Radial A line difficulty

[Lecithin5]

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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,

Which is why some folks I’ve seen will preemptively nick the site (where they will stick the arrow) with an 18g needle, just to avoid the catheter catching at the skin.

 

[drmwvr]

Which is why some folks I’ve seen will preemptively nick the site (where they will stick the arrow) with an 18g needle, just to avoid the catheter catching at the skin.

I use a 16, but that is to provide a clean first pass entry into the vessel itself...the catheter is already through the skin when you go to slide it over the wire...what it can hang up on is thickened adventitia or plaque and getting past those just requires a brisk insertion.

But as I said...do what works for you.

 

[Twiggidy]

I use a 16, but that is to provide a clean first pass entry into the vessel itself...the catheter is already through the skin when you go to slide it over the wire...what it can hang up on is thickened adventitia or plaque and getting past those just requires a brisk insertion.

But as I said...do what works for you.

Exactly

 

[MirrorTodd]

Attending just handed me a 20g iv catheter after I got perfect flash with the arrow kit and the wire threaded perfectly but pulled the wire out and it was bent to **** and there was no blood return. Lol she said I'll never go back.

 

[Twiggidy]

Attending just handed me a 20g iv catheter after I got perfect flash with the arrow kit and the wire threaded perfectly but pulled the wire out and it was bent to **** and there was no blood return. Lol she said I'll never go back.

I went from an institution that preached the gospel on 20G catheters to a place where we only use the Arrow kit. The key is when you get perfect flash you have to advance just a tiny bit otherwise you running the wire through the adventitia (is that the correct term?) of the vessel. This is especially true in old vascular patients.

Get the flash, advance a touch (and i mean a touch) and still have flow, then advance the wire and catheter.

 

[deleted697127]

Attending just handed me a 20g iv catheter after I got perfect flash with the arrow kit and the wire threaded perfectly but pulled the wire out and it was bent to **** and there was no blood return. Lol she said I'll never go back.

There’s a ton of variation in how you can do arterial lines. Thats what makes them kind of fun. Even when you already know what you’re doing it’s worth it/kinda fun asking slick attendings for tips or watching them do one.

We do most of ours awake. I prefer the arrow because i think it’s easier to thread without going through and through by just dropping the angle and threading the built in wire if you still have good pulsatile flow. The size of the arrow can make some patients unnecessarily nervous when they see it but if you are able do it quickly while building rapport, I feel like it actually reassures them a bit. If not Midaz helps.

 

[AdmiralChz]

This is a great thread, very interesting ideas! I’m not sure I agree with all the ideas floated out there but it’s important to figure out what works for YOU.

I went from an institution that preached the gospel on 20G catheters to a place where we only use the Arrow kit. The key is when you get perfect flash you have to advance just a tiny bit otherwise you running the wire through the adventitia (is that the correct term?) of the vessel. This is especially true in old vascular patients.

Get the flash, advance a touch (and i mean a touch) and still have flow, then advance the wire and catheter.

This is funny because I went through the reverse, did arrows in residency and switched to angiocaths with wire in fellowship. My success rate is subjectively just so much better with through-and-through technique. Some of my colleagues swear by the Arrow, though.

At the end of last year I hit a huge a-line slump and missed like 5 or 6 in a row. I really got in my own head about it so I looked at a TON of videos and read some online articles about it. Although there are many techniques, the take home point for me was to pick a technique and commit to it - it you’re going to do use the angiocath for through-and-through, then simply do it with intent and resist the “quick thread” urge. That was my problem and I was blowing arteries over and over - once I went back to TnT and wire, I was right back in the game.

 

[Urzuz]

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,

+1.

Also the white arrow catheters often get a little stuck on the kits they come loaded on. Even with loosening the catheter before the stick, I find that rotating the catheter while advancing helps (paradoxically) keep the entire apparatus stable while advancing the catheter forward.

 

[Twiggidy]

This is a great thread, very interesting ideas! I’m not sure I agree with all the ideas floated out there but it’s important to figure out what works for YOU.



This is funny because I went through the reverse, did arrows in residency and switched to angiocaths with wire in fellowship. My success rate is subjectively just so much better with through-and-through technique. Some of my colleagues swear by the Arrow, though.

