help with art lines

[Fungi121]

(medical student here--I was told by a colleague that the anesthesiologists are the best to ask for these questions)

Art lines--> I usually end up having to stick the patient numerous times with multiple arrows just to even get it. The feel of doing an art line hasn't "clicked" with me yet. I feel the pulse and go for it, but then I always get nothing back.....


Any advice? Or resources I can use?

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[bashwell]

This might not be possible, but any chance you can have a friend take a quick (and anonymous, don't include face) video of you attempting to place an art line at least on a model, via your cell phone or iPad or whatever, to see how you're doing it?

Otherwise:

http://lifeinthefastlane.com/ccc/arterial-line/

 

[pgg]

Good position, wrist extended a little but not extended too much. (Helpful advice, right?)

Make sure you're comfortable, not hunched over or leaning or under a drape.

Find the pulse and stick the needle right there. Use a small amount of skin traction to keep everything still. Don't try to sneak upon it, just stick the needle in it. It's often more medial than you think.

Use local in awake patients.

If you're using a kit with a wire, and the wire doesn't go in EASY put the needle through-and-through, and try to pass the wire as the blood starts spurting as you withdraw the catheter.

And do a bunch of them.

 

[psychbender]

Try to feel for the artery, not just the pulse. When you need to redirect the needle, pull all the way back before changing your angle. Small movements translate to large changes as the needle gets deeper. When redirecting, also pick a direction medial/lateral), and systematically advance/withdraw in that way by a few degrees each time before changing and moving in the opposite medial/lateral direction. Don't give up, art lines can be rather discouraging initially.

 

[deleted162650]

The arrow kits are relatively dull. They like to push the artery around instead of actually piercing it like they should. This problem is amplified in old sick pts with crappy/hardened vasculature. Try using a 20g angiocath with through and through seldinger technique and I bet your success rate goes up.

 

[pgg]

Crusty old arteries are often easier to get cannula red without using a wire at all.

A nice sharp angiocath, get the flash, turn it 180 so the bevel is down (so the tip won't snag on the back wall of the vessel), advance further into the vessel, thread off catheter. If you're successful hitting the vessel but can't get a wire in, try this technique.

 

[GA8314]

Beta blockade with a non-selective drug....... I jest, but not entirely. I'm amazed how many folks have a slight intention tremor. That's a real liability in this gig but it can be corrected.

 

[Noyac]

Try to feel for the artery, not just the pulse.

This is it!
You need to feel more than just the pulse. Feel the artery. Place two fingers on it wit ha slight separation btw your fingers. Mentally map out the artery. It should feel like a rope under the skin. Line your needle up along the axis you feel. This technique will save you and possibly a pt someday. You will be the one that will get an A line in on a pulseless pt because you always feel for the rope and not just the pulse.
Also, many times we pass directly through the artery. This is fine. Once you believe you are past the depth of the artery pull back slowly. Once blood flows then gently thread the wire.
There is still much more to Aline's but that's all I can muster on a forum.

 

[Nivens]

I was having issues with my wires not threading despite arterial bloodflow, as well as losing the vessel after I'd gotten a flash, until one of my seniors in the MICU (who hates procedures and is going into primary care, of all things), noticed that I was getting a flash, going through and through, and THEN dropping the angle of my catheter, resulting in a very steep angle of puncture and a small amount of needle actually in the vessel and therefore a small margin for error when pulling back. He suggested I drop the angle after I see the flash but before advancing through and through, so the result is a much shallower angle and therefore more steel in the vessel. Made a huge difference.

(Sorry if that's confusing. Would be so much easier to show you.)

 

[jwk]

I was having issues with my wires not threading despite arterial bloodflow, as well as losing the vessel after I'd gotten a flash, until one of my seniors in the MICU (who hates procedures and is going into primary care, of all things), noticed that I was getting a flash, going through and through, and THEN dropping the angle of my catheter, resulting in a very steep angle of puncture and a small amount of needle actually in the vessel and therefore a small margin for error when pulling back. He suggested I drop the angle after I see the flash but before advancing through and through, so the result is a much shallower angle and therefore more steel in the vessel. Made a huge difference.

(Sorry if that's confusing. Would be so much easier to show you.)

I'm not sure why, once you see a flash, you would continue to go through the back wall. Get a flash, lower the needle virtually parallel to the skin, slide the wire in, and done. I sometimes go through and through, but not when I see already see a flash.

