That arterial line is useless!

[fakin' the funk]

...Or so thinks one internist/intensivist in Canada.

Here's an editorial criticizing the use of arterial lines in ICU patients, because they have never been shown to have benefit, and only confer risk, in the form of thrombosis, infection, and overphlebotomy.

Enjoy here and giggle along with me

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Members don't see this ad.

 

[deleted171991]

I am not ICU-trained (yet), but I have always thought A-lines are overused in the SICU and underused in the MICU. Not every patient on pressors needs an A-line (we don't put one in every time we put a patient on phenylephrine infusion in the OR, do we?). However an unstable patient with low cardiovascular reserve might need one (that's where MICUs typically underuse them).

I think the question we need to ask ourselves is: will long-term beat-by-beat BP monitoring significantly change the management, compared with q5-10-15 min NIBP? And can it be replaced short-term by q 1-3-5 min NIBP (for a few hours), while we stabilize the patient? Also, maybe we should start investing in EtCO2 monitors for ICU patients, so we don't need to do ABGs just for adjusting the vents, which is sheer stupidity. We need to do what's best for the patient, not what's most comfortable for us or the nurses, because longstanding A-lines can cause severe complications.

I have gone through 3 months of MICU, during internship, without even one arterial line in any ICU patient and, guess what, the patients survived. So Dr. Garland might have a point (I have only read the abstract, for now). I am curious what the ICU guys will say.

 

[Jay K]

I think you're on to something FFP. It probably is over-utilized in SICU and underutilized in MICU. As an aside, if I anticipate the ICU's gonna keep my Aline in for a "long" time, I'll add a bio patch under that tegaderm as well - don't have any evidence to back it up, but why not?

 

[Random Anesthesiologist]

I think it definitely depends. There is more info than straight BP measurement to glean from an Aline.

 

[deleted171991]

I think it definitely depends. There is more info than straight BP measurement to glean from an Aline.

Only in mechanically ventilated patients.

 

[Random Anesthesiologist]

Only in mechanically ventilated patients.

Eh, anyone with serious carfiac issues for sure.

 

[deleted171991]

Eh, anyone with serious carfiac issues for sure.

What do you mean? AFAIK, one cannot use SVV/PPV in spontaneously breathing patients. Do the CO measuring devices work in the latter?

 

[Random Anesthesiologist]

What do you mean? AFAIK, one cannot use SPV/PPV in spontaneously breathing patients. Do the CO measuring devices work in the latter?

Valvular issues, contractility, etc

Oh I didn't realize you added to your quote.

 

[deleted171991]

Valvular issues, contractility, etc

How does a simple A-line help you with that, beyond beat-by-beat BP measurement? Why can't it be replaced with frequent NIBP measurements in all but selected patients?

 

[Random Anesthesiologist]

The upstroke slope tells a lot, as does the dicrotic notch.

 

[deleted171991]

The upstroke slope tells a lot, as does the dicrotic notch.

Nobody puts in an A-line just for that, and a bedside limited view TTE/TEE is way better for that purpose. Actually, echo is better for most purposes, except for beat-by-beat BP monitoring, predicting volume responsiveness, and frequent ABGs.

 

[Random Anesthesiologist]

Nobody puts in an A-line just for that, and a bedside limited view TTE/TEE is way better for that purpose. Actually, echo is better for most purposes, except for beat-by-beat BP monitoring, predicting volume responsiveness, and frequent ABGs.

Of course not. It's a gestalt. But not everyone needs a TEE either, especially not intubated.

I'm on CCM right now too, so I'm thinking more than just OR I guess.

 

[deleted171991]

That's why I wrote TTE/TEE. Actually, TTE is becoming much more popular in the non-cardiac ICUs.

We are entering an era where ultrasound is replacing the stethoscope. And various invasive monitors (Swan used to be a more popular religion than Christianity in America). And the nerve stimulators. And many other things (probably).

 

[BuzzPhreed]

Anyone who complains about a-lines being useless invariably sucks at putting them in.

