Large Vessel Arterial Pressure Monitoring

[pgg]

At the risk of stating the obvious, "standard of care" doesn't mean "you're not allowed to do something else if an emergency occurs and the equipment you'd normally use for an elective procedure isn't available in a timely manner" ...

It's what a reasonable practitioner in that community would do under similar circumstances. Listing edge cases isn't an argument against anything being SOC.

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[medicine2wallstreet]

The “creep” method has made my success rate pretty dang close to 100%. I don’t use the arrow / wire. Long 20G angiocath. I never look to see if there’s blood return. Why would I? I park the entire catheter in the lumen under ultrasound guidance and just withdraw the needle. There’s a right way and a wrong way to use U/S.

Everybody thinks they're the best there is. Just ridiculous.

 

[medicine2wallstreet]

In most hospitals, “land mark based skills” for a central line are not even allowed by policy. I’d much rather trainees learn ultrasound, heck maybe ONLY ultrasound, for IJs. If I were a patient (maybe an exception for some older pro that is really slick with landmark based techniques) but I would really prefer to have that line inserted under real time guidance by someone highly experienced with ultrasound.

This is folly. In a patient truly in extremis the time saved by using landmark techniques can be critical. Obviously ultrasound is superior in a controlled setting with time on your hands, no one would argue that. But sometimes life or death resuscitation efforts require immediate access. Not waiting on an ultrasound. Not teaching residents such a technique is only leaving them short handed by your own limited mind.

 

[Iso4ane]

I'm willing to admit that I'm a little bit biased given the way I trained. US got progressively more available as went through training, and I'm comfortable with both techniques. And I have no problems with going with US if I think it's going to be difficult, but I'm damn near Tiger Woods with the chip shots.

 

[NumTacos]

This is folly. In a patient truly in extremis the time saved by using landmark techniques can be critical. Obviously ultrasound is superior in a controlled setting with time on your hands, no one would argue that. But sometimes life or death resuscitation efforts require immediate access. Not waiting on an ultrasound. Not teaching residents such a technique is only leaving them short handed by your own limited mind.

I agree with you; it should certainly be taught. The problem is, of course, actually doing it on patients for elective cases. I think one of the commenters mentioned a way to teach the technique while verifying with ultrasound, which makes sense to me. It's kind of like needle crics, I "know" how to do them, practiced on a pig, but it's not second nature. However, if you use the landmark technique and have a complication, there will be lots of typing involved.

And you know, cool it with the ad hominem. There's really no need for that; we are all professionals here.

 

[Iso4ane]

Everybody thinks they're the best there is. Just ridiculous.

It's an art line. It's like staying in between the lines while driving. It doesn't take F1 level techniqueto be proficient.

 

[patriot6]

This is folly. In a patient truly in extremis the time saved by using landmark techniques can be critical. Obviously ultrasound is superior in a controlled setting with time on your hands, no one would argue that. But sometimes life or death resuscitation efforts require immediate access. Not waiting on an ultrasound. Not teaching residents such a technique is only leaving them short handed by your own limited mind.

actually, i find ultrasound to be extremely helpful in cannulating the artery with a distal pressure of 50/30

 

[T-burglar]

actually, i find ultrasound to be extremely helpful in cannulating the artery with a distal pressure of 50/30

Agreed, you aren’t taking care of a patient in extremis if you are palpating a radial pulse and sticking it on the first try lol

 

[T-burglar]

And again, the solution to the problem of ultrasound “taking too long” for the patient in extremis is a logistical one. Get more hands to help you do the procedure . Turn it on, find gel , prep and position the arm . There should be members of the team that know that their role is to facilitate the lines in an emergency.

We’ve worked out a system here where we have up to 3 physicians working at once on central lines and arterial lines in a cardiac emergency. We can do a 2 operator double stick very fast and we use ultrasound. I guarantee you we are faster than the rest of you that think you’re going to get away with landmark techniques in a spontaneously breathing cardiac patient that’s nearly bled out.

In 2023 maybe we should be asking ourselves if heart surgery should really be done in places that can’t manage this.

 

[DrN2O]

Ultrasound DOESN'T LIE? Any sonographer or echocardiographer should know a dozen ways artifacts can be generated with US. The gold standard should still be blood flow and not a computer generated image based on reflected echo that makes many assumptions about how the sound wave traveled.

However if I need to spell out for all the US devotees here, the bullseye with no flow is not an artifact. The needle is simply indenting the elastic wall, so you haven't popped through yet.

