Ultrasound and arterial lines

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This has got to be the best damn way to put in an arterial line. I'm freaking sold - was worried about it being a "crutch". Whatever. Today had three patients sicker than **** who needed an arterial line like yesterday, one the residdents had turned the wrists to hamburger, the other so edematous you could barely find a pulse, and all of them I didn't have time to supervise the residents going about doing the monitoring line per usual. One ended up being a brachial, and the US made every single one simple and easy.

What's been everyone else's experiences?

As an aside, I've bene playing around with different ways of suturing them in. What does everyone like to do for securing the lines?

Originally Posted by jdh71

This has got to be the best damn way to put in an arterial line. I'm freaking sold - was worried about it being a "crutch". Whatever. Today had three patients sicker than **** who needed an arterial line like yesterday, one the residdents had turned the wrists to hamburger, the other so edematous you could barely find a pulse, and all of them I didn't have time to supervise the residents going about doing the monitoring line per usual. One ended up being a brachial, and the US made every single one simple and easy.

What's been everyone else's experiences?

As an aside, I've bene playing around with different ways of suturing them in. What does everyone like to do for securing the lines?

for run of the mill a-lines, no. but for situations like yours, absolutely. Ive even been able to see the wire go into the artery without a flash and end up with a working a-line.

for suturing, don't waste your time on the clip most kits have with them. I use 2 sutures in an anchoring fashion. I through one on either side. I'll place a suture parallel to the a-line slightly more proximal then tie to skin. then without cutting anything, I'll wrap around the a-line hub the tie off with tail from first throw. I repeat the process on opposite side.

so it kinda looks like this below.

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A

Originally Posted by Hernandez

for suturing, don't waste your time on the clip most kits have with them. I use 2 sutures in an anchoring fashion. I through one on either side. I'll place a suture parallel to the a-line slightly more proximal then tie to skin. then without cutting anything, I'll wrap around the a-line hub the tie off with tail from first throw. I repeat the process on opposite side.

so it kinda looks like this below.

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A

Yeah, I been trying something similar. Though, I've been making a small air-knot at the skin first parallel to the the line hub, then going around the the hub and tying with the first tail of the initially knot, and then repeating on the other side.

A lines don't come out because they're not sutured. They come out because the damn line is looped around the thumb and creates a fulcrum for the patient to manipulate it. I don't suture my a lines in, instead I make a tight 180 degree turn on the wrist above the joint and then tape the hell out of it.

You may be interested in this thread

Originally Posted by proman

A lines don't come out because they're not sutured. They come out because the damn line is looped around the thumb and creates a fulcrum for the patient to manipulate it. I don't suture my a lines in, instead I make a tight 180 degree turn on the wrist above the joint and then tape the hell out of it.

Yeah getting looped can be a problem, but I've seen plenty come out for other reasons and then they come out easy. In my clientele, I don't like taking the chance of losing the line.

You may be interested in this thread

Oh, I've read through it. Long time ago.

My experience? Your gas friends don't talk to non-gas people posting in their forum. I don't get it, but it is what it is. Thought I'd ask the rest of critical care people. They can post in here if they like. I'll talk to them. I promise.

Originally Posted by jdh71

Yeah, I been trying something similar. Though, I've been making a small air-knot at the skin first parallel to the the line hub, then going around the the hub and tying with the first tail of the initially knot, and then repeating on the other side.

I think we just described the same thing

Originally Posted by Hernandez

I think we just described the same thing

I added the "air-knot"

But this one seems to be the most simple and elegant. Plus it keep the hub "in-line" so that it doesn't kink up at the surface.

I still wonder if anyone does something different with their suturing. I'm just comfortable going proman style myself.

I'll take a picture of tomorrow's a line. This is what happened when I let an attending tape an a line in. At the end of a CABG, we roll to the ICU and the first thing they see is this:

Originally Posted by proman

I'll take a picture of tomorrow's a line. This is what happened when I let an attending tape an a line in. At the end of a CABG, we roll to the ICU and the first thing they see is this:

Yeah man, I'd like to see what you do.

And that pic doesn't look so good

Not my finest tape job but you'll get the idea.

It depends on how good the pulse is, but in general I love ultrasound. In bigger people if there's a good pulse, it would probably take me longer to grab the ultrasound, get the sterile sleeve and do the line under guidance than just putting it in. In my infants or anyone with a bad pulse (especially in the situation you describe), definitely ultrasound FTW.

To suture, I put an anchor stitch proximal to the line, then pull the thread through the wing holes and tie it again. Then tape or tegaderm it down.

