That Time of Year Again (VL vs DL)

[anaesthetic]

Well that's the problem, right? If VL is the #1 goto because it's "better" for patients as you claim, then ...

Experienced anesthesiologists can't "maintain" skills that are never used.

Inexperienced anesthesiologists can't acquire skills that are never used.



More than zero. And zero is how many you should be doing, if you really actually believe that VL is the superior method for patients.

Or are you going to start including on your consent something like "I'm going to use a method I believe to be inferior to secure your airway, because I haven't done it for a while, and I want to knock the rust off, is that OK with you?"


Or maybe we could just admit that there's absolutely nothing wrong with DL for the vast, vast majority of patients we intubate.

And maybe we can acknowledge that VL isn't always easier than DL for securing some airways.

If you want to insist that your CRNAs use VL, that's a different issue. Their DL skill maintenance isn't your problem, and you're always standing right there ready to take over and get the airway if there's a problem. Maybe with DL.




I think that's wrong and ridiculous. I learned without ultrasound, and I use it now 100% of the time. I never, ever do an arterial line without it. I don't like to throw shade with the term dinosaur very often, but people who don't use ultrasound for arterial lines are dinosaurs.



Well, yeah, duh. Of course it is.

Another benefit of ultrasound for arterial lines is that after looking with the ultrasound, you might not even attempt that location at all. It is not unusual at all for me to look at some crusty old vasculopath's radial artery with ultrasound, see how small, calcified, tortuous, or thrombosed that thing is, and go look at the other side, or go straight to a brachial. You "old school" a-line starters would stab away for a couple of attempts before changing plans.



I think you should listen to yourself here, and leave your ego out of the equation and focus on the patient. It is quite clear ultrasound guided a-lines are superior to "old school" a-lines in terms of safety, smoothness and first pass success.


Also -

That is not clear at all. The whole point of this thread is how dumb this article is for its "better first pass success" endpoint, and it doesn't even claim superior safety. In fact, it found equivalent safety (~21% serious complications in both groups).

I have a wireless, bluetooth ultrasound (GE Vscan Air) with me at all times. In practice, 99% of art lines are under ultrasound, awake or post-induction, and 1% are anatomic, usually in traumas or crashing patients. No complaints about speed from anybody ever.

IMO, US has minimized incidence of hematomas and increased first pass success. I have also seen crunchy or tortuous arteries with US visualization which makes the decision to move on to a different site much easier. Also, I have seen residents, CRNAs, and even colleagues struggle with US due to poor technique (usually from advancing without visualizing the needle tip).

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[drmwvr]

We have VL in every room now. It’s always my 1st choice.

sheesh...that must be nice...I guess my place is too much in the hole paying off the agency fees for travelers that back filled the nurses that left for a travel gig.

 

[pgg]

I have a wireless, bluetooth ultrasound (GE Vscan Air) with me at all times. In practice, 99% of art lines are under ultrasound, awake or post-induction, and 1% are anatomic, usually in traumas or crashing patients. No complaints about speed from anybody ever.

I lose my stethoscope about 4x per week but it has my name on it and always eventually finds me again. If I had some kind of fancy bluetooth ultrasound on Monday, it'd be on eBay by Tuesday.

WRT speed - I don't mind making people wait. If I unexpectedly want to add an a-line during a case, I ask the circ RN or an anesthesia tech to go get me an ultrasound machine. Anesthesiologists ought to stop acting like we're inconveniencing other staff by getting equipment we want or need to do procedures.

I would feel foolish making people wait if I was blundering around like a 65 million year old reptilian fossil who didn't want ultrasound, and it took me more than one stick to get a line in. That's a bad look.

IMO, US has minimized incidence of hematomas and increased first pass success. I have also seen crunchy or tortuous arteries with US visualization which makes the decision to move on to a different site much easier. Also, I have seen residents, CRNAs, and even colleagues struggle with US due to poor technique (usually from advancing without visualizing the needle tip).

Totally agree.

 

[Arch Guillotti]

Visiting from EM. 21% major complications is wild, I can’t remember the last time I had any of these come up, knock on wood.

