radial arterial lines... annoyed

[badasshairday]

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So I'm an intern, I usually get to do radial art-lines when we admit admit a cardiac arrest to the ICU and they need hypothermia. It is part of the protocol. It kills me inside that I suck at them. Also it doesn't halp that the patients are already being cooled from the ED, so extremities are cold, and they are usually hypotensive. How the heck am I suppose to cannulate the radial artery with a SBP of 80 at best? Can barely feel a faint pulse.

 

[glorfindel]

Ultrasound.

 

[excalibur]

Ultrasound.

Did one a week ago on a code. BP on art line after cannulation was 50/34.

 

[excalibur]

If you can't feel it, then you need to see it.

 

[OB1🤙]

U/S is go-to here.

 

[alphaholic06]

Ultrasound.

This!

 

[lushmd]

If its any consolation, I think that radial arterial lines can be among the most challenging procedures that we (anesthesiologists) do. In any case, as other have already indicated, U/S is quite helpful in this situation.

 

[TrustMe]

U/S or move on up the arm to brachial or axillary.

 

[Mman]

Ultrasound.

Did one a week ago on a code. BP on art line after cannulation was 50/34.

The utility of U/S for placing a radial art line goes up exponentially as the BP gets lower. I put one in after induction on a patient recently and got BP of 39/22 when we hooked it up. Cuff was cycling and having a hard time finding the BP. EKG and end tidal were unremarkable. Jaw dropped a bit when I saw the number. After immediate big dose of phenylephrine and ephedrine and hammering in some fluid it quickly came up.

 

[prongs]

Did one yesterday on someone with barely palpable pulse despite NIBP of 180. Threw on the US and saw color, but thick calcifications all around artery. She had a history of ESRD s/p kidney Tx. I never would have hit that thing if not for US. My needle just kept bouncing around it and pushing it to the side. Once I got the needle slightly engaged, it was super crunchy getting through. I love US!

 

[anes]

Weak sauce. Ultrasound is for wimps.

Had a v. Fib arrest once during residence on the floor. Got called to the floor where ICU residents and IM residents were running the code. 2 residents were working on the right fem line. 5 nurses were trying to place a single 20-22 iv. The patient was in v fib, undergoing great chest compressions. I intubated the patient . moved to the left hand and was able to palpate pulse.with each compression. Placed arterial line. Then i moved to where the nurses were working. I asked the nurses to give me an iv kit, proceeded to place a 16 g in the same vein the couldn't get a 22 to pass.

Subsequently went to the left groin and slammed a central line in the patient (while the other team continued to attempt). Then I just slid on back to the pacu knowing that there was an ice cold orange juice with my name on it. ( I sort of like bragging about that code) even to this day.

So the moral of the story is be better than all other specilities in procedures.

back to the original post
I have had to use the ultra sound for arterial line a total of three times. One patient massively edematous from liver failure no palpable pulse. And two patients with in situ VADs. No palpable pulse either.

 

[BakerMD]

Call me crazy but if I need to put in an art line on a hypotensive patient I give some neo and then place the art line on a normotensive patient. 2 girls-1 cup. I mean 2 birds-1 stone.

 

[Bostonredsox]

U/S or move on up the arm to brachial or axillary.

Dont forget the groin. Hypotensive VF arrests who came in coding generally get a Fem CVC as they are pulseless and no one is screwing around with an US in the IJ or sticking the subclav during chest compressions (though I did do this once). If they come to you with a fem line, just stick a Fem a-line 2-3cm lateral to the CVC. You dont need a pulse or an US. Boom. done. I have done this "side-by-side fem lines" many times for really sick patients where time is of the essence and they have no blood pressure. And Arrow makes a very nice and neat Femoral Art line kit. Treat them like a cath though and dont stick high.

 

[badasshairday]

You guys spin the bevel (180 degrees) once you get flashback? Or do you spin the bevel after you get flashback and advance a smidge?