I have straddled the advent of ubiquitous US, and am now on the side of old geezer. But having a sense of anatomy and how your equipment work are still important.

 

[itwasalladream]

Who cares how you get it in as long as it's in quick.

As for the question asking about large bore art lines - I rarely go higher than radial by pure choice. Our team places additional femoral art lines for the cases we suspect may need IABP, and that covers some of the cases where there are likely to be large discrepancies. If the radial doesn't look good I have no real concerns going with brachial, it's just not my practice to stick brachial when the radial looks fine. I don't love axillary art lines because under ultrasound there's a bunch of nerves I try to avoid, but just end up making the line more difficult.

Occasionally the radial is dampened while coming off but you suspect it will get better in a few minutes. Sometimes I'll ask the surgery team to transfer the retrograde pressure tubing over to the aortic root vent (if you were using retrograde plegia for the case, and root vent has a stopcock on it like ours does). You can get a quick sense of the differential in pressure when you first separate from CPB, and get through the next 10-15 minutes knowing the central SBP is about X points above the radial. Then as the radial pressure waveform shape becomes less damp you can trust it more.

 

[Beeftenderloin]

Ultrasound DOESN'T LIE? Any sonographer or echocardiographer should know a dozen ways artifacts can be generated with US. The gold standard should still be blood flow and not a computer generated image based on reflected echo that makes many assumptions about how the sound wave traveled.

However if I need to spell out for all the US devotees here, the bullseye with no flow is not an artifact. The needle is simply indenting the elastic wall, so you haven't popped through yet.

I have straddled the advent of ubiquitous US, and am now on the side of old geezer. But having a sense of anatomy and how your equipment work are still important.

If you’re indenting the wall, you’re not going to see a bullseye, you’re going to see a shallow u shaped compressed vessel with a dot in the indented portion of the U (as long as you aren’t coming in extremely steep, in which case you may see no needle at all, just the indented vessel). If you are only tenting the vessel and somehow manage to confuse that for being inside the vessel, that’s not the fault of the ultrasound, you just don’t know what you’re looking at. That’s called USER ERROR.

 

[medicine2wallstreet]

I agree with you; it should certainly be taught. The problem is, of course, actually doing it on patients for elective cases. I think one of the commenters mentioned a way to teach the technique while verifying with ultrasound, which makes sense to me. It's kind of like needle crics, I "know" how to do them, practiced on a pig, but it's not second nature. However, if you use the landmark technique and have a complication, there will be lots of typing involved.

And you know, cool it with the ad hominem. There's really no need for that; we are all professionals her

actually, i find ultrasound to be extremely helpful in cannulating the artery with a distal pressure of 50/30

I completely agree with that I'm talking about central access.

 

[abolt18]

If you’re indenting the wall, you’re not going to see a bullseye, you’re going to see a shallow u shaped compressed vessel with a dot in the indented portion of the U (as long as you aren’t coming in extremely steep, in which case you may see no needle at all, just the indented vessel). If you are only tenting the vessel and somehow manage to confuse that for being inside the vessel, that’s not the fault of the ultrasound, you just don’t know what you’re looking at. That’s called USER ERROR.

Nah. I've had it too where I've got a bullseye, keep advancing, still no blood, then suddenly there's a tiny pop and I get blood. Best guess is some thin intimal layer that I couldn't see on US was keeping it from flowing.

 

[Onefellswoop87]

I don’t think it’s unreasonable to call ultrasound for arterial lines “best practice” vice standard of care, in order to leaving legal wiggle-room for lack of ultrasound. I say this cause ultrasound does increase success rate

However I do have a problem calling video laryngoscopy best practice or SOC, now or in the reasonable foreseeable future. Last time I looked at the data, VL improved the view obtained but did not improve success of intubation relative to DL.

 

[Beeftenderloin]

Nah. I've had it too where I've got a bullseye, keep advancing, still no blood, then suddenly there's a tiny pop and I get blood. Best guess is some thin intimal layer that I couldn't see on US was keeping it from flowing.

The description of popping in, seeing the needle intralumenal then feeling a second pop and getting flash is likely due to a small iatrogenic dissection. Have seen that one time with that exact same sequence of events and findings. Have had a true functional intralumenal catheter with a dry arrow chamber more than a few times though.

Your case is a clear dissection. Previous poster was talking about tenting the vessel wall and saying that can be mistaken for being inside the vessel. These are 2 distinct phenomena.