 

[Ezekiel2517]

Thanks for sharing, that was good for a laugh. The 6 most dangerous words in medicine - "there is no evidence to suggest...". Once had a MICU attending tell me there is no evidence to suggest that A-lines change outcomes. I was like no **** dude, that's b/c it's common fukn sense. There's also no evidence to suggest it's better to look both ways before crossing the street, but I'm pretty sure it's a smart thing to do. Any anesthesiologist here knows from experience how important an A-line can be in the OR, life-saving/preserving in some situations . You don't need a study to tell you that. The unit isn't much different, you use your training, intuition, knowledge, and personal experience to make decisions, especially when the "evidence" isn't there to tell you what to do.
A-lines are underused in the MICU b/c they are generally not as proficient with procedures. I've seen them take hours to place an A-line when there was a bounding pulse. I'm not gonna go into when they should be placed or not placed in the unit. I know they make a difference. When a pt is critically ill, their entire course can change in seconds.

 

[BLADEMDA]

The O.R. is a different beast than the ICU. We need arterial lines due to ACUTE hemodynamic changes. We can't rely on a BP cuff that fails to give a reading when the **** hits the fan.

After a day or two in the ICU the patient can do without the arterial line and outcome is the same.

 

[Mman]

I am not ICU-trained (yet), but I have always thought A-lines are overused in the SICU and underused in the MICU.

I love taking a MICU patient to the OR for dead gut when they are on 2 pressors through a 22 g peripheral IV and no arterial line.

 

[Planktonmd]

Thanks for sharing, that was good for a laugh. The 6 most dangerous words in medicine - "there is no evidence to suggest...". Once had a MICU attending tell me there is no evidence to suggest that A-lines change outcomes. I was like no **** dude, that's b/c it's common fukn sense. There's also no evidence to suggest it's better to look both ways before crossing the street, but I'm pretty sure it's a smart thing to do. Any anesthesiologist here knows from experience how important an A-line can be in the OR, life-saving/preserving in some situations . You don't need a study to tell you that. The unit isn't much different, you use your training, intuition, knowledge, and personal experience to make decisions, especially when the "evidence" isn't there to tell you what to do.
A-lines are underused in the MICU b/c they are generally not as proficient with procedures. I've seen them take hours to place an A-line when there was a bounding pulse. I'm not gonna go into when they should be placed or not placed in the unit. I know they make a difference. When a pt is critically ill, their entire course can change in seconds.

I am glad you are so sure of your beliefs... I wish I could be so certain about anything.
A lines are cool and maybe helpful but do they really make a difference in the ICU???
I don't know!

 

[deleted171991]

I love taking a MICU patient to the OR for dead gut when they are on 2 pressors through a 22 g peripheral IV and no arterial line.

Obviously that's not the kind of patient where an A-line should be skipped. But a patient on a low-dose of a single pressor does not necessarily need an A-line, most of the time.

 

[deleted171991]

Thanks for sharing, that was good for a laugh. The 6 most dangerous words in medicine - "there is no evidence to suggest...". Once had a MICU attending tell me there is no evidence to suggest that A-lines change outcomes. I was like no **** dude, that's b/c it's common fukn sense. There's also no evidence to suggest it's better to look both ways before crossing the street, but I'm pretty sure it's a smart thing to do. Any anesthesiologist here knows from experience how important an A-line can be in the OR, life-saving/preserving in some situations . You don't need a study to tell you that. The unit isn't much different, you use your training, intuition, knowledge, and personal experience to make decisions, especially when the "evidence" isn't there to tell you what to do.
A-lines are underused in the MICU b/c they are generally not as proficient with procedures. I've seen them take hours to place an A-line when there was a bounding pulse. I'm not gonna go into when they should be placed or not placed in the unit. I know they make a difference. When a pt is critically ill, their entire course can change in seconds.

People used to think the same way about Swan catheters. And the first time you see somebody with a thrombosed artery or pseudoaneurysm because of an A-line, you might change your opinion, too. We are not talking about general anesthesia in the OR. We are talking about A-lines that stay in for more than just a few hours.

We owe it to our patients to do what's best for them, as non-invasively as possible. We should continuously question "common sense", because medicine is science not religion.

