Ultrasound for radial alines

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urge

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Anyone routinely doing this? Even if the pulse is bounding?

Why/Why not?

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Nope-- only use it when I can't feel a pulse (and know they are hemodynamically stable :) seems like just an extra piece of equipment for a pretty straightforward procedure for most patients. No major benefit to be found for using it routinely unlike central line access. But interested to hear what others do.
 
Only if there's not a great pulse of I've failed a few times. The arrow kits we have have pretty dull needles. I find under u/s that the needle just bops the artery to the left or right, so it's easy to miss without the u/s.
 
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Only if I have failed after a couple of attempts.

It is a great tool, but adds 5 minutes to a 2 minute procedure.

I really struggled with my art line today and was surprised when looked at the clock after I got it in and it had only been 5 minutes.

So it would take me as long to do a routine line as it now takes me to do a difficult line.

- pod
 
Only if there's not a great pulse of I've failed a few times. The arrow kits we have have pretty dull needles. I find under u/s that the needle just bops the artery to the left or right, so it's easy to miss without the u/s.

It is like the artery is laughing at you right in the middle of the screen. So frustrating!
 
I use it like others have said, for pt. that I have made several attempts and not been successful or for pt.'s that I can not feel a radial or a brachial pulse. One of our ped's cardiac guys likes to use a doppler for the tiny kidos (<5kg). Like periop said, adds time to what usually is a very quick procedure.
 
Anyone routinely doing this? Even if the pulse is bounding?

Why/Why not?


The use of ultrasound for central lines - and it's use rapidly becoming standard of care - is because of safety data and concerns.

Those concerns aren't there with a-lines. I can't imagine why ultrasound would add anything to safety - and it does add time and complexity to a usually simple procedure.
 
Find it useful mostly in traumas when the patient is hemorrhaging and hypotensive and the pulse is almost non-palpable.
 
I use it. Mostly for nonpalpable pulses. I do pull it out when I have stuck a few times and haven't gotten it in pulse or not. I find it pretty helpful and have gotten better at it the more I use it. I have gotten to where I keep it on when I am sticking and can see the needle (or at least imagine the needle in the vessel). Alines seem to be easy or not with not alot of in between. If I have trashed one arm with a big hematoma and no aline to show for it. I will usually pull it out, I think it saves time in the end.
 
I've never seen one used for an A-line, but it seems reasonable if you're struggling. Sometimes those bounding pulses are the hardest ones as it seems like the pulse is radiating from all over wrist and you can't pinpoint the artery.
 
I find using ultrasound useful for more proximal radial arterial lines. Sometimes, the radial artery distally is difficult to cannulate with a 20 G catheter. If i'm having trouble threading the wire/catheter, then I'll move proximally and try there.

drccw
 
Anyone routinely doing this? Even if the pulse is bounding?

Why/Why not?

I can drop an A line in a corpse.:laugh:

Kinda joking.

YOU SHOULD'NT NEED ULTRASOUND FOR THIS PROCEDURE.

If you do,

1) You were not trained appropriately

2) You are NAIVE of the tricks THAT SAVE HARD A LINES


I love ultrasound.

I'VE YET TO SEE AN A LINE THAT I NEED ULTRASOUND.:smuggrin:
 
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I can drop an A line in a corpse.:laugh:

Kinda joking.

YOU SHOULD'NT NEED ULTRASOUND FOR THIS PROCEDURE.

If you do,

1) You were not trained appropriately

2) You are NAIVE of the tricks THAT SAVE HARD A LINES


I love ultrasound.

I'VE YET TO SEE AN A LINE THAT I NEED ULTRASOUND.:smuggrin:


What are your tricks for pulseless LVAD pt's, pt's where u just can't find the pulse or get a flash, and tiny/spasming arteries where it's tough to pass the wire even after through and through technique? I find most people like using ultrasound and the occasional micropuncture kit for these types.
 
What are your tricks for pulseless LVAD pt's, pt's where u just can't find the pulse or get a flash, and tiny/spasming arteries where it's tough to pass the wire even after through and through technique? I find most people like using ultrasound and the occasional micropuncture kit for these types.

