Arterial Lines?

[Inertia123]

EM intern here. Done with my ICU months for the year and haven't really gotten much opportunity to place A-lines. Had one attempt with the classic "got flash, couldn't pass wire" story. Should I be worried about this lack of experience? How commonly are you attendings in practice actually placing a-lines? I noticed that the EM RRC doesn't even qualify this procedure as one where we need a minimum performed for graduation. Thoughts?

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[bougiecric]

My personal opinion (as written in other threads): make it easy on yourself and just use US every time. Unless the patient is incredibly vasoconstricted, I can get the line on first past routinely.

That said, my impression is that the majority of ED docs (both community and academic) can't or don't do these. When I was in academics, I can't recall once seeing an ED attending place one. In the community, most docs are too busy and an art line often doesn't change ED management.

I place them because I like the procedure, you can bill for them, and the intensivists have told me multiple times they appreciate it.

This may be one of those things you have to take upon yourself to learn. If I were you, I'd start telling your attendings you're going to go attempt an art line whenever you have a critically ill patient. There's minimal downside in at least trying. Also, get good at US guided peripheral IVs, as a radial art line is essentially the same skill.

 

[Bostonredsox]

An art line is not something I expect you to have placed before I get the pt. that said, if you've put them on a pressor and you have time to throw one in that's great. I agree using US up front makes then easier and it allows you to place the line more proximally up the forearm where the radial artery is less tortuous and freely mobile. They often last longer with a good waveform up further too. Anyone who you get who is toxic that your putting on a vasopressor warrants an aline though so use those pts to practice if you have the time. Wouldn't sweat not doing a lot of them though. You putting it I saves me some time, it probably does not change your management in the Ed unless your cuff pressure is unobtainable or unreliable.

 

[EM Junkie]

I'll put them in the femoral artery about once a year, in those patients who keep coding and you can't keep a constant finger on their pulse. That's it. (Community practice for 5 years).

I've never been able to get one into the radial artery..

 

[Hair Police]

Something to consider - if you're already gowned up to do a CVC, cut the drape and do the a-line sterile at the same time. It's little added time, it decreases infection risk, you can do it much more easily under ultrasound guidance since it's already covered, and a lot of patients getting CVCs will get a-lines.

From my own resident experience, I can get the radial by touch, but much less successful than with US, and I have rarely done it on my community rotations.

 

[Rendar5]

only wanted to do it once for unobtainable BP, and then foudn out my community ICUdoesn't have RN's trained in its use nor the equipment to electronically monitor it. had to do BP's over palp.

EDIT: whoops, community ICU can do it, I meant my ED RN's aren't trained in it, and my ED doesn't have the monitoring set up, so I could place it, but would get no data from it.

 

[sylvanthus]

My hospital doesnt have the equipment in the ED to monitor it, however, I have done a couple in the CCU. I don't think it is something normally done in the ED, so don't sweat it. Youll get more throughout residency Im sure.

 

[The White Coat Investor]

I did them a lot in residency, but rarely now. You should definitely learn it though. Never thought to use an US on a radial one....gotta try that.

 

[Tiger26]

Art lines really just don't have a role in the ED. If the patient looks like death and has cuff pressures in the 70s, that's pretty reliable. If they're awake and texting on their phone with pressures in the 90s, well that's a pretty reliable indicator as well.

I'll go out on the other end of the spectrum and say I never did one during residency, though I did 3-4x the amount of central lines, intubations, chest tubes as required by the RRC during residency and regularly do nerve blocks and other u/s guided procedures, so I'd feel confident doing one if necessary. We had a highly efficient ED with the ability to have an ICU bed available in about 5 min, so they're wasn't much of a reason to delay that for the art line, especially after we had the patient intubated with a central line in.

With the ultrasound, if you can put in a PIV, you can surely do an art line.

 

[Cerberus]

I think they are rarely useful in the ED. The exception to me would be someone requiring frequent blood draws (i.e. the HIET patient I put one in recently)

 

[Arcan57]

"Ain't nobody got time for that"

 

[jendc08]

I've been out for 2.5 years and have not put one in as an attending. As far as I know, none of my colleagues are doing then either. Not my favorite procedure in residency so glad to skip it!

 

[gman33]

In residency do any procedure you can, as many times as you can.
U/S guidance makes this a pretty simple procedure most of the time.
Just like placing a PIV into a very small vein.

