Dan’s Soapbox 3

1. Dan’s Soapbox 3

2. Case 1
• 62 year old male
• HTN, DM, smoker
• Presents with left calf pain of 2 days duration
• No swelling
– Nothing to find on examination
• Recently flown to the UK
• D dimer 0.7
• USS enthusiastically performed by Dr Wheeler

3. USS report:
There is a 3cm thrombus in the left
posterior tibial vein, roughly 8cm distal
to the popliteal junction.
No other abnormality detected
Treating doctor has been informed

4. What will you do?

7. Why the alternative?
• Not really sure what to do!
• In the UK  don’t scan the calf
• Out of sight out of mind
• Risk of not doing anything
• Extension
• PE
• Recurrence
• Vs Risk of doing harm
• Bleeding from anticoagulation

8. • Single centre study over 4 years
• Retrospective review
• Clinician decision on whether anticoagulation was
given
• 14,056 lower extremity venous USS
• Included  384 patients with isolated calf vein
thrombus
• 243 = anticoagulation
• 141 = none

9. Results
• Extension to proximal DVT
• 7 controls (5%)
• 4 anticoagulated (1.6%)
• PE
• 6 controls (4.3%)
• 4 anticoagulated (1.6%)
• Clinically significant Bleeding
• 8.6 % anticoagulation Vs 2.2 % controls

10. Case 1
• 62 year old male
• HTN, DM, smoker
• Presents with left calf pain of 2 days duration
• No swelling
• Nothing to find on examination
• Recently flown to the UK
• D dimer 0.7
• 3cm posterior tibial vein thrombus

11. What should we tell our
patients…
• Anticoagulation will likely reduce risk of PE and DVT
extension (small numbers)
• Anticoagulation will also likely reduced duration of
symptoms
• Anticoagulation will increase risk of bleeding
• Which can be very bad (0.5 – 2% intracranial bleed)
• Who exactly will benefit for anticoagulation and
duration of treatment (6 weeks Vs 3 months) is unclear
• High risk (unprovoked, cancer, >5cm, near popliteal
junction, ongoing immobilisation) or severe symptoms
more likely to benefit

14. The Ideal Ketamine
sedation….?
• Prepare for the worst
• laryngospasm – very rare but serious
• Ensure patient calm and comfortable
• Coach patient on the expected experience
• Vivid dreams will occur – make them good ones
• Pre-treat with midazolam
• Pre-treat with ondansetron
• Give it slowly over 1 -2 mins
• bolus is associated with apnoea
• Aim to dissociate the patient
• Roughly 1 mg / kg
• Wake them slowly and calmly
• Have more midazolam available for emergence if required

15. • Multicentre, prospective, observational study
• Stable patients
• HR < 150
• MAP > 60
• Able to dilate IJ with valsalva
• Able to consent
• Failed peripheral access (including USS)
• Experience of performing physician
• Min 5 successful IJ catheterisations (seldinger)
• Min 5 successful peripheral ultrasound guided catheters
• 18 Gauge 4.8cm catheter over needle device (like ours!)
• Sterile procedure as used for peripheral access
• Remove when no longer required or at 24 hours (max
duration)

17. Results
• Patient characteristics mean (IQR)
• Age 44 (33 – 55)
• BMI 27 (23 – 32)
• 60% had previous IJ venous access
• 83 attempts
• success rate 88%
• Mean time to success 4.1 min from skin prep to flush (95% CI 3.5 – 4.6)
• Pain score 3.9 (3.4 – 4.5)
• Complications
• Pneumothorax 0
• Arterial puncture 0
• Line infection 0
• Loss of patency 14

18. Thoughts
• All attempts were made by physicians with
experience of over 20 ultrasound guided lines
• Majority of these had done over 20 IJV lines
• Infection rates were diagnosed by:
• Home contact after discharge within 2 weeks (12%)
• Hospital visit within 48 hours (22%)
• Chart review to see if further attendance to hospital
(66%)

19. My thoughts…
• In stable patients
• Short term IV access
• Skilled user of ultrasound
• Long cannula in the IJ is an option to consider…..

20. • http://blog.5minsono.com/csb_pacing/

21. Electrical Capture does not mean mechanical capture
Assess the patient!

22. References
• http://emupdates.com/2011/01/27/taming-the-ketamine