Radial A line difficulty

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Radial thrombosis plus ulnar thrombosis = black fingers

no one advocated attempts in the radial and ulnar on the same limb. should go without saying this is a bad idea.

my point was that in a minority of small children and even some adults the ulnar is larger than the radial - providing a bigger target by palpation or ultrasound - and can be chosen instead of the radial.

never after radial attempts on the same side.
 
you are right, and our hesitance to try it is probably dogmatic, but also that we invariably try the radial, after which you would not want to try the ipsilateral ulnar
 
Yes possibly dogmatic. I had an insane ICU attending who made me abort a radial After only 2-3 attempts, and when I refused to do ulnar, she flailed at it and failed there too.
 
Jet had a good thread on a line recovery when the wire won't thread, see if you can find it. Basically, wire won't thread, pull wire back, and use through and through technique.

The technique that has served me well is get the flash at a your 45* angle then drop the angle to about 20* and advance the needle about 1-2mm, when you actually feel the catheter go into the lumen, then thread your wire and advance catheter.

Can anybody repost the link to jets thread explaining through and through technique? I'm having difficulty finding it. Thanks.
 
You dont need that thread, just pretend im using different fonts.

If you get the flash or the little wisp of a flash, that suggests you are at least near the vessel, but cant advance the wire, then pass the whole apparatus farther than it should go (i.e. through the vessel) and remove everything but the catheter.

Pull the wire out of the arrow kit or open a second wire (seems wasteful), then SLOWLY back the catheter out, with a sterile towel or 4x4s under the catheter to catch the blood. When you get PULSATILE blood flow, advance the wire through the catheter, ensuring smooth advancement, and then advance the catheter as you would normally.

What this does is it can help take the steep angle out of the rigid arrow kit, especially if the artery curves a little at the insertion point.

It isn't flawless and i usually encourage my residents to move to a different site if the dont get it on the first attempt.
 
hello everyone...

I was hoping to get some advice.

I'm having a little trouble with radial A lines. I consistently manage to hit the artery and get flash. Unfortunately, when I advance the wire and then the catheter, I lose it.

I'm not sure what I'm doing wrong but this has happened on numerous occasions. I get flash, I advance the wire... catheter goes in... wire comes out... NO FLOW.

Any suggestions?
any general tips on A line placement would also be helpful...

thanks in advance!

Assuming you are using the Arrow Kit; if you are getting a flash of bright red blood and then can't thread the wire, it is likely you are going through the artery after you get the flash. Usually, if you are in the artery the blood continues to fill the tube, often in a pulsatile manner, until you thread the wire. The wire should go in smoothly. Never force it.

After you get the flash you should lower the angle and then thread. If you think you went through follow the "through and through" procedure described by others above. Some people just do it all the time but ideally you should practice trying to place the A-line without the "through and through procedure". Granted that I go do it all the time after a couple of fail attempts at the A-line.

Good luck.
 
The algorithm I've developed over the years for a-lines:

Assuming use of the Arrow kit with the long tube.

1. Positioning. Put a rolled-up OR towel or a-line armboard under the wrist to extend it. I like wrapping tape around the pt's thumb and using that to extend the thumb (by running the tape strip under the OR table armboard or whatever the arm is on)

2. Prep

3. Palpate artery. I agree with earlier posters about finger calibration -- the artery is often more medial than you think. I also agree with going a little more proximal. At (or just proximal to) the wrist crease, the artery is SO shallow that it's hard to get into. Easier where it's a little deeper.

4. Nick the skin with an 18g or other large needle. Keep it really flat; you don't want to get into the artery! I think this helps hugely with letting the catheter slide in without getting hung up.

5. Enter the artery at about a 30° angle. When you see a flash, lower the angle about as flat as it goes against the pt's thenar eminence.

6. If the blood is still crawling up the tube at the low angle, advance the wire. It should go in like butter. If you encounter any resistance, withdraw the wire and go to step 9.

