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Brachial A-Lines: Are they safe?

Discussion in 'Anesthesiology' started by VentdependenT, Feb 25, 2007.

  1. VentdependenT

    VentdependenT You didnt build thaT
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    After I put 5or6 of these things in with U/S in the SICU. One of the surgeons got upset upon finally noticing it and told his resident to D/C my line (which had been in about 5 days) for fear that "the patient will lose his arm."

    What sort things have you heard about the safety of these lines? Yes I understand the anatomy of that area.

    The reason I put em in was:
    Radials shot, so Im not going for Ulnar.
    WRISTS TOO FAT WITH EDEMA.
    The groin is a filthy area.
    I hate putting lines in diabetics' feet...plus DP/PostTibialArt lines dont last very long at all.

    I did a literature search and it backed me up. Seems that the dogma of Brachial ALINE= GONNA LOSE AN ARM is spread far and wide.
     
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  2. Planktonmd

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    It has been taught for a long time not to do brachial A lines and to do either radial or axillary.
    I don't think any studies support that concept, but since it is not widely practiced to place brachial A lines, then it might leave you open to lawyers if something goes wrong, and many of your attendings would testify that it's "not the standard of care".
     
  3. EtherMD

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    Same here. Radial, Axillary or Femoral. But, I know a guy who likes Brachial A-lines. Since I am in Private Practice and not academia I play it conservative most of the time. Anyone know of studies supporting the safety of brachial A-lines? Most patients who need an A-line are usually not in the best condition so co-morbidity makes me question the wisdom of a brachial a-line.

    By the way, any of you still do a modified Allen's test? I realize the data is shaky at best but I am curious to read opinions about the modified Allen's test.
     
  4. Gasboy07

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    I've always though the Allen's test is not that sensitive, and if an art line is indicated that takes priority anyway...
     
  5. johankriek

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    i know a place that does 4500 hearts a year and every single a line is placed brachial artery. NO complications. hard to argue with that. When coming off bypass the brachial estimates true aortiv pressure better than radial artery.
     
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  6. Noyac

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    True mostly, but the axillary is even more accurate in my understanding. I have put them all in and I have never seen any complications from any A-lines with regards to ischemia.

    By the way, what's a "modified Allen's Test":laugh:
     
  7. Stimulate

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    At Cleveland Clinic (#1 heart hospital) we put brachial a-lines for every heart unless there is an obvious contra-indication.

    However, we always do "through-and-through" technique using a guidewire. From listening to the rationale of the CV anesthesiologists they have had some radial a-line failures coming off pump and also they think that a more accurate pressure is better for the patient in the long run. Whether that stands up to the lawyers who knows, but obviously with careful technique there shouldn't be any arterial dissections with subsequent limb loss. I am not aware of any such cases here at CCF although I haven't researched that.
     
  8. EtherMD

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    The use of pulse oximetry on the index finger of the hand in question. This is the same test the Heart Sugeon's use to test collateral flow for Radial Artery harvesting. I use the same technique to test my collateral flow. However, does a failed allen's test mean that the femoral or axillary artery should be used?
     
  9. Planktonmd

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    Excuse my ignorance, but why do you need to do a "through and through technique" if you are going to use a guide wire?
     
  10. johankriek

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    less chance of dissecting the artery i believe
     
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  11. militarymd

    militarymd SDN Angel
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    Learned cardiac anesthesia from a CCF CV anesthesiologist who trained us in the Navy....

    He always made us put in brachial a-lines......

    Although, I have had to take one patient to the OR to get revascularization surgery for his arm because he hada brachial a line.

    The patient was septic in the ICU ...and not electively going to the OR for CABG.
     
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  12. Stimulate

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    Yes this is correct. We wait for spurting flow as we draw back into the vessel, and gently pass the guidewire and thread a 5.5" catheter. I haven't seen a dissection but I have only been in on maybe 100 hearts so far.

    One thing I forgot to mention too is that they try to get the brachial a-lines out (either d/c or change to radial) within a couple of days to reduce risk of limb ischemia.

    I don't want to give the impression that I feel this way is the only or best way to do things, I just wanted to share our practice with the forum.

    Apparently we have had numerous alumni who take jobs elsewhere and the attendings freak out when we start putting in the brachials, but after a while they adapt and some even convert... :)
     
  13. cchoukal

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    What makes the axillary safer than the brachial? the fact that it's more proximal and presumably larger caliber? Where do you access the brachial/what are the landmarks? I've been doing radials exclusively, although as an intern in the various ICUs, I did some femorals (with the Arrow harpoon kit) and and handful of DPs. They only seemed to last a day or so.
     
