Course Description
The purpose of this one-day weekend virtual CME course is to offer attendees a comprehensive understanding of dialysis access creation and maintenance. The course has been designed to be a multi-disciplinary course, with involvement of Interventional Radiologists, Nephrologists, Vascular Surgeons, and nurses involved in dialysis access care. Our guest faculty are renowned experts in dialysis access management and will deliver several lectures and participate in complex case discussion. Audience participation is anticipated and encouraged.

Overall Course Objectives
Upon completion of this course, participants will be able to:

1. Discuss keys factors in choosing best access for dialysis
2. State at least three risks and benefits to each type of hemodialysis access
3. Review the approach (surgical and endovascular) and technique of creation of various dialysis access
4. Outline best practices to monitor immature and mature fistulas
5. Describe various challenges and techniques for management of a dysfunctional dialysis access
6. Cite three reasons why a multidisciplinary approach to hemodialysis management is important

Registration is now open! 

Residents, Fellows, And Students Virtual Angio Club

Hosted via Zoom, the meeting will take place on October 13, 2021 at 8:00 PM EST and include presentations and discussions from residents and fellows enrolled in a radiology program in Canada.

Who can attend: everyone interested in Interventional Radiology (medical students, residents, fellows, faculty members, etc.)

This event is offered at no cost for all CAIR members!

Limited space available.

Who can submit a case : residents and fellows enrolled in a radiology program across Canada and who are members in good standing with CAIR.

Case criteria: 

• Presentation must be targeted to an audience with little to moderate knowledge of IR
• Educational value of presentation will be favored over complexity/rarity of the case
• The recommended file type to be used for presentations is PowerPoint or Portable Document Format (PDF)

A draft presentation of no more than 8-10minutes should be submitted by September 26, 2021 via email at cairservice@cairweb.ca

Alberta Health Services says a woman considered dead for 30 minutes was brought back to life by doctors using a new device for what’s believed to have been the first time in Canada.

Brenda Crowell of Calgary developed blood clots shortly after contracting COVID-19 earlier this year. Her health deteriorated quickly and, at one point, medical staff spent 25 minutes performing CPR to keep her alive.

“Her blood pressure had bottomed out. It was extremely low. She went into a state of shock and collapse, and some of her organs were failing,” Dr. Jason Wong, an interventional radiologist at Foothills Medical Centre, said at a news conference Thursday. Read more via CBC…

CAIR Express – your Canadian Interventional Radiology newsletter at your fingertips. Feel free to pass it along to others in your network, and most importantly, enjoy the content that is developed with you in mind.

Dr. Tara Graham is the current Chief of Vascular and Interventional Radiology at Trillium Health Partners and Lecturer at the University of Toronto, Faculty of Medicine. She completed her Interventional Radiology training at University Health Network in Toronto in 2013 and has served on the CAIR board since 2014. Her practice includes Interventional Oncology, peripheral vascular disease and aortic interventions.  She is the CAIR’s Board President and the Scientific Director of the CAIR Annual Scientific Meeting.

CAIR – Dr. Graham, it has been a little over a month since you seized power as the new CAIR Board President, what excites you most about your new position?

TG – There is a lot to be excited about! I think we have all been impacted greatly by the pandemic, as physicians and individuals. It’s been exhausting but it has given some time for reflection that I think has been valuable. I see an opportunity to help bring a community back together in a way that can be stronger than pre-COVID, with more diverse avenues for education and IR advocacy.

CAIR – What opportunities do you see for Interventional Radiology in Canada?

TG – I see a great opportunity for the involvement of Canadian IRs in evidence based medicine (EBM), clinical trials and consensus guidelines. As a discipline we have a real challenge in increasing our EBM footprint compared to other specialties; these endeavors are hard and time consuming! I think we need to harness our international collective expertise and resources in order to make impactful contributions to the IR literature and practice. Canada has world-class IRs and it’s important that we continue to lead and contribute to our discipline in this way.

