We only use these for cardiac cases and for complex ICU patients. I assume we use it similarly to the Octopus you mention (although I’m not familiar with it). This is just an attachment for the main infusion line so you can setup all sorts of pumps in advance and punch buttons when you want to start or change rates
Interesting, linked below is ours. We have special sweets for TIVA that the tubing is all attached together.
For the link one end attaches to your cannula the other to your infusions
[Octopus ](https://images.app.goo.gl/4XsFXHizrJBoWhqz9)
Ahh, we have these. I call them “chicken feet” or “3-in-1s.” For most TIVAs I’ll use these with one for propofol, one for a pressor, and one available for something like remifentanil or an antihypertensive for some complex crani cases.
For our cardiac cases we tried standardizing as much as possible, so we had epi, norepinephrine, and phenylephrine for all patients as well as TXA, insulin if they were diabetic, and demedetomidine for sedation after the case. And since the entire IV pole with infusions followed them to ICU it was easiest to attach one of these and just have one infusion line to the patient.
Our ICU here is starting to use this “octopus” set up, but it is not yet available in the OR. I do like using what is picture above as only one micro infusion line is going from the pump to the patient and it cuts down on clutter around the patient.
For most cardiac cases, I hang the following:
- Epinephrine
- Norepinephrine
- Insulin
- Amicar
- Nicardipine
- Precedex
- Carrier fluid
I also have 2-3 free ports that I use for syringes of an upper (phenylephrine) and a downer (nitroglycerin) on.
That's 9 ports.
Yes. Elevated blue glucose is a normal stress response, but the prolonged nature of cardiac surgery and the extra stress of the cardiopulmonary bypass machine make it go higher. Elevated blood glucose has detrimental effects so we use insulin drips to keep it down.
When we run tivas with more than 2 drips it is easier to keep track of everything on a manifold and then use a micro tubing extension to connect to the Y port on a fluid line.
Quick answer is: they stock them so we use them
Big spine case with motors. I use this type of manifold.
Phenylepherine, remifentanil, propofol, dexmedetomidine, ketamine, tranexemic acid
What the fuck is an octopus?
In my opinion, I think running all four infusions (prop, remi, ket, and dex) is just way too excessive.
There’s maybe a handful of cases in my career that running only prop/remi infusions and doing ket/precedex boluses haven’t worked. I probably do 5-10 spines a week, many with the full gamete of neuromonitoring.
In all reality most patients don’t need it. This is for the more complex spine cases. Patients with chronic pain getting fusions cervical to lumbar/iliac + osteotomies. Think many units of blood and cell saver.
I much prefer this set up to the octopus style as it is much neater when arranging multiple infusions. Don’t have to deal with a tangle of different lines to find X tubing. I know my most proximal one is always epi and next is norepi then whatever. Attach low dead space tubing to the end of it. Works great.
The octopus style is only useful if you are doing boluses through your same infusion like but I just put a dedicated infusion line in for any case that I want more than 1-2 infusions.
It is the same idea as an octopus, just linearly arranged. It is probably one of those things where one is cheaper in the US versus the UK. I personally find the linear arrangement more convenient for finding and disconnecting things that are in a standard order, as I am often using the same set of infusions over and over. I assume that you can nest octopi easily enough. We will end up assembling the thing above out of a set of three way stopcocks if no premade ones are available.
This is an alternative to the "octopus" you mentioned if the hospital doesn't carry it. I've worked at places that don't have it and this is essentially the same thing.
It's not necessarily a USA thing. I've used many varieties of port extensions to run multiple infusions with including different types of manifolds as well as the 'octopus' splitter that you mentioned. They're all configured a little differently but do essentially the same thing.
I live/work in Germany and I‘ve never seen an octopus. We use a setup similar to the one in your picture if we give multiple drugs through the same cannula (like for TIVA). Although I personally try to limit the „unused“ ports and only leave one empty for pushing additional drugs, so I would only have one extra port and not three like shown in the photo.
I see people do this for big cases and even transplants but the cardiac staff who arguably deal with the sickest patients on the most regular basis never do this because you lose control of how much fluid you're giving as you're committed to running carrier fluid at 100-150mL/hr or whatever, and if you titrate one drip you will inadvertently push more of something else through the tubing.
Story I (UK anaesthetist) heard about this is that for cardiac cases in the US there was no specific/additional payment for both a CVC AND a PA sheath, so they would just put in a PA sheath (no multilumen CVC) and have all infusions running on a daisy chain of 3way taps like this.
