Accidental art lines

[Hork Bajir]

Junior resident I was working with recently put an accidental 18 angio cath into the brachial artery when trying to start an IV. Fortunately it was recognized before any drugs were given. Took it out and held pressure, no big deal...

What if it was a 16? A 14? When if ever to call vascular surgery? Or take it out, hold pressure, and hope? What if patient is (or will need to be for the surgery) anticoagulated?

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[drmwvr]

Arterial groin access for IABP is bigger than 16 and sometimes 14. Just hold pressure, do pulse checks and don't make a big deal out of it. Edit for heparin: Heparin might muck things up. With an easily compressible brachial artery, I'd think reliable compression would be sufficient through heparinization and reversal if you had to go.

 

[vector2]

Junior resident I was working with recently put an accidental 18 angio cath into the brachial artery when trying to start an IV. Fortunately it was recognized before any drugs were given. Took it out and held pressure, no big deal...

What if it was a 16? A 14? When if ever to call vascular surgery? Or take it out, hold pressure, and hope? What if patient is (or will need to be for the surgery) anticoagulated?

There are a gajillion cardiac and vascular cases every year where there is a failed art line attempt (sometimes femoral or brachial) and we still go ahead and give 400u/kg of heparin. Just hold pressure and make sure they have pulses at the end of the case.

 

[WholeLottaGame7]

Oh geez. Reminds me of the time I was a CA-2 or CA-3 and my (first year) attending put a short 16g in this fat woman's AC trying for a vein and hit artery. She was like "let's leave it in, might as well use it," and I was like "uhh, that is barely in, she's fat, and when we go lateral there is a 100% chance it comes out where I'm going to have a much harder time holding pressure and getting a new one."

2 guesses as to what happened.

 

[IMGASMD]

Junior resident I was working with recently put an accidental 18 angio cath into the brachial artery when trying to start an IV. Fortunately it was recognized before any drugs were given. Took it out and held pressure, no big deal...

What if it was a 16? A 14? When if ever to call vascular surgery? Or take it out, hold pressure, and hope? What if patient is (or will need to be for the surgery) anticoagulated?

I’ve seen a dilator into the carotid, then a TLC sat there for a while with meds and fluid going overnight. Held pressure for half hour that was fine. I, the intern, get to watch TV in ICU while my fellow interns were rounding, makes it particularly memorable. Good times.

 

[Hork Bajir]

There are a gajillion cardiac and vascular cases every year where there is a failed art line attempt (sometimes femoral or brachial) and we still go ahead and give 400u/kg of heparin. Just hold pressure and make sure they have pulses at the end of the case.

True, but most of the time when someone is blowing an art line they’re using a 20g needle or smaller (hopefully)

 

[vector2]

True, but most of the time when someone is blowing an art line they’re using a 20g needle or smaller (hopefully)

For endovascular procedures or TAVR they stick an artery with a micropuncture kit and then dilate up to like an 18 fr sheath and then give 100-200u/kg heparin. Granted much of the time they use closure devices when theyre done, but many times if it's a smaller sheath they just have the nurse hold pressure at the end of the case, put on a pressure dressing, make the pt lay supine, and do pulse checks in the ICU.

Not to mention, even in the age of U/S there's probably still a fair number of people who stick the carotid with the 18g needle that comes in a central line kit. What's the treatment? Hold pressure.....

 

[Temeraire]

I hit the big red during my first central line ever as a med student (ultrasound guided, hah). Luckily I didn’t dilate. The resident who was supervising me just told me to stand there and hold pressure for 20 minutes while she went to get a coffee.

 

[Hork Bajir]

For endovascular procedures or TAVR they stick an artery with a micropuncture kit and then dilate up to like an 18 fr sheath and then give 100-200u/kg heparin. Granted much of the time they use closure devices when theyre done, but many times if it's a smaller sheath they just have the nurse hold pressure at the end of the case, put on a pressure dressing, make the pt lay supine, and do pulse checks in the ICU.

Not to mention, even in the age of U/S there's probably still a fair number of people who stick the carotid with the 18g needle that comes in a central line kit. What's the treatment? Hold pressure.....

That’s interesting, in my experience I have never seen an interventionalist NOT use some sort of percutaneous closure device even for the smaller TAVR sheaths, but good to know that there is some institutional variation around this.

