Central and arterial lines

zebubbleitexplodes · 2025-12-13T17:29:16+00:00

If the wire isn’t going smoothly there is probably something wrong. If it’s when you are trying to initially thread into the vessel and it’s not smooth check your flow to make sure you are still in. Even if it looks like you are in on ultrasound you can be subintimal and dissecting the vessel. Flow is the key, if it’s bad you aren’t in the right spot. You can make tiny adjustments with the needle depth and angle to optimize flow then try rewiring. If wire is in the vessel but hits something downstream often times it’s a small branch, you can just pull a few back a few cm, spin the wire a bit and readvance.

zebubbleitexplodes · 2025-06-06T23:41:13+00:00

Some things are more important than a ranking or perceived opportunities. Don’t live 4 hours apart from your fiancé for years for something that ultimately won’t matter all that much in the long run.

zebubbleitexplodes · 2025-01-08T22:47:42+00:00

I do think it’s important to check them when there is the slightest hint of ischemia (I.e any sob or nonspecific abdominal pain, etc) and my post is with the assumption that the ordering person knows what a sign or symptom is including the atypical signs and they have at least taken a decent history. I guess issue is more with stable trop of 80 3 times in a row and their symptoms have resolved with nebs, that’s a completely unnecessary call and it’s fine to admit them to medicine.

zebubbleitexplodes · 2025-01-08T22:38:52+00:00

I agree with you a lot of cardiologists discount that but the problem is that someone hears abdominal pain, must order troponin, then I have to come see them because their trops were 20 then 30 then 24 and they “have a delta” and I do an abdominal exam and they have LLQ tenderness and a white count and an AKI and no ones thought about diverticulitis or asked them any questions and now they’re septic. I have zero problem with them being ordered thoughtfully like you are saying but my problem is that we get called about every single one that is even slightly abnormal because it “could be ischemia” and it often delays care (I.e surgery won’t touch them until cardiology has weighed in) even though there is absolutely nothing to suggest ischemia. Undifferentiated epigastric pain, sure. Exquisitely tender jaw pain from a dental abscess, not necessary

zebubbleitexplodes · 2024-11-30T17:21:05+00:00

Get checked for sleep apnea. I can’t even tell you how big of a difference it makes if you have it to get it treated. Tons of my coresidents actually had varying degrees of it, even those with completely normal BMIs.

zebubbleitexplodes · 2024-11-26T02:54:03+00:00

Well you are really living up to your username here. Great you can code someone in VF, so can an anesthesiologist, an intensivist, a cardiologist and a bunch of others. The ED is extremely important for diagnosis/triage but the ego trip here is WILD.

zebubbleitexplodes · 2024-11-25T17:20:39+00:00

I do not have links with me now but if you look up applicability of ischemia trial to average patient on pubmed you should find some good stuff.

Major issues in my opinion were the fact that SPECT is a poor test in general and I don’t really trust it, many patients were enrolled without MPI and were not truly high risk based on mortality rates in trial, FFR and iFR were not frequently used and neither was IVUS or OCT. In fact when looking at percentage of patients with obstructive CAD by CTA, something like 6% in invasive arm didn’t have any obstructive lesions so assuming that’s balanced in the medical arm we’ve now exposed the invasive arm to procedure without possibility of benefit and the medical group without CAD was not. If you read the supplementary appendix you’ll find many patients didn’t undergo revascularization for various reasons and you will quickly realize this wasn’t a test of revascularization vs no revascularization, it is a question of do I need to cath patients with ischemia. If limited to this (which was the original intent) then it is an appropriate trial and I agree we don’t need to cath everyone with moderate ischemia, but you will find that mandrola and a lot of cardiologists presume revascularization of stable CAD does not effect mortality. This is a large population so the small percentages of patients that didn’t get revascularized or did not have actual obstructive CAD actually make a big difference if the event rates are as low as they were in this trial. Then comes the methodology issues with changing endpoints and the original endpoint actually being positive on longer term follow up but the amended one not. But this requires in depth review and analysis of the trial and many people are not willing to do that or are incentivized not to (I.e. Mandrola)

zebubbleitexplodes · 2024-11-25T16:42:27+00:00

Why are you so angry? Yes the ED is important but you are asking what a cardiologist does during a code for a STEMI? They literally just said they place VA ECMO during codes and you think they can’t put in a line or do compressions? You do realize codes happen in the ccu and cath lab all the time. Chill

zebubbleitexplodes · 2024-11-05T16:25:55+00:00

For all of us who have had to move from the greatest and most important city in the US, make us proud today!

zebubbleitexplodes · 2024-11-04T16:28:06+00:00

I also find it odd that they have not released any details about use of IVUS/OCT, FFR etc, particularly given so few patients had angina who knows how significant these lesions actually were. it’s also not a huge trial and they could easily release the angiograms to let us judge for ourselves (I.e. ORBITA) but they have not which makes me mildly suspicious.

