Arterial line

[deleted697535]

Need some help or advice on a lines.

I've probably done 500 or more and do maybe 5 to 8 a week and I'm in an awful trough with them... Like 50/50 first pass. Sometimes up to 3 times... It's embarrassing!

My setup is wrist cocked and taped to be parrallel to ceiling.

I think my fingers are too chunky to reliably find the strongest impulse and sometimes I'm 2 or 3 mm away from it...

It's getting so bad I'm considering just using USS on all my routine cases.

Today took like 30 mins. The guy was a big smoker with a previous long ICU stay and pneumonectomy but still it shouldn't take that long!

Does anyone else get this?

It's literally the only part of my game that is really lacking. Most other skills and decisions are getting really smooth

Thanks for advice!

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[Shimmy8]

If you've got fat fingers try to really use your fingertips...like the absolute tip.

 

[crash2500]

Stop using the arrow catheter...

 

[McPoyle]

I thing wrong with using US. If I get a hint that it might be challenging then I go straight to US, and l also go 4-6cm above the wrist where (I believe) the vessel is larger. I found that I had to take my ego out of it and simply do whatever it takes to improve my first pass success in order to just keep things moving. Yes, I certainly can do them with just palpating and often do, but with vasculopaths or those I think I might not nail it in my first try then I don’t see the point of avoiding US.


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[Lecithin5]

If u/s is readily available, why not? Go with whatever is quicker.

 

[Lecithin5]

I thing wrong with using US. If I get a hint that it might be challenging then I go straight to US, and l also go 4-6cm above the wrist where (I believe) the vessel is larger. I found that I had to take my ego out of it and simply do whatever it takes to improve my first pass success in order to just keep things moving. Yes, I certainly can do them with just palpating and often do, but with vasculopaths or those I think I might not nail it in my first try then I don’t see the point of avoiding US.


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Exactly

 

[deleted59964]

If you’ve done 500 you’re not on a learning curve.
Why not use u/s after having palpate and see if there is a pattern to how you are missing.
I use u/s if I don’t get it within 60 seconds ... I do adults and neonates, adult arteries look friggin huge to me. I like using u/s because it’s the same technique for all comers

 

[nimbus]

I use ultrasound for every single one these days. No reason not to. It's what I would want for myself. I don't even bother to palpate the artery. I consider it progress.

 

[rakotomazoto]

Agree with above, I call for ultrasound if I don't get it on the first attempt. Then, if the pulse is good, I make a second attempt while someone brings the machine into the room. Gotta keep things moving. If there is some reason that it might be difficult, go to ultrasound immediately.

 

[facted]

If an ultrasound is less than a minute or two away, I use it every time. No reason not to anymore.

 

[anbuitachi]

Need some help or advice on a lines.

I've probably done 500 or more and do maybe 5 to 8 a week and I'm in an awful trough with them... Like 50/50 first pass. Sometimes up to 3 times... It's embarrassing!

My setup is wrist cocked and taped to be parrallel to ceiling.

I think my fingers are too chunky to reliably find the strongest impulse and sometimes I'm 2 or 3 mm away from it...

It's getting so bad I'm considering just using USS on all my routine cases.

Today took like 30 mins. The guy was a big smoker with a previous long ICU stay and pneumonectomy but still it shouldn't take that long!

Does anyone else get this?

It's literally the only part of my game that is really lacking. Most other skills and decisions are getting really smooth

Thanks for advice!

50/50 first pass is not bad... that means you get it half the time with a single stick w/o adjusting directions right?

 

[AdmiralChz]

In residency we almost exclusively used the Arrow catheter, which I thought was fine and eventually got up to like a 80-90% success rate (which I wasn't entirely happy with). In fellowship just about everyone uses a standard long 20g IV catheter with a through-and-through technique - back out and advance a wire once you get pulsatile flow out the catheter. It's totally revolutionized my practice and my first-stick success approaches 95%. The technique does add a little bit of time, probably 10-15 seconds or so but it's entirely worth it when you aren't having to deal with multiple hematoma. Side note, I have not had nearly as good success with doing this technique with the Arrow but haven't attempted a significant number of them.