Never done it in the ED.
Had a patient I wanted to on recently, found out no proper setup in ER for monitoring/nurse training.
Could be an issue if you are boarding ICU level patients for days at a time.

 

[neusu]

Neurosurgery resident here.

We always ask for a-line/cvc in the ED for SAH patients.

While I've gotten out of practice in both recently, it is certainly something that is worth learning. The only way to become proficient is by practice.

 

[Fiddlergirl]

We always ask for a-line/cvc in the ED for SAH patients.

Why? I've just finished up a month in a neuro ICU full of SAH patients and definitely did not put an a-line in each one. And even when we did, it was in the unit not the ED. that seems a lot to ask from the ED, given the amount of time those procedures can take, when they could be done after ICU transfer. And why do you need an a-line in all of these patients, much less CVC?

 

[Birdstrike]

Give me one compelling reason an art line is needed in the ED, or is any better than a BP cuff cycled every 5 minutes?

For all you art line lovers, how often do you calibrate your art line to a manual BP, which is the gold standard for blood pressure (not arterial monitor read outs) ?

If your art line isn't calibrated, it's no better than a cuff, in fact it's worse.

If your blood pressure is changing so fast, you don't have time to push "inflate" on you BP machine, you've got bigger problems than needing an art line. If so, might want to check a pulse and start CPR.

An art line gives nurses a nice little readout they can jot down a BP from, it makes a pretty little red line on your monitor. They're convenient for everyone (accept the one who has to put it in). They might even be accurate if you've calibrated your to manual pressure reading recently. But an art line is in no way necessary in the ED, unless your ED has run completely out of blood pressure cuffs. An art line is a "gadget," nothing more.




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[Rendar5]

But what if i need q15 minute abg's?

 

[Birdstrike]

But what if i need q15 minute abg's?

If you need q15 min abg's, your hospital might need to think about breaking ground on an ICU.

 

[Arcan57]

Art lines in the ED are largely a relic of a time before we had Cardene. Also, the idea that a nurse that's running a 1:4 ratio is going to be titrating a drip based on continuous real-time readings is laughable. With proper flogging, I can barely get q30min adjustments.

 

[Rendar5]

That was complete sarcasm, birdstrike

 

[Birdstrike]

That was complete sarcasm, birdstrike

I figured it might be. Mine was, too. That's why I wrote it in clear sarcasm font...



(Oh, wait, there's no such thing, unless you recognize "purple" as such.)

 

[Cerberus]

That was complete sarcasm, birdstrike

I don't know why. We frequently board ICU patients for extended periods of time. Sure I'm deep in an urban area where resources are poor - but I expect it is coming to us all soon. With an aging, sick, fat population and diminishing reimbursement, you are all going to be ICU doctors, not to mention hospitalists and internists if you aren't already.

 

[jdh71]

Give me one compelling reason an art line is needed in the ED, or is any better than a BP cuff cycled every 5 minutes?

For all you art line lovers, how often do you calibrate your art line to a manual BP, which is the gold standard for blood pressure (not arterial monitor read outs) ?

If your art line isn't calibrated, it's no better than a cuff, in fact it's worse.

If your blood pressure is changing so fast, you don't have time to push "inflate" on you BP machine, you've got bigger problems than needing an art line. If so, might want to check a pulse and start CPR.

An art line gives nurses a nice little readout they can jot down a BP from, it makes a pretty little red line on your monitor. They're convenient for everyone (accept the one who has to put it in). They might even be accurate if you've calibrated your to manual pressure reading recently. But an art line is in no way necessary in the ED, unless your ED has run completely out of blood pressure cuffs. An art line is a "gadget," nothing more.




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Hell. Give me a compelling reason it's even needed in the ICU routinely.

 

[ORL10]

Ill go against the grain and say arterial lines are useful in the ICU and they are useful occasionally in the ED.

1. One they make sure that patients who are hypercapneic actually get an ABG, rather than, Sorry man my ER got busy so I didn't get one and now my ASA status III patients CO2 is high pH has worsened. If you say it's not a big deal then let me do it to your family member. We definitely are victims of doing too frequent ABGs, but they are not a relic of the past, I don't check ABG's for sats, or pH.

2. Non-invasive BPs can be inaccurate, AFIB?, obese, wrong cuff size, time for inflation, didn't get an accurate reading so it recycles wait 30 seconds it just needs to calculate the systolic and diastolic pressure. Ever had the situation where we go: Why is it not reading, that's not right hit recycle, ok wait does he have a pulse? I think I feel a carotid, get the US...