CAIR – What challenges do you see facing IR in Canada?

TG – It remains hard to explain to others what exactly we do as Interventional Radiologists. This includes patients, but also other physicians, our DI colleagues and hospital administrators. This is a barrier to IR access in Canada. Patients who would benefit from our care either don’t see us at all or are referred at too late a stage in their disease process. It also impacts our ability to receive resource funding at the local hospital level and ability to successfully achieve appropriate clinical time (ie. IR clinic rotations) from our DI groups.

CAIR – Are there any new upcoming CAIR projects that you can share with us?

TG – We have many exciting projects in the pipeline. The Virtual Learning Series and Virtual Angio Clubs have been very successful and we are continuing to develop content to deliver to our membership. I hope to bring these events beyond the pandemic with an in-person twist that will allow members and our industry partners to meet locally concurrent with national livestreams. CAIR is also increasing our footprint on social media platforms and in partnership with CIRSE, our very own Dr. Nevin de Korompay will take over the CIRSE Twitter account. Watch out for that one!

CAIR: For anyone reading who might be new to CAIR, how might they get involved with the organization?

TG – First step is become a CAIR member! We have a great partnership with CIRSE and our CAIR membership also comes with a CIRSE membership which is another great incentive to join. We also have many opportunities for volunteering within the organization, whether it is contributing content to CAIR express, becoming involved in our Scientific Committee for the Annual meeting, or engaging in opportunities for medical student and resident education. If you are looking to become involved, you can contact our Executive Assistant extra-ordinaire Siri Boulom at siri.boulom@cairweb.ca and she can help point you to the right direction!

CAIR – Last question, tentatively, when and where will the next in person CAIR meeting be held?  Follow-up question, have you considered Saskatoon?

TG – Great question! We are excited to announce that our very first CAIR meeting will be our Grand Slam and Catastrophes course in the beautiful Whistler BC (Feb 3-7 2022). It is a fantastic event and I encourage you all to sign up! To put on optimistic light on COVID, I think many members who have not been to this event had an opportunity to attend virtually this year. It’s even better in person, with great cases, colleagues, skiing and beer during cases for those who are interested 😊.

We also have the triumphant return of our annual meeting in Montreal May 22-29^th 2022! The Scientific Committee is getting ready to welcome everyone back with a stellar agenda and good times in one of our most popular host cities!

CAIR has never been to Saskatoon! We will be in Quebec City in 2023 but we should we add it to the candidate list for 2024? I hear it’s the Paris of the Prairies, is that true? If so, then we should definitely make it happen.

CAIR – It IS the Paris of the Prairies!  Thank you so much for taking the time to answer our questions, looking forward to all the upcoming programming and events!

When I first returned to Saskatoon after my IR fellowship, radiologists (primarily IRs though we now have some general radiologists doing them too) placed all PICCs. This was just the way it had always been.  Recently a technologist lead initiative for PICC placement at St. Paul’s Hospital in Saskatoon has resulted in a shift towards primarily tech inserted PICCs.  I wondered if there were perhaps some other sites across Canada thinking of transitioning to this model, so in the spirit of collaboration I decided to interview the techs involved. – Dr. Nicollette Sinclair

DISCLAIMER: Cole and Jacquie have been encouraged to use humour as much as possible given the excellent sense of humour of our reader(s).  When possible they will make fun of the interventional radiologists they work with, mostly implying that we are always busy doing non-work related things. This may or may not be true.

NS:  Give the reader(s) a brief introduction about who you are and what you do.

CF: My name is Cole Frandsen and I have been working as an IR Technologist at St. Paul’s Hospital in Saskatoon since 2011 upon completion of the Sask Polytech program. I am currently working on completing my Bachelor of Health Sciences degree through Thompson Rivers University. When not at the hospital I enjoy being out and travelling as much as possible; cycling, golf, skiing and being out with friends typically occupy the rest of my time.