I think ultrasound can be put to great use in the ICU setting, and we could probably use it much more than we do.

Originally Posted by proman

Not my finest tape job but you'll get the idea.

[IMG]

Yeah, I see what you did there. The only problem I have is that too many of my patients need that a-line in for longer than a single dressing can be left on. I think if I was sure my art line would come out when I took the take off, then just taping the ****er right would be the best way to go.

Originally Posted by Stitch

It depends on how good the pulse is, but in general I love ultrasound. In bigger people if there's a good pulse, it would probably take me longer to grab the ultrasound, get the sterile sleeve and do the line under guidance than just putting it in. In my infants or anyone with a bad pulse (especially in the situation you describe), definitely ultrasound FTW.

To suture, I put an anchor stitch proximal to the line, then pull the thread through the wing holes and tie it again. Then tape or tegaderm it down.

I think ultrasound can be put to great use in the ICU setting, and we could probably use it much more than we do.

I agree. If you've got a great radial pulse then why bother.

My patient population . . . ugh . . .

Originally Posted by Stitch

then pull the thread through the wing holes and tie it again. Then tape or tegaderm it down.

I've never worked with an Aline that has wings built in to secure it by.

I'm a Gas/CCM guy who posted in the referenced thread.

I'll put my plug in for the doppler. I like the fact that it gets me in the right plane without having to look at a screen. I just have to find the depth on my own. With doppler and a through and through technique my success rate is pretty high.

My $0.02

Originally Posted by MTGas2B

I'm a Gas/CCM guy who posted in the referenced thread.

I'll put my plug in for the doppler. I like the fact that it gets me in the right plane without having to look at a screen. I just have to find the depth on my own. With doppler and a through and through technique my success rate is pretty high.

My $0.02

I've never tried the doppler myself. Seems like if I'm going to go to the work to drag out some equipment why not just use the U/S. But then I like the screen.

Originally Posted by jdh71

Yeah, I see what you did there. The only problem I have is that too many of my patients need that a-line in for longer than a single dressing can be left on. I think if I was sure my art line would come out when I took the take off, then just taping the ****er right would be the best way to go.

Dressing changes aren't an issue because it's easy to take down that dressing and change it without pulling the a line out. But ultimately the longevity of any line, whether venous or arterial, depends on the nursing care. I've had a lines come out within 45 minutes of arrival to the ICU because someone didn't pay attention. Things like vigorous aspiration, repeatedly power flushing to trouble shoot, forgetting to flush after drawing blood etc defeats anything we can do.

situational to me. Had a pt needing CVC/A-line, I put in an US guided IJ and then seeing as I already had the US out, I figured I would use it for the a-line to show the med student, couldnt hit the artery twice. Put the probe down, hit it manually first stick. Was a weird day all around though...

Originally Posted by Bostonredsox

situational to me. Had a pt needing CVC/A-line, I put in an US guided IJ and then seeing as I already had the US out, I figured I would use it for the a-line to show the med student, couldnt hit the artery twice. Put the probe down, hit it manually first stick. Was a weird day all around though...

Art lines are like that. God put art-lines in my life to keep me humble

Had a very strong pulse (can see pulsation on skin)

Had the ultrasound out already for central line

was curious what it would look like during a-line

so I was using it to see (while the resident putting in the a-line was doing it the old fashion way) ... so it wasn't ultrasound-guided a-line

it was interesting to see the artery rotate away from the needle (also like a jet fighter banking away from an incoming missile)

now I know why with strong pulses, you have to apply tension to the skin and surrounding structures

I often reach for the ultrasound for radial A-lines soon after a just a few failures.

Much like with PIV insertion, going for the radial artery in the traditional spot is often more difficult with ultrasound because the artery is so superficial.

I therefore like to insert ultrasound-guided Alines about half way up the forearm in thin folks.

I also find it more "stable"/less mobile up there; less running away from my approaching needle.

HH

Originally Posted by Hamhock

I often reach for the ultrasound for radial A-lines soon after a just a few failures.

Much like with PIV insertion, going for the radial artery in the traditional spot is often more difficult with ultrasound because the artery is so superficial.

I therefore like to insert ultrasound-guided Alines about half way up the forearm in thin folks.

I also find it more "stable"/less mobile up there; less running away from my approaching needle.

HH

This is what I've been finding too.

Originally Posted by Hamhock

I therefore like to insert ultrasound-guided Alines about half way up the forearm in thin folks.

I also find it more "stable"/less mobile up there; less running away from my approaching needle.