3. Hemodynamically smooth intubation. How many patients have you coded after you intubated them, probably on more than one occasion. The A-line doesn't prevent them from coding, but it helps me titrate my pre/post intubation package the best I can. Leaking SAH undergoing laryngoscopy I want their MAP tightly controlled not into the 130's, ICH same thing, ACS, ischemic heart disease, TIGHT aortic stenosis, with valve area < 0.6 I want to maintain hemodynamic optimization best as possible with beat to beat BP monitoring. Wait you mean there is NO RCTs to show survival benefit. OK, Ill let you choose how I intubate your wife or husband, an IV in the wrist that takes me under 2 minutes to place or a cuff that uses oscillations in blood flow, averaged over 30 seconds and then calculates back from the MAP a systolic and diastolic BP.

Am I arguing about the accuracy of Non-invasve cuff pressures? NO. Probably fairly accurate in most situations. However, in my sick as snot Im actually considering an A-line, I put them in.

Also A-lines are great for patients who get frequent blood draws (DKA, hyponatremia) with less risks than a CVC. Also some people use the A-line for non-invasive cardiac output (flotrac etc...) my experince has been meh...

Anyways, if you don't put em in I dont think you are a bad doctor, but dont tell me they are worthless and have no place in the hospital. They are about as useful as the vanc/zosyn combination that you give everyone

 

[jdh71]

Ill go against the grain and say arterial lines are useful in the ICU and they are useful occasionally in the ED.

1. One they make sure that patients who are hypercapneic actually get an ABG, rather than, Sorry man my ER got busy so I didn't get one and now my ASA status III patients CO2 is high pH has worsened. If you say it's not a big deal then let me do it to your family member. We definitely are victims of doing too frequent ABGs, but they are not a relic of the past, I don't check ABG's for sats, or pH.

2. Non-invasive BPs can be inaccurate, AFIB?, obese, wrong cuff size, time for inflation, didn't get an accurate reading so it recycles wait 30 seconds it just needs to calculate the systolic and diastolic pressure. Ever had the situation where we go: Why is it not reading, that's not right hit recycle, ok wait does he have a pulse? I think I feel a carotid, get the US...


3. Hemodynamically smooth intubation. How many patients have you coded after you intubated them, probably on more than one occasion. The A-line doesn't prevent them from coding, but it helps me titrate my pre/post intubation package the best I can. Leaking SAH undergoing laryngoscopy I want their MAP tightly controlled not into the 130's, ICH same thing, ACS, ischemic heart disease, TIGHT aortic stenosis, with valve area < 0.6 I want to maintain hemodynamic optimization best as possible with beat to beat BP monitoring. Wait you mean there is NO RCTs to show survival benefit. OK, Ill let you choose how I intubate your wife or husband, an IV in the wrist that takes me under 2 minutes to place or a cuff that uses oscillations in blood flow, averaged over 30 seconds and then calculates back from the MAP a systolic and diastolic BP.

Am I arguing about the accuracy of Non-invasve cuff pressures? NO. Probably fairly accurate in most situations. However, in my sick as snot Im actually considering an A-line, I put them in.

Also A-lines are great for patients who get frequent blood draws (DKA, hyponatremia) with less risks than a CVC. Also some people use the A-line for non-invasive cardiac output (flotrac etc...) my experince has been meh...

Anyways, if you don't put em in I dont think you are a bad doctor, but dont tell me they are worthless and have no place in the hospital. They are about as useful as the vanc/zosyn combination that you give everyone

Sounds A LOT like you are arguing AGAINST the routine use of a-lines - use them when they make sense.

Vanc/Zosyn is a meeeeelion times more useful than an art line taken as a whole. The time when an art line actually made the difference as opposed to appropriate empiric abx?? Methinks you got a bit hyperbolic.

I'd say based on your logic, you're not going far enough, we should just swan everyone too, just in case, and maybe, have an esophageal echo set up before we do anything because we can be moar perfect. I don't know why you'd just stop with an art line. You never know. You just never know.

 

[ORL10]

Im against the routine use of a-lines and i use them when they make sense.

Im not sure vanco/zosyn is a meeeeelion times more beneficial, but yes maybe slightly hyperbolic, WE could probably do a better job as a whole of giving it out like skittles.