At the end of last year I hit a huge a-line slump and missed like 5 or 6 in a row. I really got in my own head about it so I looked at a TON of videos and read some online articles about it. Although there are many techniques, the take home point for me was to pick a technique and commit to it - it you’re going to do use the angiocath for through-and-through, then simply do it with intent and resist the “quick thread” urge. That was my problem and I was blowing arteries over and over - once I went back to TnT and wire, I was right back in the game.

One of the main reasons I had to abandon TnT was because we don't have the proper Arrow wires at my gig despite asking to get them many times. Our hospital is in a bit of a penny pinching phase at the moment. Any wire technique is probably preferable because if the wire goes smooth into the lumen then any catheter should follow. Most vascular surgeons will swear by this technique.

 

[anbuitachi]

ive used both. the 20G catheters are much better IMO. they tend to get a little messier but hey i dont really care. the feel is just so much better, you are able to tell much finer bits of changes in resistance. i basically just thread it like an IV catheter w/o wire and if theres any resistance at all, immediately stop and just go thru and thru and try passing the wire instead.

 

[nimbus]

ive used both. the 20G catheters are much better IMO. they tend to get a little messier but hey i dont really care. the feel is just so much better, you are able to tell much finer bits of changes in resistance. i basically just thread it like an IV catheter w/o wire and if theres any resistance at all, immediately stop and just go thru and thru and try passing the wire instead.

You lose style points if you make a mess. And I don’t like thru and thru because why make 2 holes? I like the arrow with ultrasound every single time.

 

[anbuitachi]

You lose style points if you make a mess. And I don’t like thru and thru because why make 2 holes? I like the arrow with ultrasound every single time.

well i already said id try not to go thru and thru first, if it doesn't go then i do thru/thru. the mess gets cleaned up. and i care more about getting the A line in than style points. everyones used to blood squirting out of the artery by now.

how much are those arrow kits anyway

 

[deleted697127]

You lose style points if you make a mess. And I don’t like thru and thru because why make 2 holes? I like the arrow with ultrasound every single time.

Ultrasound definitely makes it easier and quicker for me. It is what i would want if someone was placing one on me or a family member. Sure, it’s not that hard to do it without an ultrasound but as a resident, it is important to develop skills without ultrasound too for when using one might not be feasible. I distinctly remember as a ca2 getting paged for help in a disaster case with all sorts of people and extra surgical equipment in the room. I was asked to place an art line. Way too much equipment in the room to add an ultrasound. I blew it by palpation twice in front of 2 of our cardiac attendings because I had been too reliant on ultrasound prior to that case.

Its probably better to learn on ultrasound if possible in my opinion.

 

[T-burglar]

Blow on the catheter then snap your fingers three times. You’ll never go back to any other technique once you try this. Always works.

we should all stop trying to do this procedure blind in my opinion and just use ultrasound. Higher first pass success. It’s what I would want for myself as a patient.

Forget all this. Blow on the

 

[Ronin786]

As far as threading the catheter, IMO the trick is to advance the entire apparatus (needle, catheter and wire) once you've threaded the wire. Given that the wire is already in the vessel, everything will follow. Super helpful with really superficial arteries where the needle is in the artery and above the skin simultaneously. Only applies to the arrows though, which I personally prefer. Much less of a mess.

 

[vector2]

As far as threading the catheter, IMO the trick is to advance the entire apparatus (needle, catheter and wire) once you've threaded the wire. Given that the wire is already in the vessel, everything will follow. Super helpful with really superficial arteries where the needle is in the artery and above the skin simultaneously. Only applies to the arrows though, which I personally prefer. Much less of a mess.

I do the same thing not infrequently but I'm always a little nervous of someone doing the following if they're not careful when the wire is out of the needle

 

[DM27]

I can only speak regarding the wires we use, but they are very difficult to cut that way. The are more likely to severely bend or fray.

 

[vector2]

I can only speak regarding the wires we use, but they are very difficult to cut that way. The are more likely to severely bend or fray.

As you can see, I'm not an artist, but really we should be mindful of any significant shearing, fraying, transection, or a bend so bad that the wire won't easily come back out of the entry puncture.

 

[DM27]

The bend is a real concern, I’ve had some significant wire bends from extremely calcified femoral arteries that are very resistant to the catheter itself passing through.

 

[zizzer]

Here's a question I haven't seen discussed here yet: what about using phenylephrine when the pulse is weak or nonpalpable?