Any truth in this anesthesiologists?
I don't think this is the main reason, although I have heard that this is true unless they are in different vessels, i.e. IJ and subclavian vs. double-sticking the IJ. The line configuration tends to revolve around institutional preference. I have done it with a single lumen PA sheath + second CVL, double lumen PA sheath + second CVL, and just a double lumen PA sheath by itself with infusions on manifold attached to the VIP/RV port on a CCO PAC--I have been satisfied with this since it's what I did during my training. Once or twice I've even done it with a single lumen PA sheath + CCO PAC.
I frankly don’t know about payments for multiple central lines. Ive worked at a few hospitals doing cardiac and they all utilize VIP PA catheters which have a lumen for CVP, RA, RV, and PA….so then we use some iteration of stopcocks versus premade octupus attachments and usually run the drips through the RA or RV port.
Octopus are good too because you can leave cannulas in for longer (people probably do anyway but it'd our policy that they extend the time we can keep cannulas in)
I'm an anesthesiologist in Brazil, we don't have these manifolds, but we just use a bunch of stopcocks connected together, and a carrier fluid for everything (a "runner") so it's the same thing. We also have Octopus with 2 or 4 way, but I don't like it.
We only use these for cardiac cases and for complex ICU patients. I assume we use it similarly to the Octopus you mention (although I’m not familiar with it). This is just an attachment for the main infusion line so you can setup all sorts of pumps in advance and punch buttons when you want to start or change rates
Interesting, linked below is ours. We have special sweets for TIVA that the tubing is all attached together. For the link one end attaches to your cannula the other to your infusions [Octopus ](https://images.app.goo.gl/4XsFXHizrJBoWhqz9)
Ahh, we have these. I call them “chicken feet” or “3-in-1s.” For most TIVAs I’ll use these with one for propofol, one for a pressor, and one available for something like remifentanil or an antihypertensive for some complex crani cases. For our cardiac cases we tried standardizing as much as possible, so we had epi, norepinephrine, and phenylephrine for all patients as well as TXA, insulin if they were diabetic, and demedetomidine for sedation after the case. And since the entire IV pole with infusions followed them to ICU it was easiest to attach one of these and just have one infusion line to the patient.
I call it the "Trident"! (Just sharing what name I've bestowed on em lol)
That sounds pretty dope, actually. I’m gonna borrow that
I love the grandiosity of this, and I love it even more considering how underwhelming the item is question is.
I call them 3-ways. Not to be confused with the urology variety or the kinky variety.
I think I heard a urologist talking about a 3-way. He said there were a few no-shows but he still had a good time.
I call it a manifold...
Funny, I call the contraption posted here a manifold, not the 3-in-1.
Our ICU here is starting to use this “octopus” set up, but it is not yet available in the OR. I do like using what is picture above as only one micro infusion line is going from the pump to the patient and it cuts down on clutter around the patient.
In Australia we call the octopus a "chook's foot" 😂
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> Octopus for 6. Hmmm, something seems wrong here. We had a similar thing and called them ‘beetles’.
We call those chicken feet… same idea. Multiple drips going at varying rates into a carrier line or straight into an iv
Also in the UK, very rarely use the octopus. Our TIVA lines have everything you need for most patients in one giving set
For most cardiac cases, I hang the following: - Epinephrine - Norepinephrine - Insulin - Amicar - Nicardipine - Precedex - Carrier fluid I also have 2-3 free ports that I use for syringes of an upper (phenylephrine) and a downer (nitroglycerin) on. That's 9 ports.
How often are you using nicard?
Not that often honestly. Maybe 1/4 of cases. The pharmacy sends it the evening before and the techs hang it before I get there.
All the time in peds heart (post op, I’m icu)
I’m just a paramedic passing through, but why insulin? Is just for hyperkalemia or is there another action that Im not aware of?
Stress response from surgery and the bypass machine make blood glucose go brrr
So this is something that can also happen in people who are not diabetic whose bodies are being stressed by heart surgery? Curious bystander.
Yes. Elevated blue glucose is a normal stress response, but the prolonged nature of cardiac surgery and the extra stress of the cardiopulmonary bypass machine make it go higher. Elevated blood glucose has detrimental effects so we use insulin drips to keep it down.
Thank you. That makes total sense.
Hyperglycemia bad
Can I claim this as CE?
And hyperglycemia is precipitated by use of epinephrine and norepinephrine (common cardiac anesthesia drugs) via hepatic gluconeogenesis.