  14. Noyac

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    Ummm, you missed the laughing smiley face.
     
  15. Noyac

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    Bullsh*t
     
  16. Noyac

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    #1 heart hospital, thats bold. And that is something spouted quite frequently by many heart hospitals. How is the public to determine who is telling the truth. I gotta tell you that there are plenty of folks out there doing these cases that are as good or better than the big clinics. So spare us with the "#1" ****. :thumbdown:
     
  17. johankriek

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    actually cleveland has been rated number one in hearts by us news and world report for like 13 straight years... their double valves are like your hernia or d and c/
     
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  18. Mman

    Mman Senior Member
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    There is much better collateral circulation around the axillary artery than the brachial.
     
  19. Stimulate

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    Unfortunately (especially when you are on-call) sooo true. :)

    I know there a lot of other good heart hospitals out there...I was referring to US News and World report rankings (which we can debate the accuracy of all day long). If you have a problem with ranking heart hospitals I suggest you write some letters.

    Anyway, sorry you took my comment so personally, not trying to slight the efforts of others just trying to share that at a large hospital, famous for excellence in cardiac care, both surgeons and anesthesiologists favor the placement of brachial a-lines.
     
  20. Planktonmd

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    And how is making 2 holes in the artery instead of 1 going to decrease the risk of dissection?
    And where did you get that information from?
     
  21. jwk

    jwk CAA, ASA-PAC Contributor
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    Damn - I thought Time magazine was the authority on all things medical. Or was it Reader's Digest?
     
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  22. johankriek

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    You obviously haventput in many a lines.. when you go through and through and pull back til you get spurting,, you are assured more that you are in the lumen.. Too many times whenyou thread a catheter after seemingly being in the lumen the catheter doesnt go into the lumen; itdoes under the artery, or it dissects the layers of the artery. Just food for thought
     
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  23. johankriek

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    what doyou know? you are a mid- level!!
     
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  24. Planktonmd

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    Really!
    So If I put more lines I will start dissecting arteries?
    It's funny because I have been in private practice for 7 years now and I put an average of 5 A lines a day, and I have never dissected one!
    When am I going to start doing that?
    I truly think that they don't teach residents how to properly place A lines anymore.
     
  25. EtherMD

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    Relax, I am sticking with my decades of clinical experience with Radial A-lines. My heart surgeons are very happy with a good radial a-line and if it is not adequate (rare) we will place a femoral a-line temporarily.

    If we take the other 19 top rated Anesthesia Programs in the USA how many of them are using Brachial A-lines routinely? One? This means that that the overwhelming number of a-lines in the USA are placed Radial for CABG, CEA, AAA, etc. I am not stating that Brachial A-lines are not "safe" as the Cleveland Clinic does it routinely. But, most of us Don't work in Cleveland and in our area (standard of care?) the radial, axillary or femoral a-line is most commonly used.
     
  26. johankriek

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    you are dissecting the artery you just dont know it.

    what kind of cases do you do that you put in 5 alines per day.

    you must be working 12 hours per day!!!

    i put in many many alines.. And i dont go thu and thru because i gage where the catheter is by the amount of flow coming up from the arrow kit. I miss once in a great while. But the thru and thru technique if perfected is really fail safe
     
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  27. Planktonmd

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    No I am not dissecting anything!
    Because I don't use the stiff Arrow catheter and I don't use a wire, I just use a simple angiocatheter with the catheter cap attached to it so you can see the pulsating blood while you are advancing your needle, once you enter the artery you advance 1 mm and make sure you still can see the pulsating blood then you just thread the catheter.It takes few seconds and it always works.
    The last time I had to use a wire was a year ago.
    I did not say the through and through technique is wrong but I disagree that it is less traumatic to the artery unless you are aware of some study that demonstrates that.

    We do Cardiac, Carotids, Thoracotomies, AAA's....... and I supervise CRNA's so I could have 3-4 rooms and have to put lines in all of them.
     
  28. OP
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    VentdependenT

    VentdependenT You didnt build thaT
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    I haven't done an axillary yet. I fear the possible air embolus to the carotid from somebody carelessly drawing off and reflushing.

    For the aforementioned reason do you favor the L over the R? Or just get the damned thing in?
     
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  29. jwk

    jwk CAA, ASA-PAC Contributor
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    Yep - but I still don't use US News as my main information source.
     
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  30. Stimulate

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    Just out of curiousity is there a more well-known source for the public regarding hospital rankings? You seem to have some disdain for US News.
     