I agree with going to ultrasound early, especially if the patient is vasoconstricted or you just can't feel anything. I'll still occasionally use the arrow catheter in these situations. A-lines can be humbling and are by no means easy, just keep at it and don't be afraid to try new equipment or strategies.

Also never saw a use for the smaller 22 g Arrow that you have to put together - I'm not sure I ever saw someone use it successfully in residency and it's mega awkward with the two separate pieces. Anyone like using this ridiculous contraption?

 

[Lecithin5]

In residency we almost exclusively used the Arrow catheter, which I thought was fine and eventually got up to like a 80-90% success rate (which I wasn't entirely happy with). In fellowship just about everyone uses a standard long 20g IV catheter with a through-and-through technique - back out and advance a wire once you get pulsatile flow out the catheter. It's totally revolutionized my practice and my first-stick success approaches 95%. The technique does add a little bit of time, probably 10-15 seconds or so but it's entirely worth it when you aren't having to deal with multiple hematoma. Side note, I have not had nearly as good success with doing this technique with the Arrow but haven't attempted a significant number of them.

I agree with going to ultrasound early, especially if the patient is vasoconstricted or you just can't feel anything. I'll still occasionally use the arrow catheter in these situations. A-lines can be humbling and are by no means easy, just keep at it and don't be afraid to try new equipment or strategies.

Also never saw a use for the smaller 22 g Arrow that you have to put together - I'm not sure I ever saw someone use it successfully in residency and it's mega awkward with the two separate pieces. Anyone like using this ridiculous contraption?

Can I ask-why is 20 g iv cath better than the arrow? Just curious-I've never used the 20 gauge IV catheter

 

[Spacedman]

Can I ask-why is 20 g iv cath better than the arrow? Just curious-I've never used the 20 gauge IV catheter

the angiocath has a sharper cutting edge -
if hitting an artery is like spearing the olive in martini glass,
the 20g angiocath is a toothpick, the arrow is more like a straw.

 

[crash2500]

Yes to above. Multiple times I've had no flash back with the arrow only to pull the whole needle out and find a huge hematoma start to develop. I've used ultrasound with the arrow multiple times, threaded the catheter 1 cm in to the artery and never got any flashback into the module. Its fine with ultrasound because you can see your needle advancing in the center of the lumen.

Once you have a hematoma, cannulation is infinitely times harder

 

[AdmiralChz]

the angiocath has a sharper cutting edge -
if hitting an artery is like spearing the olive in martini glass,
the 20g angiocath is a toothpick, the arrow is more like a straw.

Exactly. Use both with ultrasound and you'll see what I mean - get someone with calcific peripheral vascular disease and you'll watch the artery just roll or bounce out of the way with the Arrow unless you get a direct hit at 12 O'Clock to pit it down to the tissue. With the 20 gauge it may move a little but typically you can pierce through.

 

[urge]

Can I ask-why is 20 g iv cath better than the arrow? Just curious-I've never used the 20 gauge IV catheter

Old wives' tale.

Stick to the Arrow, much superior catheter.

The thing is the wire is softer than the standalone wire allowing people to ram the wire into the tissue quite easily and when they advance the catheter it doesn't end in the artery because the wire never was in artery to begin with.

Definitely not for brutes.

 

[Noyac]

If you've got fat fingers try to really use your fingertips...like the absolute tip.

He said he had “chunky” fingers, not fat ones.

 

[GA8314]

Need some help or advice on a lines.

I've probably done 500 or more and do maybe 5 to 8 a week and I'm in an awful trough with them... Like 50/50 first pass. Sometimes up to 3 times... It's embarrassing!

My setup is wrist cocked and taped to be parrallel to ceiling.

I think my fingers are too chunky to reliably find the strongest impulse and sometimes I'm 2 or 3 mm away from it...

It's getting so bad I'm considering just using USS on all my routine cases.

Today took like 30 mins. The guy was a big smoker with a previous long ICU stay and pneumonectomy but still it shouldn't take that long!

Does anyone else get this?

It's literally the only part of my game that is really lacking. Most other skills and decisions are getting really smooth

Thanks for advice!

