garygetthecar

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A practice I am looking into tells me that they always place brachial arterial lines as they are "truer" indications of BP during CPB weaning and shortly thereafter. If there's trouble with the brachial, they place a femoral.

The risk of injury to the brachial (placed by residents, no less) is borne out in studies, although proponents often cite the CC's safe and effective usage of them. The question I have is whether or not, as a new guy in an academic setting where the practice is to place brachials, if people here would stick to their guns and say "No" or give it a try and hope nobody loses a forearm in the process.
 

sevoflurane

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Cleveland clinic?

There is no reason not to use the radial IMHO. If I am past 3-4 minutes trying to place a radial, I'll go brachial-- easy target. I'll place a handful a year. Never had a problem. Perfectly fine to go brachial IMO... but I'm of the mindset of starting distally when you can.
 
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garygetthecar

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No, not the Clinic.

I guess my real question here is what risk/benefit ratio are people using to decide whether or not to perform certain procedures when they're new to a practice?

In this case they simply don't do radials at all, which seems a little close-minded to me.
 

dr doze

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cleveland clinic?

There is no reason not to use the radial imho. If i am past 3-4 minutes trying to place a radial, i'll go brachial-- easy target. I'll place a handful a year. Never had a problem. Perfectly fine to go brachial imo... But i'm of the mindset of starting distally when you can.
+1.
 
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if the indication for a brachial is a "truer" indication of pressure for weaning of CPB, that's whack. If you go by MAP and extrapolate, any arterial line is a good arterial line. I would say no- all the way. just not worth it unless it's an emergency. go femoral if you need a "central" art line. but if there's a radial you can hit, that's the best of all.
 

periopdoc

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The risk of injury to the brachial (placed by residents, no less) is borne out in studies...
Care to support that statement with some data? References?

-pod
 

leaverus

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Yeah, that's weird. It's the first i've heard of ROUTINELY placing brachial alines. Heck, i would think it's just a waste of time. It doesn't take but a couple minutes to throw a quick radial in. And the fact that they have to tell you if they have a problem with the brachial they do a femoral means they have had problems with brachials, so what's the point? I think in your place, i'd opt to continue putting in radials - faster, easier, theorectically less riskier.
 

Mman

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A practice I am looking into tells me that they always place brachial arterial lines as they are "truer" indications of BP during CPB weaning and shortly thereafter. If there's trouble with the brachial, they place a femoral.
A "truer" indicator? How close do you need to know the BP. Do you manage differently if the BP is actually 87/45 compared to maybe 90/44?

Put the radial aline in.

When coming off pump, you can look at the TEE to know most of what you need to know. You also have a CVP and possibly a PA cath. The purpose of the arterial line isn't to give an exact BP, it's to follow the trend on a beat to beat basis.
 

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I have no problem with brachial a lines but the truer bp is a bogus argument.
 

proman

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Agree with above. If they really care that much then the surgeon should put a transducer needle in the aorta.

If I were in your shoes I'd do what everyone is used to doing for a while, then slowly change back to what you're used to if you feel the need to. I think brachials are safe, but mostly unnecessary. When I struggle with a radial, I'll use the ultrasound. Particularly since I do 99% of my a lines in awake, usually unsedated patients. Have only needed to do a few brachials or axillary.
 

BobBarker

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What about femoral art lines? If I can't get a radial, I go femoral. Never tried another site. Keep in mind, I'm an intern and I do this at night on sick as hell ICU patients with no attending or upper level in house exclusively.
 

sevoflurane

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Not a big fan of fem. art. lines for the heart room. Not as easily accessible as radials/brachial + lots of dead space in your art line tubing.
 

urge

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If I were in your shoes I'd do what everyone is used to doing for a while, then slowly change back to what you're used to if you feel the need to.
This. When in Rome... Once you establish your reputation you can do whatever you want. Once you make everyone think you are the "****" you can even put carotid a lines and people will say they are medically indicated.

Like George Carlin used to say, it's all bull ****.

I have put a small number of brachials without complications.

I have had 2 radial a lines cause hand ischemia.