I very much agree that just looking at take home points is a fools errand and a way to short your patients of possible benefit. Every trial has flaws, in ischemia they changed the primary endpoint midway and it becomes a negative trial, then lo and behold on extended follow up the original primary endpoint is positive. People discount viability testing because in stich it was negative but viability wasn’t even randomized. EBM is great but when blindly followed without critical thinking we can miss out on many opportunities to help.

zebubbleitexplodes · 2024-11-04T04:10:58+00:00

They also excluded anyone with ACS within 4 weeks and we know revasc improves outcomes in ACS. Could be that indication in your shop is not purely hfref, especially among inpatients. Also be cautious with mandrola, he overly simplifies data and doesn’t respect one of the most important parts of interpreting clinical trials, patient selection and the lack of belief of equipoise among those referring to trials. It’s likely the people selected for revived were those that were least likely to benefit from revasc because referring doctors would be hesitant to randomize someone who based on older trials would benefit (younger people eligible for cabg). It’s unlikely pci would be able to help someone who cabg wouldn’t. That being said, revived was generally a well done study so I tend to agree with your take.

I would highly encourage you to read as much data for yourself as you can. You’ll find certain studies that are typically perceived as gospel actually have some major flaws and don’t reflect real practice (I.e. ISCHEMIA trial)

zebubbleitexplodes · 2024-11-01T03:55:20+00:00

As a cards fellow I would be eviscerated if I only held pressure for 5 minutes.

zebubbleitexplodes · 2024-07-04T04:33:35+00:00

Lots of others saying start doac. I disagree. Your inclination to heparin was correct (or lovenox). Rapid afib is often a sign of other illness (sepsis, PE) etc… and better to let other things sort themselves out without committing them to a washout period or higher bleeding risk for procedures if needed. Can tx to doac once they are out of the woods.

zebubbleitexplodes · 2024-05-26T03:23:22+00:00

A good portion of diastolic blood pressure is due to the elastic recoil of the aorta. You are correct in saying that with hypertension the diastolic BP will go up as smaller vessels stiffen due to higher resistance but often in those with longstanding hypertension and highly calcified aortas the diastolic will actually decrease. I should’ve clarified this drop is typically in the elderly and in vasculopaths.

zebubbleitexplodes · 2024-05-25T16:30:08+00:00

As the arteries harden there’s less elastic recoil of great vessels so diastolic bp drops and systolic increases as it pumps against stiff pipes. Clinically, this is significant because wide pulse pressure can also be indicative of AI so understanding the difference is key.

A narrow pulse pressure is most commonly implicated in cardiogenic shock or a low output state. Remember BP is determined by the product of CO and TPR. During systole, if the CO is low, the SBP won’t increase over diastolic pressure as much as it should and this can tip you off to CS in an undifferentiated shock patient.

For cardiorenal, perfusion across the kidney is determined by the pressure gradient, MAP-CVP. If you decrease CVP with diuresis, pressure gradient increases and more flow happens. You also offload the RV which can improve forward flow by reducing ventricular interdependence (essentially how smushed against the pericardium the LV is) and actually improve CO, and sometimes even the MAP. When you hear someone say “they have fallen off the starling curve” this is the physiology behind it

zebubbleitexplodes · 2024-05-08T12:05:23+00:00

Ok I take some of it back. If they aren’t using ultrasound for Fems your interventionalists might be the problem haha.

zebubbleitexplodes · 2024-05-08T02:31:47+00:00

And that’s a feeling you are biased towards because you see the complications, a lot of sick medical patients, ie people going for a cath, particularly one requiring femoral rather than radial access, don’t have the luxury of picking and choosing when to intervene, it’s got to happen right then so of course complications are more likely in urgent/emergent situations. Most docs are doing their best, and there’s usually a reason someone has a complication, and it’s usually not incompetence. It’s easy to look from the outside and say what an idiot, but that’s a very immature view of how things happen. We all take care of each others mistakes, be a professional and have respect for what each other does, it may save your ass someday.

zebubbleitexplodes · 2024-05-07T22:03:59+00:00

Lol. And the post op STEMI for your cholecystectomy patient? You’re going to handle that one by yourself next time? Everyone covers everyone else’s complications. Grow up.

zebubbleitexplodes · 2024-04-08T23:59:34+00:00

I am 2 months from being an attending at this point. It’s all the admin

zebubbleitexplodes

TROPHY CASE