 

[Urzuz]

I completely agree with the folks above who have said you should try to feel the artery, not just the pulse. In this regard, when feeling for the artery, something I have found extraordinarily helpful is feeling with the tips of my fingers. I used to attempt arterial lines while trying to palpate with the pads of my fingers, but I found that the area was too wide and did not give me a precise enough idea as to where the artery is actually located. With the tips of my finger, the area is much more narrow, and I now have a much better sense of where the artery actually is.

 

[Nivens]

I'm not sure why, once you see a flash, you would continue to go through the back wall. Get a flash, lower the needle virtually parallel to the skin, slide the wire in, and done. I sometimes go through and through, but not when I see already see a flash.

I'm an anesthesiology intern who is supervised by medicine residents that are oftentimes terrified of procedures and insist on doing it through and through every time because that's the way they are taught, even though it makes zero sense. I had one resident actually yell "YOU'RE GOING TO DISSECT THE ARTERY!" when I attempted to wire after a flash without then going through and through.

 

[partydoc]

i find that i have better luck in the ICU if i go through and through. I like that technique for patients with arteries which are barely palpable or edemetous extremeties. i don't usually do through and through in the OR though

 

[ZzzPlz]

If you swing and miss, before you withdrawal, feel very carefully on both sides of the catheter and determine which direction you need to correct. Right at the base where it meets skin. Sounds obvious but helped me a lot before I was really comfortable feeling for the artery as mentioned above.

 

[link2swim06]

Ultrasound? Do it long axis and you can watch it go in.

 

[Wiscoblue]

The problem with going out the posterior wall is that when you come back into the lumen, your posterior wall hole will now start to make a hematoma and you don't have much time to thread the wire and push the catheter up the artery. Second chances are usually harder when there are two holes that are now bleeding.


Sent from my iPad using Tapatalk

 

[deleted162650]

If using an Arrow then do as Jwk says. If using angiocath then through and through then wire unless ur gonna go all ninja and thread it without the wire.

 

[Noyac]

I don't understand changing the angle after the flash. In my mind you should start out at the best angle and leave it there. I rest my hand in the pts Palm and that's my angle. My hand is stabilized and the tip doesn't move once I get a flash.

If you miss, then 90% of the time the artery is medial.

 

[deleted162650]

My hand is stabilized and the tip doesn't move once I get a flash.

That's what she said.

 

[sevoflurane]

I think that those individuals who are basterdizing through and through technique haven't done many of them. It's a great technique and it works awesome. It's THE way I've done my a-lines for the last 12 years. I did switch to the arrow kit this year cuz we don't carry the angiocaths I prefer for through and through. Arrow kit with a flash works great too, but through and through technique is just as flawless once you've mastered it.

Here is a link to an a-line through and though technique I made a couple of years ago. Took longer than usual, yet still super quick. Note the 3 passes honed me in to where I needed to be.

 

[sevoflurane]

Ohh yeah... and NOY is spot on. Notice that in the video I worked my way medial.

 

[GasEmDee]

Nice video and sound track Sevo! The other thing i do is to localize the artery with the tips of my fingers, rather than the pads. It gives me a little more precision.

 

[narcusprince]

When I was a resident and wanted to tighten my arterial line game to the point of maximal slickness I made my own aline simulator. I got some regular IV tubing, a cloth binder( they sell these at office max the cloth binders for iPads or laptops) wrapped the IV tubing into the binder, added cloth on the outside of binder for increased difficulty. Then I used the arterial line angiocatheter and palpated the location of the tubing on the outside and placed angiocath inside the tubing. It allowed me to check to see if my sticks were dead center or off. Really tightened my aline game.

 

[RxBoy]

Any advice? Or resources I can use?

1) Dont sweat it, you're a med student. Be happy you're touching the needle. Focus more on understanding waveforms and application. When it comes to a-lines, N=50 until you're proficient, and N=100 when you're decent at them. Unless your eyes have ultrasound beams, that's just the way it is. You will never get those numbers until residency.

2) If you somehow do have a lot of opportunities to do a-lines, learn to use an ultrasound. Long axis is an advanced technique, try short access just to see it. That way you can focus more on the mechanics of threading it, and less on locating it. Cool little test is to locate the pulse by feel alone, introduce the needle a mm and then look under u/s. Like others said, the artery is almost always more medial than you think.

 

[cockblockandrun]

I would also recommend learning how to use the ultrasound. It comes in handy when you have a restless surgeon, have a small and elderly patient with a faint pulse... ultrasound guided can be extremely useful in those situations.