JT: My name is Jacquie Turley, I’ve been working at SPH since completing the Sask Polytech program in 2012, working as a general tech while completing my undergrad at the University of Saskatchewan until 2015. Shortly after, I obtained a job in Interventional Radiology and have been there since 2016. I spent the majority of the pandemic completing the Masters in Healthcare Leadership program through Royal Roads University and plan to use these powers for good moving forward in the Saskatchewan Health Authority (SHA). Outside of work I enjoy time traveling, attending concerts, spending time with my pets, camping, cycling, and I have been recreationally lawn bowling for 7 years.

NS:  What was the driving force behind the shift from radiologist placed PICCs towards tech inserted PICCs?

CF: After attending the CAIR conference in Montreal in 2014 where I learned about technologist/nursing placed PICC lines I was motivated to pursue the process of implementing this into our practice in Saskatoon.  During our time at SPH we have seen the evolution of practice for the Interventional Radiologists, so we became more motivated to evolve our own practice as technologists as well.

Since implementation, we have had significant improvements in workflow and have consistently improved patient PICC access, not only resulting in secure IV access for inpatient treatments but also improving flow through the hospital and expediting discharge. We no longer have to wait for a  Radiologist to be available to perform these procedures, as they are typically busy doing one of the many more involved procedures that they are inundated with.

JT: I went to the CAIR conference in 2018 and did the ultrasound guided access workshop which was an excellent resource and demystified ultrasound for me. We were sick of waiting around for the radiologists who were either scrubbed in to other cases or “busy” in their offices but were actually making personal calls and online shopping/researching cricket tickets/acquiring commercial real estate. Between dictations they seemed to be getting really into Bitcoin (whatever that is).

NS: Bitcoin is a decentralized currency! Why is that so hard to understand???  Ok, Walk me through the steps of setting this program up.

CF: Myself and one of the IRs started out by contacting our provincial technologist regulatory body (SAMRT) to see if this would be something that could even be incorporated into our scope.

I was given a large amount of assistance from our Angiodynamics© rep Angela Tyler, who had previous experience assisting in the set up of similar programs. I discovered that technologist driven programs are much less common than nursing based programs. Angiodynamics© was able to provide us with our formal PICC line education modules, as well as the creation of a site specific training module with a thorough overview of the entire PICC insertion procedure that was created alongside our three interventional radiologists.

After many, many meetings with the various tiers of leadership, revisions and delays from a provincial health region amalgamation, we were successful in implementation approximately 3 years from initial start time. Dedication and motivation to succeed were our driving factors in keeping this dream on track, despite the desire to quit more than once.

JT: As far as I could tell, Cole attended 1000 meetings, responded to 32000 emails, thought about quitting 3-5 times and was road blocked by the legal department only thrice. Through sheer force of will he pushed it through all the bureaucracy and snatched victory from the jaws of defeat.

NS: What was the biggest challenge to overcome?

CF: To be honest the whole process went quite smoothly, other than the time commitment and dedication of creating all of the documentation. The SAMRT and SHA management were supportive along our journey, provided we followed the appropriate process to keep everything legit. We had an immense amount of support from our interventional radiologists, who supported us every step of the way. They attended many meetings with myself and helped create and proctor our training until we were up and running.

JT: I can see other facilities having potential issues with support from their IR’s but luckily ours do whatever we tell them to do and supported this all the way through. Quite seriously though, the doctors have to be the ones fueling this from the start as it requires a lot of trust between them and the technologists. Plus the health authority listens to doctors for some reason, so that helps.

NS: What would you do differently?

CF: While I was persistent, I think a bit of a more assertive push would have gotten things off the ground a bit faster.

JT: I would have gotten in on the ground floor so I could claim more credit for the success of this project.

NS:  What do you think is next?