 

[deleted875186]

The description of popping in, seeing the needle intralumenal then feeling a second pop and getting flash is likely due to a small iatrogenic dissection. Have seen that one time with that exact same sequence of events and findings. Have had a true functional intralumenal catheter with a dry arrow chamber more than a few times though.

Your case is a clear dissection. Previous poster was talking about tenting the vessel wall and saying that can be mistaken for being inside the vessel. These are 2 distinct phenomena.

Agreed, dissection, or needle popped through outer vessel wall but tip still in a muscular layer and not intraluminal.

 

[patriot6]

Ultrasound DOESN'T LIE? Any sonographer or echocardiographer should know a dozen ways artifacts can be generated with US. The gold standard should still be blood flow and not a computer generated image based on reflected echo that makes many assumptions about how the sound wave traveled.

However if I need to spell out for all the US devotees here, the bullseye with no flow is not an artifact. The needle is simply indenting the elastic wall, so you haven't popped through yet.

I have straddled the advent of ubiquitous US, and am now on the side of old geezer. But having a sense of anatomy and how your equipment work are still important.

this is wrong. there are plenty of times that i have no flow in my arrow (when i actually use it), but i can demonstrate with ultrasound that the needle in the middle of the lumen, so i thread the wire and catheter without any issues. i assure you, the needle is not simply endenting the elastic wall.

 

[DocVapor]

Just speaking for myself here, but sometimes when I get some sleep and come back to read my posts from the day before, I realize what a f***ing nerd I am for arguing about this stuff on the internet. And I get sad.

 

[vector2]

Nah. I've had it too where I've got a bullseye, keep advancing, still no blood, then suddenly there's a tiny pop and I get blood. Best guess is some thin intimal layer that I couldn't see on US was keeping it from flowing.

Yep, as others have said, dissection or circumferential intramural hematoma. I've done it accidentally a few times. It looks like a small pulsatile circle inside a larger circle, so bullseye sign can show up if you're in the mural layer (which will still look like you're generally in the vessel), but you won't get blood cause it's not in the true lumen.

 

[brominator]

Can also try to do ultrasound in plane , very helpful for peds. Even better use the biplane on the butterfly , best of both worlds

 

[PpfSuxTube]

This is folly. In a patient truly in extremis the time saved by using landmark techniques can be critical. Obviously ultrasound is superior in a controlled setting with time on your hands, no one would argue that. But sometimes life or death resuscitation efforts require immediate access. Not waiting on an ultrasound. Not teaching residents such a technique is only leaving them short handed by your own limited mind.

You want immediate access and your 1st thought is landmark based central access? As a ca2? Are there any other veins, routes or sites you could think of to attempt 1st?

Have you ever seen a central line in a carotid? How many central lines have you done landmark based? Do you know as an attending if you harm someone from attempting central access without using uss your insurance company may not support you?

 

[nimbus]

This is folly. In a patient truly in extremis the time saved by using landmark techniques can be critical. Obviously ultrasound is superior in a controlled setting with time on your hands, no one would argue that. But sometimes life or death resuscitation efforts require immediate access. Not waiting on an ultrasound. Not teaching residents such a technique is only leaving them short handed by your own limited mind.

We didn’t have ultrasound during residency so we only learned landmark lines. I did only landmark central lines during my first few years of practice. Now I work at a busy trauma center where I can get an ultrasound in less than a minute. I only do ultrasound guided central lines. Our practice is self insured and we require real-time ultrasound guidance for central lines for good reason. Much better to wait a minute than to stick a cordis in a carotid or bugger up a perfectly good IJ with a massive hematoma. Make your first shot your best shot with ultrasound.

 

[caligas]

Doesn’t walking/chasing the whole line in take time? Flash-wire-cath is so simple and fast.

 

[Beeftenderloin]

Doesn’t walking/chasing the whole line in take time? Flash-wire-cath is so simple and fast.

Yes, about 10 extra seconds.

 

[caligas]

Yes, about 10 extra seconds.

But 10 seconds SDN time = 20 minutes in real world.

Seriously though, I’ll give it a try.

 

[pgg]

Doesn’t walking/chasing the whole line in take time? Flash-wire-cath is so simple and fast.

Flash-wire-cath (with ultrasound out-of-plane) is what I do almost all the time.

Once the wire is in, I do flip the needle 180 and advance the whole thing a cm or so. Occasionally a radial artery is so crusty that the catheter is difficult to slide into the vessel even when that thick Arrow wire is several cm into the artery. Advancing the needle/catheter assembly over the wire until the catheter itself is well into the vessel avoids this.