 

[Ronin786]

I think that those individuals who are basterdizing through and through technique haven't done many of them. It's a great technique and it works awesome. It's THE way I've done my a-lines for the last 12 years. I did switch to the arrow kit this year cuz we don't carry the angiocaths I prefer for through and through. Arrow kit with a flash works great too, but through and through technique is just as flawless once you've mastered it.

Here is a link to an a-line through and though technique I made a couple of years ago. Took longer than usual, yet still super quick. Note the 3 passes honed me in to where I needed to be.

Love the video. Another take home point from it is if you're not getting flash, redirect a lot sooner. The artery is usually very superficial and going deeper isn't going to help as much. What watch is that btw?

Also to Noyac's point, I never did understand why you need to level your angle out. Especially with the arrow kits given how close the wire is to the needle point and how flexible it is.

 

[Planktonmd]

The way I do it is very similar to placing an IV, enter the skin with a pretty flat angle using an angiocatheter attached to a 1 ml syringe without plunger or the outer cover of the angiocatheter if you have the one that has a hole in it's tip.
Go in straight like cannulating a vein and when you see the pulsating blood in the syringe advance the needle another millimeter, if the blood continues to pulsate advance the catheter, if it stops pulsating pull out a little and go in more flat.
Very easy and no special fancy tricks.
I never understood why people feel they need to put a hole on each side of the artery to insert a catheter!!!

 

[Noyac]

Sevo's technique is solid. But I like the Arrow technique because I don't use any assistants 90% of the time. If I do have one, I will place the Arrow cath with the wire advanced and at this point I am done. I hand over the reigns to the assistant (Kendra to you Sevo) to hook up. It won't make a mess this way either since the wire is in.

Another trick, if you notice in Sevo's video he did a very good job of not making a huge mess. This is tricky to do. He is slick because he has done so many. But if you are not so slick yet then place a good bit of pressure on the artery proximal to the tip of the catheter when removing the wire and hooking up the tubing. Blood won't go everywhere and it will score you some bonus points.

 

[BCM]

1) Dont sweat it, you're a med student. Be happy you're touching the needle. Focus more on understanding waveforms and application. When it comes to a-lines, N=50 until you're proficient, and N=100 when you're decent at them. Unless your eyes have ultrasound beams, that's just the way it is. You will never get those numbers until residency.

2) If you somehow do have a lot of opportunities to do a-lines, learn to use an ultrasound. Long axis is an advanced technique, try short access just to see it. That way you can focus more on the mechanics of threading it, and less on locating it. Cool little test is to locate the pulse by feel alone, introduce the needle a mm and then look under u/s. Like others said, the artery is almost always more medial than you think.

I would also recommend learning how to use the ultrasound. It comes in handy when you have a restless surgeon, have a small and elderly patient with a faint pulse... ultrasound guided can be extremely useful in those situations.

Agree, learning to use ultrasound is very helpful. The set up takes a little longer but you save time with cannulation and less sticks.

 

[Mman]

Beta blockade with a non-selective drug....... I jest, but not entirely. I'm amazed how many folks have a slight intention tremor. That's a real liability in this gig but it can be corrected.

I disagree. I've had a slight essential tremor as long as I can remember and find it doesn't hinder procedural performance at all. Why? Because once the needle touches the skin, any tremor is gone. With things like a-lines and central lines and nerve blocks, you just break the skin and then the advancing and withdrawing of the needle is anchored within the soft tissue of the patient so any tremor is damped.

The only thing we do that it impacts for me is placing the central line over the guide wire. Some people can do it by holding the wire 12 inches away and threading the catheter onto it in mid-air. I can't. I get around by just grabbing the wire right at the tip and then pushing it into the CVP catheter. But that's really the only thing we do where you would notice my tremor.

 

[Mman]

Agree, learning to use ultrasound is very helpful. The set up takes a little longer but you save time with cannulation and less sticks.

I use ultrasound for all kinds of things and am very quick with it, but I still do not find that routinely using it for arterial lines saves time. In other words if I do 100 arterial lines without an ultrasound (for initial attempts, getting it if needed later) and 100 arterial lines with an ultrasound from the start, the 100 I did without the U/S will take a decent amount less total time.

 

[WholeLottaGame7]

I'm not sure why, once you see a flash, you would continue to go through the back wall. Get a flash, lower the needle virtually parallel to the skin, slide the wire in, and done. I sometimes go through and through, but not when I see already see a flash.

Depends on what kind of flash I get. If I get pulsatile flow, I'll drop the angle slightly and thread the wire, but if it's a true flash and then nothing, I'll just go through and through. The success rate is lower than when you get good flow back, but definitely higher than trying to thread as is.