The trick is to learn what the artery feels like and where it lies. During the placement of every a-line even the simplest bounding ones you should be taking note of a few things. Relation the the flexor tendons. Feel the "rope" of the artery as it passes down the wrist. Its like feeling the inter scalene groove with your finger tips. The more you feel for it the better you become at finding it even in those bull necks.
So even without a pulse I can place an a-line in no time as I have done many times before. I know what the tip of the needle feels like as it pops through the wall. I know I'm in frequently before the flash of blood appears. Having this skill can make a big difference in the outcome of a pt. I still remember the ruptured AAA that came in cyanotic and pulseless at the distal extremities. Anesthesiologist was getting ready to induce while belly was being prep'd. I came into help and noticed we had a few minutes before incision and there wasn't an a-line. Both the anesthesiologist and surgeon ( femoral) had failed to get one. I felt the rope of the artery (faint of course) and pop of the arrow cath. Boom I'm in. Let's go. Pt left the hospital alive.
 
JPP with all due respect, this is nonsense:D.

I think ultrasound can be useful in placing arterial lines. I think its use is limited, but very valuable when needed.

I can drop an A line in a corpse.:laugh:

Kinda joking.

YOU SHOULD'NT NEED ULTRASOUND FOR THIS PROCEDURE.

If you do,

1) You were not trained appropriately

2) You are NAIVE of the tricks THAT SAVE HARD A LINES


I love ultrasound.

I'VE YET TO SEE AN A LINE THAT I NEED ULTRASOUND.:smuggrin:
 
+1

Agree with Arch. I pull it out a couple of times a year. Had an acute left main a couple weeks back. Came to the OR in cardiogenic shock/vtach. No palp pulse. Aline took less than 2 min with USD. One stick. Helpful.
 
It should not add more than 1 minute to your time. Place probe on wrist. See pulsating target. Hit it. Really makes a difficult a line. Supa easy. :D
 
The trick is to learn what the artery feels like and where it lies. During the placement of every a-line even the simplest bounding ones you should be taking note of a few things. Relation the the flexor tendons. Feel the "rope" of the artery as it passes down the wrist. Its like feeling the inter scalene groove with your finger tips. The more you feel for it the better you become at finding it even in those bull necks.
So even without a pulse I can place an a-line in no time as I have done many times before. I know what the tip of the needle feels like as it pops through the wall. I know I'm in frequently before the flash of blood appears. Having this skill can make a big difference in the outcome of a pt. I still remember the ruptured AAA that came in cyanotic and pulseless at the distal extremities. Anesthesiologist was getting ready to induce while belly was being prep'd. I came into help and noticed we had a few minutes before incision and there wasn't an a-line. Both the anesthesiologist and surgeon ( femoral) had failed to get one. I felt the rope of the artery (faint of course) and pop of the arrow cath. Boom I'm in. Let's go. Pt left the hospital alive.

good advice

anyone here forgo seldinger all together and just thread a 20g angiocath?
 
good advice

anyone here forgo seldinger all together and just thread a 20g angiocath?

Yeah, my 'go to' a-line is a 20g (w/ TB syringe--plunger removed--attached). Get flash of blood. Roll needle bevel 180 degrees. Slide catheter off. It seems to have a higher success rate, as compared to the Arrow catheters...particularly in vasculopathic patients. I have no idea why.

If the above fails, I'll go through and through and use a wire. Rolling the needle seems to work well in kiddos, too. If I'm using a 24g, I go straight to the through and through technique, however.
 
I've grown up in the days of ultrasound. I use it for blocks, I use it for IJs. I really don't like it for a-lines, I've tried a few times, it just doesn't help me. If I struggle, or I can't get a pulse I find a doppler much more helpful. My problem is rarely a correct depth problem, its just where to put the needle. The doppler solves that one.
 
I agree with what seems to be the growing concensus... I've only tried it this year as a CA3, but i've found it quite useful in the vasculopaths or after a few failed attempts that just can't seem to hit for one reason or another. Especially since our cardiologists for whatever reason have decided they like to cath through the radial now, and then they come to the OR the next day with a wrist that looks like it's seen 3 tours in vietnam... The U/S is already readily available for the Cordis, just one quick look, pluck, reduce much further trauma to the artery.
 
Let's say I get called to the MICU for help with an art line. Blood pressure is 70/30, septic patient on norepinephrine, vasopressin, and phenylephrine. Wrist is pockmarked with previous attempts by MICU residents or staff. No palpable radial pulse. Should I

1) take a few more blind attempts?

2) go femoral or brachial?

3) grab the ultrasound and get it on the first stick and go back to watching ESPN?

It's always an easy decision...
 
JPP with all due respect, this is nonsense:D.

I think ultrasound can be useful in placing arterial lines. I think its use is limited, but very valuable when needed.

Your post made my point.

Can it be useful?

Maybe.

ARE YOU A DESiGNER IF YOU'RE LEANING ON ULTRASOUND WITH AN A LINE?


Absolutely.

NONSENSE????

Never man.
 