 

[deleted59964]

Weak sauce. Ultrasound is for wimps.

Had a v. Fib arrest once during residence on the floor. Got called to the floor where ICU residents and IM residents were running the code. 2 residents were working on the right fem line. 5 nurses were trying to place a single 20-22 iv. The patient was in v fib, undergoing great chest compressions. I intubated the patient . moved to the left hand and was able to palpate pulse.with each compression. Placed arterial line. Then i moved to where the nurses were working. I asked the nurses to give me an iv kit, proceeded to place a 16 g in the same vein the couldn't get a 22 to pass.

Subsequently went to the left groin and slammed a central line in the patient (while the other team continued to attempt). Then I just slid on back to the pacu knowing that there was an ice cold orange juice with my name on it. ( I sort of like bragging about that code) even to this day.

So the moral of the story is be better than all other specilities in procedures.

back to the original post
I have had to use the ultra sound for arterial line a total of three times. One patient massively edematous from liver failure no palpable pulse. And two patients with in situ VADs. No palpable pulse either.

you forgot to defibrillate

 

[badasshairday]

you forgot to defibrillate

 

[Mman]

Weak sauce. Ultrasound is for wimps.

/QUOTE]

LOL

Ultrasound is a tool that can be useful to you. If you don't know how to use it effectively, you aren't as good as someone who can.

I'm slick as can be placing art lines without an ultrasound, but when the need arises I can effortlessly grab the probe and whip the line in.

Gotta be multidimensional.

 

[Bostonredsox]

Weak sauce. Ultrasound is for wimps.

Had a v. Fib arrest once during residence on the floor. Got called to the floor where ICU residents and IM residents were running the code. 2 residents were working on the right fem line. 5 nurses were trying to place a single 20-22 iv. The patient was in v fib, undergoing great chest compressions. I intubated the patient . moved to the left hand and was able to palpate pulse.with each compression. Placed arterial line. Then i moved to where the nurses were working. I asked the nurses to give me an iv kit, proceeded to place a 16 g in the same vein the couldn't get a 22 to pass.

Subsequently went to the left groin and slammed a central line in the patient (while the other team continued to attempt). Then I just slid on back to the pacu knowing that there was an ice cold orange juice with my name on it. ( I sort of like bragging about that code) even to this day.

So the moral of the story is be better than all other specilities in procedures.

back to the original post
I have had to use the ultra sound for arterial line a total of three times. One patient massively edematous from liver failure no palpable pulse. And two patients with in situ VADs. No palpable pulse either.

Clearly your IM residents and MICU residents/fellows arent very good. What you have described doing from airway to aline, still confused as to why you put the aline in before the CVC during the code, and then the fem line, collectively take me about 9 minutes. The fact that two IM residents were 'working on a fem line", a procedure that takes <45 seconds from prep to suture in a code, tells me you are a gas resident at an academic shop where the IM residents walk around in white coats carrying clipboards talking about complement levels. Here at the community IM shop, I would have been done and had drank your orange juice before you had ever been paged. And US is a fantastic help for pulseless and hypotensive A lines. Though in the aforementioned code I would have put in side by side groin lines. Nevertheless, we all have awesome storys about out procedures. But being awesome for Non-US guided procedures is not an excuse to not know how to use them when the time arises, nor would I consider it weak if one was needed.

 

[VentdependenT]

ulnar.

 

[mikey014]

Clearly your IM residents and MICU residents/fellows arent very good. What you have described doing from airway to aline, still confused as to why you put the aline in before the CVC during the code, and then the fem line, collectively take me about 9 minutes. The fact that two IM residents were 'working on a fem line", a procedure that takes <45 seconds from prep to suture in a code, tells me you are a gas resident at an academic shop where the IM residents walk around in white coats carrying clipboards talking about complement levels. Here at the community IM shop, I would have been done and had drank your orange juice before you had ever been paged. And US is a fantastic help for pulseless and hypotensive A lines. Though in the aforementioned code I would have put in side by side groin lines. Nevertheless, we all have awesome storys about out procedures. But being awesome for Non-US guided procedures is not an excuse to not know how to use them when the time arises, nor would I consider it weak if one was needed.

can you be my doctor when i code? seriously.. 🙂

 

[pgg]

You guys spin the bevel (180 degrees) once you get flashback? Or do you spin the bevel after you get flashback and advance a smidge?