HH

I agree. The radial artery is also much more tortuous when it's superficial. You feel a better pulse because you can compress the artery better against the radial styloid. I tend to be at least 3 cm from the crease of the wrist, blind or US. The few times the surgeons do radial artery grafts I make sure the residents and fellows look at the dissection, it really helps understand the space.

stopped suturing a long time ago and use u/s when no pulse for whatever reason (edematous, LVAD etc)

Originally Posted by The Pill Counter

stopped suturing a long time ago and use u/s when no pulse for whatever reason (edematous, LVAD etc)

Yes. US makes putting an art line in LVAD patients much easier.

Originally Posted by MTGas2B

I'm a Gas/CCM guy who posted in the referenced thread.

I'll put my plug in for the doppler. I like the fact that it gets me in the right plane without having to look at a screen. I just have to find the depth on my own. With doppler and a through and through technique my success rate is pretty high.

My $0.02

One of the peds anesthesia attendings I worked with in residency that did lots of peds cardiac loved the doppler for peds a-lines. Especially on the <10kg kiddos. He rarely used U/S for his a-lines but usually doppler. He always used U/S for the neck line though.

JDH, you mentioned putting in a brachial A-line. I've never seen that at my place, as the attendings are wary even of brachial ABGs due to distal ischemia etc. As a med student though, I did brachial ABGs all the time and no one batted an eyelash (of course after failed radial ABGs). What's your take on this? And is it standard to put in brachial a-lines if there's no other choice? (I've put in dorsalis pedis ones, but again, no brachials)

Originally Posted by flipmd

JDH, you mentioned putting in a brachial A-line. I've never seen that at my place, as the attendings are wary even of brachial ABGs due to distal ischemia etc. As a med student though, I did brachial ABGs all the time and no one batted an eyelash (of course after failed radial ABGs). What's your take on this? And is it standard to put in brachial a-lines if there's no other choice? (I've put in dorsalis pedis ones, but again, no brachials)

I've heard that before too, about the distal ischemia, especially where I did residency. There should be enough collaterals around the elbow so that a simple brachial poke shouldn't cause a problem. I've seen some talk about axillary line placement and that one does make me nervous, especially adjacent to the distal end of the brachial plexus. I usually try radial, then brachial, then femoral. Though I'd have to say with the U/S I'm almost always putting in radials now.

The brachial and axillary arteries both have enough collateral arteries to be safely used for short term cannulation. I don't do either sites without ultrasound which helps avoid the nerves. The brachial plexus is higher up, at the supraclavicular artery level, the axillary artery does have the radial, median and ulnar nerves surrounding it. The brachial artery does have nerves at risk too, the median and ulnar. We will frequently cover the origin of the left subclavian artery during endovascular stenting of thoracic aorta dissection or aneurysm. Less than 15% of patients develop ischemia, which is pretty remarkable.

Originally Posted by jdh71

I've heard that before too, about the distal ischemia, especially where I did residency. There should be enough collaterals around the elbow so that a simple brachial poke shouldn't cause a problem. I've seen some talk about axillary line placement and that one does make me nervous, especially adjacent to the distal end of the brachial plexus. I usually try radial, then brachial, then femoral. Though I'd have to say with the U/S I'm almost always putting in radials now.

Actually, there are no collaterals around the elbow, that is why some people are so afraid of brachial a-lines. There are collaterals around the axillary artery so this is considered "safer" by some people. I have put in many brachial a-lines and had my first complication about a month ago. It was an obese pt. on crazy doses of vasopressors and I couldn't get a radial. She unfortunately got distal limb ischemia had to go to the OR for a thrombectomy. I have recently put in several axillary a-lines (due to a new attending that I worked with that would not allow brachial a-lines) and kind of like them. That may be my new go to a-line if I can't get a radial. Also in severe vasculopaths, axillary may be the only actual pressure measurement. I had a pt. recently with terrible peripheral vascular disease. Had an axillary a-line for about a week from her CABG and we wanted to change it. Put in a radial a-line without difficulty (pt. NOT on pressors) and the systolic readings were 80-100 points different than the axillary line (radial systolics in the 70's while axillary systolics were in the 150-170 range).