Typically intubating either for respiratory failure not improving with BIPAP, status epilepticus, severely altered mental status, or airway-proximate bleeding (hemoptysis, upper GI bleed, trauma). I use VL first for the non bleeders and DL +\- bougie first for the bleeders. I am single covered at night, no ENT coverage and there is a crna but they are also responsible for ~300 bed hospital with ob so I’d have no confidence they would be available if I needed help. For urgent but not crash airways like worsening angioedema I do call them esp since we do not have a fiber optic scope. I think mid year CA 1 is probably a fair comparison. I only do about 5-6 intubations per month, I wouldn’t expect to be as good as anyone from the anesthesia team. When I trained we did not have VL until 3rd year.

So there is no anesthesiologist for a 300+ bed hospital? Or they take home call and just let the CRNA manage OB?

No fiberoptics scope is terrible for a hospital that size. I have done a couple dozen over the years in the ER. Much rather be called before the descent into the rabbit hole than after.

 

[Arch Guillotti]

I lose my stethoscope about 4x per week but it has my name on it and always eventually finds me again. If I had some kind of fancy bluetooth ultrasound on Monday, it'd be on eBay by Tuesday.

WRT speed - I don't mind making people wait. If I unexpectedly want to add an a-line during a case, I ask the circ RN or an anesthesia tech to go get me an ultrasound machine. Anesthesiologists ought to stop acting like we're inconveniencing other staff by getting equipment we want or need to do procedures.

I would feel foolish making people wait if I was blundering around like a 65 million year old reptilian fossil who didn't want ultrasound, and it took me more than one stick to get a line in. That's a bad look.


Totally agree.

I agree with asking folks to get stuff but most of the time it is quicker if I just get it myself.

 

[gcc322]

Was there this amount of pushback whenever U/S became standard of care for central line placement? Honest question…

 

[chessknt]

79% of the time without major complications, apparently!

I mean is there a comparable study of anesthesiologists intubating the same population with better outcomes? I imagine not because these airways are emergent, you don't have time to page someone who may not be available. I wouldnt fixate on this statistic because of the population being studied here...

 

[aneftp]

Let's be honest. Defaulting to VL for all intubations and refusing to provide anesthesia without a VL in the building is weaksauce.

Do you refuse to place IV's without ultrasound in the building as well?

Do you do regional blocks without ultrasound?

Do you do central lines without ultrasound?

It’s become the standard (especially for Medicare compliance with central lines to use ultrasound)

The old timers at my place think you are weak if you using ultrasound for your central lines or a line. Had a gsw. One anesthesiologist was trying to put in use ultrasound for central line. The older timer slapped chordis subclavian (dirty line but at that point no one care with patient arresting). Old timer slapped on in in 30 seconds without ultrasound.

 

[vector2]

I mean is there a comparable study of anesthesiologists intubating the same population with better outcomes? I imagine not because these airways are emergent, you don't have time to page someone who may not be available. I wouldnt fixate on this statistic because of the population being studied here...

I don't know if any study particularly answers that question, although there are plenty of studies in multiple intubating specialties that show that success rate goes up and complication rate goes down with increasing experience.

Additionally, my anecdotal experience working at one of the busiest level I trauma centers in the country is that anesthesiologists are significantly better than EM and CCM at managing challenging emergent airways, not just from the procedural side but also from the pharmacologic side wrt induction doses and use of push dose pressors.

 

[Arch Guillotti]

Additionally, my anecdotal experience working at one of the busiest level I trauma centers in the country is that anesthesiologists are significantly better than EM and CCM at managing challenging emergent airways, not just from the procedural side but also from the pharmacologic side wrt induction doses and use of push dose pressors.

100% agree. I have been bashed before for going in the EM forum and commenting before on their airway skills.

I have never called an EM physician for help but the opposite is not true. Generally they do a good all things considered.

 

[chessknt]

I don't know if any study particularly answers that question, although there are plenty of studies in multiple intubating specialties that show that success rate goes up and complication rate goes down with increasing experience.

Additionally, my anecdotal experience working at one of the busiest level I trauma centers in the country is that anesthesiologists are significantly better than EM and CCM at managing challenging emergent airways, not just from the procedural side but also from the pharmacologic side wrt induction doses and use of push dose pressors.

