Radial A-lines

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dbiddy808

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Aloha! I'm a soon-to-be CA1 and I am wondering if we are given an option of what equipment we get to use to place radial a-lines. Up until around 6 months ago I was struggling with arrows, then I switched to plain-old angiocaths, with better results. A couple of weeks ago one of the MICU attendings I work with suggested I try the kits with the guidewires and since then I've been pretty much getting my a-lines on the first stick (I have only done 4 this way....and have probably jinxed myself).
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dbiddy808 said:
(I have only done 4 this way....and have probably jinxed myself).
Click to expand...


You can't make a decision about a technique after only 4 tries at it. After you've done a few hundred, then you can decide what you like best.
 
dbiddy808 said:
Aloha! I'm a soon-to-be CA1 and I am wondering if we are given an option of what equipment we get to use to place radial a-lines. Up until around 6 months ago I was struggling with arrows, then I switched to plain-old angiocaths, with better results. A couple of weeks ago one of the MICU attendings I work with suggested I try the kits with the guidewires and since then I've been pretty much getting my a-lines on the first stick (I have only done 4 this way....and have probably jinxed myself).
Click to expand...

Highly institution and hospital dependent. County hospitals will have some of the guidewire kits available, but will mostly have arrows or standard 20 gauge angiocaths. Private hospitals should have a much wider variety. I would get comfortable with all of them. If you have done a hundred arrows, switch to the guidewire kits and angiocaths and suction catheter kits.
 
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I realize that my experience is limited, but it in my limited exoperiece the guide-wires seem so effortless....

I worry about everyone in the OR waiting for me to do something as simple as start an A-line. For someone with limited experience (having done only around 30-40 of them) it can be frustrating at times, especially compared to the other basic proceedures such as intubations, subclavians, IJs.
 
dbiddy808 said:
I realize that my experience is limited, but it in my limited exoperiece the guide-wires seem so effortless....

I worry about everyone in the OR waiting for me to do something as simple as start an A-line. For someone with limited experience (having done only around 30-40 of them) it can be frustrating at times, especially compared to the other basic proceedures such as intubations, subclavians, IJs.
Click to expand...

There will be some days that are just destined to be bad regardless. The key is knowing when to reposition your attempt. I have also found that palpating until I no longer feel the artery then sticking the area beyond the edge of my finger has greatly decreased the number of my missteps.

The guidewire kits are pricey so that would be the only disadvantage I can think of for them.
 
Our CV anesthesiolgists are the best at lines I have ever seen. Having learned from them, I always just use a 20g 1.88" angiocath. These guys never miss. My preferred method is to put the barrel of a 3cc syringe on the end, which makes it easy to see that you have continuing flow when you change the angle after the intial flash. I start at about a 30-40 degree angle, and when I get a flash, imediately drop it down to about 10 degrees and advance just a bit. If the flow stops, I pull the needle part of the assembly back very slightly while leaving the catheter where it is. If flow returns, I just spin the catheter in.

Another thing these guys taught me that makes it easy to do these by yourself is to attach a pig tail flushed with a heparin syringe to the catheter. It makes the whole process very neat, as you have time to tape it in securly, and then can hook up the transducer line without worrying about pulling the catheter out by mistake. The stopcock on the pig tail also makes it easy to get any air that may be in the line out.
 
sweep arpeggio said:
Our CV anesthesiolgists are the best at lines I have ever seen. Having learned from them, I always just use a 20g 1.88" angiocath. These guys never miss. My preferred method is to put the barrel of a 3cc syringe on the end, which makes it easy to see that you have continuing flow when you change the angle after the intial flash. I start at about a 30-40 degree angle, and when I get a flash, imediately drop it down to about 10 degrees and advance just a bit. If the flow stops, I pull the needle part of the assembly back very slightly while leaving the catheter where it is. If flow returns, I just spin the catheter in.

Another thing these guys taught me that makes it easy to do these by yourself is to attach a pig tail flushed with a heparin syringe to the catheter. It makes the whole process very neat, as you have time to tape it in securly, and then can hook up the transducer line without worrying about pulling the catheter out by mistake. The stopcock on the pig tail also makes it easy to get any air that may be in the line out.
Click to expand...

I'm assuming you take the pigtail off after you suture/tape everything in. The pigtails we have aren't made of pressure material and would bend/crease themselves if compressed.
 
Just a straw poll on the same topic - do you sew or tape your a-lines in? I realize that many are for surgery only, but, at the same time, if they need an a-line, it's likely the a-line will stay in at least throught the PACU/SICU.