This is pretty common practice where I work to raise the pressure, but it seems counterproductive by decreasing the size of the artery. I would rather just grab an ultrasound. Any thoughts?

 

[deleted162650]

Here's a question I haven't seen discussed here yet: what about using phenylephrine when the pulse is weak or nonpalpable?

This is pretty common practice where I work to raise the pressure, but it seems counterproductive by decreasing the size of the artery. I would rather just grab an ultrasound. Any thoughts?

Use ephedrine . . . or U/S.

 

[MirrorTodd]

Here's a question I haven't seen discussed here yet: what about using phenylephrine when the pulse is weak or nonpalpable?

This is pretty common practice where I work to raise the pressure, but it seems counterproductive by decreasing the size of the artery. I would rather just grab an ultrasound. Any thoughts?

Wouldn't a small dose of epi be better? More contractility=more bounding in pulse to feel. (this is merely an exercise in academics, I'm not actually advocating for it)

 

[deleted697535]

We should all be using ultrasound for art lines... Its unacceptable that culture believes that blinding stabbing a needle into someones forearm is acceptable. We wouldnt do it in the neck so why is the hand ok?

I did one last week and it was totally uneventful afaik. Met patient again yest unrelated. Paraesthesia on median aspect of hand. Not terminal obviously. But very annoying for her. Obvi i skewered the nerve

 

[anbuitachi]

We should all be using ultrasound for art lines... Its unacceptable that culture believes that blinding stabbing a needle into someones forearm is acceptable. We wouldnt do it in the neck so why is the hand ok?

I did one last week and it was totally uneventful afaik. Met patient again yest unrelated. Paraesthesia on median aspect of hand. Not terminal obviously. But very annoying for her. Obvi i skewered the nerve

i dont put in carotid Arterial lines.. does anyone? i know theres collateral but still seems risky

 

[anbuitachi]

Here's a question I haven't seen discussed here yet: what about using phenylephrine when the pulse is weak or nonpalpable?

This is pretty common practice where I work to raise the pressure, but it seems counterproductive by decreasing the size of the artery. I would rather just grab an ultrasound. Any thoughts?

i mainly use it so i know exactly where the artery is. sometimes the pulse is so weak i dont feel it, or barely feel it. making it palpable helps locate the artery. i dont think the diameter actually changes that much

 

[T-burglar]

using ultrasound for all lines and being consultant level skilled at it elevates your practice. Being a luddite in anesthesia or medicine is just mind-blowing to me. The answer to the question "well what are you going to do when you need to place a line fast and theres no ultrasound??" is "don't put yourself in that ****ing position" . Do emergent cases in a room with a dedicated US device, or next to the closet where they are kept, or some other logistic solution. Figure it out.

 

[anbuitachi]

using ultrasound for all lines and being consultant level skilled at it elevates your practice. Being a luddite in anesthesia or medicine is just mind-blowing to me. The answer to the question "well what are you going to do when you need to place a line fast and theres no ultrasound??" is "don't put yourself in that ****ing position" . Do emergent cases in a room with a dedicated US device, or next to the closet where they are kept, or some other logistic solution. Figure it out.

i dont think everyone is in a situation to do that. some places ive been to have 1 ultrasound for their department. also what if an emergency comes and you have multiple MDs there to help? are you going to do A line with US, then have the other person wait for the US for central line? i mean in an ideal world it'd be great to have ultrasounds for everyone, but its just not the case in many places. same with ABG machines. there just aren't enough to go around

 

[vector2]

Here's a question I haven't seen discussed here yet: what about using phenylephrine when the pulse is weak or nonpalpable?

This is pretty common practice where I work to raise the pressure, but it seems counterproductive by decreasing the size of the artery. I would rather just grab an ultrasound. Any thoughts?

Keep in mind that phenylephrine is both a veno- and arterial constrictor. For anyone who's not profoundly hypovolemic, a slug of phenylephrine will autotransfuse some of that blood that's pooling in the veins post-induction back into the arterial system and will likely maintain CO and radial artery blood flow.

