A line with no flow

[Bones411]

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Had 2 recent encounters with arterial line placements that I could not wrap my head around.

1) Patient who is 20 years post Fontan for lap chole, first attempt on a line good pulse on palpation, no flow obtained through the catheter, second attempt used ultrasound and despite there being no flow through the arrow catheter able to watch the wire go into the artery on long axis

2) Severe AS for valve replacement, crunchy vasculature throughout, same experience

Was it a little clot at the end? Any other ideas?

 

[norski]

I've had that happen to me a couple of times, US guided, but no wire. Had clotting as my main suspects, certainly looked that way when I pulled the catheter out.

Edit: I got flash on these, though. Assuming you got a flash on arterial puncture?

 

[nimbus]

Had 2 recent encounters with arterial line placements that I could not wrap my head around.

1) Patient who is 20 years post Fontan for lap chole, first attempt on a line good pulse on palpation, no flow obtained through the catheter, second attempt used ultrasound and despite there being no flow through the arrow catheter able to watch the wire go into the artery on long axis

2) Severe AS for valve replacement, crunchy vasculature throughout, same experience

Was it a little clot at the end? Any other ideas?

Very unlikely to be a clot if you used an Arrow.

Is it possible there was intimal dissection and the wire and catheter were in the false lumen?

 

[Hoya11]

Had 2 recent encounters with arterial line placements that I could not wrap my head around.

1) Patient who is 20 years post Fontan for lap chole, first attempt on a line good pulse on palpation, no flow obtained through the catheter, second attempt used ultrasound and despite there being no flow through the arrow catheter able to watch the wire go into the artery on long axis

2) Severe AS for valve replacement, crunchy vasculature throughout, same experience

Was it a little clot at the end? Any other ideas?

This should prove to you that US for a routine radial Aline is limited...

It sounds like on both attempts the catheter was not in the vessel, no flow, not in...

I am not sure why you would thread the wire without a flash, into what you then interpreted as the artery which was probably just along side the artery

 

[deleted547339]

This should prove to you that US for a routine radial Aline is limited...

It sounds like on both attempts the catheter was not in the vessel, no flow, not in...

I am not sure why you would thread the wire without a flash, into what you then interpreted as the artery which was probably just along side the artery

I do it all the time. If I have an icu patient that is a challenging a-line or challenging PIV I’ll thread it without seeing flash. Mind you, I’m an attending, so I only do this if everyone else has failed so my subset of patients I’m doing these procedures on is very preselected. I only try PIVs if multiple nurses and the fellow have failed and I only try a-lines if the resident and fellow have failed. But I would say maybe 1/5 of these have no flash but work perfectly.

 

[periopdoc]

I’m convinced the Arrow catheter frequently gets a plug of skin in the needle.

There are at least 3 placements this year where I have threaded the catheter successfully, despite no flash.

If I’m placing an a-line on a hypotensive patient, I’ve taken to threading the wire through the needle immediately after piercing the skin, then retracting it before trying to advance the needle into the artery. This seems to have eliminated the problem.

 

[Crabbygas]

I nick the skin first with an 18ga needle and put the arrow in that. Seems to work ok.

 

[Maverikk]

I’ve had a few alines with no flash that threaded like butter with a great waveform, this is all with ultrasound after a few attempts. Mostly people with ‘tough skin’ who are vacationing in Florida every year. I like the idea of just sticking the epidermis with an 18G will give that a try next time I meet one of these snowbirds

 

[Maverikk]

I’m convinced the Arrow catheter frequently gets a plug of skin in the needle.

There are at least 3 placements this year where I have threaded the catheter successfully, despite no flash.

If I’m placing an a-line on a hypotensive patient, I’ve taken to threading the wire through the needle immediately after piercing the skin, then retracting it before trying to advance the needle into the artery. This seems to have eliminated the problem.

Do you do these with ultrasound? I’ve tried advancing the wire to the black line to prevent skin plugs but it inevitably gets pushed back even in old ladies with fragile skin

 

[periopdoc]

Yes. Depending on the patient, I usually try once or twice by palpation before grabbing the ultrasound. Today's patient, I went straight to U/S since I knew he was a hard stick. I've placed an a-line in him before, and the ICU was unable to secure a line last night.

