A-line questions

[bryanboling5]

I'm an RN in a community Med/Surg/Cardiac ICU and I've got a question about a-lines. I work at night, so our PulmCCM doc is never here to ask.

One of our RT and I were talking tonight about how great it is to have a patient with an A-line because it's so much easier to draw ABGs and labs (easier on the staff, but also on the patient because they don't have to get stuck so often). Our docs rarely put in a-lines (I also work in a CT ICU at another hospital where almost ALL my patients have them...) or Central lines for that matter. It's really difficult to get them. (I've had patients on pressors without either before.) I think if nothing else, it makes frequent labs/gases nicer for all concerned. The argument I frequently hear is the risk of infection with a-lines and central lines, but don't you risk phlebitis and infection with frequent venipuncture and more importantly, frequent arterial sticks? Not to mention, I can imagine that you cause some damage every time you stick the radial artery for ABGs, some of the vent patients are getting gases several times a day.

Basically, our hospitalists will only put these lines in in a desperate situation (some not even then because they "don't feel comfortable" doing them) and mostly the PulmCCM doc or anesthesia (also rare at night) has to do them. (Cards will put them in if they're seeing the patient and they are already here).

Is there really compelling evidence that the risk of infection outweighs the risks of damage from frequent sticks? Not trying to second guess, just trying to learn and unfortunately not many chances to ask anyone here.
Thanks!
Bryan

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[Hernandez]

I'm an RN in a community Med/Surg/Cardiac ICU and I've got a question about a-lines. I work at night, so our PulmCCM doc is never here to ask.

One of our RT and I were talking tonight about how great it is to have a patient with an A-line because it's so much easier to draw ABGs and labs (easier on the staff, but also on the patient because they don't have to get stuck so often). Our docs rarely put in a-lines (I also work in a CT ICU at another hospital where almost ALL my patients have them...) or Central lines for that matter. It's really difficult to get them. (I've had patients on pressors without either before.) I think if nothing else, it makes frequent labs/gases nicer for all concerned. The argument I frequently hear is the risk of infection with a-lines and central lines, but don't you risk phlebitis and infection with frequent venipuncture and more importantly, frequent arterial sticks?

the risk of phlebitis and infection are quite small from venipuncture, I don't know off the top of my head the risk of infection for a-lines but it's (for simplistic purposes) 1% for central lines for infection 1% for pneumo and we're also seeing that DVTs are also a fairly frequent complication. There is even a mod on here who's son died due to an air embolism due to a central line placement. I've seen a CVC line end up in the plural space and I've seen a PICC that some how made into the space around the SC joint and was pumping in TPN there. While yes they are nice for nursing and for reduced phlebotomy they are an invasive procedure and should not be used unless their is an indication. As you've noticed, most Cardio-thoracic pts have them, and that's the nature of their surgical care.

Failed peripheral IV access should almost never be the reason for CVC placement, in a medicine ICU; TPN, pressor and occasional CVP monitoring are about the only frequent indication. My personal opinion is that pressors should never be used in a peripheral IV, I've seen too many of those infiltrate and cause necrosis, granted only 1 of those was due to the admitting refusing to place one and the other was an arrest in the ED so they used what they had.

I'm not directing this at you, but there are 1 or 2 ICU nurses that always give me crap about placing a CVC in my ICU pts, and I quote them the same data and explicitly tell them I'm not placing one as nursing convenience is not an appropriate indication for CVC placement.

 

[Bertelman]

Infection risk is definitely higher with an indwelling cath than with frequent sticks.

 

[Paseo Del Norte]

While not a true traditional critical care perspective, I have to agree. Invasive lines should be placed because clear indications exist and benefits outweigh the risks. In addition, we should look at discontinuing "higher risk" modalities as soon as possible IMHO.

I actually have central line and RIC line protocols and have never in three years of flying been in a situation where I even considered utilising these modalities. (Placing a central line or converting a peripheral to a RIC myself.)

Then again, I tend to be rather conservative with procedures.

