beta blockers for HTN
-Vaso for hypotension, or neo
Avoid: Beta agonists -> increased release of from carinoid !
GA = Sympathectomy, decreased NE and Epi concentrations
Phenylephrine (PE, trade name Neosynephrine aka Neo)
pure alpha 1 agonist
increase ABP, decrease HR
CO effect mixed +/- venous return, decreased HR
Norepinephrine (NE, trade name Levophed aka Levo)
alpha1 and beta1, some beta2
relaxation of venous resistance
NE enhances venous return +CO
+ionotropy, little chronotropy
+HR, +SV, +CO
Potency of NE:PE 20:1
NE levels increased in cardiac failure
PeriOp circulating Catecholamine levels
NE and Epi decreased by
-thiopental (even more in uremic)
-spine surgery + prop or iso
NE and Epi increased by
-1.5 mac Desflurane
-rapid increase in Isoflurane
-abdominal surg + sevo/n2o
little effect from roc/vec
Comparing NE to PE in specific studies and circumstances
-PE resulted in higher MAP, no differencve in LV fx vs. Levo
-PE imparied LV function, unchanged with levo
Pulmonary HTN cardiac surgery pts
-CI maintained with NE, decreased with PE
-NE improved (reduvced) ratio of mean PA pressure to SBP
From the anesthesia patient safety foundation newsletter:
An incident of Lewis acid mediated sevoflurane degradation occurred in 1996.5,6 Several bottles of sevoflurane had cloudy drug, a pungent odor, marked acidity (pH <1), and high fluoride (863 ppm), all indicating substantial anesthetic degradation and formation of HF, in quantities far exceeding the safe limits of 3 ppm over an 8 hr average. Abbott subsequently determined that increasing the water content in sevoflurane formulations decreased Lewis acid-dependent sevoflurane degradation.7 They changed the sevoflurane formulation to contain at least 300 ppm water, in order to prevent Lewis acid degradation and formation of toxic degradants. The new “water-enhanced” sevoflurane formulation was approved later that year by the U.S. Food and Drug Administration (FDA), and awarded patent protection.
Why is all this important? Generic sevoflurane formulations do not contain Lewis acid inhibitors, nor can they contain water in concentrations higher than 130 ppm. As Dr. Baker concludes, “a potential remains for sevoflurane instability, . . . therefore some vigilance regarding product integrity remains prudent.”
Quick hit notes from QBanks and Obstetric Anesthesia and Uncommon Disorders
-autosomal dominant CTG-trinucleotide repeat
-impaired muslce relaxation
-Succinycholine –> excessive fasciulations, difficult intubation
-restrictive lung disease -> P/O resp failure
-poor cough/pharyngeal muscle dysynch. -> aspiration/PNA
-imparied response to hypoxia and hypercarbia (senstive to opioids, benzos, barbs, inh)
-comorbidities include: cardiomypathy/dysrhythmias/av block, DM, adreneal insufficiency, thyroid dysfx
-OB pt with MD: increased heart failure risk and myotonic crisis, also increased is placenta accreta, failed labor
-Monitoring: Myotnoia can appear as sustainaed tetanus (even if there is actually sig blockade) -> too early extubations
-MYOTONIC CRISIS: marked contracture of skeletal muscles, 2-3+minutes, ventilation compromised, NOT relieved by nerve block/nmbd/GA
-Prevent Crisis: Warm patient, handle muscles gently, avoid succ and shivering
-Treat Crisis: Procainamide (100mg/min to 1g caution with conduction defects), dantrolene, phenytoin (if localized only, some suggest direct injection of local anesth into muscle)
Plan: avoid succ, easy on resp depressant meds, no superior regional vs. GA
Anesthesia was induced with propofol and either remifentanil 1 microg/kg or sufentanil 0.25 microg/kg. Propofol was continued using a target-controlled infusion (TCI) system. Maintenance infusion rates for remifentanil and sufentanil were 0.25 and 0.0025 microg.kg-1.min-1 [or 0.15mcg/kg/hr for sufenta] respectively.
The median extubation time was similar in the remifentanil and sufentanil groups (10 minutes [interquartile range, 5-19 minutes] and 16 minutes [interquartile range, 10-30 minutes], respectively). Remifentanil was associated with the need for significantly fewer adjustments to maintain hemodynamic stability compared with sufentanil (0.8 vs 2.1; P=0.037), greater use of postoperative morphine (44.8% vs 22.6% of patients, P=0.01; mean IV morphine dose per patient: 4 vs 1.3 mg, P=0.016), and higher intraoperative opioid costs per patient euro vs euro P<0.001). The incidence of PONV did not differ significantly between groups.