Sure that makes sense--but the fixation on the complication rate in this study on emergent airways compared to a controlled situation (ie the OR) where only anesthesia intubates isn't fair. I am sure we would have better results for everything if the most qualified specialist was always available for that particular problem/procedure but the reality is that the system cannot operate at that level in the vast majority of the country.

 

[vector2]

Sure that makes sense--but the fixation on the complication rate in this study on emergent airways compared to a controlled situation (ie the OR) where only anesthesia intubates isn't fair. I am sure we would have better results for everything if the most qualified specialist was always available for that particular problem/procedure but the reality is that the system cannot operate at that level in the vast majority of the country.

That's not the rate I'm comparing. I'm pretty confident in all situations in all locations that the anesthesiologist airway complication rate would be lower. Obviously it's not realistic for anesthesiologists to do every airway in every part of the hospital, but we should at least put to rest the nonsense idea that some people hold that EM or CCM physicians have a similar apples to apples airway complication rate as anesthesiologists.

This is a series of >3000 emergent non-operative intubations where the first responder was a resident with at least 24 months of anesthesia training. The overall airway complication rate was 4%. Difficult intubation rate was 10%. Esophageal intubation rate was 2.8%.

3,423 Emergency Tracheal Intubations at a University Hospital: Airway Outcomes and Complications

Background. There are limited outcome data regarding emergent nonoperative intubation. The current study was undertaken with a large observational dataset to evaluate the incidence of difficult intubation and complication rates and to determine predictors of complications in this...

pubs.asahq.org

By comparison, in the study from the OP the first pass success rate with VL was 85% and the first pass success with DL was 70%.

 

[nimbus]

Was there this amount of pushback whenever U/S became standard of care for central line placement? Honest question…

Yeah there was. Weak sauce and all that.

 

[woopedazz]

Got a few cardiac colleagues who still do seeker-needle CVCs with no US. Makes me uncomfortable, but they swear by it.

 

[Radetzky]

This study answers only one question- what is safer when an inexperienced person with terrible FPS with either method is intubating in ED/ICU.

I would argue FPS matters in these situations even if the signal wasn’t borne out in the study.

They are 2 different tools. VL wouldn’t have helped me when I turned up to an arrested patient on the medical floor with only the tools in my airway roll. DL wouldn’t have helped me that difficult anterior airway.

 

[T-burglar]

They hit the carotid multiple times per year guaranteed

 

[CoolDoc1729]

So there is no anesthesiologist for a 300+ bed hospital? Or they take home call and just let the CRNA manage OB?

No fiberoptics scope is terrible for a hospital that size. I have done a couple dozen over the years in the ER. Much rather be called before the descent into the rabbit hole than after.

I have not seen an anesthesiologist at night and when I have called the crna answers the phone and comes alone with all their stuff. 4-5x over the last 8 years, it doesn’t come up often. When we have traumas(not a trauma center, but they get dumped off by friends or whatever ) the crna responds, alone. So I don’t think there is an attg at night, but maybe there is and the crna only calls if they have trouble?

Occasionally I am asked by nursing sup to intubate inpatients because the crna is busy. Another reason I assume there’s no attg in house. (They then balk at bringing them to the ER, but a few times have brought them just for intubation then transported back upstairs. My ER is way too busy for me to go up to the floors. )

 

[pgg]

I mean is there a comparable study of anesthesiologists intubating the same population with better outcomes? I imagine not because these airways are emergent, you don't have time to page someone who may not be available. I wouldnt fixate on this statistic because of the population being studied here...

I think the population argument is a gigantic red herring. It is a very real phenomenon of ER and ICU docs encountering peri-induction arrests and hypotension that we very, very rarely see when we do them. And when you look at their preparation, drug choices/doses, post-intubation sedation plan, and the controlled/uncontrolled chaos of their world, you think OF COURSE that patient coded.

The explanation of "it was an emergency" or "the patient was really sick" - I don't really mean to beat up on them, but I think many of their peri-induction issues are avoidable. I mean, if you saw a resident skip preoxygenation or do halfway job of it, not have suction available, dose drugs by the syringe, not give vasopressors or give them in the third person by directing a nurse to hopefully start an infusion once pharmacy gets around to sending a bag, and have no real plan for post-intubation sedation, you'd take that resident aside and have a chat when the CPR was over.