Or what I just said could just be a bunch of BS. Any time I think I know what pressors do to blood vessels I read this article:

https://www.jtcvs.org/article/S0022-5223(05)00609-4/pdf

 

[vector2]

i dont think everyone is in a situation to do that. some places ive been to have 1 ultrasound for their department. also what if an emergency comes and you have multiple MDs there to help? are you going to do A line with US, then have the other person wait for the US for central line? i mean in an ideal world it'd be great to have ultrasounds for everyone, but its just not the case in many places. same with ABG machines. there just aren't enough to go around

You're still right for the time being, but we're rapidly reaching the point where even the most podunk of podunk hospitals will have a couple U/S machines lying around. I used to preach to my (non-CA1) residents to keep trying the a-line anatomically because you never know when you're going to be in a situation where it's not available, but honestly once they have the fundamentals of an anatomic stick down, I would rather have them tackle the learning curve for being really, really good at hitting small targets with ultrasound vs. becoming a voodoo palpation method wizard.

 

[nimbus]

i dont think everyone is in a situation to do that. some places ive been to have 1 ultrasound for their department. also what if an emergency comes and you have multiple MDs there to help? are you going to do A line with US, then have the other person wait for the US for central line? i mean in an ideal world it'd be great to have ultrasounds for everyone, but its just not the case in many places. same with ABG machines. there just aren't enough to go around

Since a serviceable ultrasound is now $2000, that’s no longer a valid argument.

 

[anbuitachi]

Since a serviceable ultrasound is now $2000, that’s no longer a valid argument.

That's a lot of money. Imagine losing it and crying for a week

 

[deleted50478]

We should all be using ultrasound for art lines... Its unacceptable that culture believes that blinding stabbing a needle into someones forearm is acceptable. We wouldnt do it in the neck so why is the hand ok?

I did one last week and it was totally uneventful afaik. Met patient again yest unrelated. Paraesthesia on median aspect of hand. Not terminal obviously. But very annoying for her. Obvi i skewered the nerve

What’s blind about feeling an artery and sticking it? In expert hands non-US is faster and has just as high a success rate as US-guided.

 

[vector2]

What’s blind about feeling an artery and sticking it? In expert hands non-US is faster and has just as high a success rate as US-guided.

I'm not at the 40,000+ a-lines done like Blade, but I've done few in my day. I would bet my 'first stick, no redirect, no fanning, no finagling, just flash and go' success rate is maybe 70-80% when anatomic/palpation sticking our average pt who needs an a-line (fat, diabetic vasculopath coming for vascular, cardiac, thoracic, major abdominal). Otoh, my first pass ultrasound success rate is well over 90-95%.

 

[nimbus]

I'm not at the 40,000+ a-lines done like Blade, but I've done few in my day. I would bet my 'first stick, no redirect, no fanning, no finagling, just flash and go' success rate is maybe 70-80% when anatomic/palpation sticking our average pt who needs an a-line (fat, diabetic vasculopath coming for vascular, cardiac, thoracic, major abdominal). Otoh, my first pass ultrasound success rate is well over 90-95%.

Mine too except my “no redirect” rate on blind sticks was more like 30-40%. Maybe I just sucked and I practiced for over 10 years after training doing blind A-lines without US.

It’s definitely 95%+ with US. Many times I’ll just stick another site if I don’t see a good target on ultrasound saving the patient an unnecessary stick.

In my hands, blind sticks are an inferior technique so I quit doing it that way.

 

[Twiggidy]

We should all be using ultrasound for art lines... Its unacceptable that culture believes that blinding stabbing a needle into someones forearm is acceptable. We wouldnt do it in the neck so why is the hand ok?

I did one last week and it was totally uneventful afaik. Met patient again yest unrelated. Paraesthesia on median aspect of hand. Not terminal obviously. But very annoying for her. Obvi i skewered the nerve

There's nothing that says this sort of complications doesn't happen even using an ultrasound. Sometimes stuff happens. I believe people need to know how to do invasive lines without an ultrasound for reason that what if your starting a case or doing an emergency and a colleague down the hall is using it for a block/line/whatever? Not every institution has multiple ultrasounds and I wouldn't advise delaying case progression or waiting during an emergency because you can't place a line without an ultrasound.

Edit: I see this has also been addressed above, but my position remains the same. THB, it comes down to patient selection for me. Now I do most of my arterials with an ultrasound just to get things moving but i will once in a while do it blind just so I dont lose the skill. Same with neck lines. Patient selection. A thick neck will always get an ultrasound on it. A slender person I can 90 some odd percent of the time press and show you where the IJ is refilling on the neck. This is also why we're taught to use the finder needle and not go straight to the big needle (although one of my crazy attendings in fellowship did this but I never really liked his style anyway)

I think you're limiting you skills by NOT knowing how to do these things without an ultrasound

 

[Southpaw]

There's nothing that says this sort of complications doesn't happen even using an ultrasound. Sometimes stuff happens. I believe people need to know how to do invasive lines without an ultrasound for reason that what if your starting a case or doing an emergency and a colleague down the hall is using it for a block/line/whatever? Not every institution has multiple ultrasounds and I wouldn't advise delaying case progression or waiting during an emergency because you can't place a line without an ultrasound.