7. If the blood flow stops when you lower the angle, raise the angle back up and adjust the position of the tip of your needle a little so that you get good blood flow when you flatten the angle. If you get good flow, advance the wire. If you can never manage to get good flow with the flat angle, go to step 9.

8. Twist the catheter to advance it into the artery. If you've made a skin nick and the wire went in with zero resistance, I've found that the catheter very nearly always slides in without a hitch.

9. If the initial wire pass met resistance, or you were never able to get good flow at the shallow angle, raise the angle back up and plunge that thing through-and-through. Remove the needle, grab a wad of 4x4s to catch the mess, slowly back out the catheter and use a separate wire once you get good pulsatile flow. If you get piddly continuous oozing flow, you can try the wire but it's pretty unlikely to be successful.

10. Practice, practice, practice, practice. The way to get good at anything is just to do it over and over and over. You'll develop a feel for it.


This method sounds complicated but really it's not. And I've found it to have a really high success rate.
 
You dont need that thread, just pretend im using different fonts.

If you get the flash or the little wisp of a flash, that suggests you are at least near the vessel, but cant advance the wire, then pass the whole apparatus farther than it should go (i.e. through the vessel) and remove everything but the catheter.

Pull the wire out of the arrow kit or open a second wire (seems wasteful), then SLOWLY back the catheter out, with a sterile towel or 4x4s under the catheter to catch the blood. When you get PULSATILE blood flow, advance the wire through the catheter, ensuring smooth advancement, and then advance the catheter as you would normally.

What this does is it can help take the steep angle out of the rigid arrow kit, especially if the artery curves a little at the insertion point.

It isn't flawless and i usually encourage my residents to move to a different site if the dont get it on the first attempt.

Thanks for the help! I think I've unknowingly done this (or some bootleg version) before and it definitely worked.

One clarification....one of two things happens to me....

1. Hit the artery, pulsatile past the black line, feed the wire and feel resistance so I back out, change angle, good flow, wire still won't feed....at this point go through and through? Or any other suggestions?

2. Dinky bright red flash and no pulsatile flow (can feel the artery really well right inline where my needle is) ...now do through and through in this situation too?
 
Thanks for the help! I think I've unknowingly done this (or some bootleg version) before and it definitely worked.

One clarification....one of two things happens to me....

1. Hit the artery, pulsatile past the black line, feed the wire and feel resistance so I back out, change angle, good flow, wire still won't feed....at this point go through and through? Or any other suggestions?

2. Dinky bright red flash and no pulsatile flow (can feel the artery really well right inline where my needle is) ...now do through and through in this situation too?

1. yes

2. you can, but its probably a setup and a situation where your angle is oblique to the line of the artery and you may still have trouble. if the pulse is good, i would trace the artery out better and restick
 
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The algorithm I've developed over the years for a-lines:

Assuming use of the Arrow kit with the long tube.

1. Positioning. Put a rolled-up OR towel or a-line armboard under the wrist to extend it. I like wrapping tape around the pt's thumb and using that to extend the thumb (by running the tape strip under the OR table armboard or whatever the arm is on)

2. Prep

3. Palpate artery. I agree with earlier posters about finger calibration -- the artery is often more medial than you think. I also agree with going a little more proximal. At (or just proximal to) the wrist crease, the artery is SO shallow that it's hard to get into. Easier where it's a little deeper.

4. Nick the skin with an 18g or other large needle. Keep it really flat; you don't want to get into the artery! I think this helps hugely with letting the catheter slide in without getting hung up.

5. Enter the artery at about a 30° angle. When you see a flash, lower the angle about as flat as it goes against the pt's thenar eminence.

6. If the blood is still crawling up the tube at the low angle, advance the wire. It should go in like butter. If you encounter any resistance, withdraw the wire and go to step 9.

7. If the blood flow stops when you lower the angle, raise the angle back up and adjust the position of the tip of your needle a little so that you get good blood flow when you flatten the angle. If you get good flow, advance the wire. If you can never manage to get good flow with the flat angle, go to step 9.

