Grr Art lines..

[Dissected]

Hey everyone

I am just finishing up my intern year in surgery. I consider myself to be above average when it comes to procedures/skills for my level, however I'm having a lot of trouble with my art lines this year. We use the Arrow kits.

I have one specific problem: I am able to get a pulsatile flash just fine (usually with or without ultrasound), and my wire passes freely at or just past the black line. I know what it feels like to not pass freely so I'm pretty confident that it is passing into the artery. Then when I go to advance my catheter, it gets about half way in and stops. Sometimes I can see a flash come up my catheter, sometimes not. Then when I go to take my wire out, it gets completely stuck..and I have to forcibly remove it along with my catheter. The end of the wire is bent at a right angle when it comes out and it looks god awful.

I'm able to get them about 50% of the time..but the other 50% this exact thing happens and it is very perplexing to me. Any suggestions?

---

Members don't see this ad.

 

[core0]

Hey everyone

I am just finishing up my intern year in surgery. I consider myself to be above average when it comes to procedures/skills for my level, however I'm having a lot of trouble with my art lines this year. We use the Arrow kits.

I have one specific problem: I am able to get a pulsatile flash just fine (usually with or without ultrasound), and my wire passes freely at or just past the black line. I know what it feels like to not pass freely so I'm pretty confident that it is passing into the artery. Then when I go to advance my catheter, it gets about half way in and stops. Sometimes I can see a flash come up my catheter, sometimes not. Then when I go to take my wire out, it gets completely stuck..and I have to forcibly remove it along with my catheter. The end of the wire is bent at a right angle when it comes out and it looks god awful.

I'm able to get them about 50% of the time..but the other 50% this exact thing happens and it is very perplexing to me. Any suggestions?

For the arrow get blood flowing up the column. Then lower the back so its more parallel to the arm. The blood should still be flowing. Then advance the wire all the way. It should go easily. If it doesn't then pull the wire back, make sure there is flow and try to advance again. If the wire doesn't advance all the way it probably won't go. If that doesn't work, and you have good flow, advance the wire as far as it will go, push the catheter in, pull the wire out, pull the catheter back until it has flow. Then advance the wire into the catheter (should be all the way extended) then try to thread the catheter. Hope this helps.

 

[dpmd]

Hey everyone

I am just finishing up my intern year in surgery. I consider myself to be above average when it comes to procedures/skills for my level, however I'm having a lot of trouble with my art lines this year. We use the Arrow kits.

I have one specific problem: I am able to get a pulsatile flash just fine (usually with or without ultrasound), and my wire passes freely at or just past the black line. I know what it feels like to not pass freely so I'm pretty confident that it is passing into the artery. Then when I go to advance my catheter, it gets about half way in and stops. Sometimes I can see a flash come up my catheter, sometimes not. Then when I go to take my wire out, it gets completely stuck..and I have to forcibly remove it along with my catheter. The end of the wire is bent at a right angle when it comes out and it looks god awful.

I'm able to get them about 50% of the time..but the other 50% this exact thing happens and it is very perplexing to me. Any suggestions?

Yes, quit trying to advance the catheter without the wire actually in the artery. The black line isn't the "stop here because you are in the artery" point, it is the "I am just leaving the needle" point.

 

[thedrjojo]

Another trick i have with A lines, which isn't really your problem, but a common problem, especially with the arrow kits, is when the catheter gets stuck at the skin, I use an 18 gauge needle to make a little skin nick (like you would for a central line or any other seldinger technique) to help the catheter get past the skin

 

[balaguru]

Hey everyone

I am just finishing up my intern year in surgery. I consider myself to be above average when it comes to procedures/skills for my level, however I'm having a lot of trouble with my art lines this year. We use the Arrow kits.

I have one specific problem: I am able to get a pulsatile flash just fine (usually with or without ultrasound), and my wire passes freely at or just past the black line. I know what it feels like to not pass freely so I'm pretty confident that it is passing into the artery. Then when I go to advance my catheter, it gets about half way in and stops. Sometimes I can see a flash come up my catheter, sometimes not. Then when I go to take my wire out, it gets completely stuck..and I have to forcibly remove it along with my catheter. The end of the wire is bent at a right angle when it comes out and it looks god awful.

I'm able to get them about 50% of the time..but the other 50% this exact thing happens and it is very perplexing to me. Any suggestions?

As has been said earlier you are describing a classic finding when the wire is not in the artery. Next time you see anesthesia put a line in a hypotensive pt ask them for pointers. They are actually pretty decent at it. With that said I must add that I've found the effort expended to place an art line is inversely proportional to how long it will last. I use to break out the Doppler or ultrasound on non-palpable radial or DP arteries. Now if I can't place it by palpation I just go to a fem line.

 

[caffeinemia]

My sage advice is to... ummm....just dilate the artery, specially those carotids...

 

[SLUser11]

If I'm concerned it will be difficult or if it is not palpable, then I will use the ultrasound and a micro puncture kit.

My preference for site is radial > DP > Brachial (much higher risk of bleeding complications) = femoral

I still somehow place 10+ art lines a year, typically when anesthesia is having difficulty with placement and I'm tired of waiting to start my case.

Reading the OP's comments, I think the main issue is that the guidewire is not getting passed far enough. It should be advanced to the base of the arrow kit, not to the black line, as the black line is the starting point for the guidewire being out of the needle.

Before I read that line from the OP, I assumed he was coming in at too sharp of an angle. I take a 45 degree approach or less. When advancing the catheter over the wire, I tend to spin it to prevent it getting stuck on skin.

Also, if it doesn't thread right away, I wouldn't give completely up. I've been able to salvage plenty of catheters by slowly backing out the catheter itself until you regain pulsatile blood flow, then re-advancing the guidewire through the catheter.

Also, if I can't get it within the first minute, I go right to ultrasound, which is typically sitting right there. With ultrasound, you'll almost never miss. I think 5 minutes of troubleshooting, etc, just ends up with a thrombosed, overly-traumatized radial artery.

I never go to the groin anymore. Never have to....

There's some worthless art line advice from a butt surgeon.

 

[illixir]

Agree with what everyone is saying. If your wire is getting bent, you're through and through, which actually isn't the worst thing. The wire should go freely the whole way down, I actually prefer the other kits with the manual wiring of the needle, I never seem to have this problem then. Usually the problem is the angle, the wire makes it out of the needle and is into the artery but has to be on a trajectory somewhat in line with the artery. If i have trouble wiring it as you're describing, I salvage the catheter by pulling out the wire(which as you've described is often bent, you can often still pull the bent wire out while leaving the catheter in), connecting a flush to the catheter and slowly withdrawing until i get arterial blood in the flush and then flushing the artery with a cc or two while I advance, it goes in extremely easy then. I've never been unable to ultimately get the line if I'm through and through. This is actually how an anesthesiologist I know does all of her a-lines, she says her technique is to always go through and through with the needle from the arrow kit, pull everything out and then float it in. Don't really think that's the best way to do it but you never have to deal with the wire. When I've tried pulling the catheter back and reinserting a wire, I feel like sometimes my wire goes back through the vessel wall and the catheter again after i thread that onto it so it hasnt always worked and I then have to use the flush. Also you're usually in this situation because the wire is bent; I suppose you could use the back end of the bent wire but I don't really like to.

As a sidenote, I really like axillary lines after radial lines, especially in the ICU where the ultrasound is always around.

 

[Dissected]

Thanks for the advice everyone. I'll take a peek at this thread right before my next few and keep all of this in mind! I'm confident that during one of my next 7 ICU/trauma months I will get more comfortable with these.