JT: I think this lays really good ground work with the SAMRT and the health authority to develop an advanced technologist program in our practice. This role would take on some of the simpler/low-risk IR procedures and administration/patient follow-up roles to free up the IRs for more real estate and cricket ticket acquisitions. With IR developing so quickly and taking on new procedures all the time, the technologists seeking job satisfaction are keen to expand their practice and help get patients timely care and maintain rapid access to procedures.

CF: I WILL be getting in on the ground floor of developing advanced practice in Saskatchewan and claiming my share of the credit for this project.

Thanks to both Cole and Jacquie for taking the time to answer my questions, if there are any techs out there reading this who want to get more info, feel free to email Cole at cole.frandsen@saskhealthauthority.ca. Now they both need to get back to work, there are PICCs to do!

Dr. Ruairi Meagher 

I heard a rumour of a new state of the art Siemens Angio suite in the works out east (wayyyyyy East, past Toronto!!) and wanted to get the details for everyone we know relies on the CAIR Express for their IR news.  I found my way to Dr. Ruairi Meagher (someone gave me his email), who was kind enough to answer some questions.

NS: Dr. Meagher, tell the readers a bit about yourself and your IR practice.

RM: I am an interventional radiologist practicing in Saint John New Brunswick currently in my 5^th year of practice. I did my IR fellowship at CHUM in Montreal and currently practice in a group of 5 IRs. We enjoy a very collaborative practice both amongst the IR’s as well as virtually all services across the hospital with a very broad practice scope.

NS: Tell us about your new Siemens ARTIS ICONO OR suite? When will you be up and running?

RM: Our biplane Artis Icono hybrid suite is one of two fully OR compatible angiosuites in the radiology department. It is a large footprint suite with the ability to host our surgical, anaesthesia and perfusion colleagues simultaneously. Siemens has really worked with us to provide as much functionality as possible packed into one suite and we are really excited to have it up and running. COVID permitting we should be operational 2022.

NS:  What hurdles did you overcome to plan such a room? How will the suite be used?

RM: Beyond the usual funding and space planning issues we all encounter with renovations, including moving our ultrasound department and finding a spot to move them,  we had to decide as a GROUP what functionality/equipment we wanted for the next 10 years eg. single plane, multimodality CT angiosuite, biplane, hybrid OR etc. Our biggest hurdle for the ARTIS ICONO biplane was beyond neuro intervention and advanced aortic branch cases could the unit still handle the high volume bread and butter IR we will throw at it every day. With our current volumes we can’t afford to have a room sit idle, or having physicians waiting for their preferred room to be available. We are planning on leveraging ICONO’s Case Flows to set up the room prior to patient or physician entering to facilitate each case for example  head position stroke and PE,  to radial position TACE, UFE, mesenteric to left side TAVR and TIPS,  to right side for splenic/portal to vascular access from head to toe. The floor mounted plane integrates with a highly mobile table to reach from head to toe and finger tip.

NS:  What types of cases and patient care challenges do you hope to solve?

RM:  The most appealing advantage of this particular biplane is its dual spin time resolved multiphase CTA. In the right patient population we are hoping to skip the conventional diagnostic CT and have patients brought from ambulance to the angiosuite and undergo multiphase CTA, with the ability to do perfusion imaging in certain instances, while the team prepares for EVT. Eventually it may be possible to acquire dynaCT images from both planes simultaneously shortening imaging time and hopefully gaining added information with dual energy capabilities objectively distinguishing blood from contrast post procedure. I am also looking forward to 4 dimensional CTA in vascular malformation cases. We haven’t had a biplane up until now and are hoping to shorten aortic branch graft cases considerably.

NS:  How will patients benefit from this significant investment?

RM: Having a second large footprint hybrid angiosuite will allow for further collaboration in our hospital and maintain services during future maintenance and eventual renovations. Currently there is no finer imaging suite for stroke intervention and as the sole provider for acute stroke intervention in the province the patients win big time with the investment. The suite also offers increased opportunities for interventional oncology and continued collaboration with our surgical colleagues to offer the gamut of minimally invasive treatments.

