A-Lines Sterile

[PMPMD]

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Speak of the devil, just had a pt roll in w/ septic shock, had bilateral prior radial harvests. My staff (only guy here who didn't train here), doesn't like brachials so he had me put in an axillary. It was fun; hadn't done that one before.

 

[proman]

I think for cardiac cases, brachial a-lines (or axillary if needed) give a much better estimation of central aortic pressures than radial a-lines. Especially when on high dose vasopressors or inotropes. I have taken care of multiple pt's whose brachial or axillary pressure reading was markedly higher than their radial a-line reading even when not on vasopressors. I don't always trust radial pressures as much in severe vasculopathic pt's. Not to say that I don't put in radial a-lines on them, but if something doesn't seem right I have a lower tolerance to start checking other sites for BP confirmation.

I think this is spot on. There's nothing intrinsically wrong with doing brachial a lines. I've started using the 6cm 18ga Angiocath that comes in the central line kits for them. Nice and long. Apparently my SICU has adopted a policy to suture all a lines in. Sigh.

 

[Bertelman]

I see brachial artery access being used more and more frequently at other institutions. I head from someone applying for a CT fellowship that at CC, fellows shoot for the brachial aline first. I always thought brachials were taboo. Ive seen many dusky hands in the ICU but I've seen it with axillary and radials as well.

Whats it like at other institutions?

It's taboo at my place. I've seen attendings go for femoral and even DP before they even considered brachials. I don't get it.

 

[IlDestriero]

It's taboo at my place. I've seen attendings go for femoral and even DP before they even considered brachials. I don't get it.

They probably don't want to break out the ultrasound.😉
We use the brachial for difficult preemie alines. Though, I always worry about perfusion off the hand. Not that long ago we had an amputation from sepsis and a clotted radial aline. (placed elsewhere) I've never seen that before.

Cheers!

 

[Bertelman]

They probably don't want to break out the ultrasound.😉
We use the brachial for difficult preemie alines. Though, I always worry about perfusion off the hand. Not that long ago we had an amputation from sepsis and a clotted radial aline. (placed elsewhere) I've never seen that before.

Cheers!

We have ultrasound, and I actually wouldn't try a brachial at my current level of training without U/S. I offered up the ultrasound every time.

 

[jetproppilot]

Do most people place them with sterile gloves, or just use regular gloves without touching the puncture site/catheter tip? I've been at two places, one did the former and the other the latter.

I read most responses to this thread.

Here's my response:



To think there are people out there advocating

FULL STERILE TECHNIQUE

for an A line is

SILLY.

Waste of time. Waste of resources.

Why do you dudes perpetuate something you

learned in residency but has no place in private practice, nor is there any good supporting literature to your practice?

RULE OF THE DAY FOR OUR ANESTHESIA RESIDENTS OUT THERE:

You don't need to gown and drape for an a line.

Jesus.

You don't even need to drape.

I'm waiting for the dudes out there advocating this type of B.S. to make their pre op nurses gown and drape for IV placement!

 

[WholeLottaGame7]

I'm waiting for the dudes out there advocating this type of B.S. to make their pre op nurses gown and drape for IV placement!

We're all just one raging phlebitis away from this actually happening...

 

[Mman]

I'm gonna start going full gown and glove and sterile prep of the airway prior to intubation. Seems like we'd probably have less VAP that way....

 

[PMPMD]

I'm gonna start going full gown and glove and sterile prep of the airway prior to intubation. Seems like we'd probably have less VAP that way....

Put on one of those ortho space suits just to be safe.

 

[pie944]

Put on one of those ortho space suits just to be safe.

Wearing one of those is on my bucket list.

 

[Bertelman]

Hope the rest of your list is a little more exciting.

 

[Idiopathic]

Any evidence that suturing actually accomplishes anything? I never suture but also never wrap the tubing around the thumb (ie create a pivot).

increases the likelihood of occupational exposure, anemia and infection.

 

[Idiopathic]

I'm gonna start going full gown and glove and sterile prep of the airway prior to intubation. Seems like we'd probably have less VAP that way....

careful, we are getting close to this. we have moved to disposable laryngoscope blades.