 

[Bobblehead]

There's some institutional/speciality bias of course but in general arterial lines are used for invasive hemodynamic monitoring, not for either nursing or patient convenience although that gets blurry very quickly as soon as you step into the 'real world'. If you've got a difficult to wean ventilator patient who's also nearly impossible to get ABGs from, you may be better off putting an a-line in although if the patient is difficult for ABGs, an a-line may also be challenging.

A-lines do get infected. There's some older literature about infection rates (Band 1979, Raad 1993) so take it for whatever you think it's worth. The rates increase after 4-6 days. Also keep in mind, CR-BSI is a 'never event' for payment purposes.

I've personally never placed an a-line for blood draws. If the patient is so difficult that they can't get venous blood draws, it's likely they've already gotten a CVC for venous blood draws. That may obviate the need for an a-line if you accept VBGs for your vent monitoring.

This is all before someone invokes the mechanical complications of a-lines. Every institution has a horror story of someone's hand falling off after a-line placement due to inadequate collateral circulation or creating a pseudo-aneurysm after a challenging placement attempt etc.

 

[bryanboling5]

Thanks for all the responses! If there is data that shows an increased risk, then I'm all for not doing it. Most of our docs when asked are just really vague about it. I do know that a lot of the docs that cover here at night are not comfortable putting them in and so a lot of nurses have wondered if the refusal is legit or because they just don't want to do it.

I would never want an a-line just for lab draws. I agree with the poster who said that pressors should not be given through a PIVL. I've done that more times than I care to and it always makes me uncomfortable, yet I can't get a CVL put in half the time when I ask.

 

[SLUser11]

Thanks for all the responses! If there is data that shows an increased risk, then I'm all for not doing it. Most of our docs when asked are just really vague about it. I do know that a lot of the docs that cover here at night are not comfortable putting them in and so a lot of nurses have wondered if the refusal is legit or because they just don't want to do it.

I would never want an a-line just for lab draws. I agree with the poster who said that pressors should not be given through a PIVL. I've done that more times than I care to and it always makes me uncomfortable, yet I can't get a CVL put in half the time when I ask.

I think most people who are current on the critical care literature can produce some data to support their bias, as the numbers can be manipulated rather easily.

Honestly, making a snap judgment based on your post, I would guess that lack of comfort with the procedure factors in about as much as the other reasons. Of course, I don't know that I can completely disagree with the logic, because those specific doctors, with lack of comfort doing procedures, may carry artificially elevated complication rates.



I don't know how many times I've walked into an ICU setting where a patient is on 2-3 pressors, through a peripheral line, for a BP of 70/30, and I find a big fat chick with the BP cuff on her left calf....I place an art line, and her pressure is actually normal.......

Of course, I believe the complications are very real, specifically hand ischemia. I make sure the junior residents do an allen's test prior to placement, but that doesn't prevent all hand problems.

I had a fun one a couple nights ago, where she was hypotensive on pressors (renal failure, big and fat with BP cuff on calf), and the fingers on both of her hands were ischemic, she had a Fem-pop on one side, and a ridiculously calcified femoral artery on the other side. I'm sure a few of us have had these before, where you have to basically spear the artery like you are fishing with a sharpened stick....not easy.

 

[bigtuna]

Welcome to private practice...a-lines reimburse for sh_t and can take a while to put in sometimes

 

[proman]

From ProceduresConsult (written by Fleischer, chair of anesthesiology at Penn):

INDICATIONS
Continuous blood pressure measurement is necessary because of hemodynamic instability.
Continuous blood pressure measurement is necessary for the safety of certain anesthetic techniques, such as deliberate hypotension, cardiopulmonary bypass, or major vascular surgery involving arterial clamping.
Continuous blood pressure measurement is necessary for monitoring administration of vasoactive drugs.
Frequent blood gas measurements are needed.
Frequent blood sampling is needed in patients without central venous access.
Noninvasive blood pressure monitoring is difficult or impossible, such as in patients who are severely obese, have burned extremities, or are in shock.
CONTRAINDICATIONS
Absolute contraindications
Infection at the site of insertion
Traumatic injury proximal to the site of insertion
Relative contraindications; may be outweighed by other considerations
Failure to demonstrate collateral flow in small vessels (e.g., by Doppler ultrasonography)
Presence of arteriovenous (AV) shunt in the limb in question
History of surgery disrupting lymphatics of the upper extremity, such as a mastectomy with lymph node dissection
Arterial insufficiency in the distribution of the artery to be cannulated.

