- Joined
- Apr 21, 2003
- Messages
- 8,362
- Reaction score
- 18
the ulnar artery is often overlooked in kids.
i intentionally overlook it in everybody
the ulnar artery is often overlooked in kids.
i intentionally overlook it in everybody
i intentionally overlook it in everybody
Radial thrombosis plus ulnar thrombosis = black fingers
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.
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!
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?
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?
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?
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.
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
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?
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. ,
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.
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.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.
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.
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...
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.
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
What's with the "twisting" the catheter off the needle? There threads on it or something?
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.
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....