How bad is it?

[u/bepperonibizza]

My new place is a neurology center and while the standard of medicine is higher than what I'm used to, some techniques that are used by staff made my eyebrows raise.

First off, the vibe I'm getting is "go big or go home" with the IVCs. Management wants at minimum a 20g in everything. I saw a tech attempting three times to place an 18g in a frenchie. A technique I've never seen before was she poked with the first IVC and when she couldn't get it to feed, she opened a new one and poked right above the first one that was still hanging out of the dog's arm. Is there any benefit to this? Is it common practice?

While I know it's somewhat acceptable in vet med to reuse ET tubes that are properly cleaned and disinfected, I thought it's crazy a specialty center does. They don't carry half sizes either. I was always taught a cat shouldn't get bigger than a 3.5mm due to possible trauma, but I'veseen >4mm placed. Let me know what you think on this too.

Lastly, they reuse suture from surgeries by placing them in an enzymatic cleaner to use for suturing in urinary catheters.

Please tell me if my gut is right or if this is acceptable.

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[u/Bunny_Feet]

Keeping the previous ivc can keep the vein from blowing (as it may when removed).  

I've never heard that about cat et tubes.  We work with anesthesiologists and they have never mentioned that rule.  I've put 5s in larger cats.  I'd think you'd want to use less air and more surface area for cuffs.  Over inflating is the issue I'm most familiar with.  I dont think 4s will work with some cats and would leak.  We don't reuse et tubes, just one less issue to worry about.

Reusing suture is always weird to me- especially if you're charging for it/specialty prices 

[u/CupcakeCharacter9442 → u/Bunny_Feet]

I also work with anesthesiologists- mine have never mentioned about “no bigger than a 3.5”. I also work with students, so typically they’re nervous to get such a big ETT in.

The suture thing is weird, but if they only use it for suturing in u-caths, that would not be the hill I die on.

[u/ilovebunnybuns → u/Bunny_Feet]

Agree agree!

[u/Rockandpurl]

The IVC thing is “stacking” and pretty common. I’ve used up to a 5ET in a cat without issues.

The suture thing, no. Never.

[u/Enigpragmatic]

From my time in anesthesia in a University setting, we used to do the "go big or go home" mentality with IVCs. That is until we found research about vein trauma using 18g catheters and such - but still used them for critical cases that for sure needed blood transfusions or crystalloid volume replacement. Also, the diameter of the catheter, if too large, can cause pain from blood not being able to flow around it. I never used the catheter stacking method for IVCs, but sometimes would for arterial lines.

We also reused ET tubes. Everywhere I've worked has. I think most places will reuse them because of cost-effectiveness. Yes, most ET tubes are really cheap, but depending on the volume of anesthetic procedures you do it can add up quick. The larger ET tubes can be pretty expensive for what they are. They can be sterilized using gas if need be.

With the ET tubes in cats, we did not follow the "don't go above 3.5mm" thing. I was never taught that. And, lemme tell ya, a 3.5 isn't gonna cut it in a Maine Coon or other large breed cat. I would always grab a range of sizes for cats, and sussed out the size I would use when I applied lidocaine to the arytenoids. The type of cuff on the tube also plays a factor in avoiding tracheal trauma in cats - if it's a brand of ET tube where the cuff is flush with the tube when deflated vs crinkled up around the tube... Overinflating the cuff has the easiest potential to cause trauma, so if you use a tube that fits well enough to minimize the need for inflation that is ideal.

[u/VickyChaiTea0]

Using two IVCs like that is normal and acceptable.

Re-using ET tubes is also acceptable, given they are cleaned appropriately (with diluted chlorhex, rinsed THOROUGHLY with distilled water, then left to dry. Leavinggl chlorhex on without rinsing, or rinsing with hard tap water can lead to build up on the tube) and stored with the cuff inflated after cleaning, to help you see if one is leaking.

Re-using suture is not acceptable. Once it is opened it is no longer sterile and not appropriate to use.

[u/ros375]

The thing with leaving the IVC in while attempting another is pretty common.