If the wire doesn't slide in with ZERO resistance, then I will take the extra 10 seconds with the ultrasound to really walk it in precisely.

 

[DrN2O]

Flash-wire-cath (with ultrasound out-of-plane) is what I do almost all the time.

Once the wire is in, I do flip the needle 180 and advance the whole thing a cm or so. Occasionally a radial artery is so crusty that the catheter is difficult to slide into the vessel even when that thick Arrow wire is several cm into the artery. Advancing the needle/catheter assembly over the wire until the catheter itself is well into the vessel avoids this.

If the wire doesn't slide in with ZERO resistance, then I will take the extra 10 seconds with the ultrasound to really walk it in precisely.

Although flipping the bevel 180 is some next level jedi s***

 

[Maverikk]

Anybody know what exactly the cardiologists inject to dilate the radial artery (what do they use and what doses)? I recall a thread awhile ago mentioning it…seemed interesting I think it was a combination of nitro and something else? Anyone ever try this? I usually just go up to brachial if needed

 

[DrN2O]

Topical lido before. Intraaterial nicardipine or nitro, which rarely works for me when the line start to die.

Anybody know what exactly the cardiologists inject to dilate the radial artery (what do they use and what doses)? I recall a thread awhile ago mentioning it…seemed interesting I think it was a combination of nitro and something else? Anyone ever try this? I usually just go up to brachial if needed

 

[ProwlerturnGas]

I clearly remember in residency doing a heart case and looking under US at a RIJ that was congenitally absent. Otherwise normal guy. Huge left IJ. Really brought home to me that US is SOC. I also become very good at US guided subclavians in fellowship which has served me well

 

[T-burglar]

It’s not infrequent at all that a RIJ will be diminutive compared with the left, which can be a clue to a discontinuous caval system in a left SVC. I’ve run into undiagnosed left SVC more than once .

In any event, ultrasound should be standard of care for arterial or central venous access period.

 

[FiO2@21]

This is folly. In a patient truly in extremis the time saved by using landmark techniques can be critical. Obviously ultrasound is superior in a controlled setting with time on your hands, no one would argue that. But sometimes life or death resuscitation efforts require immediate access. Not waiting on an ultrasound. Not teaching residents such a technique is only leaving them short handed by your own limited mind.

People may disagree with me but:

If you need “life or death” access just put in an IO. The days of people doing landmark fem lines during a code should be over.

If you need large bore access an ultrasound 14-16G PIV is probably still faster than a landmark subvlavian frequently.

 

[sanityonleave]

I clearly remember in residency doing a heart case and looking under US at a RIJ that was congenitally absent. Otherwise normal guy. Huge left IJ. Really brought home to me that US is SOC. I also become very good at US guided subclavians in fellowship which has served me well

I do a lot of ultrasound subclavians these days. They're great lines. I also use fluoro not infrequently in the OR for lines, esp in patients with abnormal anatomy.

Also I'm firmly on the side of ultrasound for everything. Ultrasound is basically ubiquitous at this point - and if you're having trouble getting an ultrasound to the room in an emergency, you need to change your workflow. Fun fact: I worked in an extremely resource limited setting (think refugee camp in an active conflict area) and we were using pentothal and halothane (in 2021) with no vent or oxygen tanks... but I still had ultrasound.

I've had to go to the trauma bay or to the OR to stop some "experienced" folks who are believers in landmark techniques flailing around in the groin / wherever without ultrasound -- it might be /marginally/ faster if you a) get it in first try and b) are draping the ultrasound so as to make the line sterile for that approach. The former frequently does not happen, and if it's truly the "seconds matter" emergency you can just skip all the sterility nonsense and put in a dirty line.

Maybe I just haven't worked with these extraordinary landmark wizards who always hit in first shot in the patient with barely-palpable femoral pulses, but my experience has been that these folks dramatically underestimate the time it takes them to cannulate via the landmark approach because they don't account for the 3-4-5 needle redirects, several punctures where they can't thread the wire because they're off center in the vessel, and the hematoma from lacerating the artery with a giant 18 gauge needle.

 

[anbuitachi]

didnt read every post here.

what is the data on outcome/mortality morbidity, on sick patients with brachial arterial lines vs radial arterial lines? sure there may be some difference at some point, but how does that affect outcome??

i only put brachials if patient has terrible radial. otherwise they get a radial, even traumas. am i killing people by not putting in a brachial? what if i have a NIBP on their brachial?!