As for PAC's and esophageal echo, now I think maybe you are exaggerating a touch. Those are more invasive tests, that carry significant more risks than a radial A-line does. PACs are useful in some instances so I don't think they are dead, but mostly unhelpful. Esophageal echo is helpful again in some instances (LVADs post-op CV surgery patients where TTE is limited) but by and large are unnecessary in MICU and or ED.

My point was why I think arterial lines can be helpful in the ED/ICU with explicit examples of when I use it, as other posters had mentioned they are never helpful. My counter argument is that in a select group of patients they may help guide your immediate pre-peri-post induction anesthesia and/or vasopressor therapy during critical moments and help guide ventilatory management in select patients.

I get your "emperor has no clothes" argument but I'm saying my non-evidenced based practice is to use them on occasion for the aforementioned reasons.

 

[jdh71]

I get your "emperor has no clothes" argument but I'm saying my non-evidenced based practice is to use them on occasion for the aforementioned reasons.

My non-evidence based practice is to also use them when I think they will help. Maybe we are not saying such different things.

 

[Rendar5]

eh most of your examples are inpt, and I do agree with their inpatient use in select instances. But for the ED, I'm either using endtidal CO2 or a vbg in place of that abg in assessing pCO2 status. If they're going to get multiple blood gases upstairs, by all means throw it in upstairs. If beat-to-beat BP is that important, they need to be in the OR or need to have an intensivist taking care of them in the ED if they're not able to go upstairs yet, and that guy can place the A-line himself if he wants it as we've gone from the initial resusc stage to the continuous management stage. Honestly, I don't see it being an ED procedure when the ED itself isn't going to be using it so much as the guy upstairs.

 

[Rendar5]

It's kind of in the same vein that thoracentesis is not an ED procedure generally except in extreme situations.

And in that same vein, the OP shouldn't have to worry in the very rare situation he'll need to place an a-line. I've never done a thoracentesis in residency, and did not have any concerns about the one I did perform as an attending; it uses the same guiding principles as chest tubes and needle thoracostomies (just pick a different spot). The same goes since A-line placement is a simple continuation of procedures he'll have plenty of , specifically u/s guided PIV placement (just go for the noncompreasible vessel ) and femoral central lines (just go for the artery instead of the vein)

 

[Cerberus]

Ill go against the grain and say arterial lines are useful in the ICU and they are useful occasionally in the ED.

1. One they make sure that patients who are hypercapneic actually get an ABG, rather than, Sorry man my ER got busy so I didn't get one and now my ASA status III patients CO2 is high pH has worsened. If you say it's not a big deal then let me do it to your family member. We definitely are victims of doing too frequent ABGs, but they are not a relic of the past, I don't check ABG's for sats, or pH.

Eh, studies show if you are trending PCO2, VBG is fine - and easier to get.

2. Non-invasive BPs can be inaccurate, AFIB?, obese, wrong cuff size, time for inflation, didn't get an accurate reading so it recycles wait 30 seconds it just needs to calculate the systolic and diastolic pressure. Ever had the situation where we go: Why is it not reading, that's not right hit recycle, ok wait does he have a pulse? I think I feel a carotid, get the US...

It's very rare - and I work in an environment where I see A LOT of critically ill patients - that I have a patient that NIBP doesn't correlate with the clinical picture I am seeing in front of me. If I saw a a-line flatline, my first thought probably wouldn't be to start compressions anyway - it would be to make sure it's actually working and feel for a pulse.

3. Hemodynamically smooth intubation. How many patients have you coded after you intubated them, probably on more than one occasion. The A-line doesn't prevent them from coding, but it helps me titrate my pre/post intubation package the best I can. Leaking SAH undergoing laryngoscopy I want their MAP tightly controlled not into the 130's, ICH same thing, ACS, ischemic heart disease, TIGHT aortic stenosis, with valve area < 0.6 I want to maintain hemodynamic optimization best as possible with beat to beat BP monitoring. Wait you mean there is NO RCTs to show survival benefit. OK, Ill let you choose how I intubate your wife or husband, an IV in the wrist that takes me under 2 minutes to place or a cuff that uses oscillations in blood flow, averaged over 30 seconds and then calculates back from the MAP a systolic and diastolic BP.

I don't really think having a second by second blood pressure reading is going to affect my management much more than the 90seconds it takes to get a NIBP. We're not in the OR and I usually don't have a esmolol/phenylephrine/norepi drip ready for micromanagement of BP. What I do have is push dose pressors, but again, I'm not sure waiting the 90 seconds it takes for the NIBP to cycle is going to change a whole lot (plus if I'm really worried about peri/post intubation hypotension I'll usually pretreat w/ a push dose - I've never seen a patient go from normo/hypertensive to the level of hypotension resulting in a code). Generally the patient's I see coding during intubation are brady'ing down due to hypoxemia and the ones that code from hypotension still give me time to cycle the BP.