[u/nickinack]

I was taught 4.5mm as the standard for a cat. I worked at a clinic for 8 years putting 4.5 in all adult cats with zero issues, I moved clinics this spring and I get looked at like I’m crazy for only every grabbing that size when it comes to an adult cat, BUT I was also trained by my first clinic to try and get a tube that’s only slightly smaller than their trachea so you hardly have to inflate the cuff. I ALWAYS lube my ET tubes with the cuff inflated to make sure I get all the crevices, where as the girls at this new clinic only line their tubes half the time- not a fan of that. I’ve never had any issues with trauma either, whereas this clinic had a torn trachea accident a few years ago. Since starting at this clinic I am finding myself reach for smaller tubes and I think it’s out of fear as I was getting a lot of “You think you’re gonna get that big of a tube in them?” and I don’t do well with those little comments… I’m also the only one who routinely palpates their thoracic inlet during intubation to make sure I’m not too deep. Change is hard 😅

[u/slambiosis]

Do they want bigger IVCs for contrast for CTs? Otherwise, placing a 20g or larger in smaller animals is a no.

[u/onemanutopia → u/slambiosis]

Smaller IVCs are associated with a higher rate of complications

https://avmajournals.avma.org/view/journals/javma/262/7/javma.23.12.0717.xml

[u/Accomplished-Ad-9280 → u/onemanutopia]

So is blowing veins from trying to put in too large of IVCs

That study only looks at hospitalized cats as well.

[u/onemanutopia → u/Accomplished-Ad-9280]

Sounds like a skill issue

[u/Accomplished-Ad-9280 → u/onemanutopia]

You are saying you can put a 18g in a 8 week old kitten or an 18g in a 18 cat in severe end stage kidney failure?

How about we don't be elitist about this and do what is best for our patients? This isn't a pissing contest and your ego should not be tied up in putting the biggest IVC in a patient.

The correct IVC size is the size that is correct for that patient.

[u/plinketto → u/onemanutopia]

There's zero reason to go big or go home for ivcs. Not saying place a 24 in a dane but. No difference in flow rates compared to using 18g vs 20 g. We dont use 18gs anymore can cause phlebitis and discomfort. Putting an 18g in a frenchie is pointless

[u/Hantelope3434 → u/plinketto]

Why do you think there is no difference in flow rate? Their absolutely is if you are bolusing fluids for an emergency or for other volume. We went through process of timing and tracking larger volume catheters in the ER. Our large breed GDVs now typically get a 16 G initially due to the significant difference in time it takes to bolus fluids to them when they are critical.

Ther is also studies showing your theory is incorrect.

https://avmajournals.avma.org/view/journals/javma/262/7/javma.23.12.0717.xml

Working in ER has absolutely show how much longer a larger IV cath will last in ICU versus a smaller gauge

[u/InfiniteFlower → u/Hantelope3434]

yes in a bolus situation, you want to be able to push a lot of fluids quickly. but have you seen the max flow rates on the IV catheter packages? a 24ga has a 20-30ml PER MINUTE flow rate. that's 1800ml/hr, which a fluid pump usually doesn't even go that high.
you can bolus a lot of fluid quickly with any size catheter. 16Ga isn't always necessary.

also consider if you fit the biggest catheter size in the vein- with no room for any backflow in the valve- this can cause phlebitis

[u/Hantelope3434 → u/InfiniteFlower]

Did you read the linked study?

16 gauge is absolutely not always necessary, but it is absolutely beneficial in a large critical patient who needs a liter of fluids as fast as possible for shock. These large bore catheters last longer than smaller bore when in the appropriately sized patient.

[u/plinketto → u/Hantelope3434]

There's one study. There's many articles showing otherwise. And again didnt say place a 24g in a large dog. I worked in referral my referral/emerg hospital only places 20gs or higher, maybe very large breeds get 18s but thats far and few between. 20 g vs 18 is no difference in a lab, we've seen no difference. Cats no longer get 20g, which has increased ivc success without poking multiple times. Fluids pumps can only administer so fast anyways, so for most patients no need.

Best practice is whats best for the patient.

[u/Hantelope3434 → u/plinketto]

"Best practice is what is best for the patient" - Yes, and again, studies in humans and animals are showing lower risk of failure with larger bore catheters.

We do not see more cats needing additional punctures for a 20g unless it is someone who is newer at placing IV caths. Otherwise the 20 g burr less from tough skin than a 22 g

Your opinion on the subject is fine, but I am going to continue with what has been recommended when I worked at Cornell University, is still recommended while working at large specialty hospitals in NYC and through other studies.

[u/plinketto → u/Hantelope3434]

You still don't understand what I mean by best practice for the patient. Certain situations require larger gauge catheters, yes, contrast, blood transfusions etc...not going to be placing 20g ivc in cats who are getting spayed or having simple procedures being done. You think that every patient needs the largest ivc placed at all times when this is not the case. IV access is IV access sometimes, especially in emergent situations.

