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Anyone routinely doing this? Even if the pulse is bounding?
Why/Why not?
Why/Why not?
Anyone routinely doing this? Even if the pulse is bounding?
Why/Why not?
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.
Anyone routinely doing this? Even if the pulse is bounding?
Why/Why not?
Anyone routinely doing this? Even if the pulse is bounding?
Why/Why not?
I can drop an A line in a corpse.
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.
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.
I can drop an A line in a corpse.
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.
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.
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?
JPP with all due respect, this is nonsense.
I think ultrasound can be useful in placing arterial lines. I think its use is limited, but very valuable when needed.
Yes
If I have any trouble, plan B is through & through, then a wire as I withdraw.
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.
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
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.
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.
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...
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.
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.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.
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.
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 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.
Have you guys run into any problems with complications from brachial a-lines? Ischemia/thrombosis, nerve injury?
The doppler, embrace the doppler. Even with the LVAD folks you find it with a doppler.