My basic argument this thread is that we shouldn't take these annual articles comparing VL and DL seriously, because the people being studied aren't us, and do things we don't do.

 

[pgg]

The old timers at my place think you are weak if you using ultrasound for your central lines or a line. Had a gsw. One anesthesiologist was trying to put in use ultrasound for central line. The older timer slapped chordis subclavian (dirty line but at that point no one care with patient arresting). Old timer slapped on in in 30 seconds without ultrasound.

Ugh

I feel like everyone here and you know better, but I'll state the should-be-obvious anyway: the fact that someone can (most of the time) slam in a central line in 30 seconds doesn't mean either

A) that they can do it successfully every time

or

B) that they can do it with no morbidity every time

Because someone routinely gets away with something isn't a defense of the technique.

It is not (NOT!) a defense of outdated but "fast" techniques to say that sometimes in an emergency it's better to go faster with more risk. And in the occasional case when they don't hit it immediately, they end up being slower than if they'd just picked up the ultrasound in the first place.

You're not new to this and neither am I; we've both seen these old school guys quickly get lines. You and I did it too, before ultrasound was everywhere. We've also seen them miss, or tag the carotid, or take longer than they would've if they'd simply taken 60 seconds more to pick up an ultrasound probe.

I think we should stop admiring the dinosaurs who refuse to use new, proven, unquestionably superior techniques, because MOST of the time they're slick and quick with the old way. They're not great. They're just old in the outdated sense, not the wise sense.

You know how many times I've punctured a carotid in the last 5 years? Zero.

You know how many times that old timer has punctured a carotid in the last 5 years? Neither does he ... but it isn't zero.

 

[anaesthetic]

You know how many times I've punctured a carotid in the last 5 years? Zero.

You know how many times that old timer has punctured a carotid in the last 5 years? Neither does he ... but it isn't zero.

I have a zero puncture rate as well.

My partners who still do anatomic lines: non-zero. According to our anesthesia techs who watch them do lines, it’s at least once or twice every few weeks.

We had a carotid dilation for an elective CABG a couple of years ago, and a through-and-through carotid puncture recently (detected via US prior to dilation). These complications are mostly preventable, IMO.

 

[Katheudontas parateroumen]

Background, I am a MICU attending that supervises residents and fellows of all years in IM, EM and micu; I’m also anesthesia attending supervises CRNA/SRNAs. Did not read the study but gathered probably everything I need to know from this discussion; also that every one of these studies usually say the same thing: first pass success increased. I also personally think it is a no brainer that VL gives a superior view. This is especially true in these “emergent” situations where positioning the patient and of yourself is not ideal. That is the power of VL, that I do not need very good snifffing positions for a good view. Therefore, especially when teaching non-anesthesia residents, VL is the default in out of OR situations. VL has vastly lower learning curve. An airway that would almost be impossible for an intern looks “easy” with VL. Even then, there is certainly still a learning curve and skill involved.

A point I kind of want to see where you all think is, do you feel all VL equipment are essentially equal? McGrath vs glide vs cmac? I tend to say no. This has to do with the curvature of the blade. To me, the superior VL is the glide or cmac Dblade hyperangulated. The reason I think this is this truly gives one an advantage of seeing past “the second curve”, especially in anterior airways. The normal Cmac, McGrath are just Mac blades. I don’t think that my view vastly would improve if I DL with a MAC vs those because they give the same curve and thus view. Certainly these can be used as learning tools for DL.

Another great point as some of you have mentioned, VL needs much less lifting therefore much less stimulation. I don’t have any data but definitely anecdotally this makes a significant difference.

Also another point, what in my option as is shared across this board is the pre induction, actual induction, post induction care is almost or even more important than the actual airway itself. These are specifically trained in anesthesia.

 

[vector2]

VL technique is similar to DL, but it is distinct enough that bad VL technique can create a view worse than average DL technique. One of my greatest pet peeves is when trainees just hub the VL blade into the mouth without a good scissor/opening of the mouth, or when they smush the tongue and bring it along for the ride instead of avoiding it and following the hard palate, or when they scoop the epiglottis and make the airway more anterior instead of engaging the vallecula correctly.

And an important corollary to this is that VL technique varies significantly not only between VL devices, but also between subtypes of blades within each particular VL device.

