A-line complication, no Allen’s test

Started by NumTacos
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Allen’s test prior to radial a-line?

  • Total voters
    66
  • Poll closed .
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ucladoc2b said:
The plaintiff’s expert sounds like a dinosaur. That opinion is unbelievable. Swan-Ganz? Really?
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I read some of the comments, looked like that guy hadn’t practiced in years.
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UscGhost said:
Just goes to show that they can pay an expert to say anything
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I think medical “expert” witness need to have case logs how many procedures they have done in the last 6-12 months

You can’t be an “expert” if you have not done recent procedures. Pretty much eliminates 90% of the expert witness talent pool

Everyone knows you lose proficiency the less and less you do. Can’t be an expert when you aren’t proficient.
 
Poll needs a "never have I ever done an Allen test" option.


I do believe ultrasound for radial arterial lines should be standard of care. I routinely see small, calcified, torturous, thrombosed, or even absent vessels that lead me to move to an alternate site before even picking up a needle.

And I have a suspicion that 98% of these rare a-line complications are happening in patients who get landmark/blind insertions done with a sewing machine technique.
 
aneftp said:
I think medical “expert” witness need to have case logs how many procedures they have done in the last 6-12 months

You can’t be an “expert” if you have not done recent procedures. Pretty much eliminates 90% of the expert witness talent pool

Everyone knows you lose proficiency the less and less you do. Can’t be an expert when you aren’t proficient.
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I would think a competent defense attorney would hammer this point home so hard that the jurors would go home with headaches.
 
pgg said:
Poll needs a "never have I ever done an Allen test" option.


I do believe ultrasound for radial arterial lines should be standard of care. I routinely see small, calcified, torturous, thrombosed, or even absent vessels that lead me to move to an alternate site before even picking up a needle.

And I have a suspicion that 98% of these rare a-line complications are happening in patients who get landmark/blind insertions done with a sewing machine technique.
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If I or my family were to need an A-line, I would 100% request U/S guidance only.
 
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No winners in this story. A patient lost his fingers and an anesthesiologist got dinged for providing generally accepted standard care.

Peripheral vascular disease is not a good disease to have or treat. High risk anesthesia needs to be compensated better than the easier stuff (ambulatory/office based).
 
pgg said:
Poll needs a "never have I ever done an Allen test" option.


I do believe ultrasound for radial arterial lines should be standard of care. I routinely see small, calcified, torturous, thrombosed, or even absent vessels that lead me to move to an alternate site before even picking up a needle.

And I have a suspicion that 98% of these rare a-line complications are happening in patients who get landmark/blind insertions done with a sewing machine technique.
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An ironic post on a thread touching on how expert witness can be disconnected from reality.
 
pgg said:
Do you disagree with me?
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"I do believe ultrasound for radial arterial lines should be standard of care."

I don't do hearts or vascular, but I am not seeing that among many of the folks who do at my shop unless it doesn't go in quickly.
 
Lab Lover said:
"I do believe ultrasound for radial arterial lines should be standard of care."

I don't do hearts or vascular, but I am not seeing that among many of the folks who do at my shop unless it doesn't go in quickly.
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I would have said the same thing about IJ central lines 15 years ago. I did them blind/landmark for years and they almost always went in quickly.

Likewise, I learned how to place arterial lines without ultrasound. They almost always went in quickly.

Now ultrasound for IJs is de facto standard of care in the USA.

And I think anyone who doesn't routinely use ultrasound for arterial lines is a dinosaur. My opinion. It's certainly not standard of care, but it ought to be.

I think radial art lines that are "positional" or get dampened are almost entirely a consequence of putting them in vessels that shouldn't have been cannulated in the first place. And if those people had looked with ultrasound first, they'd have seen the vessel was marginal or outright unsuitable and gone to the other arm, or more proximal, or brachial with attempt #1.

There is no good reason not to use ultrasound for radial art lines. It's not about skill or experience. It's about not sticking vessels that shouldn't get stuck.

My opinion.
 
pgg said:
I would have said the same thing about IJ central lines 15 years ago. I did them blind/landmark for years and they almost always went in quickly.

Likewise, I learned how to place arterial lines without ultrasound. They almost always went in quickly.

Now ultrasound for IJs is de facto standard of care in the USA.