8. Twist the catheter to advance it into the artery. If you've made a skin nick and the wire went in with zero resistance, I've found that the catheter very nearly always slides in without a hitch.

9. If the initial wire pass met resistance, or you were never able to get good flow at the shallow angle, raise the angle back up and plunge that thing through-and-through. Remove the needle, grab a wad of 4x4s to catch the mess, slowly back out the catheter and use a separate wire once you get good pulsatile flow. If you get piddly continuous oozing flow, you can try the wire but it's pretty unlikely to be successful.

10. Practice, practice, practice, practice. The way to get good at anything is just to do it over and over and over. You'll develop a feel for it.


This method sounds complicated but really it's not. And I've found it to have a really high success rate.

This is great...I was typing while this was posted....original angle flash but no pulsatile very cherry red , through and through? Or do you have to have that pulsatile flow?
 
This is great...I was typing while this was posted....original angle flash but no pulsatile very cherry red , through and through? Or do you have to have that pulsatile flow?

you almost always have to have pulsatile flow to feel good about it. once youve done enough you will see that wisp (sometimes this can mean you have some clot or tissue in the end of your needle) and be able to thread the wire + catheter

in the situation you describe, i would imagine that a slow withdrawal back would capture that pulsatile flow, but possibly not. i usually restick these
 
This is great...I was typing while this was posted....original angle flash but no pulsatile very cherry red , through and through? Or do you have to have that pulsatile flow?

Just try to pass the catheter. I had one this week, not pulsatile, darkish blood, but wire was smooth. Blood was pulsing slightly in the extension tubing I connected, but I wasn't sure it was in until we went to the room and transduced it.
With really sick patients it may not spray across the room or be all that red.
 
Thanks for the help! I think I've unknowingly done this (or some bootleg version) before and it definitely worked.

One clarification....one of two things happens to me....

1. Hit the artery, pulsatile past the black line, feed the wire and feel resistance so I back out, change angle, good flow, wire still won't feed....at this point go through and through? Or any other suggestions?

2. Dinky bright red flash and no pulsatile flow (can feel the artery really well right inline where my needle is) ...now do through and through in this situation too?

The black line is where the wire tip is at the needle tip as the black plastic wire handle thing passes the black line. Pulsatile flow to the black line doesn't mean anything that I know of.
 
One downside people keep mentioning about through and through is the mess. Once you get slick you can do it without getting a single drop of blood on the four by four, it isn't that hard
 
One downside people keep mentioning about through and through is the mess. Once you get slick you can do it without getting a single drop of blood on the four by four, it isn't that hard

i dont trust it if i dont have blood coming back out of the catheter, i allow blood to spurt back if needed before i thread the wire. im pretty slick, so everyone is a little different.
 
i dont trust it if i dont have blood coming back out of the catheter, i allow blood to spurt back if needed before i thread the wire. im pretty slick, so everyone is a little different.

If blood shoots through the catheter like a rocket I have no problem blocking it with the wire before it gets to the hub and then threading the wire
 
If blood shoots through the catheter like a rocket I have no problem blocking it with the wire before it gets to the hub and then threading the wire

i like the visceral sensation i get from seeing the pulse. i dont mind 3cc of blood on the 4X4, thats what its for. you dont win any prizes or even get considered for any if you dont lose a drop of blood, and sometimes the speed at which the blood comes back gives you some valuable information about how likely you will be to successfully cannulate the vessel.

but thats what medicine in general and anesthesiology in particular are so great - many ways to achieve the same goal
 
i like the visceral sensation i get from seeing the pulse. i dont mind 3cc of blood on the 4X4, thats what its for. you dont win any prizes or even get considered for any if you dont lose a drop of blood, and sometimes the speed at which the blood comes back gives you some valuable information about how likely you will be to successfully cannulate the vessel.

but thats what medicine in general and anesthesiology in particular are so great - many ways to achieve the same goal

I have been doing these alot with US as mentioned, and generally rate after a TLC. So I have a big enough drape out already the mess doesnt bother me.