In my mind the interesting question is: how big is too big? (Cue the jokes...) Obviously most people don’t care if you stick an important artery with an 18 gauge. By the same token, I think most people would agree that accidental placement of a large introducer into a major artery at the very least should merit consideration of a vascular surgery consult- even if all they want to do are pulse checks and hold some pressure, If the patient’s limb falls off and you did not consult them then your goose is cooked. Am I correct that the consensus here seems to be vascular consult not necessary (or wait and see) even for a 14 gauge stick?

 

[T-burglar]

Holding pressure should be fine . I’ve been amazed in the past at the size of arterial holes that can be solved by simply holding pressure. If it’s a big enough hole a perclose device is usually involved, but not for a 14g hole

 

[anbuitachi]

had a surgeon dilate subclavian artery for perm cath.. held pressure for like 30 minutes

 

[IMGASMD]

had a surgeon dilate subclavian artery for perm cath.. held pressure for like 30 minutes

Subclavian, dilated......ouchy

 

[coffeebythelake]

Subclavian, dilated......ouchy

How do you hold pressure on that?

 

[caligas]

How do you hold pressure on that?

Open the chest.

 

[deleted162650]

Ive posted this one before, but for those that just tuned in:

During my CA-3 year, one of the junior surgical residents placed a VasCath into the vertebral artery. Through-and-through the IJ into the vertebral near it's takeoff at the base of the neck. The line got used for CRRT overnight. Labs were drawn the following morning and when the pO2 came back at 100 everybody went "Huh, that's weird." Hillarity ensued.

Of course it was the VA so the patient did fine after the line was surgically removed on a Saturday morning by a very irritated vascular surgeon.

 

[coffeebythelake]

Ive posted this one before, but for those that just tuned in:

During my CA-3 year, one of the junior surgical residents placed a VasCath into the vertebral artery. Through-and-through the IJ into the vertebral near it's takeoff at the base of the neck. The line got used for CRRT overnight. Labs were drawn the following morning and when the pO2 came back at 100 everybody went "Huh, that's weird." Hillarity ensued.

Of course it was the VA so the patient did fine after the line was surgically removed on a Saturday morning by a very irritated vascular surgeon.

This is amazing. No neuro complication?

 

[deleted162650]

This is amazing. No neuro complication?

Nope. You can't kill a vet (no matter how hard you try).

 

[drmwvr]

...the line was surgically removed on a Saturday morning by a very irritated vascular surgeon

Is there another kind?

 

[deleted162650]

Is there another kind?

I’ve known exactly 2 that were all around good, chill guys.

 

[DM27]

I’ve seen someone put a 14 in the brachial artery, no issues, just held pressure for like 5-10 and put a pressure dressing on.

For reference, most radial access cardiac caths are done with a 5Fr micropuncture which is roughly equivalent to a 15g IV.

 

[Twiggidy]

Ive posted this one before, but for those that just tuned in:

During my CA-3 year, one of the junior surgical residents placed a VasCath into the vertebral artery. Through-and-through the IJ into the vertebral near it's takeoff at the base of the neck. The line got used for CRRT overnight. Labs were drawn the following morning and when the pO2 came back at 100 everybody went "Huh, that's weird." Hillarity ensued.

Of course it was the VA so the patient did fine after the line was surgically removed on a Saturday morning by a very irritated vascular surgeon.

So who went to Tahiti to present that case?

 

[Twiggidy]

Nope. You can't kill a vet (no matter how hard you try).

I was just thinking that when I read your post. You can give two to the back of the head to a VA patient and they'll still walk OVER YOU out of the hospital. It's when you do anesthesia standard of care is when they decide they want to die.

 

[Twiggidy]

I’ve known exactly 2 that were all around good, chill guys.

I only know one from back in residency. Patients would be moving like crazy during awake carotids and he's just be like "It's cool man" and actually my vascular attending from internship was cool too. My dude spilled some blood on his alligator shoes during an AVF, stopped the surgery, took a blue towel to clean off his shoes, and got back to business. That was my guy.

 

[Mman]

I put a 14g in the brachial artery trying to hit this big juicy vein right above one time. Nice flash, catheter threads easy, hold a little pressure to pull out needle and hook up IV and the blood shot past the patient's hand. Held pressure for about 5 or 10 minutes and kept the pulse ox on that hand for the case and periodically checked the arm throughout the case and nothing bad happened.

 

[woopedazz]

had a surgeon dilate subclavian artery for perm cath.. held pressure for like 30 minutes

Same happened to a colleague; when the blood started squirting, they freaked out and pulled the wire. Chest filled with blood --> thoracotomy.