I have had a couple legs go ischemic after femoral lines.

Axillary a lines have been good so far.


What you want to avoid, in your group, at all cost is to be the guy they point fingers at, for not "following protocol".
 

urge

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Hell, a good surgeon can tell by putting a finger on the aorta.
I work with crap surgeons I'm sure. "Pressure feels a lot higher then 70/30"... until they stick and needle an it reads 70/30.

I don't trust any surgeon.
 

urge

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I have no problem with brachial a lines but the truer bp is a bogus argument.
A "truer" indicator? How close do you need to know the BP. Do you manage differently if the BP is actually 87/45 compared to maybe 90/44?
Radial a lines are notorious for poor monitoring after bypass. 20-30 points off is not uncommon.

More like 90/40 vs 60/20.
 
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garygetthecar

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"What you want to avoid, in your group, at all cost is to be the guy they point fingers at, for not "following protocol."

+1

Thanks for the replies, everyone!
 

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Neither gives any numbers to get an idea of the safety of brachial catheterization.


How about some real data


Your partners are probably basing their decision to employ brachial a-lines on experience and the 1990 Bazaral et al (Cleveland Clinic) study that showed a significantly better correlation between brachial pressures and aortic pressures than radial pressures and aortic pressures after bypass.

Comparison of Brachial and Radial Arterial Pressure Monitoring in Patients Undergoing Coronary Artery Bypass Surgery. Bazaral et al.

Immediately after CPB the brachial pressures were 99.5 +/- 7.5%, 98.9 +/- 3.5%, and 97.4 +/- 2.9% of aortic, whereas respective radial pressures were 92.1 +/- 14.6%, 94.7 +/- 5.6%, and 90.8 +/- 7.4%.
and some pretty good safety data.

Our follow-up is limited to routine clinical evaluation, and among the 3,057 patients we are aware of one who required a postoperative brachial thrombectomy and who had no sequelae."

A 2002 review article by Scheer et al in Critical Care looked at the complications of peripheral arterial catheters and concluded they are safe.


Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Scheer et al

Only one serious complication was found in a study of 1000 patients [62] in which the brachial artery was used for invasive monitoring in ambulatory patients. This complication was an infected haematoma arising from a pseudoaneurysm. Another study that employed the brachial artery for arterial blood sampling in 6185 patients [63] also showed a small number of complications (incidence 0.2%), mainly paresthesias.

Pediatric patients?

Catheterization of the radial or brachial artery in neonates and infants. Schindler et al

Looked at the outcomes of 200 brachial a-lines placed in <5 kg infants, 142 brachial a-lines placed in 5-10 kg infants, and 44 in 10-20 kg infants. (more radials were placed in the larger infants.)

CONCLUSIONS: Even considering the nature of a retrospective study design, we conclude that the brachial artery could be considered for cannulation in neonates and small children.

Really crazy?

Long-term brachial artery catheterization: ischemic complications. Moran et al.

157 patients who had 225 percutaneous transbrachial hepatic artery catheters placed for infusion of chemotherapeutic agents, catheters remained in situ from 1 day to 14 months (median 68 days)...

Amputation, ischemic ulceration, major neuromuscular sequelae, and peripheral embolization to the head or lower limbs did not occur. This study suggests that long-term brachial artery catheterization is associated with a low incidence of permanent ischemic complications.
One could also look at the body of evidence of brachial artery catheterization for invasive cardiology procedures using even larger catheters. Lots of theoretical concerns that are not born out by the studies.

Show me some data that brachials carry a significant risk. I have looked for it and can't find it. Perhaps you are a better researcher than I.

- pod
 

periopdoc

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If it were up to me, brachials for all bypass and major open vascular cases. Radials for everything else. However, when in Rome...

- pod
 

Mman

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Radial a lines are notorious for poor monitoring after bypass. 20-30 points off is not uncommon.

More like 90/40 vs 60/20.
Not uncommon? No way it's off by 20-30 points on the mean more than 5% of the time when coming off pump. And I have a hard time believing that a brachial aline which is 15-20 cm closer to the aorta is going to give that much better of a signal compared to the femoral artery. In my experience, the waveform on a femoral is far more likely to be accurate compared to the waveform on a brachial.