  31. Noyac

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    Wouldn't any air be pushed downstream to the brachial, radial and then capillaries? Or do you use long catheters that reach the bifurcation of the inominate artery?
     
  32. cchoukal

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    The flushes are pressurized, often to 150-300 mmHg, which is obviously higher than systolic or mean arterial pressure, meaning that whatever you flush in (saline, bubbles) should travel retrograde back to the aorta/noodle. Does this actually happen or is it a theoretical risk?
     
  33. OP
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    VentdependenT

    VentdependenT You didnt build thaT
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    I have been using the long catheters for the brachial a-lines. If I were to use one for the axillary I think the distal end of that bad boy would be flappen around the opening to the R carotid off the brachiocephalic/inominate . Hence serving as the perfect delivery device for a cerebral air embolism.

    Do you use the standard arrow to hit the axillary? I would think that bad boy would try and slip out on the typical "chunky" patient.
     
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  34. TIVA

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    Retrograde flow through arterial lines during flushing is a real phenomenon.

    At last year's IARS conference, there was a team that used dopplers and echo to show that you can get air embolisms to the other parts of the body by careless and aggressive art line flushing.

    I think they recommended you should flush at less than 0.5 or 1 cc per second; anything faster and fluid is being redirected back up the arm and towards the aorta and brain.
     
  35. Noyac

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    OK, sounds fair enough. I really didn't think air bubbles could travel retrograde unless the flow inside the artery was completely reversed.

    As far as the catheter size. If I need it to remain for a long period of time then I will place a longer cath but if I only need it for the case and the arm is not obese then I will use an arrow. I haven't done one in a long time now and we used radials for CABG's. I seem to find a way to get it in the radial. If the radial has been mucked up at the wrist I move up a few inches and can usually get it there. Also, an attending of mine used to tell me to not feel for the pulse but to feel the anatomy of the artery (it feels like a rope in the arm even when pulseless). This way if a pt were to come to you pulseless you still have a chance of placing one. For example, a partner of mine was taking a ruptured AAA back who had essentially no BP. The surgeon had attempted an a-line and they had given up. Things were obviously crazy and there was no time to waste. I walked in to see if I could assist and saw that there was no a-line. I felt for the "rope" in the arm and stuck it. Bingo. I always knew why my attending stressed this skill and at that point I was greatful.
     
  36. OP
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    VentdependenT

    VentdependenT You didnt build thaT
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    You slick bastard.

    I'll try the "rope" out next time.
     
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  37. joshmir

    joshmir Senior Member
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    hey vent-

    any resident-to-resident tips on brachial a-lines w/ US guidance?

    where to you place them?

    do you image in long axis or short access?

    through and through technique w/ wire or arrow?

    pearls?

    pitfalls? what structures are you scared of hitting?

    thanks brutha-

    -j
     
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  38. Noyac

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    Are you trying to make the A-line placement longer than the case itself?
     
  39. Planktonmd

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    :laugh:
     
  40. OP
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    VentdependenT

    VentdependenT You didnt build thaT
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    No. I used U/S in the UNIT because I had the time to do so. Intra-op while everyone is waiting we will usually just go for it....if we can feel a pulse. If not then those more experienced than I (attending) will go blindly.

    Never-the-less it only takes a couple of minutes to get the Site Rite on the patients arm and have the vessel (short axis) in view and the arrow heading towards it. Not much to ask for.

    Anypoops,
    I didn't want to have to poke the patients brachial artery multiple times. I was worried about causing an aneurysm or a big ass hematoma which could potentially close off the vessel.

    These people were very edematous and I really couldn't feel anything. No radial, no brachial, no DP. So I said what the hell and grabbed the U/S. I didn't want to go digging in the Groin of a 300lb'er liver patient for a femoral line but its a viable option. I just never had to go there.

    Chloroprep the blubbery arm. I start looking medial side mid-arm and find the vessel there. Wherever its juiciest I go. Visualize the needle going in with yer U/S (no through and through needed but it happens), pull back on the syringe and get good flow, throw in the guidewire then the catheter and kaboomskie. Done deal.
     
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  41. Noyac

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    I'm just bustin yer balls Venty. You are obviously more tech savy than I am and I'm jealous. Well may not jealous but impressed.:thumbup:
     
  42. OP
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    VentdependenT

    VentdependenT You didnt build thaT
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    If I'm so f$&king tech savy how come my george forman grill has melted into my kitchen counter top?
     
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  43. Noyac

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    Don't worry, once you finish your residency you will have granite counter tops and nothing will melt into it. Or if you want you can go with the concrete style my wife and I are planning for. They are unique and very durable.
     

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