First, hats off to you for being aware of some areas you can improve upon, and then admitting it to others. AND, asking for advice on the matter. Frankly, that tells me you are a good doc, so well done.

I can't speak for your situation, but anyone who tells you A-lines are a synch, are not telling you the truth. It's not a weakness of mine, but we all get into tough A-lines. Also, you can make the case for US.

I don't routinely use US and have gotten rather cavalier about positioning because it's not been a major problem, but it's true that you should take some time to set yourself up for success.

Also, while if you are far off the mark, new holes may need to be made, but I typically find simply coming out near the surface, and redirecting rather than making a new poke will suffice. Go slow, redirect, know that it's probably a bit more medial than you sense, and hope for the best.

 

[GA8314]

I use ultrasound for every single one these days. No reason not to. It's what I would want for myself. I don't even bother to palpate the artery. I consider it progress.

I'd agree with others that this is not at all a bad idea. It should probably be the standard???

 

[deleted162650]

I typically find simply coming out near the surface, and redirecting rather than making a new poke will suffice. Go slow, redirect, know that it's probably a bit more medial than you sense, and hope for the best.

We still talkin' about A-lines here??

 

[dhb]

I'd agree with others that this is not at all a bad idea. It should probably be the standard???

Anyone that claims he can get any aline within 5min with u/s is lying.

 

[Nephro critical care]

I was absolutely terrible at arterial lines in IM residency and through the first year of fellowship. I have a hand tremor and when you are dealing in millimeters it matters. I found I was spending too much time with arterial lines which was taking away time from patient care. But you can't make do without them as in critically ill patients the q5 minute automated BPs are in my opinion unacceptable. Especially peri-intubation. I am sure we would have less perintubation codes if everyone had an arterial line.
Then I slowly managed to get better. By doing arterial lines every attempt I could get. I never let the medstudents,residents,NP do the arterial line if I had the time. And followed the rules which were :
1. U/S 100% of the time if available.
2. Take 2 minutes to prep the wrist with tape , towels , position flat. Talk to the patient , numb appropriately and get him to position wrist. If being done after intubation first few minutes with etomidate/roc on board is golden time(but doesn't mean you shouldn't numb well)
3. Get needle directly above radial artery. That's the benefit of U/S you can enter artery at directly above artery without a micrometer deviation. If you go to a side and a hematoma forms the artery will be much harder to get in next time. Some people have long thin fingers good for palpating pulse but I don't and I recognize my sensory limitations and use U/S.
4. Use Argon 20 gauge not the Arrow. The benefit of the Argon is that once you enter blood vessel you can see blood spurting and that's when you should put guidewire(remember to use flexible side of wire because there is a stiffer side too). Don't put guidewire if there is a measly drip of blood. Those Arrows don't last long either they peter out in a day and are thus good for OR but not in the ICU where you may need the catheter for a week. Plus the Argon has wings with holes so easy to suture. ICU lines should always be sutured in.
5. The guidewire has to float into the vessel like butter. Don't advance wire if you meet resistance as it is invariably going into SC tissue and will send the vessel into vasospasm.
6.Best location is about an inch above the wrist. Usually it's easy to get the best acute angle there. Higher up the artery is deeper and its harder to get into the vessel at an acute angle which is what you need.
7. If you get vasospasm it's better to go to the other wrist rather than spend 15 minutes trying to coax a guidewire into an angry artery. And trust me it will get angrier the more you poke at it. Arterial lines are either got in 5 minutes with U/S or never.
8.If you get good at arterial lines you will be an absolute bomb at central lines as it's much easier to get a guidewire into a 1 cm IJ rather than a 1 mm radial. Putting radials is great for developing hand eye coordination. It's time well spent if you have it.

 

[Swamp Gas]

In fellowship just about everyone uses a standard long 20g IV catheter

I use IV caths in peds and arrows in adults (out of habit/training). Can’t believe it never occurred to me to use IV caths in all comers. Thanks for the post, I look forward to trying it.

 

[facted]

Anyone that claims he can get any aline within 5min with u/s is lying.

Not ANY aline, but at least 90%. Not even a question.

 

[deleted697535]

Thanks guys. Ive done plenty of art lines with USS and it's usually quick.