I use a radial aline every time. If the patient is likely to be very unstable, we'll probably also have the surgeon put in a femoral line after we start but before on pump so I can use both and compare the two.

And I'm not anti brachial aline. I'd rather put a bra
chial than an axillary because our vascular surgeon told me he'd rather fogarty out a clot from a brachial than try to go repair an axillary artery that had a problem.
 

urge

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Not uncommon? No way it's off by 20-30 points on the mean more than 5% of the time when coming off pump. And I have a hard time believing that a brachial aline which is 15-20 cm closer to the aorta is going to give that much better of a signal compared to the femoral artery. In my experience, the waveform on a femoral is far more likely to be accurate compared to the waveform on a brachial.
I didn't say femorals were bad. They are good. The radials are the so-so ones.
 

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Did radials for all CABGs and for cases that warranted an art line in training. In my current group, CABGs get brachials and other cases that warrant art lines get radials. i was told the rationale behind this was that they had an occasional problem with radials crapping out, and with both arms tucked, you're stuck. I didn't have a good counter arguement, and since the negligible and theoretical increased risk of the brachial art line is not high enough for me to be labeled as 'the guy that does it differently than his partners,' i started doing brachials for CABGs.

We're splitting hairs here guys, I don't think it matters.
 

CVRN

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Does anyone find that the brachial lines don't last as long once pt's in ICU? I've never seen brachial alines at my institution and I could see them getting kinked off pretty quick once they start waking up.
 

periopdoc

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When I was a fellow, the ICU guys would occasionally ask me to come up and place brachials in patients who kept losing their radial a-lines. I assume that kinking was not an issue and longevity was at least acceptable. If you are worried about kinking, stick high.

- pod
 

sevoflurane

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Earlier this year I did an AVR/MVR that didn't go as smoothly as usual. Pump times were up and myocardial preservation was compromised. Had to go back on bypass + IABP. Once we finally separated, trying to get an ABG was a pain in the arse. She was peripherally vasoconstricted to all hell and the epi/norepi didn't help any. Couldn't draw back on the radial a-line yet my wave form was intact. This is one of the few times I wish I had a brachial... yet a VBG provided me with most of what I needed.

I still use r. a-lines and have no problem putting in brachials if the radials give me any smack. I view a-lines like IV's. Start distally and work your way centrally (of course it's not that easy if it craps out on you in the middle of the case.. but that almost never happens).
 

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. Couldn't draw back on the radial a-line yet my wave form was intact. .

BTW, this has happened to me on occasion and aspirating with the syringe trying to get the sample sometimes causes air bubbles to develop in the tubing. I never know what to do at that point. I hate to flush the tubing because that just flushes all the air bubbles into the artery and obviously i can't aspirate the bubbles out because the blood doesn't draw; i've tried disconnecting the tubing to no avail - what to do?

Also, as long as we're on the subject of unconventional alines, anyone placing ulnar when they can't get radial? Anyone have qualms about that?
 

Hawaiian Bruin

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This discussion brings up the tangential question of what kinds of catheters are being used for the radial artery. It used to be the norm at our place that we'd use 20g jelco IV catheters, which were prone to kinking and often didn't correlate well with an aortic or femoral measurement when coming off pump.

For about a year now we've moved toward using the Arrow QuickFlash, which is much more resistant to kinking, and I've had much fewer problems aspirating from them than the old jelcos. For whatever reason, they also seem to correlate significantly better to aortic pressures than jelcos did.

What are you guys using out there?
 

proman

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Does anyone find that the brachial lines don't last as long once pt's in ICU? I've never seen brachial alines at my institution and I could see them getting kinked off pretty quick once they start waking up.
I've found brachials to be very prone to getting damaged with elbow bending. That's why I prefer axillary artery catheters.