I prefer the Arrow catheters without wires. Flash, spin 180, advance, thread. If it isn't easy and smooth, I go through & through, then back out until blood spurts on some 4x4s, wire in, catheter in.


Unless I'm using u/s, in which case the procedure is put the catheter in the lumen and be done with it.

Weak sauce. Ultrasound is for wimps.

All through residency I think I used u/s or doppler for an a-line a bare handful of times. I'm good at it without u/s, though this procedure, more than any other, can be humbling.

Now, when I come across a patient who's not a guaranteed chip shot (famous last words), I just use the ultrasound. I don't need to make my life harder than it already is for bragging rights. The machine is Right There. Why not use it?

Do you wear an eye patch when intubating, just to prove you can do it without the use of depth perception?

Maybe you hold your breath when placing central lines, to prove that you're just as fast when your O2 sat is 86% as you are when it's 98%. Oxygen's weak sauce, you know. 🙂

 

[sevoflurane]

Do you wear an eye patch when intubating, just to prove you can do it without the use of depth perception?

Maybe you hold your breath when placing central lines, to prove that you're just as fast when your O2 sat is 86% as you are when it's 98%. Oxygen's weak sauce, you know. 🙂

You're making me laugh half way across the world.

Touché pgg, touché.

 

[excalibur]

Weak sauce list...

Ultrasound, glidescope, Fiberoptic scope, peripheral nerve stimulator, Mac blades, 7.0 and 7.5 ETT, stylets, bougies, blue cushion for art lines, Mastisol spray, 20 g PIV's, skin temp strips, and ETCO2.

 

[anes]

you forgot to defibrillate

The Patient did receive multiple shocks throughout the code. Again, I was NOT running the code. I was called as the airway person. After intubating, I thought that at least a single working IV NOW would be more important than the central line kit that was being open as we speak. So i Placed my 16g IV. Epinephrine Vasopressin boluses were administered through this line. In the mean time the right groin was prepped and needles were ready to poke. So i figured they had it handled. And I had time to place an arterial line... that's why I went to the Arterial line, which was placed in 15 seconds. After this was secured that they still couldn't get a femoral line, I moved to the groin line and secured it.
periperal 16g in large vein not able to do than a central line? Is CVP your only concern?

I mean I've brought out patients with a 16g IV on milrinone, vasopressin, and norepi.

Everything I did, and the order I did it in I'm willing to defend as to why I went in that order. I'm sure a lot of you would have chosen a different order of things.

 

[anes]

Weak sauce list...

Ultrasound, glidescope, Fiberoptic scope, peripheral nerve stimulator, Mac blades, 7.0 and 7.5 ETT, stylets, bougies, blue cushion for art lines, Mastisol spray, 20 g PIV's, skin temp strips, and ETCO2.

Agree.... ramps, reverse trendelenburg, anything smaller than a miller 3. All weak sauce

 

[Mman]

I mean I've brought out patients with a 16g IV on milrinone, vasopressin, and norepi.

If anything in this thread is weak sauce, that is it. Lawsuit waiting to happen when something extravasates.

 

[Bostonredsox]

The Patient did receive multiple shocks throughout the code. Again, I was NOT running the code. I was called as the airway person. After intubating, I thought that at least a single working IV NOW would be more important than the central line kit that was being open as we speak. So i Placed my 16g IV. Epinephrine Vasopressin boluses were administered through this line. In the mean time the right groin was prepped and needles were ready to poke. So i figured they had it handled. And I had time to place an arterial line... that's why I went to the Arterial line, which was placed in 15 seconds. After this was secured that they still couldn't get a femoral line, I moved to the groin line and secured it.
periperal 16g in large vein not able to do than a central line? Is CVP your only concern?