Originally Posted by TrustMe

Actually, there are no collaterals around the elbow, that is why some people are so afraid of brachial a-lines. There are collaterals around the axillary artery so this is considered "safer" by some people. I have put in many brachial a-lines and had my first complication about a month ago. It was an obese pt. on crazy doses of vasopressors and I couldn't get a radial. She unfortunately got distal limb ischemia had to go to the OR for a thrombectomy. I have recently put in several axillary a-lines (due to a new attending that I worked with that would not allow brachial a-lines) and kind of like them. That may be my new go to a-line if I can't get a radial. Also in severe vasculopaths, axillary may be the only actual pressure measurement. I had a pt. recently with terrible peripheral vascular disease. Had an axillary a-line for about a week from her CABG and we wanted to change it. Put in a radial a-line without difficulty (pt. NOT on pressors) and the systolic readings were 80-100 points different than the axillary line (radial systolics in the 70's while axillary systolics were in the 150-170 range).

Sorry about your limb ischemia, but that sure looks like an awful lot of arteries around the elbow . . .

Anyway, if you guys think the axillary is safe enough, then I'm not going to argue too much.

Well I guess it's attending-dependent then. Which means I probably won't be doing brachials anytime soon anyway. Gotta look it up one of these days though. Thanks!

A patient of mine went to the OR today for thrombectomy after a brachial a-line from yesterday caused complete distal ischemia. No flow in the radial or ulnar arteries, hand was mottled and pulseless.

It'd be nice to see some data on this but I certainly wouldn't be eager to start one of those anytime soon.

Rethinking my secondary preference for brachials a bit . . . I'd like to see how the gas guys do the axillary. I think I know how I'd do it, but it'd be interesting to see how they position, where they start their look, and where they tend to stick. Nice thing is, even in FAT people there usually not a huge amount of overlying sub-q tissue there.

In other news used the U/S to good effect after the residents beat some poor guy's arm to death - in their defense the guy was 20L+, on a pressor, with a failing liver and high INR. Maybe I should have hopped in sooner, but if you don't let people struggle a little bit in residency they don't grow.

Nurse didn't like the number though and told me I'd placed it wrong. Wave form was good, wasn't my fault she was going to ned to go back up on the norepi .

I have never done an axillary a-line in the OR so don't know how I would position the pt. there. But in the ICU, I abduct their arm to 90 degrees at the shoulder and then rotate their arm so that their elbow is at 90 degrees and their hand is near the top of the bed. I secure their arm in that position so they don't move. I palpate for the artery 1-2 finger widths distal to the axillary crease and start there, working more proximal if I need to. The artery there is usually pretty large so I haven't had to move around much. Can use U/S if desired. I use a 20ga. 12 cm catheter for these as well as brachials.

You use the 12cm for brachials to? I don't have much experience with brachials, any reason why?

I feel like the brachial artery is usually 1-2 cm deep (sometimes more) so if you use a 3.5-4 cm catheter you only have half of the catheter in the artery. This doesn't leave much room for movement/error. Plus the 12cm catheter gives you a better central pressure estimation.

Originally Posted by TrustMe

. I palpate for the artery 1-2 finger ... Can use U/S if desired. I use a 20ga. 12 cm catheter for these as well as brachials.

These thoughts are only marginally related to this thread, but I thought I would toss them out there anyway.

I still use ultrasound for A-lines as I described in my posts above.

However, the discussion of the axillary A-line got me thinking of another reason to maybe reach for ultrasound earlier:

Nerve injury or pain.

When I think of the axillary artery and ultrasound, I think of ultrasound for guided peripheral nerve blocks of the m/r/u and then sliding as needed for musculocutaneous....Trust's post about doing this blind made me think about sticking the needle into one of those three nerves if not using ultrasound...which then made me think of all the times patients have complained of servere pain during blind radial A-lines (yes, I know A-lines hurt)...I wonder if some of those very painful and technically difficult radial A-lines are just blind radial nerve sticks...if you miss just a bit lateral/radial to the radial artery, you are often sticking the radial nerve.

Thoughts?

HH

Originally Posted by TrustMe

I have never done an axillary a-line in the OR so don't know how I would position the pt. there. But in the ICU, I abduct their arm to 90 degrees at the shoulder and then rotate their arm so that their elbow is at 90 degrees and their hand is near the top of the bed. I secure their arm in that position so they don't move.

I position the arm in the same way. I use US for all my axillary since it's deeper, I can usually just use 1 stick, lower chance of hematoma from multiple sticks, sometimes there's a giant vein right in my path, and I get to avoid all those big nerves. If I'm doing an axillary a line chances are I've spent some time on the radial and the clock is ticking,

Originally Posted by TrustMe

I feel like the brachial artery is usually 1-2 cm deep (sometimes more) so if you use a 3.5-4 cm catheter you only have half of the catheter in the artery. This doesn't leave much room for movement/error. Plus the 12cm catheter gives you a better central pressure estimation.