If you've got the emergency don't you think you have first dibs on the US machine? If it's enough of a departmental problem that requires buying another US machine, then your department needs to spine-up and push the hospital to buy one. I understand that's easier said than done. I get awful frustrated when a hospital won't improve safety for what I need, which is roughly the cost of one spine screw.

Anyway, I use US and I won't go back. If I didn't have US I'd do what everyone else does. Feel for the pulse and stab. But like @nimbus my first pass rate without any redirection whatsoever wasn't high. When you start routinely using US for alines you start to see why that is.

 

[Twiggidy]

If you've got the emergency don't you think you have first dibs on the US machine? If it's enough of a departmental problem that requires buying another US machine, then your department needs to spine-up and push the hospital to buy one. I understand that's easier said than done. I get awful frustrated when a hospital won't improve safety for what I need, which is roughly the cost of one spine screw.

Anyway, I use US and I won't go back. If I didn't have US I'd do what everyone else does. Feel for the pulse and stab. But like @nimbus my first pass rate without any redirection whatsoever wasn't high. When you start routinely using US for alines you start to see why that is.

It's MUCH easier said than done.

 

[AdmiralChz]

It's MUCH easier said than done.

In residency, the department asked over and over again for more ultrasounds - our ORs were split amongst buildings and the old building really only had 1 or 2 mobile ultrasounds for 22 ORs (cardiac rooms used the iE33 cardiac probe bleh). Eventually the hospital somehow found old refrigerator-looking/sized 2 screen ultrasound machines, had them rehabbed and said “use this.” It was comical. Let me see if I can get a picture of it.

 

[Twiggidy]

In residency, the department asked over and over again for more ultrasounds - our ORs were split amongst buildings and the old building really only had 1 or 2 mobile ultrasounds for 22 ORs (cardiac rooms used the iE33 cardiac probe bleh). Eventually the hospital somehow found old refrigerator-looking/sized 2 screen ultrasound machines, had them rehabbed and said “use this.” It was comical. Let me see if I can get a picture of it.

People laugh at me because I use the oldest portable US in the hospital because it's always available because no one else likes it. Quite honestly that's probably why we can get more new ones because I'm "that guy" still using the old POS but it doesnt mean I'm stuck in the mud without it. I honestly advocate US as well but I also realize I don't work in the fantasy world where US are A) always available and B) always working. Things break, things disappear, and things are being used and sometimes all three happen at the worst time.

 

[DM27]

Palpation is still my initial go to for a-lines. It is highly worthwhile for all trainees to become proficient with both, since if you will be using ultrasound as your "backup" you should hopefully be proficient with it. One major value I found with ultrasound guided a-lines is there are some moments where I can see what is going on with ultrasound that helps me troubleshoot future non ultrasound a-lines.

 

[vector2]

Another reason I like going straight to U/S is that I can do the a-line in the proximal mid forearm where the artery is usually not palpable. At my shop we lack the rigid plastic wrist boards and only have those foam pieces of crap which you have to manually tape and which don't really hold the wrist in extension. During tucked arm cases, I get many fewer issues with "positional" a-lines when the catheter enters a segment of artery unaffected by wrist position.

 

[deleted50478]

Another reason I like going straight to U/S is that I can do the a-line in the proximal mid forearm where the artery is usually not palpable. At my shop we lack the rigid plastic wrist boards and only have those foam pieces of crap which you have to manually tape and which don't really hold the wrist in extension. During tucked arm cases, I get many fewer issues with "positional" a-lines when the catheter enters a segment of artery unaffected by wrist position.

I do them a couple of inches up from the wrist by palpating without issue and without “positional” issues.

I’m not anti-US or too proud to use it if I need it. If the artery is unusually difficult to palpate or if I can’t wire on first pass or with my back-up plan, through-and-through technique, I’ll use the ultrasound.