 

[Mman]

Obviously that's not the kind of patient where an A-line should be skipped. But a patient on a low-dose of a single pressor does not necessarily need an A-line, most of the time.

I'm not disagreeing. Just providing an anecdote similar to what I deal with on a more than once monthly basis of arterial lines (and central lines) being way underutilized in the MICU.

 

[vaibh]

I think evidence based practice is good for developing someones academic CV , may be good for patients but while practicing we need to tailor to particular patients need as well as particular environment where patient is being monitored. Goal with a line is to make sure someone is aware of patients Hemodynamics continually , yes it can be done with BP cuff in OR setting where someone is constantly checking it , but is much different in ICU setting where nurses may decide to talk about their kids and blah blah while patients bp may sink down without being noticed, and meanwhile if you have more then 20 patients to take care of , you cannot just keep checking on 3-4 patients every 1-2 hrs. Also course of patients in icu is more chronic then in OR and continuous cuff measurements may give then nerve injuries / brusing. After some time it does become painful if you have seen 90 yr old granny who may have lott of pain when cuff squeezed their arm tightly. Regarding evidence , there is no evidence that giving any drug in ACLS gives benefit yet if patient is coding most will give something ! So I guess its more situation rather than evidence based articles !

 

[BuzzPhreed]

I am glad you are so sure of your beliefs... I wish I could be so certain about anything.
A lines are cool and maybe helpful but do they really make a difference in the ICU???
I don't know!

In our ICU the protocol to get BP's is q15mins in sick patients. A lot can happen in a sick patient in 15 minutes. NIBP? On pressors? Cop-0ut. Put a g-damn a-line in! If you can't do it, call someone who's good at it.

This study is *****ic. I don't have complications with my a-lines. If I did I'd know about it. I can't speak for the pulmonologists I work with who sometimes take 45 minutes (or more) to put one in. I'm talking about mine. Place them more proximally. Always use an ultrasound. Always re-cleansed with CHX after placed. And always dressed with benzoin and a Tegaderm with a CHX patch. How do I know? I'm often called to place a-lines (and other lines) in our little hospital after "others" have struggled with -- and in many cases pooched the site -- and still can't get. I've also rescued some sloppy-ass technique.

It's unbelievable to me sometimes what passes as "acceptable" technique in ICUs. Then again not everyone is Lebron James or Rory McIlroy.

 

[Mman]

This study is *****ic. I don't have complications with my a-lines.

The old adage would suggest you haven't done enough.

I'd suggest it's more likely that complications are pretty rare and when they happen the patient often has a ton of other issues going on so it might be missed.

But if you put a catheter in an artery often enough, it will cause a complication eventually. There is no way to stop that.

 

[BuzzPhreed]

The old adage would suggest you haven't done enough.

I'd suggest it's more likely that complications are pretty rare and when they happen the patient often has a ton of other issues going on so it might be missed.

But if you put a catheter in an artery often enough, it will cause a complication eventually. There is no way to stop that.

Well over a thousand of them my friend. I'm not going to fully "out" myself here, but there's a reason... In any given week, I put in 3-10. For the past 7.5 years. I am the friggin' Albert Einstein of a-lines.

 

[Leo Spaceman]

Well over a thousand of them my friend. I'm not going to fully "out" myself here, but there's a reason... In any given week, I put in 3-10. For the past 7.5 years. I am the friggin' Albert Einstein of a-lines.

@BuzzPhreed... just curious...what technique do you use? go through and through and pull back until blood-spurt, or go in until you see flash, and thread in catheter? I'm IM, and our fab CT-surg PAs swear by the through& through technique.

 

[pgg]

because medicine is science not religion.

13. THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.



In a MICU, the typical (non-anesthesiologist) intensivist's response to hypotension is to write an order in the chart, for the nurse to call the pharmacy, to mix and tube up a bag of norepinephrine, for the nurse to put on a pump, and go find another nurse who isn't playing Farmville or whatever the current Facebook fad is to witness her program it, to infuse at a rate that will be titrated every q10-15 minutes at best. Farmville obligations and shift change permitting.