 

[Impromptu]

Lots of good advice here. Adding all of them to your skillset will make you better, because even when you become a master at arterial lines, you'll still struggle occasionally.

Another possible trick is that as you are advancing with an Arrow, you can try short bursts of 1-2 mm forward motion to spear the artery rather than one smooth motion. The smooth motion may indent and compress the artery so you don't know that you passed through it, or more likely, it might push the artery to the side. But the spearing may allow you to better catch it, like a mighty hunter.

If the nurses have wrapped 7 wrist bands of varying nature around his wrist and I don't feel like cutting them off, or they used the intern's vein with lots of tape coming into the artery's space, I'll move to the middle of the forearm and use a doppler ultrasound to guide my attempt. It gives you similar information as palpating the pulse, and the artery is usually a little bigger there, so easier to thread once you hit it.

 

[chfo]

Most people don't realize that moving the needle through the skin and subcutaneous tissue that the artery moves with the tissue.

I recommend moving sub-millimeter amounts, and reassessing location of artery by palpation continuously. Adjust lateral angle based on how the artery moves.

Nobody taught me this, just learned it on my own. First pass success using arrow, and threading the wire immediately after flash, is very high, and very quick. 90% success. Remaining 5% requires through and through. Other 5% requires withdrawing needle to skin and finding another path through the subcutaneous tissue.

 

[Mman]

Most people don't realize that moving the needle through the skin and subcutaneous tissue that the artery moves with the tissue.

I recommend moving sub-millimeter amounts, and reassessing location of artery by palpation continuously. Adjust lateral angle based on how the artery moves.

"Sub-millimeter"? So if the artery is 0.5 cm deep, do you take 10 or 20 movements before you get down to it? That's gotta take forever. Want to know what I do? Stick it. One smooth motion. If you don't get it back out and redirect slightly. If you make small enough movements, in some arteries you will just push them out of the way without ever breaking into them.

 

[k12balla]

For vasculopathic patients, ultrasound with the arrow kit i.e. 20g needle connected to 3cc syringe with constant mild negative pressure until you get flow or through and through if you prefer. Then guidewire, then catheter. For extremely difficult ones, ensure the artery is pulsatile with a decent internal diameter of the intima (as opposed to the much larger external adventia border). If it has become severely atherosclerotic, work your way up the forearm or go for the brachial. For newbies, I would recommend using US combined with tactile sensation to get better feedback at first, and then eventually do it soley by feel. It's a similar to having new residents intubate with a video laryngoscope initially to get a better feel for the anatomy etc, and then learning how to DL.

 

[sluggs]

CCM here but I read this forum a lot. I have a lot of patients who are vasculopaths, anasarcic or both. I learned this technique from an anesthesia ccm guy with psoriasis on his finger tips, who could not feel pulses:
1. sonosite with sterile cover
2.cross sectional view
3. put needle in artery and thread
I have used this for 5 years, have essentially stopped doing art lines blind (except for the occasional young skinny patient), and am a lot happier. If I can't get an art line like this, it probably ain't gettable.

 

[chfo]

"Sub-millimeter"? So if the artery is 0.5 cm deep, do you take 10 or 20 movements before you get down to it? That's gotta take forever. Want to know what I do? Stick it. One smooth motion. If you don't get it back out and redirect slightly. If you make small enough movements, in some arteries you will just push them out of the way without ever breaking into them.

It doesn't take long at all, actually. Because I have a very high first pass success rate, I don't have to worry about making multiple quick attempts with the associated problems.
1) surrounding tissue/nerve/vein/tendon trauma
2) double-sticking the artery and causing a posterior bleed and hematoma


The reason why I recommend the small movements is that with readjustment, you're not really "pushing" the artery out of the way, you're just finding the correct tissue plane to travel down to get to the artery. Quick movements probably just break through the different planes more easily, not because the artery is prevented from getting pushed out of the way.

Nothing is more satisfying than putting the needle through the skin, finding the correct tissue plane, piercing the artery, threading the wire, then the catheter, in one swoop. 10 seconds tops. Smooth operator.

 

[Mman]

It doesn't take long at all, actually. Because I have a very high first pass success rate, I don't have to worry about making multiple quick attempts with the associated problems.
1) surrounding tissue/nerve/vein/tendon trauma
2) double-sticking the artery and causing a posterior bleed and hematoma


The reason why I recommend the small movements is that with readjustment, you're not really "pushing" the artery out of the way, you're just finding the correct tissue plane to travel down to get to the artery. Quick movements probably just break through the different planes more easily, not because the artery is prevented from getting pushed out of the way.