I mean I've brought out patients with a 16g IV on milrinone, vasopressin, and norepi.

Everything I did, and the order I did it in I'm willing to defend as to why I went in that order. I'm sure a lot of you would have chosen a different order of things.

I missed the 16g you put it in. I thought you went airway->art line->CVC, which is dumb. You do not need an art line in a code at all, it is a monitoring tool that can be put in if the patients survivies. and a 16g is a problem waiting to happen when that vasopressin starts extravasating. Code goes airway->central access. When I go to a floor code its 'what is their code status and whats the fingerstick?" From their its ACLS, slam in an airway, slam in a femoral. Continute ACLS. Everything else after that varies (chest tube, cath lab, OR, pacer, etc) depending on why they are coding. EVERYONE who codes atleast that I am the first to get to, gets a femoral line. With the exception of one who had elephant size legs with anasarca who I elected to stick the chest and then alternate feeding the wire, dilating and feeding the catheter with the timing of the other residents chest compressions. Unless they have a chemoport or picc or other similar access, they get a fem.

And as a reminder, the tip of the fem line is down in the iliac/fem region, very far from the RA and is not an equivalent measurement of the CVP as subclav/IJ. The values will be different.

 

[Bostonredsox]

Agree.... ramps, reverse trendelenburg, anything smaller than a miller 3. All weak sauce

I detest miller blades. I can intubate with them. But I strongly prefer a mac 4. Not sure how thats weaksauce, just a blade preference IMO.

 

[Dwindlin]

I detest miller blades. I can intubate with them. But I strongly prefer a mac 4. Not sure how thats weaksauce, just a blade preference IMO.

You work at a horse hospital or something? 😀

 

[Bostonredsox]

You work at a horse hospital or something? 😀

Haha no we just have a large population of obese wide mouthed fattys lol. If they are small old ladies I use a Mac 3. My algorithm is Mac 3 or 4 depending on size, if I cant see deep enough I switch from 3 to 4, if I cant see anything at all I try different positional manuevers, next is an airtract which i dont have alot of good luck with, Next is bougie. LMA obviously if we cant ventilate the pt anywhere in this process. We only have one glidescope and the CRNA keeps with with him/her. If I know they are gonna be tough up front (the elective ones) I call the CRNA ahead of time to bring it. We are supposively getting our own for the unit soon...like when hell freezes over. Lastly for the floor codes I have a rolled up bougie in my back pocket and an 11 blade in my breast pocket. But no no horses 😉

 

[bkell101]

Random question....

Rad Aline, flash, then some people rotate 180 degrees...what does this do?

 

[IlDestriero]

If anything in this thread is weak sauce, that is it. Lawsuit waiting to happen when something extravasates.

Yeah, that's stupid.
If they need the pressors it's central line time. I've put a few in at the end of the case when a sick patient went South in the OR.
Anyway, the ultrasound is a valuable tool, and you don't want to be learning as you go in an urgent situation. Call for it next time and get some experience with US guided Alines and PIVs.

 

[IlDestriero]

Random question....

Rad Aline, flash, then some people rotate 180 degrees...what does this do?

It changes the orientation of the bevel so that, theoretically, you don't go through the back wall when you try to advance.

 

[glorfindel]

Do you wear an eye patch when intubating, just to prove you can do it without the use of depth perception?

Maybe you hold your breath when placing central lines, to prove that you're just as fast when your O2 sat is 86% as you are when it's 98%. Oxygen's weak sauce, you know. 🙂

Weak sauce list...

Ultrasound, glidescope, Fiberoptic scope, peripheral nerve stimulator, Mac blades, 7.0 and 7.5 ETT, stylets, bougies, blue cushion for art lines, Mastisol spray, 20 g PIV's, skin temp strips, and ETCO2.

Funniest thread ever...