The Allen's test has a positive predictive value of 0.87 and a negative predictive value of 0.18 (Glavin 1989 PubID 2672870). There's really no good reason to perform it. A lines don't reimburse well but they constitute good medical practice for the indications above, particularly in the obese. As an aside, before I go to the femoral artery, I'll try a realtime ultrasound guided axillary line with a 3 Fr 5cm catheter.

 

[SLUser11]

The Allen's test has a positive predictive value of 0.87 and a negative predictive value of 0.18 (Glavin 1989 PubID 2672870). There's really no good reason to perform it. A lines don't reimburse well but they constitute good medical practice for the indications above, particularly in the obese. As an aside, before I go to the femoral artery, I'll try a realtime ultrasound guided axillary line with a 3 Fr 5cm catheter.

You quote a study that's 20 years old, and yet with a simple google search, since I'm not in the mood for a formal lit search, I'm able to find several articles that do show its utility:

http://www.journals.elsevierhealth.com/periodicals/ejcts/article/PIIS1010794007007452/abstract

http://icvts.ctsnetjournals.org/cgi/content/full/4/4/332

----Luckily that one did most of the literature review for me.....of course, this was in CABG patients, where the radial artery was surgically removed, so you're doing even more damage to the hand's blood supply than a temporary catheter.

Then again, on my same google search, I had some other ones that said it wasn't any good:

http://ats.ctsnetjournals.org/cgi/content/full/70/4/1362

Editorial: http://content.onlinejacc.org/cgi/content/full/j.jacc.2006.06.022v1


I guess my point is that its utility is debated. And, as I've said before, we can all drag up some literature to support our bias. However, it is the simplest and fastest of available bedside procedures, with a PPV of 0.87 according to your study.....definitely cheaper and faster than a formal doppler, let-alone MRI, etc. And, it can help guide your therapy.

If you occlude a radial artery and a patient's hand turns blue, are you really going to put in a radial a-line? Some say that you could, but I wouldn't.



As for the axillary line, I have to admit that I don't have that one in my bag of tricks. It seems to me, without any real knowledge of the procedure, that it could be tough to take care of due to its location, and may be prone to kinking. I'll have to do a literature search to see where it stands in comparison to femoral lines as far as rates of infection, malfunction, and limb ischemia.




In defense of your article, though, I doubt the Allen's test has changed much in the last 20 years....except maybe for the # seconds used as a cutoff.

 

[proman]

You quote a study that's 20 years old, and yet with a simple google search, since I'm not in the mood for a formal lit search, I'm able to find several articles that do show its utility:

If you occlude a radial artery and a patient's hand turns blue, are you really going to put in a radial a-line? Some say that you could, but I wouldn't.

In defense of your article, though, I doubt the Allen's test has changed much in the last 20 years....except maybe for the # seconds used as a cutoff.

Surgically removing the radial artery isn't really the scenario we're talking about. We've had at least 1 patient that I know of lose a leg to a femoral a line. Really really bad.

The age of a study doesn't concern me too much. After all, you're advocating using a clinical exam that was published 80 years ago by a medicine fellow at Mayo. It's always helpful to go to the primary literature:
Allen, Edgar. Thromboangiitis Obliterans: Methods of Diagnosis of Chronic Occlusive Arterial Lesions Distal to the Wrist with Illustrative Cases.
American Journal of Medical Sciences, August 1929 178(2): 237-243.
Remarkably this journal is still in print and the full text is available through Ovid. The article is a case series of symptomatic patients. The key is symptomatic. Now if you advocated dopplering the hand with occlusion, I'd probably agree with you. But really the Allen's test to detect ulnar occlusive disease in the asymptomatic patient to determine whether it's safe to put the radial artery at risk is a medical myth that continues to be perpetuated. As a screening tool it's marginal at best.