As for SAH, most of the drips we use do not have a sudden onset of action, so if you're going by a aline reading, you run the risk of overshooting and making them hypotensive.

Also A-lines are great for patients who get frequent blood draws (DKA, hyponatremia) with less risks than a CVC.

This is where I agree with you and the primary reason I'll put one in.

 

[Bostonredsox]

I think they have good utility in MICU pts, not every pt, but many. We have so many huge fattys with gigantic cuffs or some cuff on there forearm that were hoping is giving good readings so we can titrate our pressors. I put Aline's In those pts. Sick as snot pts with underlying afib requiring drips, my experience is the dynamaps are extremely inaccurate in this population. They get Aline's. I really can't think of a situation where it altered management in the Ed for a pt that eventually came to me. As I said before, if you have time it saves me 5 min later on, but certainly not a must do procedure in the Ed.

I will add that if you see this pt tanking and ending up on three pressors upstairs, even with US Aline's get harder to place the more clamped down their vessels get. Often easier to get in while your still on low dose levophed.

 

[Xerxes1729]

In general, arterial lines are indicated in patients who will have an ICP monitor placed, since the combination allows you to measure cerebral perfusion pressure. I also personally like them in cardiogenic shock patients. I've gotten comfortable with radial, axillary, and femoral lines. The slickest approach, I think, is to put in a femoral arterial line when placing a central line - one prep, one drape, sterile the whole time, and one dressing.

 

[Bostonredsox]

In general, arterial lines are indicated in patients who will have an ICP monitor placed, since the combination allows you to measure cerebral perfusion pressure. I also personally like them in cardiogenic shock patients. I've gotten comfortable with radial, axillary, and femoral lines. The slickest approach, I think, is to put in a femoral arterial line when placing a central line - one prep, one drape, sterile the whole time, and one dressing.

Except that I almost never place fem lines in the MICU. Not unless the jugulars and subclavians are either occupied or inaccessible. The other exception is a pt who codes on the floor. I sometimes put side by side fem lines in them and if they survive, change them out for appropriate lines later.

 

[deleted547339]

Except that I almost never place fem lines in the MICU. Not unless the jugulars and subclavians are either occupied or inaccessible. The other exception is a pt who codes on the floor. I sometimes put side by side fem lines in them and if they survive, change them out for appropriate lines later.

appropriate lines?

 

[Bostonredsox]

appropriate lines?

Lines associated with less infection in rct's. Femorals are temporary and appropriate for code situations and in cases where that's all that as available. In all other cases the pt should have a jugular or subclavian and a radial art line.

 

[ORL10]

1. The agreement is poor between PCO2 in VBG and ABG with a mean difference traditionally ~ 8, with usually the PCO2 being overestimated on a VBG. A venous C02 doesn't always allow me to accurately identify the mixed acid/base disturbances present in critically ill patients with shock and CO2's > 45 (the exact patient I mentioned above.)

2. NIBP can be inaccurate in the aforementioned situations.

3. What I was saying is having an arterial line in the specific situations we mentioned SAH, ICH, severe hypotension in my opinion is easier to titrate my sedative and or my vasopressor with. IN the SAH example when you stick the laryngoscope in you know if you have blunted their sympathetic surge with propofol + opiate of choice. Propofol's onset of action is relatively immediate and that plus fentanyl is what I am usually using before induction and will add additional doses peri-intubation if they appear to have hypertension during laryngoscopy. If the aneurysm is unsecured I pull the laryngoscope out if anticipated easy mask, or have an assistant push more opiate +/- sedative.

Push dose pressors for the reasons you have mentioned above, or if I over shoot.

4. You have never seen a trauma patient or massive GIB patients BP cuff read some ridiculously high number right before coding and or becoming extremely hypotensive? I've seen this many times, which I assumed was because they were clamped down so much, and when that resolved or was taken away with sedatives, hypotension/cardiac arrest can ensues.

I'm not saying this is mandatory, or standard of care or that a future RCT is going to study whether patients with HH3 SAH benefit from peri-intubation optimization of BP management. Nor do I know if this benefits the pt with severe hypotensive, known AS or CAD only that it's reasonable to do this if you have the resources (residency program with two operators, savvy nursing etc..). If you work in other environments you do the best with what you got.