For trainees and recent grads, if you frequently miss without using the ultrasound, I’d say to try to improve your technique. If that doesn’t work, it’s okay to be ultrasound dependent I guess.

 

[dhb]

This is also why we're taught to use the finder needle and not go straight to the big needle (although one of my crazy attendings in fellowship did this but I never really liked his style anyway)

I always stick with the big needle.
Miller 4 way of life.

 

[vector2]

🙂🙂

I do them a couple of inches up from the wrist by palpating without issue and without “positional” issues.

I’m not anti-US or too proud to use it if I need it. If the artery is unusually difficult to palpate or if I can’t wire on first pass or with my back-up plan, through-and-through technique, I’ll use the ultrasound.

For trainees and recent grads, if you frequently miss without using the ultrasound, I’d say to try to improve your technique. If that doesn’t work, it’s okay to be ultrasound dependent I guess.

To each their own, man. As I said earlier, I don't have Blade numbers but between critical care fellowship and staffing >200-250 cardiac, vascular, and thoracic cases over the past couple years, I can safely say my anatomic one-stick success rate as an attending is maybe 70-80%. Including redirects, fanning, through and through, or a 2nd (maybe 3rd) fresh stick I get up to 90-95%. Using U/S from the getgo, first pass success is >90-95%. Without a doubt I'm sure there are people here who are absolute palpation gangstas, but the above is just an honest assessment of myself. I have no doubt that in a hypothetical magic OR where the U/S is on, gelled, and ready to place on the patient's arm, going straight to U/S is faster 100% of the time. If the U/S isn't in the room, it's likely a wash between taking the time to go grab it/set it up vs. just anatomically 2nd sticking a better spot.

 

[dhb]

If i have difficulties with an a-line i just call the GI fellow

 

[abolt18]

There's nothing that says this sort of complications doesn't happen even using an ultrasound. Sometimes stuff happens. I believe people need to know how to do invasive lines without an ultrasound for reason that what if your starting a case or doing an emergency and a colleague down the hall is using it for a block/line/whatever? Not every institution has multiple ultrasounds and I wouldn't advise delaying case progression or waiting during an emergency because you can't place a line without an ultrasound.

Edit: I see this has also been addressed above, but my position remains the same. THB, it comes down to patient selection for me. Now I do most of my arterials with an ultrasound just to get things moving but i will once in a while do it blind just so I dont lose the skill. Same with neck lines. Patient selection. A thick neck will always get an ultrasound on it. A slender person I can 90 some odd percent of the time press and show you where the IJ is refilling on the neck. This is also why we're taught to use the finder needle and not go straight to the big needle (although one of my crazy attendings in fellowship did this but I never really liked his style anyway)

I think you're limiting you skills by NOT knowing how to do these things without an ultrasound

We've got an attending who will have you palpate and mark where you think the artery is with a marker. Same with the IJ and carotid. Then you throw the US on to see how you did and correlate your palpation technique to real life imaging and figure out where you may be off. So far, I've missed my mark for the IJ 3/3 with him haha.

 

[Twiggidy]

Another reason I like going straight to U/S is that I can do the a-line in the proximal mid forearm where the artery is usually not palpable. At my shop we lack the rigid plastic wrist boards and only have those foam pieces of crap which you have to manually tape and which don't really hold the wrist in extension. During tucked arm cases, I get many fewer issues with "positional" a-lines when the catheter enters a segment of artery unaffected by wrist position.

That's actually a good point. I never thought to place the line in the final arm position which will likely result in fewer positional lines. I like that and will probably adopt that practice.

 

[deleted162650]

That's actually a good point. I never thought to place the line in the final arm position which will likely result in fewer positional lines. I like that and will probably adopt that practice.

So you’re gonna place it with the arm tucked? 😕

Just go full baller and stab straight through the sheet and pink foam.

 

[Twiggidy]

So you’re gonna place it with the arm tucked? 😕

Just go full baller and stab straight through the sheet and pink foam.

Transfoam-Transforearm Art Line......might need the long catheter for that one

 

[AnesRunner]

As an academic anesthesiologist who gets called all the time by colleagues after 30 minutes of poking to do US-guided radials, please learn the US-guided approach. It's fine if you want to do palpation-guided to start, but please learn it at least as the back-up option. An US-guided technique should take no longer than 30sec with >98% first pass success. Much more elegant and faster. If you don't have ready access to an US, you should question your facility and what they provide to you.