Of course there won't be data showing an a-line is any better than a q5min NIBP under those circumstances.

 

[Mman]

Well over a thousand of them my friend. I'm not going to fully "out" myself here, but there's a reason... In any given week, I put in 3-10. For the past 7.5 years. I am the friggin' Albert Einstein of a-lines.

That isn't very many my friend. And this isn't a dick swinging contest.

I'm pointing out the old adage of that if you haven't had a complication you haven't done the procedure enough. Complications happen. You can't stop it. You can't prevent a thrombus from forming on the tip of your catheter 2 days from now. You can't see the intimal wall thickness right where you decided to stick resulting in an aneurysm (can't be seen on u/s). Stuff happens. The minute anybody thinks they are above it, that's when it'll jump up and bite you. Always respect the possibility of a complication.

 

[deleted171991]

I agree. The only way to avoid a complication is to avoid the procedure. Everything in medicine (and life) is risks vs benefits. I just tend to think that the benefits of A-lines in the ICU are overrated. Same goes for most invasive lines.

Why do we use central lines? They are not for fluid resuscitation, because many intensivists don't place Cordises (so that the nurses won't whine that they don't have enough ports). To me, it doesn't make sense placing anything smaller than a Cordis in a central vein, when taking the risks into account. Yet most ICU patients get a triple lumen with three slow ports. A 20G peripheral is better than one of those lumens, and a good 18G is probably better than all three.

Many central lines are for pressors. Why? So that nurses don't have to watch a peripheral IV to make sure it doesn't get infiltrated. It's not about patient benefits; it's about avoiding risks due to personnel incompetence/laziness. There are very few chemicals which are so irritating or risky they require a central line. What's so complicated about checking on one's patient and her IVs regularly, like we do in the OR, when one's covering only 2 patients?

Same goes for putting in central lines for the multiport benefit, because some nurses don't know how to manage a stopcock-based system (on a microdrip/pump carrier), both in the SICU and MICU. No patient benefit again. Not to speak about the "no peripheral access" excuse, which is just another way of saying "we are too lazy to keep looking for a peripheral vein with an ultrasound".

 

[BuzzPhreed]

That isn't very many my friend. And this isn't a dick swinging contest.

Ummm... that is a lot. And I'm not the one who started swinging the dick.

Secondly, I started to think I was getting good at them after maybe the first 100 I did -- not including the ones I did in residency (back sometime before 2007) -- but then I started to get really good. Repetitively I figured out the mistakes other people routinely make when they try to do it. I've even talked about this before on this forum. I don't **** around. I do it exactly as I described. And the nurses know to have all the stuff ready because it's going to be ready to be hooked-up about 30 seconds after I walk in the room.

So, some people are really good at getting the spinal on the first stick... every time. Some people can put an epidural in a 600 lbs. parturient who is at 10-cm and flopping around like an epileptic having a grand mal seizure... with one arm tied behind their back. Some people can intubate a gravid fire ant... blindfolded.

I'm telling you, a-lines to me are like a quickly-solved Rubik's cube to others. I've figured it out and I don't struggle. You practice enough with the right technique and you're going to get good at it and get it -- every time.

So I'm not going to apologize for that. And I don't have complications. That's why I always look with an ultrasound. I know that those of you who truly want to pull out and swing your dicks think it's macho not to use one. Here's a tip: if you can't see the artery pulsing with the ultrasound don't waste your time. And put it more proximally. I bet your complication rate drops to zero -- like mine -- if you start doing that. So, put your penis away.

This "study" is *****ic. I'm sick of *****s trying to change how I practice when they should be listening to advice on how to get better at their technique instead. Haven't lost a thumb. Haven't had an infection. Haven't had an aneurysm (cause I haven't done a through-and-through since before 2008). If it suddenly happens after, I dunno, probably 1,400 of them, you'll be the first to know, Mman. I promise.

 

[Mman]

Ummm... that is a lot. And I'm not the one who started swinging the dick.

I think I did 1000 my first year out of residency. That was 5 years ago. I'm still a rookie. And I'm an All Star who nails it left handed blindfolded every time.