Longer catheters are better but at a greater risk of thrombosis. There are some Cook catheters that are 3 Fr 5 or 8 cm. I've learned the hard way that 5 cm is too short, 8 cm is a minimum for brachial or radial.

Originally Posted by Hamhock

I still use ultrasound for A-lines as I described in my posts above.

However, the discussion of the axillary A-line got me thinking of another reason to maybe reach for ultrasound earlier:

Nerve injury or pain.

...which then made me think of all the times patients have complained of servere pain during blind radial A-lines (yes, I know A-lines hurt)...I wonder if some of those very painful and technically difficult radial A-lines are just blind radial nerve sticks...if you miss just a bit lateral/radial to the radial artery, you are often sticking the radial nerve.

Art lines shouldn't hurt. Use a lot of local. I typically place 3-5 cc of lidocaine 1% with a bit of bicarb. My patient population is different than yours: I mostly deal with ambulatory cardiac surgery patients who came in from home, or recent hospitalization. So the last thing I want to do is have a catecholamine surge. A lot of local does not alter the anatomy (I think it actually makes it easier), and the bicarb keeps the lido from burning. I've found many people are timid on the local, it only makes things easier.
As for the radial nerve: the nerve proper is much deeper. There are small superficial sensory branches in close proximity to the artery that aren't anything to worry about. I've yet to see the radial nerve on US.

Originally Posted by proman

I've yet to see the radial nerve on US.

Look just lateral/radial to the artery in short axis next time you place a radial line.

The nerve is the hyperechoic tail extending from the 'head' formed by the round radial artery.

Occasionally, it can be a bit difficult to see but usually it is as clear cut. I block the radial (well, mostly me residents do nowadays) all the time for hand.

HH

Try to upload the image to an image sharing site and then link it. I'd like to see what you're calling the nerve. You describe more of a "wrist block" than a radial nerve block. Proper radial nerve blocks are done at the axillary level, mid-humeral, or elbow.

From Chan's Textbook of Regional Anesthesia:

"The radial nerve passes along the front of the radial side of the forearm. It arises first from the lateral side of the radial artery and beneath the supinator muscle. About 3 inches above the wrist, it leaves the artery, pierces the deep fascia and divides into two branches."

Radial nerve proper (motor and sensory) at the forearm and wrist is a deep nerve on the dorsum of the wrist. There is a superficial (sensory) branch that runs on the radial side and base of thumb. I doubt these can be visualized on ultrasound.

Originally Posted by proman

Try to upload the image to an image sharing site and then link it. I'd like to see what you're calling the nerve. You describe more of a "wrist block" than a radial nerve block. Proper radial nerve blocks are done at the axillary level, mid-humeral, or elbow.

From Chan's Textbook of Regional Anesthesia:

"The radial nerve passes along the front of the radial side of the forearm. It arises first from the lateral side of the radial artery and beneath the supinator muscle. About 3 inches above the wrist, it leaves the artery, pierces the deep fascia and divides into two branches."

Radial nerve proper (motor and sensory) at the forearm and wrist is a deep nerve on the dorsum of the wrist. There is a superficial (sensory) branch that runs on the radial side and base of thumb. I doubt these can be visualized on ultrasound.

I just realized my post was both non-functional and identifying.

I have edited it and removed the link (I hope).

Although I am very familiar with Chan's work, I believe that there is a difference between pre-procedural (ie OR) regional anesthesia in the otherwise non-acute patient and the patients we (EM) see in the ED. We (or others on the anesthesiology board) have discussed this previously.

Clearly I am not so smooth...at posting images to this board.

However, I will try to find within the next few days either published or my unpublished images identifying the (sensory) radial nerve just adjacent to the radial artery (although, I'll admit, it is a bit difficult to identify distally and there is a separation between the artery and nerve).

HH

I've used ultrasound twice for this purpose, both times in moribund patients. I prefer grabbing the doppler in tricky cases, as it's usually slightly quicker and I'm impatient. A handful of times, when it's been appropriate, I've resorted to the cath lab trick of topical nitroglycerin over the radial artery to induce some vasodilation. In my experience this has been successful although some of my colleagues find it useless.

Originally Posted by proman

b. I doubt these can be visualized on ultrasound.

http://nerveatlas.ucsf.edu/video/RadialV2PhLg_Prog.mov

not the ideal pic I have been trying to get online, but I am struggling to "upload" to a site that is both accessible and does not identify me without a lot of work

HH

Hey!
Axillary artery catheterization through the armpit is associated with nerve injuries and frequent infection.