NS:  What other technologies will be applied in the suite?

RM: Ultrasound will be a must. We are considering Siemens wireless probes to take advantage of the main imaging display and minimize footprint. Transesophageal echo for our TAVR and Dissection cases. Perfusionists are present during our cardiac valve cases with dedicated hook ups and monitors for them. Two PC’s with Third party HIS/RIS/PACS and advanced image processing are integrated into the Siemens control cockpit.  Patient monitoring both at the bedside and anaesthesia integrated into the main display. Third party table mounted injector. Large rail mounted display which can swing to either side of the patient as well as both ceiling mounted 24 inch monitors on a boom for the second operator. Closed circuit video camera for Procter led cases in these COVID times. We are using one of the large display inputs for chromecast /apple airplay as well as cellphone and micro blog paging integration as needed.

NS: What does the future hold for this suite?

RM: CASES! Lots of cases. We would be happy for people to stop in and check out the suite once operational — provided you have your vaccine. There will be a huge variety of work going through the room. The volume in our IR practice just keeps increasing. While we were not hit as hard as other parts of the country our case volume actually increased during COVID. We are fortunate to practice in a hospital that is large enough to do a wide variety or interesting work while being small enough people have to work at maintaining good working relationships. We have an open door policy, we are happy to work with anyone who is willing to work with us.

NS:  Anything else you would like to mention?

RM: Did you see Andre De Grasse win gold in the 200m? That was awesome!

*This content was created by CAIR editors on behalf of Siemens as a CAIR industry partners.  CAIR makes no claims, promises, or guarantees about the accuracy, completeness, or adequacy of the content, and expressly disclaims liability for errors and omissions in the contents of this article. Reference to any specific commercial product, process, or service, or the use of any trade, firm or corporation name is for the information and convenience of the public, and does not constitute endorsement, recommendation, or favoring by the CAIR.

Dr. Sinclair and Dr. Woodley-Cook had the pleasure of speaking with one of their fellowship mentors, Professor John Kachura. Below are snippets from their interview, edited with minor revisions (with permission). 

(Teaser transcript below)

Dr. John Kachura completed his diagnostic imaging residency at the University of Toronto in 1994 and fellowship in vascular and interventional radiology at University Hospital and Boston City Hospital in Boston, Massachusetts in 1985.  He is a Professor in Medical Imaging at The University of Toronto and a Staff Radiologist in the Department of Medical Imaging at the Joint Department of Medical Imaging at UHN/Mt. Sinai in Toronto. Dr. Kachura is the vascular and interventional radiology Fellowship Supervisor at the Joint Department of Medical Imaging in Toronto and has co-authored over 60 peer-reviewed papers. Dr. Kachura was the President of the Canadian Interventional Radiology Association (CAIR) between 2011 – 2013. His professional and research interests include but are not limited to interventional oncology and obstetrical interventions.

CAIR – Thank you for joining us. Tell us how you became Prof. John Kachura

JK – Well, I went to the University of Toronto medical school and graduated in 1989 (a long time ago). I was originally in the Internal Medicine program but my last elective in medical school was Radiology at the Wellesley Hospital, now defunct. I really enjoyed the breadth of material and the intricacies of radiology and I decided to switch. So, after a year of intense medical internship, I switched to Radiology at U of T. I finished my Radiology residency (at U of T) in 1994 and did a fellowship in Boston at Boston City Hospital University Medical Centre for a year and then came back to Toronto working on staff at the Wellesley Hospital for three years before leaving for UHN/Mt. Sinai, where I have been on staff since 1998.

CAIR – Fascinating. Who is or was your mentor and why?