Now, as for the axillary point, it's a skill anesthesiologists usually have because the technique is very similar to that of the transarterial axillary nerve block. That's why I like using ultrasound: it lets me visualize the nerves and avoid skewering them. It's not really in the axilla, but the upper humerus, in the lateral third of the artery prior to the takeoff of the deep brachial artery.

 

[SLUser11]

The age of a study doesn't concern me too much. After all, you're advocating using a clinical exam that was published 80 years ago by a medicine fellow at Mayo. It's always helpful to go to the primary literature:
Allen, Edgar. Thromboangiitis Obliterans: Methods of Diagnosis of Chronic Occlusive Arterial Lesions Distal to the Wrist with Illustrative Cases.
American Journal of Medical Sciences, August 1929 178(2): 237-243.

That's a nifty article you found, but I sort of already said that here:

In defense of your article, though, I doubt the Allen's test has changed much in the last 20 years....except maybe for the # seconds used as a cutoff.

Anyway, my point wasn't the age of the article, but the fact that you gave stats from it like it was unique and concrete, even though there's lots of articles with varying numbers regarding the test's utility.

What I'm saying is that it's very easy to find "facts" to support your bias, and so it's easy to win an argument against anybody who deals in absolutes. e.g. "I've never had a line infection...EVER!" (old post paraphrased) Or "There's really no good reason to perform (an Allen's test)."

People who talk like that, experts or not in their field, will most likely be eating a lot of their words in as little as 10-15 years on many topics, because our evidence-based medicine is changing all the time.

There are plenty of "universal truths" that are being challenged all the time, and our voodoo is constantly being exposed....in my field, it is things like bowel preps, bowel rest, perioperative antibiotics, to explore or not, to divert or not, etc.

I think people who are well-read and real students of medicine should not develop a dismissive, know-it-all attitude that results in these absolute statements. Instead, we should be more Socratic, and acknowledge that we are knowledgeable because we know that we don't know.

I'll be the first to admit that there are lots of things I do in patient care that are more voodoo than stone cold facts.

Surgically removing the radial artery isn't really the scenario we're talking about. We've had at least 1 patient that I know of lose a leg to a femoral a line. Really really bad.

Now, as for the axillary point, it's a skill anesthesiologists usually have because the technique is very similar to that of the transarterial axillary nerve block.

Interesting that you talk about not placing a femoral catheter because of possible leg ischemia, but you'll place catheters in the axilla without hesitation. I definitely think it's safer to knock off a radial artery than a brachial or axillary artery.

I would guess that the ischemia rate would be lower in the axilla than in the groin due to less atherosclerotic disease, but I'd be guessing, in less you have an article to share....I've been too busy to do that lit search yet. I wonder if this axillary technique doesn't have a small spec of voodoo as well....


Anyway, I don't want you to think I'm attacking you. I like your contributions, and the fact that you know your stuff....I just love to argue and play devil's advocate...plus, I can't pass up an opportunity to jump up on my soapbox....ask my surgical forum buddies (e.g. Castro) about that....

 

[proman]

Interesting that you talk about not placing a femoral catheter because of possible leg ischemia, but you'll place catheters in the axilla without hesitation. I definitely think it's safer to knock off a radial artery than a brachial or axillary artery.

I would guess that the ischemia rate would be lower in the axilla than in the groin due to less atherosclerotic disease, but I'd be guessing, in less you have an article to share....I've been too busy to do that lit search yet. I wonder if this axillary technique doesn't have a small spec of voodoo as well....

No worries, I had hoped others would join in on their practice to liven up the CCM forum a bit.

You've brought up a lot of points:
I know you disagree that central line infections are preventable. I think they are, and reflect local practices for both physicians and nurses. I have yet to have an elective line that I've placed get infected, but I'm sure it will happen at some point. It's not being dogmatic or an absolutist, but a reflection of my institution's practice.