What I'm gonna trial is just using the USS to get the line of the radial. And Mark it. And also compare where I 'thought' it was via palpation....

If that doesn't help me figure out where I'm going wrong with palpation, I'll just use uss live to enter the radial. I've done that on about 100 lines and it's not too difficult for me

 

[urge]

Thanks guys. Ive done plenty of art lines with USS and it's usually quick.

What I'm gonna trial is just using the USS to get the line of the radial. And Mark it. And also compare where I 'thought' it was via palpation....

If that doesn't help me figure out where I'm going wrong with palpation, I'll just use uss live to enter the radial. I've done that on about 100 lines and it's not too difficult for me

It takes a while to get good with US. But once you get it you will be able to get the toughest a lines ever.

 

[Aether2000]

US for aline placement can also demonstrate aberrant anatomy. Recently did an ulnar arterial line when the US of the radial artery demonstrated significant proximal stenosis with a sharp curve as its course.

 

[Laryngophed]

I was absolutely terrible at arterial lines in IM residency and through the first year of fellowship. I have a hand tremor and when you are dealing in millimeters it matters. I found I was spending too much time with arterial lines which was taking away time from patient care. But you can't make do without them as in critically ill patients the q5 minute automated BPs are in my opinion unacceptable. Especially peri-intubation. I am sure we would have less perintubation codes if everyone had an arterial line.
Then I slowly managed to get better. By doing arterial lines every attempt I could get. I never let the medstudents,residents,NP do the arterial line if I had the time. And followed the rules which were :
1. U/S 100% of the time if available.
2. Take 2 minutes to prep the wrist with tape , towels , position flat. Talk to the patient , numb appropriately and get him to position wrist. If being done after intubation first few minutes with etomidate/roc on board is golden time(but doesn't mean you shouldn't numb well)
3. Get needle directly above radial artery. That's the benefit of U/S you can enter artery at directly above artery without a micrometer deviation. If you go to a side and a hematoma forms the artery will be much harder to get in next time. Some people have long thin fingers good for palpating pulse but I don't and I recognize my sensory limitations and use U/S.
4. Use Argon 20 gauge not the Arrow. The benefit of the Argon is that once you enter blood vessel you can see blood spurting and that's when you should put guidewire(remember to use flexible side of wire because there is a stiffer side too). Don't put guidewire if there is a measly drip of blood. Those Arrows don't last long either they peter out in a day and are thus good for OR but not in the ICU where you may need the catheter for a week. Plus the Argon has wings with holes so easy to suture. ICU lines should always be sutured in.
5. The guidewire has to float into the vessel like butter. Don't advance wire if you meet resistance as it is invariably going into SC tissue and will send the vessel into vasospasm.
6.Best location is about an inch above the wrist. Usually it's easy to get the best acute angle there. Higher up the artery is deeper and its harder to get into the vessel at an acute angle which is what you need.
7. If you get vasospasm it's better to go to the other wrist rather than spend 15 minutes trying to coax a guidewire into an angry artery. And trust me it will get angrier the more you poke at it. Arterial lines are either got in 5 minutes with U/S or never.
8.If you get good at arterial lines you will be an absolute bomb at central lines as it's much easier to get a guidewire into a 1 cm IJ rather than a 1 mm radial. Putting radials is great for developing hand eye coordination. It's time well spent if you have it.

Not to be that guy, but exactly how many people arrest on you at induction?

 

[Laryngophed]

US for aline placement can also demonstrate aberrant anatomy. Recently did an ulnar arterial line when the US of the radial artery demonstrated significant proximal stenosis with a sharp curve as its course.

So the radial was stenosed and you elected to cannulate the ulnar?

 

[GA8314]

We still talkin' about A-lines here??

haha

 

[facted]

US for aline placement can also demonstrate aberrant anatomy. Recently did an ulnar arterial line when the US of the radial artery demonstrated significant proximal stenosis with a sharp curve as its course.

Also allows you to go a few inches more proximal where you have a bigger vessel. I do this routinely.