I am interested in the theory though, going to try a few through and through techniques on my next few lines, ill let you know how it goes.
 
My current us a line technique is to go out of plane but actually track the needle tip in realtime. Once I see the shiny tip in the vessel lumen, I flatten out, then advance my needle several mm more under us, keeping my tip in the vessel lumen. This usually means keeping the probe in the same spot but tilting it to follow as the needle goes up the arm. Then I look down and usually I see blood in my arrow chamber. I use the arrow wire but I probably don't need to as I have my needle and catheter tip several mm into the artery at this point. On two occasions, I've looked down and seen no blood in the chamber, but the catheter slid in easily and I got a great arterial waveform. Tissue plug or something I suppose.
 
This is great...I was typing while this was posted....original angle flash but no pulsatile very cherry red , through and through? Or do you have to have that pulsatile flow?

Blood climbing up the tube indicates that your needle tip is within the vessel lumen and you have a high likelihood of success with the rest of the placement. If the blood isn't climbing up the tube, it's not impossible that you'll have an easy time of the rest of it, but it's less likely. I would say, try to adjust the needle so that you do get flow up the tube at the flat angle. If you can't get flow, go ahead and gently try to pass the wire, it might work. But if you get any resistance, either try a new stick or go through-and-through.

I wonder whether a lot of these with a flash and no flow are due to kind of "side-biting" the artery, where you aren't in the center of the vessel.
 
Interestingly, I've had multiple times where I use an ultrasound and see the needle and the catheter go in, without flash, proceed to advance wire and then catheter, then get blood flow. Maybe bypassing an atherosclerotic part of the vessel? Regardless, its a nice way to do it vs short axis out of plane. ,

The Arrow is notorious in my hands for getting plugged on the way to the target. I have taken to inserting the needle to whatever depth I feel is deep enough, then running the wire through to unclog the tip before proceeding. Not too uncommonly, there is brisk blood flow on withdrawing the wire. Sometime there isn't and I encounter blood flow as I withdraw the needle (through and through). Rethread the wire, then the catheter when blood flow observed. I have observed the same phenomenon on ultrasound when I can see the needle and catheter sitting in the artery. In this case I don't bother looking for blood flow. Just thread the wire with real-time visualization of it threading into the lumen, then thread the catheter.

- pod
 
This thread is good for residents starting out and getting a little frustrated with a-lines.

I'm a through and through guy... there is some finess to it, but rarely does it let me down.

I'm gonna see if I can get a video uploaded for you young jedi's out there to see this technique in real time.
 
Robotic Lobectomy today. This one took 3 sticks in an awake patient... but a nice lido weal made him feel nothing. I usually nail it on the first one, so a little tiny bit frustrating :oops:. Not usually the case yet still a 1 minute a-line.


[YOUTUBE]:mad:[/YOUTUBE]

Couple of things to note:

  1. Use the white arrow 20G angiocath and not the wimpy pink 20G ones (they tend to kink). The arrows can bend and are reinforced (just like the ones in the kit. Strong like bull.
    Don't use these:

    Angiocath_I.jpg
  2. Always fill your angio cath and hub with your left over lidocaine (or saline). It will transmit the flash to the hub much, much faster... and requires less blood entering the catheter. Helps with the hypotensive patients who may not give you a good “flash”.
  3. This particular a-line took a couple more sticks than usual, good teaching points can be had though. Every step is calculated. If you notice, each stick gave me information. First stick, was too lateral... so for my second stick I swept medial. The second stick was too medial... so I knew the 3rd stick had to go in the middle. You should always fan in one direction vs. just blindly sticking. Be systematic with your approach.
  4. Notice my left finger is always feeling for the pulse (but NOT compressing it)... giving me feedback in real time. Good for brady-arrhytmias where an atrial beat is not conducted and therefore you may not get a flash. Just good to feel this rather than relying on the screen. Keeps your eyes focused on the field and the task at hand.
  5. Angle is pretty shallow so the depth of the catheter as it hits the radial will be deeper. Steeper angles might make passing the wire a little difficult.
Thorough and through technique. Pretty nice option IMHO. Learn it and have it as your primary tool or as a back up option.