 

[deleted547339]

Lines associated with less infection in rct's. Femorals are temporary and appropriate for code situations and in cases where that's all that as available. In all other cases the pt should have a jugular or subclavian and a radial art line.

What about this article?

http://www.ncbi.nlm.nih.gov/pubmed/22809915

 

[Tiger26]

As pointed out in the metaanalysis above, there's probably not that much difference in outcomes with line site now that we've started to sterilize sites better and gown/drape patients.

Still, this will take a long time to disseminate, so I probably only put in 1-2 femoral lines a year, which means that it doesn't make any sense to throw in an art line at the same time.

If I haven't a patient coding, it's way faster and just as efficacious to drill an IO. If I get them stabilized, I can just go IJ or subclavian afterward in a more controlled environment where I or my residents have less chance of getting stuck by a needle from chest compressions.

 

[Bostonredsox]

What about this article?

http://www.ncbi.nlm.nih.gov/pubmed/22809915

We've had multiple discussions on this topic including the more recent large meta analysis. The general thought from most practitioners is that there is still a higher infection risk with femoral, definitely more risk the longer it is left in, than the chest and neck lines. We don't have io at my shop. So a fresh code, they get a femoral line. If they survive the arrest I swap it for a jugular later that day.

and it's not just about sterilization at insertion. I have rounded on a pt and seen a pool of **** in between their legs rising up to the level of my line in a cdiff septic shocker whose flexiseal fell out. It's much harder to keep the groin clean over the x amount of days the pt will need the line. Takes 5 min to swap it for an IJ.

 

[Birdstrike]

1. The agreement is poor between PCO2 in VBG and ABG with a mean difference traditionally ~ 8, with usually the PCO2 being overestimated on a VBG. A venous C02 doesn't always allow me to accurately identify the mixed acid/base disturbances present in critically ill patients with shock and CO2's > 45 (the exact patient I mentioned above.)

2. NIBP can be inaccurate in the aforementioned situations.

3. What I was saying is having an arterial line in the specific situations we mentioned SAH, ICH, severe hypotension in my opinion is easier to titrate my sedative and or my vasopressor with. IN the SAH example when you stick the laryngoscope in you know if you have blunted their sympathetic surge with propofol + opiate of choice. Propofol's onset of action is relatively immediate and that plus fentanyl is what I am usually using before induction and will add additional doses peri-intubation if they appear to have hypertension during laryngoscopy. If the aneurysm is unsecured I pull the laryngoscope out if anticipated easy mask, or have an assistant push more opiate +/- sedative.

Push dose pressors for the reasons you have mentioned above, or if I over shoot.

4. You have never seen a trauma patient or massive GIB patients BP cuff read some ridiculously high number right before coding and or becoming extremely hypotensive? I've seen this many times, which I assumed was because they were clamped down so much, and when that resolved or was taken away with sedatives, hypotension/cardiac arrest can ensues.

I'm not saying this is mandatory, or standard of care or that a future RCT is going to study whether patients with HH3 SAH benefit from peri-intubation optimization of BP management. Nor do I know if this benefits the pt with severe hypotensive, known AS or CAD only that it's reasonable to do this if you have the resources (residency program with two operators, savvy nursing etc..). If you work in other environments you do the best with what you got.

How often do you calibrate your A line to a manual (not monitor cuff) blood pressure?

Isn't nearly all of what we know about "blood pressure" in general, based off of a manual cuff BP of a patient in a seated position with the cuff at the level of their heart?

How do you know your CPP numbers (Cpp= map-icp) mean anything if there's no standard for calibrating A-line BP readings, and generally a lines are placed and often a manual BP never again checked for days, or weeks?

http://www.sjtrem.com/content/pdf/1757-7241-21-78.pdf

 

[Rendar5]

We've had multiple discussions on this topic including the more recent large meta analysis. The general thought from most practitioners is that there is still a higher infection risk with femoral, definitely more risk the longer it is left in, than the chest and neck lines.

"We have reviewed the literature and decided to ignore it and go by older dogma because we like it better" ????

 

[Bostonredsox]

"We have reviewed the literature and decided to ignore it and go by older dogma because we like it better" ????

Lol. No more like there are multiple studies showing decreased infection with chest and jugular lines compared with femorals and one meta analysis does not change that. Show me 3-4 reproducible rct's showing equal infection rates and well talk.