However, with regard to normal curvature VL like regular CMAC and McGrath, I do find that my grade of view is still better with McGrath despite the geometry being the mostly the same. That's simply due to the fact that the camera is positioned at the nadir of the blade and is pointing a bit anteriorly. But with a very anterior airway you're right. One needs a hyperangulated blade (McGrath X, D-blade, glide lo pro, etc).

 

[BLADEMDA]

 

[BLADEMDA]

Anyone using the McGrath X blade routinely? Any tips or comments about the X blade vs the standard McGrath blade in terms of ett placement? Does it help to use the hyperangulated stylet from the glidescope?

mcgrath x blade - Google Search

www.google.com

Let's assume the Mcgrath Mac 3 blade resulted in a poor glottic view, what's the likelihood the X blade improves the view enough to intubate the patient?

 

[vector2]

Anyone using the McGrath X blade routinely? Any tips or comments about the X blade vs the standard McGrath blade in terms of ett placement? Does it help to use the hyperangulated stylet from the glidescope?

Use X blade frequently along with standard mcgrath, but only when I suspect very anterior airway or pt is in C-collar/limited mouth opening etc. The blade is a bit more narrow and slippery which can pose some issues with the tongue draping on both sides of it / sliding around, but the view is comparable to hyper angulated glide or a d-blade.

I def recommend using hyperangulated glide scope (or other rigid) stylet with the X. Alternatively can just bend your stylet to match the curve but this is suboptimal imo

 

[BLADEMDA]

GlideScope Spectrum Single-use Blades | Verathon

GlideScope offers the widest range of single-use video laryngoscopes with the latest advancements in lighting and camera tech

www.verathon.com

Anyone use the Low Profile VL Miller blade? How would a VL Miller blade compare to the Glidescope hyperangulated blade?

 

[Maz777]

Not surprising. I DL 99% of patients in the OR. For ED/ICU intubations, I tend to VL if time allows (since conditions/positioning is usually suboptimal). DL if it's a code and they are pounding on the chest. I'd use a McGrath in those situations if we had them (we don't).

Nothing beats an older (and compact) Glidescope with titanium reusable blade. The plastic (and bulkier) disposable ones for Glides and CMACs are garbage. They usually take up too much space in the oropharynx/hypopharync and frequently make intubating more difficult. If that it all that is available, I will just DL. Luckily, we have the compact titanium Glides around in most places.

 

[aneftp]

Not surprising. I DL 99% of patients in the OR. For ED/ICU intubations, I tend to VL if time allows (since conditions/positioning is usually suboptimal). DL if it's a code and they are pounding on the chest. I'd use a McGrath in those situations if we had them (we don't).

Nothing beats an older (and compact) Glidescope with titanium reusable blade. The plastic (and bulkier) disposable ones for Glides and CMACs are garbage. They usually take up too much space in the oropharynx/hypopharync and frequently make intubating more difficult. If that it all that is available, I will just DL. Luckily, we have the compact titanium Glides around in most places.

View attachment 373234

With Covid everything going towards disposable. Even fiber optic scopes. One of my colleagues used disposable fiber optic scope for difficult intubation last week as a defacto bougie with a camera. And cut it after it entered through the vocal cords. That’s a new technique I may have to try one day. Disposable. So don’t need to worry about the reusable fiber optic scope being cut and ruined.

The lo profile glidescope disposable are 8mm thinner than the regular sleeves I believe.

 

[vector2]

. One of my colleagues used disposable fiber optic scope for difficult intubation last week as a defacto bougie with a camera. And cut it after it entered through the vocal cords. That’s a new technique I may have to try one day.

That's a new one. I'm gonna have to grab some shears and cut one next time I'm about to throw one away just to see what it's like.

Do you know if it was an ambu scope?

 

[norski]

That's a new one. I'm gonna have to grab some shears and cut one next time I'm about to throw one away just to see what it's like.

Do you know if it was an ambu scope?

View attachment 373239

I did that once with an ambu. Suspected difficult intubation, we just got the ambus and my doc had one opened anyway. DL got a grade 3. Preloaded the tube, then just angled the tip through the cords. Fun exercise to hold the rather crappy view and steer the ambu at the same time. Expensive exercise, though. Something like $400 a pop?

