Jetpearl NUMBER 3

[jetproppilot]

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When placing an a-line, once you cannulate the artery, lets say you cant advance the wire without resistance. Pull the wire all the way back to the starting position, then push the needle(with the catheter on it) all the way through the artery. Remove the needle/wire thinghy, leaving only the plastic catheter in the wrist. now advance the wire as far as it can go so it is protruding thru the needle. Place a buncha 4X4s under the plastic catheter to absorb blood. Holding the needle with the wire protruding thru it in your right hand, use your left hand to back out the plastic catheter VERY VERY SLOWLY until a pulsating flow emerges. Advance protruding wire/needle until the needle hub is once again against the back of the catheter. Simultaneously PUSH AND TWIST arterial catheter forward as far as it will go. Remove needle wire thinghy.

Should save alotta second sticks for you.

 

[cchoukal]

The through and through trans-arterial is a GREAT technique. I use it frequently in the ICU and my success rate is very high. If I don't have access to a separate spring wire, I'll cut the back cap off of the arrow a-line kit, which allows the shuttle-wire apparatus to slide out the back end of the arrow, allowing you to use the wire on its own, which is slightly easier than using the wire while it's still in the needle apparatus.

Great tip, Jet.

 

[SleepIsGood]

When placing an a-line, once you cannulate the artery, lets say you cant advance the wire without resistance. Pull the wire all the way back to the starting position, then push the needle(with the catheter on it) all the way through the artery. Remove the needle/wire thinghy, leaving only the plastic catheter in the wrist. now advance the wire as far as it can go so it is protruding thru the needle. Place a buncha 4X4s under the plastic catheter to absorb blood. Holding the needle with the wire protruding thru it in your right hand, use your left hand to back out the plastic catheter VERY VERY SLOWLY until a pulsating flow emerges. Advance protruding wire/needle until the needle hub is once again against the back of the catheter. Simultaneously PUSH AND TWIST arterial catheter forward as far as it will go. Remove needle wire thinghy.

Should save alotta second sticks for you.

Not following here. Can you try again?😕

 

[drmwvr]

Variation on Jetprop's theme: Same technique except attach a 3 cc syringe after pulling out your stylet apparatus and while very slowly backing out, apply gentle negative pressure on the syringe until arterial blood flashes. Then it's just a matter of advancing the catheter/syringe assembly forward to the hub.

 

[lane]

I've done the same, except I cut (or just break) the plastic top off the arrow kit to remove the wire from the needle. I then insert the wire only (without the needle) as described above

 

[rsgillmd]

When placing an a-line, once you cannulate the artery, lets say you cant advance the wire without resistance. Pull the wire all the way back to the starting position, then push the needle(with the catheter on it) all the way through the artery. Remove the needle/wire thinghy, leaving only the plastic catheter in the wrist. now advance the wire as far as it can go so it is protruding thru the needle. Place a buncha 4X4s under the plastic catheter to absorb blood. Holding the needle with the wire protruding thru it in your right hand, use your left hand to back out the plastic catheter VERY VERY SLOWLY until a pulsating flow emerges. Advance protruding wire/needle until the needle hub is once again against the back of the catheter. Simultaneously PUSH AND TWIST arterial catheter forward as far as it will go. Remove needle wire thinghy.

Should save alotta second sticks for you.

Wait, so you are saying you push the guidewire through as far as it can go before beginning to back out? I do the opposite. If I get a flash but not good flow or have difficulty threading, I'll back the guidwire up and go through and through like you described. However, I don't reinsert the guidewire until I have good pulsatile flow again. If the flow is not good I don't try to thread the catheter (assuming normal BP -- I realize flow can be poor in hypotensive patients).

So I guess it is a small variation on the same technique. I think this is a good pearl. The through and through technique has saved me many times.

I would also add another tip I got from an attending -- on your forearm you'll see two creases where the wrist bends. Place your A-lines proximal to the proximal crease. If you go too distal it will be positional, and with too much flexion and extension the catheter may become permanently kinked.

I had a busy day, and while running the OB floor I let a CRNA place the A-line in a patient (long story -- I'll post the case in the private forum when I get a chance). The A-line worked fine until a little after the patient got to the recovery room (from her C/S). It showed its positional nature and dampened waveform, but the means were still accurate so I left it alone. This patient is now about to be transferred to the medical ICU. The nurse couldn't draw from the A-line and the waveform really sucked. In trouble shooting I noticed that the CRNA had placed the A-line about as distal as you can go and there was a kink in the catheter. I tried to fix the kink, but inadvertently pulled the A-line. So I restarted an A-line on the other side more proximally and have a great waveform. The patient is able to flex her hand on her abdomen without loss of the waveform, and there is good blood draw.

I've tried to warn the CRNAs about their bad habits, but they don't listen. That is why I place my own A-lines unless I have more important things to do (like today).

OK I apologize. I'm getting off topic. Time to get some sleep. Again Jet, great pearl about the through and through technique.

 

[sevoflurane]

I would also add another tip I got from an attending -- on your forearm you'll see two creases where the wrist bends. Place your A-lines proximal to the proximal crease. If you go too distal it will be positional, and with too much flexion and extension the catheter may become permanently kinked.

Agreed. The r. artery is also less tortuous and it's caliber becomes much larger the more proximal you go. This tends to help out in vasoconstricted/shocky patients on high dose pressors. You will still get a reliable waveform and are able to draw blood without a problem. If I'm asked to place an a-line in this type of patient and they don't have a pulse, I'll place it 2" from the crease. If you really need it and are having a hard time, do it with an USD. Don't let USD hurt your ego. I bust it out once or twice a year. Nice to see a target on the screen. Never fails.