Nothing is more satisfying than putting the needle through the skin, finding the correct tissue plane, piercing the artery, threading the wire, then the catheter, in one swoop. 10 seconds tops. Smooth operator.

I find it hard to believe you can make that many small movements in 10 seconds. I suspect you aren't making "sub-millimeter" movements as that small of a motion is hard to even control/detect (a 1/2 millimeter is less than the distance from needle to catheter in an arrow kit). What I don't find is it hard placing an a-line in less than 10 seconds. It isn't. Nor is it hard to get it on your first pass once you know what you are doing.

 

[SouthSideSteve]

I have used this for 5 years, have essentially stopped doing art lines blind (except for the occasional young skinny patient), and am a lot happier.

Not sure how sticking a needle in a pulsatile artery is "blind". I do thousands of Alines a year (on severe vasculopaths/VADs/etc) and use ultrasound a handful of times.

It's a nice tool to have but wholly unnecessary for arterial lines. If you know the anatomy you can get a line on a pulseless patient.

 

[Planktonmd]

I do thousands of Alines a year

Blade... is that you???

 

[nimbus]

Not sure how sticking a needle in a pulsatile artery is "blind". I do thousands of Alines a year (on severe vasculopaths/VADs/etc) and use ultrasound a handful of times.

It's a nice tool to have but wholly unnecessary for arterial lines. If you know the anatomy you can get a line on a pulseless patient.

Please teach us sensei.

 

[Arch Guillotti]

Not sure how sticking a needle in a pulsatile artery is "blind". I do thousands of Alines a year (on severe vasculopaths/VADs/etc) and use ultrasound a handful of times.

So you do at least 200 art lines a a year. Assuming you work 46 weeks per year thats 2000/46=43.47 art lines a week or over 8 a day? That is impressive!

 

[Mman]

So you do at least 200 art lines a a year. Assuming you work 46 weeks per year thats 2000/46=43.47 art lines a week or over 8 a day? That is impressive!

Seems a bit much. I think I do a lot because I do almost all a-lines in my patients while the CRNA/AA handles the airway and it probably averages out to about 3 per day at this point. Some days only 1, a busy day might be 5. But we sort of spread out our rooms so no doc has a bunch of big/sick cases.

 

[ArMed]

Although I haven't adopted this approach, there are some that ONLY use the Sonosite, they think it makes them look slick, and to an untrained patient, it may.
I think it's important to become familiar with the subtle resistance of the artery wall and the subsequent "pop" feeling as you pierce it. An ultrasound can help you visualize this in real time as you're starting out.

Also, when I "cheat" with an ultrasound, I like to track the radial up to the mid-forearm. More proximal lines tend to dampen less over time IMO.

 

[chfo]

Seems a bit much. I think I do a lot because I do almost all a-lines in my patients while the CRNA/AA handles the airway and it probably averages out to about 3 per day at this point. Some days only 1, a busy day might be 5. But we sort of spread out our rooms so no doc has a bunch of big/sick cases.

Do you have actual indications for art line placement or are you just trying to get reimbursement cut for over utilization?

 

[Mman]

Do you have actual indications for art line placement or are you just trying to get reimbursement cut for over utilization?

I'm very conservative about using arterial lines. But at a major level 1 trauma center we do lots of major cases that require invasive monitoring. The pittance we get in reimbursement for them is irrelevant to clinical decisions.

 

[nimbus]

I think it's important to become familiar with the subtle resistance of the artery wall and the subsequent "pop" feeling as you pierce it. An ultrasound can help you visualize this in real time as you're starting out.
IMO.

This. And I have easy access to US so i use it most of the time.

 

[jk1979]

a-line placements will become easier as technology using ultrasound and smart catheters begins to gain traction

 

[SouthSideSteve]

So you do at least 200 art lines a a year. Assuming you work 46 weeks per year thats 2000/46=43.47 art lines a week or over 8 a day? That is impressive!

I do between 6-10 a day. I don't have the time or the desire to get you an exact number. Between 7 cardiac rooms and 3 ICUs (60+ beds) I do more than I'd care to. I have been paged on numerous occasions by very good cardiac anesthesia attendings (whom I have tons of respect for clinically) to assist with lines. I'm just a stupid CT PA though. Alines are not a terribly difficult skill when you get the reps I do.

I just hate how much of a crutch US has become. For CVLs I can see it, but using it for EVERY Aline is absolutely stupid & wasteful (of time & resources). I will even use US on occasion, but 98% of the I can get a line by knowing anatomy. Radial harvests might help with that, who knows.