JK – During radiology residency, I enjoyed most of the things we learned but I was unsure in what area to subspecialize. My first rotation through interventional radiology was at Mt. Sinai Hospital during my R3 year with Dr. Murray Asch and Dr. Nasir Jaffer. In fact, Dr. Murray Asch was my first mentor. As soon as I started the rotation with Dr. Asch, I knew VIR was what I wanted to do.  In Boston, I had a couple of mentors: The Chair of Radiology and Radiologist-in-Chief at the time, Dr. Joseph T. Ferrucci II and the head of VIR at the time, Dr. Kent Yucel. Back in Toronto, I would consider Dr. CS Ho and the recently departed Dr. Ken Sniderman as well.

CAIR – What part of IR were you drawn to?

JK – I liked using my hands to do procedures. I was fairly good at basic procedures during my internship and it seemed satisfying to do something to help someone in the immediate term. Although I enjoyed the complexity of internal medicine, you had to deal with a lot of chronic conditions, for which there were no easy answers.

CAIR – Would you consider yourself a “vascular” or “body” IR (or both)?

JK – I would consider myself both. Early on in the stenting days, I would scrub in with the vascular surgeons to insert stent grafts. As interventional oncology progressed in the late 90s and early 2000s, I gravitated towards that and I tend to be involved with more interventional oncology than other areas such as peripheral vascular disease now but I like to do all procedures.

CAIR: Cool! I know this is a difficult question that you have probably never thought of, but how would you describe your favourite catheter?

JK – I like to teach my fellows that the 4F C2 glide catheter is the most versatile catheter known to peoplekind.

CAIR – Do you have a favourite CAIR city?

JK – The first host city was Niagara on the Lake, which produced a lot of memories, which I still remember. CAIR went back a couple of years later. The times there were great. I enjoyed Halifax and I enjoyed Calgary. As long as it’s not in Toronto, I’ll enjoy it.

CAIR – What’s your favourite song to sing at karaoke?

JK – Hidden content. Watch the video.

CAIR – What was your last publication?

JK – I was co-author with Dr. Mafeld of a letter to the editor in CVIR. I was very pleased that the words “Trump” and “fake news” were used. (The link can be found here).

CAIR – What is your favourite closure device?

JK – My first two favourite closure devices are this and this (shows us the 2nd and 3rd digits of his right hand). Hopefully on the fellow’s hand.

CAIR – What if there is operator fatigue?

JK – Then you have another hand. Or another fellow…

*For the remaining riveting questions, watch the full video, click on the image below*

Dr. Kenneth Sniderman being awarded the Medal of Bravery after saving a drowning stranger trapped beneath a boat.

The VIR community recently lost one of its pioneers and mentors, Dr. Kenneth Sniderman, who passed away in April 2021 following a battle with cancer. Below are two statements from Dr. Simons, who worked alongside Dr. Sniderman and Dr. Bernstein, a VIR fellow that trained under Dr. Sinderman.  

Dr. Martin E. Simons 

Dr. Ken Sniderman was a pioneer in Angiography and Interventional Radiology in Canada, and the rest of the world as well. 

He trained in Toronto, New York and Boston, and was on staff at NYU, publishing widely on angiography and angioplasty, with landmark papers on renal arteriography and angioplasty. 

He returned to Toronto and the Toronto General Hospital in 1985, and began his long and distinguished career at TGH, the Toronto Hospital and the University Health Network, (all the same place, just different names).  He published many papers here as well, particularly a landmark paper on iliac angioplasty. 

In his 35 years in Toronto, he trained innumerable fellows and residents, many with high profile positions all over the world. 

He was ahead of his time in many ways.  He became very sub specialized, at a time when this was unusual.  Most radiologists in that era did multiple modalities and organ systems. 

He was also ahead of his time in practicing patient centred care.  He was not afraid to embrace the clinical aspects of Interventional Radiology, long before it became the norm, and he set an example to all of us, on how we should treat and respect our patients 

His angiographic technique was superb.  Every angiogram Ken did was a work of art.  He was meticulous in his technique.  Many fellows remember the attention to detail that Ken brought to every case. 