 

[deleted59964]

1. ....But you can't make do without them as in critically ill patients the q5 minute automated BPs are in my opinion unacceptable. Especially peri-intubation. I am sure we would have less perintubation codes if everyone had an arterial line.

2..... Get needle directly above radial artery. That's the benefit of U/S you can enter artery at directly above artery without a micrometer deviation.

1. I disagree ... while it's nice to have an art line - if you know what's going to happen to the physiology wen you induce, tube, and switch to PPV -- with experience you should be able to do a stable induction without one ... you can also just keep your fingers on the pulse.

2. I disagree ... check out lateral resolution and ultrasound. every tool has it's limits. this particular limit is a PITA when cannulating very small arteries.

 

[dhb]

Not ANY aline, but at least 90%. Not even a question.

Well i did say any . The point is it can be tricky to hit the artery right in the middle when it's smallish, not that it would be easier without u/s.

 

[Nephro critical care]

Not to be that guy, but exactly how many people arrest on you at induction?

One recently did almost. I misjudged how bad his preload would drop, he had RV dysfunction on echo and I had become a little laissez faire on watching BPs after intubation and he dropped from 159/80 to 55/31 after etomidate/sux 5 minutes after intubation. Gave a neo push and BP still remained 50s. Luckily I had at least got a levo drip on hand and fluid bolus going so PEA didn't happen. But close catch and I should have on retrospect got the A line in prior to intubation. I intubate about 80-90 pts in the ICU a year myself, PEA has happened in fellowship although not recently thankfully.

 

[Maverikk]

Doing it blind (with the arrow)-
Get it- you're done
Don't- it should be a subcutaneous prick don't fret about your academic colleagues, go medial, poke advance then come out slowly. I do two fingers, roll the artery and feel where it is. Then I occlude distally, hit the artery between my fingers at 45, drop to 20-30 (may have to advance a few mm if you don't get bloodflow), if the wire doesn't advance like butter it's a prob.
If I use U/S then micropuncture kit which gives you thinner wire for the vaculopaths. I have a minimal threshold for this.

 

[dchz]

Anyone that claims he can get any aline within 5min with u/s is lying.

With the new gen of trainees playing video games all their lives, US (not counting the time it takes to get it in the room) is just about as fast as 2 attempts on the arrow.

 

[dchz]

One recently did almost. I misjudged how bad his preload would drop, he had RV dysfunction on echo and I had become a little laissez faire on watching BPs after intubation and he dropped from 159/80 to 55/31 after etomidate/sux 5 minutes after intubation. Gave a neo push and BP still remained 50s. Luckily I had at least got a levo drip on hand and fluid bolus going so PEA didn't happen. But close catch and I should have on retrospect got the A line in prior to intubation. I intubate about 80-90 pts in the ICU a year myself, PEA has happened in fellowship although not recently thankfully.

I think you replied to the wrong thread?

 

[deleted697535]

Not to be that guy, but exactly how many people arrest on you at induction?

Fwiw if I'm intubating in a periarrest situation and there's time for an a line, then they're getting an a line. And I agree with prev poster. A line and visual capnog are essential tools in these situations I believe. Especially on your own in unfamiliar environs with unwell patients.

It actually starting to annoy me when I see juniors attempting to tube really sick people without these.

 

[facted]

Well i did say any . The point is it can be tricky to hit the artery right in the middle when it's smallish, not that it would be easier without u/s.

Ultrasound vastly improves first time success. Can you get many a lines first time without it? Sure. But on average, ultrasound hands down beats no u/s. Also super useful for difficult peripheral IVs.

 

[Nephro critical care]

I think you replied to the wrong thread?

No, i am replying to the right thread. Someone asks me if anyone has coded on me during intubation and recently one nearly did. He was then not waking up over night and I was worried about an ischemic CNS ischemic hypoperfusion event. But later on patient woke up. It’s kind of hard to cause CNS anoxia without a real 10 minute CPR events or maybe prolonged severe hypoxia <70% for 10 minutes. At least I haven’t seen one.

 

[Aether2000]

Yes Physio- we did cannulate the ulnar artery, that was larger than normal and had excellent flow on doppler US. The radial was stenosed proximally preventing passage of the cannula, but had decent blood flow beyond the stenotic segment at 30cm/sec.