And I think anyone who doesn't routinely use ultrasound for arterial lines is a dinosaur. My opinion. It's certainly not standard of care, but it ought to be.

I think radial art lines that are "positional" or get dampened are almost entirely a consequence of putting them in vessels that shouldn't have been cannulated in the first place. And if those people had looked with ultrasound first, they'd have seen the vessel was marginal or outright unsuitable and gone to the other arm, or more proximal, or brachial with attempt #1.

There is no good reason not to use ultrasound for radial art lines. It's not about skill or experience. It's about not sticking vessels that shouldn't get stuck.

My opinion.
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I tell residents/fellows that inspecting the artery with an ultrasound is like checking that a window isn't nailed shut before attempting to open it. 😉 If an artery is obviously too small and torturous, I don't attempt that site. If it is heavily calcified but otherwise patent, I forgo the relatively dull Arrow art line and obtain a micropuncture kit used by cardiologists or vascular surgeons.
 
pgg said:
I do believe ultrasound for radial arterial lines should be standard of care. I routinely see small, calcified, torturous, thrombosed, or even absent vessels that lead me to move to an alternate site before even picking up a needle.

And I have a suspicion that 98% of these rare a-line complications are happening in patients who get landmark/blind insertions done with a sewing machine technique.
Click to expand...
I agree with the first paragraph.

Second paragraph: you have absolutely no data to back this up, only hubris. Even if you use ultrasound for the insertion, you are only visualizing a small % of the artery from the brachial artery to the palmer arch. A critical lesion in any of that long stretch could cause ischemia to the radial distribution. Are you scanning the entire forearm before you poke a radial artery?

Case in point: I did a completely routine A line under ultrasound, needle tip in the middle of the artery on the first try. The patient's hand started to turn pale before i even finished the central line. The vascular surgeon even visualized the palmer arch, completely intact. Yet the patient's hand continued to turn pale... I got REALLY LUCKY that someone saw that hand, or else I could have been sued as well.
 
pgg said:
Poll needs a "never have I ever done an Allen test" option.


I do believe ultrasound for radial arterial lines should be standard of care. I routinely see small, calcified, torturous, thrombosed, or even absent vessels that lead me to move to an alternate site before even picking up a needle.

And I have a suspicion that 98% of these rare a-line complications are happening in patients who get landmark/blind insertions done with a sewing machine technique.
Click to expand...
I think ultrasound should be used if available. Its faster and more successful first attempt.

That being said, i did it for years without it..no known complications
 
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dchz said:
I agree with the first paragraph.

Second paragraph: you have absolutely no data to back this up, only hubris. Even if you use ultrasound for the insertion, you are only visualizing a small % of the artery from the brachial artery to the palmer arch. A critical lesion in any of that long stretch could cause ischemia to the radial distribution. Are you scanning the entire forearm before you poke a radial artery?

Case in point: I did a completely routine A line under ultrasound, needle tip in the middle of the artery on the first try. The patient's hand started to turn pale before i even finished the central line. The vascular surgeon even visualized the palmer arch, completely intact. Yet the patient's hand continued to turn pale... I got REALLY LUCKY that someone saw that hand, or else I could have been sued as well.
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Fair

The only data I have is anecdotal/personal. Since I started exclusively using ultrasound hand lowered my threshold for putting in a brachial arterial line, I just about never have a radial line that gets dampened or quits working during a case. I'm making the leap to suggest there's probably a correlation between a poorly functioning a-line (+/- multiple attempts) and distal malperfusion.
 
In pediatric cardiac cases (particularly neonates/infants), I no longer even think first about there being an arterial line problem when there is a waveform issue with papaverine running. Sure, I will check the extremity but it in the age of direct cannulation with ultrasound and suturing lines of adequate length, the issue is invariably related to the aortic cannula and/or malperfusion related to rewarming.
 
pgg said:
I would have said the same thing about IJ central lines 15 years ago. I did them blind/landmark for years and they almost always went in quickly.

Likewise, I learned how to place arterial lines without ultrasound. They almost always went in quickly.

Now ultrasound for IJs is de facto standard of care in the USA.

And I think anyone who doesn't routinely use ultrasound for arterial lines is a dinosaur. My opinion. It's certainly not standard of care, but it ought to be.

