Lousy with procedures...CA-1 here I come!

I saw an attending hit the IC on an IJ placement. On x ray it looked like it went down the wrong side...hooked up a pressure transducer and guess what. 90mmHg.

I've missed a ton of art lines this year so far too (pgy-1). And had a few misses on subclavians. I do have to say though, that if the anatomy is right and the patient isn't too fat, the IJ is a great approach. I'm still scared for July though, of course I don't think that we'll be thrown into a heart room on July 1 or anything.

I'm right there with you all concerning procedures. I'm doing my Anesthesia month right now(PGY1) and while I finally feel a little more comfortable with intubation, I'm having a miserable time with the lines.

I have yet to get an A-line out of ~6 chances. It is almost laughable now how I can miss the radial this many times. What are the odds you wouldn't hit it once when you stab into a 2X2 inch area on the wrist over and over.

My attending, who is about the most laid back guy in the world told me not to worry it will all come with practice. He said not to get to frustrated when you miss because in anesthesia, "no matter how bad it seems, it could always be worse."

You guys will be fine. Just learn to be very fast with the setup for each procedure and it won't matter how long it takes you to actually cannulate your target. If it takes you 15 minutes to set up and prep and 15 minutes to cannulate, you will get in trouble.

For you wrist butchers: The radial is almost invariably more medial to where you are palpating it. If you miss, aiming more medially (AFTER withdrawing to skin level - remember that the bevel is like a scythe and if you swing it side to side trying to redirect while still deep in tissue, you will cut everything in its path) greatly increases your chances of hitting your target. There are also bone and tendon landmarks for a more distal approach at the wrist (i.e., right between the distal radial prominence and the closest flexor tendon), however the more distal you are, the smaller the caliber of the radial artery.

Please remember to do a quick Allen's test before making any attempt and use a pulse ox on a finger of that hand to more accurately perform the Allen's test.

In the OR, you will also have more options should a couple of passes at the radial fail (brachial artery, axillary artery, etc.).

If you get a flash of blood using an Arrow arterial kit but cannot thread the wire into the artery, withdraw the wire to its starting position, push the entire unit deeper into the wrist to the point that no blood is flowing into the unit, remove the cannulator/wire unit leaving the catheter in place, then extend the the wire out of the end of the cannulator to its fullest extent. You can then begin to very slowly and carefully withdraw the catheter until its distal end pops back into the lumen of the artery (which you have purposefully pushed past). Once the blood is freely flowing (spurting your colleague in the face - don't stand directly in front of the catheter), slowly and gently place the wire/cannulator assembly back into the catheter and the extended wire should now pass easily into the lumen of the artery and you should then be able to easily spin the catheter off the Arrow cannulator and the rest of the way into the artery.

That is just one of MANY salvage techniques you will learn during residency so don't worry about your skills now. You WILL become the line placement expert, especially with arterial and IJ lines.

Thanks for the tips UT

I am in the same boat. I suck at subclavians, go the femoral down though, never attempted IJ. I failed at all atempted A-lines (tried radial and femoral). It is the most fustrating thing when youve got a bounding pulse slapping your finger and you cant stick the artery to save your life.

No problem. Also remember that threading the wire of the Arrow kit and spinning off the catheter into the radial artery should be smooth and PAINLESS. If your patient is trying to jump off the table when you do either, you are most likely not in the artery.

UTSouthwestern,
You better go into academic anesthesia!

sean wilson said:

The one IG I tried was perfect, except that I canulated the IC instead.

😱

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See, so you HAVE done an a-line 👍

We use a 20ga. angiocath and an arrow wire for A-lines. Simply use the cath to get a flash and push all the way through. Remove the needle then slowly withdraw the cath until you get pulsatile flow, thread the wire then advance the cath over the wire and voila! I hate those stupid arrow a-line contraptions.. they are clumsy and messy compared to this method. Took me about a dozen tries to get confident at it (not counting 100's of ABGs as an intern). For neck lines I always grab a doppler just to get a feel for the anatomy... its really amazing just how much variation there can be from person to person. Twice I have found people with IJ's coursing directly over the carotid which can make for a huge booboo if you're too aggressive with the needle. If you think these are fun, wait till you have to learn epidurals and lumbar plexus blocks, fun stuff!

I felt the same way when I started surgery residency 2 years ago; you're one up on me as I had changed a few lines over wires as a student but NEVER even stuck the femoral, SC, IJ, etc.

Don't forget that you are there to learn and don't let anyone make you feel bad about that. I was a bit timid early in my intern year (especially when someone in the OR would be barking to hurry up) but I quickly learned that no one walks in there knowing how to do these things without a lot of practice.

At my institution, scrub nurses/ CRNA's/ (and rarely) upper levels would try to fuss at you for taking your time (sometimes would resort to demeaning comments) but I'd remind myself that we all had our first year out and they are no different. Now I tell students you are there to learn, become good at what you do; walk in there like you belong there, and don't be sorry!

I also remind myself what it felt like to be doing things for the first time when I teach someone something and consider it one of my goals to break the cycle of beating on those who are new and trying to learn.

Good luck; most of us felt the same way- you'll be fine.

used to have lots of trouble getting these...an icu attending gave me some advice that has made things easy for me...haven't missed a radial artery stick since then.

three things:

*with the tip of your index finger search for the stongest radial artery pulsation.

*enter the skin and aim for the tip of your index finger where the pulsation feels strongest, not where you think the artery is going to be below your finger.

*use a very slight angle of inclination when entering the skin.

Fiend said:

UTSouthwestern,
You better go into academic anesthesia!

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I will at some point, but current debt dictates otherwise. In other words, show me the money.

sean wilson said:

One thing I am worried about it the fact that you increase your risk of being stuck by a flinching patient when you leave your finger on the forearm while penetrating the skin. Let's hope nobody gets stuck with a dirty needle...

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Easy.. put them to sleep first then put the line in.. you can spend all the time in the world once the drapes go up. 5mg of Vec also helps stop any "flinching"

UTSouthwestern said:

Please remember to do a quick Allen's test before making any attempt and use a pulse ox on a finger of that hand to more accurately perform the Allen's test.

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While it won't hurt to take the extra 30 seconds to do it, the Allen's test has pretty much been proven not to be particularly useful for predicting complications secondary to radial artery cannulation. In other words, don't rely on it and/or don't see a "positive" test as an absolute contraindication for placing an arterial line in the radial artery.

-Skip