If they do a meta analysis tomorrow showing aspirin doesn't affect outcomes in STEMI are you going to ignore the 15 previous trials showing benefit and stop giving it?

Meta analysis are at their core, the weakest bodies of evidence. And as far as I have read, there are no head to head rct's showing equal infection risk in groin lines, whereas there are multiple older studies showing an increased risk. If there is any question, coupled with the fact they are less versatile lines (floating pacers, swans) and more cumbersome once the pt has the ability to get out of bed, why would you put one unless you had too? The answer, because I'm talking to mostly Ed docs, is because they are faster for the most part and you are all pressed for time. That does not change the fact that they are more likely to get infected and should be swapped out upstairs. Which we do very regularly.

 

[subtle1epiphany]

I did my residency at a medical center where any patient on vasoRx or vented automatically required an arterial catheter. Furthermore, we did the same for DKA as they required frequent labs as mentioned above. We also adjusted the ventilator to provide respiratory compensation as determined by Winter's Formula, etc. In three years I placed more than 70 or so arterial lines in six months, mostly radial, but also femoral, brachial, and dorsalis pedis.
Currently at my fellowship, we do the exact opposite. I placed maybe a dozen or so in a year and a half. We have etCO2 (not a replacement for pCO2, but provides information) and adjust our ventilators to clinical status, rarely drawing a gas. The best argument for an arterial tracing is when it is fed into a pulse contour analysis unit like a PICCo or Flo-Trac, although there are issues with those machines as well.

I'd say that I agree more with Birdstrike and JDH, it is important to realize that this is not a therapy, it is a measurement device. We have seen in the ICU that more invasive monitoring makes us feel warm and cozy, but it is not benign. Refer to the era of PA catheters and supra-normal resuscitation for a great example.
However, in some select situations mentioned above as well, there is enormous utility to having that arterial catheter. If I have a pt with an ICP monitor, yes I would like an arterial tracing to get CPP. During a code, it is nice to be able to dose epinephrine/vasopressin by the diastolic pressures, but I'd rather have etCO2 than the arterial tracing.

The reality is that in Critical Care and Emergency Medicine we need to focus on meaningful interventions.
Reacting to each beat of an arterial pressure transducer is one hell of lot of interventions, are they all meaningful? If the pressure is low, then you act, does it matter how low or how often?

 

[Rendar5]

Lol. No more like there are multiple studies showing decreased infection with chest and jugular lines compared with femorals and one meta analysis does not change that. Show me 3-4 reproducible rct's showing equal infection rates and well talk.

If they do a meta analysis tomorrow showing aspirin doesn't affect outcomes in STEMI are you going to ignore the 15 previous trials showing benefit and stop giving it?

Meta analysis are at their core, the weakest bodies of evidence. And as far as I have read, there are no head to head rct's showing equal infection risk in groin lines, whereas there are multiple older studies showing an increased risk. If there is any question, coupled with the fact they are less versatile lines (floating pacers, swans) and more cumbersome once the pt has the ability to get out of bed, why would you put one unless you had too? The answer, because I'm talking to mostly Ed docs, is because they are faster for the most part and you are all pressed for time. That does not change the fact that they are more likely to get infected and should be swapped out upstairs. Which we do very regularly.

good answer

 

[jdh71]

What about this article?

http://www.ncbi.nlm.nih.gov/pubmed/22809915

A look at that systemic review (and the recent cochrane: http://www.ncbi.nlm.nih.gov/pubmed/22419292) makes me feel a bit better about femoral lines but not too much better.

However, I didn't think it was that great a review with only two RTCs included, and the fact that IJs seems better than fems based on their analysis which they went onto blame on "outliers". The accompanying editorial did well to sell the overall idea, but I remain skeptical, and I have my preferences (everything else being equal now, right?)

Just like anything else I think fem lines are fine as far as they go, but I do not prefer them in the MICU.

 

[Bostonredsox]

A look at that systemic review (and the recent cochrane: http://www.ncbi.nlm.nih.gov/pubmed/22419292) makes me feel a bit better about femoral lines but not too much better.

However, I didn't think it was that great a review with only two RTCs included, and the fact that IJs seems better than fems based on their analysis which they went onto blame on "outliers". The accompanying editorial did well to sell the overall idea, but I remain skeptical, and I have my preferences (everything else being equal now, right?)

Just like anything else I think fem lines are fine as far as they go, but I do not prefer them in the MICU.