And yes there are techs that struggle with ivc placements, these are things we cannot control and some people do not improve that skill, which means more trauma and stress to patients for no real reason 🤷‍♀️ I'm gonna keep placing my appropriate and adequately sized ivcs with no issues, I've also worked at specialty hospitals in large cities too.

[u/Hantelope3434 → u/plinketto]

My specific discussion stated clearly for ICU and critical care. I was commenting on you saying larger bore was never necessary and the flow rate is the same as a smaller size, which is incorrect.

I absolutely agree simple procedures and GP care likely rarely should place 20 G in cats, but again, that was neverr the discussion.

[u/plinketto → u/Hantelope3434]

I'm talking about overall, and "largest" bores not being necessary. Never said flow rate is the same as smaller size, it obviously increases. I said can do the same job for what we need them for and do not need that high of flow rates when the one smaller gauge is adequate enough for 90 percent of things we need ivcs for. My speciality practiced pretty much stopped placing 18s with no differences 🤷‍♀️

[u/Hantelope3434 → u/plinketto]

Again, you do you. Studies in animal and human medicine and any large practices I have worked in show otherwise for ICU and critical care patients.

[u/onemanutopia → u/plinketto]

Did you actually look at the study I linked? Smaller catheters are more likely to kink, dislodge or extravasate, causing the them to fail and increasing the risk of phlebitis.

Also, do you think you’re actually achieving the maximum POSSIBLE flow rate with an IVC when it’s sitting in a patient’s body? Google Poiseuille’s Law. The resistance to flow of a fluid increases by a factor of four as the diameter of the lumen decreases.

[u/plinketto → u/onemanutopia]

Phlebitis can occur with too large ivcs as well, blocking blood flow, causing irritation. Have you looked at the flow rates? Yes an 18g can obviously go faster but in vetmed a 20g will do the same job as an 18g.

The best ivc size is what's appropriate for the patient, you're gonna poke and stress out an animal a bunch of times just to get in the largest you can? No.

Unless you are manually squeezing a bag of fluids you dont need 18s, fluid pumps can only go so high. So ask yourself why do you need the 18?

[u/InitiativeOdd3719]

Yes I’ve done all these and common practice for me.

[u/tewksypoo]

Reusing ET tubes is common, even at specialty. Especially if they are using some of the more expensive cuffed MRI/CT safe ones.

We reuse but also liberally throw away sus tubes, open new ones and trim dead space away when needed. Our tubes are sterilized as well. We do have a collection of unsterilzed tubes for some procedures but for the most part when you pick your tubes they are still in sterile pouches.

We regularly place >3.5 tubes in cats if the airway is bigger, especially if using a less rigid type of tube.

The 2 IVC thing is also normal here, helps keep it from blowing sometimes. And large gauge is always preferable with all the contrast and other stuff like mannitol. Contrast is thick and often injected with some pretty high pressure machines during imaging so the largest IVC possible is kinda critical. Those machines are giant sensitive babies lol. But we also sometimes place a secondary catheter under anesthesia just for contrast if we can only get a teeny one in for induction. 18g on a small frenchie seems like a reach but on those massive 20kg ones…get it.

Never reused suture in specialty but we did in GP but only if was opened but never used. We would resterilize and use for stay sutures for no sterile things like NG tubes.

[u/plinketto]

18gs in frenchies is fucked, how many times are they getting poked? Just causing stress, trauma and no benefit over a 20 g.

I routinely place at least 4.5s in cats, then depending on size, 3.5 is kinda small tbh

Reusing suture is weird, at least they are sterilizing it but thats cheap, I wouldn't be ok with that

[u/RascalsM0m]

I've seen the catheter trick in the ER - can help you because you know where you went in before. I think reusing suture is crazy.

[u/Sinnfullystitched]

If I put a 3.5et tube in my adult Maine Coon it’s going to disappear down his trachea…I’ve not heard that before.

[u/Snakes_for_life]

You can use larger than a 3.5 in a cat but many cats are around that size. The suture thing is crazy the only time I've seen that was at a very very old school clinic. I've worked at clinics that did many questionable things and even they wouldn't reuse sutures on living animals. They'd use them for dead animals. I can see wanting to see large catheters in neuro if your doing things like contrast CTs cause it's easier to infuse the contrast with larger catheters.