Ken was a tireless worker, and loved teaching fellows. and residents.  He loved his career, and his passion for his work was contagious.  He was never afraid to learn new techniques as he came along, and adapted to all the changes that have occurred in Medicine since he began his career. 

He learned ultrasound and nonvascular interventional radiology, many years after starting practice, and excelled at this as well. 

For those of us in IR, the passing of Ken Sniderman, is like the end of an era.  Hopefully, his passion, enthusiasm and wisdom, will carry on through the many trainees he has nurtured over his career. 

He is missed by his colleagues at UHN/MSH, and by his family and friends.  Our condolences go out to Ken’s wife Franci and his three sons, Michael, Adam and Robert. 

Dr. Ondina Bernstein 

Ken was a fabulous teacher and colleague.  Countless interventional radiologists across Canada, and indeed the world, were fortunate enough to learn from his vast expertise, techniques, attention to detail and patient-centred approach. His enthusiasm for IR was always apparent, even when called for emergency cases during the dead of night! Ken will be missed but always remembered with fondness and great respect.  

This segment will feature a unique pearl learned by a junior VIR staff during residency or fellowship to share with our community. This pearl is written by Dr. Joel Woodley-Cook from Scarborough Health Network.

A Dr. Sniderman Nugget: How to Reduce Pain Associated with Local Anesthesia Injection 

It became clear early on in VIR fellowship that Dr. Sniderman had many passions in life. Two of these passions included teaching and patient care. He would literally sacrifice himself for both passions, whether it was during his Friday morning teaching rounds despite being in pain from a recent fractured hip or giving patients his personal mobile number and getting calls throughout the night regarding post-UFE pain management.

Dr. Sniderman bestowed many pearls upon his mentees, including the liberal use of roadmapping, vascular ultrasound tips, being careful (and typically avoiding altogether) of advancing a wire beyond a catheter^*, and teaching the Subway sandwich artist to hollow out the bun to reduce carb intake. Dr. Sniderman was a strong advocate for patient safety and comfort, and although he taught numerous techniques and tricks, one stands out as it highlights his empathy, prioritizing patient comfort, and improving the patient experience.

The following technique was taught by Dr. Sniderman after he read a 5 Things To Know About CMAJ article on how to reduce the pain of local anesthesia injection [1].

Below is a summary of these tricks on how to reduce the pain of local anesthesia injection:

1. Using a smaller diameter needle

• Encourages slow injection thereby reducing pain from volume expansion.

2. Warming the injection solution

• At the beginning of the day, Dr. Sniderman would warm his vials for the day.
• Resources vary, but a gel warmer, towel warmer, or warm water bath can be used.

3. Buffering lidocaine with sodium bicarbonate

• The burning sensation of lidocaine, an acid with a pH of 4.7, can be reduced with a 10:1 mix of 1% lidocaine:8.4% sodium bicarbonate.
• Prior to warming, Dr. Sniderman would add 5 mL of sodium bicarbonate to the 50 mL bottle of 1% lidocaine (with or without epinephrine).

4. The initial injection should be perpendicular to the skin

• Injections performed at 90^o intersect fewer dermal nerve endings, which tend to branch out.

5. Pause after initial subdermal injection

• The first injection should be a 0.2 – 0.5 mm subdermal injection, as opposed to intradermal, followed by a pause.

6. Maintain visible anesthetic ahead of the advancing needle tip

• This ensures anesthetizing downstream nerves prior to tip penetration.

^*I recall Dr. Sniderman’s analogy of the tip of a wire acting like a sword, which should be “unsheathed” from the catheter to prevent dissection instead of sticking the vessel wall with the pointy bit.

Reference:

1. Strazar R, Lalonde D. Minimizing injection pain in local anesthesia. CMAJ. 2012;184:2016.