I think radial art lines that are "positional" or get dampened are almost entirely a consequence of putting them in vessels that shouldn't have been cannulated in the first place. And if those people had looked with ultrasound first, they'd have seen the vessel was marginal or outright unsuitable and gone to the other arm, or more proximal, or brachial with attempt #1.

There is no good reason not to use ultrasound for radial art lines. It's not about skill or experience. It's about not sticking vessels that shouldn't get stuck.

My opinion.
Click to expand...

Let’s be real, the substrate on patients is deteriorating quickly. 10 years ago when I was doing art lines it was far easier to get them blind. These days I find massive atheromas routinely on echo that I never saw way back. PVD/PAD is getting to a point where people never die and the vessels just calcify more and more.

Patients are sicker, the vessels are worse, the equipment is necessary now. It’s incredibly obvious who can sink or swim technically now haha
 
I don’t do an Allen’s but I do US for all alines. It’s led to me not even attempting a side for some patients. It also wouldn’t be hard to quickly scan the ulnar before attempting the radial, and document pulsatile flow visualized in the ulnar.

I have had one patient where the hand got very white/pale after the aline, so I pulled it.
 
I don't see how uss helps much in this particular medicolegal case.
The claim isnt that they dissected the radial or damaged the nerve. The claim is that the cannulated an artery that wasnt well perfused eventually. If anything uss would enable cannulation of these poor flow radials not decrease them.
I dont think there's any scientific evidence to promote or refute that. Certainly not Allen's.

Uss may have prevented this only if there was absolutely no pulsation visible but that would have also been elicited under palpation. Even then I have colleagues that would give the radial " one go".

I prefer brachial, you cant use femoral here so really I dont see much alternative fir these huge cases with arms tucked. This was obviously sick guy. Needed tee and fast surgeon and prayers
 
Ischemic complications from radial cannulation are vanishingly small - that's why we use the radial. Likely this complication had little to do with the art line technique and mostly to do with underlying critical illness, high dose vasoactive support and blood loss.

The challenge with "proving" that ultrasound guidance reduces complications is you'd need a huge n since overall complications are so low. I suspect like a lot of landmark approaches for people who trained without ultrasound and still routinely practice that way, their first pass success rate is fairly high - but for folks who do not I've seen a lot of flogs. Given the ubiquity of ultrasound I'm not sure I can see an argument for not using it routinely -- is anyone arguing that ultrasound is worse? I've seen a lot of vessels that even if I could get into them wouldn't be worth it - as one of my partners says, "If you can bill for an angioplasty when the art line goes in, it's not going to last very long." But I also can't prove that non-US guided access has more complications.

I will say that the ESVS (and I suspect the 'mericans say the same) states that for vascular surgeons ultrasound is the standard of care for femoral and brachial perc access. So I think if you're doing non-ultrasound lines anywhere but the radial you are not following standard of care.

I also do ultrasound for all my subclavs (and I do more than anyone in our department by a wide margin, even the "old guard"), and I get a lot of "back in my day" -- but I've supervised ~200 without ever having someone drop a lung.

As a fun anecdote -- we had to float a PAC from the LIJ in someone with a CRT-D and some abandoned leads in the innominate - expected it to be difficult. I called for c-arm and one of my very senior partners told me I was being ridiculous and scrubbed in -- "I've never failed to get a swan in in 30 years of practice and I've never used fluoro." Our rad tech was slow (I should have called earlier) and so he proceeded to **** around for 15 minutes unsuccessfully. Once the c-arm was there he broke and said "Well I guess since the x-ray is already here you can just use it."

I'm sure that guy still tells the junior folks that he has never failed to put a PAC in in 30 years of practice.

Oh, and it goes without saying that the Allen's test is a garbage waste of time. People who still put it in their radial art line notes are the same people who write they had the circulator hold cricoid during RSI.
 
Last edited:
Use ultrasound routinely because it’s there, why not make life easier. I get put in our complicated vascular room a lot because I’ve been there awhile, no reason to do it blind other than a sense of superiority. That being said if I worked with residents I would want them to be proficient in both, there are urgent situations where you need it fast.

Allen’s test: I just put the pulse ox on the finger and occlude. Why not? Should take you 10 seconds, only problem with Allen’s is the high rate of false positives. If both sides don’t pass do you go to femoral/brachial? Some vascular patients have tiny crusty arteries. I use the micro puncture kit as much as possible for my alines, like I said I like to keep my life easy
 
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