But like I said, that doesn't prevent complications. Doesn't prevent aneurysms, bleeding, or thrombosis. A foreign object in an artery isn't natural. You can't prevent a complication.

 

[Jay K]

@BuzzPhreed... just curious...what technique do you use? go through and through and pull back until blood-spurt, or go in until you see flash, and thread in catheter? I'm IM, and our fab CT-surg PAs swear by the through& through technique.

I know you asked B.P, but if you can get it in via one hole, why place two holes in the poor artery? If you already happened to go through-and-through, then by all means salvage away, but to do so intentionally?

 

[Leo Spaceman]

I know you asked B.P, but if you can get it in via one hole, why place two holes in the poor artery? If you already happened to go through-and-through, then by all means salvage away, but to do so intentionally?

I asked because as an IM resident, it's the procedure I've had the most problem with, and most surgeons seem to swear by the 2 holes method though I've been hesitant to try it.

 

[fakin' the funk]

How does a simple A-line help you with that, beyond beat-by-beat BP measurement? Why can't it be replaced with frequent NIBP measurements in all but selected patients?

You think ICU patients are getting "frequent" NIBP measurements? How about q15-30, *max*. If you are running NIBP q5min in the ICU, it's time to think about an A-line.

You think ICU patients have reliable NIBP measurements? Some do, but many don't: your rapid Afibber, your clamped-down septic shocker, your vasculopath.

 

[fakin' the funk]

Only in mechanically ventilated patients.

Only in SOME mechanically ventilated patients.

I.e., those with TV > 8ml/kg, those NOT participating in ventilation, those in sinus.

How many ICU patients is that? I'm gonna go with < 2%.

 

[fakin' the funk]

People used to think the same way about Swan catheters. And the first time you see somebody with a thrombosed artery or pseudoaneurysm because of an A-line, you might change your opinion, too. We are not talking about general anesthesia in the OR. We are talking about A-lines that stay in for more than just a few hours.

The first time I see one of those, or see an arterial-line related bloodstream infection...will be the first time I see one.

 

[deleted171991]

The first time I see one of those, or see an arterial-line related bloodstream infection...will be the first time I see one.

I am waiting for the latter, too. But try putting in an A-line in a non-sterile (but clean) fashion in the ICU...

I am pretty sure I have seen a (A-line related?) pseudoaneurysm, but it was femoral. I have also seen a couple of patients with a thrombosed wrist artery listed in the PMH, but I have never asked what caused it.

As an OR attending, I tend to be as minimalist as I can, while not cutting corners on safety. So if I feel like I need a line, even just for safety reasons, the patient gets one.

I also tend be much more liberal when considering A-lines, than with central lines. I think the latter are hugely overused in the ICU, especially by people who equate them to better IV access.

But I also think that, regarding A-lines, the golden path is somewhere between MICU and SICU.

 

[fakin' the funk]

to infuse at a rate that will be titrated every q10-15 minutes at best. Farmville obligations and shift change permitting.

Of course there won't be data showing an a-line is any better than a q5min NIBP under those circumstances.

Totally agree with you.

Just to play devil's advocate, in fellowship I had to "take away" nitroprusside from the nurses in our CT surgery ICU. All those patients had A-lines (obviously), and the nurses were very, very sensitive to BP's over target range. So they would titrate the SNP up q1min...when the SNP is being carried by saline running at 5ml/hr. If they had NIBP they would only titrate q5-10 or whatever. But they were aggressive b/c of the A-line. So yeah, it only takes a couple of calls for BPs of 40/20 due to them "overshooting" for me just to take that med off the MAR everywhere I saw it.

 

[fakin' the funk]

I think the number is higher. Anyway, that's another reason to better select the patients who get A-lines.

It's not.

You think your mechanically ventilated patients in the ICU aren't participating in their ventilation (i.e. developing negative pleural pressures)...they are.

 

[deleted171991]

You think ICU patients are getting "frequent" NIBP measurements? How about q15-30, *max*. If you are running NIBP q5min in the ICU, it's time to think about an A-line.