At Duke, in my program, we don't do CCU, but, in the MICU, I was sewing in all my a-lines (the MICU and CCU are the only ones that do, and all get sewn in). All over the hospital, we have the guidewire lines. In the ED, the staff aren't attuned to when I ask for sutures (but, then again, they're not used to when the docs ask for a sterile gown to put lines in - years of practice (of surgeons ungloved in scrubs, 24 on/24 off for 6 weeks) have trained them as they are). Respiratory puts in some of the a-lines in the ED (they look at me funny when I ask/say I'd like to do it), and they and every other unit that puts a-lines in tapes them in.

So what do you gas guys do at your hospitals?
 
UTSouthwestern said:
I'm assuming you take the pigtail off after you suture/tape everything in. The pigtails we have aren't made of pressure material and would bend/crease themselves if compressed.
Click to expand...

Actually our pigtails are made of the same tubing as the a-line setup. In our CV OR's, a-lines both radial and femoral are almost always put in pre-op holding.

We sew in our femoral lines but rarely ever have I sewn in a radial.
 
sweep arpeggio said:
Actually our pigtails are made of the same tubing as the a-line setup. In our CV OR's, a-lines both radial and femoral are almost always put in pre-op holding.

We sew in our femoral lines but rarely ever have I sewn in a radial.
Click to expand...

Our pigtails are definitely not.

We have the needleless securing devices that aren't worth **** IMO. I have seen a handful come off when a patient sweats during rewarming. Had a cordis do that as well. I sew all of them in. If an attending insists I tape or use that needleless device, I wrap the wrist like a mummy.
 
Wow. I'm a little bit nervous because I have only put in 3 or 4 A-lines in my entire life and will be starting as a CA-1 in July. I am going to look like a fool, no? There will definately be a steep (e.g. 90 degrees) learning curve.
 
drlard said:
Wow. I'm a little bit nervous because I have only put in 3 or 4 A-lines in my entire life and will be starting as a CA-1 in July. I am going to look like a fool, no? There will definately be a steep (e.g. 90 degrees) learning curve.
Click to expand...

Preparation will be key for you. Have everything ready to go so that as soon as the patient is in the OR and asleep (or awake), you are ready to go then you can take 10-15 minutes to get it right. If it takes you 10-15 minutes to get the hand/wrist extended and to find your kit, gloves, etc., then you will look slow. Do a search on art lines in this forum and you will find another post that has a lot of good tips on getting these on your first pass as well as some salvage techniques when you get flow but can't advance a guidewire or catheter.
 
drlard said:
Wow. I'm a little bit nervous because I have only put in 3 or 4 A-lines in my entire life and will be starting as a CA-1 in July. I am going to look like a fool, no? There will definately be a steep (e.g. 90 degrees) learning curve.
Click to expand...


Don't sweat it my brother. We'll all be caught up in a few months.
 
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I learned with a #20 angiocath and guide wire but those floppy caths barely last 1 hour before they start collapsing. I finally but the bullet and mastered the arrow kits during the first couple of weeks of my icu rotation. It really make things easier when the patient is tubed and sedated and you have all the time in the world to get it right. The arrows are really clumsy especially when you already have a tenous stick but they stay open forever and can be bent at any angle and not kink. One trick that helps me is to get a flash and then just jam it all the way through the artery, then slowly withdraw back until i get good flow and advance the wire. If the patient is awake i'll spray the site with some benzoin and put a couple of clear opsites and some tape, otherwise I always sew it in.
 
drlard said:
Wow. I'm a little bit nervous because I have only put in 3 or 4 A-lines in my entire life and will be starting as a CA-1 in July. I am going to look like a fool, no? There will definately be a steep (e.g. 90 degrees) learning curve.
Click to expand...

Every new ca1 looks like a fool. You'll get over it quick.
 
Apollyon said:
Just a straw poll on the same topic - do you sew or tape your a-lines in? I realize that many are for surgery only, but, at the same time, if they need an a-line, it's likely the a-line will stay in at least throught the PACU/SICU.

At Duke, in my program, we don't do CCU, but, in the MICU, I was sewing in all my a-lines (the MICU and CCU are the only ones that do, and all get sewn in). All over the hospital, we have the guidewire lines. In the ED, the staff aren't attuned to when I ask for sutures (but, then again, they're not used to when the docs ask for a sterile gown to put lines in - years of practice (of surgeons ungloved in scrubs, 24 on/24 off for 6 weeks) have trained them as they are). Respiratory puts in some of the a-lines in the ED (they look at me funny when I ask/say I'd like to do it), and they and every other unit that puts a-lines in tapes them in.

So what do you gas guys do at your hospitals?
Click to expand...


