Tag Archives: Procedures

Ready for discharge?

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Interesting case from my MICU month.  Pt is a middle aged  WM with hx of HIV, CVA presented to the ED with hypoxic respiratory failure and sepsis. Intubated in the ED and admitted to the unit. Pt self extubated few hours later in the MICU. Responded well to fluids, antibiotics and O2 nasal cannula.  Few days later, nurse d/c’ed his RIJ central line.

Within minutes,  pt became severely altered, O2 sats plummeted to the 60s and  bedside ultrasound showed significant air bubbles in the cardiac chambers.

What happened? When central line was removed, the wound site was not immediately occluded (with fingers, dressing with tape, etc). As pt inhaled, air traveled through the communicating conduit into the central blood vessel.

What to do now? Intubate for severe respiratory distress. Place pt in left lateral decubitus position and Trendelenburg position–prevents air from traveling to the pulmonary arteries causing airflow obstruction. Hyperbaric oxygen therapy, if you suspect cerebral embolism, as it decreases mortality.

The pt was intubated, placed on his side with bed tilted down. Did fine and transferred to floor the next day.

Ketofol losing sexiness

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I rarely use ketofol at Jewish, but will let you guys use it at UL when you want. But this article gives a similar opinion to mine: Ketofol does not hold much benefit if any over Ketamine or Propofol.

For quick procedures where you want muscle relaxation (joint reductions or cardioversion), I use propofol. For painful procedures and trauma patients (traction pins, intubating marginal BP patients, chest tubes) I prefer ketamine.

Propofol with the K does NOT seem to decrease emergence reactions. Though Midazolam does so do give 1-2mg midazolam with your ketamine.

My main issue is anecdotally that the ketofol duration of sedation is noticeably shorter than ketamine. I believe this is due to a lower ketamine dose. And we all know that once the dissociative threshold of ketamine is reached, higher doses simply lengthen the duration of effect. You can’t get “more dissociated” just like you can’t be “very unique.”

I don’t even want to mention etomidate here, as I see only one indication for etomidate (as of 2015 where we are on the brink of taking the head injury stigma away from ketamine).

Article is worth a read.

Ultrasound IVs

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We are pretty spoiled at UL with our nurses being the best in the hospital, and being savvy with ultrasound-guided IVs. But when you leave UL to moonlight or graduate and start a new job, don’t expect your nurses to be able to place USN IVs. At Jewish the docs do them all. Nurses in places other than UL are quick to call IV therapy, very quick.

Here is a nice article, one of the simplest but

DSI

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DSI works. Weingart’s original article was descriptive. Now he follows with a prospective observational study. I actually haven’t read the whole article yet because like a good book, I just don’t want it to be over. Everyone needs to read this.

Also we all need to quit being slackers on room9er. Lets try to get a few more posts in before the holidays hit us.

Expert central lines

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Fall: it’s that time of year when the PGY-1s start holding down the MICU.

If your MICU experience is like mine, you’ll get a few texts on the overnight from the medicine PGY-3s asking for help placing central lines. I’d put in a couple subclavians in the OR as a medical student and the venerable (legendary) Jason Mann had shown me some tricks, but I was definitely nervous being the go-to person.

Found these great videos for EM docs on central line placement. Most of the videos I’d seen before were showing you how to identify landmarks and such – these are a level beyond that and offer some great information and tricks for more expert line placement. Worth watching about once a year through residency.

Here’s part 1. Just search for parts 2-5 if it’s helpful.