I haven't spelled out the reasons I don't consider femoral lines second line choice (my personal preferences in no particular order):
1) End artery, known ischemic complications
2) Infectious risk
3) More traumatic, because of what I perceive is a large catheter (16ga) for the size of the artery
4) Perception by nursing that patients with femoral a lines have to stay flat, can't sit up and can't get PT)

The axillary artery has many collateral arteries because of the shoulder there isn't much risk of ischemia, although complete disruption of the artery can cause ischemia (as in trauma). I don't know what's been published on it. A quick PubMed search brings up mostly cardiac surgery uses of the axillary for anterograde perfusion.

Anesthesia and Analgesia published a very nice review article on radial artery cannulation in the December 2009 issue, pg 1763-81.
Have a Happy New Year everyone

 

[emergiQ]

No worries, I had hoped others would join in on their practice to liven up the CCM forum a bit.

You've brought up a lot of points:
I know you disagree that central line infections are preventable. I think they are, and reflect local practices for both physicians and nurses. I have yet to have an elective line that I've placed get infected, but I'm sure it will happen at some point. It's not being dogmatic or an absolutist, but a reflection of my institution's practice.

I haven't spelled out the reasons I don't consider femoral lines second line choice (my personal preferences in no particular order):
1) End artery, known ischemic complications
2) Infectious risk
3) More traumatic, because of what I perceive is a large catheter (16ga) for the size of the artery
4) Perception by nursing that patients with femoral a lines have to stay flat, can't sit up and can't get PT)

The axillary artery has many collateral arteries because of the shoulder there isn't much risk of ischemia, although complete disruption of the artery can cause ischemia (as in trauma). I don't know what's been published on it. A quick PubMed search brings up mostly cardiac surgery uses of the axillary for anterograde perfusion.

Anesthesia and Analgesia published a very nice review article on radial artery cannulation in the December 2009 issue, pg 1763-81.
Have a Happy New Year everyone

Femoral artery isn't an end artery. All your other reasons, though, are valid at my institution.

 

[SleepIsGood]

Thanks for all the responses! If there is data that shows an increased risk, then I'm all for not doing it. Most of our docs when asked are just really vague about it. I do know that a lot of the docs that cover here at night are not comfortable putting them in and so a lot of nurses have wondered if the refusal is legit or because they just don't want to do it.

I would never want an a-line just for lab draws. I agree with the poster who said that pressors should not be given through a PIVL. I've done that more times than I care to and it always makes me uncomfortable, yet I can't get a CVL put in half the time when I ask.

The docs at your institution have their reason for not putting indwelling catheters...there's no question that the risk of infetion is more with catheters than with sticks.

You should really ask the physicians at your hospital. It's not your role to second guess them. An internet forum isnt where you are going to get the answers you want. Yes, an A line is convenient for YOU...but often isnt what a patient needs.

 

[SLUser11]

The docs at your institution have their reason for not putting indwelling catheters...there's no question that the risk of infetion is more with catheters than with sticks.

You should really ask the physicians at your hospital. It's not your role to second guess them. An internet forum isnt where you are going to get the answers you want. Yes, an A line is convenient for YOU...but often isnt what a patient needs.

Disagree 100%. This sort of question is exactly what forums like this one are for. People have questions, maybe they don't feel comfortable asking their superiors or colleagues, and they can ask them here.

It's not like his Q is out of line. As for the "how dare you second guess your physician" comment, that would breed a bunch of mindless robot nurses, and probably contribute to never events. It's not like us doctors are infallible.

"The docs have their reasons" is such a mindless blanket statement. There are so many things that we do in medicine that are voodoo-ish or just plain wrong, and I'm sure some of us would love it if everyone would just trust us and quit questioning our outdated and incorrect methods.


What sort of forum does this create when an "SDN Moderator" as your tag implies chastises people for asking questions and trying to improve their understanding of medical decision making?

I'm sorry, but I just couldn't disagree with you more in this approach, and I hope posters are not intimidated or dissuaded from asking questions here.

 

[SleepIsGood]

Disagree 100%. This sort of question is exactly what forums like this one are for. People have questions, maybe they don't feel comfortable asking their superiors or colleagues, and they can ask them here.