 

[aneftp]

That's a new one. I'm gonna have to grab some shears and cut one next time I'm about to throw one away just to see what it's like.

Do you know if it was an ambu scope?

View attachment 373239

Yes same one. Use the smaller size scope.

 

[periopdoc]

The two places i do locums have a McGrath in every OR. Now that I'm President here, we will have one in every OR as well. $1,200 bucks times every OR is still vastly cheaper than the cost of one truly, irrevocably lost airway.

I started using them exclusively in heart, heads, and in anything else where I want minimal stimulation. If you watch your a-line when you DL vs VL, you'll see what I mean. Not nearly as stimulating as the prep, though.

I've slowly started doing the majority of my airways with the McGrath. It is less stimulating and so there is less post-induction hypotension.

I still do all my alines blind first, but have the ultrasound in the room. If I don't get it within 5 min/ first stick, I'll switch.

I do like to practice subclavians so that I have a blind technique for central lines.

Otherwise it's all U/S guided.

 

[Ronin786]

That's a new one. I'm gonna have to grab some shears and cut one next time I'm about to throw one away just to see what it's like.

Do you know if it was an ambu scope?

View attachment 373239

Definitely cut one open. I've never used it as a bougie but if you cut it you'll realize it's nothing more than a suction port and a 30G wire going to a camera at the tip.

 

[IMGASMD]

That’s a funny way of spelling Miller 2

The most anesthesia joke.

 

[ToKingdomCome]

I’m anesthesia CCM. Let’s be honest video is easier to intubate. Should you be able to DL as an anesthesiologist ? 100%, yes. The study also shows how bad EM and non anesthesia CCM are at intubating. I witness this first hand that myself and the other anesthesia CCM people run absolute laps around the non anesthesia CCM people in terms of intubation and management of the peri intubation phase. It’s kinda scary how bad some are.

 

[drmwvr]

My partners who still do anatomic lines: non-zero. According to our anesthesia techs who watch them do lines, it’s at least once or twice every few weeks.

gonna have to guess your techs have no idea what they're looking at. If they do, y'all have a big problem...

 

[drmwvr]

One of my colleagues used disposable fiber optic scope for difficult intubation last week as a defacto bougie with a camera. And cut it after it entered through the vocal cords.

What? Why? Why not just load a tube and drive it like you would a conventional FOB? You lose sight of the target, f around with trauma shears and loading a tube, risk dislodging the scope and risk the off chance of FB debris from cutting the disposable scope...that's just dumb...

 

[anaesthetic]

gonna have to guess your techs have no idea what they're looking at. If they do, y'all have a big problem...

These techs have been around for decades before ultrasound was ubiquitous. They know what they’re looking at.

Does a falling tree make a sound if there’s nobody around to hear it? Does a carotid get poked if there’s no ultrasound around?

 

[FiO2@21]

There was a neat study I read a year or two ago. 200 patients had a first intubation in the OR and a 2nd intubation in the ICU. Exclusively anesthesiology residents or attendings. They had roughly 1 grade view worse in the unit.

I personally DL in the OR, VL in the unit. If it looks like a traditionally easy one with the ability to reasonable position I'll use a Mac 3/4 shaped glide and DL with it with the screen as backup. If not I use the LoPro.

 

[Simba1711]

I just vl in the unit when I get called for stat airways. Less headache for me. Usually patient is full stomach , I don’t have a thorough history , non optimal positioning , I don’t have time to fully preoxygenate them , I’m around staff I’ve never worked with and may not know where to grab stuff , etc.

 

[ProwlerturnGas]

I am at a job now that no one (nurses, techs, etc) have seen a McGrath. I have my own that I purchased for military deployments if I needed a reliable VL. The comments I get! Wonder why no one else uses them, never have an airway problem.

 

[ToKingdomCome]

I am at a job now that no one (nurses, techs, etc) have seen a McGrath. I have my own that I purchased for military deployments if I needed a reliable VL. The comments I get! Wonder why no one else uses them, never have an airway problem.