She was peripherally vasoconstricted to all hell and the epi/norepi didn't help any. Couldn't draw back on the radial a-line yet my wave form was intact.
I think we've all seen this many times. I've never had much luck rewiring those lines. I think what's happened is that the artery is thrombosed and the pressure is transmitted through the thrombosis, but obviously there's nothing to draw back.[/QUOTE]

Also, as long as we're on the subject of unconventional alines, anyone placing ulnar when they can't get radial? Anyone have qualms about that?
I fear ulnar a lines. And femorals. I've seen hand and leg loss from both.
I think the advantage the axillary artery is the redundant collateral flow because of the shoulder.

For about a year now we've moved toward using the Arrow QuickFlash, which is much more resistant to kinking, and I've had much fewer problems aspirating from them than the old jelcos. For whatever reason, they also seem to correlate significantly better to aortic pressures than jelcos did.

What are you guys using out there?
My preference is 1.88 inch BD Angiocath made with FEP polymer. No one really knows which catheter is the ideal one.
 

periopdoc

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I use the 20g arrow for radials and a 5 Fr micropuncture for brachials. Occasionally I put the 5 Fr micropuncture into the radial as well if the patient is going to be in the unit for a long time.

I don't use ulnars cause I want some flow to the hand after I have or one of my residents has made a hash of the radial artery.

I don't personally place femorals. My surgeons usually do that. If we can get away with it, I will ask them to place it after the patient is prepped so that it can be used for intra-operative interventions if necessary.

RE: can't draw. These are pretty much FUBARed and unsalvageable. You can try heparin and lidocaine, but it rarely works. Usually, it is the result of poor flushing leading to thrombus formation. With more experience and care, I get fewer a-lines crapping out on me.

- pod
 

Bertelman

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BAlso, as long as we're on the subject of unconventional alines, anyone placing ulnar when they can't get radial? Anyone have qualms about that?
I don't use ulnars cause I want some flow to the hand after I have or one of my residents has made a hash of the radial artery.
- pod
Exactly. If you want to go for the ulnar on your first try, that's one thing. I wouldn't go there after you or someone else has stabbed away at the radial with a drawer full of 20 g caths.
 

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I fear ulnar a lines. And femorals. I've seen hand and leg loss from both.
I was at two hospitals where they used femorals for on pump cases i don't think they had any serious problems.
Like everything else i believe it's more a case of improper placement and management of the line that will cause problems.
 
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Mman

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Also, as long as we're on the subject of unconventional alines, anyone placing ulnar when they can't get radial? Anyone have qualms about that?
I've never done an ulnar, but have done lots of dorsalis pedis a lines.
 

IlDestriero

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I'm comfortable with femoral a lines in kids when I can't place a radial line. That's really only happened with really little peds cardiac pts.
 
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Oggg

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For a brachial line, do you use the tiny 20g angiocath or arrow, or do you put in that long catheter thats used for femoral a lines?

At my place we do radials for everything. If we cant get it, I use the ultrasound to get it. Or I do a femoral with ultrasound. Or my partners ask the surgeon to do it (lame)
 

MTGas2B

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Our standard for hearts is left radial pre induction and femoral placed by the intern after we're prepped.

A few weeks ago we had an acute type a dissection come in. Couldn't get a radial in. Surgeon placed a femoral awake. I placed a brachial. He was in false lumen I was in true. They really wanted that brachial out post op. I broke with when in Rome.


On the iPhone
 
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periopdoc

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Academic myth >> data.

- pod
 

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For true vasculopaths particularly in the ICU, sometimes a brachial A-line is all you can get. Reliable, 99% you won't struggle with USG location or placement, can get it in <3mins, nurses are happy ( :thumbup: ), 20G should suffice. A personal favorite so far when I need to go there.

I don't know that it should be routine though.
 

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We place both radial and femoral A-lines for all pump cases. About 10% of the time, we observe a large 20-30 point difference in in systolic pressure coming off pump. For example the femoral line reads 90/50 while the radial is reading 60-70/50. The femoral line helps us avoid giving unnecessary volume and inotropes. By the time we leave the room, the pressures have usually equalized.