It's not like his Q is out of line. As for the "how dare you second guess your physician" comment, that would breed a bunch of mindless robot nurses, and probably contribute to never events. It's not like us doctors are infallible.

"The docs have their reasons" is such a mindless blanket statement. There are so many things that we do in medicine that are voodoo-ish or just plain wrong, and I'm sure some of us would love it if everyone would just trust us and quit questioning our outdated and incorrect methods.


What sort of forum does this create when an "SDN Moderator" as your tag implies chastises people for asking questions and trying to improve their understanding of medical decision making?

I'm sorry, but I just couldn't disagree with you more in this approach, and I hope posters are not intimidated or dissuaded from asking questions here.

Listen. This is the Student DOCTOR forum.

I'm not certain what specialty of medicine you belong to. Nonetheless, you should recognize that the above nurse is trying to UNDERMINE the physicians' choice of management. It's implicit in his questioning.

Now, do you want to side with the nurse to further chastise those physicians decisions? Well I wont. IF the nurse has a question,then she should ask the physician at the hospital. Not make posts somehow criticizing the DOCTOR's choice.

The public sometimes reads this forum. They need to know that doctors have reasons for making certain clinical decisions. There are nurses that like to 'prey' (see the TV show Hawthorne RN) and try to make false assertions about doc's managments under the false pretense of being a 'patient advocate'. It's actually a power-trip.

I'm not intimidating him. It's just if you come into a PHYSICIAN'S forum and start trying to undermine docs, people will have problems. Nurses have a forum of their own: www.allnurses.com He can continue to undermine docs over there if he likes. Asking questions is one thing. Undermining is totally different.

 

[proman]

We've veered off topic.

The OP was asking a general question which generated a great discussion. Questions about specific management of individual patients are best dealt by asking the attending physician of that patient. He is welcomed to continue asking general questions.

Now let's get back to a-lines.

 

[bryanboling5]

Listen. This is the Student DOCTOR forum.

I'm not certain what specialty of medicine you belong to. Nonetheless, you should recognize that the above nurse is trying to UNDERMINE the physicians' choice of management. It's implicit in his questioning.

Now, do you want to side with the nurse to further chastise those physicians decisions? Well I wont. IF the nurse has a question,then she should ask the physician at the hospital. Not make posts somehow criticizing the DOCTOR's choice.

The public sometimes reads this forum. They need to know that doctors have reasons for making certain clinical decisions. There are nurses that like to 'prey' (see the TV show Hawthorne RN) and try to make false assertions about doc's managments under the false pretense of being a 'patient advocate'. It's actually a power-trip.

I'm not intimidating him. It's just if you come into a PHYSICIAN'S forum and start trying to undermine docs, people will have problems. Nurses have a forum of their own: www.allnurses.com He can continue to undermine docs over there if he likes. Asking questions is one thing. Undermining is totally different.

Maybe you should re-read my post. I specifically said that I'm NOT second-guessing. I'm not trying to undermine anyone. I am legitimately trying to learn. The particular MDs in question are almost never here at night so I don't get the opportunity to ask them directly. If I could, I would. The few chances I've had to talk with one in particular, he's been an excellent teacher.

I greatly respect MDs and know that your education is far superior. I'm sorry that you've had issues with nurses, but you don't know me. If you did, you'd realize how absurd it is to assert that I'm on a power trip and out to undermine any physician.

The reason I didn't post this on allnurses is, I don't want a nurse's opinion. I can ask a dozen nurses what they think. I WANT a MD's opinion. I'm really at a loss to see why you think I'm anti-MD. If I've said something to give that impression, I'm sorry.

I don't want this to turn into a fight, but I wanted to address your comments about me. I've really enjoyed reading the dicussion back and forth about this and I'm learning that it isn't so cut and dried. Some MDs favor one thing, some another. Besides, it seems to have perked up the forum... (BTW, I HATE Hawethorne)

 

[The right Path]

I read the OP's original post several times and couldn't construe any intent to undermine physicians' choice of management. Seemed like a legitimate question to me in the spirit of evidence based practice and patient advocacy.

