That arterial line is useless!

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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.


CT PA here. I do 5+ Aline's a day. Every single one is through and through. To me through and through is the best way to know you are in the artery. I won't say I'm the best, but I rarely don't get a line quickly.

90% of the time I use an 18ga Jelco & no wire. I'll pull back to get flash and then insert the needle a few cm back into the catheter, then thread the catheter over it.

In the ICU I'll use an Argon kit or the Arrow kit, just because it's easier. I still go through and through.

I've watched a lot of residents struggle with Aline's and most of the time switching to through & through helps.

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I put all my cardiac arterial lines high up in the radial artery under live ultrasound. No need for through and through.

I've done arterial lines every other way there is to do them. There is no question in my mind that this is the optimal way.

That said, if I'm in a room that doesn't have an ultrasound sitting there already, I do it the normal way with an Arrow kit.

I thought I had never had an Aline complication ever until a few months ago, when a chip shot, first stick line I put in for an afib ablation developed a pseudoaneurysm some time later. It can happen to anyone if you do enough of them.

I agree with the general sentiment that the MICU puts in too few, and the SICU too many.
 
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No capnography there?

Nope. We're backward, though I should specify I was talking about practice in the ICU (certainly not the OR!). I can't say I really understand why. Certainly Non-invasive CO2 measurements are a much better "first line" approach.

Oddly enough I was never taught the "through and through" method initially, but typically use the Arrow kits and the wire. I don't really like ultrasound for anything peripheral unless visualization and palpation are expected to be very difficult. Any method that relies on a single puncture "should" be better, I suppose, but it's difficult to compare rates of complications since they're relatively rare events. But there's no question that major complications can occur, even if they're more typically associated with the manipulations occurring in the cath lab.
 
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."
Not as a ca1. But some of my attendings use the info in the clinical picture to make changes.

It's different in the ICU where there are some decisions based on art line readings by attendings.
 
CT PA here. I do 5+ Aline's a day. Every single one is through and through. To me through and through is the best way to know you are in the artery. I won't say I'm the best, but I rarely don't get a line quickly.

90% of the time I use an 18ga Jelco & no wire. I'll pull back to get flash and then insert the needle a few cm back into the catheter, then thread the catheter over it.

In the ICU I'll use an Argon kit or the Arrow kit, just because it's easier. I still go through and through.

I've watched a lot of residents struggle with Aline's and most of the time switching to through & through helps.
Thanks : )
 
Anyone who complains about a-lines being useless invariably sucks at putting them in.
Dude, I used to ace A-lines in residency. Putting in Arrows was one my favorite procedures. Do you really think I would go into CCM if I hated/sucked at lines? Food for thought.

Some of us actually care about what's best for the patient, so we keep questioning our own "standards of care".
 
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Not as a ca1. But some of my attendings use the info in the clinical picture to make changes.

It's different in the ICU where there are some decisions based on art line readings by attendings.

They received information from it that they couldn't have surmised from the patient's history or clinical picture?

Not saying I don't believe you. I am just a firm believer that there are a lot of soap box topics that are good to know but clinically are irrelevant, and this is one of them.
 
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.

Snort...a thousand of anything in anesthesia is just getting started.
 
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All my hearts:

20g angiocath
Long Arrow wire
Arrow art line.

Flash with angiocath, advance through. Remove needle. Slowly back out cath and with good flow insert wire. Arrow cath over wire.

I've seen the Arrow art cath push the artery around under US.
 
All my hearts:

I've seen the Arrow art cath push the artery around under US.


I have seen the same thing, thats why long ago I changed from how I did it in training (arrow all in one) to an angiocath. The angiocath punctures the calcified arteries much better
 
Out of curiosity, how sterile are you all doing your lines? Do you use sterile gloves? Biopatch? Drapes/Towels?
 
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Where I trained, it used to be clean in the (cardiac) OR (clorhex, regular gloves), sterile in the ICU (mask, towels, sterile gloves).
 
Plus they all go to the ICU, and the A-line will stay in for 2-3 days. Which did not change our policy in the OR, with no infectious consequences. Actually the worse complications we had from A-lines were skin breaks from blue towels used to extend the hand (if left there for the ICU).

I always find it laughable that we use sterile precautions for A-lines, when clean is enough for peripheral IVs.
 
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I always figured sterile was necessary for the kits due to the longer catheters having higher risk for contamination during placement. That's rarely a problem for arrows.

I almost always do my A-lines blind unless the patient has an exceptionally poor pulse or an LVAD. Even with CVCs, while I use the ultrasound for all IJs, I keep myself well versed with the landmark techniques, just for the sake of having the skill. An ultrasound is a luxury that isn't always available, especially at smaller hospitals.

Regarding upstroke on the waveform, I always correlate the pressure reads to the cuff. Oftentimes the Aline is reading a falsely high pressure, especially if it's in the radial.
 
Why is it that hearts get better care than other cases?
First, hearts don't often get their a-lines pulled in the PACU, so the risk profile may be different.

Second, where do you stop, put your foot down, and tell the Good Idea Fairy to back off? When she demands a gown for the a-line? Ortho joint style space suits? 72-hour limits for the line before it has to be changed out like an IV? Why not 24 hours?


Really, unless you're in the habit of sticking your finger or tongue on the catheter, it's pretty easy to keep the sterile bits sterile even when using non-sterile gloves. Compared to a pair of ordinary gloves, a 4-pack of blue towels and a set of sterile gloves don't cost much ... but they aren't free either.
 
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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.

Buzz,

You are making the argument that technique is the cause of all complications from an A-line. You may be correct. However, how do you know this? Most would argue that MANY complications from a-line's are not technique dependant. You think otherwise. I'm curious why you think this. Do you also think this is true of other procedures you do (like an epidural, etc)?

Second, how do you know you haven't had a complication? Do you do post-op checks 7 days out on all your patients? If you follow all the patients you do a-lines on for their hospital course, even perhaps weeks after the case, you are an amazing person - way better than I could ever hope (or want) to be.
 
An arterial line has
A HUGE UPSIDE and
VERY LITTLE DOWNSIDE.
I have a very low threshold for placing one during the big spine procedures we often perform.
As far as the ICU is concerned, one could argue
EVERY CRITICALLY ILL PATIENT SHOULD HAVE ONE.
 
An arterial line has
A HUGE UPSIDE and
VERY LITTLE DOWNSIDE.
I have a very low threshold for placing one during the big spine procedures we often perform.
As far as the ICU is concerned, one could argue
EVERY CRITICALLY ILL PATIENT SHOULD HAVE ONE.

Downsides: limb ischemia, thrombus formation, infection, pseudoaneurysm formation, potentially falsely high/overdampened pressure readings leading to unnecessary intervension, etc.

While I agree that these are mostly negligible in the OR, they are very real in the ICU, especially if we lose track of line time. When rounding, I make every effort possible to discontinue them as soon as I'm no longer using them for medical decision making.

Also, if by 'critically ill' you are referring to any patient physically in the ICU, I would have to strongly disagree. There are several patients present for observation who are reasonably clinically stable. I would not place the line unless there was a STRONG indication to do so.
 
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