The last line was essentially what I was getting at.

 

[jdh71]

Back to the topic of art lines, though not necessarily in anyway suggesting they need to be put in in the ED, this weekend I had a lady, one day post-partum from an emergent c-section with twins at 35 weeks for HELLP and history of antiphospholipid ab, go from all looks pretty good to crump on me in the MICU ended up on two pressors before we got everything stabilized, and I don't even bother NOT using the U/S in these types of patients any longer, and even then it took me a bit to get the line (and I'm fair to midland at putting these in by now [no self-proclaimed expert though]). So, IF you're going to be doing them I see zero shame in using the U/S, and I like the suggestion above about as long as you've got the fem draped, and you think you might need one, going ahead and putting one in right there. The fem is the easiest stick, especially with the U/S (put it in the pulsing one this time!!) - probably wouldn't eat up too much time in the ED, IF you were already there and set up for it.

 

[Bostonredsox]

Had a floor transfer down to me last night. Afib RVR, acute chf though she wasn't. In much distress to me. But she was massive, 300+ pounds. She's running RVR in the 180s. Had been given 10 then 20 of dilt on floor. Hospitalist sent to me because pressure was in high 80s and he was concerned she may need to be cardioverted or w/e. I look at this massive woman, with the biggest cuff we have, wrapped barely around her forearm, and then at her pressure, cycled twice in the 90s. I never trust dynamaps readings in fib pts, let alone massively obese ones. So I put an art line in her wrist. Systolics in 140s. Plenty of pressure room. Bolus esmolol and start a drip and after about an hour or so she's 110-115 HR with sbp still in the 120s. Also loaded her with dig as her level was 0.

But classic pt where there's just no way the cuff can be reliable with the need to titrate a vasoactive agent. Simple minimally invasive radial art makes a difference. So if this patient were in Ed and you couldn't control hr with this questionable BP! a quick art line and then comfortably knowing you have pressure room for esmolol or dilt or w/e you prefer before you send him upstairs could be of use.

 

[Venko]

Lol. No more like there are multiple studies showing decreased infection with chest and jugular lines compared with femorals and one meta analysis does not change that. Show me 3-4 reproducible rct's showing equal infection rates and well talk.

If they do a meta analysis tomorrow showing aspirin doesn't affect outcomes in STEMI are you going to ignore the 15 previous trials showing benefit and stop giving it?

Meta analysis are at their core, the weakest bodies of evidence. And as far as I have read, there are no head to head rct's showing equal infection risk in groin lines, whereas there are multiple older studies showing an increased risk. If there is any question, coupled with the fact they are less versatile lines (floating pacers, swans) and more cumbersome once the pt has the ability to get out of bed, why would you put one unless you had too? The answer, because I'm talking to mostly Ed docs, is because they are faster for the most part and you are all pressed for time. That does not change the fact that they are more likely to get infected and should be swapped out upstairs. Which we do very regularly.

good answer

I'm sorry meta analysis is the weakest form of evidence?

I'm not a research heavy guy so I'm probably the only one who isn't following this logic.

If there is a meta analysis on aspirin for chest pain...it will likely have evaluated the fifteen trials you mention and yes I would have great pause on the action.

My understanding is that a meta analysis is essentially the best form of literature because if you have lots of high quality RCTs on the subject you get an even better meta analysis. If you have lots of poorly done set of fifteen trials, you get at least as good but most likely better meta analysis when you combine them.

Am I way off base?


As for A lines, I would add that in some of the less efficient throughput locations I worked, we used a lines regularly on our boarded critical care patients. So I think LOS in the ED is a factor on their utility.

 

[Tiger26]

I'm sorry meta analysis is the weakest form of evidence?

I'm not a research heavy guy so I'm probably the only one who isn't following this logic.

If there is a meta analysis on aspirin for chest pain...it will likely have evaluated the fifteen trials you mention and yes I would have great pause on the action.

My understanding is that a meta analysis is essentially the best form of literature because if you have lots of jig quality RCTs on the subject you get an even better meta analysis. If you have lots of poorly done set of fifteen trials, you get at least as good but most likely better meta analysis when you combine them.

Am I way off base?


As for A lines, I would add that in some of the less efficient throughput locations I worked, we used a lines regularly on our boarded critical care patients. So I think LOS in the ED is a factor on their utility.

Agree--my understanding is that meta analysis is the top of the pyramid in terms of research quality