Cut down A-lines

[TheSandMan]

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This is a direct spin off of the cut down epidural thread.

Right now I am on a pediatric cardiothoracic rotation, where we do cut down a-lines routinely. Its so easy that it almost a joke.

Would any of the attendings out there consider a cutdown a-line on a adult with impossible to get a-line eg. that multiple gunshot wound trauma with no blood pressure? Seems to me that the potential morbidity from a cut-down aline would be less that for a brachial line.

 

[urge]

Who does the cut down? Anesthesia or Surgery?

I think you are right. Cut downs shouldn't be seen as a big deal.

 

[militarymd]

This is a direct spin off of the cut down epidural thread.

Right now I am on a pediatric cardiothoracic rotation, where we do cut down a-lines routinely. Its so easy that it almost a joke.

Would any of the attendings out there consider a cutdown a-line on a adult with impossible to get a-line eg. that multiple gunshot wound trauma with no blood pressure? Seems to me that the potential morbidity from a cut-down aline would be less that for a brachial line.

If you have a bunch of people sitting around with nothing else to do, that's fine, but when you're the only person there.....there's no point. You know why they're hypotensive.

 

[Planktonmd]

This is a direct spin off of the cut down epidural thread.

Right now I am on a pediatric cardiothoracic rotation, where we do cut down a-lines routinely. Its so easy that it almost a joke.

Would any of the attendings out there consider a cutdown a-line on a adult with impossible to get a-line eg. that multiple gunshot wound trauma with no blood pressure? Seems to me that the potential morbidity from a cut-down aline would be less that for a brachial line.

If I can't get an A line because a patient is in hypovolemic shock I will concentrate on correcting the problem rather than wasting time on the A line.
This reminds me of what happened 2 days ago:
94 Y/O patient trying to die in the recovery room after bowel resection.
He was extubated in the OR but did not do well in recovery and I re intubated him after 30 mg of Propofol, as soon as I put the tube in his BP went down to nothing and he became pulseless (combination of Propofol + hypovolemia + low EF + mild aortic stenosis + positive pressure ventilation in my opinion).
So, I was in the process of resuscitating him when my Junior associate who just finished residency arrived and his first action even before he understood the story was to start working on a femoral A line 🙂
I appreciated the gesture but it made me think how we were trained to do these things as a reflex.
It takes years to learn that monitors including invasive hemodynamic monitors are nice to have but in an emergency they are never your first priority.

 

[Arch Guillotti]

So, I was in the process of resuscitating him when my Junior associate who just finished residency arrived and his first action even before he understood the story was to start working on a femoral A line 🙂

That sounds like a medicine resident at a code feverishly working the femoral TLC while completely ignoring the airway.

 

[OB1🤙]

That sounds like a medicine resident at a code feverishly working the femoral TLC while completely ignoring the airway.

You stole my post.

 

[jetproppilot]

That sounds like a medicine resident at a code feverishly working the femoral TLC while completely ignoring the airway.

 

[drccw]

I try to impress on all the residents and students that nary a life was saved by an arterial line. Concentrate on the things that are going to make a difference: airway and access. So yes I am ok with the medicine resident struggling with a femoral tlc- they are ignorant in airway so let them work at something that keeps them out of the way. What does amuse me at codes is a medicine intern at each limb trying to get an abg. I tell them it's going to suck; the patient will be acidotic hyercatbic and hypoxic; let's focus on what's important: ABCs. So to the question at hand: radial cutdown for an arterial line? MAybe if I wasn't busy doing something else but odds are I would be busy. I have done many a trauma and even a ruptured AAA without an a line. Like it has been said hypovolemic shock doesn't require beat to beat bp. In my hands a cutdown would probably do more harm than good for a patient and I am willing to bet the same is true for most anesthesiologists.

 

[mille125]

If I can't get an A line because a patient is in hypovolemic shock I will concentrate on correcting the problem rather than wasting time on the A line.
This reminds me of what happened 2 days ago:
94 Y/O patient trying to die in the recovery room after bowel resection.
He was extubated in the OR but did not do well in recovery and I re intubated him after 30 mg of Propofol, as soon as I put the tube in his BP went down to nothing and he became pulseless (combination of Propofol + hypovolemia + low EF + mild aortic stenosis + positive pressure ventilation in my opinion).
So, I was in the process of resuscitating him when my Junior associate who just finished residency arrived and his first action even before he understood the story was to start working on a femoral A line 🙂
I appreciated the gesture but it made me think how we were trained to do these things as a reflex.
It takes years to learn that monitors including invasive hemodynamic monitors are nice to have but in an emergency they are never your first priority.

well said

 

[isoman2000]

This story reminds me of a time during a panniculectomy the pt suddenly became hypotensive with a pressure of 50/30 or some other insane number, well some epi fixed that up, and I proceeded to start an A-line in this svelte creature, having difficulty finding a radial pulse so this surgeon breaks scrub to try to start an a-line, he asks me at some point what he should do, my response "finish the case so we can get her off the table, an a-line will not save her but finishing the case will".

 

[Consigliere]

This story reminds me of a time during a panniculectomy the pt suddenly became hypotensive with a pressure of 50/30 or some other insane number, well some epi fixed that up, and I proceeded to start an A-line in this svelte creature, having difficulty finding a radial pulse so this surgeon breaks scrub to try to start an a-line, he asks me at some point what he should do, my response "finish the case so we can get her off the table, an a-line will not save her but finishing the case will".

Wow, what a fantastic, amusing anecdote. You sure saved the day!🙄

Jackass

 

[isoman2000]

Thanks what a polite clinically thoughtful germane post, we all benefited from your wisdom here.

 

[TheSandMan]

Damn, this is a tough crowd 🙂 OK, bad example for private practice folks - in the academic center, there are usually extra hands to help around, but if its just you, obviously you must prioritize and an aline is not your priority.

The reason I asked, the pediatric CT service Im on does about 6 serious cardiac cases a day (eg. tetrology of felot repairs, fontan completions, etc). Seeing these cut downs, they just look so ******edly simple that it seems like a great backup for the impossible aline. I gather from the responses above that no-one does them, and im sure i never do them again once i leave the service.

 

[cloud9]

This is a direct spin off of the cut down epidural thread.

Right now I am on a pediatric cardiothoracic rotation, where we do cut down a-lines routinely. Its so easy that it almost a joke.

Would any of the attendings out there consider a cutdown a-line on a adult with impossible to get a-line eg. that multiple gunshot wound trauma with no blood pressure? Seems to me that the potential morbidity from a cut-down aline would be less that for a brachial line.

I would just resuscitate them until you get the pressure better. If the pulse is barely palpable, the pressure is low. Trauma's will be acidotic from poor perfusion, they will need calcium if being transfused (likely will need transfusion), they will likely have a wide difference on their ET CO2-PACO2. I don't know what the ABG will tell you if the pt is so volume depleted that a cut down is needed to get teh line.

Sounds like a cut down is a way to circumvent the problem rather than fixing the problem and getting the line later

 

[Consigliere]

Thanks what a polite clinically thoughtful germane post, we all benefited from your wisdom here.

You're welcome dork.