I pull out the ultrasound a handful of times a year for a truly difficult a-line. It isn't routine and I can get an a-line in damn near anybody without it. But every now and then it comes in handy and when it does it makes the impossible look fairly routine.
 
What are your tricks for pulseless LVAD pt's, pt's where u just can't find the pulse or get a flash, and tiny/spasming arteries where it's tough to pass the wire even after through and through technique? I find most people like using ultrasound and the occasional micropuncture kit for these types.

Hear is a trick for a backside(Ala SN2) attack for LVAD patients. Find out what the patients native heart function is. If so turn down the LVAD flow especially with the HM II it will allow you to uncover pulsitile blood flow. Many times with LVADS the patients have native heart function enough for a small periods of pulsitile flow.
 
A few weeks ago we were struggling with an A-line. We pulled out the U/S and the struggling was over in a few minutes. I also use the U/S for IVs in very obese patients with a lot of padding in the arms.


We should make use of the technology that is available to us.

Cambie
 
A few weeks ago we were struggling with an A-line. We pulled out the U/S and the struggling was over in a few minutes. I also use the U/S for IVs in very obese patients with a lot of padding in the arms.


We should make use of the technology that is available to us.

Cambie

Agreed. Now I only use it when I've already struggled quite a bit, but in my limited experience it is amazing how resistant some arteries are to a needle poking into them. I've seen arteries that you can hit nearly square on under direct vision with ultrasound and the artery just pushes away to the side. It's only when you are perfectly centered that you can get into it.

For routine use, it'd be overkill. But every now and then it can be quite useful.
 
I don't use US for radial alines.

I have tried it successfully for radial alines, so I have no problem doing it.

If I have trouble getting a radial aline without US I just go to another site.

That being said, I have always gotten an arterial line if needed.
 
Hear is a trick for a backside(Ala SN2) attack for LVAD patients. Find out what the patients native heart function is. If so turn down the LVAD flow especially with the HM II it will allow you to uncover pulsitile blood flow. Many times with LVADS the patients have native heart function enough for a small periods of pulsitile flow.

Patients get LVADs for cardiogenic shock. I would not put a patient back in cardiogenic shock to attempt an arterial line when I have an ultrasound to see the damn thing a put a needle through it. US also allows you to see when the artery is clotted or otherwise not a good site. I've also yet to see the mythical "vasospasm" but have seen a ton of hematoma.
 
I agree with not turning off an assist-device. If you are not getting a good pressure wave at the extremity it is best to get a central aline tracing from the femoral if you really need it.

Turning off the assist device is asking for trouble.
 
I've also seen heavily calcified radial arteries that I elected to avoid further attempts on.

But I'd still rather try with an ultrasound than move on to another site such as femoral or brachial or axillary. (I will however go for the DP in most folks with little hesitation)
 
We do it here for our lvads. Do not turn it off just decrease the flow. Tuesday we did a sacral debridement on a patient w an lvad could not feel a pulse, one of the staff suggested they turn down the lvad flow. The patients native heart beat could then be palpated.
 
We do it here for our lvads. Do not turn it off just decrease the flow. Tuesday we did a sacral debridement on a patient w an lvad could not feel a pulse, one of the staff suggested they turn down the lvad flow. The patients native heart beat could then be palpated.

That would freak me the hell out.

Then again, I can count on one hand the # of LVADs I encountered as a resident. Sick hearts were not my program's specialty.
 
I think U/S can be useful as an educational tool to make you better at a-lines done WITHOUT U/S. A couple ways:

Try comparing where you THINK the artery is, by palpating and marking with pen, with where it ACTUALLY is, on U/S. You can do this on yourself or colleague also

Visualizing what you're doing with that needle in real time (I like the long-axis in-plane view).

Measuring artery diameters. Is this vasculopath gonna need a 22g cannula?
 
Let's say I get called to the MICU for help with an art line. Blood pressure is 70/30, septic patient on norepinephrine, vasopressin, and phenylephrine. Wrist is pockmarked with previous attempts by MICU residents or staff. No palpable radial pulse. Should I

1) take a few more blind attempts?

2) go femoral or brachial?

3) grab the ultrasound and get it on the first stick and go back to watching ESPN?

It's always an easy decision...

:thumbup::thumbup:
 
We do it here for our lvads. Do not turn it off just decrease the flow. Tuesday we did a sacral debridement on a patient w an lvad could not feel a pulse, one of the staff suggested they turn down the lvad flow. The patients native heart beat could then be palpated.

sounds like they dont need an LVAD
 
Thought about this thread yesterday, had a case in a 55 BMI cardiopulmonary cripple with fat edematous wrists about as thick as my leg. Couldn't feel a thing. I've used doppler many times to scout out a good first place to stick the needle, but haven't ever used u/s for an a-line. Ultrasound was sitting right there because I was going to use it for a central line, I thought what the hell ...

