US Guided PIV

Thanks to Lakshman Swamy for the tip for this one! US guided peripheral IV placement is a game changer. If you’re not doing this, you should. In fact, a lot of the RNs in our hospital are trained to do this now as well! It certainly saves time and pain (for us and our patients) when it comes to placing PIVs. In many cases, this can seriously reduce the need for central access and/or PICC/midline catheters.

A lot of patients can get by with PIVs, but are “hard sticks,” keep blowing IVs, or need more reliable catheters for blood draws. Using US to place these allows for selection of better, deeper veins that aren’t readily visible to the eye or amenable to palpation. And, this is 100% within the scope of practice for RNs, so train the RNs in your ICU to do this as well (note, you may have to address some hospital policies first). I’ve found when I train new ICU NPs, those with experience placing PIVs with US often pick up arterial line, PICC/midline, and central line placement much faster.

Brown EM Blog has a great post offering tips for success in US PIV placement. Additionally, 5 Minute Sono has some great videos. And finally, a nice CME article on the process is available here.

Being Ambidextrous

I want to highlight an episode of our podcast, Critical Care Scenarios, today. But, it’s an episode I had nothing to do with. My co-host, Brandon Oto, has started an occasional series called TIRBO (The Intermittent Rantings of Brandon Oto) where he just talks for a few minutes about a particular topic. In this episode, he discusses doing certain procedures with your non-dominant hand. I wanted to share this in case readers aren’t regular listeners to the podcast (why aren’t you??). Also, I thought I’d take a minute to add in some of my thoughts.

I teach a lot of procedures. I teach our APP Fellows. I teach procedures to our students at Georgetown University. I do central line workshops for all the new APPs/CRNAs in the Department of Anesthesiology at UK. And one thing I’m constantly harping on is positioning. Positioning the patient and positioning yourself. This is the number 1 cause of procedural troubles (I don’t have RCT data to back that up, but I stand by it).

Twisting and contorting yourself not only is a good way to hurt yourself, either acutely or over the long term, but it’s a great way to make a simple procedure really difficult. If you’re uncomfortable, you’ll subconsciously rush and take short cuts. Your body wants to make the discomfort stop and the best way to do that is to stop doing what’s causing the discomfort (i.e. the poor position). But, most critical care providers are stubborn and so we won’t quit until we get it. So, we rush. Which in the long run actually prolongs things.

So, how does all this related to using your non-dominant hand? Sometimes the best position you can get into is going to be a compromise. I’m right handed, so I prefer to put femoral lines in standing on the patient’s right. But, that’s not always an option. Or if it is, the right femoral might not be good. So, I can reach over the patient to get to the left femoral, but that’s sometimes too much of a stretch (pun intended) and hurts my back). So, I can stand on the other side and twist myself to use my right hand, but that’s usually hard on my aging spine as well. So, I’ve developed the ability to go left-handed.

Similarly, I always teach to set your supplies on a table to your right (if you’re right handed) to do IJ line from the head of the bed. But, frequently in my place, that’s where the vent is and I might not be able to get a table there. So, I set my supplies up on the left. I can then twist and contort myself (a no-no), or I can use my left hand.

So, when you’re learning, learn with your dominant hand. But as you grow in your skills, branch out and learn to do some stuff with your non-dominant hand. It really comes in handy at times.

One-Handed Knots

I’ve been doing a lot of procedures lately and I’ve been thinking about how we tie knots. Strange thing to think about, but we do it a lot. Most of the procedures that we do in the ICU require some suturing (chest tubes, arterial lines, central lines) and suture needs to be tied.

Now, most ICU providers who aren’t surgeons probably use an instrument tie for this. And it works fine. But I did a few surgical rotations in school and first assisted on lots of different cases. So the surgeons and surgical PAs taught me their ways. So the one that I use most often is the one-handed knot.

Once you get facile with it, it’s faster than an instrument tie. It also allows you to have a hand (somewhat) free for other things. I particularly like it when I’m putting in a line that I’d like to keep a finger on until that suture is good and secured. And – I think – it makes you look like you have some special skill.

There are lots of good instructional videos out there, but I really like this one from Rishi Kumar. He’s an intensivist (and a good follow in general, BTW) so he approaches this from that perspective. In this video, he walks you through the technique and explains why, as an intensivist, he uses the one-handed knot. (We have mostly the same reasons, so that probably biases me a little as well, haha!) Like him, I also prefer to tie left-handed, even though I’m right-handed. I don’t really know why, I guess that’s how I learned and it’s all muscle memory at this point. It probably is worth practicing with both hands and being ambidextrous with the technique.

You can get a knot tying board like he uses, or just get some extra suture (or regular old thread) and practice on anything. I like his steering wheel suggestion. I used to practice by sewing up rips and tears in my kids’ stuffed animals. Now that we have a puppy, there is ample opportunity to practice on her toys when she loves them too much! I also recommend wearing gloves when you practice because the feel is slightly different. But, please don’t wet your hand (like he suggests) if you’re practicing on your steering wheel in traffic!

Placing Lines

One of the most common procedures that we do in the ICU is place some sort of invasive line in a blood vessel. These may be arterial lines or vascular access lines in the form of central venous catheters or PICC lines. In this episode of the Critical Care Scenarios podcast, Brandon Oto and I discuss how, when, and why we place lines. Listen here.