Hope this helps y’all. :)
 
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How in god's name are you not getting fired immediately for videotaping in the OR? I would literally get sh#&-canned like instantaneously at every institution I have ever worked at. I would advise to remove video ASAP even with the "anonymity" that the forum provides. Nice technique, though. Always nice to see how others do it.
 
How in god's name are you not getting fired immediately for videotaping in the OR? I would literally get sh#&-canned like instantaneously at every institution I have ever worked at. I would advise to remove video ASAP even with the "anonymity" that the forum provides. Nice technique, though. Always nice to see how others do it.

Hey... I was placing an a-line... not video taping. It’s just a hand. No patient information or way of identifying the patient is there. So no HIPPA violations + this is for teaching purposes on a student doctor network... but...
Some places are a bit more laid back...
but...
You’ve put the scare in me.
Thanks for ruining the fun. ;)
So off it goes.

So here is another version of an A-line placement that hasn't been brought up yet: No wire method. A bit more challenging @ times.


[YOUTUBE]http://www.youtube.com/watch?v=uy7d-lOrAGs[/YOUTUBE]

I wonder if he got canned....?

Kiding B-bone, kiding....
 
MY MILLION DOLLAR QUESTION that hasn't come up yet...

How in the heck do y'all avoid "false positives" ie getting a venous 'flash'?

I can't tell you how many times I've fallen for it. Feel the pulse. Insert needle. Nice! A flash. Wait, it's kind of slow. But it's coming. It looks bright red. Okay let's try and transfix.

Pull back on the catheter. Non-pulsatile flow.

Damn me.

It's frustrating, but I would say this happens on up to a quarter of my a-lines.

Then I get another catheter to avoid my now clotted needle. Oh, hell no, the attending is making a break for the other wrist. Damn, he got it.

Sigh.

Anyways, how do y'all avoid this conundrum? I am constantly a sucker for the venous flash and pursue it on the chance that maybe the person has atherosclerosis. Perhaps I went through the vessel to quickly. Etc.
 
I like the skin nick with another needle, not too much wrist extension, and the thumb taped way lateral to open things up. Great points in this thread.
 
How in god's name are you not getting fired immediately for videotaping in the OR? I would literally get sh#&-canned like instantaneously at every institution I have ever worked at. I would advise to remove video ASAP even with the "anonymity" that the forum provides. Nice technique, though. Always nice to see how others do it.

I watched a CT surgeon hand his Iphone to his NP and make her record his bedside emergent pericardial window in our MICU like 3 weeks into intern year. It is an amazing video and still manages to both maintain sterility and not show any patient identifiers, essentially a video from the clavicle to the umilicus, shot with the NP standing at the head of the bed. If there are no HIPPA violations, it is not illegal and there would be no grounds for termination. I take pictures of **** all the time.

ALso had an ED attending show me a pic he took of an angioedema pt who had isolated uvular swelling. The pic is close up all you can see is the inside of the mouth. Again, no patient identifiers.
 
I watched a CT surgeon hand his Iphone to his NP and make her record his bedside emergent pericardial window in our MICU like 3 weeks into intern year. It is an amazing video and still manages to both maintain sterility and not show any patient identifiers, essentially a video from the clavicle to the umilicus, shot with the NP standing at the head of the bed. If there are no HIPPA violations, it is not illegal and there would be no grounds for termination. I take pictures of **** all the time.