You think ICU patients have reliable NIBP measurements? Some do, but many don't: your rapid Afibber, your clamped-down septic shocker, your vasculopath.

And those are the ones who deserve to have an A-line.

I am not against lines per se. I just think that the every procedure has risks, and we should have strong reasons for any procedure.

 

[deleted162650]

You think ICU patients have reliable NIBP measurements? Some do, but many don't: your rapid Afibber, your clamped-down septic shocker, your vasculopath.

A few days ago I picked a pt up from the SICU to bring to the OR. NIBP 90's/50's via a cuff on the calf. Dude's on Levo at 30 via a 20g peripheral in the forearm. On arrival to the OR I notice that the portion of the cuff that's supposed to overlie the artery is over the tibia. After repositioning, NIBP is 120's /60's. An A-line coulda saved this guy a lot of pressors and the risk of badness had that IV infiltrated (which I'm sure woulda been picked up about as quickly as the malpositioned cuff was by the ICU team).

 

[fakin' the funk]

I agree. The only way to avoid a complication is to avoid the procedure. Everything in medicine (and life) is risks vs benefits. I just tend to think that the benefits of A-lines in the ICU are overrated. Same goes for most invasive lines.

Why do we use central lines? They are not for fluid resuscitation, because most ICU *****s don't place Cordises (so that the nurses won't whine that they don't have enough ports). To me, it doesn't make sense placing anything smaller than a Cordis in a central vein, when taking the risks into account. Yet most ICU patients get a triple lumen with three slow ports. A 20G peripheral is better than one of those lumens, and a good 18G is probably better than all three.

Many central lines are for pressors. Why? So that nurses don't have to watch a peripheral IV to make sure it doesn't get infiltrated. It's not about patient benefits; it's about avoiding risks due to widespread personnel incompetence/laziness. There are very few chemicals which are so irritating or risky they require a central line. What's so complicated about checking on one's patient and her IVs regularly, like we do in the OR, when one's covering only 2 patients?

Same goes for putting in central lines for the multiport benefit, because *****ic nurses don't know how to manage a stopcock-based system (on a microdrip/pump carrier), both in the SICU and MICU. No patient benefit again, just laziness. Not to speak about the "no peripheral access" excuse, which is just another way of saying "we are too lazy to keep looking for a peripheral vein with an ultrasound".

FFP, I know where you're coming from. You have a solid theoretical rationale on these point and others on this topic. That theory holds up in practice in the OR...in a situation with a physician directly observing and performing all care related to a single patient. The problem is, these points break down quickly when the practical setting is when you the physician has 15-20 patients to care for, and (mostly) on the nursing side, with a nurse who may have 2 sick-ass patients to care for, who has a variable degree of experience and skill, who is limited in what they can do by pharmacy and nursing regulations, and who has responsibilities in addition to direct patient care. Same goes for RTs and other people on the care team.

So yes, the resistance in an 18g PIV is blah blah blah lower than the big port on a 7fr triple lumen CVC. And yes, pressors can be safely given peripherally if it's a good IV in a good vein. But if you were a sick-ass ICU patient bleeding to death from varices, would you want a stable, reliable central line (of WHATEVER size) or a tenuous 20g PIV? Let's say you're actually hand-pumping blood into such a patient and the IV blows -- what now? Try putting a central line in a hypovolemic agitated shocky ICU patient. What happens when your ultrasound-guided PIV "falls out" i.e. gets tugged out or otherwise f'ed with -- now you have a sick-ass patient with NO IV access. Well done, I say.

If you are headed into an ICU fellowship, great, I hope it goes well for you. I don't know you personally. But I would encourage you NOT to take the tack of "well that's how it's done in the OR, why can't we do it that way in the ICU" because that reasoning simply falls apart in the logistics of the ICU, and you will make enemies quickly trying to make them work.

 

[nimbus]

I do an above average number of Aline's because I do hearts and trauma at a big busy hospital. Had my first complication after 18 years this year. It was a little old lady with a cool bluish numb hand 3 days post cabg. We took her back to OR and pulled out some impressive clot by balloon embolectomy. Still I have never regretted placing an Aline. Not even that one. There have been many times I have regretted not placing one up front.