 

[deleted171991]

One recently did almost. I misjudged how bad his preload would drop, he had RV dysfunction on echo and I had become a little laissez faire on watching BPs after intubation and he dropped from 159/80 to 55/31 after etomidate/sux 5 minutes after intubation. Gave a neo push and BP still remained 50s. Luckily I had at least got a levo drip on hand and fluid bolus going so PEA didn't happen. But close catch and I should have on retrospect got the A line in prior to intubation. I intubate about 80-90 pts in the ICU a year myself, PEA has happened in fellowship although not recently thankfully.

You don't need an a-line. Just put the NIBP q1-2min.

Also, if you think the patient can crash, give a pressor before inducing. And I mean a real pressor, such as levo.

 

[Ronin786]

There's no reason ultrasound should be standard for arterial lines. Next thing you won't be able to do a PIV without U/S.

 

[vector2]

There's no reason ultrasound should be standard for arterial lines. Next thing you won't be able to do a PIV without U/S.

Agree it shouldn't be standard per se, but I think the threshold should be to call for U/S if you can't palpate an awesome point of maximal impulse on someone's wrist within 10 seconds. I would still attempt the stick as long as I felt some kind of discernible pulse, but I wouldn't be wasting time since U/S will be in room for second attempt if I miss.

 

[nimbus]

There's no reason ultrasound should be standard for arterial lines. Next thing you won't be able to do a PIV without U/S.

If I don't see an obvious superficial vein, I get the ultrasound. No reason not to.

 

[mostwanted]

I routinely use the arrow without ultrasound with 90% first pass rate. I agree with urge, it is a better catheter.
I think positioning is important. Use the wrist splint or rolled up gauze. Turn the wrist fully, don't have it at an angle. I typically start closer to the wrist bc artery is more superficial and allows me to move proximally if needed. If wire doesn't advance smoothly advance and do it through and through. If on through and through there is no significant flashback, don't pull the catheter out all the way instead leave a little bit of the tip in to prevent bleeding and go more proximal with a new arrow or 20g. If needed after 2 attempts I go to US. If not a decent vessel move to brachial. Ideally entire process should be no more than 10 minutes.


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[nimbus]

I routinely use the arrow without ultrasound with 90% first pass rate. I agree with urge, it is a better catheter.
I think positioning is important. Use the wrist splint or rolled up gauze. Turn the wrist fully, don't have it at an angle. I typically start closer to the wrist bc artery is more superficial and allows me to move proximally if needed. If wire doesn't advance smoothly advance and do it through and through. If on through and through there is no significant flashback, don't pull the catheter out all the way instead leave a little bit of the tip in to prevent bleeding and go more proximal with a new arrow or 20g. If needed after 2 attempts I go to US. If not a decent vessel move to brachial. Ideally entire process should be no more than 10 minutes.


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This is exactly what I used to do before going to ultrasound for every Aline. Then I went to ultrasound for every Aline for hearts because the machine was always in the room. It worked so well that the anesthesia techs know to bring me an ultrasound machine whenever they set up an Aline for me.

 

[Ezekiel2517]

I typically start closer to the wrist bc artery is more superficial and allows me to move proximally if needed.

I'd advise not to stick too distally near the wrist. Give yourself a few cm. The radial artery makes a bend distally near the wrist that often will make it difficult to pass the wire.

 

[Urzuz]

Arterial lines are easier with a 20g Angiocath for the reasons mentioned above, but the actual Arrow catheter itself is superior.

On Monday do this -- open an Angiocath, open an Arrow, and dispose of the needles. With your fingernails, lightly pinch down on both catheters. What you will find is that the Arrow catheter is more resilient and won't be affected at all, whereas the Angiocath will have an obvious deformity/indentation to it even after a light pinch.

What this tells me is this -- for short term perioperative use, the choice of catheter probably doesn't matter, so you can choose either with equivalent results. However, for long term arterial line cannulation (sepsis, ICU patient, etc), Arrow is probably the superior choice since the catheter itself is of higher quality and less likely to give problems down the road. I don't have any evidence to support this, but it just seems logical to me.