I push the wire through after piercing the skin to dislodge any skin plug. I don't go through the skin with the wire at the tip.

 

[vector2]

Happens to me a few times a year. Using ultrasound and arrow I visualize the needle tip in the vessel but there is no flash. Wire threads like butter and catheter bleeds profusely once in. No idea what's causing the plug in the needle.

 

[T-burglar]

This should prove to you that US for a routine radial Aline is limited...

It sounds like on both attempts the catheter was not in the vessel, no flow, not in...

I am not sure why you would thread the wire without a flash, into what you then interpreted as the artery which was probably just along side the artery

You can have a bullseye on the ultrasound image with no flash in the catheter or arrow. As others have posted, ultrasound has actually helped me be confident enough to wire the vessel even though there is no blood return. These catheters have all worked perfect. It is palpation and reliance on blood return that is limited, not ultrasound. The trick is learning to use ultrasound to achieve a near 100% first pass success, which is much more involved than just getting a through and through ultrasound appearance on some artery somewhere.

Use an arrow catheter. Use the ultrasound to quickly scan both radials. Go for the one that is larger and more free of disease. Choose radial over brachial if at all possible because the artery runs a straighter course and tortuosity will be less of a factor in failed cannulation. After you get vessel puncture scan distally and reposition the tip of the metal needle dead center in the vessel lumen (don't just drop the ultrasound as soon as you see flash and try to wire). This is another reason to choose radial if possible because its easier to see your hardware in the vessel with ultrasound since its such a superficial artery. Sometimes the ultrasound won't resolve the needle tip easily on a deep brachial attempt.

 

[Laryngophed]

Very unlikely to be a clot if you used an Arrow.

Is it possible there was intimal dissection and the wire and catheter were in the false lumen?

This is my guess. I've placed several using a longitudinal, in-plane approach and seeing the wire slide along the inferior border of the vessel makes me wonder just how often it actually injures and then dissects the intima. I'm guessing more often than we think. But that would account for needle/wire/catheter in vessel with no flow.

 

[deleted162650]

If you’re doing an in-plane approach there is no need for a wire. 20g angiocath and just thread that thing up into the vessel a little ways and slide off the cath.

 

[drmwvr]

The a lines that are "impossible" are the ones that correspond with the pathology at hand...frogged up aortic valves, stenotic carotid or coronary arteries.....the reasons the a line is difficult is the reason they present to surgery...if it isn't, you're just sh***y.....

 

[periopdoc]

As I’ve stated on here before, I track my times very closely when starting up cardiac cases. My mean time for placement of a-lines is a little skewed by the occasional truly difficult line, but my mode is 3 min. That’s probably 90% of my placements. I get the occasional 1 min and the rare 5 min.

Still, there are the occasional lines that are seemingly impossible for no reason at all.

No sense beating yourself up about it, or thinking you are ****ty. It’s just a fact of life. Some a-lines are challenging for no obvious reason whatsoever. No shame in it.

 

[Hork Bajir]

I think US for art lines is the way to go- although adding 15 seconds to set up the US will consistently add 15 seconds to your procedural time, it will often save many minutes of blind digging around before then calling for the US as a backup (and announcing to the room that you are having trouble). More importantly, I’m confident that almost all of the time I can direct thread the arterial line on the first attempt with US (everyone else at my institution likes to transfix). Why make two holes in the artery when you could have only one?? Esp in older vasculopaths with crunchy arteries where the holes don’t seal/heal as nicely, and then you end up with a peri-arterial hematoma that can distort the vessel and dampen your trace. Sure, you can usually direct thread without the US... but it’s not as consistent, and trying to salvage the line by transfixing is much harder when your approach is at the shallower angle needed to direct thread. First attempt = best attempt, just like with intubation- why not optimize for first pass success?

 

[Psai]

No ultrasound through and through seldinger technique master race.

Vasculopath or not.

First pass success 90s.

Ballin