One stick, done seconds later, so easy.

I'm going to start using it more often, especially in awake patients.
 
ah, good situation. Seems like every tool has a place and time. You just need to have the presence of mind pull the trigger and use it.

Thought about this thread yesterday, had a case in a 55 BMI cardiopulmonary cripple with fat edematous wrists about as thick as my leg. Couldn't feel a thing. I've used doppler many times to scout out a good first place to stick the needle, but haven't ever used u/s for an a-line. Ultrasound was sitting right there because I was going to use it for a central line, I thought what the hell ...

One stick, done seconds later, so easy.

I'm going to start using it more often, especially in awake patients.
 
Thought about this thread yesterday, had a case in a 55 BMI cardiopulmonary cripple with fat edematous wrists about as thick as my leg. Couldn't feel a thing. I've used doppler many times to scout out a good first place to stick the needle, but haven't ever used u/s for an a-line. Ultrasound was sitting right there because I was going to use it for a central line, I thought what the hell ...

One stick, done seconds later, so easy.

I'm going to start using it more often, especially in awake patients.
Some patients I routinely use the ultrasound are sick septic female obese patients. Usually these patients are the worst increase skin thickness, hypotensive, edematous. I go straight to ultrasound in these cases.
 
I busted it out the other day as well. Had a post-op CABG (emergent from the cath-lab) on POD#1 in the ICU. Radial a-line wouldn't return blood and had crappy wave-form. Needed to be replaced. Large pt. to say the least. I look at the arms to find a good location and see that the brachial and radial locations had multiple attempts (assuming from the OR). Bad start. I try higher on the radial a couple of times and get nothing. Bust out the U/S, one shot at the brachial and had a wonderful new a-line. Like others have said, not a common use for the U/S but it has it's place and can be useful.
 
I busted it out the other day as well. Had a post-op CABG (emergent from the cath-lab) on POD#1 in the ICU. Radial a-line wouldn't return blood and had crappy wave-form. Needed to be replaced. Large pt. to say the least. I look at the arms to find a good location and see that the brachial and radial locations had multiple attempts (assuming from the OR). Bad start. I try higher on the radial a couple of times and get nothing. Bust out the U/S, one shot at the brachial and had a wonderful new a-line. Like others have said, not a common use for the U/S but it has it's place and can be useful.

I find I use U/S more in this setting: postop, in ICU, already had multiple attempts, and/or edematous from sepsis/etc. I have a low US threshold for brachial sites.
 
Yeah, my 'go to' a-line is a 20g (w/ TB syringe--plunger removed--attached). Get flash of blood. Roll needle bevel 180 degrees. Slide catheter off. It seems to have a higher success rate, as compared to the Arrow catheters...particularly in vasculopathic patients. I have no idea why.

If the above fails, I'll go through and through and use a wire. Rolling the needle seems to work well in kiddos, too. If I'm using a 24g, I go straight to the through and through technique, however.

I'm a huge fan of the "barrel roll" technique as you describe.
 
Have you guys run into any problems with complications from brachial a-lines? Ischemia/thrombosis, nerve injury?

I haven't seen it in my short career. However, one of our vascular anesthesia attendings has told me of cold hand cases he's had to do from them. Actually he almost beat my @$$ for trying a brachial in his room when I struck out on a radial.

I believe there's some data on this and there was not a significant increase in ischemic complications with brachial vs radials. I believe the hypothesis was, the larger caliber of vessel outweighs the lack of collaterals. We did them routinely for cardiac where I trained.

In my practice, I would exhaust both radials thoroughly before going higher.


Just noticed today is my 10th year SDN anniversary - how time flies!
 
Found some references on brachial vs radial:

Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine
Bernd V Scheer, Azriel Perel and Ulrich J Pfeiffer? Critical Care 2002, 6:199-204

Mann S, Jones RI, Millar-Craig MW, Wood C, Gould BA, Raftery EB: The safety of ambulatory intra-arterial pressure monitoring: a clinical audit of 1000 studies.
Int J Cardiol 1984, 5:585-597.

"Only one serious complication was found in a study of 1000 patients [62] in which the brachial artery was used for invasive monitoring in ambulatory patients. This complication was an infected haematoma arising from a pseudoaneurysm. Another study that employed the brachial artery for arterial blood sampling in 6185 patients [63] also showed a small number of complications (incidence 0.2%), mainly paresthesias."
 
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