ALso had an ED attending show me a pic he took of an angioedema pt who had isolated uvular swelling. The pic is close up all you can see is the inside of the mouth. Again, no patient identifiers.
Feel free to do whatever you want, based on the fact that some other surgeon is videotaping or that no one has freaked out cuz you took a few pictures. In my institution, there are signs everywhere that say "No cameras past this point" and "no unauthorized photography" etc. Most hospital systems, especially large academic institutions, take patient privacy very seriously. Even the implication that privacy might be compromised is enough to freak them out and go on a witchhunt. They don't know what you're taking a picture or video of and can't tell that it lacks identifying data. They may just notice somebody pointing their personal cell phone camera at a sleeping patient who did not sign a release form for some very non-official purpose (e.g. youtube, studentdoctor, your own personal library, etc). People tend to get pretty freaked out about being photographed/videotaped without their permission in any situation, but while in the hospital/under anesthesia/etc would make it worse in most situations.

As an example: While I was a resident, one of the chief surgical residents at a satellite site (6 months from graduating), had a patient in the OR with a tattoo on his penis that read "HOTROD". He thought this was hilarious (which it was) and took a photo. He emailed it to a few of the OR staff. One of the recipients thought this was inappropriate and alerted not the department or hospital, but the local media. Flash forward a few days and the resident is immediately fired with no warning/remediation/appeal. Done deal.

http://www.foxnews.com/story/0,2933,317468,00.html

So while you may see others doing this and think it's an innocent thing to do, the hospital/university/patient may think otherwise, and in my opinion the potential upside (whatever that is) is far outweighed by the risk of derailing one's career permanently.
 
Feel free to do whatever you want, based on the fact that some other surgeon is videotaping or that no one has freaked out cuz you took a few pictures. In my institution, there are signs everywhere that say "No cameras past this point" and "no unauthorized photography" etc. Most hospital systems, especially large academic institutions, take patient privacy very seriously. Even the implication that privacy might be compromised is enough to freak them out and go on a witchhunt. They don't know what you're taking a picture or video of and can't tell that it lacks identifying data. They may just notice somebody pointing their personal cell phone camera at a sleeping patient who did not sign a release form for some very non-official purpose (e.g. youtube, studentdoctor, your own personal library, etc). People tend to get pretty freaked out about being photographed/videotaped without their permission in any situation, but while in the hospital/under anesthesia/etc would make it worse in most situations.

As an example: While I was a resident, one of the chief surgical residents at a satellite site (6 months from graduating), had a patient in the OR with a tattoo on his penis that read "HOTROD". He thought this was hilarious (which it was) and took a photo. He emailed it to a few of the OR staff. One of the recipients thought this was inappropriate and alerted not the department or hospital, but the local media. Flash forward a few days and the resident is immediately fired with no warning/remediation/appeal. Done deal.

http://www.foxnews.com/story/0,2933,317468,00.html

So while you may see others doing this and think it's an innocent thing to do, the hospital/university/patient may think otherwise, and in my opinion the potential upside (whatever that is) is far outweighed by the risk of derailing one's career permanently.

Sorry, I should have been more clear.

One, I always ask the patient if I mind taking a picture of theur rare rash or skin lesion for educational purposes, and ensure them there will be no identifiable features. If they say I would rather not, I dont.

Second, only an idiot would email pictures they have taken to staff. That is common sense. Discression must always be used.

And I two have worked in many hospitals, academic and community shops, and have yet to be at one that prohibits physicians photographing important physical exam findings for teaching purposes provided the patient consents.

But never taking any photos of rare physical exam findings is a bit much. How do you think all those lovely pictures of malar rashes and marfans frames got into all those textbooks you have read along the way? People took pictures....
 
I still would get a written consent/release.

Sorry, I should have been more clear.

One, I always ask the patient if I mind taking a picture of theur rare rash or skin lesion for educational purposes, and ensure them there will be no identifiable features. If they say I would rather not, I dont.

Second, only an idiot would email pictures they have taken to staff. That is common sense. Discression must always be used.

And I two have worked in many hospitals, academic and community shops, and have yet to be at one that prohibits physicians photographing important physical exam findings for teaching purposes provided the patient consents.