I enjoyed reading this thread, very interesting information, and nice to see opinions and practices outside of my hospital.

FWIW, we don't rely heavily on a-lines in our hospital, most often the physician that places it, doesn't bother to suture it.

Anecdotally, I haven't encountered a patient with a superficial or BSI associated with the a-line.

From what I've heard (haven't done the lit review, sorry) a-line infection rates are lower than central line infection rates. And those are stratified by femoral, IJ, SC from higher to lower risk of BSI.

In our hospital, the primary use when they are placed is hemodynamic monitoring. And most often they are placed in OR. When we have them, they are the preferred method for obtaining ABG rather than a stick.

We're pretty conservative compared to other hospitals in ABG frequency. The vast majority are done for a change in condition (deterioration, obviously), and then sometimes before changing vent settings and sometimes after changing vent settings. And that's generally if the clinical picture is equivocal. And of course practice varies by pulmonologist. Rarely is an ABG done "just to see".

Of course our donor cases all have a-lines and frequent ABG's. However, those are usually placed by the CTDN RN who assumes entire management of the patient in collaboration with the donor team.

 

[Paseo Del Norte]

I agree and I enjoy the discussion. While I am active on nursing forums I too want a physicians perspective. With all the pushing to prevent infections and hospital related complications, this is a great topic to discuss.

Along with that, have you noted any change in use of PA catheters? Over the past couple of years, I have noticed a steep decline in PA cath utilisation in my area of the country. While I have not reviewed the literature in depth are people also looking at PA use in the same way as Art and central lines? Clearly, complications can occur and perhaps risk versus benefit is more of a consideration?

 

[The right Path]

I agree and I enjoy the discussion. While I am active on nursing forums I too want a physicians perspective. With all the pushing to prevent infections and hospital related complications, this is a great topic to discuss.

Along with that, have you noted any change in use of PA catheters? Over the past couple of years, I have noticed a steep decline in PA cath utilisation in my area of the country. While I have not reviewed the literature in depth are people also looking at PA use in the same way as Art and central lines? Clearly, complications can occur and perhaps risk versus benefit is more of a consideration?

We rarely, rarely use them except for some notworthy cases. Granted, I work in the ICU/NSICU rather than our CCU which takes the majority of the true cardio patients, but even there PA lines are rarely used. According to studies, and no I can't cite a reference off the cuff here, but their use doesn't change outcomes to a statistically significant degree.

Now, here is an example of a case in which we did monitor Swan numbers: Patient with SAH due aneurysm, unfortunately for her, concurrent anterior wall MI, and then on top of that cerebral artery vasospasm. So in order to rescue her cerebral perfusion, we had to be very careful about the hemodilution, hypervolemia, hypertension treatment and balance that with her hemodynamic numbers, particularly CI, SVR, PAOP. It worked out well in the end, she had a good out come

Another notable exception is our donor patients. The CTDN nurse always places a Swan- for evaluating cardiac function and trying to keep the lungs "dry" enough to be salvagable.

 

[sevo85288]

complication rate from radial arterial lines is very low. i will find the reference to the Loyola Univ paper that followed 50,000 rad aline for complications...very low rate. central lines complication rates are dependent of the location and operator experience. of course, rates of infections are higher than alines... I agree with the original poster that you need an arterial line if a patient is on the vent and/or receiving inotropes/vasopressors.

 

[Firebird]

Thanks for all the responses! If there is data that shows an increased risk, then I'm all for not doing it. Most of our docs when asked are just really vague about it. I do know that a lot of the docs that cover here at night are not comfortable putting them in and so a lot of nurses have wondered if the refusal is legit or because they just don't want to do it.

I would never want an a-line just for lab draws. I agree with the poster who said that pressors should not be given through a PIVL. I've done that more times than I care to and it always makes me uncomfortable, yet I can't get a CVL put in half the time when I ask.

I don't think someone even has has to suggest that literature proves art Lines es have more risk than arterial puncture. Common sense tells you that you don't do a surgical procedure to place an indwelling line because it makes life easier on. "all involved".