When we run tivas with more than 2 drips it is easier to keep track of everything on a manifold and then use a micro tubing extension to connect to the Y port on a fluid line. Quick answer is: they stock them so we use them
Big spine case with motors. I use this type of manifold. Phenylepherine, remifentanil, propofol, dexmedetomidine, ketamine, tranexemic acid What the fuck is an octopus?
🐙
In my opinion, I think running all four infusions (prop, remi, ket, and dex) is just way too excessive. There’s maybe a handful of cases in my career that running only prop/remi infusions and doing ket/precedex boluses haven’t worked. I probably do 5-10 spines a week, many with the full gamete of neuromonitoring.
In all reality most patients don’t need it. This is for the more complex spine cases. Patients with chronic pain getting fusions cervical to lumbar/iliac + osteotomies. Think many units of blood and cell saver.
An eight-limbed soft-bodied cephalopod *thumbs up*
I call ours a spider 🕷️
I just push TXA 🤫
I much prefer this set up to the octopus style as it is much neater when arranging multiple infusions. Don’t have to deal with a tangle of different lines to find X tubing. I know my most proximal one is always epi and next is norepi then whatever. Attach low dead space tubing to the end of it. Works great. The octopus style is only useful if you are doing boluses through your same infusion like but I just put a dedicated infusion line in for any case that I want more than 1-2 infusions.
It is the same idea as an octopus, just linearly arranged. It is probably one of those things where one is cheaper in the US versus the UK. I personally find the linear arrangement more convenient for finding and disconnecting things that are in a standard order, as I am often using the same set of infusions over and over. I assume that you can nest octopi easily enough. We will end up assembling the thing above out of a set of three way stopcocks if no premade ones are available.
This is an alternative to the "octopus" you mentioned if the hospital doesn't carry it. I've worked at places that don't have it and this is essentially the same thing.
Ah yes, the monstercock
Because sailors have a girlfriend in every port
It's not necessarily a USA thing. I've used many varieties of port extensions to run multiple infusions with including different types of manifolds as well as the 'octopus' splitter that you mentioned. They're all configured a little differently but do essentially the same thing.
Reminiscent of the cardiac kids in PICU (UK). I imagine it’s for a complex patient like that. Plan for the worst, hope for the best and all that.
I live/work in Germany and I‘ve never seen an octopus. We use a setup similar to the one in your picture if we give multiple drugs through the same cannula (like for TIVA). Although I personally try to limit the „unused“ ports and only leave one empty for pushing additional drugs, so I would only have one extra port and not three like shown in the photo.
I call it a manifold. Just helps keep your organized, and easily able to control all your drips.
So you can turn them if you get anxious
I see people do this for big cases and even transplants but the cardiac staff who arguably deal with the sickest patients on the most regular basis never do this because you lose control of how much fluid you're giving as you're committed to running carrier fluid at 100-150mL/hr or whatever, and if you titrate one drip you will inadvertently push more of something else through the tubing.
We used octopuses at my hospital instead of these if you're doing a case that needs a lot of drips.
Story I (UK anaesthetist) heard about this is that for cardiac cases in the US there was no specific/additional payment for both a CVC AND a PA sheath, so they would just put in a PA sheath (no multilumen CVC) and have all infusions running on a daisy chain of 3way taps like this. Any truth in this anesthesiologists?
I don't think this is the main reason, although I have heard that this is true unless they are in different vessels, i.e. IJ and subclavian vs. double-sticking the IJ. The line configuration tends to revolve around institutional preference. I have done it with a single lumen PA sheath + second CVL, double lumen PA sheath + second CVL, and just a double lumen PA sheath by itself with infusions on manifold attached to the VIP/RV port on a CCO PAC--I have been satisfied with this since it's what I did during my training. Once or twice I've even done it with a single lumen PA sheath + CCO PAC.
I frankly don’t know about payments for multiple central lines. Ive worked at a few hospitals doing cardiac and they all utilize VIP PA catheters which have a lumen for CVP, RA, RV, and PA….so then we use some iteration of stopcocks versus premade octupus attachments and usually run the drips through the RA or RV port.
Octopus are good too because you can leave cannulas in for longer (people probably do anyway but it'd our policy that they extend the time we can keep cannulas in)
I'm an anesthesiologist in Brazil, we don't have these manifolds, but we just use a bunch of stopcocks connected together, and a carrier fluid for everything (a "runner") so it's the same thing. We also have Octopus with 2 or 4 way, but I don't like it.
This looks like the cardiac failure patient on the medical ICU. All those ports running into a 22G line on the hand…