Tape. Much faster and my humble opinion is you can secure it well enough.
 
drlard said:
Wow. I'm a little bit nervous because I have only put in 3 or 4 A-lines in my entire life and will be starting as a CA-1 in July. I am going to look like a fool, no? There will definately be a steep (e.g. 90 degrees) learning curve.
Click to expand...

We all looked like fools in the beginning, so don't sweat it- thats why theres a residency!
Private practice is where I really refined my skills- it just takes volume, volume, volume. Lets see..my previous practice we did almost 500 hearts annually, a ton of vascular stuff, etc- I've probably done a few thousand A lines- but you know what? Like UT said, even when you're deft at something, theres still gonna be days where you think you should apply at Taco Bell cuz you're missing stuff- rare, but it happens. Just remember practice makes perfect...no it doesnt....practice makes ALMOST perfect.
Keep your head up. Deftness will come.
 
On my 1st heart month, , it took me like 10 minutes and many sticks until i finally got an a-line on every patient for the 1st 2 weeks. Then an attending showed me how he did it one day, and i got every aline almost always on the 1st stick starting that day from then on. It was a complete 180 degree turnaround

His trick was to feel for the pulse a little more proximally in the arm, and enter the skin at least 1cm more distal then where you are feeling the pulse (rather than right next to your finger or under your finger or whatever). Then just aim for the pulse at a pretty shallow angle. Get flash, advance a tiny bit, drop the angle, make sure there still is flow, then thread the catheter. Works like a freakin' charm on almost every patient... the ones with fat wrists, weak pulses, etc.

Of course, for those vasculopaths with 99% of their arteries clotted off... only prayer seems to work.
 
On my 1st heart month, on every patient, it took me at least 10 minutes and multiple sticks until i finally got an a-line each day for the 1st 2 weeks. Then an attending showed me how he did it one day, and i got every aline almost always on the 1st stick starting that day from then on. It was a complete 180 degree turnaround

His trick was to feel for the pulse a little more proximally in the arm, and enter the skin at least 1cm more distal then where you are feeling the pulse (rather than right next to your finger or under your finger or whatever). Then just aim for the pulse at a pretty shallow angle. Get flash, advance a tiny bit, drop the angle, make sure there still is flow, then thread the catheter. Works like a freakin' charm on almost every patient... the ones with fat wrists, weak pulses, etc.

Of course, for those vasculopaths with 99% of their arteries clotted off... only prayer seems to work.
 
you know you got skills when you have to resort to injecting papaverine peri-vascular just to get the artery dilated enough for your catheter...
 
militarymd said:
You can't make a decision about a technique after only 4 tries at it. After you've done a few hundred, then you can decide what you like best.
Click to expand...

you have to do something a few hundred times before you can decide which technique you prefer... wow.

this is a neat thread. i am not an anesth. resident but i have done about 50 a-lines. i have always used the wire kit and it works well for me. but i think i'll try some of these other techniques too.

btw, my worst experience with placing an a-line (as an intern) was on a unit patient who was septic... i tried 3 times on one side, and then on the fourth try i placed it in the opp side. unable to perform a good allen test because he was tubed, paralyzed, and unconscious... i spent the rest of the night thinking about him losing one of his hands cos i sucked so badly placing the line...
 
Celiac Plexus said:
you have to do something a few hundred times before you can decide which technique you prefer... wow.

this is a neat thread. i am not an anesth. resident but i have done about 50 a-lines. i have always used the wire kit and it works well for me. but i think i'll try some of these other techniques too.

btw, my worst experience with placing an a-line (as an intern) was on a unit patient who was septic... i tried 3 times on one side, and then on the fourth try i placed it in the opp side. unable to perform a good allen test because he was tubed, paralyzed, and unconscious... i spent the rest of the night thinking about him losing one of his hands cos i sucked so badly placing the line...
Click to expand...

Sounds like the patient had high, but non-modifiable risks...you got to do what you got to do..

I'm still trying to figure out the best way to do a-lines when my inital attempts fail.
 
I suggest you learn to use them all. Once you are comfortable with one, switch to a different cath. This way when you finish residency and start your practice at St. Elsewhere you will know how to use what they have . Looking like a "fool" is ok in residency but NOT in practice. Get competent with everything.
One little trick, tip, or whatever that I like to use is, once the cath is in the artery and connected to the transducer, lay a small tegaderm over in to secure it. Then you can sew right thru the tegaderm without pulling the whole thing out or haveing someone that is trying to help you pull it out. I prefer to sew it even if i plan on d/cing it after the case. this is for many reasons but you never know when it will get pulled on and that is usually when you need it most. And it never hurts to practice your knots.
 
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