But never taking any photos of rare physical exam findings is a bit much. How do you think all those lovely pictures of malar rashes and marfans frames got into all those textbooks you have read along the way? People took pictures....
 
MY MILLION DOLLAR QUESTION that hasn't come up yet...

How in the heck do y'all avoid "false positives" ie getting a venous 'flash'?

I can't tell you how many times I've fallen for it. Feel the pulse. Insert needle. Nice! A flash. Wait, it's kind of slow. But it's coming. It looks bright red. Okay let's try and transfix.

Pull back on the catheter. Non-pulsatile flow.

Damn me.

It's frustrating, but I would say this happens on up to a quarter of my a-lines.

Then I get another catheter to avoid my now clotted needle. Oh, hell no, the attending is making a break for the other wrist. Damn, he got it.

Sigh.

Anyways, how do y'all avoid this conundrum? I am constantly a sucker for the venous flash and pursue it on the chance that maybe the person has atherosclerosis. Perhaps I went through the vessel to quickly. Etc.

I don't think your problem is venous sticks. You are probably getting into the artery but not into the center of it.

The remedy? Practice, practice, practice, practice. Your first-attempt success rate will go up. Give my algorithm above a try, see what you think. But really, the way to get to the point where you can get line before your attending snags it -- is to just do it over and over.
 
Sometimes they are very, very superficial. Like PIV superficial. You need to palpate very lightly. You can often feel the body of the artery under your fingertips. These are more prone to rolling. You can feel the artery bounce of your needle and deflect to the right, withdraw and it goes back to midline, try again and deflect off to the left. Had to push through with force one of these to puncture the artery and place it with through and through. You do enough under ultrasound you will see the needle deflects the artery to the side even with a perfect midline shot very often.
 
The algorithm I've developed over the years for a-lines:

Assuming use of the Arrow kit with the long tube.

1. Positioning. Put a rolled-up OR towel or a-line armboard under the wrist to extend it. I like wrapping tape around the pt's thumb and using that to extend the thumb (by running the tape strip under the OR table armboard or whatever the arm is on)

2. Prep

3. Palpate artery. I agree with earlier posters about finger calibration -- the artery is often more medial than you think. I also agree with going a little more proximal. At (or just proximal to) the wrist crease, the artery is SO shallow that it's hard to get into. Easier where it's a little deeper.

4. Nick the skin with an 18g or other large needle. Keep it really flat; you don't want to get into the artery! I think this helps hugely with letting the catheter slide in without getting hung up.

5. Enter the artery at about a 30° angle. When you see a flash, lower the angle about as flat as it goes against the pt's thenar eminence.

6. If the blood is still crawling up the tube at the low angle, advance the wire. It should go in like butter. If you encounter any resistance, withdraw the wire and go to step 9.

7. If the blood flow stops when you lower the angle, raise the angle back up and adjust the position of the tip of your needle a little so that you get good blood flow when you flatten the angle. If you get good flow, advance the wire. If you can never manage to get good flow with the flat angle, go to step 9.

8. Twist the catheter to advance it into the artery. If you've made a skin nick and the wire went in with zero resistance, I've found that the catheter very nearly always slides in without a hitch.

9. If the initial wire pass met resistance, or you were never able to get good flow at the shallow angle, raise the angle back up and plunge that thing through-and-through. Remove the needle, grab a wad of 4x4s to catch the mess, slowly back out the catheter and use a separate wire once you get good pulsatile flow. If you get piddly continuous oozing flow, you can try the wire but it's pretty unlikely to be successful.

10. Practice, practice, practice, practice. The way to get good at anything is just to do it over and over and over. You'll develop a feel for it.


This method sounds complicated but really it's not. And I've found it to have a really high success rate.

A few other interns and I have been using this for the past week ...my success rate has skyrocketed... I'm printing this and hanging it in our fishbowl for other residents ....thank you for this and all over the other tips in this forum which I am finding to be very very true
 
Sometimes they are very, very superficial. Like PIV superficial. You need to palpate very lightly. You can often feel the body of the artery under your fingertips. These are more prone to rolling.