How much did you pay for one and what’s the upkeep cost of having your own mcgrath

 

[ProwlerturnGas]

How much did you pay for one and what’s the upkeep cost of having your own mcgrath

I paid $1800. Seller off ebay (now wondering where it came from having read the threads above!). Came with a bunch of 3 and 4 blades. The only upkeep so far is replacement batteries. One battery lasts about 3 months or so. I’m in a busy practice and the McGrath is pretty much all I use. The battery is about 40$ apiece if I remember correctly.

 

[okayplayer]

I paid $1800. Seller off ebay (now wondering where it came from having read the threads above!). Came with a bunch of 3 and 4 blades. The only upkeep so far is replacement batteries. One battery lasts about 3 months or so. I’m in a busy practice and the McGrath is pretty much all I use. The battery is about 40$ apiece if I remember correctly.

How do you clean the blades or are they disposable (sorry, don’t use McGrath often)?

 

[ProwlerturnGas]

How do you clean the blades or are they disposable (sorry, don’t use McGrath often)?

One use per person unfortunately. I have the hospital buying the blades now

 

[aneftp]

it’s $1250 direct from Medtronic (coviden) manufacturer website. Just mention you are medical provider for your own personal use. My friend just got one direct. Extra battery is maybe $60 extra. Extra sleeve disposal blades something like $10-15 each cheaper if you buy in bulk

 

[ProwlerturnGas]

it’s $1250 direct from Medtronic (coviden) manufacturer website. Just mention you are medical provider for your own personal use. My friend just got one direct. Extra battery is maybe $60 extra. Extra sleeve disposal blades something like $10-15 each cheaper if you buy in bulk

Cheaper now. I bought my McGrath in 2019

 

[anbuitachi]

Every anesthesiologist is given a mcgrath in my department. the ORs are filled with mcgrath disposable blades.
Its maybe believed that disposing plastic blades is better than disposing entire DL blades. Our DL blades are not cleanable. They go straight to the trash after each use.

 

[anbuitachi]

I rarely use a stylet with the mcgrath. Maybe like once in every 100

do you curve it?

Well that's the problem, right? If VL is the #1 goto because it's "better" for patients as you claim, then ...

Experienced anesthesiologists can't "maintain" skills that are never used.

Inexperienced anesthesiologists can't acquire skills that are never used.



More than zero. And zero is how many you should be doing, if you really actually believe that VL is the superior method for patients.

Or are you going to start including on your consent something like "I'm going to use a method I believe to be inferior to secure your airway, because I haven't done it for a while, and I want to knock the rust off, is that OK with you?"


Or maybe we could just admit that there's absolutely nothing wrong with DL for the vast, vast majority of patients we intubate.

And maybe we can acknowledge that VL isn't always easier than DL for securing some airways.

If you want to insist that your CRNAs use VL, that's a different issue. Their DL skill maintenance isn't your problem, and you're always standing right there ready to take over and get the airway if there's a problem. Maybe with DL.




I think that's wrong and ridiculous. I learned without ultrasound, and I use it now 100% of the time. I never, ever do an arterial line without it. I don't like to throw shade with the term dinosaur very often, but people who don't use ultrasound for arterial lines are dinosaurs.



Well, yeah, duh. Of course it is.

Another benefit of ultrasound for arterial lines is that after looking with the ultrasound, you might not even attempt that location at all. It is not unusual at all for me to look at some crusty old vasculopath's radial artery with ultrasound, see how small, calcified, tortuous, or thrombosed that thing is, and go look at the other side, or go straight to a brachial. You "old school" a-line starters would stab away for a couple of attempts before changing plans.



I think you should listen to yourself here, and leave your ego out of the equation and focus on the patient. It is quite clear ultrasound guided a-lines are superior to "old school" a-lines in terms of safety, smoothness and first pass success.


Also -

That is not clear at all. The whole point of this thread is how dumb this article is for its "better first pass success" endpoint, and it doesn't even claim superior safety. In fact, it found equivalent safety (~21% serious complications in both groups).

another benefit of using ultrasound with arterial line is its far easier to thread off the needle and not having to go thru and thru, thus making one hole in the artery instead of 2

 

[Simba1711]

We have extra McGrath’s in the workroom and we are each supplied with our personal McGrath. Problem is that people walk out with McGrath’s so we only have one extra McGrath in the workroom now. 1250 is not bad for McGrath. Do you guys use rigid stylet or malleable stylet for the xblades ?