Go too far proximal however and it starts to dive.

 

[RabbMD]

Additionally, Once the artery is pulsing out the catheter, you can move the orientation of the catheter in different vectors if the guidewire is not advancing into the artery easily. This sometimes helps in vasculopaths.

 

[bullard]

This pearl has never worked for me and I've been trying it every time I get into this situation (which fortunately is now increasingly rare!). I get flash, can't thread, go through and through with catheter, then slowly back out...and at some point I'll get weak blood flow but never pulsatile blood flow where I can appropriately wire through the catheter.

So my question is, WTF is going on here? Was my initial flash not artery but some random vein? Or did I just hit the side of the artery and that's why I can't pull the catheter back into it?

 

[Frank Rizzo]

This pearl has never worked for me and I've been trying it every time I get into this situation (which fortunately is now increasingly rare!). I get flash, can't thread, go through and through with catheter, then slowly back out...and at some point I'll get weak blood flow but never pulsatile blood flow where I can appropriately wire through the catheter.

So my question is, WTF is going on here? Was my initial flash not artery but some random vein? Or did I just hit the side of the artery and that's why I can't pull the catheter back into it?

The through and through technique is actually how i do all of my a-lines. If you want to perfect this technique, do it for your initial a-line attempt a couple of times, that way the artery isn't all banged up or in spasm while you're learning it.

As far as your particular problem, it could be anything. Possibly nicked the side of the artery, possibly hematoma from your previous stick( which a lot of times can still give you a weak pulsatile flow), spasm. Backing the catheter out to quickly can also cause this. If this is the case, sometimes it can be salvaged by carefully reinserting the needle in the cath and pushing through the artery again. What you have to watch out for is accidentally pushing the needle through the side of the cath... so if you meet any resistance reinserting the needle, stop.

 

[nap$ter]

I've done the same, except I cut (or just break) the plastic top off the arrow kit to remove the wire from the needle. I then insert the wire only (without the needle) as described above

this is why i'm a short arrow kit guy, not a long arrow kit guy. on the short kits you don't have to cut or break anything; the wire just slides right out the back so you can use it free-hand for transfixed catheters.

i'm becoming a convert to old-school jelco's - the slide is smoooth..

 

[inmyslumber]

Anyone use lidocaine SQ before placing A-lines in asleep patients? Have been told it decreases arterial spasm and makes a "second pass" at the artery easier.

 

[OB1🤙]

Jet- may I humbly suggest you add some sort of description to the titles of your pearls, so as to make future searches through them easy?

We have a general institutional preference for 20g jelcos for a-lines. We do have the big Arrow kits as well as the little Quickflash ones for those who prefer them, and while I can use those, I still prefer the jelco for ease of threading.

Sometimes I'll put an empty 1cc syringe on the end of it, sometimes I won't, but here's the technique:

1) Feel pulse, advance at ~30 degrees, hit artery. Easier said than done sometimes.

2) Drop angle, advance 1mm into vessel to get the catheter all the way intraarterial (much like starting an IV), if still blood flow, spin catheter into artery. Voila, done.

3) If flow stopped when advancing, your needle went out the back wall of the artery. So push the whole assembly all the way through the vessel, remove needle, get a wire, and do as JPP describes. Pull catheter back SLOWLY, achieve pulsatile flow (better have a stack of 4x4s, towel, chux, etc), wire through jelco, jelco over wire into vessel.

I like this because if it's a good vessel, no through-and-through is needed. If it's a tough vessel, you aren't dicking around with the big Arrow assembly, cutting things off of it, etc. That and I'm sure a 20g jelco is a small fraction of the cost of an Arrow kit.

Disadvantages are that the jelco kinks more easily, so if someone is going to the unit for a few days after, it's probably worth putting in something sturdier.

 

[rsgillmd]

Anyone use lidocaine SQ before placing A-lines in asleep patients? Have been told it decreases arterial spasm and makes a "second pass" at the artery easier.

Yes. I was taught the same thing and use it. However, it is hard for me to do any study of my own because most A-lines go smoothly. So since there is no harm, and it is plausible, I use SQ lido for all A-lines placed asleep.

 

[rsgillmd]

......get a wire, and do as JPP describes. Pull catheter back SLOWLY, achieve pulsatile flow (better have a stack of 4x4s, towel, chux, etc), wire through jelco, jelco over wire into vessel......

The problem I have here as well as in my old institution was getting a wire. The Arrow kits which we have here also have the wire with them. Where I trained, on the 20 ga. catheter kits you could easily remove the wire without having to cut. The kits I use now are like my old 22 ga. catheter kits -- the wire is stuck to the assembly unless I cut it. So if I have to do through and through I push the wire all the way down so that it goes first when reentering the catheter. However this generally necessitates passing the needle back into the catheter, so I may resort to cutting the wire. Either that or start using the Jelcos more frequently. We didn't have 20 ga. Jelcos where I trained, but have them here. But the problem I have is that if I'm placing an A-line, it'll probably be there for at least a few days. I don't know if the Jelcos are sturdy enough to withstand repeated manipulation by nurses.

 

[ssmallz]

Thats the only technique I use, works like a charm. cuts down on dissections which can make recannulation w/a 2nd attempt much tougher

 

[dhb]

Or did I just hit the side of the artery and that's why I can't pull the catheter back into it?

I would bet on that.
Through and through can save you but using it as your main approach is unnecessary imho.