Yes, exactly why it's easier to go a little more proximal. It's SO hard to get in the artery when it's right under the dermis.
 
Had the weirdest thing. Using arrow catheter. Got good flash both times. Blood is climbing up the chamber. Drop angle of needle and wire threads like butter way past the black line. Try to twist off the white catheter and get so much resistance that the catheter ends up getting bent. Happened 2 times and ended up creating hematoma. Amy tips on what I should have done differently? Or way to save it next time. I’m

Attending ended up going brachial with ultrasound
 
Had the weirdest thing. Using arrow catheter. Got good flash both times. Blood is climbing up the chamber. Drop angle of needle and wire threads like butter way past the black line. Try to twist off the white catheter and get so much resistance that the catheter ends up getting bent. Happened 2 times and ended up creating hematoma. Amy tips on what I should have done differently? Or way to save it next time. I’m

Attending ended up going brachial with ultrasound

dump your arrow kits and just use an angiocath (if your insitutiion has).. the feel with the wire is much better when you are holding onto the wire yourself
 
What's with the "twisting" the catheter off the needle? There threads on it or something?
 
Had the weirdest thing. Using arrow catheter. Got good flash both times. Blood is climbing up the chamber. Drop angle of needle and wire threads like butter way past the black line. Try to twist off the white catheter and get so much resistance that the catheter ends up getting bent. Happened 2 times and ended up creating hematoma. Amy tips on what I should have done differently? Or way to save it next time. I’m

Attending ended up going brachial with ultrasound

Instead of hitting it and then dropping your angle when you see flow, start and insert with that shallow angle from the beginning. 20-30 degrees, SHALLOW ANGLE, that way when you hit it your wire path is more direct. I think something is going wrong for you when you "drop your angle". Just dont do that, hit it with a shallow angle, dont change anything when you get flow, just slowly advance the wire at that point
 
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What's with the "twisting" the catheter off the needle? There threads on it or something?

I think the idea is that it gives the catheter some forward momentum and shears off any resistance from the skin or tissue on the sides of the catheter as it goes in, whereas the skin or tissue would stop the advancement, with a twisting catheter it doesnt get held up
 
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What's with the "twisting" the catheter off the needle? There threads on it or something?

Nothing to do with threads. It's just that there's a lower coefficient of friction between the catheter and skin when you use a twisting motion while sliding the catheter into the artery.
 
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One thing I do is this: when I have to go through and through, especially on a patient who I suspect may have lots of calcifications, I will usually use a separate 0.015" wire as opposed to the 0.018" wire that comes with the arrow kit. I find that the 0.015" wire can get past calcifications a little easier than the 0.018" wire.

Some patients are nearly impossible to cannulate with a pink catheter or Arrow catheter, and the micropuncture kit, with its highly echogenic needle tip, can really help.
 
Nothing to do with threads. It's just that there's a lower coefficient of friction between the catheter and skin when you use a twisting motion while sliding the catheter into the artery.

:cool:

If the wire is in, it's in. Watching people make hesitation twists with a catheter instead of a briskly placing it over the wire into the vessel is maddening, especially in difficult sticks where added motion just risks bunging the thing up.

But if it works, it works, I guess....
 
:cool:

If the wire is in, it's in. Watching people make hesitation twists with a catheter instead of a briskly placing it over the wire into the vessel is maddening, especially in difficult sticks where added motion just risks bunging the thing up.

But if it works, it works, I guess....

The wire may be in but that doesn't mean the catheter is always going to slide forward in one smooth motion, at least not with the arrow kits I use. Most of the time I think you're right, but with some of the leatherskinned folks who've spent an entire lifetime in the sun and have a 1000 pack-year history, the twist is required to get the catheter to actually advance instead of just catching at the skin and tenting it up. IMO, the phenomenon is analogous to what happens when trying to try to run the dilator over the wire for a central line with an inadequately long/deep skin nick,
 
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