I also go to brachial pre-induction when I can't get a radial. In that case, I skip the femoral line.
 

Oggg

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In residency we did lots of circ arrest cases and those cases got radial and fem a line and the radial was often dampened coming off bypass
 

TrustMe

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All but one of our staff place brachial a-lines for pump cases. That one almost refuses to ever place a brachial. They will try radial for 15-20 minutes before they will even consider brachial. No one else thinks twice about brachial. I can't remember the last time we had a complication in a cardiac case from a brachial a-line. I have personally had one brachial a-line complication recently (my first ever after having placed many brachial's in residency/fellowship) but it wasn't a cardiac case. I have also had one radial a-line complication so I guess those two sites are equal for me. I personally don't see the big deal. I always prefer upper extremity vs. femoral. My new favorite is the axillary. If it's not an emergency and I can't get radial, I like trying the axillary (unless they are anticoagulated, in which case I prefer brachial because you can compress it against the humerus, unlike the axillary where there is nothing to compress it against if they are bleeding.)

That is all.
 

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One of our attendings here who came back to Academia after 35 yrs PP CT has us place the long (femoral) cath in the radial art or brachial art if radial is difficult for all hearts. I now do this for all liver tx and lung tx. In my exp brachial has been easier first stick.
 

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Not a big fan of fem. art. lines for the heart room. Not as easily accessible as radials/brachial + lots of dead space in your art line tubing.
Random thought off topic slightly: I use to think that there is more dead space with a femoral but after my fellowship where my PD broke all my stupid and bad habits made a good point. When standing your wrists are near or even below your hip (femoral art) so you can use the same tubing for femoral and no need for extensions. Done it ever since and never used an extension. Works just fine.
 

Oggg

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When you do axillary, is the puncture site in the armpit as per a transarterial axillary block? Or is it under the clavicle as per an infraclavicular block (or subclavian line)? It seems like the armpit would be a dirty place for an a-line, and you have the median and ulnar nerves to avoid. And at the infraclavicular level you have the brachial plexus cords. (I suppose you could hurt the median nerve if you were way too medial with your brachial a line as well)
 

TrustMe

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When you do axillary, is the puncture site in the armpit as per a transarterial axillary block? Or is it under the clavicle as per an infraclavicular block (or subclavian line)? It seems like the armpit would be a dirty place for an a-line, and you have the median and ulnar nerves to avoid. And at the infraclavicular level you have the brachial plexus cords. (I suppose you could hurt the median nerve if you were way too medial with your brachial a line as well)
For axillary a-lines I find the axillary crease and go about 2 finger widths distally to that. I have never done one similar to an infraclavicular approach but would like to learn. I will occasionally use U/S for subclavian central lines so I don't see any reason I couldn't do this for an infraclavicular approach for an a-line.
 

Oggg

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I would be afraid to do an axillary art line because there are nerves all over the artery in the axilla and infraclavicularly. At least for the brachial artery you can see and hopefully avoid the median nerve
 

europeman

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I'm a surgeon here so I have a different perspective.... Being called for complications of a lines.

Dissections, emboli, pseudo aneurysms etc

Axillary lines are safe with ultrasound because it is large and in the unlikely event it clots or there is an issue, there are distal collaterals which can (most of the time) perfume the arm. When you look at netter for example these are the small branches coming off Axillary artery towards the distal part which can back flow when there is proximal occlusion. At our unit where we use Axillary lines as first choice, we have only had one worst drop which was temporary from presumed brachial plexus trauma over last 10 years. You really need to be trained and good at ultrasound though. Blind sticks here are not wise.

All the cold/blue hands we have had were from lines which were placed too distally by our new fellows (ie these were really brachial). Hence there were no collaterals.

Brachial lines dangerous because no collaterals.

Radial good cuz ulnar can save you most of time. Most uncomfortable for patient though and tenuous with movement sometimes.



Regarding where to place Axillary lines.... VERY proximal.... In Axillary! If you plaxe distal to crease then you should make sure your angle is such that the actual insertion in the artery is proximal to it and in Axillary.... Not brachial artery


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