As an aside, every time someone who is not my actual friend says "my friend", my defenses go up. That's because usually they have just tried to rip me off or been condescending and insulting.

 

[deleted171991]

If you are headed into an ICU fellowship, great, I hope it goes well for you. I don't know you personally. But I would encourage you NOT to take the tack of "well that's how it's done in the OR, why can't we do it that way in the ICU" because that reasoning simply falls apart in the logistics of the ICU, and you will make enemies quickly trying to make them work.

I am aware of the politics. Even in the OR, things are not always the way we like them; I might have to do certain things just to keep the PACU nurses happy (and I do them, unless it's risky for the patient - I still remember having to re-instate renal dopamine as an intern, because of a stupid MICU nurse, even after showing him the studies). I am very careful about picking my battles with nurses: I am respectful or friends with most of those I work with. That doesn't mean that I have to like the politics.

I think we should always keep an open mind to change, and possibly get inspired by people who do things differently with similar outcomes. Twenty years ago they were putting in Swans left and right, and one couldn't even question the idea. Ten years ago, the CVP monitors were a must. And so on. People are naturally resistant to change, so we should advocate for it in a slow, easier to digest and accept, manner.

tl;dr
Some people were too quick to judge the article mentioned by the OP, because it goes against the current dominant religion.

 

[deleted171991]

But if you were a sick-ass ICU patient bleeding to death from varices, would you want a stable, reliable central line (of WHATEVER size) or a tenuous 20g PIV? Let's say you're actually hand-pumping blood into such a patient and the IV blows -- what now? Try putting a central line in a hypovolemic agitated shocky ICU patient. What happens when your ultrasound-guided PIV "falls out" i.e. gets tugged out or otherwise f'ed with -- now you have a sick-ass patient with NO IV access. Well done, I say.

I would want a Cordis, or two 14-16G peripherals. How many times do these bleeding patients get a Cordis in the ICU, versus a semi-worthless (for volume purposes) triple lumen CVC? How many times do they get pressors, instead of fluids and blood? That has nothing to do with OR vs ICU, just with good medical practice.

I am not a Cordis or PIV fan just because of the theoretical flow equations. I am because I have manually pumped fluids on triple lumens and on peripheral IVs, and I know the difference. It's not about my ego, it's about what's best and safest for the patient. That's why, despite my barking here, I will put in a line whenever there might be an indication for it.

 

[OB1🤙]

Not to be too tangential, but we use the Arrow quad lumen cvcs as our default, and they're pretty great. One of the ports works well as a reasonable volume line.

I do some routine CABGs with just one of these lines.

 

[deleted171991]

Not to be too tangential, but we use the Arrow quad lumen cvcs as our default, and they're pretty great. One of the ports works well as a reasonable volume line.

I do some routine CABGs with just one of these lines.

The ones we had during residency had a 18G port and two 20's. All irrelevant since the length for the ports was about three times the length of a peripheral IV catheter, hence 1/3rd the flow.

Those Arrow CVCs are 8.5F. And some of them are pressure injectable. Sounds like good stuff. I remember placing something similar in the EJ during residency; a lot of fun.

 

[AStark]

I've never seen any A-line complications in the unit, but as an intern on cardiology I saw pseudoaneurysms, femoral artery thrombosis, and massive groin hematomas. But those were complications from the cath lab.

Unfortunately my centre relies heavily an ABGs for vent management, and nothing gives an RT a look of panic more than questioning the need for an A-line in a patient NOT on pressers.

 

[pgg]

Unfortunately my centre relies heavily an ABGs for vent management, and nothing gives an RT a look of panic more than questioning the need for an A-line in a patient NOT on pressers.

No capnography there?

 

[Ignatius J]

Valvular issues, contractility, etc

Oh I didn't realize you added to your quote.

Honest question- has analyzing the upstroke of an arterial line tracing ever changed your management?

Ever had a patient on Levophed and thought "Damn, look at that tracing. Let's switch to dobutamine."